Woonsocket Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Woonsocket, Rhode Island.
- Location
- 262 Poplar Street, Woonsocket, Rhode Island 02895
- CMS Provider Number
- 415041
- Inspections on file
- 22
- Latest survey
- April 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Woonsocket Health Center during CMS and state inspections, most recent first.
Surveyors identified multiple food service safety violations, including a dietary aide preparing food without a beard restraint, an ice machine drainage pipe lacking the required air gap, and ice build-up from a leaking freezer fan contaminating an unsealed box of cheddar cheese omelets. The Food Service Director confirmed each of these deficiencies during interviews.
The facility failed to ensure safe and appropriate dialysis care for a resident on peritoneal dialysis by not maintaining required physician orders, documentation, and monitoring, and for two residents on hemodialysis by not administering or notifying providers about missed medications and supplements on dialysis days, in violation of facility policy and professional standards.
The facility did not implement required antibiotic reviews or time outs for residents prescribed antibiotics for conditions such as cellulitis, surgical wound infection, elevated WBC, and endocarditis. Medical records lacked documentation of antibiotic reassessment, and both the Infection Preventionist and DON confirmed that these reviews were not completed, reflecting a failure to follow the facility's antibiotic stewardship protocols.
Surveyors found that the facility did not document whether several residents received, refused, or had contraindications to pneumococcal vaccination. Immunization records for these residents lacked evidence of the required vaccines being offered or administered, and staff interviews confirmed that documentation was missing until the issue was identified during the survey.
A resident with a stage III coccyx pressure ulcer and low body weight was found lying on an air mattress set to an inappropriate weight setting, causing discomfort and pain. The mattress was set to 'firm' or 'max inflate' at 350 lbs, despite the resident weighing 98.5 lbs. There was no physician order or care plan for the air mattress, and both an LPN and the DON confirmed these omissions when interviewed.
A resident with end stage renal disease and anxiety related to dialysis did not receive prescribed Lorazepam on multiple occasions because the medication aide failed to notify the charge nurse about the need for a new prescription, and the pharmacy did not deliver the medication without it. This lapse in communication among staff resulted in missed doses as ordered by the provider.
The Medical Director failed to implement a resident care policy for the transcription and implementation of orders, leading to inconsistencies in how orders were documented and coordinated. Staff interviews revealed a lack of standardized procedures, and there was no evidence of comprehensive training for all nurses on the use of the verbal/telephone order book.
The facility failed to maintain a sanitary environment in four kitchenettes. Observations revealed food debris, sticky substances, and accumulated dirt in various appliances and surfaces. The Director of Environmental Services acknowledged the need for cleaning.
The facility failed to implement comprehensive care plans for three residents on anticoagulation therapy, specifically in monitoring for signs of abnormal bleeding. Despite having care plans that included interventions to observe for symptoms like unexplained bruising and nosebleeds, there was no evidence that these plans were being followed, as confirmed by staff interviews and record reviews.
The facility failed to follow its emergency cart equipment procedure, resulting in missing essential items and empty oxygen tanks. Additionally, the facility did not follow psychiatric consultant orders for a resident, leading to missed lab tests and unreported low valproic acid levels.
The facility failed to act on a pharmacist's recommendation to monitor a resident's phenytoin trough concentration in a timely manner. Despite the nurse practitioner authorizing the test, it was not conducted until over a month later, revealing a high concentration of the medication. Interviews confirmed that the test should have been done shortly after the order was given.
The facility failed to administer medications as ordered for two residents. One resident with serious conditions did not receive Lasix and Potassium, despite their availability, and expired shortly after. Another resident missed multiple doses of essential medications, and the provider was not notified in a timely manner. The Director of Nursing Services acknowledged these failures.
The facility failed to promptly identify and intervene for acute changes in a resident's condition, leading to the resident's death. Despite significant findings from a chest X-ray, ordered medications were not administered, and emergency services were not called. Interviews revealed a lack of communication and failure to follow protocols.
The facility failed to provide appropriate catheter care for two residents. One resident's urine output was not consistently documented, and another resident's suprapubic catheter was not changed monthly as required. Both the LPN and DON acknowledged these deficiencies during the surveyor interviews.
A facility failed to ensure a resident with a G-tube received appropriate care by not maintaining the head of the bed at 30 degrees as required by the care plan and physician's orders. The resident was found lying flat during tube feeding, and staff acknowledged the oversight.
