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 a history of falls and mobility limitations exited the facility unsupervised during severe weather, after previously demonstrating attempts to leave. The care plan was not updated to address wandering or elopement risk, and staff were unaware of the resident's absence until the individual was found outside with frostbite and injuries, requiring hospitalization. The facility failed to provide adequate supervision and did not revise the care plan following earlier incidents.
A resident with a history of smoking and falls, while on oxygen therapy, was able to use a personal lighter in their room, resulting in the ignition of oxygen tubing and a minor fire that damaged the floor and equipment. The facility was aware of the resident's risk factors but did not provide evidence of adequate supervision or environmental safeguards to prevent this accident.
A resident with multiple comorbidities was admitted with a Stage 2 pressure ulcer and surrounding blisters, but the initial skin assessment lacked measurements and a detailed description. No treatment order was obtained or implemented for six days, and staff interviews confirmed that wound care was not provided during this period.
A resident with anxiety, depression, and heart failure, who required significant assistance with ADLs, reported being treated rudely by two nursing assistants, including being spoken to with explicit language when requesting their phone. The incident was corroborated by a roommate and acknowledged by one staff member, who received a verbal warning for disrespectful conduct. The resident expressed ongoing fear of the night shift staff, and facility leadership could not provide evidence that the resident was treated with dignity and respect.
A resident with multiple medical conditions, including a recent fracture, sepsis, and opioid use disorder, was transferred to the hospital after a verbal altercation with staff. The facility did not provide the required written information about its bed-hold policy to the resident or their representative prior to the transfer, as confirmed by record review and staff interviews.
A resident with a history of opioid addiction and other medical conditions did not receive prescribed Methadone for two days due to the medication being unavailable. The DON reported delays in obtaining the medication from the treatment center, and the resident exhibited behavioral changes during this period. The facility could not demonstrate that the resident was kept free from significant medication errors.
A resident with multiple medical conditions did not receive any of the 17 ordered doses of Insulin Lispro over several days, as confirmed by MAR review and staff interviews. This omission led to persistently elevated blood glucose levels, clinical decline, and eventual transfer to an acute care hospital. Facility policy required insulin administration as ordered, but no evidence was provided that the medication was given.
The facility did not provide a qualified dietitian to assess and address the nutritional needs of four residents with complex medical conditions, despite multiple provider recommendations and orders for dietary consults. Staff interviews confirmed that no dietitian had been available for several months, resulting in residents not receiving required dietary evaluations.
A resident with progressive MS was not weighed monthly as required by facility policy, resulting in a significant weight gain of 24.3 lbs going undetected for over three months. Staff interviews confirmed that ongoing weight monitoring was not performed or ordered, and the lapse was only discovered after surveyor inquiry.
A resident with intact cognition and complex medical needs repeatedly refused prescribed medications, but staff attempted to administer them by mixing them into a nutritional supplement without a provider's order and physically restraining the resident. These actions, including unauthorized medication administration and failure to document and report refusals, violated the resident's rights and facility policy.
Failure to Provide Adequate Supervision Resulting in Resident Elopement and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of falls, partial weight bearing status, and an amputation was able to exit the facility unsupervised during inclement weather. The resident had previously demonstrated attempts to leave the building, including an incident where the resident attempted to exit the facility and refused to return to the unit, but the care plan was not updated to address this behavior. There was no evidence that an elopement evaluation was completed after the initial incident, nor was the care plan revised to include interventions for wandering or elopement risk prior to the subsequent event. On the day of the incident, the resident exited the building in the early morning hours without staff knowledge, during a snowstorm with freezing temperatures. The resident fell outside after dropping a cane and was unable to get up, remaining outside for approximately an hour. The resident was found by staff after calling for help, presenting with significant frostbite and blisters on both hands, and was subsequently hospitalized for further evaluation and treatment. Staff interviews revealed that the resident was able to disengage the alarm system using the emergency exit button, and that staff were not aware of the resident's absence until the resident was discovered outside. The facility's policy required adequate supervision and individualized care planning for residents at risk of wandering or elopement. However, the resident's care plan did not reflect the risk behaviors observed, and staff, including the Administrator and DON, were unaware of the prior incident and did not implement additional supervision or interventions. The lack of timely assessment and care plan updates contributed to the resident's ability to leave the facility undetected, resulting in an unwitnessed fall and frostbite injuries.
