Citations in Rhode Island
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Rhode Island.
Statistics for Rhode Island (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Rhode Island
A resident with dementia and severe cognitive impairment, care-planned for sexually inappropriate behavior and to be seated away from the opposite gender, was instead seated between two residents of the opposite gender in a community room while two staff members were present. Another cognitively impaired resident with behavioral disturbances struck this resident in the eye and forehead, causing a laceration and a bleeding scratch. Staff interviews confirmed that the two residents were known not to get along and that the resident with sexually inappropriate behaviors was supposed to be kept away from the opposite gender, yet the DON and Administrator could not provide evidence that this care plan intervention was followed or that the resident was kept free from physical abuse.
The facility failed to maintain a safe, functional, sanitary, and comfortable environment when roof leaks allowed brown water to penetrate ceiling tiles and overhead light fixtures on a second-floor care area. Towels, buckets, and laundry carts were placed in hallways and outside rooms to collect actively leaking water, leaving floors wet and slippery while many cognitively impaired residents sat or ambulated nearby. The Maintenance Assistant acknowledged the leak had started the prior day and that he had not yet removed snow from the roof as instructed, while the Administrator and Director of Operations confirmed awareness of the worsening leaks but could not show evidence of effective immediate interventions. Authorities later found water inside the second-floor fire panel, which appeared tampered with, and ordered evacuation of residents after determining the environment was unsafe.
A resident with end-stage renal disease, anemia, and full dependence for ADLs, but cognitively intact, was physically assaulted by a roommate with a known history of anxiety, delusional disorder, agitation, and aggressive behaviors. The aggressive resident had documented episodes of throwing meal trays, restlessness, and non-compliance with redirection and medications, and a physician’s order required behavior monitoring and shift-by-shift documentation. On the day of the incident, staff heard screaming and found one resident in a wheelchair with facial swelling and bloody, lacerated lips, while the roommate stood nearby holding a meal tray; both residents later confirmed that the roommate had punched the victim multiple times. Despite prior behavioral concerns and care plan interventions directing staff to intervene, monitor, and document behaviors, the behavior record for that day did not reflect the aggressive episode, and leadership and staff acknowledged awareness of the aggressor’s history of aggression and prior physical aggression toward the victim.
A resident with a history of an unwitnessed fall and confusion was evaluated for underlying causes, and after contaminated clean-catch urine specimens, a straight-catheter specimen confirmed a UTI with significant bacterial growth. The NP ordered IV vancomycin with trough monitoring before the fourth dose and a target range of 15–20 mg/L, but staff did not obtain trough levels at three ordered intervals, and the first level drawn was subtherapeutic, leading to a dose increase. The resident completed the antibiotic course and later experienced another fall with genital bleeding, altered status, and inability to stand, and was transferred to the hospital where sepsis with a urinary source was identified; the DON could not show evidence that appropriate treatment and services had been provided, and a pharmacy representative noted that subtherapeutic vancomycin levels increase the chance of not eradicating infection.
A resident with ESRD on hemodialysis and dependent on staff for all ADLs had a physician order for Sevelamer 3200 mg TID with meals to treat hyperphosphatemia, with the care plan directing coordination of medications with dialysis days. Over a three‑month period, MAR review showed 27 missed doses of Sevelamer. Lab results from the dialysis center documented rising phosphorus levels during this time. Facility nursing staff reported the drug was unavailable and placed on hold, and the DON was initially unaware that the medication supply came from the dialysis center. Dialysis center staff stated they were not informed the resident had run out of Sevelamer, despite being the supplier, and the NP attributed the increased phosphorus levels to the resident not receiving the medication.
A resident with sepsis, bacteremia, and a recent UTI was prescribed IV vancomycin 1 g every 12 hours for 12 days, for a total of 24 doses, under the facility’s antibiotic stewardship policy. An Antibiotic Time Out was completed by the IP and reviewed with the resident’s NP, but the December MAR showed the resident actually received 25 doses. In interviews, the NP reported being unaware of the extra dose, and the IP acknowledged that the antibiotic time out failed to identify the additional scheduled dose. This reflects a failure of the facility’s IPCP and antibiotic stewardship program to effectively monitor and control antibiotic use as ordered.