The facility failed to ensure that nursing staff had the appropriate competencies to provide care for a resident with a change in condition, leading to inadequate response to the resident's respiratory distress and hypoxia. The resident, who had multiple diagnoses including COPD, was not properly assessed or treated, and the Nurse Practitioner was not notified in a timely manner. The facility lacked evidence of training and competencies related to changes in condition for the involved nursing staff.
Food Service Safety and Sanitation Deficiencies in Main Kitchen
Penalty
Summary
Surveyor observations in the main kitchen revealed several failures to comply with professional food service safety standards. A dietary aide with full facial hair was observed preparing food on two separate occasions without wearing a required beard restraint, as mandated by the Rhode Island Food Code. The Food Service Director (FSD) confirmed during interviews that the staff member was not in compliance with the beard restraint requirement. Additionally, the ice machine's drainage pipe was found inserted directly into the floor drain without the required minimum one-inch air gap, a violation of plumbing code designed to prevent contamination. The FSD acknowledged this deficiency. Furthermore, in the walk-in freezer, surveyors observed a significant ice build-up from the freezer fan dripping onto an unsealed box containing an opened package of cheddar cheese omelets. The FSD confirmed the presence of the leak and the ice accumulation on the food packaging, stating that the food should be discarded.
Failure to Provide Safe and Appropriate Dialysis Care and Medication Administration
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for residents requiring peritoneal dialysis (PD) and hemodialysis, as evidenced by multiple deficiencies in following professional standards, facility policy, and physician orders. For one resident on PD, there was no individualized physician order specifying the dialysis prescription details such as number of cycles, fill volume, dwell time, glucose concentration, or technique, despite facility policy requiring this information. Staff interviews confirmed that the PD prescription was managed remotely by an offsite dialysis nurse and not documented in the resident's medical record. Additionally, the facility did not obtain or document a full set of vital signs before, during, and after PD treatments, nor did they consistently assess or document the resident's stability, level of consciousness, comfort, or signs of complications as required by policy. Further deficiencies were noted in the documentation and handling of PD therapy. The facility did not maintain a resident binder in the room to record required information such as initial drain volume, total ultrafiltration, or average dwell time. Staff reported that fluid from the PD machine was routinely drained directly into the toilet rather than into a collection bag as specified in policy, with the tubing sometimes coming into contact with toilet water. The Director of Nursing Services was unaware of the resident's PD prescription and could not provide evidence of required documentation or adherence to policy regarding monitoring and documentation of the PD process and catheter site. For two residents receiving hemodialysis, the facility failed to administer or offer multiple prescribed medications and nutritional supplements on dialysis days, as documented in the Medication Administration Records. There was no evidence that the physician or dialysis center was notified of these missed medications. Staff and nurse practitioners confirmed that they were not informed of the missed doses and would have expected to be notified to adjust medication timing. The facility was unable to provide evidence of effective communication with the dialysis center or providers regarding these missed medications, as required by physician orders and facility policy.
Failure to Monitor and Reassess Antibiotic Use
Penalty
Summary
The facility failed to establish and implement an effective Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program with protocols and a system to monitor antibiotic use. Specifically, for four residents who were prescribed antibiotics for various conditions—including cellulitis, surgical wound infection, elevated white blood cell count, and endocarditis—there was no evidence in the medical records of an antibiotic review or an antibiotic time out being conducted as required by facility policy and CDC guidelines. The policy required reassessment of antibiotic therapy within 2-3 days of initiation to determine appropriateness, but this process was not documented for any of the residents reviewed. Interviews with the Infection Preventionist and the Director of Nursing Services confirmed that antibiotic time outs were not being completed, and neither could provide evidence that such reviews had occurred for the residents in question. The lack of documentation and process for antibiotic review was consistent across all four cases reviewed, indicating a systemic failure to monitor and reassess antibiotic use as part of the facility's infection control practices.
Failure to Document Pneumococcal Vaccination Status in Resident Records
Penalty
Summary
The facility failed to ensure that the medical records of four residents included documentation regarding the administration, refusal, or contraindication of the pneumococcal vaccination. Record reviews for these residents, who were admitted or readmitted between July 2024 and October 2023, did not show evidence that the pneumococcal vaccines (PCV13, PCV15, PCV20, or PPSV23) were offered, received, or declined. This lack of documentation was identified during a review of immunization records. During interviews, the Infection Preventionist stated that pneumococcal vaccinations are typically administered soon after consent is obtained at admission, but was unable to provide documentation for the affected residents. The Director of Nursing Services also could not provide evidence that the required immunization documentation was present in the residents' medical records until the issue was brought up by surveyors.
