Sunny View Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Warwick, Rhode Island.
- Location
- 83 Corona Street, Warwick, Rhode Island 02886
- CMS Provider Number
- 415023
- Inspections on file
- 22
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 4 (3 serious)
Citation history
Health deficiencies cited at Sunny View Nursing Home during CMS and state inspections, most recent first.
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 severe cognitive impairment and a history of wandering was not consistently provided with a required TekTone elopement prevention device, as facility policy and physician orders were not followed. The device was not checked every shift, and documentation was lacking. As a result, the resident was able to exit the facility undetected, was found outside without the device, and sustained a significant injury.
A resident with severe cognitive impairment and a known risk for wandering was not properly monitored due to an incorrectly transcribed physician order for checking a TekTone elopement prevention device. The device was not checked every shift as required, and documentation was incomplete, resulting in the resident eloping from the facility without the device and sustaining a hip fracture.
A resident with mild cognitive impairment and a history of elopement risk was not accurately coded in the MDS for use of a TekTONE elopement prevention bracelet, despite care plan documentation and staff acknowledgment of the device's use. The MDS Coordinator confirmed the omission, and the DNS could not provide evidence of proper documentation in the assessment.
Two residents with complex medical conditions did not have required weekly skin assessments documented, despite physician orders and MAR sign-offs indicating completion. The DON was unable to provide evidence that these assessments were performed or recorded as required.
A resident's medical records were not accurately maintained, leading to incorrect documentation of Spironolactone administration and unfulfilled orders for hemorrhoid treatment and blood pressure monitoring. The facility failed to transcribe and implement new medical orders, and the administrator could not provide evidence of accurate documentation until prompted by a surveyor.
The facility failed to meet food safety standards, with several items in the kitchen and dining room found open and undated, contrary to the Rhode Island Food Code. Additionally, ground beef was stored without proper labeling, and steamed broccoli was served at an unsafe temperature. The Food Service Director and Dietary Cook acknowledged these lapses.
The facility failed to implement and track its QAPI actions, as shown by the absence of documented actions, measurements, or tracking systems in their 2024 and 2025 QAPI binders. Despite the QAPI plan's commitment to a formal methodology for improving performance and outcomes, no evidence of such efforts was found. The Administrator acknowledged this failure during an interview.
The facility did not complete annual performance reviews for four nurse aides, as required. A review of personnel files showed no evidence of evaluations for these staff members, and the Administrator could not provide documentation during an interview.
The facility failed to maintain an effective training program for staff, as 8 out of 10 employees reviewed did not receive required annual training in abuse, dementia management, and infection control. The Administrator could not provide evidence of completed training for these staff members.
A facility failed to provide a resident or their representative with written information about the bed-hold payment policy upon the resident's transfer to a hospital. The resident, diagnosed with congestive heart failure, was transferred without the required Bed Hold Notice being completed or documented. The Administrator acknowledged this oversight during an interview.
A resident with a history of pelvic fracture and osteoarthritis was not assisted with shaving, resulting in unwanted facial hair. Despite requiring supervision for personal hygiene, the resident was observed with facial hair, and staff interviews confirmed the lack of assistance. The DON acknowledged the oversight in care.
A resident was not administered a prescribed bowel protocol, leading to hospitalization. Despite having a physician's order for a specific bowel protocol, the resident went several days without a bowel movement, and the facility's records showed no evidence of the protocol being followed. Staff interviews confirmed the failure to implement the orders.
A resident with a stage 3 pressure ulcer did not receive the recommended foam silicone dressing treatment for 7 days after a wound specialist's assessment. The treatment was supposed to be applied three times weekly, but the facility failed to implement it, as acknowledged by the DON.
A resident with type 2 diabetes did not receive their prescribed Victoza injections on two consecutive days due to the medication being unavailable. The facility failed to order the medication promptly, leading to elevated blood sugar levels and additional insulin administration. Staff interviews revealed that the provider was not notified of the medication's unavailability, and the Director of Nursing acknowledged the oversight.
The facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) of Non-coverage Form to four residents discharged with Medicare Part A services. This form is required to inform beneficiaries about potential non-coverage and financial responsibility. The Administrator acknowledged the oversight but could not provide evidence of completed forms.
