The Dawn Hill Home For Rehab And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Bristol, Rhode Island.
- Location
- One Dawn Hill Road, Bristol, Rhode Island 02809
- CMS Provider Number
- 415050
- Inspections on file
- 43
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at The Dawn Hill Home For Rehab And Healthcare during CMS and state inspections, most recent first.
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 dementia and a documented tomato allergy consumed food with red tomato sauce and was subsequently ordered a one-time dose of Reglan 10 mg by a provider, with instructions for close monitoring for allergic reaction. The MAR showed the Reglan entry coded to refer to progress notes, where an LPN documented that the medication was pending pharmacy delivery, but there was no evidence that the dose was ever administered or that the provider was notified of the omission. A Pyxis inventory showed Reglan was routinely stocked, and in interviews the LPN confirmed the medication was not given and the DON stated she would have expected the medication to be administered as ordered and the provider notified and documentation completed if it was not.
A resident with dementia had a tomato allergy documented in the EHR, yet was served food containing red tomato sauce despite this known allergy. A progress note recorded that the resident consumed the tomato sauce and required close monitoring for signs and symptoms of an allergic reaction. The DON later acknowledged in an interview that the resident had a documented tomato allergy and should not have been served a tomato product, and the issue came to light after a community complaint alleging the resident experienced an acute medical episode due to an allergic reaction.
Two residents with hypertension received Hydralazine despite physician orders specifying administration only above certain systolic blood pressure thresholds. Medication records showed the drug was given multiple times when blood pressure was below the ordered limits, and LPNs confirmed these errors during surveyor interviews. The DON could not provide evidence that the residents were free from unnecessary medications.
A resident admitted after back surgery did not receive adequate pain management due to the facility's failure to administer the correct dosage of oxycodone for severe pain, as indicated in the hospital's COC form. Additionally, the facility did not administer Decadron, a prescribed steroid, due to a lack of transcription and communication with the provider. This resulted in the resident being transferred back to the hospital for pain management.
A resident admitted after back surgery did not receive prescribed medications due to unavailability and lack of staff communication with the provider. Despite protocols, staff failed to utilize available resources like the Pyxis machine and did not notify the provider about missed doses. The facility's Regional DON and NP expected adherence to medication orders and communication, which was not met.
A newly admitted resident who underwent back surgery was transferred back to the hospital due to the facility's failure to have prescribed medications available. The facility did not accurately maintain the resident's medical records, missing orders for Decadron and incorrect dosage for oxycodone. The Regional DON acknowledged the oversight but could not provide evidence of accurate record maintenance.
A resident with an ileostomy experienced inadequate care due to the facility's failure to provide the correct size ostomy supplies, leading to leakage and redness around the stoma. Staff interviews confirmed that the available appliance did not fit properly, causing stool to leak into a surgical wound. The resident was transferred to the hospital after family concerns about the care provided.
The facility failed to properly label and store medications in two medication storage rooms. In the North Medication Storage Room, a vial of Tuberculin was found opened and undated, contrary to manufacturer instructions. Similarly, in the East Medication Storage Room, a bottle of Ativan Intensol was opened and undated. Both LPNs present acknowledged the oversight, and the DON confirmed the expectation for medications to be dated upon opening.
A facility failed to maintain professional standards in administering IV antibiotics via a PICC line and in medication administration for residents. An LPN did not assess for blood return or scrub the needleless connector before reconnecting IV tubing for a resident with bacteremia. Additionally, a medication technician administered whole tablets instead of crushed ones to a resident with dysphagia, contrary to special instructions.
A resident with a Suprapubic Catheter (SPC) was not provided appropriate catheter care as per the care plan, which required the catheter bag to be maintained below bladder level to prevent CAUTI. Surveyors observed the catheter bag lying on the mattress next to the resident, and staff interviews confirmed the failure to adhere to the care plan.
A facility failed to maintain accurate medical records for a resident with urinary retention, resulting in conflicting catheter size orders. Staff interviews revealed the current catheter size was 18 Fr, but the order for 16 Fr was not discontinued. Additionally, another resident's advance directives were mistakenly uploaded, conflicting with the resident's Do Not Resuscitate and No Artificial Nutrition orders. The DON acknowledged these discrepancies.
