The Friendly Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Woonsocket, Rhode Island.
- Location
- 303 Rhodes Avenue, Woonsocket, Rhode Island 02895
- CMS Provider Number
- 415044
- Inspections on file
- 26
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at The Friendly Home during CMS and state inspections, most recent first.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report highlights insufficient safety measures and lack of proper oversight, but does not specify particular incidents or resident details.
A resident with recent spinal surgery did not receive prescribed pain medications as ordered. The Buprenorphine patch was not available and was falsely documented as administered, while Dilaudid was given at half the prescribed dose on two occasions. Staff interviews and record reviews confirmed these discrepancies, and the DON acknowledged the failure to follow physician orders.
A facility failed to properly store and document controlled medications, as a Nursing Assistant improperly signed for Buprenorphine patches meant for a resident with chronic pain. The patches were not recorded in the controlled substance count book, and the nurse on duty did not recall receiving them. The Director of Nursing confirmed the breach in protocol.
A resident with hypertension and C. diff was administered Hydralazine outside of prescribed blood pressure parameters and received Senna Plus despite having diarrhea and an active C. diff infection. The facility staff failed to follow physician orders, and the APRN and Assistant Director of Nursing were unaware of these deviations.
A facility failed to notify a resident's representative of significant changes in medical treatment, including new medications and the insertion of a foley catheter, for a resident with moderately impaired cognition. Despite the facility's policy requiring such notifications, there was no evidence that the representative was informed. Interviews confirmed the lack of communication, with the representative expressing dissatisfaction, particularly regarding the foley catheter insertion.
The facility failed to ensure nursing staff had the necessary competencies for wound VAC, PICC line, and IV medication administration. Several RNs and LPNs hired between 2021 and 2023 lacked documented training and competency assessments. The Staff Development Coordinator and DON could not provide evidence of completed training during a surveyor's investigation.
The facility was found to have multiple food safety and hygiene deficiencies, including improper cold holding temperatures for meals, failure of staff to wear required beard restraints, and improper storage of staff lunches with resident desserts. These issues were acknowledged by the Food Service Director during the survey.
The facility did not conduct a thorough facility-wide assessment to determine necessary resources for resident care during routine and emergency operations. The assessment lacked details on resident care needs, staff competencies, physical environment, and cultural considerations. It also failed to document resources like equipment, services, personnel, and third-party agreements. The Administrator acknowledged these deficiencies.
The facility failed to follow physician's orders for wound care and monitoring, resulting in deficiencies for several residents. A resident with multiple diagnoses did not receive required body audits and wound care treatments, while another with mild cognitive impairment had unaddressed edema. Additionally, a resident with severe cognitive impairment had a skin tear without proper documentation or provider notification. These issues highlight lapses in care and monitoring by the facility staff.
The facility failed to follow physician's orders for two residents. One resident, with diagnoses including failure to thrive and malnutrition, had orders to offload heels while in bed, but observations showed this was not done. Another resident, with diabetes, had orders for blood sugar checks with specific reporting parameters, but elevated levels were not reported to the provider. The DNS confirmed these failures, with no explanations provided.
Two residents in an LTC facility did not receive proper pressure ulcer care. One resident with severe cognitive impairment was not consistently using a Heelz-up device as ordered, and records falsely indicated compliance. Another resident's wound care deviated from the physician's order, using an incorrect dressing. Staff interviews confirmed these discrepancies, and the DON could not explain the failures.
A facility failed to properly manage a resident's PICC line and IV antibiotic administration. The resident, with multiple health issues, had a PICC line dressing saturated with dried blood, which was not changed despite acknowledgment by an LPN. Additionally, an RN did not follow IV priming protocol, resulting in medication spillage and improper handling of IV tubing. The Director of Nursing expected adherence to protocols, which was not observed.
The facility failed to maintain proper infection control during wound care for two residents. An LPN and SDC did not adhere to contact precautions, failing to perform hand hygiene and clean equipment. In another case, an RN exited a resident's room wearing a soiled gown and used a gloved finger to pack a wound dressing. The DNS confirmed these lapses, indicating a deficiency in the infection prevention and control program.
A facility failed to conduct weekly skin audits for a resident as per physician's orders, despite signing off on them as completed. The resident, with diagnoses including tinea cruris and type 2 diabetes, was hospitalized for wounds and a change in mental status, indicating neglect in wound care. The DON acknowledged the missed audits, which contributed to the deficiency.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential accidents. Specific actions or omissions by staff or management that led to this deficiency are not detailed in the report, nor are any particular incidents or resident conditions described.