The facility failed to provide scheduled weekly showers to four residents, who were unable to perform activities of daily living independently. Despite being scheduled for showers, residents expressed frustration and reported missed showers, with no documentation to confirm when showers were provided. Staff interviews revealed that showers were given once a week without documentation, and the facility's DNS acknowledged the lack of evidence for scheduled showers.
A resident experienced an acute change in condition, including vomiting and an unknown cardiac event, but did not receive timely and thorough assessments. The DNS on the evening shift did not document vital signs or report the vomiting to the physician. Similarly, the overnight nurse did not complete a full assessment or notify the physician. The NP confirmed that vomiting should prompt assessment and notification. The lack of prompt intervention led to the resident becoming unresponsive and passing away after unsuccessful resuscitation efforts.
During a survey, tartar sauce was found stored at 62 degrees F in the dining room and 50 degrees F in the main kitchen, both exceeding the acceptable cold holding temperature of 41 degrees F. The Food Service Director confirmed the temperature deviations.
The facility failed to maintain an infection prevention and control program during a potential GI virus outbreak and did not follow proper infection control practices during a wound dressing change. Residents exhibited symptoms of a GI illness, but the facility did not initiate a line list for surveillance. Additionally, an LPN did not follow proper procedures during a wound dressing change, including not changing gloves and performing hand hygiene.
The facility failed to ensure that a resident received care consistent with professional standards of practice to prevent pressure ulcers. Despite a physician's order and care plan to offload heels while bed resting, surveyor observations revealed the resident's heels were resting directly on the mattress. This led to the development of a right heel pressure ulcer, which was confirmed by staff interviews and record reviews.
A facility failed to ensure a working call system was accessible to a resident with an upper extremity impairment. The resident's adaptive call pad was repeatedly observed out of reach, and staff confirmed it should be placed near the resident's hands due to contractures. The DON confirmed the expectation for the call pad to be within reach.
The facility failed to complete significant change in status assessments within 14 days for four residents who were admitted to hospice services, as required by CMS regulations. The Director of Nursing Services confirmed the lapse during an interview.
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 to Ensure Elopement Prevention Device Placement and Monitoring
Penalty
Summary
A deficiency occurred when a cognitively impaired resident, identified as being at risk for wandering and elopement, was not provided with the required elopement prevention device (TekTone bracelet) as per facility policy and physician orders. The resident had a history of dementia, cognitive decline, and other medical conditions, and was care planned for frequent visual checks and interventions to prevent elopement. The facility's policy required that the TekTone device be checked every shift, and the physician's order specified the same; however, the order was incorrectly transcribed to require checks only once weekly, and documentation showed the device was last checked three days prior to the incident. On the night of the incident, the resident was not in their room during medication administration, and staff had not seen the resident for over an hour before the resident was found outside the facility. The resident was discovered in the rear parking lot without the TekTone device, having sustained a large hematoma and a left hip fracture. Staff interviews confirmed that the resident did not have the device on at the time of the incident, and that checks for the device were not performed as required by policy or physician order. Further review revealed that the resident had previously removed the TekTone bracelet, and there was no evidence in the records that the device was consistently in place or checked as required. The facility was unable to provide documentation that the required checks were performed, and the resident's elopement was facilitated by the absence of the device, which would have triggered door locks to prevent exit. The failure to follow policy and physician orders directly led to the resident's successful elopement and subsequent injury.
Failure to Accurately Monitor and Document Elopement Prevention Device
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's medical records were complete and accurately documented regarding the monitoring of an elopement prevention device, specifically a TekTone device. The facility's policy required that the bracelet be checked each shift and documented in the treatment record. However, a physician's order to check the device every shift was incorrectly transcribed to be completed only once weekly, and documentation showed that the last check occurred three days prior to the resident's elopement. There was no evidence that the device was checked as ordered, and the resident was found outside the facility without the device, having sustained injuries including a large hematoma and a hip fracture. The resident involved had a history of dementia, cognitive decline, and severe cognitive impairment, and was identified as being at risk for wandering and elopement. The care plan included interventions such as frequent visual checks and redirecting the resident away from exits. Despite these interventions, the failure to accurately transcribe and implement the physician's order for device monitoring led to the resident's unsupervised exit from the facility and subsequent injury. Staff interviews confirmed the device was not on the resident at the time of the incident, and the order transcription error was acknowledged by the Director of Nursing Services.
