Royal Middletown Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Middletown, Rhode Island.
- Location
- 193 Forest Avenue, Middletown, Rhode Island 02842
- CMS Provider Number
- 415040
- Inspections on file
- 23
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Royal Middletown Nursing Center during CMS and state inspections, most recent first.
A resident with Alzheimer's disease and cardiac comorbidities was actively dying and experiencing increased pain and agitation when a hospice RN recommended more frequent scheduled and PRN Morphine and Ativan for end-of-life comfort. An RN texted these recommendations to the physician, who approved them, but the new orders were never entered on the MAR or implemented. As a result, only the prior, less frequent PRN and TID Lorazepam and PRN Morphine orders remained active, and the last doses of Ativan and Morphine were administered many hours before the resident's death. The physician later stated the nurse should have implemented the hospice recommendations, and the DON acknowledged the resident did not receive the comfort medications as ordered.
A resident on hospice with Alzheimer’s disease, hypertension, and coronary artery disease experienced apnea, tachycardia, pain, and agitation near end of life. Hospice recommended increasing scheduled Morphine and Ativan to Q2H with additional PRN dosing Q1H for breakthrough symptoms, but facility records showed these recommendations were not communicated to the physician or implemented. The MAR reflected the last Morphine and Ativan doses were given many hours before the resident’s death, and there were no nursing progress notes documenting assessment of the resident’s condition during the final hours, despite facility policy requiring communication with hospice, adherence to hospice interventions, and ongoing monitoring. The DON confirmed the resident did not receive medications per hospice recommendations and that ongoing monitoring was not documented.
A resident with hypertension and atrial fibrillation had physician orders for metoprolol and amiodarone that included specific HR parameters requiring the medications to be held when the HR was below 60. Review of MARs showed that metoprolol and amiodarone were documented as administered on multiple occasions despite HRs below the ordered parameters, while metoprolol was also held numerous times for low HR. Staff, including a CMT, an RN, the DON, and the Infection Preventionist, acknowledged that the medications should not have been given when the HR was below the parameters and that CMTs were expected to obtain vital signs and notify nursing when medications were held. Record review showed no evidence that the provider was notified of the repeated held doses, and the provider reported she was unaware of the frequent holds and expected both adherence to parameters and notification when the medications were held.
During a norovirus outbreak, a resident with dementia and GI symptoms was placed on contact precautions with posted signage and a physician’s order requiring gown, gloves, and hand hygiene on room entry and exit. A nursing assistant entered and exited the resident’s room without wearing PPE, did not perform hand hygiene, then accessed a clean linen room and returned to the resident’s room still without PPE. The staff member later acknowledged knowing the resident was on contact precautions for norovirus and that she failed to follow the posted instructions, while facility leadership stated they expected staff to adhere to the contact precaution requirements.
Two residents with wounds did not consistently receive wound care as ordered by the physician, due to delays in transcribing new treatment orders and missed or incorrect treatments. Documentation showed that wound care was not completed on several occasions, and updated orders were not promptly implemented, resulting in residents not receiving necessary wound management.
The facility did not obtain, review, or report ordered lab tests and failed to complete required COVID-19 testing for two newly admitted residents, resulting in delayed care and hospitalization for one resident with a UTI and COVID-19. Staff and leadership confirmed that physician orders were not followed and providers were not notified of abnormal or missing results during a COVID-19 outbreak.
Surveyors found that two newly admitted residents did not have ordered lab tests completed or reported, and COVID-19 testing was not performed as required. One resident with a UTI and a urostomy was not tested for COVID-19 or had lab results reported, leading to hospitalization for UTI and COVID-19. Another resident did not have a UA C&S completed or COVID-19 testing done as ordered, and abnormal lab results were not communicated to a provider. Staff confirmed these lapses during interviews, and the facility was experiencing a COVID-19 outbreak at the time.
A resident with dementia and moderate cognitive impairment reported that a NA grabbed their forearm tightly and attempted to force care, resulting in fear and arm discomfort. The facility did not promptly or thoroughly investigate the allegation, failing to interview involved staff or document the investigation as required by policy.
Two residents in the facility were not provided with respiratory care consistent with professional standards. One resident with COPD was receiving oxygen at a higher flow rate than prescribed, while another resident was receiving oxygen without a documented physician's order. Staff acknowledged these discrepancies, indicating a failure in adhering to proper protocols for oxygen administration.
A resident with end-stage renal disease and moderate cognitive impairment did not receive the prescribed medication Xphozah on multiple occasions, as revealed by a review of the Medication Administration Record. Staff interviews indicated a lack of awareness about the missed doses, and the DON could not provide evidence of administration.
During a survey of the main kitchen, several food items were found improperly stored, including a red liquid in a prep pan without an identifier and stored beyond 7 days, a deli salad without an identifier or date, and frozen protein without an identifier. Additionally, three bags of frozen, sliced orange vegetables were found in clear plastic bags without identifiers or dates. The Food Service Director acknowledged the lack of proper labeling and dating, indicating non-compliance with food safety regulations.
The facility did not implement a water management program based on industry standards and the CDC toolkit for Legionella prevention. The Maintenance Director acknowledged not performing flushing maintenance of unoccupied resident rooms as required, although water temperatures were checked. The water management binder lacked documentation of necessary maintenance activities, indicating non-compliance with CDC Legionella prevention protocols.
A facility failed to ensure a resident's drug regimen was free from unnecessary drugs by not checking vital signs before administering Carvedilol, despite physician's orders to hold the medication if certain parameters were not met. The Director of Nursing Services could not provide evidence that the required checks were performed.
