Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Silver Creek Rehab And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to obtain written authorization for residents who deposited personal funds with the facility. Four residents had facility-held balances, but record review showed missing authorization evidence for three residents and an incomplete form for one resident, including absent date, resident name, Medicaid number, and witness signature. The BOM could not provide completed authorization forms for the affected residents.
Failure to follow physician orders affected three residents. One resident’s simvastatin for cholesterol control was discontinued without a documented provider order or rationale, another resident’s ordered weekly weights were not obtained and the order was incorrectly transcribed, and an RN applied Triad cream to a resident’s buttocks rash instead of the ordered triple antibiotic ointment.
Expired drugs and biologicals were found in the central supply area and in medication carts. Surveyors observed expired Prosource TF liquid, Pink Bismuth, Gerimox, Nitroglycerin tablets prescribed for a resident, and Gerilanta, and an LPN acknowledged the expired items should have been discarded. The DON stated the items should have been removed upon expiration.
Failure to provide privacy during a skin treatment. A resident admitted with erythema intertrigo was observed lying in bed with only a towel over the pelvic area while a RN left the door open and the privacy curtain only partially closed to retrieve a treatment cart from the hallway. The resident remained visible from the hallway, including when the RN exited the room with the resident still wearing only a brief and pants around the ankles. The RN acknowledged the privacy issue, and the DON stated the curtain should have been fully drawn.
Inaccurate MDS coding failed to reflect the status of two residents with dental concerns and one resident receiving clozapine. One resident had broken and missing teeth documented in a dental consult, another was edentulous, yet their MDS dental sections did not match their status and the care plans did not reflect the dental issues. A third resident had a clozapine order for schizophrenia/depression, but the MDS did not code the resident as receiving an antipsychotic; the DON acknowledged the assessments were inaccurate.
A resident with erythema intertrigo had a raised, circular diffuse fungal rash on the right buttocks. The Wound Care NP recommended cleansing the area and applying nystatin cream BID, but the record did not show the antifungal was implemented. The attending MD expected the recommendation to be carried out, and the DON could not provide evidence that it was.
A resident with generalized muscle weakness and impaired upper extremities had a physician order for a daily left-hand roll, but surveyors observed the device was not applied on multiple occasions. The assigned RN said she was unaware of the order and acknowledged it was not transcribed to the TAR, and the DON confirmed the omission.
Unnecessary topical wound treatment remained ordered after a resident's wound had resolved. A resident admitted with generalized muscle weakness had Santyl ointment, calcium alginate, and a bordered gauze dressing ordered for a Stage III pressure ulcer on the left medial knee. The Wound Care NP documented the wound was resolved and recommended stopping the treatment, but staff still observed a dressing in place and the TARs did not show Santyl was discontinued; the MD stated the order should have been stopped after the NP's recommendation.
A resident with schizophrenia had an order for clozapine and a clozapine level, but the lab obtained a clonazepam blood level instead. The TAR showed the clozapine level as completed, yet the lab report confirmed the wrong test was performed, and the DON and NP acknowledged the error.
Failure to maintain sanitary technique during resident treatments. An RN applied topical cream to multiple body sites without changing gloves or performing hand hygiene between areas, moving from a dirtier area to a cleaner area. The same RN also treated a resident’s wound and skin tear while wearing double gloves, removed only the outer pair, and continued the treatment without removing all gloves, performing hand hygiene, or donning clean gloves before applying the dressing; the DON stated staff would be expected to change gloves and perform hand hygiene between treatments.
Survey Results Not Readily Accessible: The facility failed to post the results of the most recent surveys in a place readily accessible to residents, family members, and legal representatives. Surveyors observed that the results were not available without staff assistance, and a front desk attendant stated the binder was kept inside the front desk office. The Administrator stated he was unaware the survey results were supposed to be available without asking for staff assistance.
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.
Failure to Obtain Written Authorization for Resident Personal Funds
Penalty
Summary
The facility failed to obtain written authorization from residents who chose to deposit personal funds with the facility for 4 of 7 residents reviewed. Resident IDs 2, 6, 77, and 111 each had personal funds held by the facility, with balances of $425.17, $603.75, $2,265.68, and $2,607.32, respectively. Record review showed no evidence that a written authorization was obtained from the resident or representative for Residents 2, 77, and 111, and for Resident 6 there was no completed authorization form including the date, resident's name, Medicaid number, and witness signature. During interview, the Business Office Manager was unable to provide evidence that the authorization forms were completed in their entirety for the residents whose personal funds were held by the facility.