Inaccurate MDS Coding for Elopement Prevention Device
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessment accurately reflected the status of a resident assessed as an elopement risk. Record review showed that the resident, who had diagnoses including mild cognitive impairment and muscle weakness, was readmitted to a semi-secure unit and had a care plan in place requiring the use of a TekTONE elopement prevention bracelet. Despite this, quarterly MDS assessments did not indicate the presence of the TekTONE bracelet in the Restraints and Alarms section. During interviews, the MDS Coordinator acknowledged the resident wore the bracelet and admitted it was not accurately coded in the MDS, and the DNS was unable to provide evidence that the device was documented in the assessment.
Failure to Document and Complete Physician-Ordered Skin Assessments
Penalty
Summary
The facility failed to meet professional standards of quality by not ensuring that weekly skin assessments ordered by physicians were completed and documented for two residents. For one resident admitted with altered mental status and a history of falls, a physician's order required weekly skin evaluations with documentation under observations. Although the Medication Administration Record (MAR) indicated that the assessment was completed, there was no evidence in the weekly skin evaluation observations or progress notes to confirm that the assessment was actually performed on the specified date. Similarly, another resident admitted with Parkinson's Disease, dementia, and a nasal bone fracture had a physician's order for weekly skin evaluations. The MAR showed that these assessments were signed off as completed on two occasions, but a review of the weekly skin evaluation observations and progress notes did not provide evidence that the assessments were conducted or documented as required. During an interview, the Director of Nursing Services was unable to provide documentation to support that the assessments had been completed per the physician's orders.
Failure to Maintain Accurate Medical Records and Implement Orders
Penalty
Summary
The facility failed to accurately maintain the medical record of a resident, leading to discrepancies in medication administration and unfulfilled medical orders. The resident, admitted in January 2025 with conditions such as exocrine pancreatic insufficiency, orthostatic hypotension, and repeated falls, had a medication order for Spironolactone increased from 25 mg to 37.5 mg. However, both dosages were documented as administered on the same day, despite the LPN denying the administration of the 25 mg dose. The facility administrator acknowledged the expectation for staff to discontinue the old medication order and initiate a new one, but could not provide evidence of accurate documentation. Additionally, the facility failed to transcribe and implement new orders for the resident, including the use of tucks pads for hemorrhoid pain and twice-daily blood pressure assessments. The resident reported not receiving treatment for hemorrhoid pain, and staff interviews confirmed that these orders were not transcribed or completed. The administrator was unable to provide evidence that these orders were entered into the resident's record until the surveyor brought it to their attention.
Food Safety and Labeling Deficiencies in Kitchen and Dining Room
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. In the main kitchen, several items in the reach-in refrigerator were found open and undated, including a container of fruit salad, a pitcher of orange liquid, and a bottle of prune juice. Similarly, in the main dining room kitchenette, items such as a container of whole milk, a bottle of prune juice, and a squeeze bottle of grape jelly were also open and undated. The Food Service Director (FSD) acknowledged that these items should have been labeled and dated upon opening, as per the Rhode Island Food Code. Additionally, during an inspection of the walk-in refrigerator, three white plastic tubes containing ground beef were found without labels identifying the contents. The FSD confirmed that these should have been labeled with the common name of the food. Furthermore, during the lunch meal service, the temperature of steamed broccoli with butter was recorded at 102°F, below the required safe hot holding temperature of 135°F. The Dietary Cook, Staff J, admitted to not checking the temperature before plating the meal, and the FSD confirmed that the broccoli was not at the safe temperature, indicating a lapse in food safety protocols.
