Bayview Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in North Kingstown, Rhode Island.
- Location
- 860 North Quidnessett Road, North Kingstown, Rhode Island 02852
- CMS Provider Number
- 415063
- Inspections on file
- 28
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Bayview Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
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.
A resident with hypotension did not receive Midodrine as ordered for multiple low blood pressure readings, and prescribed wound care for the resident's left posterior calf was not completed on one occasion, with documentation indicating the resident was sleeping. Both failures were acknowledged by nursing staff and the DON.
A resident with atrial fibrillation and hypotension received Metoprolol Tartrate despite consistently low blood pressure readings, after medication administration parameters were inadvertently removed from the order. Staff administered the medication without holding it for low systolic BP as originally directed, resulting in the resident receiving unnecessary medication.
A resident receiving Warfarin for deep vein thrombosis did not receive two scheduled doses after a PT/INR test, due to a lack of documentation of test result review and absence of a new Warfarin order. The Coumadin Alert order, which helps ensure proper medication administration, was not transcribed until several days later, and staff confirmed the missed doses and documentation gaps.
A facility failed to conduct a quarterly care plan meeting for a resident with Parkinson's Disease and muscle wasting, as required by their policy. Despite a complaint from a family member and the facility's policy mandating such meetings, only one meeting was held since the resident's admission. Interviews with staff confirmed the oversight.
A resident with severe cognitive impairment and Parkinson's disease did not have a bowel movement for seven days, despite interventions. The facility lacked a formal bowel protocol, and staff failed to notify a physician, leading to a deficiency in care.
The facility failed to maintain an effective infection prevention and control program during a Covid-19 outbreak. Staff used ineffective disinfecting wipes and did not adhere to Enhanced Barrier Precautions for a resident with a foley catheter. Additionally, staff did not comply with PPE requirements, using KN95 masks instead of N95 masks and failing to wear gowns in rooms under contact precautions.
A resident with impulse control issues following a stroke physically abused another resident with severe cognitive impairment, resulting in skin tears. The incident was unprovoked and witnessed by staff, highlighting a failure in the facility's responsibility to protect residents from abuse.
A resident with bipolar disorder and schizophrenia did not receive a scheduled dose of Risperdal, leading to a relapse in psychosis with homicidal ideations and auditory hallucinations. The facility failed to transcribe and administer the medication as ordered, resulting in a deficiency.
The facility failed to develop and implement comprehensive care plans for two residents, one with PTSD and another with wandering behaviors. A resident with adjustment disorder and psychosis was documented as wandering without a care plan in place, despite residing on a secured unit. Another resident with PTSD lacked a trauma-informed care plan, despite regular psychiatric evaluations. Staff interviews confirmed the absence of appropriate care plans for these residents.
A resident with dementia experienced a deficiency in wound care management due to the facility's failure to obtain a timely wound care consult and inconsistent documentation of wound assessments. Despite a care plan requiring regular evaluation, a wound care consult ordered in April was delayed until August. Staff interviews revealed a lack of awareness and adherence to the wound care order, with inconsistent documentation of wound details.
The facility did not complete annual performance reviews for NAs, as required. A review of personnel files showed that three NAs, hired between July 2022 and July 2023, did not have documented annual evaluations. The Administrator confirmed the absence of these evaluations during an interview.
The facility failed to maintain food safety standards, with improperly labeled and stored food items in the main kitchen and kitchenettes. Uncooked chicken, pureed chicken, and egg rolls were found with expired or missing labels. Additionally, during lunch service, several meal options were held at unsafe temperatures above 41°F. The FSD acknowledged these issues, indicating a lapse in food safety protocols.
A resident with dementia and hearing impairment had a physician's order for daily use of hearing aids, but the facility failed to accurately document this. Despite records indicating compliance, the resident was observed without hearing aids, and staff admitted the right hearing aid had been broken for weeks.
A resident with bipolar disorder and schizophrenia exhibited homicidal ideations, leading to a recommendation for plastic utensils and 15-minute safety checks, which were not implemented. Additionally, a recommendation for weekly orthostatic blood pressure monitoring was overlooked, with no evidence of it being conducted. Staff interviews confirmed the oversight and lack of communication regarding these safety measures.
