Silver Creek Rehab And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bristol, Rhode Island.
- Location
- 7 Creek Lane, Bristol, Rhode Island 02809
- CMS Provider Number
- 415031
- Inspections on file
- 27
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Silver Creek Rehab And Healthcare Center during CMS and state inspections, most recent first.
A fire occurred in a resident's room due to improper clearance between a reclining chair and an electric baseboard heater. The facility failed to maintain the required 6-inch clearance, leading to charring on the chair and wall. Despite the fire, many rooms still had combustible items too close to heaters, posing a risk to residents.
The facility failed to provide proper ostomy care for three residents, leading to issues such as peristomal skin breakdown, inconsistent appliance sizing, and a lack of documented treatment plans. One resident experienced pain and bleeding due to an improperly sized appliance, while another had a prolapsed stoma without proper treatment documentation. Staff interviews revealed inconsistencies in care and a lack of communication with physicians.
The facility failed to maintain proper infection control practices for Enhanced Barrier Precautions (EBP) and COVID-19 precautions. A resident with an MDRO did not receive care with the required PPE, as staff were unsure about EBP requirements. Another resident with COVID-19 was not protected by full PPE use, as a staff member entered the room without eye protection. Interviews confirmed a lack of adherence to infection control guidelines.
A facility failed to provide necessary treatment and services for a resident with deep tissue injuries (DTIs) on both heels. Despite a care plan and physician's order for daily skin prep, the facility did not document weekly assessments of the DTIs, including measurements, staging, exudate, pain, wound bed, or wound edges. Interviews with an LPN and the DON confirmed the lack of documentation for three consecutive weeks, contrary to facility policy and expectations.
The facility failed to protect residents from abuse, as a resident with severe cognitive impairment was involved in two incidents of physical abuse. One resident was found with a sheet over their head, and another reported feeling scared of the same perpetrator. Despite these incidents, the facility's staff did not conduct a thorough investigation, and a non-ambulatory resident was moved into the same room as the alleged perpetrator.
A facility failed to investigate an alleged abuse incident involving a resident who reported feeling scared of their roommate, who allegedly put a blanket over their face. Despite being aware of this allegation, the ADNS and a social worker did not conduct an investigation. Subsequently, another incident occurred where the same resident was found on top of another resident, holding a sheet over their face, causing the resident to scream. The second resident, who was severely cognitively impaired and receiving hospice services, was at risk due to the facility's failure to investigate the initial allegation.
A resident with a history of dysphagia and on a minced and moist diet was left unsupervised with whole pizza slices, leading to a fatal choking incident. Despite being aware of the resident's dietary restrictions, staff failed to provide necessary supervision, resulting in the resident's death after unsuccessful resuscitation efforts.
A resident on a minced and moist diet due to dysphagia was given whole pizza slices by another resident, leading to a fatal choking incident. Despite staff awareness, the resident was left unsupervised while eating, resulting in choking. Attempts to clear the airway were unsuccessful, and the resident later died at the hospital. The facility lacked a policy for outside food, contributing to the incident.
A resident with severe cognitive impairment became aggressive during a coloring activity, causing a skin tear on another resident's hand and kicking them. Despite the incident, no interventions were added to the aggressive resident's care plan. The facility's Director of Nursing acknowledged the incident as physical abuse but could not demonstrate that the facility had protected the resident from abuse.
Fire Incident Due to Improper Clearance from Baseboard Heaters
Penalty
Summary
The facility failed to maintain a safe environment for residents, resulting in a fire incident. A nursing assistant discovered a piece of paper on fire in a resident's room, which was unoccupied at the time. The fire was extinguished after a code red was initiated. The fire was attributed to a lack of clearance between a reclining chair and an electric baseboard heater, which was positioned too close to the heater, causing charring on the chair and the wall above the heater. Surveyor observations and interviews revealed that the facility had not ensured the required 6-inch clearance between furniture and electric baseboard heaters, as specified by the manufacturer's instructions. Many resident rooms had combustible items, such as beds, chairs, and bedding, in direct contact with or too close to the heaters. This was observed even after the fire incident, indicating a failure to address the hazard promptly. The residents involved included one with dementia and moderate cognitive impairment, and another with intact cognition. The latter resident reported that furniture had been rearranged in their room, possibly due to cold weather, which led to the unsafe placement of the recliner. The facility's inability to provide evidence of maintaining a hazard-free environment was noted during the surveyor's interviews with the administration.