Failure to Implement Hospice-Recommended End-of-Life Comfort Medication Orders
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when hospice-recommended end-of-life comfort medication orders were not implemented. The resident, admitted with diagnoses including Alzheimer's disease, hypertension, and atherosclerotic heart disease, was declining and experiencing increased pain and agitation. A hospice RN assessed the resident in the late afternoon and recommended scheduling Morphine concentrate 5 mg every 2 hours and Ativan (Lorazepam Intensol) 0.5 mg every 2 hours, with PRN orders for both medications every hour for breakthrough pain or agitation. At the time of the resident's death, the MAR still reflected prior orders: Lorazepam Intensol 0.25 ml three times daily, Lorazepam Intensol 0.25 ml every 2 hours PRN for restlessness, and Morphine sulfate 0.25 ml every 2 hours PRN for pain greater than 4, with no evidence that the hospice recommendations had been entered or activated. The RN on duty stated she texted the new hospice recommendations to the resident's physician, and the surveyor verified a text message indicating new hospice recommendations for scheduled and PRN every 1-hour Ativan and Morphine, to which the physician responded "ok." However, the RN could not provide evidence that the orders for scheduled every-2-hour Morphine and Ativan or the hourly PRN orders were ever implemented. The resident's physician indicated that the nurse should have implemented the hospice recommendations after they were approved. MAR review showed the last dose of Ativan was given at 10:00 PM the night before death and the last dose of Morphine at 2:13 PM the previous afternoon, approximately 8 and 16 hours, respectively, before the resident died at 6:17 AM. The DON acknowledged that the resident did not receive Ativan and Morphine as ordered for end-of-life comfort.
Failure to Implement Hospice End-of-Life Recommendations and Monitor Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that hospice services met professional standards and that hospice recommendations were communicated, implemented, and documented for a resident receiving end-of-life care. The resident, admitted in January 2026 with diagnoses including Alzheimer’s disease, hypertension, and atherosclerotic heart disease of the native coronary artery, was on hospice services. A facility policy titled “Coordination of Hospice Services Policy” stated that the facility would communicate with hospice, identify and follow all interventions put into place by hospice and the facility, monitor medications and medical supplies provided by hospice as indicated in the plan of care, and provide ongoing monitoring of resident conditions. On 1/30/2026, hospice documentation showed that during an end-of-life visit between 4:00 PM and 5:00 PM, the hospice RN assessed the resident as having periods of apnea, a racing pulse, increasing pain, and agitation, with any movement causing groaning and grimacing. The hospice RN recommended scheduling Morphine concentrate 5 mg every 2 hours and Ativan concentrate 0.5 mg every 2 hours, with PRN orders for Morphine 5 mg every hour and Ativan 0.5 mg every hour for breakthrough symptoms. Record review revealed that earlier on 1/30/2026 at 11:55 AM, facility staff had spoken with hospice about the resident’s respiratory rate of 30 and restlessness and received a recommendation to increase the frequency of PRN medication from every 4 hours to every 2 hours, which the physician approved. However, further review of the clinical record, including progress notes, physician’s orders, and the MAR, failed to show that the additional hospice recommendations from the late afternoon end-of-life visit were communicated to the physician or implemented. The MAR showed the last dose of Ativan was given at 10:00 PM on 1/30/2026 and the last dose of Morphine at 2:13 PM on 1/30/2026, approximately 8 and 16 hours, respectively, before the resident’s death at 6:17 AM on 1/31/2026. Additionally, there were no nursing progress notes documenting assessment of the resident’s condition between 11:55 AM on 1/30/2026 and the time of death, despite the facility policy requiring ongoing monitoring. During interview, the DON acknowledged that the resident did not receive Morphine and Ativan per hospice recommendations and that there was no evidence of ongoing monitoring of the resident’s condition at end of life.
Failure to Follow Medication Hold Parameters and Notify Provider for Low Heart Rate
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice related to administration of blood pressure and antiarrhythmic medications with ordered parameters. The resident was admitted with diagnoses including hypertension and atrial fibrillation and had a care plan addressing hypertension, with interventions to administer antihypertensive medications as ordered and obtain vital signs as ordered. Physician orders dated 12/7/2025 directed that metoprolol 100 mg twice daily be held for systolic blood pressure less than 110 or heart rate (HR) less than 60, and that amiodarone 200 mg once daily be held for HR less than 60. Review of the December 2025 and January 2026 MARs showed multiple instances where metoprolol and amiodarone were documented as administered despite HRs below the ordered parameters. Specifically, metoprolol was documented as given on several dates when the resident’s HR ranged from 48 to 58, all below the hold parameter of HR less than 60. Amiodarone was also documented as administered on one date when the HR was 58, below the ordered parameter. At the same time, the MAR showed that metoprolol was held on numerous occasions in both December and January due to low HR, indicating repeated occurrences where the resident’s HR was below the ordered threshold. Staff interviews confirmed that CMTs were expected to obtain vital signs prior to administering metoprolol or amiodarone and to hold the medications and notify the nurse if vital signs were outside the ordered parameters. The CMT and RN acknowledged that, based on the documented HRs, the medications should not have been administered on the identified dates. The DON and Infection Preventionist also acknowledged that the medications were documented as administered when the HR was below the parameters. Record review did not show evidence that the provider was notified of the multiple held doses of metoprolol due to low HR, and the provider stated she was unaware that the medication was being held often and would have expected notification when the medications were held, as well as adherence to the ordered parameters.
