Stillwater Assisted Living And Skilled Nursing Com
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenville, Rhode Island.
- Location
- 20 Austin Avenue, Greenville, Rhode Island 02828
- CMS Provider Number
- 415123
- Inspections on file
- 24
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Stillwater Assisted Living And Skilled Nursing Com during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow physician orders for lab monitoring for two residents. One resident with a history of acute pulmonary edema had an order for periodic BNP testing, but the scheduled BNP was not completed as documented on the MAR or elsewhere in the record, despite the resident reporting ongoing leg swelling. Another resident with hypertension had a physician order for a repeat BMP in one week, but there was no evidence in the record that this lab was obtained as ordered. These omissions show that physician-directed lab tests were not carried out as required.
The facility failed to maintain proper food safety standards, with food items stored at incorrect temperatures and lacking a certified Food Safety Manager during meal preparations. Observations revealed food items like salads and sandwiches were not kept at the required cold holding temperatures, and a cook without the necessary certification was responsible for evening meals.
The facility breached residents' privacy by posting a resident's name and weight visibly at their room entrance and failing to close a privacy curtain during a wound dressing change for another resident. The incidents were confirmed by staff interviews and surveyor observations.
A facility failed to conduct necessary laboratory tests for a resident on Atorvastatin, despite a physician's order and pharmacist's recommendation for a lipid panel and hepatic function panel. The DON could not provide evidence that these tests were performed.
A resident readmitted with surgical wounds did not receive proper wound assessment or treatment upon re-admission. The facility's initial skin assessment lacked detailed wound descriptions, and no treatment orders were in place until two days later. Staff interviews confirmed the oversight in wound assessment and treatment inquiry.
A facility failed to follow professional standards for administering IV antibiotics via a PICC line for a resident with MRSA. The resident, receiving Vancomycin, did not have a physician's order for the required 10 ml saline flush before and after medication administration, as per facility policy. Both a nurse and the facility's pharmacist confirmed the absence of this order, highlighting a deficiency in adhering to established protocols.
The facility failed to ensure nursing staff had the necessary competencies to manage a PICC line for a resident with sepsis due to MRSA. Discrepancies in catheter length measurements were noted, with staff unable to accurately measure or explain the process. The Nursing Staff Educator expected staff to use the lines on the catheter for measurement, indicating a lack of competency in PICC line management.
The facility was found to have several deficiencies related to food storage and sanitation in the main kitchen and two kitchenettes. Issues included unlabeled and undated food items in the walk-in freezer, expired food in refrigerators, and improper labeling of food from external sources. Additionally, food-contact surfaces of equipment had encrusted grease and soil accumulations, and equipment such as a microwave contained dried food particles and debris. The facility also did not comply with the Rhode Island Food Code regarding the air gap requirement for the ice machine, posing potential food safety risks. These observations, along with record reviews and staff interviews, indicated systemic issues in maintaining professional standards for food service safety.
A resident with type 2 diabetes mellitus did not receive their prescribed insulin on multiple occasions, and there was no evidence of an order to hold the insulin or notification to the provider. Interviews confirmed the facility's failure to follow professional standards of practice.
A resident with pressure ulcers did not receive necessary treatment as per physician's orders. The resident had an unstageable pressure ulcer on the left posterior calf, which required daily dressing changes. However, the dressing changes were incorrectly scheduled for Monday, Wednesday, and Friday, leading to 9 missed dressing changes. The error was acknowledged by the Infection Preventionist and the Regional Infection Preventionist.
A resident with a history of traumatic subdural hemorrhage and Down syndrome experienced multiple falls due to the facility's failure to use a prescribed gait belt for transfers and ambulation. Despite clear instructions from the Rehabilitation Department, staff did not utilize the gait belt, leading to repeated falls and injuries.
A facility failed to provide appropriate care for a resident with a suprapubic catheter. The resident's drainage bag was repeatedly observed hung above the level of their bladder, contrary to facility policy. Staff acknowledged the improper positioning during interviews.
The facility failed to establish an IPCP that includes an antibiotic stewardship program with protocols and monitoring systems. Two residents were prescribed antibiotics without evidence of urine culture and sensitivity tests to confirm appropriateness. Interviews revealed a lack of processes for reviewing or obtaining necessary diagnostic tests.
Failure to Follow Physician Orders for Laboratory Testing for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received treatment and care in accordance with professional standards of practice by not following physician orders for laboratory testing. For one resident with a history of acute pulmonary edema and intact cognition, the physician ordered a Brain Natriuretic Peptide (BNP) test to be obtained every second Monday in February and August. The February Medication Administration Record showed the BNP was scheduled but not signed off as completed on the specified date, and further record review did not show evidence that the BNP was obtained as ordered. During an interview, the resident reported being given a fluid pill for leg swelling that had not helped, and the Assistant Director of Nursing Services acknowledged that the ordered BNP test was not completed. For a second resident admitted with hypertension, the physician documented a new order in a progress note for a repeat Basic Metabolic Panel (BMP) to be obtained in one week. Record review failed to show that this repeat BMP was completed within the ordered timeframe. In an interview, the Assistant Director of Nursing Services was unable to provide evidence that the repeat BMP had been obtained as ordered. These missed laboratory tests, despite clear physician orders, constitute the failure to provide care and services in accordance with professional standards of quality.