A resident with intact cognition was unable to reach their call bell, which had fallen to the ground, leading them to yell for help due to pain for half an hour. The facility's policy requires call bells to be within reach, but this was not adhered to, as confirmed by a nursing assistant and the DON.
The facility failed to follow physician orders for daily weight monitoring for two residents with cardiac conditions. Weights were not obtained on multiple occasions, and there was no notification to the MD or NP about these omissions. Staff interviews revealed a lack of awareness about the need to report missed weights, and the DON expected weights to be obtained and reported if not.
A resident with a history of CHF and A-fib was readmitted to an LTC facility but did not receive prescribed medications for 16 days due to incomplete admission orders. The admitting nurse transcribed orders from a document listing pre-admission medications instead of obtaining the correct discharge summary. This oversight led to the resident's return to the hospital with difficulty breathing, and the hospital contacted the facility about the missed discharge orders.
A resident receiving hospice care was found in bed covered in dried blood and feces, as reported by the family to the Rhode Island Department of Health. The resident, with a history of joint implant, diabetes, and congestive heart failure, was initially thought to be covered in feces by staff, but it was later identified as blood. The Director of Nursing Services could not provide evidence that the resident was checked on at the start of the shift.
A resident with type 2 diabetes did not receive prescribed Humalog insulin for four days due to unavailability. Staff interviews revealed a lack of communication with the pharmacy and provider. The DON confirmed the facility had an insulin emergency kit, but no actions were taken to address the unavailability.
A facility failed to maintain accurate medical records for a resident on hospice care. The resident's Ativan order was discontinued, yet Health Status Notes incorrectly indicated its use. The Nurse Practitioner acknowledged the error, and the DON expected a review of current medications during visits.
A facility failed to maintain proper hospice documentation for a resident receiving hospice care. Despite a physician's order and a hospice plan of care, the necessary Hospice Recommendation forms were missing from the facility's records. Interviews with hospice staff confirmed that the forms were provided, but they were not found in the resident's hospice binder, indicating a lapse in maintaining complete records.
A resident with dementia pushed another resident with Alzheimer's, resulting in a dislocated shoulder. The incident was witnessed by a staff member, but the facility failed to provide evidence of measures taken to prevent such abuse, highlighting a deficiency in protecting residents from harm.
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.
Failure to Administer Ordered Medication After Known Food Allergy Exposure
Penalty
Summary
The facility failed to ensure services were provided in accordance with professional standards of quality by not following a physician’s order for a resident who had a known tomato allergy. The resident, admitted with dementia and with a documented tomato allergy of unknown severity in the electronic health record since June 2025, consumed food containing red tomato sauce. A nurse practitioner documented that the resident had eaten red tomato sauce despite the allergy and ordered a one-time dose of Reglan 10 mg with continued close monitoring for any signs and symptoms of allergic reaction. A corresponding physician’s order for Reglan 10 mg once was entered on the same date. Review of the Medication Administration Record for that month showed Reglan coded as “9” by an LPN, indicating to refer to progress notes. A progress note by the same LPN documented that the Reglan was pending delivery from the pharmacy, and there was no evidence in the record that the medication was ever administered or that the provider was notified that the ordered medication was not given. An inventory summary for the facility’s Pyxis automated dispensing machine showed that it routinely stocked at least three 5 mg Reglan tablets. In an interview, the LPN acknowledged that the Reglan was not administered and could not provide evidence of provider notification, and the Director of Nursing stated that Reglan is regularly stocked in the Pyxis and that she would have expected the medication to be administered as ordered and the provider notified and documentation completed if it was not.
Failure to Prevent Serving Allergen-Containing Food to Resident With Documented Tomato Allergy
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with a documented tomato allergy was not served tomato products. The resident, admitted in July 2024 with dementia, had an allergy to tomatoes recorded in the electronic health record as of 6/24/2025, with the severity listed as unknown. Despite this documented allergy, a progress note by the Nurse Practitioner dated 10/9/2025 at 10:30 AM states that the resident was noted to have eaten red tomato sauce in their food that afternoon, which they are allergic to, and that the resident required continued close monitoring for any signs and symptoms of allergic reaction. During a surveyor interview on 2/5/2026, the Director of Nursing Services acknowledged that the resident had a documented tomato allergy and should not have been served a tomato product. The deficiency was identified following a community-reported complaint submitted to the Rhode Island Department of Health on 1/27/2026 alleging that the resident experienced an acute medical episode as a result of an allergic reaction. The survey findings, based on clinical record review and staff interview, confirmed that the facility served food containing tomato sauce to the resident despite the known allergy documented in the resident’s record.