Failure to Administer Pain Medications per Physician Orders
Penalty
Summary
A deficiency was identified when a resident, recently readmitted with diagnoses including spinal fusion and orthopedic aftercare, did not receive prescribed pain management medications according to physician orders. The resident was ordered to receive a Buprenorphine patch on a specific date, but the medication was not available in the facility at the time, and a nurse signed off on the administration despite it not being given. This was confirmed through staff interviews and record reviews, which showed the patch was not applied as ordered. Additionally, the same resident was prescribed Dilaudid 4 mg by mouth every six hours as needed for pain, but records revealed that only 2 mg doses were administered on two occasions, contrary to the physician's order. Staff interviews confirmed that the lower dose was given, and the Medication Administration Record inaccurately reflected the administration of the full prescribed dose. The Director of Nursing acknowledged that the resident did not receive the medications as ordered.
Improper Handling of Controlled Medications
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with currently accepted professional principles, as evidenced by the mishandling of controlled medications. A review of the facility's policies revealed that only authorized, licensed nursing and pharmacy personnel should have access to controlled medications. However, a pharmacy shipping manifest showed that a Nursing Assistant (NA), Staff A, signed for the delivery of Buprenorphine patches, a controlled opioid medication, which is against the facility's policy. The controlled substance count book did not show evidence that the Buprenorphine patches had been received and added to the count, indicating a lapse in the proper documentation and handling of controlled substances. The incident involved a resident who was admitted to the facility with a chronic inguinal wound and pain to the left hip, for which a physician had ordered Buprenorphine patches. The patches were delivered to the facility, but the nurse on duty, Staff B, did not recall receiving them, and the NA who signed for them acknowledged that he should not have done so. The Director of Nursing Services confirmed that the NA improperly signed for the medication and that the controlled medication was not documented as received in the narcotic book, as required by the facility's policy.
Failure to Follow Physician Orders and Inappropriate Medication Administration
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice by not adhering to physician orders for a resident with hypertension and an active diagnosis of C. diff. The resident was admitted with diagnoses including hypertension and adult failure to thrive. A physician's order was in place for Hydralazine to be administered as needed for systolic blood pressure above 145. However, the medication was administered multiple times when the resident's blood pressure readings were below the specified parameters, indicating a failure to follow the physician's order. The Nurse Practitioner was unaware of this deviation, and the Assistant Director of Nursing could not provide evidence that the staff followed the order as written. Additionally, the resident was administered Senna Plus, a laxative, daily despite having diarrhea and a positive test result for C. diff. The administration of Senna Plus continued even after the resident's representative reported several loose stools, and a new physician's order was obtained to test for C. diff. The APRN stated that Senna Plus should not be administered during an active C. diff infection and was unaware that the resident was receiving it. The Assistant Director of Nursing confirmed that the medication was given despite the active diagnosis of C. diff and ongoing diarrhea, further highlighting the facility's failure to adhere to appropriate treatment protocols.
Failure to Notify Resident's Representative of Medical Changes
Penalty
Summary
The facility failed to notify the resident's representative of significant changes in the medical treatment of a resident with moderately impaired cognition, as indicated by a BIMS score of 9 out of 15. The resident, who was admitted with diagnoses including dementia and cognitive communication deficit, experienced several changes in medical treatment, including the initiation of new medications for high blood pressure and prostatitis, as well as the insertion of a foley catheter. Despite the facility's policy requiring notification of the resident's representative in such cases, there was no evidence that the representative was informed of these changes. Interviews with the resident's representative and facility staff confirmed the lack of communication regarding the resident's medical status changes. The representative expressed dissatisfaction with the facility's failure to communicate, particularly regarding the insertion of the foley catheter, which they would not have agreed to. Staff interviews revealed that the facility's policy mandates notifying the resident's representative of changes in medical status, especially for cognitively impaired residents, but this was not adhered to in this case.