A resident with hypo-osmolality, hyponatremia, and psychogenic polydipsia had physician and NP orders for a 1500 mL/day fluid restriction with specific allocations per meal and nursing shift, and instructions for staff to monitor and document daily fluid intake. NAs reported they did not document or communicate fluid amounts for residents, while an LPN indicated that intake was marked as completed in the TAR without recording actual volumes. Record review showed only check marks for completion of the fluid restriction order, with no per-shift intake amounts documented, contrary to the detailed physician order and the expectations of the Medical Director and Administrator.
A Registered Nurse on an overnight shift failed to complete the medication pass and required treatments, monitoring, and documentation for most residents under her care. Record review showed that medication and treatment orders were not carried out for 40 of 48 residents reviewed during that shift, and the only drugs documented as given were Oxycodone, Ritalin, and Lorazepam, with documentation noted as inaccurate. When the missing documentation was discovered by the oncoming shift, the DON and Administrator suspected possible diversion by the agency nurse and were unable to produce evidence that residents received their ordered medications and treatments in accordance with professional standards of practice.
The facility failed to revise care plans to reflect current needs for g-tube management and recurrent falls. A resident with a g-tube and tactile impulses had physician orders for continuous use of an abdominal binder, but the care plan, last updated months earlier, did not include this intervention, as confirmed by the DNS. In addition, one resident with a history of frequent falls and another resident with dementia and unsteadiness experienced multiple falls, yet one care plan was not updated after numerous fall events and the other lacked any fall-related focus area, with the DNS unable to provide evidence of appropriate care plan revisions.
A resident with a G-tube and severe cognitive impairment, dependent on staff for dressing, had physician orders to wear an abdominal binder at all times, except during ADL care or showering, to help manage the gastrostomy site. A complaint alleged the resident frequently damaged or pulled out the G-tube and that proper precautions, including consistent binder use, were not implemented. During surveyor observation, the resident was found in bed without the abdominal binder, which was located on a shelf across the room. An LPN acknowledged she had not assisted the resident to put the binder on that morning, and the DON stated she would have expected the binder to be in place, demonstrating failure to follow the physician’s orders.
Failure to Follow Care Plan Leads to Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by not following an existing care plan intervention to keep the resident away from members of the opposite gender. One resident with dementia and severe cognitive impairment, documented by a BIMS score of 7/15, had a care plan focus area noting increased episodes of sexually inappropriate behavior toward other residents, with an intervention to seat the resident away from residents of the opposite gender in the dining room. On the date of the incident, this resident was seated in the community room between two residents of the opposite gender, including another resident with dementia, mood and behavioral disturbance, unspecified psychosis, and a BIMS score of 1/15. Surveillance video reviewed by surveyors showed that two staff members were present in the area and did not separate the resident from residents of the opposite gender as required by the care plan. An altercation occurred in which the second resident struck the care-planned resident in the eye and forehead, causing a small laceration to the left forehead and a bleeding scratch under the right eye. A facility incident report documented that the second resident struck the first resident with a fist after the first resident allegedly attempted to touch the second resident’s genital area. A nursing assistant later stated she had been told that the first resident attempted to touch the second resident’s groin, but also reported that after facility staff reviewed the surveillance video, it was determined that no such attempt occurred. A registered nurse reported that the two residents “don’t mix” and that staff try to keep them separated, and also confirmed that the resident with sexually inappropriate behaviors was to be kept away from residents of the opposite gender for a long time. The DNS and Administrator were unable to provide evidence that the care plan intervention to keep the resident away from residents of the opposite gender was followed, and the Administrator could not provide evidence that the resident was kept free from physical abuse.
Roof Leaks, Water Intrusion, and Compromised Fire Panel Create Unsafe Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment when active water leaks from the roof penetrated ceiling tiles and electrical fixtures on the second floor. Surveyors observed multiple areas on two second-floor units with towels on the floor that were saturated with brown-colored water, as well as waste and laundry baskets and buckets placed in hallways and outside resident rooms to collect water from active leaks. Water was seen leaking from ceiling tiles and overhead light fixtures, with visible water staining on numerous ceiling tiles and wall surfaces. Floor surfaces were wet and slippery, particularly around the water collection buckets. Many residents, including those with mild to severe cognitive impairments, were observed sitting or ambulating near the active leaks and containers collecting water. During interviews, the Maintenance Assistant acknowledged the roof leak, stated it had started the day prior, and reported he had been instructed to remove snow from the roof to prevent continued leaking but had not yet done so. The Administrator acknowledged that the leaks had become progressively worse throughout the morning and that the facility was in the process of obtaining a quote to repair the roof. The Director of Operations confirmed awareness that the leaking water was coming from the roof and that a contractor had been called to assess and fix the damage, but he could not provide evidence of any immediate interventions implemented to ensure a safe, functional, sanitary, and comfortable environment. Subsequent evaluations by external authorities identified water inside the second-floor fire panel, which appeared to have been tampered with, and led to the establishment of a fire watch and orders to evacuate first the second floor and then the entire facility due to the water damage, active leaks, and compromised conditions.