Failure to Follow Contact Precautions During Norovirus Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program during a norovirus outbreak, specifically by not following transmission-based contact precautions for a resident on isolation. A community complaint reported that residents had norovirus, and the facility’s own policies required contact precautions, including use of appropriate PPE such as gowns and gloves, for residents with symptoms consistent with norovirus gastroenteritis. The facility’s Norovirus Prevention and Control policy directed that symptomatic residents be placed on Contact Precautions, ideally in single rooms or cohorted, and that these precautions continue for at least 48 hours after symptom resolution. The Infection Preventionist reported that a resident positive for norovirus had been admitted and that multiple residents subsequently developed GI symptoms, with 21 residents identified as having nausea, vomiting, or diarrhea and placed on contact precautions per RIDOH and Medical Director direction. Resident ID #4, who had dementia and had been readmitted to the facility in November 2025, had a physician’s order for contact precautions due to GI symptoms, and contact precaution signage was posted outside the resident’s room instructing staff to perform hand hygiene and wear a gown and gloves upon entry. During surveyor observation, a nursing assistant (Staff C) entered and exited this resident’s room without wearing a gown or gloves and failed to perform hand hygiene upon exit. Staff C then entered a clean linen storage room, handled clean linens, and re-entered the resident’s room still without appropriate PPE. In a subsequent interview, Staff C acknowledged awareness that the resident was on contact precautions for norovirus, recognized the posted signage, and admitted not following the required PPE and hand hygiene practices. Both the Infection Preventionist and the Administrator stated they expected staff to follow the posted contact precaution signage and wear appropriate PPE when entering the resident’s room.
Failure to Provide Wound Care as Ordered for Two Residents
Penalty
Summary
The facility failed to ensure that two residents with wounds received necessary treatment and services consistent with professional standards of practice. For one resident admitted with multiple wounds, including to the right ankle, buttock, thigh, and abdomen, there were several instances where wound care orders from the wound physician were not transcribed in a timely manner, resulting in incorrect or missed treatments. Specifically, wound treatments for the right buttock and abdomen were not updated according to new physician orders, leading to the resident receiving outdated treatments for several days. Additionally, documentation failed to show that certain wound treatments were completed as ordered on specific dates, and one wound treatment order for the right thigh was not transcribed or administered for 13 consecutive days. Another resident with a coccyx wound also experienced lapses in wound care management. The care plan required specific wound treatments and follow-up with the wound physician, but the treatment administration record did not show evidence that wound care was completed as ordered on multiple dates. When the wound physician updated the treatment order to a new regimen, the order was not transcribed until two days later, resulting in the resident receiving the incorrect treatment. There was also a missed wound treatment on the morning following the transcription of the new order. Interviews with the wound physician and the facility administrator confirmed that wound care orders were expected to be transcribed and treatments completed as ordered. However, the facility was unable to provide evidence that these processes were consistently followed, resulting in residents not receiving wound care in accordance with physician orders and professional standards of practice.
Failure to Complete and Report Lab Tests and COVID-19 Testing for New Admissions
Penalty
Summary
The facility failed to obtain, review, and report laboratory tests as ordered, and did not complete required COVID-19 testing for two newly admitted residents. For one resident with a history of urinary tract infection (UTI) and neuromuscular bladder dysfunction, the facility did not report positive urinalysis and culture results to a provider or implement interventions, despite care plan instructions to monitor and report abnormal lab values. This resident was also not tested for COVID-19 on admission, day two, or day four, as required by physician order and facility policy, even though the resident had signed a COVID-19 testing consent form. The same resident was later transferred to the hospital with symptoms including shortness of breath, cough, and blood in the urostomy and nephrostomy tube, and was diagnosed with both a UTI and COVID-19. Staff interviews confirmed that the required COVID-19 testing was not performed and that the positive UTI lab results were not communicated to a provider or acted upon prior to hospitalization. The Infection Preventionist acknowledged that the lab results were not reviewed until the day the resident was sent to the hospital, and that no provider notification or intervention occurred. A second resident, also newly admitted with a history of UTIs and muscle weakness, had a physician's order for urinalysis and culture that was not completed, and COVID-19 testing on admission and day two was not performed as ordered. This resident later tested positive for COVID-19. Staff and leadership interviews confirmed that physician orders for lab tests and COVID-19 testing were not followed, and that providers were not notified of outstanding or abnormal results. The facility was experiencing a COVID-19 outbreak at the time, with a significant number of residents testing positive.
Failure to Complete and Report Laboratory and COVID-19 Testing Orders for New Admissions
Penalty
Summary
Surveyor observation, record review, and staff interviews revealed that the facility failed to obtain, review, and report laboratory tests as ordered, notify providers of abnormal or missing test results, and complete ordered COVID-19 testing for two of three newly admitted residents reviewed. For one resident with a history of urinary tract infection (UTI) and neuromuscular bladder dysfunction, physician orders for a complete blood count (CBC) and complete metabolic panel (CMP) were not transcribed or completed as ordered. Additionally, a urinalysis with culture and sensitivity (UA C&S) was obtained, but the positive results were not reported to a provider, and no interventions were implemented. The resident was not tested for COVID-19 on admission, day two, or day four, despite signed consent and physician orders. The resident was later hospitalized with a UTI and COVID-19 after presenting with shortness of breath, cough, and blood in the urostomy and nephrostomy tube. A second resident, also with a history of UTIs, had a physician order for a UA C&S that was not completed. Laboratory tests, including a CBC, were obtained without a corresponding physician order, and abnormal results were not reported to a provider. This resident also was not tested for COVID-19 on admission or day two as ordered, and subsequently tested positive for COVID-19. Staff interviews confirmed that required laboratory tests and COVID-19 testing were not completed as ordered, and that abnormal results were not communicated to providers. The facility was experiencing a COVID-19 outbreak at the time of the survey, with multiple residents testing positive. Staff, including registered nurses, the infection preventionist, the DON, and the medical director, acknowledged that physician orders were not followed, laboratory results were not reviewed or reported, and COVID-19 testing protocols were not adhered to for new admissions. These failures resulted in delays in care and contributed to the hospitalization of at least one resident.