A resident with an indwelling Foley catheter experienced a deficiency in care when the facility failed to change the catheter before obtaining a urine sample, leading to contamination. Despite a care plan to monitor for UTIs, the urine sample was contaminated, and the order for urinalysis and culture was discontinued. Staff interviews confirmed the expectation to change the catheter, but no evidence was provided that this was done.
A facility was found to have a medication error rate of 10.34% during a survey, exceeding the acceptable limit of 5%. Errors included mixing Lorazepam and Oxycodone in the same cup, administering only one Senna tablet instead of two, and using insufficient water to flush a g-tube. The LPN involved acknowledged the errors, and the DON could not provide evidence of proper administration.
The facility failed to ensure proper storage and labeling of medications, as well as maintaining security of medication carts. A medication cart was left unlocked and unattended, and several medications were found expired or improperly labeled. Staff acknowledged these issues, and the Director of Nursing could not provide evidence of proper storage.
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.
Failure to Follow Physician Orders for Medication and Wound Care
Penalty
Summary
The facility failed to ensure that nursing services were provided in accordance with professional standards of quality by not following physician's orders for a resident with hypotension. The resident had a physician's order for Midodrine 5 mg to be administered three times daily as needed for low blood pressure, specifically when systolic was less than 100 or diastolic less than 60, and for vital signs to be taken every shift for seven days. Despite multiple documented instances where the resident's blood pressure readings met the criteria for administration of Midodrine, there was no evidence in the Medication Administration Record that the medication was given as ordered. Both a registered nurse and the Director of Nursing Services confirmed that the medication was not administered when indicated. Additionally, the facility did not follow a physician's order for wound care for the same resident. The order specified cleansing the left posterior calf with normal saline, patting dry, applying calcium alginate, and covering with bordered gauze every evening shift. On one evening shift, the wound treatment was not completed, and the nurse documented that the resident was sleeping. The Director of Nursing Services was unable to provide evidence that the wound care was performed as ordered on that date.
Failure to Ensure Drug Regimen Free from Unnecessary Medications
Penalty
Summary
A resident with a history of atrial fibrillation and hypotension was admitted to the facility and prescribed Metoprolol Tartrate, with specific parameters to hold the medication if the systolic blood pressure was less than 100. Upon admission, the resident's blood pressure readings were consistently low, with the highest being 78/48. Despite these low readings, the medication was administered on multiple occasions, as documented in the Medication Administration Record (MAR). The original physician's order included parameters to hold Metoprolol for low systolic blood pressure, but after a revision to the administration times by a registered nurse, these parameters were no longer visible in the order. Staff interviews confirmed that the medication was given even when the resident's blood pressure was below the specified threshold, and staff were unaware that the parameters had been removed from the order. This resulted in the resident receiving unnecessary medication contrary to the original physician's instructions.
Failure to Ensure Resident Free from Significant Medication Errors with Warfarin Administration
Penalty
Summary
A resident with a diagnosis of deep vein thrombosis was admitted to the facility and prescribed Warfarin to treat and prevent blood clots. The physician ordered a PT/INR test to be performed, which was completed as scheduled. However, there was no evidence that the PT/INR results were reviewed or that the provider was notified of the results. Additionally, there was no documentation of a new Warfarin order for continued therapy following the test. As a result, the resident did not receive Warfarin doses on two consecutive days. Further review showed that a Coumadin Alert order, intended to ensure staff awareness and proper administration of Warfarin, was not transcribed until several days after the missed doses. Staff interviews confirmed the lack of documentation regarding the PT/INR results and the absence of a Warfarin order during the period in question. The Director of Nursing acknowledged the delay in transcribing the Coumadin Alert and confirmed the missed medication doses.