Failure to Provide Proper Pressure Ulcer Care and Mattress Management
Penalty
Summary
A resident with a history of a sacral pressure ulcer and low body weight was readmitted to the facility and was found to have a stage III pressure ulcer on the coccyx. The facility's policy states that a low air loss mattress should be used to provide therapeutic benefits for residents at risk for or suffering from pressure ulcers. However, during multiple observations, the resident was found lying on an air mattress that was set to 'firm' or 'max inflate' at a setting of 350 lbs, which was not appropriate for the resident's actual weight of 98.5 lbs. The resident reported discomfort, describing the mattress as hard and lumpy, and stated that frequent repositioning was necessary due to pain from the wound. Record review revealed there was no physician order or care plan in place for the use of the air mattress for this resident. Interviews with an LPN and the Director of Nursing confirmed that the mattress was not set according to the resident's weight and that neither a care plan nor a physician order for the air mattress was in place until after the issue was identified by the surveyor.
Failure to Administer Prescribed Lorazepam Due to Communication Breakdown
Penalty
Summary
A deficiency occurred when a resident with diagnoses including end stage renal disease, dependence on renal dialysis, and anemia did not receive Lorazepam as ordered prior to dialysis sessions. The physician had prescribed Lorazepam 1 mg to be administered once a day on Monday, Wednesday, and Friday before dialysis to address the resident's increased anxiety related to the procedure. However, review of the March 2025 Medication Administration Record showed that the medication was not administered on several specified dates. Interviews with staff revealed that the pharmacy did not deliver the Lorazepam because a new prescription was not received until later in the month. The Director of Nursing Services confirmed that the medication aide failed to communicate the need for a new prescription to the charge nurse, resulting in the resident not receiving the medication as ordered. The lack of timely communication between staff and the provider led to the failure to obtain and administer the medication as prescribed.
Failure to Implement Resident Care Policy for Order Transcription and Implementation
Penalty
Summary
The Medical Director failed to implement a resident care policy to coordinate care for residents related to the transcription and implementation of orders by providers. The facility's policy required that orders be accurately completed and entered into the Electronic Medication Administration Record (EMAR) by authorized staff. However, interviews with various staff members, including Licensed Practical Nurses (LPNs), Registered Nurses (RNs), Nurse Practitioners (NPs), and the Medical Director, revealed inconsistencies in the process of transcribing and implementing orders. Some staff members indicated that orders were written on lab slips, while others mentioned the use of a verbal/telephone order book, and some orders were verbally communicated without being transcribed into the book or EMAR promptly. This inconsistency led to a lack of proper documentation and coordination of medical care for residents. The facility's assessment highlighted the importance of having adequately trained medical practitioners and written guidance regarding current regulations and protocols developed by the Medical Director. Despite this, the surveyor interviews revealed that the Medical Director and other staff members were not fully aware of or did not consistently follow the established protocols for transcribing and implementing orders. The Director of Nursing Services and the Administrator also confirmed that there was no evidence of comprehensive education and training for all nurses regarding the use of the verbal/telephone order book. The deficiency was further evidenced by the lack of a standardized process for handling orders, as described by various staff members. The Medical Director's oversight was insufficient in ensuring that all staff members were educated and trained on the proper procedures for transcribing and implementing orders. This failure to implement and enforce a consistent policy for order transcription and implementation compromised the coordination of medical care for residents in the facility.
Facility Fails to Maintain Sanitary Kitchenettes
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment in four observed kitchenettes. On the 1st floor, the [NAME] Point unit kitchenette had a toaster oven with a buildup of food debris. On the 2nd floor, the Cold Spring Place kitchenette had a freezer with brown debris and a dry sticky red substance, a refrigerator with a red sticky substance, and a toaster oven with food debris. The Park Square unit kitchenette on the same floor had a countertop with a brown sticky substance, a microwave with brown food debris, flooring with brown and gray substances, a freezer with brown debris and a dry sticky brown substance, a refrigerator with a dry white substance and sticky yellow and red substances, and a toaster oven with food debris. On the 3rd floor, the [NAME] Hill unit kitchenette had a freezer with a dry sticky brown substance and a refrigerator with a clear sticky substance along the bottom drawers, shelving, and drawer handle. The toaster oven in this kitchenette also had a buildup of food debris. During an interview, the Director of Environmental Services acknowledged these observations and indicated that the areas needed to be cleaned.