Deficiency in Nursing Staff Competency and Training
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skills to provide safe and effective care to residents, as required by resident assessments and individual care plans. Specifically, the facility did not have evidence of completed competencies and skills sets for wound vacuum-assisted closure (Wound VAC) device management, peripherally inserted central catheter (PICC) line dressing changes, and intravenous (IV) medication administration for several licensed nurses. This deficiency was identified during a surveyor's review of records and interviews with staff members. The surveyor's investigation revealed that Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) hired between 2021 and 2023 had not completed the necessary training and competency assessments for these critical care procedures. During interviews, both the Staff Development Coordinator and the Director of Nursing Services were unable to provide evidence that the required education and competencies were completed before these nurses provided care. This lack of documentation and training was brought to the facility's attention by the surveyor, indicating a significant oversight in staff training and competency verification processes.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies observed during a survey. Firstly, the cold holding temperatures for turkey sandwiches and chef's salads were found to be significantly above the acceptable range, with temperatures recorded at 60 degrees F and 59 degrees F, respectively. This was observed during a lunch meal service on the North unit, and the Food Service Director acknowledged the discrepancy in temperature control. Additionally, the facility did not comply with the requirement for food employees to wear hair and beard restraints. A Dietary Aide, identified as Staff I, was observed on multiple occasions without a beard restraint while handling food and serving beverages. Furthermore, the facility improperly stored staff lunches in the same refrigerator as resident desserts, which is against the Rhode Island Food Code that mandates separate storage to prevent contamination. The Food Service Director confirmed the improper storage practice during an interview.
Facility Fails to Document Comprehensive Resource Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment, dated [DATE], was found lacking in several critical components. It did not adequately address the care required by the resident population, considering their diseases, conditions, physical and cognitive disabilities, and overall acuity. Additionally, the assessment failed to identify the staff competencies needed to provide the required level and types of care for the residents. Furthermore, the assessment did not include essential details about the physical environment, equipment, services, and other physical plant considerations necessary for resident care. It also overlooked any ethnic, cultural, or religious factors that might affect the care provided, including activities and food and nutrition services. The document lacked evidence of the facility's resources, such as medical and non-medical equipment, services like physical therapy and pharmacy, personnel details, and agreements with third parties for services or equipment during normal and emergency operations. During an interview, the Administrator acknowledged these deficiencies in the facility assessment.
Deficiencies in Wound Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician's orders for several residents, leading to deficiencies in wound care and monitoring. Resident ID #273, who was readmitted with multiple diagnoses including an abscess and cellulitis, did not receive the required admission and weekly body audits as ordered. Additionally, the wound care treatments for this resident's right foot and heel were not completed as per the physician's orders, resulting in a lack of wound dressing changes for several days. Staff C admitted to signing off on these tasks without completing them, and was unaware of the resident's wound conditions due to not performing any assessments or treatments. Another deficiency was identified with Resident ID #64, who was admitted with hypertension and exhibited mild cognitive impairment. The resident was observed with mild edema in the lower legs and ankles over several days, yet there was no documentation or interventions recorded in the resident's file. Staff D was unaware of the edema and had not notified the resident's provider, leading to a delay in obtaining necessary physician's orders to address the condition. Resident ID #90, with severe cognitive impairment and neuropathy, was found with a bandage on the left shin without any documentation or orders explaining its presence. The bandage covered a scab and a skin tear, which appeared wet and soggy. Staff D acknowledged the lack of documentation and provider notification regarding the open area. The facility only obtained treatment orders for the skin tear after the surveyor brought it to their attention, indicating a failure to monitor and address the resident's skin integrity as per the care plan.
Failure to Follow Physician's Orders for Heel Offloading and Glucose 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's orders for two residents. Resident ID #73, who was readmitted with diagnoses including adult failure to thrive and malnutrition, had a physician's order to offload bilateral heels while in bed. However, surveyor observations over several days revealed that the resident's heels were not offloaded and were resting directly on the mattress. Interviews with the registered nurse and the Director of Nursing Services (DNS) confirmed the failure to follow the physician's order, with no explanation provided for the oversight. Additionally, Resident ID #85, admitted with a diagnosis of diabetes, had a physician's order for blood sugar checks twice a day with instructions to call the provider if levels were below 50 mg/dl or above 250 mg/dl. The September 2024 Treatment Administration Record showed multiple instances of blood sugar levels exceeding 250 mg/dl, yet there was no evidence that these were reported to the provider as required. The DNS acknowledged that the elevated blood sugar levels were not reported to the physician, despite expectations that staff would adhere to the physician's order.
