St Antoine Residence
Inspection history, citations, penalties and survey trends for this long-term care facility in North Smithfield, Rhode Island.
- Location
- 10 Rhodes Avenue, North Smithfield, Rhode Island 02896
- CMS Provider Number
- 415106
- Inspections on file
- 29
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at St Antoine Residence during CMS and state inspections, most recent first.
The facility failed to implement and document required antibiotic stewardship "time outs" or day-three reviews for multiple residents receiving antibiotics for conditions such as dementia with suspected infection, diverticulitis, pneumonia, and sepsis. Clinical records for several antibiotic courses, including Doxycycline, Cefpodoxime, Clindamycin, and IV Meropenem, did not contain evidence of a review two to three days after initiation to assess infection status, appropriateness of the antibiotic, or potential de-escalation. The IP reported that antibiotics are discussed verbally in staff meetings but that time outs or reviews are not documented without a physician order, and the DON could not provide documentation that such reviews were completed.
A resident with hemiplegia, partial foot amputation, vascular dementia, and total dependence for transfers experienced multiple incidents while using a stand aid, including sliding to the floor, falling backward, and being lowered to the floor when knees buckled. Despite facility policy requiring post-fall rehab screens, no rehab screens were documented after several of these falls, and the rehab director was unaware of the events and the resident’s non-compliance and knee buckling. Later, rehab formally recommended use of a full-body Hoyer lift with two staff for all transfers, but nursing did not update the care plan or the NA assignment sheet, which continued to direct use of a stand aid, and leadership acknowledged that the resident’s changed transfer status was not clearly communicated to caregivers.
A resident with pneumonia and acute respiratory failure had a physician order for PRN oxygen at 2 L/min, but surveyors repeatedly observed the resident receiving 3 L/min. An RN initially stated there was an order for 3 L/min, but upon review of the EMR acknowledged the order was for 2 L/min, and the Unit Manager also confirmed the discrepancy. Despite the surveyor notifying staff of the incorrect flow rate, the resident continued to receive oxygen at 3 L/min, contrary to facility policy and professional standards requiring adherence to the ordered oxygen flow rate.
A resident with dementia and a history of pre-cancerous scalp lesions developed a cancerous wound on the right temple. After an initial course of topical treatment, the wound was left unassessed and untreated for several months, despite facility policy requiring weekly skin checks. The wound deteriorated, and maggots were eventually discovered, leading to hospital transfer. Staff and DON interviews confirmed the lack of wound monitoring and treatment during this period.
The facility did not update its facility-wide assessment to include wound vac therapy, despite providing this service to a resident with osteomyelitis and other conditions. The assessment failed to reflect the resources and services actually offered, and the Administrator was unable to provide documentation showing that the assessment was revised when wound vac treatment was initiated.
A resident with a surgical wound and a PICC line did not have Enhanced Barrier Precautions (EBP) implemented as required by facility policy. PPE such as gowns and gloves were not available near the room, and staff did not wear gowns during care. Nursing staff and the DON confirmed that EBP should have been in place for this resident.
A resident with advanced dementia and severe cognitive impairment was subjected to physical abuse by staff, including being dragged, forcefully pushed into a chair, and pinned in bed, instead of being redirected as per the care plan. Staff used manual restraint and unreasonable force, causing distress to the resident, and did not follow established interventions for managing resistive behavior.
A facility failed to act on pharmacy recommendations for a resident prescribed Clozapine, leading to a lapse in medication administration. The resident, with Alzheimer's and schizophrenia, did not receive the medication for 11 days due to an error. Despite a pharmacy recommendation for prompt action, the issue was not addressed until the resident was hospitalized for suicidal ideation and self-harm. Staff interviews revealed no system to highlight priority recommendations, risking resident safety.
A resident with Alzheimer's and schizophrenia was readmitted to a facility without proper medication reconciliation, leading to the discontinuation of essential medications like Clozapine and Trazadone. Despite recommendations to continue these medications, they were not updated, resulting in the resident experiencing delusions, paranoia, and self-harm, ultimately requiring hospitalization. The facility's failure to adhere to its medication reconciliation policy was confirmed by staff interviews.