Deficiencies in Ostomy Care and Documentation
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for three residents with ostomies. Resident ID #99, who was readmitted with a diagnosis including necrotizing fasciitis, experienced pain and bleeding around the stoma site. The record review revealed that the stoma site had mild peristomal skin breakdown due to an improperly sized stoma appliance and inadequate drainage of irrigation fluids. Despite these issues, there was no evidence that the physician was contacted or that a treatment plan was implemented for the skin breakdown. Additionally, there was no documentation indicating when the ostomy appliances should be changed or the type and size of appliances to be used. Resident ID #60, admitted with an ileostomy, also lacked specific orders for changing the ostomy appliance. Interviews with staff revealed inconsistencies in the care provided, with different staff members cutting the appliance to different sizes. The resident was unsure of who changed the ostomy appliances or how often they were changed, indicating a lack of communication and documentation regarding the resident's care plan. Resident ID #24, with a colostomy, had a prolapsed stoma, but there was no evidence that the prescribed treatment of applying granulated sugar was documented as administered. Staff were unable to provide specific information on when the ostomy appliance should be changed, and there was a lack of communication with the physician regarding the treatment plan. The physician was unaware of the prolapsed stoma and the treatment involving sugar, highlighting a significant gap in the coordination of care and communication within the facility.
Inadequate Infection Control Practices for EBP and COVID-19 Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) and COVID-19 precautions. For Resident ID #76, who was readmitted with a diagnosis requiring assistance with personal care and tested positive for an MDRO, staff members were observed not wearing the required personal protective equipment (PPE) such as gowns during high-contact activities like transferring and providing personal care. Despite signage indicating the need for EBP, staff members were unsure about the requirements and mistakenly believed the precautions were for the resident's roommate. Interviews with staff confirmed a lack of understanding and adherence to the EBP guidelines. In another instance, the facility failed to adhere to COVID-19 precautions for Resident ID #78, who tested positive for COVID-19 and was placed on droplet contact precautions. A nursing assistant entered the resident's room without wearing the required eye protection, despite facility signage and expectations for full PPE use, including a gown, gloves, N95 mask, and eye protection. Interviews with staff, including the Director of Nursing Services, confirmed the expectation for full PPE use, highlighting a deficiency in the facility's infection control practices.
Failure to Document and Monitor Deep Tissue Injuries
Penalty
Summary
The facility failed to provide necessary treatment and services to promote wound healing and prevent new ulcers from developing for a resident with a deep tissue injury (DTI). The resident, who was readmitted to the facility with diagnoses including muscle weakness and obesity, had a care plan indicating a risk for impaired skin integrity. The care plan included interventions such as evaluating the wound for size, depth, margins, exudate, edema, granulation, infection, necrosis, eschar, gangrene, and documenting the progress of wound healing on an ongoing basis. Despite a physician's order to apply skin prep to the DTIs on the resident's right and left heels daily, the facility failed to document weekly assessments of the DTIs, including measurements, staging, exudate, pain, wound bed, or a description of wound edges on specified dates. Interviews with a Licensed Practical Nurse and the Director of Nursing Services confirmed the lack of documentation for three consecutive weeks, which was against the facility's policy and the Director's expectations.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by two incidents involving a resident with severe cognitive impairment. The first incident occurred when a resident with dementia, anxiety, and depression was found on top of another resident, who was non-ambulatory and receiving hospice services, with a sheet over their head. This incident was reported to the Rhode Island Department of Health, and it was revealed that the perpetrator had a history of severe cognitive impairment, as indicated by a BIMS score of 4 out of 15. The victim, who had a BIMS score of 0, was dependent on others for all activities of daily living. A second incident involved another resident who reported feeling scared of the same perpetrator, claiming that a blanket was put over their face. This resident, who had intact cognition with a BIMS score of 15, was moved to another room for safety. Despite these allegations, the facility's Assistant Director of Nursing and Social Worker did not conduct a thorough investigation, citing being too busy. The Social Worker also moved the non-ambulatory resident into the same room as the alleged perpetrator, despite the previous accusation of abuse. The Regional Director of Nursing acknowledged the failure to keep the non-ambulatory resident free from abuse.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an alleged abuse incident involving resident-to-resident abuse. On 7/31/2024, Resident ID #3 reported feeling scared of their roommate, Resident ID #1, and alleged that Resident ID #1 had put a blanket over their face. Despite being aware of this allegation, the Assistant Director of Nursing (ADNS) and the Social Worker, Staff C, did not conduct an investigation. Instead, Resident ID #3 was moved to another room for safety reasons. The facility's policy requires immediate reporting and investigation of any suspected abuse, but this was not followed. On 8/1/2024, another incident occurred where Resident ID #1 was found on top of Resident ID #2, holding a sheet over their face, causing Resident ID #2 to scream. Resident ID #2, who was severely cognitively impaired, non-ambulatory, and receiving hospice services, was at risk due to the facility's failure to investigate the initial allegation. Staff B, a Nursing Assistant, witnessed this incident but was unaware of the previous allegation against Resident ID #1. The Regional Director of Nursing acknowledged that no investigation was initiated on 7/31/2024, despite multiple staff members being aware of the initial abuse allegation.
