Saint Elizabeth Home East Greenwich
Inspection history, citations, penalties and survey trends for this long-term care facility in East Greenwich, Rhode Island.
- Location
- 1 Saint Elizabeth Way, East Greenwich, Rhode Island 02818
- CMS Provider Number
- 415010
- Inspections on file
- 33
- Latest survey
- November 28, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Saint Elizabeth Home East Greenwich during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering entered another resident's room and was found in a compromising situation, while the required motion sensor alarm meant to alert staff was not activated. The incident occurred despite care plans and physician orders for safety interventions, and documentation confirming the alarm's use was missing. Staff confirmed the alarm was not functioning at the time of the event.
A resident with a history of physical aggression and severe cognitive impairment physically assaulted another cognitively impaired resident in the dining room when no staff were present. The victim sustained bruises and scratches, and the incident was unprovoked. The facility's lack of supervision and failure to prevent the altercation resulted in a deficiency related to resident protection from abuse.
The facility was found deficient in food storage and labeling practices, with multiple instances of improperly labeled or unlabeled food items in various kitchens. Additionally, equipment food contact surfaces, such as microwaves, were not maintained clean, with accumulations of food matter and debris observed. The Director of Dining Services acknowledged these issues, indicating a failure to adhere to the facility's food service policy and cleaning schedule.
Two residents did not receive care according to physician's orders, as a nurse failed to administer prescribed nutritional supplements and monitor blood pressure during medication administration. Despite this, the MAR inaccurately documented that these tasks were completed. The DON expected adherence to physician's orders.
A resident with a history of confusion eloped from a facility after staff failed to supervise adequately and disabled door alarms. The resident was found on a main road, confused and cold, and was taken to a hospital. Staff did not notice the resident's absence until the next morning, and the family was not informed until after emergency services had located the resident. The facility's missing resident policy was not followed, and the Director of Nursing Services acknowledged the failure to provide adequate supervision.
A resident eloped from the facility unsupervised, leading to an Immediate Jeopardy citation. The resident was unaccounted for approximately 10 hours and was found on a busy roadway. Staff failed to follow the missing resident policy, did not notify family or police timely, and did not respond to alarms. The facility's Administrator acknowledged that the alarms had been turned off by staff, contributing to the incident.
A resident with severe cognitive impairment and dysphagia, requiring a pureed diet, was given a regular textured cookie by a staff member, leading to a fatal choking incident. Despite immediate intervention, the resident expired. The staff member acknowledged the error, and the Director of Nursing confirmed the resident was given food not in the prescribed form.
A resident with dementia pinched another resident with Alzheimer's, causing a skin tear that required treatment. Staff confirmed the incident occurred during an attempt to separate the residents after one tried to touch the other's food. Both residents were unable to recall the event due to impaired cognition, and the facility failed to provide evidence of protection from abuse.
A resident with Alzheimer's and diabetes suffered a skin tear after being pinched by another resident. Despite a physician's order for wound care, the facility failed to document the wound's size, edges, and surrounding tissue condition. Interviews with the Unit Manager and DON confirmed the lack of proper documentation.