Failure to Investigate Alleged Physical Abuse
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of physical abuse involving a resident with dementia, anxiety, and depression who was moderately cognitively impaired and required moderate assistance for activities of daily living. The incident, reported to the Rhode Island Department of Health, involved a Nursing Assistant (NA) allegedly grabbing the resident's right forearm tightly and insisting the resident be washed, despite the resident's refusal, and attempting to pull the resident out of a wheelchair. The resident appeared frightened and reported discomfort in the right arm following the incident. Record review and staff interviews revealed that the facility did not conduct timely or comprehensive interviews with the implicated NA or other staff members, nor did they document a thorough investigation as required by facility policy. The Director of Nursing Services (DNS) acknowledged being aware of the incident and the NA's unusual behavior but did not initiate interviews or collect statements until prompted by the surveyor. The only written statement from the NA was obtained during the survey, and no further documentation of an investigation was provided.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents using oxygen. Resident ID #1, who has chronic obstructive pulmonary disease (COPD) and is dependent on supplemental oxygen, was observed receiving oxygen at a higher flow rate than prescribed. The physician's order specified an oxygen flow rate of 1.5 liters per minute, but observations on two occasions showed the resident receiving between 3.5 and 4 liters per minute. The resident confirmed that only nursing staff adjust the oxygen flow rate. A registered nurse acknowledged the discrepancy and adjusted the flow rate to the correct level. Resident ID #4, who was readmitted with diagnoses including stroke and anxiety, was receiving oxygen without a documented physician's order specifying the frequency, flow rate, and method of delivery. Observations showed the resident receiving oxygen at 2 liters per minute continuously since readmission. Staff confirmed the absence of a proper order for the oxygen administration. The Interim Director of Nursing Services and the residents' physician both expressed expectations that proper orders should be in place for oxygen administration, highlighting the facility's failure to adhere to professional standards of practice.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident received medication in accordance with professional standards of practice, specifically failing to administer Xphozah as prescribed. The resident, who has a history of brain damage, dementia, and end-stage renal disease, was readmitted to the facility with a physician's order for dialysis three times a week and a prescription for Xphozah to manage elevated phosphorus levels. Despite a physician's order obtained on 9/26/2024 for Xphozah to be administered twice daily, the Medication Administration Record for October 2024 showed that the medication was not given on several specified dates. Interviews with facility staff revealed a lack of awareness regarding the missed doses. A Medication Technician confirmed the resident's dialysis schedule and noted that the resident eats breakfast before leaving for dialysis. However, the Registered Nurse was unaware of the missed doses, and the Director of Nursing Services could not provide evidence that the medication was administered as ordered. The resident, who has moderate cognitive impairment, expressed uncertainty about the medications they were supposed to take, indicating a reliance on staff for medication management.
Improper Food Storage Practices Identified in Main Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards of food service safety in the main kitchen, as observed during a survey. Specifically, during an initial tour of the main kitchen, several food items were found to be improperly stored. These included a red liquid in a prep pan dated 3/31 without an identifier and stored beyond 7 days, a deli salad without an identifier or date, and frozen protein dated 4/3/24 without an identifier. Additionally, three bags of frozen, sliced orange vegetables were found in clear plastic bags without an identifier or date in a white reach-in freezer in the back room. The Food Service Director acknowledged during a surveyor interview that the mentioned foods were not labeled with their identifiers, and some were without dates. The director also acknowledged that the tomato soup should have been discarded. These observations indicate a lack of compliance with food safety regulations regarding proper labeling and storage of food items in the facility's main kitchen.
Deficiency in Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to implement a water management program based on industry standards and the CDC toolkit for Legionella prevention. The Maintenance Director admitted to not conducting flushing maintenance of unoccupied resident rooms as required, despite checking water temperatures. The facility's water management binder lacked evidence of necessary maintenance activities, indicating a gap in compliance with Legionella prevention protocols outlined by the CDC.
Failure to Monitor Vital Signs Before Administering Carvedilol
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs. Specifically, for one resident, there was a physician's order for Carvedilol with parameters to hold the medication if the heart rate was below 60 or systolic blood pressure was below 100. However, record reviews revealed that from March 1, 2024, through March 31, 2024, and from April 1, 2024, through April 9, 2024, the medication was administered without evidence of checking the resident's blood pressure or heart rate prior to administration. During an interview, the Director of Nursing Services could not provide evidence that these vital signs were being checked as required.
Latest citations in Rhode Island
A cognitively impaired resident with dementia and severe BIMS impairment, care planned and ordered to wear a wander guard with regular placement and function checks, eloped from the facility after being last seen in an activity room with a visitor. Staff later could not locate the resident for dinner, and searches were initiated while the resident’s whereabouts were unknown for several hours. Witnesses, including the Activities Director, Receptionist, another resident’s family member, and the visitor, reported that the resident and visitor exited through the main entrance without a wander guard alarm sounding and without use of a door code. The visitor admitted driving the resident to the spouse’s home without notifying staff. EMS and hospital records documented that the resident had been missing for several hours, was confused, could not recall events, and reported severe throat and chest pain, arriving at the hospital with an ankle monitoring device in place. Upon the resident’s return, the facility discarded the original wander guard without testing its functionality and could not provide evidence of consistent monitoring per policy and physician orders, resulting in an Immediate Jeopardy situation.