Failure to Protect Resident From Physical Abuse by Aggressive Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a roommate. The facility’s own policy, revised in October 2022, prohibits mistreatment and abuse and defines abuse as the willful infliction of injury resulting in physical harm, pain, or mental anguish. Despite this, an incident occurred in which two residents were heard screaming in their shared room, and staff who responded found one resident with blood on the upper and lower lips and later-documented facial injuries, including swelling to the eye, a lump on the cheek, bruising to the face, and lacerations to the lips. The injured resident, who was cognitively intact with a BIMS score of 15 and dependent on staff for all ADLs, reported being struck multiple times in the head and face while seated in a wheelchair after refusing a request from the roommate to close the bedroom door. The resident who committed the assault had a documented history of anxiety disorder, delusional disorder, and behavioral issues, including verbal aggression and increased agitation. The care plan for this resident, revised in August 2024, identified behaviors such as verbal aggression and agitation and included interventions for staff to intervene when the resident became agitated, document all behaviors, attempt to identify patterns, and encourage medication compliance. Nursing progress notes in December 2025 and early January 2026 documented an increase in agitation and aggressive behaviors, including repeatedly throwing meal trays on the hallway floor, being non-compliant with redirection and re-education regarding safety, and continued restlessness and agitation with care. A psychiatric evaluation noted ongoing behavior disturbance and non-compliance with medications. A physician’s order dated mid-December 2025 directed staff to monitor and document the aggressive resident’s behaviors and record the number of episodes every shift. However, the January 2026 Treatment Administration Record did not show evidence of behaviors on the date of the physical altercation, despite the documented violent incident that day. During interviews, the aggressive resident admitted to punching the roommate in the face, and the injured resident reported that the roommate had been physically aggressive in the past and that the facility was aware of this history. Staff and facility leadership also acknowledged the resident’s history of aggressive behaviors. The lack of effective monitoring, documentation, and intervention in response to the known behavioral history and physician’s order contributed to the failure to keep the injured resident free from physical abuse.
Failure to Monitor Vancomycin Trough Levels and Provide Appropriate UTI Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services for a resident treated for a UTI with IV vancomycin, who later experienced a fall and was admitted to the hospital with sepsis. The resident had an unwitnessed fall and increased confusion in November 2025, prompting the NP to order blood work and a urine sample to evaluate for underlying causes. Two urine specimens collected by clean catch on consecutive dates were reported by the lab as suggestive of contamination, with instructions to repeat testing if clinically indicated. A subsequent provider order directed staff to obtain a urine specimen via straight catheterization every shift until obtained, and a specimen collected on 11/28/2025 later resulted positive for a UTI with two organisms at a colony count greater than 100,000. Following the positive urine culture, the resident was started on antibiotic therapy, including IV vancomycin. The NP ordered vancomycin 1 g IV twice daily for 12 days, with instructions to monitor vancomycin trough levels before the fourth dose and to maintain a target trough range of 15–20 mg/L. The December MAR showed the resident received vancomycin from early to mid-December with dose adjustments based on trough levels. However, record review did not show evidence that vancomycin trough levels were obtained prior to each fourth dose on three separate dates, representing three missed opportunities to monitor levels as ordered. The first trough level was not obtained until 12/10/2025, at which time the level was 12.1 mg/L, below the desired therapeutic range, and the dose was then increased from 1 g to 1,250 mg. Ten days after completion of the antibiotic course, progress notes documented that the resident sustained a fall, was bleeding from the genital area, appeared not at baseline, was shaky, unable to stand, and pale, and was transferred to an acute care hospital where the resident was admitted with sepsis. Hospital documentation indicated concern for sepsis with a urinary focus of infection, and the resident received broad-spectrum antibiotics, including vancomycin, along with fluids and blood. During interviews, the NP stated she expected staff to obtain vancomycin trough levels after the third dose and before the fourth dose to ensure therapeutic levels, acknowledged that trough levels were not completed on the three specified dates and that the 12/10/2025 trough was subtherapeutic. The DON was unable to provide evidence that the facility provided appropriate treatment and services for the resident diagnosed with a UTI who subsequently fell and was admitted for sepsis, and a pharmacy representative stated that subtherapeutic vancomycin trough levels increase the likelihood of failing to destroy an infectious organism.