Failure to Prevent Accident Hazard Involving Oxygen and Smoking Materials
Penalty
Summary
A deficiency occurred when the facility failed to provide an environment free from accident hazards and did not ensure adequate supervision to prevent accidents for a newly admitted resident. The resident, who had a history of smoking, multiple rib fractures, and falls, was admitted with these risk factors known to the facility. Despite this, the resident was able to access and use a personal lighter in their room while on oxygen therapy. This resulted in the resident accidentally igniting their oxygen tubing, causing a minor fire that damaged the floor and the oxygen concentrator. Surveyor observations confirmed physical evidence of the incident, including a discolored area on the floor and photographic documentation of burnt oxygen tubing and burn marks on the oxygen concentrator. Interviews with facility leadership revealed that the facility was aware of the resident's smoking history at admission but could not provide evidence that appropriate measures were taken to minimize accident hazards or provide adequate supervision. The resident confirmed using the lighter to find shoes in the dark, which led to the fire.
Failure to Initiate Timely Pressure Ulcer Treatment and Documentation
Penalty
Summary
A resident admitted in November 2025 with a history of laminectomy, diabetes mellitus, and obesity was found to have a Stage 2 pressure ulcer on the coccyx and popped blisters in the same area upon admission. The initial skin assessment documented the presence of these wounds but did not include measurements or a detailed description. There was no evidence that a treatment order for the wounds was obtained or implemented at the time of admission. Review of the clinical record and staff interviews confirmed that the resident's wound was not treated for six days following identification. The admitting nurse acknowledged failing to obtain a treatment order upon admission, and the wound nurse confirmed that standard practice requires a complete assessment and prompt initiation of treatment orders for identified wounds. Documentation did not show that the resident received any wound care from the time the wounds were first identified until six days later.
Failure to Treat Resident with Dignity and Respect During Care
Penalty
Summary
A resident with diagnoses including anxiety, depression, and heart failure, who was cognitively intact and required substantial assistance with activities of daily living, reported being treated disrespectfully by two nursing assistants during care. The resident stated that the staff were rude and, when requesting their phone, one staff member responded with explicit language indicating disregard for the resident's request. The incident was corroborated by the resident's roommate, who overheard the verbal exchange and confirmed the use of inappropriate language by the staff. Documentation also showed that the resident expressed fear for their safety at the facility, stating they felt threatened by the staff involved. Further review revealed that one of the staff members admitted to telling the resident they did not care about the phone and suggested the resident look for it themselves. The staff member received a verbal notice for violating employee conduct rules, including disrespectful conduct. During interviews, the resident expressed ongoing fear and anxiety related to the night shift staff, specifically those involved in the incident. Facility leadership, including the Director of Social Work and the Administrator, were unable to provide evidence that the staff treated the resident with dignity and respect.
Failure to Provide Bed-Hold Policy Notification Upon Hospital Transfer
Penalty
Summary
The facility failed to provide written information regarding its bed-hold policy to a resident or the resident's representative prior to the resident's transfer to a hospital. According to the facility's own Bed Hold Policy, residents and/or their representatives must be informed of the policy whenever a resident is transferred for hospitalization or therapeutic leave. However, clinical record review and staff interviews confirmed that this requirement was not met for a resident who was transferred to the hospital following a verbal altercation with staff. The resident in question had been admitted with multiple diagnoses, including an intertrochanteric fracture of the left femur with surgical repair, sepsis secondary to cellulitis of the left lower extremity, and was on daily Methadone for opioid use disorder. Despite these complex medical needs, there was no documentation in the clinical record that the resident was offered a bed-hold upon transfer. Both the DON and the Administrator confirmed during interviews that the required notification was not provided.
Failure to Administer Prescribed Methadone Due to Medication Unavailability
Penalty
Summary
A deficiency occurred when a resident admitted with multiple diagnoses, including a left femur fracture with surgical repair and sepsis secondary to cellulitis, did not receive prescribed Methadone for opioid addiction. The resident had physician orders for Methadone 40 mg in the morning and 60 mg in the evening, but the Medication Administration Record (MAR) showed that both doses were missed on two consecutive days. Documentation indicated that the medication was unavailable as the reason for the missed doses. The Director of Nursing (DON) reported that the orders for Methadone were faxed to the substance abuse treatment center after it had closed, and despite multiple calls and messages, the medication did not arrive until the resident's third day at the facility. During this period, the resident exhibited behavioral changes, including verbal aggression, which led to a behavioral health evaluation. The facility was unable to provide evidence that the resident was kept free from significant medication errors, as the resident never received the prescribed Methadone during their stay.