A resident with Alzheimer’s disease, dementia, severe cognitive impairment, documented exit-seeking behavior, and a care plan identifying high elopement risk and the use of a wander guard was inadequately supervised. Earlier in the day, an LPN observed the resident attempting to open an exit door and redirected the resident, who was later last seen in their room. The resident subsequently exited a secured unit through a stairwell door that only briefly alarmed and was not connected to the wander guard system, descended to a basement level, and left through an exterior door. Because wander guard sensors were only placed at elevators and not at exit doors or stairwells, the resident’s departure went undetected until a Code Orange was called and the elopement protocol initiated, after which staff located the resident off premises and returned the resident to the facility.
A cognitively intact resident with spinal stenosis and post-stroke hemiplegia/hemiparesis was discharged from the hospital with documented referrals to a spine center for evaluation and possible spinal steroid injections, which were reiterated in a later provider note citing ongoing lower extremity weakness. Despite these physician-ordered referrals and the resident’s repeated attempts to reach the appointment scheduler, the facility did not schedule or facilitate the neurosurgical consultation. The unit secretary, who was responsible for scheduling, reported being unaware of the referrals, and neither she nor the DON could provide any evidence that efforts were made to arrange the appointment, leading to a prolonged delay in the resident’s surgical follow-up.
A resident with dysphagia, autonomic dysfunction, seizure disorder, a G-tube, and dependence on staff for feeding had physician orders and a care plan requiring a minced and moist diet with thin liquids given by spoon only while upright. Video from a room camera showed a nurse providing thin liquids through a straw while the resident was lying down and continuing despite the resident coughing. Additionally, a physician ordered every-shift monitoring and documentation of vital signs, including lung sounds, O2 saturation, temperature, and signs of aspiration for seven days, but the MAR showed that required vital signs were not obtained on multiple shifts. The DON confirmed these deviations from physician orders and expected practice.
A resident with intact cognition and a history of hypertension used the call light for toileting assistance when a CNA entered the room and yelled statements such as not "playing games" and telling the resident to wait, causing the resident to become upset. A nursing supervisor heard the CNA yelling, went to the room, and observed the resident visibly upset, while an LPN’s written statement described the CNA’s tone as very rude and yelling about having been with another resident. The CNA later acknowledged speaking loudly to the resident, and during interviews, the administrator and DON could not demonstrate that the resident had been free from verbal abuse as required by the facility’s abuse prohibition policy.
A resident with Alzheimer’s disease receiving hospice services was observed by an RN to be grimacing, with swelling and bruising of the right ankle, and an x-ray later confirmed displaced fractures of the medial and lateral malleolus. Facility policy required that responsible family or legal representatives be notified within 24 hours of significant condition changes or injuries and that this notification be documented in the medical record. A NP documented the fracture findings and ordered that hospice and the resident’s representative be contacted, but there was no documentation that the representative was notified. In interviews, the resident’s representative reported learning of the injuries from hospice staff, the RN acknowledged not notifying the representative, and the DON could not provide evidence that immediate notification occurred, resulting in a deficiency for failure to notify the representative of a significant change in condition.
A resident with Alzheimer's disease, severe cognitive impairment, and non-ambulatory status, receiving hospice care, was found grimacing with swelling and bruising to the right ankle after being brought to the dining room. An x-ray later confirmed acute to subacute displaced fractures of both the medial and lateral malleolus, with no cause identified in the record, making it an injury of unknown origin. A hospice aide reported that during care, the resident became agitated and flailed while two CNAs held the resident's arms and legs, but care was not stopped and the nurse was not notified of the behavior. The RN on duty could not show that the injury of unknown origin was reported to RIDOH, and the DON acknowledged that the incident was not reported, resulting in a failure to report an alleged violation and injury of unknown origin as required.
A non-ambulatory hospice resident with severe cognitive impairment developed swelling and bruising of the right ankle after being taken to the dining room and receiving care in the room, during which the resident became agitated and flailed while a hospice aide and two CNAs continued care and physically held the resident’s arms and legs. An RN later noted the ankle changes, obtained an x-ray order from a provider, and imaging confirmed acute to subacute displaced fractures of both the medial and lateral malleolus. The clinical record and interviews with the RN, DON, and NP showed that no thorough investigation was conducted into the origin of the injury, no potential causes were documented or identified, and no interventions to prevent further or potential injury were documented, despite regulatory requirements and a community complaint alleging lack of notification and unclear cause of the injury.
A resident with CHF, afib, moderate cognitive impairment, and low body weight was mistakenly given another resident’s clozapine 150 mg and melatonin 3 mg by a CMT who entered the wrong room and failed to verify identity, contrary to facility policy requiring multiple resident-identification checks. The resident did not receive ordered warfarin and metoprolol during this pass. Subsequently, the resident was found unresponsive with abnormal respirations, tachycardia, and hypoxia, required EMS intervention with suctioning, high-flow oxygen via BVM, and IV emergency cardiac medication, and was admitted to the hospital with altered mental status, profound hypothermia, pleural effusion, and aspiration pneumonia, later transitioning to comfort care and expiring. The DON was unable to show the resident was kept free from significant medication errors, and the Medical Director stated she expected correct medications to be given to the correct resident.