Failure to Conduct Quarterly Care Plan Meeting
Penalty
Summary
The facility failed to provide a resident the right to participate in the development and implementation of their person-centered plan of care. This deficiency was identified during a survey following a community-reported complaint to the Rhode Island Department of Health. The complaint, submitted on October 17, 2024, raised concerns about the care received by a resident diagnosed with Parkinson's Disease and muscle wasting and atrophy. The complainant, a family member, expressed that no care plan meeting had been held since the resident's admission in May 2024, which could have addressed the concerns raised. The facility's policy requires comprehensive, person-centered care plans to be developed by an interdisciplinary team, including the resident and/or their representative, and to be conducted on admission, quarterly, annually, and with significant changes in condition. However, the record review revealed that only one care planning meeting was conducted on May 31, 2024, and there was no evidence of a quarterly care plan meeting. Interviews with the Social Worker and the Director of Nursing Services confirmed that a quarterly care planning meeting was not conducted for the resident, which is contrary to the facility's expectations.
Failure to Manage Constipation in Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with constipation, leading to a significant health deficiency. The resident, who was admitted with diagnoses including dehydration, urinary tract infection, and Parkinson's disease, was severely cognitively impaired and dependent on staff for toileting. Despite having a care plan in place to manage constipation, the resident did not have a bowel movement for seven days. The facility's records showed that various interventions, including Milk of Magnesia, Dulcolax Suppository, and Fleet Enema, were administered but were ineffective. However, there was no evidence that a physician was notified of the resident's condition, as required by the facility's expectations. Interviews with staff revealed inconsistencies in the implementation of the bowel protocol. Registered Nurse Staff B and Licensed Practical Nurse Staff C indicated that a bowel list was generated for residents who had not had a bowel movement in 72 hours, and a protocol was to be followed. However, the Director of Nursing Services confirmed that the facility did not have a formal bowel protocol. Additionally, the Advanced Practice Registered Nurse, Staff A, was not informed of the resident's prolonged lack of bowel movements, which affected the treatment decisions. This lack of communication and protocol adherence contributed to the deficiency in care for the resident.
Infection Control Deficiencies During Covid-19 Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, particularly in response to a Covid-19 outbreak. Surveyor observations revealed that the facility used Micro-Kill+ Disinfecting, Deodorizing Cleaning Wipes with Alcohol, which are ineffective against Covid-19, to clean multi-use resident equipment. This was observed in the Country Unit, where numerous residents were on isolation precautions due to Covid-19. The facility did not have dedicated care equipment or appropriate disinfecting wipes readily available, and staff were observed using ineffective wipes to clean equipment used in Covid-19 positive rooms. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) for a resident with an indwelling foley catheter. The resident was not placed on EBP, and there was no signage or isolation cart indicating the required precautions. The Unit Manager acknowledged the oversight, noting that the resident had been moved to a new room without the necessary precautions being transferred. The facility also failed to ensure staff compliance with PPE requirements. Staff were observed entering Covid-19 positive rooms wearing KN95 masks instead of the required N95 masks and without eye protection, despite signage indicating the need for these precautions. Furthermore, a staff member entered a room under contact precautions for MRSA without donning a gown, as required by facility policy and posted signage. These failures in infection control practices were acknowledged by staff during surveyor interviews.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving two residents. Resident ID #42, who has intact cognition but impulse control issues following a stroke, approached Resident ID #46, who has severe cognitive impairment due to dementia, and began yelling before hitting Resident ID #46 on the left arm multiple times. This resulted in two skin tears on Resident ID #46's arm. The incident was witnessed by a nursing assistant who confirmed that Resident ID #42 was verbally aggressive and that the attack was unprovoked. The facility's policy on abuse prevention states that residents have the right to be free from abuse, including physical abuse by other residents. Despite this policy, the facility's investigation revealed that Resident ID #42's aggressive behavior was known due to his speech impairment and impulse control issues. The Director of Nursing Services acknowledged that Resident ID #46 was not kept free from physical abuse, indicating a failure in the facility's responsibility to protect residents from abuse by others.