Failure to Implement and Track QAPI Actions
Penalty
Summary
The facility failed to effectively implement and track its Quality Assurance and Performance Improvement (QAPI) actions, as evidenced by a lack of documented actions, measurements, or tracking systems in their 2024 and 2025 QAPI binders. This deficiency was identified during a record review and staff interview, where it was noted that the facility's QAPI plan included a commitment to using a formal and consistent methodology for planning, designing, measuring, assessing, and improving organizational performance and resident outcomes. However, the absence of evidence in the QAPI binders indicated that the facility did not follow through on these commitments. During an interview, the Administrator acknowledged the facility's failure to develop and implement systems to measure and track performance in identified problem areas.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete an annual performance review for every nurse aide at least once every 12 months, as required. This deficiency was identified during a record review and staff interview, which revealed that the personnel files for four nurse aides, Staff E, F, G, and H, lacked evidence of a completed performance evaluation within the last 12 months. Staff E was hired on 5/30/2023, Staff F on 9/27/2021, Staff G on 7/19/2021, and Staff H on 4/16/2023. During an interview with the Administrator on 3/12/2025, she was unable to provide documentation of the required evaluations for these staff members.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for annual training for existing employees, as required by their facility assessment. This deficiency was identified through a record review and staff interviews, which revealed that 8 out of 10 employees reviewed did not receive the necessary annual education or training in areas such as abuse and neglect, dementia management, and infection control. The facility assessment, dated January 1, 2024, specified that these training topics should be completed upon hire and annually for all staff. Specific staff members, including Nursing Assistants, a Dietary Cook, a Licensed Practical Nurse, and a Registered Nurse, were found to lack evidence of having received the required training. During an interview, the Administrator acknowledged the expectation that all outlined training should have been completed but was unable to provide evidence that the necessary education and training had been completed for the staff members in question.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide written information to a resident or their representative regarding the facility's bed-hold payment policy upon the resident's transfer to a hospital. This deficiency was identified for one of the two residents reviewed, specifically for a resident with a diagnosis of congestive heart failure. The facility's policy requires that a Bed Hold Notice be completed and attached to the resident's transfer papers, and that the representative's decision concerning the bed hold be documented in the resident's medical record. Upon review, it was found that the resident was transferred to the hospital, but there was no evidence that the bed hold policy was offered or documented as required. During an interview, the facility's Administrator acknowledged that the bed hold notification was not completed. This oversight indicates a failure to adhere to the facility's established procedures for notifying residents or their representatives about bed hold policies during hospital transfers.
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to ensure that a resident maintained the ability to perform activities of daily living, specifically personal hygiene related to shaving. The resident, admitted in January 2025 with diagnoses including pelvic fracture and osteoarthritis, required supervision or assistance for personal hygiene as per the Admission Minimum Data Set (MDS) assessment. However, observations on two separate occasions revealed that the resident had a moderate amount of facial hair, approximately half an inch in length, indicating a lack of assistance with shaving. Interviews conducted by the surveyor revealed that the resident had lost their razor and had not been assisted with shaving by the facility staff, despite expressing a desire to have their facial hair shaven. Nursing Assistant, Staff A, acknowledged that she should have assisted the resident with shaving, and Registered Nurse, Staff B, confirmed that shaving is part of resident care. The Director of Nursing Services also acknowledged that the resident should have been assisted with shaving, highlighting a lapse in the facility's provision of necessary personal hygiene assistance.
Failure to Administer Bowel Protocol as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the administration of a bowel protocol. The resident, who was readmitted to the facility following a hospital stay for fecal impaction and a urinary tract infection, had a physician's order for a bowel protocol that included administering prune juice, Milk of Magnesia, Dulcolax suppository, and Fleet Enema in a specific sequence if bowel movements did not occur. However, documentation revealed that the resident went several days without a bowel movement on multiple occasions, and there was no evidence that the bowel protocol medications were administered as ordered from late September to mid-October 2024. The deficiency was confirmed through record reviews and staff interviews. The Medication Administration Records for September and October 2024 did not show that the bowel protocol was followed, and the resident was eventually transferred to the hospital on October 15, 2024. During interviews, both a registered nurse and the Director of Nursing Services acknowledged that the bowel protocol orders were not implemented according to the physician's instructions. This lack of adherence to the prescribed bowel protocol contributed to the resident's hospitalization.
Failure to Implement Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure that a resident with a pressure ulcer received the necessary treatment and services to promote healing, consistent with professional standards of practice. The resident, admitted in January 2025, had a diagnosis that included a pressure ulcer with an unspecified stage. A wound specialist assessment later identified a stage 3 pressure wound on the resident's right ischium. A treatment recommendation was made on March 4, 2025, to apply a foam silicone dressing three times weekly. However, the March 2025 Treatment Administration Record showed no evidence that this treatment was implemented from March 4 to March 11, 2025, resulting in a 7-day delay in treatment. The Director of Nursing Services acknowledged during an interview that the treatment was not implemented until 7 days after the wound specialist's recommendation.