Resident Chokes on Unsupervised Meal
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who required assistance while eating, leading to a fatal choking incident. The resident, who had a history of Barrett's esophagus, hemiplegia, hemiparesis, and dementia, was on a minced and moist diet due to dysphagia and was documented to require supervision during meals. Despite these needs, the resident was left unsupervised with whole pizza slices, which were not part of the prescribed diet, resulting in a choking incident. On the day of the incident, another resident gave the resident two whole pizza slices, which the resident began to eat unsupervised. A registered nurse, aware of the dietary restrictions, attempted to educate the resident about the choking hazards but left the resident alone twice. The resident was later found choking, and despite attempts by staff to perform the Heimlich maneuver and CPR, the resident's airway remained obstructed until EMS arrived and removed the blockage. Unfortunately, the resident did not survive the incident. Interviews with staff and family members revealed that the resident had previously been supervised while eating a specially prepared minced and moist pizza for their birthday. However, on the day of the incident, the lack of supervision and failure to adhere to the resident's dietary restrictions directly contributed to the choking event. The facility's failure to provide the necessary supervision and dietary adherence resulted in the resident's death.
Resident Chokes on Unsupervised Meal, Resulting in Fatality
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 a history of Barrett's esophagus, hemiplegia, hemiparesis, and dementia, was on a minced and moist texture diet due to dysphagia and being edentulous. Despite these dietary restrictions, the resident was given whole pizza slices by another resident, which was not part of the prescribed diet. The resident was left unsupervised while consuming the pizza, which led to a choking incident. The incident occurred when a pizza delivery was made to another resident, who then shared the pizza with the resident in question. A staff member, RN Staff C, was aware that the resident had received whole pizza slices and attempted to educate the resident about the choking hazard. However, the resident reacted defensively, and the staff member left the resident unsupervised twice. During this time, the resident consumed most of the pizza, leaving only the crust, before choking. When the choking incident occurred, staff attempted the Heimlich maneuver and CPR, but were unsuccessful in clearing the airway. EMS was called and continued resuscitation efforts, eventually removing the obstruction, but the resident was pronounced deceased at the hospital. The facility lacked a policy for food brought in from outside, and the Director of Nursing Services acknowledged that the resident should have been supervised while eating the pizza.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving two residents during a coloring activity. Resident ID #5, who has severe cognitive impairment, became agitated and aggressive towards Resident ID #4, who has moderate cognitive impairment. During the altercation, Resident ID #5 grabbed a pen and caused a skin tear on Resident ID #4's hand, which required medical treatment. Additionally, Resident ID #5 was observed kicking Resident ID #4 in the legs. The incident was reported to the Rhode Island Department of Health, and the facility's policy on abuse prohibition was not effectively implemented to prevent this occurrence. The facility's records revealed that Resident ID #4 was admitted with dementia and anxiety, while Resident ID #5 was admitted with dementia and depression. Despite the incident, there was no evidence of interventions being put in place in Resident ID #5's care plan to address the physical aggression. The Director of Nursing Services acknowledged the incident as physical abuse according to the facility's policy but could not provide evidence that the facility had kept Resident ID #4 free from such abuse.
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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