Failure to Prevent Administration of Unnecessary Antihypertensive Medications
Penalty
Summary
The facility failed to ensure that two residents' drug regimens were free from unnecessary drugs, specifically regarding the administration of antihypertensive medication. For one resident with a diagnosis of essential hypertension, a physician's order specified that Hydralazine 50 mg should be administered only if the systolic blood pressure (SBP) was greater than 160. However, medication administration records showed that the resident received Hydralazine multiple times when their SBP was below 160, with readings as low as 117. This was acknowledged by an LPN during a surveyor interview, confirming that the medication was given contrary to the physician's order. Another resident, also diagnosed with essential hypertension, had a physician's order for Hydralazine 25 mg every six hours, to be held if the SBP was less than 110. Despite this, records indicated that the medication was administered on several occasions when the resident's SBP was below 110, with readings as low as 88. This was similarly acknowledged by another LPN. The Director of Nursing Services was unable to provide evidence that these residents were free from unnecessary medications, as required.
Inadequate Pain Management and Medication Oversight
Penalty
Summary
The facility failed to provide adequate pain management for a resident who was admitted after undergoing extensive back surgery. Upon admission, the resident was supposed to receive oxycodone for pain management as per the hospital's Continuity of Care (COC) form, which indicated a dosage of one to two tablets every four hours as needed. However, the facility only administered one tablet of 5 mg oxycodone, even when the resident's pain was severe, reaching 8 out of 10 and 9 out of 10 on the pain scale. The facility did not have an order for the two-tablet dosage, which was necessary for severe pain, leading to the resident being transferred back to the hospital for pain management. Additionally, the facility failed to administer Decadron, a steroid medication prescribed to treat inflammation, as indicated in the hospital COC form. The medication was not transcribed or addressed with the provider, and the resident did not receive the scheduled dose. The oversight was acknowledged by the Regional Director of Nursing Services, who noted that the Decadron order was not listed in one section of the COC document but was present on another page. The Nurse Practitioner involved did not recall being informed about the Decadron order, contributing to the deficiency in the resident's care.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the lack of administration of prescribed medications upon admission. The resident, who had undergone extensive back surgery, was admitted to the facility with multiple diagnoses including fusion of the spine, radiculopathy, type II diabetes, high blood pressure, GERD, and hyperlipidemia. Despite having physician's orders for several medications, including Atorvastatin, Calcium Carbonate, Carvedilol, Polyethylene Glycol, Metformin, and Senna-Docusate Sodium, the resident did not receive these medications at the scheduled time on the day of admission. The report highlights that the facility's staff did not follow the established protocol for obtaining medications when they were unavailable. The Registered Nurse interviewed stated that she would check the Pyxis machine and notify the provider if a medication was unavailable, but there was no evidence that the provider was informed about the missed medication administrations. Additionally, the Registered Pharmacist confirmed that some of the medications were available in the Pyxis machine and others were available as facility stock, indicating a failure in the medication administration process. Further deficiencies were noted when a physician's order for Mounjaro, a medication for diabetes, was not administered as it was unavailable. The Licensed Practical Nurse responsible for administering the medication did not notify the resident's provider about the unavailability, which was acknowledged during a surveyor interview. The Regional Director of Nursing Services and the Nurse Practitioner both expressed expectations that the staff should have ensured the resident received the medications as ordered and communicated any issues to the provider, which did not occur in this instance.