Surveyors observed significant cleanliness issues in the kitchen, including dust and grease accumulation on equipment and floors. A dietary cook was found working with exposed food while wearing acrylic nails without gloves. Trash containers were also left uncovered when not in use. The Food Service Director acknowledged these deficiencies.
Two residents at risk for pressure ulcers did not receive the required offloading of heels as per physician orders. One resident with a stroke and severe cognitive impairment had a Deep Tissue Pressure Injury, and another resident with protein calorie malnutrition was at risk for skin breakdown. Observations showed non-compliance with orders, confirmed by LPNs and acknowledged by the DON.
The facility failed to maintain proper infection control practices for residents with wounds, as staff did not change gloves or perform hand hygiene during wound care. Additionally, two residents with pressure injuries were not placed on Enhanced Barrier Precautions (EBP), and staff did not wear protective gowns during care. These deficiencies were acknowledged by staff and the Infection Preventionist.
A facility failed to ensure a Nurse Practitioner provided necessary orders for a resident's care. The resident, with vascular dementia and cerebrovascular disease, showed signs of acute cystitis, but a urine culture and sensitivity order was not provided. The NP acknowledged the oversight, and the Medical Director expected the NP to follow up with the order.
Failure to Implement and Document Antibiotic Stewardship Time-Outs
Penalty
Summary
The deficiency involves the facility’s failure to establish and implement an Infection Prevention and Control Program that includes an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use, specifically the lack of documented antibiotic “time outs” or day-three reviews. For five residents receiving antibiotics, clinical record review did not show evidence that a review was conducted two to three days after antibiotic initiation to determine if a bacterial infection was present, whether the antibiotic, dose, and route were appropriate, or if therapy could be narrowed or shortened. One resident admitted with dementia received Doxycycline 100 mg twice daily for 10 days, and another resident with diverticulitis of the large intestine received Doxycycline 100 mg twice daily for seven days, with no documentation of an antibiotic time out or day-three review for either course. A resident admitted with pneumonia received Cefpodoxime Proxetil 200 mg twice daily for seven days, another resident with dementia received Clindamycin 300 mg three times daily for 10 days, and a resident with sepsis received Meropenem 500 mg IV every 12 hours for six days; in all three cases, records lacked documentation of an antibiotic time out or day-three review. During an interview, the Infection Preventionist stated that antibiotics are discussed verbally at staff meetings but that antibiotic time outs or reviews are not documented unless there is a physician’s order. In a subsequent interview, the Director of Nursing Services was unable to provide evidence that antibiotic time outs or reviews had been completed for these residents.
Failure to Update Transfer Status and Rehab Screening After Multiple Stand-Aid Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate assistive devices and supervision to prevent accidents for a resident who used a stand aid for transfers. The facility’s Falls Prevention & Management policy and post-fall guidelines required submission of rehab screens after falls for residents not on hospice and communication of changes in status to the interdisciplinary team. Resident ID #165, admitted in 2018 with hemiplegia/hemiparesis following cerebrovascular disease, partial traumatic amputation of the left foot, and vascular dementia, was non-ambulatory and dependent on staff for all transfers, with intact cognition per a recent MDS. Progress notes documented multiple stand-aid related incidents: on 10/17/2025 the resident lost balance and slid to the floor; on 10/31/2025 the resident fell backwards from the stand aid; on 11/1/2025 the resident was noted to be non-compliant with instructions while using the stand aid; on 12/29/2025 the resident was lowered to the floor by two NAs during a stand-aid transfer and was described as non-compliant and at high risk for falling; and on 12/30/2025 the resident was again lowered to the floor when knees buckled during a stand-aid transfer in the shower room. Despite these repeated falls and documented concerns, record review did not show that rehab screens were submitted after the falls on 10/31/2025, 11/1/2025, 12/29/2025, and 12/30/2025, contrary to the facility’s fall procedure. The Unit Manager RN stated that rehab screens should be submitted after a fall and that all screens are scanned into the EMR, but no such documentation was found. The Director of Rehabilitation confirmed she could not provide evidence that rehab screens were completed following these falls and reported she was unaware that the resident had fallen from the stand aid, had been non-compliant with instructions, or had experienced knee buckling during transfers with the device. This lack of post-fall rehab screening and communication meant that the rehab department was not informed of the resident’s repeated stand-aid related incidents. Additionally, the facility failed to update and communicate changes in the resident’s transfer status and assistive device needs after a rehab evaluation. Assignment documentation indicated the resident required assistance of 1–2 staff with a stand aid for all transfers, and the fall care plan last revised on 12/30/2025 continued to direct use of a stand aid. After a hospitalization for change in medical status, a rehab evaluation on 1/13/2026 recommended use of a full-body Hoyer lift with two staff for all transfers, documented on a Transfer Status Form signed by OT and PT. The Director of Rehabilitation stated this recommendation was communicated in writing to nursing and that the resident’s whiteboard was updated. However, record review showed the care plan was not revised and the NA assignment sheet was not updated to reflect the new Hoyer lift requirement. The Unit Manager RN acknowledged that the resident’s transfer status had not been updated on the assignment sheet or in the care plan, and the DON acknowledged that rehab screens were not provided after each fall and that the facility failed to clearly communicate the resident’s status to NAs, contributing to ongoing risks during transfers.