Failure to Follow Pressure Ulcer Care Protocols
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for two residents, leading to deficiencies in treatment and prevention of pressure ulcers. Resident ID #35, who has severe cognitive impairment and was readmitted with an unstageable pressure ulcer on the right heel, was observed multiple times with their heels resting directly on the mattress, despite a physician's order to use a Heelz-up device to offload pressure. The treatment administration records inaccurately indicated that the device was used, and there was no evidence of resident refusal. Interviews with staff confirmed the non-compliance with the physician's order, and the Director of Nursing Services could not explain the oversight. Resident ID #103, admitted with a right femur fracture and muscle wasting, had a physician's order for specific wound care involving Vashe, medi-honey mixed with collagen powder, and a foam bordered dressing. However, during an observation, the registered nurse deviated from the prescribed treatment by using Puracol Plus AG with silver instead of the ordered medi-honey and collagen powder mixture. The nurse acknowledged the deviation, and the Director of Nursing Services was unable to provide an explanation for not following the physician's order.
Deficiency in PICC Line Management and IV Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice regarding the management of a peripherally inserted central catheter (PICC) for a resident receiving intravenous (IV) antibiotic treatment. The resident, who was readmitted with conditions including an abscess, cellulitis, an ulcer, and diabetes mellitus, had physician orders for regular assessment of the PICC site and measurement of the external catheter. However, the facility's records showed that these measurements were signed off as completed without documentation. During an observation, the resident's PICC line dressing was found to be saturated with dried blood, and the dressing was not adhering properly to the skin. Despite acknowledgment from a Licensed Practical Nurse (LPN) that the dressing needed changing, there was no evidence that the dressing was changed or that the status of the PICC was documented. Additionally, during a medication administration task, a Registered Nurse (RN) failed to follow the facility's policy for priming the IV tubing, resulting in medication spilling onto the cart. The RN also placed uncapped IV tubing on the resident's bed, which is against protocol. The PICC line dressing was observed to have light red drainage, indicating a need for a dressing change, which was not documented as completed. The Director of Nursing Services expressed that it was expected for the IV to be primed per policy and for the PICC line dressing to be changed when necessary, but these expectations were not met as per the observations and record reviews.
Infection Control Lapses in Wound Care Procedures
Penalty
Summary
The facility failed to maintain proper contact precautions for a resident with MRSA in the nares and VRE in a wound. During a surveyor observation, a Licensed Practical Nurse (LPN) and the Staff Development Coordinator (SDC) were observed conducting wound care without adhering to infection control protocols. The LPN did not remove gloves or perform hand hygiene after handling personal items, and the SDC failed to clean scissors and surfaces before and after the procedure. The SDC also handled wound vac tubing without gloves and did not clean the equipment or surfaces before exiting the resident's room. In another incident, a Registered Nurse (RN) was observed performing wound care on a resident with a displaced fracture of the femur. The RN exited the resident's room wearing a soiled gown to retrieve additional supplies, failing to perform hand hygiene. Upon returning, the RN continued the procedure with the same gown and used a gloved finger to pack the wound dressing instead of a sterile implement like a q-tip. The RN acknowledged these lapses in protocol during a surveyor interview. The Director of Nursing Services (DNS) confirmed that the staff did not follow expected infection control practices. The DNS stated that the LPN and SDC should have performed hand hygiene and cleaned equipment and surfaces, while the RN should have used a q-tip for wound packing and removed the gown before leaving the room. These deficiencies highlight lapses in maintaining an effective infection prevention and control program, particularly in wound care procedures.
Failure to Conduct Weekly Skin Audits
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding skin assessments. A review of the facility's policy on skin protocol indicated that weekly skin observations were required for every resident, with documentation maintained in the residents' medical records. However, for one resident, there were seven weeks of missed skin audits, despite a physician's order for weekly body audits every Friday. These audits were signed off as completed in the Treatment Administration Record, but there was no evidence of the audits being conducted on the specified dates. The resident in question was readmitted to the facility with diagnoses including tinea cruris and type 2 diabetes. A community-reported complaint alleged that the resident was hospitalized for wounds and a change in mental status, suggesting neglect due to improper wound care. The resident was later seen by a wound physician for worsening wounds, resulting in new treatment orders. The Director of Nursing Services acknowledged during an interview that the weekly skin audits were not completed as ordered, contributing to the deficiency in care.
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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