Failure to Administer Ordered Sevelamer for Dialysis Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring dialysis received Sevelamer as ordered to manage hyperphosphatemia, consistent with professional standards of practice. The resident, who was readmitted with end stage renal disease and dependence on hemodialysis three times a week, was cognitively intact with a BIMS score of 15 and dependent on staff for all ADLs. The care plan included coordinating medications with dialysis days. A physician’s order dated 10/1/2025 prescribed Sevelamer 3200 mg three times daily with meals for elevated phosphorus levels. Review of the MARs for November and December 2025 and January 2026 showed that the resident did not receive 27 scheduled doses of Sevelamer across multiple dates and times. Laboratory results from the hemodialysis center showed the resident’s phosphorus level was elevated at 5.5 on 12/19/2025 and had further increased to 7.5 by 1/12/2026. During interviews, an RN at the facility stated that Sevelamer had not been available for a while and had been placed on hold due to unavailability, and that the medication was only recently received from the dialysis center. The dialysis center RN reported that Sevelamer was ordered three times daily with meals and that the center was unaware the resident had run out of the medication, as the facility had not communicated this, even though the dialysis center supplied it. The NP stated that the increased phosphorus levels were due to the resident not receiving Sevelamer. The DNS reported she was initially unaware that the resident’s Sevelamer supply came from the dialysis center and could not provide evidence that the medication had been administered as ordered.
Failure to Monitor Antibiotic Use Resulting in Extra Vancomycin Dose
Penalty
Summary
The facility failed to establish and implement an Infection Prevention and Control Program (IPCP) that included an effective antibiotic stewardship program with protocols and a system to monitor antibiotic use. The facility’s own ANTIBIOTIC STEWARDSHIP policy, last revised in September 2025, required that antibiotics be prescribed and administered under the guidance of the stewardship program and that prescribers provide complete antibiotic orders, including duration of treatment, start and stop dates, and number of days of therapy. A resident with diagnoses including sepsis and bacteremia, who had recently completed a course of IV antibiotics for a UTI, was ordered vancomycin 1 gram every 12 hours for 12 days beginning on 12/2/2025, for a total of 24 doses. An Antibiotic Time Out assessment was completed by the Infection Preventionist (IP) for this vancomycin order and reviewed with the resident’s Nurse Practitioner. Record review showed that, despite the clear order for 24 doses, the December 2025 Medication Administration Record documented that the resident received 25 doses of vancomycin. During an interview, the Nurse Practitioner stated she was unaware that the resident had received an extra dose. In a separate interview, the IP, in the presence of the Director of Nursing Services, acknowledged completing the antibiotic time out for the vancomycin but failed to identify that the resident was scheduled to receive an additional, non-ordered dose. These actions and omissions demonstrated that the facility did not effectively monitor antibiotic use or ensure that the resident received only the prescribed number of antibiotic doses, as required by the facility’s antibiotic stewardship policy and IPCP requirements.
Failure to Monitor and Document Fluid Intake for Resident on Fluid Restriction
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with fluid restrictions received treatment and care in accordance with physician orders and professional standards. The resident was re-admitted in December 2025 with diagnoses including hypo-osmolality and hypernatremia, and had a care plan noting potential for fluid overload related to polydipsia and hyponatremia. A physician’s order dated 12/12/2025 directed staff to encourage the resident to limit fluid intake every shift for monitoring. After the resident was found on the bathroom floor with a large lump on the forehead and sent to the hospital, the hospital documented psychogenic polydipsia and hyponatremia with a sodium level of 119 and serum osmolality of 252, and recommended a 1500 mL fluid restriction. Following this, a 12/24/2025 physician order specified a 1500 mL/day fluid restriction with detailed allocations for dietary and nursing fluids per meal and per shift, and the NP reinforced the importance of adherence and instructed nursing staff to monitor daily fluid intake and report acute changes. Despite these orders, staff interviews revealed that NAs did not document or communicate the amount of fluids consumed for any residents, while an LPN stated that fluid intake for this resident was documented by NAs and signed off as completed in the TAR. Record review showed that the fluid restriction orders were only marked as completed with check marks, with no documentation of the actual amounts of fluid provided or consumed per shift as ordered. The Medical Director stated an expectation that intake amounts be monitored and documented per shift, and the Administrator acknowledged that the facility failed to monitor the resident’s fluid intake according to the physician’s order.