Failure to Follow Physician Orders for Medication, Weights, and Skin Treatment
Penalty
Summary
The facility failed to ensure services met professional standards of quality when it did not follow physician orders for three residents. One resident with hyperlipidemia was ordered simvastatin 10 mg at bedtime for cholesterol control, but the medication was discontinued without evidence of a provider order or documented rationale. The record also did not show evidence that a lipid panel had been obtained, and the RN and DNS were unable to explain why the medication had been stopped. The DNS later stated the simvastatin had been discontinued in error, and the physician then ordered a lipid panel. A second resident had a physician order for weekly weights after a 10-pound weight gain in one month, but the weight record did not show that weekly weights were obtained as ordered. The order was also incorrectly transcribed as weekly weights every 4 weeks. A third resident with erythema intertrigo had an order to cleanse the buttocks with normal saline, apply triple antibiotic ointment, and cover with a dry sterile dressing, but during observation an RN applied Triad cream instead of the ordered ointment. The RN acknowledged the wrong treatment was applied, and the DNS confirmed there was no treatment order for Triad cream.
Expired medications and supplies found in central storage and medication carts
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with currently accepted professional principles in the facility’s central medication supply area and in medication carts. Surveyors observed expired items in the first-floor central supply area, including one unopened box and one opened box of Prosource Tube Feeding liquid, three bottles of Pink Bismuth, and two bottles of Gerimox, all with expiration dates that had passed or were listed as expired. During the observation, an LPN acknowledged that these items were expired and should have been discarded. Surveyors also observed expired medication in medication carts. In the East and South Unit medication carts, a bottle of Nitroglycerin 0.4 mg tablets prescribed for a resident was found with an expiration date that had passed, and the LPN present acknowledged it should be discarded. In the lower-level medication cart, a bottle of Gerilanta 12 fluid ounces was observed with an expiration date of 11/2025. The DON stated it was her expectation that the items would have been removed from central supply and medication carts upon expiration.
Failure to Provide Privacy During Skin Treatment
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity by not providing privacy during a skin treatment. The resident was admitted in May 2023 with a diagnosis that included erythema intertrigo. During surveyor observation on 1/23/2026 at 11:45 AM, a RN was observed treating the resident while the resident lay on his/her back in bed with only a towel draped over the pelvic region and the rest of the body exposed. The RN walked from the bedside to the doorway to retrieve the treatment cart from the hallway, leaving the resident's door completely open and the privacy curtain only partially closed, making the resident visible from the hallway. The RN then returned to complete the treatment and exited the room, leaving the resident wearing only a brief with pants around his/her ankles, with the door still open and the resident visible to staff walking by in the hallway. In interview immediately after the observation, the RN acknowledged the curtain was only partially closed and the door was completely open. The DON later stated the privacy curtain should have been drawn completely to provide privacy.
Inaccurate MDS Coding for Dental Status and Antipsychotic Use
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected residents’ status for two residents with dental concerns and one resident prescribed clozapine. Resident ID #6 was readmitted with diagnoses including type 2 diabetes mellitus, dysphagia, and need for assistance with personal care. During surveyor observation and interview, the resident stated having dental concerns and showed several broken or missing teeth. A dental consult documented eight missing teeth and three broken teeth, but the annual MDS Section L indicated no oral or dental problems, including broken natural teeth. The record also did not show that the resident’s dental status was accurately reflected in the care plan. Resident ID #9 was admitted with muscle weakness and told the surveyor s/he was edentulous. However, the admission MDS Section L was coded as unable to examine and did not indicate edentulous status, and the admission/readmission evaluation also documented the oral cavity as unable to examine. The record did not show that the resident’s dental status was accurately reflected in the care plan. Resident ID #27, who had diagnoses including schizophrenia and depression, had a physician’s order for clozapine 75 mg every evening, but the annual MDS Section N did not code the resident as receiving an antipsychotic medication. The DON acknowledged that the resident’s MDS assessments were coded inaccurately and did not reflect the resident’s status.
Failure to Implement Ordered Antifungal Treatment for Fungal Rash
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice to promote and maintain skin integrity for one resident with a fungal rash. The resident was admitted with diagnoses including erythema intertrigo. A Wound Care Nurse Practitioner documented a recommendation to cleanse the area with wound cleanser and apply nystatin cream twice daily to the resident’s right buttocks fungal rash, and an RN documented that the resident had a raised, circular diffuse area on the right buttocks consistent with a fungal rash during wound rounds. However, the record did not show that the recommended nystatin cream was implemented. During interviews, the attending physician stated he would have expected staff to carry out the Wound Care Nurse Practitioner’s recommendation, and the DON was unable to provide evidence that the nystatin cream had been implemented.