Failure to Maintain Accurate Medical Records for Newly Admitted Resident
Penalty
Summary
The facility failed to accurately maintain the medical record of a newly admitted resident who had undergone extensive back surgery. Upon admission, the facility did not have the resident's medications available, leading to the resident being transferred back to the hospital for pain management on the same day. The resident's neurosurgeon had prescribed Decadron, a steroid medication, but the facility was unaware of this prescription. The resident was admitted with diagnoses including fusion of the spine and radiculopathy. A review of the hospital's Continuity of Care (COC) document indicated that the resident was to receive oxycodone for pain management, with a specific dosage that was not accurately reflected in the facility's records. Additionally, the COC form showed that the resident was to receive Decadron at a specific time, but there was no evidence in the facility's records that this medication was administered or addressed with the provider. During an interview, the Regional Director of Nursing Services acknowledged that the staff should have addressed the medication orders with the provider and documented the interaction, but was unable to provide evidence that the facility maintained accurate medical records.
Inadequate Ostomy Care Due to Incorrect Supplies
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for a resident with an ileostomy. The resident was admitted with an ileostomy and had a mid-abdominal wound and surgical wounds on the left lower abdomen. A complaint was submitted to the Rhode Island Department of Health alleging inadequate ostomy care. The facility's policy on colostomy and ileostomy care required proper application and documentation of ostomy appliances, but the facility did not have the correct supplies for the resident. The resident's family requested a hospital transfer due to concerns about ostomy and wound care, and the hospital confirmed that the ostomy appliance was not adhered properly, leading to stool leakage into a surgical wound. Interviews with facility staff revealed that the ostomy wafer did not adhere to the resident's skin, and the available appliance was not the correct size. Staff acknowledged redness and leakage around the peristomal area. The wound nurse confirmed that the wafer was leaking and had ordered a smaller size, but it was not available in time to prevent leakage. The Director of Nursing Services admitted that the resident did not receive the appropriate size ostomy supplies, resulting in fecal leakage into the abdominal wound.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to adhere to professional standards for labeling and storing drugs and biologicals in two of the three medication storage rooms observed. During a surveyor observation in the North Medication Storage Room, a vial of Tuberculin Purified Protein Derivative was found opened and undated. The Licensed Practical Nurse (LPN) present, Staff E, acknowledged the oversight and confirmed that the vial should have been dated upon opening. The manufacturer's instructions specified that the vial should be discarded 30 days after opening. In a separate observation in the East Medication Storage Room, a bottle of Ativan Intensol was also found opened and undated. LPN Staff F confirmed that the bottle should have been dated when opened. The instructions on the bottle indicated it should be discarded 90 days after opening. The Director of Nursing Services later confirmed that she expected all medication bottles to be dated once opened and acknowledged that both the Ativan Intensol and Tuberculin should be discarded.
Deficiencies in IV and Medication Administration Practices
Penalty
Summary
The facility failed to maintain professional standards of practice in the administration of intravenous (IV) antibiotics via a peripherally inserted central catheter (PICC) line for a resident diagnosed with bacteremia. During an observation, a Licensed Practical Nurse (LPN) did not assess for blood return before administering ampicillin intravenously, which is necessary to ensure the patency of the PICC line. Additionally, the LPN disconnected the IV tubing due to an infusion pump alarm and failed to scrub the needleless connector on the resident's catheter before reconnecting the IV tubing. Both the LPN and the Director of Nursing Services acknowledged these lapses in protocol during interviews. The facility also failed to adhere to medication administration instructions for a resident with dysphagia, who was supposed to receive medications in crushed form. A Certified Medication Technician administered whole tablets of Seroquel with cranberry juice, contrary to the special instructions to crush the medication. This deviation from the prescribed method of administration was acknowledged by the technician and the Director of Nursing Services during interviews.
Failure to Maintain Proper Catheter Care for Resident with SPC
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with a Suprapubic Catheter (SPC). The resident was admitted with a diagnosis of obstructive and reflux uropathy. According to the care plan and physician's orders, catheter care was to be provided every shift, and the catheter bag was to be maintained below the bladder level to prevent backflow of urine, which could increase the risk of catheter-associated urinary tract infections (CAUTI). However, during surveyor observations, the catheter bag was repeatedly found lying flat on the mattress next to the resident, contrary to the care plan instructions. Surveyor interviews with the resident and staff revealed a lack of adherence to the care plan. The resident was unaware of who placed the catheter bag on the mattress. Nursing Assistants and an LPN acknowledged the catheter bag should have been placed lower than the bladder level. The Assistant Director of Nursing Services also confirmed the improper placement of the catheter bag and stated that staff were expected to maintain it below the bladder level as per the care plan.