The facility failed to ensure that a CMT had demonstrated competency in resident identification during medication administration and did not complete the required quarterly medication aide evaluations. Despite only one documented evaluation and no evidence of competency in verifying resident identity, the CMT was scheduled to pass medications and entered the wrong room, administering clozapine 150 mg and melatonin 3 mg intended for another resident to a frail, elderly resident with CHF and Afib. The resident, who weighed 79.2 pounds, subsequently developed tachycardia, shortness of breath, altered mental status, profound hypothermia, a small pleural effusion, and aspiration pneumonia, was admitted to the hospital for comfort measures only, and later died. The DON acknowledged that quarterly evaluations were required and could not provide evidence that the CMT had demonstrated competency in medication administration per state requirements.
Elopement of Cognitively Impaired Resident Despite Wander Guard Device
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary supervision and maintain an effective elopement prevention system for a cognitively impaired resident identified as an elopement risk. The resident had diagnoses including dementia, cognitive communication deficit, and anxiety disorder, and a Quarterly MDS showed a BIMS score of 4/15, indicating severe cognitive impairment. The resident’s care plan, initiated after prior attempts to leave the facility, required use of a wander guard bracelet, weekly assessment of the device’s functioning and battery status, and visual checks or supervision for safety. Physician orders directed staff to check placement of the Tektone wander guard bracelet every shift and to check its functionality weekly. Documentation on the March Treatment Administration Record indicated the device was in place on the day of the incident and that its functionality had been checked and found operational several days earlier. On the day of the elopement, staff observed the resident wearing the wander guard bracelet in the activities room during a bingo activity in the mid-afternoon. An LPN reported last seeing the resident in the activity room seated with a visitor and wearing the wander guard. Later, when the LPN attempted to escort the resident to dinner, the resident could not be located, and a subsequent call to the resident’s spouse confirmed that the spouse did not have the resident and was unaware the resident was missing. The facility’s elopement protocol was then initiated, and staff, along with law enforcement, conducted searches of the building and surrounding community. During this time, staff and management did not know the resident’s whereabouts for several hours. Interviews and witness accounts established that the resident exited the facility through the main entrance with a visitor. The Activities Director stated that she did not see the resident or visitor leave and did not hear a wander guard alarm at the exit. The Receptionist reported seeing the resident and a visitor walking toward the main entrance and also did not hear an alarm. A visitor later admitted that she removed the resident from the facility at the resident’s request to go home, drove the resident to the spouse’s house, dropped the resident off, and left without notifying staff; she stated that the wander guard alarm did not sound when they exited and that she had never been given a door code. A family member of another resident reported seeing the visitor leave with the resident through the main entrance without hearing an alarm or seeing a code entered. The resident ultimately arrived at the spouse’s home with a sandwich in hand, appeared confused, and could not explain how they had gotten there. EMS and hospital records documented that the resident had been missing from the facility for several hours, could not recall their whereabouts, and reported severe throat and chest pain; the hospital record also noted that the resident arrived with an ankle monitoring device in place. Following the resident’s return, the facility did not evaluate or test the wander guard device that had been in use at the time of the elopement. A Regional Nurse documented that a new wander guard device was applied to the resident’s left ankle, and later acknowledged in interview that the original device had been discarded without assessment. The Regional Administrator and Regional Nurse were unable to provide evidence that the previous device had been checked or tested for functionality upon the resident’s return. The Administrator stated that it was unclear whether the wander guard system had failed, whether an alarm had sounded without staff response, or whether a visitor had entered a door code, and confirmed that visitors should not have the door code. The facility was also unable to provide documentation confirming that staff consistently monitored the resident in accordance with facility policy and physician orders. These failures resulted in the resident leaving the facility unsupervised for approximately six hours while staff were unaware of the resident’s whereabouts, placing the resident at risk for serious injury, serious harm, serious impairment, or death, and constituted a situation of Immediate Jeopardy.
Failure of Elopement Prevention and Supervision for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and maintain an effective elopement prevention system for a resident assessed as a high elopement risk. The resident had Alzheimer’s disease, dementia, severe cognitive impairment (BIMS score of 00), a documented history of exit-seeking behaviors, and a care plan identifying high elopement risk, prior elopements, recent attempts to leave, verbalizations about leaving, and wandering behavior requiring a wander guard. On the morning of the incident, an LPN observed the resident attempting to open the unit exit door at approximately 9:30 AM; the resident was redirected and escorted back to the dining room. The resident was last seen in their room at approximately 10:00 AM. Despite residing on a secured unit and wearing a wander guard, the resident eloped from the unit via a stairwell door that alarmed when opened but stopped alarming after the door closed and after a period of time. The wander guard system was configured so that sensors were only located at the elevators and did not detect the resident at the unit exit doors or stairwell. The resident used the stairwell to descend several flights to the basement level and exited through a basement exterior door, leaving the building undetected. A Code Orange was not called and the elopement protocol not initiated until approximately 11:20 AM, at which time the resident had already traveled off premises and was later observed walking along a main road and crossing a four-lane street before being located and returned to the facility at approximately 11:45 AM.
Failure to Arrange Neurosurgical Follow-Up for Resident With Spinal Stenosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services were provided in accordance with professional standards of quality for a resident admitted with spinal stenosis and post-stroke hemiplegia/hemiparesis. The resident was admitted in October 2025 with diagnoses including spinal stenosis and left-sided weakness following a stroke. A Continuity of Care - Post-Acute Facility document dated 10/24/2025 indicated that, upon hospital discharge, a referral to a spine center was placed to evaluate the need for spinal steroid injections. A subsequent provider progress note dated 11/17/2025 documented the resident’s ongoing chronic lower extremity weakness related to lumbar disc protrusions and reiterated the need for outpatient neurosurgical follow-up, with an additional referral placed at that time. Record review and interviews showed that, despite these clear and repeated physician-ordered referrals, the facility did not schedule or facilitate the required neurosurgical consultation. The resident, who had a Brief Interview for Mental Status score of 14/15 indicating cognitive intactness and ability to express needs, reported making multiple unsuccessful attempts to contact the facility’s appointment scheduler to obtain the neurosurgical consultation for spinal injections. During an interview, the Unit Secretary responsible for scheduling appointments stated she was unaware of the referrals, and neither she nor the Director of Nursing Services could provide evidence that any efforts were made to arrange the neurosurgical appointment. A community complaint alleged that the resident waited approximately five months without resolution of the needed surgical follow-up appointment.