Failure to Administer Scheduled Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident received necessary behavioral health care and services, leading to a deficiency. The resident, who was readmitted to the facility with diagnoses including bipolar disorder and schizophrenia, had a care plan that included the administration of anti-psychotic medication, specifically Risperdal, as ordered. However, a physician's order for an intramuscular injection of Risperdal every 14 days was not administered on the scheduled date, and the order was discontinued without a new order being transcribed or administered the following day as instructed by the Nurse Practitioner. As a result of the missed dose, the resident experienced a relapse in psychosis, exhibiting homicidal ideations and auditory hallucinations, and was considered a danger to themselves and others. The psychiatric evaluation noted the resident's worsening mood and psychosis, and the need to restart the Risperdal injection along with additional oral medication. The deficiency was identified during a surveyor interview, where it was revealed that the nurses failed to transcribe and administer the medication as expected.
Failure to Implement Comprehensive Care Plans for Residents with PTSD and Wandering Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, one with post-traumatic stress disorder (PTSD) and another with wandering behaviors. Resident ID #65, who was readmitted with diagnoses including adjustment disorder and psychosis, was documented as wandering during a Minimum Data Set (MDS) assessment. Despite residing on a secured unit, the resident had multiple incidents of wandering outside the building, as noted in progress notes. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing Services, confirmed the absence of a care plan addressing the resident's wandering behaviors. Resident ID #49, readmitted with a diagnosis of PTSD, was also found to lack a trauma-informed care plan. The resident's comprehensive MDS assessment indicated PTSD, anxiety, and depression, and psychiatric services documented ongoing concerns related to the resident's past traumas and current mental health status. Despite regular psychiatric evaluations and supportive therapy sessions, there was no evidence of a care plan identifying trauma triggers and interventions for the resident's PTSD. Interviews with the Social Worker and the Director of Nursing Services revealed a lack of awareness of the resident's PTSD diagnosis and the absence of a corresponding care plan. The deficiency highlights the facility's failure to create and implement individualized care plans for residents with specific needs, such as those with PTSD and wandering tendencies. This oversight was acknowledged by the facility's staff during interviews, indicating a gap in the facility's care planning process for addressing the unique needs of these residents.
Failure in Timely Wound Care Management
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding wound care management. A resident with a diagnosis including dementia was admitted with impaired skin integrity related to an abrasion. The care plan required regular evaluation and documentation of the healing process, as well as monitoring for signs of complications. However, a wound care consult ordered in April was not obtained until August, approximately four months later. The resident's wound care documentation was inconsistent and did not adhere to the facility's policy or professional standards. The facility's policy required detailed documentation of wound assessments, including wound bed color, size, and drainage, which was not consistently recorded. The resident's wound was noted to have changed over time, with various treatments applied, but the documentation failed to provide comprehensive details as required. Interviews with facility staff revealed a lack of awareness and adherence to the wound care consult order. The Unit Manager was unaware of the initial order for a wound consult, and the Director of Nursing Services expected weekly wound measurements and descriptions, which were not consistently documented. The Wound Physician confirmed that the resident's initial wound consult was delayed, and the facility was expected to measure the wound weekly in her absence.
Failure to Conduct Annual Performance Reviews for Nursing Assistants
Penalty
Summary
The facility failed to complete an annual performance review for every Nursing Assistant (NA) at least once every 12 months, as required. This deficiency was identified during a record review and staff interview, which revealed that three NA personnel records, specifically those of Staff D, E, and F, lacked evidence of a completed annual performance evaluation. Staff D was hired in February 2023, Staff E in July 2022, and Staff F in July 2023. During an interview with the Administrator, it was acknowledged that these NAs had not received their yearly performance evaluations, and there was no evidence to suggest that these evaluations had been conducted within the last 12 months.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. In the main kitchen, several food items were improperly labeled and stored. Uncooked chicken and pureed chicken were found with expired use-by dates, and a package of egg rolls was unlabeled and undated. In the Ocean Unit Kitchenette, cooked oatmeal and vanilla ice cream were found without proper labeling or with expired dates. Similarly, in the Country Unit Kitchenette, a dessert was found without a use-by date. The Food Service Director (FSD) acknowledged these items should have been labeled, dated, and discarded according to the dates. During a lunch service observation, several plated meal options were found at unsafe temperatures. A salad plate, a chicken salad sandwich, and a tossed salad with cottage cheese were all held at temperatures above the safe limit of 41 degrees Fahrenheit. The FSD confirmed that these temperatures were not safe for serving and that the food should have been refrigerated. These observations indicate a failure to maintain proper food storage and temperature control, which are critical for ensuring food safety in the facility.