Inaccurate Medical Records and Advance Directives Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with urinary retention, as evidenced by conflicting physician orders regarding the size of the urinary catheter. The resident's physician order list contained multiple orders with different catheter sizes and balloon volumes, leading to confusion about the correct size to be used. During interviews, staff revealed that the resident's current catheter size was 18 Fr, and the order for 16 Fr should have been discontinued. This inconsistency in documentation indicates a lack of adherence to accepted professional standards for maintaining medical records. Additionally, the facility failed to accurately document the resident's advance directives. The resident was documented as having a Do Not Resuscitate order and No Artificial Nutrition directive. However, another resident's advance directives, indicating a Full Code Status and the administration of artificial nutrition via a feeding tube, were mistakenly uploaded into the resident's records. This error was acknowledged by the Director of Nursing Services, who confirmed the discrepancies in the resident's medical records regarding both the catheter orders and advance directives.
Deficiency in Call System Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a working call system was available and within reach for a resident, leading to a deficiency in providing adequate means for the resident to call for assistance. The policy titled Call Bell Policy requires staff to ensure the resident's safety by keeping the call bell within reach. However, during a surveyor observation, a resident was found yelling for help due to pain for half an hour because the call bell had fallen to the ground and was not accessible. The resident, who had intact cognition as indicated by a Brief Interview for Mental Status score of 15 out of 15, confirmed that the call bell was out of reach. A nursing assistant acknowledged the issue, and the Director of Nursing Services stated that the call bell should have been within the resident's reach.
Failure to Follow Physician Orders for Weight Monitoring
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by not following physician orders for obtaining daily weights for two residents. Resident ID #1, admitted with atherosclerotic heart disease and congestive heart failure, had a physician's order for daily weight monitoring to manage their condition. However, the daily weights were not obtained on several specified dates, and there was no evidence that the physician or nurse practitioner was notified of the missed weights. Similarly, Resident ID #2, who was admitted with congestive heart failure and supraventricular tachycardia, also had a physician's order for daily weight monitoring. The facility failed to obtain the resident's weights on multiple dates across November and December, and there was no documentation indicating that the physician or nurse practitioner was informed of these omissions. Interviews with staff revealed a lack of awareness regarding the necessity to report the inability to obtain weights, and the Director of Nursing Services expressed an expectation that weights should be obtained as ordered and reported if not.
Failure to Administer Prescribed Medications Upon Readmission
Penalty
Summary
The facility failed to obtain complete admission orders for a resident's immediate care upon readmission from the hospital, resulting in the resident not receiving prescribed medications. The resident, who had a history of congestive heart failure and persistent atrial fibrillation, was readmitted to the facility from the hospital but did not receive the necessary medications, including amiodarone, Anora Ellipta, and furosemide, for 16 days. This oversight occurred because the admitting nurse transcribed medication orders from a document listing medications prior to the hospital admission, rather than obtaining the correct discharge summary or continuity of care form. The deficiency was identified following a community-reported complaint to the Rhode Island Department of Health, which alleged that the resident was not administered the prescribed amiodarone upon readmission, leading to a return to the hospital. The facility's records lacked evidence of a hospital discharge summary or physician's orders for the medications dated on the day of readmission. Interviews with staff, including the Unit Manager and the Director of Nursing Services, confirmed that the correct discharge documents were not obtained, and the resident's medication orders were inaccurately transcribed from the wrong document. The resident was eventually transferred back to the hospital due to difficulty breathing, where it was confirmed that the missed medications contributed to the resident's condition. The hospital contacted the nursing facility regarding the missed discharge orders, highlighting the failure to administer the prescribed medications. The resident's physician expressed an expectation that the nurse should have contacted the hospital to request the correct continuity of care form and follow the instructions provided.