Failure to Follow Physician Order for Oxygen Flow Rate
Penalty
Summary
The deficiency involves the facility’s failure to provide oxygen therapy in accordance with physician orders and professional standards of practice for one resident using supplemental oxygen. Facility policy and Lippincott Nursing Procedure require a practitioner’s order for oxygen therapy and that the oxygen flow rate be set at the amount specified in the order, with documentation of the rate of flow. The resident, admitted with diagnoses including pneumonia and acute respiratory failure, had a physician’s order dated 12/13/2025 for oxygen at 2 liters per minute as needed. Despite this, surveyor observations on multiple dates and times showed the resident receiving oxygen at 3 liters per minute instead of the ordered 2 liters per minute. During an observation and interview, an RN stated that the resident was receiving oxygen at 3 liters per minute and asserted there was an order for 3 liters per minute. Upon review of the electronic medical record at the surveyor’s request, the RN acknowledged that the actual order was for 2 liters per minute. The Unit Manager also acknowledged that the order indicated 2 liters, not 3 liters, as observed. Later the same day, after the facility had been informed by the surveyor that the oxygen flow rate was incorrect, the resident was again observed receiving 3 liters per minute. The Director of Nursing Services stated she would have expected the resident to receive oxygen at 2 liters per minute, as ordered.
Failure to Monitor and Treat Resident's Cancerous Lesion Resulting in Maggot Infestation
Penalty
Summary
A resident with dementia and severe cognitive impairment was admitted to the facility with multiple pre-cancerous lesions on the scalp, including one on the right temple. Dermatology consultations identified the need for follow-up and, eventually, a MOHS procedure after a biopsy confirmed squamous cell carcinoma. Despite initial treatment with Aquaphor ointment as ordered, documentation shows that after this course ended, the lesion was left untreated for several months, from February to late June, with no evidence of ongoing assessment or monitoring of the wound during this period. The facility's policy required weekly skin checks and documentation of any wounds, but records failed to show that the right temple lesion was assessed or documented in weekly skin checks from December through early September. During this time, the resident's family declined further dermatology appointments and requested in-house wound care, but there was no evidence of consistent wound assessment or treatment until the wound's condition worsened. Orders for topical antibiotics and other treatments were only initiated after a significant lapse in care. The deficiency culminated when staff discovered maggots in the resident's right temple wound, prompting transfer to an acute care hospital. Hospital records confirmed a large, necrotic wound with maggot infestation, and interviews with facility staff and the DON acknowledged the lack of wound assessment and treatment for several months. The failure to monitor, assess, and treat the resident's wound in accordance with professional standards led to the development of a severe wound with maggot infestation.
Failure to Update Facility Assessment for Wound Vac Therapy
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. Record review showed that the facility's assessment, dated 1/30/2025, listed several special treatments and conditions but did not include wound vac therapy, which was a service provided to at least one resident. The assessment also did not reflect updates or modifications when new services, such as wound vac treatment, were introduced. A resident was admitted with multiple diagnoses, including osteomyelitis and was receiving wound vac therapy to the left foot. The facility's documentation did not show that wound vac treatment was considered in their resource planning or assessment. During an interview, the Administrator confirmed that not all services listed in the assessment were actually provided and could not provide evidence that the assessment was updated to include wound vac therapy during the resident's admission.