Failure to Protect Resident from Abuse Due to Inactive Safety Interventions
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse during a resident-to-resident incident. On the morning of the incident, a nursing assistant found one resident on top of another in a private room, with the resident on top disrobed from the waist down and making thrusting motions, while the other resident was fully clothed. The incident was discovered during routine rounds, and both residents were separated and assessed. The resident who was found on the bottom had severe cognitive impairment, a history of wandering, and had previously entered other residents' rooms, including the room of the resident involved in this incident. The care plan for this resident included interventions such as monitoring whereabouts, redirecting from other rooms, and placing a stop sign at the doorway to deter entry. The resident whose room was entered had a diagnosis of dementia but was cognitively intact according to recent assessments. This resident's care plan included a motion sensor at the door to alert staff if someone entered the room, as well as a stop sign to deter entry. Previous nursing notes documented prior incidents of the wandering resident entering this room and touching the resident inappropriately, which led to the implementation of the motion sensor and stop sign interventions. Physician orders required the motion sensor to be plugged in at a specific time each morning and unplugged at night, with documentation in the treatment administration record (TAR). On the day of the incident, staff interviews and record reviews revealed that the motion sensor alarm was not plugged in as ordered, and there was no documentation in the TAR to confirm it was activated. Staff who responded to the incident noted that the alarm did not sound when they entered the room, and the Director of Nursing confirmed that the sensor was not plugged in at the time. There was no evidence provided that the resident was kept free from abuse, as required by facility policy and regulatory standards.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident with a known history of physical aggression struck another resident multiple times in the face while in the dining room. At the time of the incident, both residents, who had severe cognitive impairment and dementia, were seated at opposite ends of a table. The aggressor resident became physically violent without provocation, and staff were not present in the dining room when the incident began, as one had just left to assist with care elsewhere. The incident was witnessed by a hospice RN who intervened and called for additional staff. Following the altercation, the victim was assessed and initially showed no visible injuries. However, a subsequent skin assessment revealed multiple bruises and scratches on the victim's hands and forearms, consistent with defensive wounds. The victim, who was unable to recall the incident due to cognitive impairment, was otherwise calm and in good spirits during later observations. The aggressor was sent for a psychiatric evaluation after the event. The facility's abuse prohibition policy requires that all residents be free from abuse, including physical harm. Despite the known behavioral history of the aggressor and interventions in place, the lack of staff supervision in the dining room at the time of the incident allowed the abuse to occur. The facility was unable to provide evidence that the victim was kept free from abuse, as required by policy.
Deficiencies in Food Storage and Equipment Cleanliness
Penalty
Summary
The facility failed to ensure proper food storage and labeling practices in accordance with professional standards for food service safety. During an inspection, surveyors observed multiple instances of improperly labeled or unlabeled food items in the main kitchen, kitchenettes, and house kitchens. These included sliced lemon wedges, frozen waffles, bagels, fish sticks, cooked chicken legs, pasta, eggplant parmesan, diced tomatoes, ice cream with freezer burn, and English muffins past their sell-by date. The Director of Dining Services acknowledged these findings and confirmed that the items should have been labeled, dated, and discarded as per the facility's food service policy and regulations. Additionally, the facility did not maintain cleanliness of equipment food contact surfaces as required. Surveyors found microwaves in several units with accumulations of dried food matter and greasy residue, as well as a freezer drawer with food particles and debris. The Director of Dining Services noted that the Shahbaz staff, responsible for cleaning these areas, were expected to follow a weekly cleaning schedule, which was not adhered to, resulting in the observed deficiencies.
Failure to Administer Supplements and Monitor Blood Pressure
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, specifically in following physician's orders for nutritional supplements and blood pressure monitoring. Resident ID #6, who was admitted with diagnoses including dementia and diabetes, had physician's orders for a house supplement and Pro-Stat AWC for weight loss and wound care, respectively. During a surveyor observation, RN Staff A was seen administering morning medications to Resident ID #6 but did not administer the prescribed supplements. Despite this, the February 2025 Medication Administration Record (MAR) indicated that the supplements were documented as administered by RN Staff A. Similarly, Resident ID #54, with diagnoses including dementia and hypertensive heart disease with heart failure, had physician's orders for furosemide and Pro-Stat AWC, with instructions to monitor blood pressure. During the same observation, RN Staff A administered furosemide but did not administer the supplement or obtain the resident's blood pressure. The MAR inaccurately documented that the supplement was given and the blood pressure was recorded. In an interview, RN Staff A admitted to not administering the supplements or obtaining the blood pressure, despite documenting otherwise. The Director of Nursing Services expressed that it was expected for nurses to follow physician's orders.
Resident Elopement Due to Inadequate Supervision and Disabled Alarms
Penalty
Summary
The facility failed to ensure adequate supervision and safety for a newly admitted resident, leading to an elopement incident. The resident, who had a history of confusion and forgetfulness following a hospital stay for a brain hemorrhage, was last seen by staff between 8:00 PM and 9:00 PM. Despite the resident's known condition, staff did not maintain proper supervision, and the resident was able to leave the facility unnoticed. The door alarms, which should have alerted staff to the resident's departure, were turned off by staff members, allowing the resident to exit the building without detection. The resident was found by a newspaper delivery person on a main road, confused and inadequately dressed for the cold weather, and was taken to a police station before being transferred to a hospital for evaluation. The facility's staff failed to notice the resident's absence until the following morning, and the family was not informed until after the resident had already been located by emergency services. The facility's missing resident policy, which includes notifying the family and police within 30 minutes of discovering a resident is missing, was not followed. Interviews with staff revealed a lack of communication and adherence to protocols. The charge nurse on duty during the night shift did not conduct rounds or check on the resident, and the staff failed to respond to door alarms. The facility's Director of Nursing Services acknowledged that the staff did not follow the missing resident policy and could not provide evidence of adequate supervision to prevent the elopement. This deficiency placed the resident at risk for harm due to exposure to cold weather and confusion, as well as potential injury from being unsupervised outside the facility.