Failure to Implement Anticoagulation Therapy Monitoring
Penalty
Summary
The facility failed to implement comprehensive person-centered care plans for three residents receiving anticoagulation therapy, specifically in monitoring for signs and symptoms of abnormal bleeding. Resident ID #48, admitted with diagnoses including a fracture of the left tibia and hypertension, had a care plan that included monitoring for abnormal bleeding due to anticoagulation therapy. However, there was no evidence that this care plan was being implemented, as confirmed by a registered nurse during a surveyor interview. Similarly, Resident ID #62, admitted with conditions such as an intertrochanteric fracture of the right femur and pulmonary embolism, had a care plan to monitor for abnormal bleeding, but again, no evidence was found that this was being followed, as confirmed by staff during an interview. Lastly, Resident ID #118, who had diagnoses including venous thrombosis and gastrointestinal hemorrhage, also had a care plan to monitor for abnormal bleeding. The Director of Nursing Services acknowledged that the care plans for these residents were not being implemented as required. The deficiency was identified through record reviews and staff interviews, which revealed that the facility's policy on anticoagulation therapy monitoring was not being followed. The care plans for the residents included specific interventions to observe for signs of abnormal bleeding, such as unexplained bruising, nosebleeds, and bleeding gums. Despite these documented interventions, there was no evidence that the staff were actively monitoring the residents for these symptoms. The Director of Nursing Services confirmed the lack of implementation of the care plans during a surveyor interview, acknowledging that the residents were receiving anticoagulant medications but were not being adequately monitored for potential side effects as outlined in their care plans.
Failure to Follow Emergency Cart Procedures and Psychiatric Consultant Orders
Penalty
Summary
The facility failed to meet professional standards of quality by not following its emergency cart equipment procedure for four out of four emergency carts observed. Specifically, the emergency carts were missing essential items such as a blood spill kit, normal saline, an ambu bag, a canister for the suction machine, and non-rebreather masks. Additionally, some oxygen tanks were found to be empty or nearly empty. These deficiencies were acknowledged by the respective staff members present during the surveyor observations. The Director of Nursing Services was unable to provide evidence that the 11:00 PM to 7:00 AM nurse checks the emergency cart nightly to ensure all equipment is available. The facility also failed to follow psychiatric consultant orders for a resident admitted with anxiety and depression. The geriatric psychiatry recommendation to check valproic acid level and liver function tests was not transcribed or completed as ordered. This oversight was only identified when brought to the facility's attention by the surveyor. The Director of Nursing Services acknowledged that the orders for the labs were missed, and they weren't completed until after the surveyor's intervention. The resident's valproic acid level was found to be below the therapeutic range, and there was no evidence that this low level was reported to the Nurse Practitioner prior to the surveyor's notification.
Failure to Act on Pharmacist's Recommendation for Phenytoin Monitoring
Penalty
Summary
The facility failed to ensure that irregularities identified by the Clinical Consultant Pharmacist during the monthly Medication Regimen Review (RR) were acted upon for a resident taking phenytoin, a medication used to control seizures. The resident, who was readmitted to the facility with diagnoses including vascular dementia and epilepsy, had a recommendation from the pharmacist to monitor phenytoin trough concentration. This recommendation was accepted and authorized by the nurse practitioner, but the order was not processed in a timely manner. The phenytoin trough level was not obtained until over a month later, revealing a high concentration of the medication. Interviews with the nurse practitioner and the Director of Nursing Services confirmed that the phenytoin trough level should have been obtained shortly after the order was given. The delay in obtaining the phenytoin concentration resulted in a high level being detected, which could have been avoided with timely monitoring. The facility's failure to act promptly on the pharmacist's recommendation led to this deficiency.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to keep residents free from significant medication errors for two residents. Resident ID #118, who had diagnoses including hypertensive heart disease and chronic obstructive pulmonary disease, was observed with labored breathing and other symptoms. A STAT chest x-ray revealed several serious conditions, and the physician ordered Lasix and Potassium. However, the medications were not administered as ordered, despite being available in the facility. The resident expired shortly after the missed doses, and interviews with staff confirmed the expectation that the medications should have been administered promptly. Resident ID #119, admitted with diagnoses including hepatic encephalopathy, essential tremor, COVID-19, and alcoholic cirrhosis of the liver, also experienced significant medication errors. The resident missed multiple doses of prescribed medications, including Xifaxan, Lactulose, Benztropine, and Lagevrio. The record review failed to show evidence that the provider was notified of the missed doses in a timely manner. The Director of Nursing Services acknowledged the missed doses and confirmed that the provider should have been notified if medications were unavailable and not administered as ordered.