Failure to Follow Physician Orders for Dysphagia Management and Vital Sign Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of practice and followed physician orders for a resident with significant swallowing difficulties and other complex medical conditions. The resident, admitted with diagnoses including seizure disorder, autonomic dysfunction, presence of a gastrostomy tube, bilateral upper extremity contractures, and dysphagia, was dependent on staff for eating. A physician’s order dated 1/6/2026 specified a house diet with minced and moist texture and thin liquids to be provided by spoon only. The care plan initiated on 12/4/2024 also identified swallowing difficulty and included an intervention to provide thin liquids via spoon. A community complaint and video footage from the resident’s room showed that during an overnight shift, a nurse gave the resident a drink using a straw while the resident was lying down and continued to provide liquids while the resident was coughing, contrary to the physician’s order and care plan. The DON confirmed, after reviewing the video, that the nurse provided thin liquids with a straw while the resident was not upright and continued despite the resident’s coughing. The facility also failed to follow a physician’s order related to monitoring for possible aspiration. A physician’s order dated 3/19/2026 directed staff to obtain and document the resident’s vital signs, including lung sounds, oxygen saturation, temperature, and signs and symptoms of aspiration such as coughing or runny nose, every shift for seven days. Review of the March 2026 Medication Administration Record showed that vital signs were not obtained during the 3:00 PM–11:00 PM and 11:00 PM–7:00 AM shifts on 3/23/2026, and the 11:00 PM–7:00 AM shift on 3/24/2026. In an interview, the DON stated she expected vital signs to be obtained and documented each shift as ordered and acknowledged that the facility failed to ensure physician orders were followed for this resident.
Failure to Protect a Resident From Verbal Abuse by Nursing Assistant
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a nursing assistant. The resident was admitted with diagnoses including hypertension and had an admission MDS Brief Interview for Mental Status score of 15/15, indicating intact cognition. On the evening in question, after the resident used the call light for toileting assistance, Nursing Assistant Staff A entered the room and yelled, "I'm not playing games with you tonight, you keep pressing the call light, and I told you to wait." The resident reported being upset by this interaction. A Nursing Supervisor, Staff B, who was on duty at the time, responded to the resident’s room after hearing Staff A yelling and observed the resident to be visibly upset. An LPN, Staff C, provided a written statement indicating she heard Staff A speaking in a very rude tone and yelling, "I told you to wait, I was with another resident." Staff A’s own written statement acknowledged that she spoke back to the resident loudly. During an interview with the Administrator and the Director of Nursing Services, they acknowledged the findings and were unable to provide evidence that the resident was free from verbal abuse during this incident, in contrast to the facility’s abuse prohibition policy defining verbal abuse as disparaging or derogatory oral, written, or gestured language within a resident’s hearing.
Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s representative of a significant change in condition, specifically an injury of unknown origin resulting in right ankle fractures. The facility’s policy dated 10/19/2023 requires responsible family members or legal representatives to be notified as soon as possible, or within 24 hours, of any changes in the resident’s condition, including significant physical changes and any accidents resulting in injury, with documentation of such notification in the medical record. The resident, admitted in October 2025 with Alzheimer’s disease and receiving hospice services, was observed on 3/9/2026 by an RN to be grimacing after being brought to the dining room, and further assessment revealed swelling and bruising of the right ankle. An x-ray was ordered and later confirmed acute to subacute fractures of the medial malleolus with displacement and a moderately displaced fracture of the lateral malleolus. A subsequent progress note by a nurse practitioner documented the fracture findings and included an order to contact hospice and the resident’s representative to review the results. However, record review did not show any evidence that the resident’s representative was notified by the facility of the injuries, nor was there documentation of such notification in the medical record as required by policy. During interviews, the resident’s representative stated that they were not notified by the facility and instead learned of the injuries from hospice staff. The RN who first identified the bruising and swelling acknowledged that she did not notify the resident’s representative. The Director of Nursing Services was unable to provide evidence that the resident’s representative was immediately notified when the injuries were identified, confirming the failure to follow the facility’s notification policy.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the Rhode Island Department of Health (RIDOH) for a resident with Alzheimer's disease who was non-ambulatory, dependent on staff for all transfers, and had severe cognitive impairment. The resident, who was on hospice services, was brought to the dining room by staff and was later observed grimacing, with swelling and bruising to the right ankle. An x-ray obtained that evening confirmed acute to subacute fractures of both the medial and lateral malleolus with displacement. A subsequent nurse practitioner note documented the fracture findings and included an order to contact hospice and the resident's representative, but the clinical record did not identify a cause for the injury, classifying it as an injury of unknown origin. Record review also failed to show that this injury of unknown origin was reported to RIDOH. During interviews, a hospice aide reported that after lunch she provided care to the resident in the room, accompanied by two CNAs. She stated the resident was not in discomfort before care, but became agitated during care and flailed upper and lower extremities, while one CNA held the resident's legs and another held the resident's arms; she did not stop care or notify the nurse of the resident's behavior. After care, the resident was transferred to a chair and returned to the dining room, and the aide later learned of the swollen ankle after returning from lunch, without knowing how the injury occurred. The RN on duty at the time of injury identification was unable to provide evidence that the injury of unknown origin was reported to RIDOH, and the Director of Nursing Services acknowledged that the facility did not report the injury to RIDOH, confirming the failure to report the alleged violation and injury of unknown origin as required.