Failure to Implement Enhanced Barrier Precautions for Resident with Wound and Indwelling Device
Penalty
Summary
The facility failed to follow its own Enhanced Barrier Precautions (EBP) policy and standard infection control practices for a resident with a surgical wound and an indwelling medical device. According to the facility's EBP policy, residents with wounds or indwelling medical devices require a physician order for EBP, and personal protective equipment (PPE) such as gowns and gloves should be immediately available near or outside the resident's room. Additionally, a trash can should be positioned inside the room near the exit for discarding PPE prior to leaving. Record review showed that the resident was readmitted with osteomyelitis, enterococcus infection, a surgical wound, and a peripherally inserted central catheter (PICC) for intravenous antibiotics, but there was no physician order for EBP as required by policy. Surveyor observations revealed that gowns and gloves were not immediately available near or outside the resident's room, and a trash can for discarding PPE was not positioned as required. The resident reported that staff did not wear gowns when providing personal care. Interviews with nursing staff and the Director of Nursing confirmed that EBP should have been in place for the resident due to the presence of wounds and a PICC line, but these precautions were not implemented.
Failure to Protect Resident from Abuse through Improper Physical Restraint
Penalty
Summary
A resident with diagnoses including dementia and anxiety disorder, and severely impaired cognition as indicated by a Brief Interview for Mental Status score of 0 out of 15, was involved in an incident where staff failed to protect the resident from abuse. The resident, who was known to be at risk for self-care deficits and had care plan interventions to redirect and reapproach if resistive, became agitated and combative, attempting to enter another resident's room. Staff responded by physically escorting the resident to the common area and later to the resident's room. Multiple staff members, including a registered nurse and a licensed practical nurse, were observed by other staff to use excessive force and physical restraint on the resident. Witness accounts described the resident being dragged down the hallway by the arm and walker, forcefully pushed into a chair, and later thrown into bed and pinned down by the chest and head. Staff were also reported to have made statements indicating a punitive approach, and did not follow the care plan interventions of redirection and calm re-approach. The resident was visibly distressed and attempted to resist, including spitting and kicking at staff. The facility's own investigation, as well as staff interviews, substantiated that the actions taken by the staff constituted abuse, including the use of manual physical restraint and unreasonable confinement. The Director of Nursing confirmed that the staff did not follow expected procedures, such as monitoring the resident from a distance or leaving the resident alone once safe, and acknowledged that the resident was abused during the incident. The survey team concluded that the actions taken by staff resulted in a deficiency related to the failure to protect the resident from abuse.
Failure to Act on Pharmacy Recommendations for Clozapine
Penalty
Summary
The facility failed to develop and maintain policies and procedures to act on pharmacy-identified irregularities marked as Clinical Priority for a resident using Clozapine, an atypical antipsychotic medication. The resident, who had diagnoses including Alzheimer's disease and schizophrenia, was readmitted to the facility with a medication order for Clozapine to be administered for 30 days. However, the medication was discontinued after 30 days due to an error, and the resident did not receive the medication for 11 days. A pharmacy consultation report dated 1/28/2025 recommended a prompt response to continue the medication, but the recommendation was not signed by the Nurse Practitioner until 2/3/2025, the same day the resident was transferred to the hospital. The resident exhibited suicidal ideation, medication refusal, and self-injurious behaviors, leading to hospitalization. Interviews with staff revealed that there was no system in place to highlight priority recommendations requiring prompt responses, and the Director of Nursing Services confirmed that pharmacy recommendations marked as Clinical Priority should have been reviewed within 24 hours. The facility's lack of a system to ensure prompt action on pharmacy reports placed residents at risk for serious harm.