Failure to Promptly Identify and Intervene in Resident's Acute Change in Condition
Penalty
Summary
The facility failed to promptly identify and intervene for acute changes in a resident's condition, leading to the death of a resident with a history of COPD, heart disease, and gastrointestinal hemorrhage. The resident exhibited labored breathing, abdominal distention, and abnormal vital signs, but the LPN did not notify the NP, expecting her to complete her routine rounds. The chest X-ray revealed significant findings, including pneumonia and congestive heart failure, but the ordered medications were not administered promptly. On the morning of the resident's acute change, the Nursing Assistant notified the LPN, who assessed the resident but did not contact the NP. The NP was only informed during her routine visit later that day. Despite the critical findings from the chest X-ray, the medications Lasix and KCL were not administered as ordered. The resident's condition deteriorated, and emergency services were not called, leading to the resident's death. Interviews with staff revealed a lack of communication and failure to follow protocols for acute changes in condition. The resident's Primary Care Provider and the Medical Director both indicated that they would have expected the resident to be sent to the hospital given the severity of the condition. The Director of Nursing Services acknowledged the failure to promptly identify and intervene in the resident's acute change in condition.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for two residents with suprapubic catheters. Resident ID #78, admitted with chronic kidney disease, urinary tract infection, hematuria, and obstructive and reflux uropathy, had a physician's order to empty the Foley drainage bag every shift. However, the facility did not consistently document urine output measurements as required. Out of 90 opportunities, 27 instances lacked documentation, and 17 instances recorded urine output inaccurately using terms like small, medium, or large instead of precise measurements. The Director of Nursing Services could not provide evidence of proper documentation during the surveyor interview. Resident ID #115, admitted with a disorder of the urinary system, urinary tract infection, obstructive and reflux uropathy, and urine retention, had a suprapubic catheter in place. The facility failed to maintain a current order to change the suprapubic catheter monthly. The last recorded change was on 3/21/2024, and there was no current order for subsequent changes. Both the Licensed Practical Nurse and the Director of Nursing Services acknowledged the absence of a current order during their interviews with the surveyor.
Failure to Maintain Proper Bed Elevation for Resident with G-Tube
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube (G-tube) received appropriate treatment and services to prevent complications. The resident, who was readmitted to the facility in January 2024 with diagnoses including adult failure to thrive and gastro-esophageal reflux disease, had a care plan and physician's orders specifying that the head of the bed (HOB) should be elevated at 30 degrees continuously during tube feeding to prevent aspiration. However, during a surveyor observation on April 22, 2024, the resident was found lying flat in bed while the tube feeding was running, contrary to the prescribed orders and care plan instructions. A registered nurse acknowledged the oversight and immediately corrected the bed position, but this indicated a lapse in following the prescribed care plan and physician's orders for the resident's safety and well-being. Further interviews with the Director of Nursing Services confirmed that the expectation was for the HOB to remain elevated at 30 degrees or more for residents receiving continuous tube feeding. The Director was unable to provide evidence that the resident had consistently received the appropriate treatment to prevent complications related to tube feedings. This deficiency highlights a failure in adhering to established protocols and ensuring the resident's care plan was properly implemented to prevent potential complications such as aspiration.
Failure to Ensure Nursing Staff Competencies
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to provide nursing and related services to assure resident safety, as identified in the plan of care for a resident with a change in condition. The resident, who had diagnoses including gastrointestinal hemorrhage, hypertensive heart disease without heart failure, and COPD, was observed with labored breathing and a grossly distended abdomen. The following day, the resident was found cold, clammy, and non-responsive, with a pulse oximetry reading of 68% on room air. Despite being placed on a non-rebreather mask with oxygen, the resident's condition did not improve, and they were pronounced dead shortly after. There was no evidence that the Nurse Practitioner was notified of the resident's change in condition at the time of the assessments. Interviews with the Nurse Practitioner and Medical Director revealed that they were not informed of the resident's respiratory distress and hypoxia in a timely manner. The facility's Education Coordinator was unable to provide evidence of education or competencies related to changes in condition for the nurses who cared for the resident. The Director of Nursing Services was also unaware that assessment and early identification of problems were part of the staff training and competencies section of the facility assessment. This lack of appropriate training and competency assessment contributed to the failure to provide adequate care for the resident during a critical change in condition.
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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