Failure to Investigate Injury of Unknown Origin and Identify Cause of Ankle Fractures
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an injury of unknown origin for a non-ambulatory resident with Alzheimer’s disease who was dependent on staff for all transfers and had severe cognitive impairment. The resident, who was on hospice services, was brought to the dining room by staff and later exhibited grimacing, with swelling and bruising noted to the right ankle. An x-ray obtained the same day confirmed acute to subacute displaced fractures of both the medial and lateral malleolus. Although the nurse on duty notified the provider and obtained the x-ray order, the clinical record lacked documentation of any investigation into how the injury occurred, any determination or discussion of potential causes, or identification of the origin of the fractures. Surveyor interviews revealed that a hospice aide, accompanied by two CNAs, had taken the resident to the room after lunch to provide care. During care, the resident, who had not shown discomfort beforehand, became agitated and flailed upper and lower extremities while one CNA held the resident’s legs and another held the resident’s arms; care was continued despite the agitation, and the nurse on duty was not notified of this behavior. After care, the resident was transferred to a chair and returned to the dining room, and the hospice aide later learned of the swollen ankle but did not know how the injury occurred. The RN who discovered the swelling and bruising, the DON, and the NP all acknowledged there was no thorough investigation, no documentation establishing the origin of the injuries, and no evidence of implemented measures to prevent further or potential injury, and the facility could not provide investigative findings or evidence of required reporting.
Fatal Medication Error Due to Failure to Verify Resident Identity
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a Certified Medication Technician (CMT) administered another resident’s medications without verifying identity. On the evening medication pass, the CMT, identified as Staff A, entered the wrong room and gave clozapine 150 mg and melatonin 3 mg, which were prescribed for a different resident, to Resident ID #1. This administration occurred despite a facility policy requiring staff to verify resident identity using methods such as checking an identification band, reviewing a photograph attached to the medical record, and, if necessary, confirming identity with other personnel. All patient identifiers were missed, and the resident did not receive his or her regularly scheduled medications, including warfarin 0.5 mg and metoprolol 12.5 mg. Resident ID #1 had been admitted in October 2025 with diagnoses including congestive heart failure and atrial fibrillation and was over a specified advanced age. A recent MDS assessment showed moderately impaired cognition with a Brief Interview for Mental Status score of 10 out of 15. The resident weighed 79.2 pounds, and the provider documented that the clozapine dose administered in error was a significant concern given the resident’s small body habitus. Record review confirmed there were no physician orders for clozapine 150 mg or melatonin 3 mg for this resident. Following the medication error, progress notes documented that late on the night of the error, the LPN (Staff B) recorded that the resident had received another resident’s medications and had missed his or her own scheduled warfarin and metoprolol. The next morning, staff found the resident unresponsive with abnormal breathing, pale skin, a heart rate of 136 bpm, and an oxygen saturation of 90%, prompting transfer via EMS. EMS records described the resident as unresponsive with audible gurgling, excessive oral secretions requiring suctioning, a fast and irregular heart rate between 150–190 bpm, and severely depressed respirations requiring bag-valve-mask support and IV emergency heart medication. Hospital records documented elevated heart rate, shortness of breath, altered mental status, profound hypothermia, a chest x-ray showing a small left pleural effusion and aspiration pneumonia, and subsequent transition to end-of-life care, with the resident expiring several days later. During interviews, the DON could not demonstrate that the resident was kept free from significant medication errors, and the Medical Director stated she would have expected the correct medications to be administered to the right resident.
Failure to Ensure CMT Medication Competency and Required Quarterly Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a Certified Medication Technician (CMT) had the required competencies and quarterly evaluations to safely administer medications, as required by Rhode Island regulations. State regulations mandate that medication technicians must complete a State‑approved course, demonstrate competency in drug administration, and receive quarterly evaluations by the Director of Nursing (DON) or RN designee, with documentation placed in personnel files. The facility’s own assessment stated that department‑specific training and competencies are completed throughout employment to ensure staff can safely and competently provide the required care. However, review of the CMT’s personnel record showed she was hired as a CMT/Nursing Assistant and had only one medication administration evaluation since hire, with no evidence of the four required quarterly evaluations. Record review of the CMT’s “Medication Administration Competency” document showed no evidence that she had demonstrated competency in identifying a resident prior to medication administration. Despite this, she was scheduled to administer medications periodically. On the evening in question, the CMT entered the wrong room and administered medications intended for another resident to Resident ID #1, without verifying the resident’s identity and missing all patient identifiers. The medications administered in error included clozapine 150 mg and melatonin 3 mg, which were prescribed for another resident. Resident ID #1 had been admitted in October 2025 with diagnoses including congestive heart failure and atrial fibrillation and was over a specified advanced age. Following the medication error, a provider note documented that the CMT had administered the wrong medications by entering the wrong room and failing to verify identity, and that the clozapine dose was of significant concern given the resident’s low body weight of 79.2 pounds. The resident subsequently presented to the hospital with elevated heart rate, shortness of breath, and altered mental status, was found to have profound hypothermia, a small left pleural effusion, and aspiration pneumonia, and was admitted for inpatient comfort measures only. The resident later expired. The DON acknowledged that medication aide evaluations are required at least quarterly and was unable to provide evidence that the CMT had demonstrated competency in medication administration per state requirements.
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