Failure to Conduct Medication Reconciliation Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that Resident ID #1 was free from significant medication errors, as evidenced by the lack of medication reconciliation upon the resident's readmission from the hospital. The resident, who had diagnoses including Alzheimer's disease and schizophrenia, was readmitted with specific medication orders, including Clozapine and Trazadone. However, the facility did not complete a medication reconciliation to compare the hospital's medication orders with those prior to hospitalization, as required by their policy. The error was compounded when the facility transcribed the hospital's 30-day medication orders without clinical justification, leading to the discontinuation of essential medications like Clozapine and Trazadone. Despite a psychiatric practitioner's recommendation and a nurse practitioner's agreement to continue these medications, the orders were not updated, resulting in the resident not receiving the necessary medications. This oversight was identified only after the resident exhibited increased delusions and paranoia, prompting a medication review. The resident's condition deteriorated, leading to suicidal ideation, hallucinations, and self-injurious behavior, necessitating a hospital admission. Interviews with the Nurse Practitioner and Director of Nursing Services confirmed the transcription error and the failure to conduct a medication reconciliation. The facility's actions resulted in the resident's transfer to an acute hospital for a month-long treatment, highlighting the significant medication error and its impact on the resident's health.
Food Safety and Cleanliness Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in the main kitchen, as observed by surveyors. There was a significant accumulation of dust and grease on various kitchen surfaces, including the hood system, stove, flat top griddle, and convection oven. Additionally, the floor behind kitchen equipment was found to be dirty with dust and debris. These observations were made on multiple occasions, indicating a persistent issue with cleanliness and maintenance in the kitchen area. Furthermore, a dietary cook was observed working with exposed food while wearing acrylic nails and not using gloves, which is against the Rhode Island Food Code. Additionally, trash containers in the kitchen were left uncovered when not in use, contrary to the requirements of the food code. The Food Service Director acknowledged these deficiencies during an interview, confirming the need for cleaning and adherence to food safety protocols.
Failure to Offload Heels for Residents at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received the necessary treatment and services to promote healing and prevent new ulcers from developing. Resident ID #153, who was readmitted with a stroke and severe cognitive impairment, had a physician's order to offload heels at all times due to a Deep Tissue Pressure Injury on the left heel. However, surveyor observations on multiple dates revealed that the resident's heels were not offloaded as ordered. An LPN acknowledged the failure to follow the physician's order during an interview. Similarly, Resident ID #38, admitted with protein calorie malnutrition and at risk for pressure injuries, had a physician's order to offload both heels every shift. Surveyor observations on several dates showed that the resident's heels were not offloaded as required. An LPN confirmed the non-compliance during an interview, and the Director of Nursing Services expressed an expectation for staff to adhere to the physician's orders.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. Three residents with wound care needs were not provided with proper infection control measures. For Resident ID #77, the LPN did not change gloves or perform hand hygiene between cleaning the wound and applying a collagen dressing, which was acknowledged by the staff member. Similarly, for Resident ID #153, the same LPN failed to change gloves and perform hand hygiene between cleaning the wound and applying betadine. Resident ID #162 also experienced inadequate infection control practices. During a dressing change, the LPN placed a soiled dressing on the resident's bed, used a finger instead of an applicator to apply medication, and did not change gloves or perform hand hygiene before touching various items in the room. These actions were acknowledged by the staff member and the Director of Nursing Services, who expected adherence to infection control guidelines. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with pressure injuries. Resident ID #77 and Resident ID #146, both with open wounds, were not placed on EBP, and staff failed to wear protective gowns during wound care. The Infection Preventionist confirmed that these residents should have been on EBP, indicating a lack of awareness and adherence to infection control policies among staff.
Failure to Provide Necessary Physician Orders for Resident Care
Penalty
Summary
The facility failed to ensure that a Nurse Practitioner provided necessary orders for a resident's immediate care. The resident, who was admitted in October 2023, had diagnoses including vascular dementia and cerebrovascular disease. A progress note dated October 21, 2024, authored by the Nurse Practitioner, documented a late entry for October 17, 2024, indicating that the resident had abnormal weight gain, increased edema, and hypotension. A bladder scan revealed urine retention, leading to the insertion of a Foley catheter. However, a urine sample was not sent to the lab for culture and sensitivity as ordered, despite the resident showing signs of acute cystitis, such as slurred speech and disorientation. The physician's orders did not include an order for a urine culture and sensitivity. During interviews, a Licensed Practical Nurse stated she was unaware of the need for a urine culture and sensitivity. The Nurse Practitioner acknowledged failing to provide the necessary order for the urine culture and sensitivity before or on October 17, 2024, when the resident's condition changed. The Medical Director expressed that he expected the Nurse Practitioner to follow up and provide the order for the urine culture and sensitivity.
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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