Failure to Administer Victoza Leads to Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Victoza, an injectable medication prescribed to help lower blood sugars. The resident, who was admitted with a diagnosis of type 2 diabetes mellitus, did not receive the Victoza injection as ordered on two consecutive days. The medication was noted as unavailable, and it was not ordered from the pharmacy until two days after the missed doses. This oversight led to elevated blood sugar levels, requiring additional insulin administration according to the sliding scale. The nursing progress notes did not indicate that the provider was notified about the unavailability of Victoza, and interviews with staff confirmed that the provider was not informed. The Director of Nursing Services acknowledged the failure to administer the medication as ordered. The lack of timely communication and action to ensure the availability of the medication contributed to the deficiency, impacting the resident's blood sugar management.
Failure to Provide SNFABN Forms to Residents
Penalty
Summary
The facility failed to provide proper notice to residents and/or their representatives regarding changes in Medicare Part A coverage, specifically related to the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) of Non-coverage Form. This deficiency was identified for four residents who were discharged with Medicare Part A services. The SNFABN is required by Medicare to inform beneficiaries when care that is usually covered may not be paid for due to reasons such as not being medically reasonable and necessary or being considered custodial. The absence of this form means that residents were not informed about their potential financial responsibility for services not covered by Medicare. Record reviews revealed that the last covered days of Medicare Part A services for the residents in question were on various dates, yet there was no evidence that the SNFABN form was issued to them or their representatives. During an interview, the facility's Administrator acknowledged that the forms should have been issued but could not provide evidence that they were completed. This oversight affected four residents, identified as Resident ID #294, #295, #296, and #297, indicating a systemic issue in the facility's process for notifying residents about changes in their Medicare coverage.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to provide necessary services to residents who were unable to perform activities of daily living, specifically regarding scheduled showers. Four residents were affected by this deficiency, as they did not receive their scheduled weekly showers. Resident ID #1, admitted with multiple rib fractures, was scheduled for a shower every Friday evening but only received 2 out of 5 scheduled showers. The resident expressed frustration and noted the lack of documentation for missed showers. Staff interviews confirmed the absence of documentation requirements for showers. Resident ID #3, diagnosed with retinitis pigmentosa, was overheard complaining about not receiving a shower for several days. The resident was scheduled for a shower every Tuesday morning, but there was no documentation to confirm when the last shower was provided. Staff interviews revealed that showers were given once a week without documentation, and a shower was only offered after the issue was brought to the facility's attention by the surveyor. Resident ID #4, with a diagnosis of depression, was dependent on staff for ADLs and had not received a shower in the past month, despite being scheduled for a weekly shower every Friday morning. Resident ID #5, with a history of falling, expressed a desire for more frequent showers than the once-a-week schedule allowed. The facility's Director of Nursing Services acknowledged the lack of documentation and the expectation for staff to accommodate residents who missed scheduled showers or requested additional ones, but no evidence was provided to confirm that the residents received their showers as scheduled.
Failure to Address Acute Change in Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care for Resident ID #38, who experienced an acute change in condition involving vomiting and an unknown cardiac event. Despite the resident exhibiting symptoms such as vomiting, being pale and tired, and ultimately becoming unresponsive, there was a lack of timely and thorough assessments conducted by the nursing staff. The Director of Nursing Services (DNS) on duty during the evening shift did not document vital signs or report the vomiting to the physician. Similarly, the nurse on the overnight shift failed to complete a full assessment, including vital signs, and did not notify the physician of the resident's condition. The Nurse Practitioner (NP) acknowledged that vomiting should be considered a change in condition warranting assessment and notification to medical staff. The facility's failure to promptly identify and intervene during this resident's acute change in condition, as outlined in their policy, had serious consequences, leading to the resident being found unresponsive and ultimately passing away after resuscitation efforts were unsuccessful.
Improper Cold Holding Temperatures for Tartar Sauce
Penalty
Summary
The facility failed to properly store and serve food under sanitary conditions, as identified during a survey on 3/22/2024. Tartar sauce was observed at 62 degrees F in the dining room, above the acceptable cold holding temperature of 41 degrees F. Additionally, the tartar sauce served from the main kitchen was recorded at 50 degrees F, still not meeting the required temperature. The Food Service Director acknowledged the deviation from the acceptable cold holding temperature during an interview.