Food Safety and Certification Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by surveyor observations and staff interviews. During a lunch meal tray service, it was observed that certain food items, such as bean salad and turkey salad sandwiches, were not maintained at the required cold holding temperature of 41°F or below. Further inspection of the walk-in refrigerator revealed additional food items, including turkey salad and egg salad, also stored at temperatures above the required limit. The Food Service Director (FSD) and the cook acknowledged these discrepancies and discarded the improperly stored food items. A follow-up visit revealed a similar issue with chicken salad, which was also stored at an inappropriate temperature. Additionally, the facility did not ensure the presence of a certified food protection manager during all meal preparation times. The surveyor found that a cook responsible for preparing and serving evening meals did not possess the necessary Food Safety Manager certification. The kitchen staff schedule confirmed that this uncertified cook was the only one working during several evening meal services. The FSD was unable to provide evidence of a certified Food Safety Manager being present during these times, as required by the Rhode Island Food Code.
Privacy Breaches in Resident Care
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical information, as evidenced by two separate incidents. In the first incident, a resident's name and weight were visibly posted at the entrance of their room, which was accessible to anyone passing by in the hallway. This was observed by surveyors on multiple occasions, and the Assistant Director of Nursing Services confirmed the visibility of the information during an interview. In the second incident, a registered nurse did not ensure privacy during a wound dressing change for a resident with a stage 3 pressure ulcer on the left heel. The nurse failed to close the privacy curtain between the resident and their roommate, leaving the resident exposed during the medical procedure. The Director of Nursing Services later stated that staff are expected to provide privacy for residents, indicating a lapse in adherence to the facility's privacy policy.
Failure to Monitor Atorvastatin Therapy with Required Lab Tests
Penalty
Summary
The facility failed to ensure that a resident receiving Atorvastatin, a medication prescribed to treat high cholesterol, received appropriate monitoring through laboratory tests as per professional standards of practice. A pharmacist recommended an annual lipid panel and hepatic function panel to monitor the therapeutic effects and potential side effects of Atorvastatin. The provider agreed to this recommendation, and a physician's order was issued to obtain these laboratory tests. However, a review of the records revealed no evidence that the lipid panel and hepatic function panel were conducted as ordered. During an interview, the Director of Nursing Services was unable to provide documentation that these tests were obtained.
Failure to Assess and Treat Resident's Surgical Wounds
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, who was readmitted to the facility with a history of a right ankle fracture and surgical wounds, did not have their wounds assessed or described in detail upon re-admission. The facility's Admission Skin assessment, completed by a registered nurse, did not include an assessment or description of the surgical wounds, and the admission nursing progress note failed to document any wound assessment or treatment implementation. Additionally, there was no evidence of a treatment order for the resident's right lower extremity wounds from the time of admission until two days later. The Director of Nursing Services later documented the presence of multiple wounds on the resident's right lower extremity and a pressure wound on the right heel. During interviews, staff acknowledged the failure to assess the wounds upon re-admission and the lack of inquiry about treatment orders, which contributed to the deficiency.
Failure to Follow PICC Line Protocol for IV Antibiotic Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice in the administration of intravenous (IV) fluids for a resident receiving antibiotics via a peripherally inserted central catheter (PICC) line. The resident, admitted in March 2025 with a diagnosis of sepsis due to methicillin-resistant Staphylococcus aureus (MRSA), had a PICC line placed on March 6, 2025, and was receiving Vancomycin intravenously every 12 hours. However, the facility did not have a physician's order for a 10 ml saline flush before and after administering the Vancomycin, as required by the facility's pharmacy policy. During interviews, both a registered nurse and the facility's contracted pharmacist confirmed the absence of the necessary saline flush order. The pharmacist further indicated that a 10 ml saline flush should be administered before and after medication administration via the PICC line, as well as an additional flush on shifts when the antibiotic is not administered. This oversight in following the established protocol for PICC line maintenance and medication administration led to the identified deficiency.
Inadequate PICC Line Management by Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to manage a peripherally inserted central catheter (PICC) for a resident diagnosed with sepsis due to methicillin-resistant Staphylococcus aureus (MRSA). The resident was admitted with a PICC line, and discrepancies in the external catheter length measurements were noted. Initially, the external catheter length was recorded as 0 cm, but a subsequent measurement by RN Staff D during a dressing change showed an 8 cm length. Staff D later acknowledged an error in his initial measurement and admitted to not reviewing previous measurements before documenting the new one. Further interviews with other nursing staff, including RN Staff C and RN Staff A, revealed that they were unable to accurately explain how to measure the external catheter length of a PICC line. The Nursing Staff Educator, Staff E, indicated that the external portion of a PICC line has small lines for measurement, which staff are expected to use. This deficiency highlights a lack of competency among the nursing staff in managing PICC lines, which is critical for ensuring resident safety.