Failure to Apply Ordered Hand Roll
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received the ordered treatment to help maintain or improve ROM. The resident was admitted in October 2020 with diagnoses including generalized muscle weakness, and a Quarterly MDS assessment showed impairment to both upper extremities. A physician's order revised on 10/31/2025 directed staff to apply a left-hand roll daily for the resident. Surveyor observations did not show the hand roll in place on multiple occasions on 1/20/2026, 1/21/2026, and 1/22/2026. During interview, the assigned RN stated she was unaware of the physician's order for the hand roll and acknowledged that the order was not transcribed to the TAR. A CNA later applied the hand roll during observation, and the resident tolerated it and maintained the device in place. The DON also acknowledged that the order was not transcribed to the TAR and stated she would expect it to be there for daily documentation of application.
Unnecessary topical wound treatment remained ordered after wound resolved
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs when a topical wound treatment remained in place after the wound had resolved. The resident was admitted in January 2025 with generalized muscle weakness and had a physician's order starting 10/16/2025 for Santyl Ointment, calcium alginate, and a bordered gauze dressing to the left medial knee for a Stage III pressure ulcer. A Wound Care Nurse Practitioner note dated 12/18/2025 documented that the left medial knee wound was resolved and recommended discontinuing the treatment order. However, during observation on 1/22/2026, the resident still had a dressing to the left medial knee, and the RN acknowledged the wound was closed but the treatment order remained in place. Review of the December 2025 and January 2026 TARs did not show that Santyl was discontinued as recommended, and it was signed off as completed for 30 of 34 opportunities. The resident's physician stated he would expect staff to follow the Wound Care Nurse Practitioner's recommendations and that Santyl should have been discontinued after the 12/18/2025 recommendation.
Incorrect Laboratory Test Obtained Instead of Ordered Clozapine Level
Penalty
Summary
Provide timely, quality laboratory services/tests to meet the needs of residents was not met for Resident ID #27, who was admitted in May 2023 with schizophrenia and had a physician order for clozapine 75 mg daily and a clozapine level to be obtained. The December 2025 Treatment Administration Record showed the clozapine level was signed off as completed, and the lab slip dated 12/12/2025 listed additional testing for a clozapine level. However, the Lab Results Report for that date showed that a clonazepam blood level was obtained instead of the ordered clozapine level. During interviews, the DON acknowledged that the laboratory completed a clonazepam level and not a clozapine level as ordered, and the NP stated it was her expectation that the clozapine level would have been obtained as ordered.
Failure to Maintain Hand Hygiene and Glove Changes During Treatments
Penalty
Summary
The facility failed to ensure a sanitary environment during treatments for 2 residents. Resident #27 was admitted in May 2023 with a diagnosis including erythema intertrigo. During observation on 1/23/2026 at approximately 10:45 AM, RN Staff A applied Triad cream to the resident’s left and middle buttocks, groin, and armpit without changing gloves or performing hand hygiene between applications. The nurse moved from the dirtiest area to the cleanest area of the resident’s body. Resident #122 had physician’s orders for daily treatment of a right posterior calf wound and a right forearm skin tear. During observation on 1/23/2026 at 11:38 AM, Staff A wore two pairs of gloves on each hand, removed the soiled dressing from the right lower leg, and cleansed the wound. She then removed only the outer pair of gloves and continued the treatment without removing all gloves, performing hand hygiene, or putting on new clean gloves before applying the clean dressing. In interview immediately afterward, Staff A acknowledged that she removed only the outer pair of gloves and did not perform hand hygiene until after completing the treatment. The DNS stated she would expect staff to change gloves and perform hand hygiene when applying the cream to different sites and to remove gloves and perform hand hygiene before applying the new treatment.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to post the results of the most recent surveys in a place readily accessible to residents, family members, and legal representatives of residents. During a surveyor observation on 1/20/2026 at approximately 9:00 AM, the survey results were not available to be reviewed without asking for staff assistance. During an interview on 1/22/2026 at 11:33 AM, the front desk attendant stated that the survey results binder was kept in the rack inside the front desk office. During an interview on 1/23/2026 at 12:48 PM, the Administrator stated that he was unaware the survey results were supposed to be available without asking for staff assistance.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bristol
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Dawn Hill Home For Rehab And Healthcare | 0.7 mi | ★★★★★ | 9 | 0 |
| Warren Operations Ri, Llc Dba Warren Center | 2.4 mi | ★★★★★ | 13 | 0 |
| Grace Barker Nursing Center | 3.4 mi | ★★★★★ | 4 | 0 |
| Crestwood Nursing & Rehabilitation Center Inc | 3.8 mi | ★★★★★ | 3 | 0 |
| Mill Brook Rehabilitation And Healthcare Center | 5.5 mi | ★★★★★ | 0 | 0 |
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