Infection Control Deficiencies in GI Illness Outbreak and Wound Dressing Changes
Penalty
Summary
The facility failed to maintain an infection prevention and control program to prevent the transmission of communicable diseases and infections during a potential gastrointestinal (GI) virus outbreak on two nursing units. Residents exhibited signs and symptoms of a GI illness, including vomiting and nausea, but the facility did not initiate a line list for appropriate surveillance as per their policy. The Infection Preventionist and Director of Nursing Services acknowledged that the outbreak protocol was not followed, and a line list was not completed for residents showing symptoms between February 8 and February 15, 2024. Additionally, the facility staff did not conduct appropriate infection control practices during wound dressing changes. A Licensed Practical Nurse (LPN) was observed changing a resident's wound dressing without removing dirty gloves, performing hand hygiene, or donning new gloves before applying the clean dressing. The LPN also touched the resident's wound care supply bag with dirty gloves and returned it to a clean supply closet, further breaching infection control protocols. The Director of Nursing Services confirmed that the nurse did not follow proper infection control practices during the wound dressing change. The facility was unable to provide evidence that it maintained an effective infection prevention and control program to prevent the transmission of communicable diseases and infections in both the GI illness outbreak and the wound dressing change scenarios.
Failure to Prevent Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards of practice to prevent pressure ulcers. Resident ID #36, who was admitted in January 2024 with a diagnosis including traumatic hemorrhage of the cerebrum, had a physician's order to offload heels while bed resting. The care plan developed on 1/24/2024 also included approaches to prevent skin breakdown, such as keeping bony prominences from direct contact and offloading heels to reduce pressure. However, surveyor observations on multiple occasions revealed that the resident's heels were resting directly on the mattress, not offloaded as required by the care plan and physician's order. Further record review showed that there was no evidence of skin impairment to the resident's right heel on 3/5/2024 and 3/12/2024. However, a document dated 3/19/2024 revealed the development of a right heel pressure ulcer. During interviews, both a Registered Nurse and the Director of Nursing Services acknowledged that the resident's heels were not offloaded and confirmed that physician orders were not followed. The facility was unable to provide evidence that care consistent with professional standards of practice was provided to prevent pressure ulcers.
Failure to Ensure Accessible Call System for Resident
Penalty
Summary
The facility failed to ensure that a working call system was available and accessible to a resident with an upper extremity impairment. The resident, who was admitted in May 2022 with a diagnosis of cerebrovascular disease, was observed multiple times with the adaptive call pad placed out of reach. This was noted on several occasions, including 3/20/2024 at 9:33 AM, 3/22/2024 at 12:20 PM, 1:45 PM, and approximately 4:25 PM, and 3/25/2024 at 9:20 AM. During an observation and interview on 3/25/2024 at 9:20 AM, an LPN acknowledged that the adaptive call pad was out of the resident's reach and should be placed near the resident's hands due to contractures. The LPN then placed the call pad within reach, and the resident demonstrated the ability to trigger the call light. The DON confirmed that the expectation was for the call pad to be within the resident's reach.
Failure to Complete Significant Change in Status Assessments
Penalty
Summary
The facility failed to complete a significant change in status assessment (SCSA) within 14 days after a significant change in the resident's physical or mental condition for four residents. According to the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, an SCSA is required when a resident elects or revokes the hospice benefit. The report identified that Resident ID #7, admitted with cerebrovascular disease, was admitted to hospice services on January 1, 2024, but no SCSA was completed. Similarly, Resident ID #9, with congestive heart failure, was admitted to hospice services on February 25, 2024, without an SCSA being completed. Resident ID #17, diagnosed with dementia, was admitted to hospice services on December 23, 2023, and Resident ID #30, with adult failure to thrive, was admitted to hospice services on August 6, 2023, both without the required SCSA being completed within the mandated timeframe. During an interview with the Director of Nursing Services on March 25, 2024, it was confirmed that the significant change in status assessments were not completed for the four residents mentioned. The Director acknowledged that the assessments should have been completed within 14 days of the residents' admission to hospice services, as required by CMS regulations. The failure to complete these assessments indicates a lapse in adhering to the regulatory requirements for monitoring and documenting significant changes in residents' health status.
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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