Food Storage and Sanitation Deficiencies Identified in Main Kitchen and Kitchenettes
Penalty
Summary
The facility failed to ensure that food was stored and distributed in accordance with professional standards for food service safety in the main kitchen and two kitchenettes observed. The deficiencies included unlabeled and undated food items in the walk-in freezer, expired food items in refrigerators, and improper labeling of food brought from external sources. Additionally, food-contact surfaces of equipment were found to have encrusted grease deposits and other soil accumulations, indicating a lack of proper cleaning and maintenance practices. The report also highlighted issues with the cleanliness of equipment, such as a microwave with dried food particles and debris. Furthermore, the facility was found to be non-compliant with the Rhode Island Food Code regarding the air gap requirement for the ice machine in the main kitchen. The absence of an adequate air gap and the overflowing drain posed potential risks to food safety and sanitation. The observations made during the survey, along with record reviews and staff interviews, revealed a pattern of deficiencies in food storage, labeling, cleanliness, and equipment maintenance across the main kitchen and kitchenettes, indicating a systemic failure in ensuring compliance with professional standards for food service safety.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Resident ID #65, who was admitted with diagnoses including type 2 diabetes mellitus and a urinary tract infection, had a care plan indicating an increased risk for hypo/hyperglycemia with an intervention to administer medication as ordered. However, the Medication Administration Report revealed that the resident's insulin was not administered on four specific dates between March and April 2024, without any evidence of an order to hold the insulin or notification to the provider. Interviews with the Nurse Practitioner and the Assistant Director of Nursing Services confirmed that the facility did not notify the provider or administer the insulin as per the physician's order.
Failure to Provide Necessary Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice. The resident, who was readmitted in February 2024 with diagnoses including pressure-induced deep tissue damage and a Methicillin Resistant Staphylococcus Aureus infection, had a physician's order dated 3/26/2024 for daily dressing changes on an unstageable pressure ulcer on the left posterior calf. However, the Medication Administration Records for March and April 2024 indicated that the dressing changes were scheduled for Monday, Wednesday, and Friday instead of daily, resulting in 9 missed dressing changes. During an interview on 4/10/2024, the Infection Preventionist and the Regional Infection Preventionist acknowledged that the wound order was transcribed incorrectly.
Failure to Use Assistive Devices for Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident received appropriate assistive devices to prevent accidents. The resident, who was admitted with diagnoses including traumatic subdural hemorrhage and Down syndrome, experienced multiple falls. These incidents occurred on various dates, including falls on 2/4/2024, 2/24/2024, 3/17/2024, and 3/23/2024. The resident's care plan included an order for safe patient handling, which required the use of a gait belt for transfers and ambulation. However, surveyor observations on 4/9/2024 revealed that staff did not use a gait belt during ambulation and transfers with the resident, despite this requirement being communicated in multiple ways by the Rehabilitation Department. Interviews with the Director of Rehabilitation and a Physical Therapist confirmed that the expectation was for staff to use a gait belt for all transfers and ambulation when assisting the resident. The Physical Therapist was unable to explain why the staff did not utilize the gait belt during the observed instances. This failure to use the prescribed assistive device contributed to the resident's repeated falls and subsequent injuries, including a readmission to the hospital for an acute subdural hematoma.
Improper Positioning of Suprapubic Catheter Drainage Bag
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a suprapubic catheter. The resident, admitted in February 2024 with diagnoses including obstructive and reflux uropathy and chronic kidney disease stage 3, was observed multiple times on 4/10/2024 with their drainage bag hung on the back of their wheelchair near their shoulders, above the level of their bladder. This was contrary to the facility's policy, which states that the drainage bag should be kept below the resident's waist/bladder. During interviews, both a registered nurse and the infection preventionists acknowledged that the drainage bag was improperly positioned and should be moved below the resident's waist/bladder.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an Infection Prevention and Control Program (IPCP) that includes an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. This deficiency was identified for two residents. Resident ID #124 was admitted with diagnoses including a urinary tract infection and vascular dementia. The resident was prescribed Macrobid, but there was no evidence of a urine culture and sensitivity test to determine if the antibiotic was appropriate. Similarly, Resident ID #129 was admitted with diagnoses including a urinary tract infection and cough and was prescribed cefuroxime axetil. Again, there was no evidence of a urine culture and sensitivity test to confirm the appropriateness of the antibiotic. Interviews with the Nurse Practitioner and Infection Preventionist revealed that the facility lacked a process for reviewing or obtaining laboratory or diagnostic testing to determine if the prescribed antibiotics were still indicated or if adjustments were needed. The Nurse Practitioner stated that staff should call the hospital for results or repeat cultures in-house if no sensitivities are available. The Infection Preventionist was unable to provide evidence of such a process, highlighting a gap in the facility's antibiotic stewardship program.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