Failure to Administer and Document Medications and Treatments During Overnight Shift
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received treatment and care in accordance with professional standards of practice by not following provider orders for medications and treatments during a specific overnight shift. A facility-reported incident dated 1/14/2026 indicated that during the 11:00 PM to 7:00 AM shift on 1/2/2026, a Registered Nurse (Staff A) did not fulfill assigned nursing responsibilities. Record review showed that medication orders were not administered and treatment orders were not completed for 40 of 48 residents reviewed during that shift, covering the period from 11:00 PM on 1/2/2026 into 7:00 AM on 1/3/2026. Surveyor interviews with the Director of Nursing Services (DNS) and the Administrator on 1/20/2026 revealed that when the oncoming shift identified missing documentation, their initial concern was possible medication diversion by the agency nurse. The only medications documented as administered during the shift were Oxycodone, Ritalin, and Lorazepam, and the DNS and Administrator stated that the nurse’s documentation was inaccurate. They reported that when contacted, the agency nurse refused to return to the facility to complete the documentation. The DNS and Administrator were unable to provide evidence that residents received their ordered medications and treatments in accordance with professional standards of practice during the 11:00 PM to 7:00 AM timeframe in question.
Failure to Revise Care Plans for G-Tube Management and Recurrent Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents’ care plans were revised by the interdisciplinary team to reflect current physician orders and changes in condition, specifically related to a gastrostomy tube (g-tube) and recurrent falls. One resident with a history of a cerebrovascular accident, muscle weakness, and a g-tube had physician orders dated 9/4/2025 to encourage use of an abdominal binder at all times on every shift, and a subsequent order dated 1/7/2026 specifying that the resident was to wear the abdominal binder, with removal allowed only during ADL care or showering. The resident’s care plan, which included a focus area initiated on 6/24/2025 for behavior problems of tactile impulses (including pulling the g-tube), was last revised on 8/26/2025 and did not include the abdominal binder as an intervention. During an interview, the DNS acknowledged that the care plan was not revised to include the abdominal binder. The deficiency also includes failure to revise care plans in response to multiple falls for two residents. One resident experienced multiple falls on several dates in December 2025 and January 2026. Although this resident had a care plan focus area initiated on 2/3/2025 for frequent falls secondary to generalized weakness, decreased neuromuscular coordination, and cognitive impairment, the last revision was on 12/2/2025 and did not include added interventions related to the subsequent falls. The DNS was unable to provide evidence that the care plan was updated following these events. Another resident, admitted with dementia and unsteadiness on feet, sustained multiple falls in December 2025. Review of this resident’s care plan failed to show any focus area for falls, and the DNS could not provide evidence that the care plan was revised to address falls.
Failure to Follow Physician Orders for Abdominal Binder Use with G-Tube Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with a gastrostomy tube received care in accordance with professional standards and physician orders regarding the use of an abdominal binder. The resident, admitted with a diagnosis including a gastrostomy tube and assessed as having severe cognitive impairment with dependence on staff for dressing, had physician orders dated 9/4/2025 to encourage use of an abdominal binder at all times on every shift, and a subsequent order dated 1/7/2026 specifying that the resident was to wear the abdominal binder and may remove it only during activities of daily living care or showering. A community complaint alleged that the resident frequently damaged or pulled out the G-tube and that the facility did not implement proper precautions, including use of an abdominal binder, to prevent the resident from pulling out the tube. During surveyor observation, the resident was seen in bed without the abdominal binder in place under the shirt, and the binder was found on a shelf across the room from the resident’s bed. In the presence of the surveyor, an LPN acknowledged that the resident was not wearing the abdominal binder and admitted she had failed to assist the resident to put it on that morning. In a subsequent interview, the Director of Nursing Services stated that she would have expected the abdominal binder to be in place on the resident. These observations and interviews demonstrated that staff did not follow the physician’s orders for continuous use of the abdominal binder, except during specified care activities, resulting in the cited deficiency.
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