Resident Found in Bed with Dried Blood and Feces
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as evidenced by an incident where the resident was found in bed covered in a large amount of dried blood and feces. The resident, who had been readmitted to the facility with diagnoses including a joint implant, diabetes mellitus, and congestive heart failure, was receiving hospice care. A complaint was submitted to the Rhode Island Department of Health after the resident's family discovered the condition on October 6, 2024. A photograph accompanying the complaint showed the resident lying in bed with dark brown matter, which appeared to be dry and cracking, on both legs, the bed sheet, and the shirt. Interviews with staff revealed that a Licensed Practical Nurse (LPN) and two nursing assistants (NAs) were involved in cleaning the resident. Initially, the substance was thought to be feces, but during a shower, the LPN realized it was blood. The Director of Nursing Services indicated that NAs typically check on residents at the start of the shift, around dinner time, and around 10:00 PM, but there was no evidence that the resident was checked on at the start of the shift. The resident passed away on October 7, 2024, and was unable to be interviewed.
Failure to Administer Insulin Due to Unavailability
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of insulin. The resident, who was readmitted to the facility in September 2024 with conditions including type 2 diabetes mellitus and was receiving hospice care, had a physician's order for Humalog insulin to be administered at bedtime. However, the Medication Administration Record showed that the resident did not receive the prescribed insulin on four consecutive days, as it was documented as unavailable. There was no evidence that the provider was notified about the unavailability of the insulin during this period. Interviews with staff revealed a lack of communication and follow-up regarding the unavailability of the medication. A Licensed Practical Nurse admitted to not remembering if she contacted the pharmacy or the provider about the missing insulin. The Nurse Practitioner was unaware of the situation and stated that she would have expected the nurse to notify both the pharmacy and the provider. The Director of Nursing Services confirmed that the facility had an insulin emergency kit and that the order could have been adjusted if the Humalog kwikpen was unavailable, but there was no evidence of any such actions being taken.
Failure to Maintain Accurate Medication Records for Hospice Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was readmitted in September 2024 with conditions including a joint implant, diabetes mellitus, and congestive heart failure, and was receiving hospice care. The deficiency was identified during a record review which revealed discrepancies in the documentation of the resident's medication orders. Specifically, Health Status Notes written by a Nurse Practitioner on 9/30/2024 and 10/4/2024 indicated that the resident was to use Ativan for anxiety as part of hospice care, despite the fact that the Ativan order had been discontinued on 9/13/2024 and was not reordered until 10/6/2024. During interviews conducted by the surveyor, the Nurse Practitioner acknowledged the expectation that the resident would be on Ativan due to hospice care, but confirmed that there was no active order for the medication at the time of her notes. The Director of Nursing Services also stated that she would expect the Nurse Practitioner to review the resident's current medications during her visits. This oversight in maintaining accurate and complete medical records for the resident led to the identified deficiency.
Deficiency in Hospice Documentation for Resident
Penalty
Summary
The facility failed to ensure that hospice services met professional standards for a resident receiving hospice care. A physician's order was placed for a hospice evaluation and admission, and the resident began receiving hospice care shortly thereafter. The hospice plan of care indicated that the resident would be seen by a nurse multiple times a week initially, and then weekly for the following weeks. However, the facility did not have the necessary Hospice Recommendation forms on file, which are crucial for communicating recommendations and assessments made by hospice nurses. Interviews with hospice staff revealed that the resident was seen by hospice nurses on specific dates, but the required documentation was missing from the facility's records. The hospice nurse who saw the resident the day before their passing confirmed that she provided the necessary form to the facility, but it was not found in the resident's hospice binder. The Nurse Practitioner and the Director of Nursing Services both expressed expectations that the hospice documentation should be complete and available for review, highlighting the deficiency in maintaining proper records for hospice care provided to the resident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving two residents. Resident ID #2, who has a history of dementia and other mental health issues, pushed Resident ID #1 into a precaution bin, causing Resident ID #1 to fall and sustain a dislocated left shoulder. This incident was witnessed by a Nursing Assistant, Staff A, and reported to the Rhode Island Department of Health. The facility's internal investigation confirmed the incident, but the facility was unable to provide evidence that Resident ID #1 was kept free from abuse. Resident ID #1, who has Alzheimer's Disease and anxiety, was admitted to the facility in March 2021 and has a BIMS score indicating impaired cognition. Resident ID #2, admitted in March 2022, also has impaired cognition with a BIMS score of 7 out of 15. Despite the presence of cognitive impairments in both residents, the facility did not evaluate the effectiveness of interventions or provide immediate measures to ensure the safety of residents, leading to the failure to prevent resident-to-resident abuse.
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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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