Resident Elopement Due to Policy Non-Compliance and Alarm Failure
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in the elopement of a resident, which led to an Immediate Jeopardy citation. The resident was last seen by staff at approximately 8:00 PM and was later found unsupervised on a busy roadway at 4:00 AM by a passerby. The facility's policy for a missing resident was not followed, as staff failed to notify the family and police in a timely manner. The resident was unaccounted for approximately 10 hours, and the staff did not respond to any alarms during the night shift. The facility's Director of Nursing Services and Administrator acknowledged that the resident eloped unsupervised, despite the presence of alarmed doors that should have been activated. It was revealed that the alarms had been turned off by staff, and no alarms were responded to during the night shift. The Administrator admitted that the facility staff did not follow the missing resident policy, and the resident was seen on another facility's video footage at 2:31 AM. The incident highlighted a significant lapse in the facility's procedures and staff actions, leading to the resident's elopement and subsequent Immediate Jeopardy citation.
Failure to Provide Appropriate Diet Texture Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a resident received food in the appropriate form, leading to a fatal choking incident. The resident, who had severe cognitive impairment and required a mechanically altered diet of pureed texture due to dysphagia, was given a regular textured oatmeal chocolate chip cookie by a staff member. This was contrary to the resident's dietary requirements as outlined in their care plan and physician's orders. The incident occurred during a dinner meal when the resident was observed choking, and despite immediate intervention with the Heimlich maneuver and the arrival of EMS, the resident expired. The deficiency was identified through a combination of record reviews, staff interviews, and surveyor observations. The staff member involved acknowledged the error, stating it was an accident and that they were aware of the dietary requirements documented in a binder available in the dining room. The Director of Nursing Services confirmed that the resident expired while eating a cookie that was not in pureed form. The incident highlights a critical lapse in adhering to dietary protocols for residents with specific dietary needs, resulting in a tragic outcome.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents. Resident ID #1, who has a diagnosis of dementia and severely impaired cognition, pinched Resident ID #2 on the leg, causing a skin tear. This incident occurred while Resident ID #2, who has Alzheimer's disease and severely impaired cognition, was being assisted out of a chair. The pinching incident was reported to the Rhode Island Department of Health, and the resulting skin tear required medical treatment for 22 days. Interviews with staff, including a Nursing Assistant and the Unit Manager, confirmed that Resident ID #1 pinched Resident ID #2 during an attempt to separate the two residents after Resident ID #2 attempted to touch Resident ID #1's food. Both residents were unable to recall the incident due to their impaired cognition. The Director of Nursing Services acknowledged the incident and was unable to provide evidence that Resident ID #2 was kept free from physical abuse, highlighting a deficiency in the facility's ability to protect residents from abuse.
Failure to Document Wound Care Properly
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive care plan. The resident, who was readmitted to the facility with Alzheimer's disease and type II diabetes, suffered a skin tear after being pinched by another resident. A physician's order was issued to treat the wound with normal saline, xeroform, and a foam dressing every three days. However, the facility did not document the wound's size, edges, wound bed, shape, or the condition of the surrounding tissue as required by regulations. The deficiency was further highlighted during interviews with the Unit Manager and the Director of Nursing Services, who both acknowledged the lack of proper documentation. The Unit Manager described the wound as a flap of skin that bled initially, but confirmed that no measurements or identifying characteristics were recorded. The Director of Nursing Services also confirmed the absence of documentation for the skin tear on the specified dates. An interview with the resident was attempted, but the resident was unable to recall the incident due to impaired cognition.
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 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 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 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 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 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 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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