Failure to Administer Prescribed Insulin Resulting in Hospital Transfer
Penalty
Summary
A resident with diagnoses including end stage renal disease and dysphagia was admitted to the facility with a physician's order for Insulin Lispro to be administered subcutaneously three times daily. Review of the Medication Administration Record revealed that the resident did not receive any of the 17 prescribed doses of Insulin Lispro over a six-day period. Staff interviews confirmed that the assigned nurse did not recall administering the medication, and the Director of Nursing Services was unable to provide evidence that the insulin was given as ordered. Facility policy required subcutaneous insulin to be administered safely and accurately according to provider orders. During this period, the resident experienced persistently elevated blood glucose levels, with documented readings significantly above the normal range for diabetics. The resident's condition deteriorated, as evidenced by lethargy, low blood pressure, elevated heart rate, and critically high blood glucose levels, ultimately resulting in transfer to an acute care hospital. The Nurse Practitioner confirmed that staff were expected to follow provider orders for medication administration.
Failure to Provide Qualified Dietitian Services for Residents
Penalty
Summary
The facility failed to provide a qualified dietitian to assess and address the individual nutritional needs of four residents, despite multiple documented recommendations and physician orders for dietary consultations. Clinical record reviews revealed that residents with complex medical conditions, including progressive multiple sclerosis, myxedema coma, dysphasia, type two diabetes, and Alzheimer's disease, did not receive dietary consults during their admissions. In several cases, care plans and progress notes specifically identified the need for dietary evaluation, and providers placed orders or made recommendations for dietitian involvement, but there was no evidence that these consults were completed. Interviews with staff, including the Director of Nursing Services (DNS) and a Nurse Practitioner, confirmed that the facility had not had a dietitian on staff for several months and that residents were not being seen by a dietitian as required. The DNS acknowledged the expectation for residents to be seen by a dietitian on admission, quarterly, and as indicated, but was unable to recall when the last clinical assessment by a dietitian occurred. The lack of dietary consultations persisted despite repeated requests and recommendations from both residents and healthcare providers.
Failure to Monitor Resident Weight as Required by Policy
Penalty
Summary
The facility failed to ensure ongoing monitoring of a resident's weight status, as required by its own policy and standard clinical practice. The policy specified that residents should be weighed weekly for the first four weeks after admission and then monthly unless otherwise indicated, with all weights documented in the medical record. A resident with progressive Multiple Sclerosis was admitted and initially weighed according to policy, but after the last recorded weight, no further weights were obtained for over three months. There was also no evidence of a current physician's order to continue monthly weight monitoring, and this lapse was not identified by facility staff. Interviews with the Nurse Practitioner and the Director of Nursing Services confirmed that they were unaware of the missed weight checks and acknowledged the failure to monitor the resident's weight as required. When a weight was finally obtained after the surveyor's inquiry, it was found that the resident had gained 24.3 pounds since the last recorded weight. This significant weight gain went undetected due to the lack of ongoing monitoring, contrary to facility policy and expectations.
Failure to Honor Resident's Right to Refuse Medications
Penalty
Summary
A deficiency occurred when facility staff failed to honor a resident's right to refuse medications and treatments. The resident, who had diagnoses including myxedema coma and dysphagia and demonstrated intact cognition, repeatedly refused prescribed medications. Despite these refusals, staff made multiple attempts to administer the medications, including mixing them into a nutritional supplement without a provider's order. On one occasion, a medication technician enlisted another staff member to physically hold the resident's arm while attempting to administer the medications, resulting in the resident spitting out the mixture and expressing distress. Progress notes and staff interviews confirmed that the resident was agitated, cried, and verbally objected to the administration attempts. Facility policy states that residents have the right to refuse medications and treatments, and staff are expected to document and report refusals rather than attempt to coerce or force compliance. Interviews with the DON and Nurse Practitioner confirmed that medications should not be mixed into food or drink to coerce residents, and refusals should be documented and reported to medical providers. The actions taken by staff, including physical restraint and unauthorized mixing of medications, directly violated the resident's rights and facility policy.
Some of the Latest Corrective Actions taken by Facilities in Rhode Island
Explore Popular Searches