Inaccurate Documentation of Hearing Aid Use
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with hearing impairment. The resident, who was admitted with a diagnosis including dementia, was noted to have bilateral hearing limitations and required the use of hearing aids. A physician's order was in place for the insertion of bilateral hearing aids every morning and removal at bedtime. However, the Medication Administration Records (MAR) for July and August 2024 inaccurately documented that this order was completed daily, despite the resident being observed without hearing aids on August 21, 2024. During interviews, staff acknowledged the discrepancy, revealing that the resident's right hearing aid had been broken for several weeks, and the order was inaccurately documented as completed. The Unit Manager confirmed that the hearing aid had been broken for approximately six weeks. The Director of Nursing Services expressed an expectation for staff to accurately document the resident's use of hearing aids as ordered, highlighting a failure in maintaining accurate medical records for the resident's hearing aid use.
Failure to Implement Safety Measures and Monitoring for Resident with Psychiatric Needs
Penalty
Summary
The facility failed to provide services that meet professional standards of quality for a resident with a history of bipolar disorder and schizophrenia. Upon readmission, the resident exhibited homicidal ideations and auditory hallucinations, expressing a desire to harm others. A psychiatric evaluation recommended the use of plastic utensils during meals and 15-minute safety checks due to the resident's condition. However, during a surveyor observation, the resident was found using metal utensils, and the Food Service Director was unaware of the need for plastic utensils. Both the Nurse Practitioner and the Assistant Director of Nursing Services confirmed that plastic utensils should have been provided as part of the safety measures. Additionally, the facility failed to implement a recommendation to monitor the resident's orthostatic blood pressure weekly for four weeks. The psychiatric evaluation included this recommendation, but there was no evidence that the resident's blood pressure was monitored as ordered. Interviews with nursing staff revealed that the recommendation was overlooked, and no order was transcribed to carry out the monitoring. The Director of Nursing Services acknowledged the expectation for nursing to obtain the resident's orthostatic blood pressure as ordered.
Failure to Change Catheter Leads to Contaminated Urine Sample
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with an indwelling Foley catheter. The resident, who was readmitted to the facility with diagnoses including obstructive uropathy and urine retention, had a care plan that included monitoring for signs and symptoms of urinary tract infections (UTIs). A physician's progress note indicated that the resident had a recurrent UTI, and a urinalysis with urine culture was recommended. However, the urine sample obtained was contaminated, and the order for the urinalysis and culture was subsequently discontinued. Interviews with staff revealed that the resident's catheter was not changed prior to obtaining the urine sample, which led to the contamination. Both the Licensed Practical Nurse and the Nurse Practitioner acknowledged the contamination and the expectation that the catheter should have been replaced before collecting the urine specimen. The Director of Nursing Services also confirmed that the catheter should have been changed and was unable to provide evidence that this procedure was followed, resulting in the deficiency.
Medication Administration Errors via G-Tube
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 10.34% error rate observed during a medication administration task. This was determined through surveyor observation, record review, and staff interviews. Specifically, during the administration of medications via a gastrostomy tube (g-tube), three errors were identified out of 29 opportunities. These errors included the improper mixing of Lorazepam and Oxycodone in the same medication cup, administering only one Senna tablet instead of the prescribed two, and flushing the g-tube with only 15 ML of water instead of the ordered 30 ML before and after medication administration. The resident involved, identified as Resident ID #51, had specific physician orders for the administration of Senna, Lorazepam, and Oxycodone, as well as instructions to flush the feeding tube with 30 ML of water before and after medication administration. The Licensed Practical Nurse, Staff H, acknowledged these errors during a surveyor interview. Additionally, the Director of Nursing Services was unable to provide evidence that the medications were administered according to the physician's orders and the facility's policy, further confirming the deficiency.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, as well as maintaining security of medication carts. During a surveyor observation, it was found that one of the medication carts was left unlocked and unattended in an area accessible to residents. This occurred on the Ocean Unit cart, where the cart was observed unlocked and unattended multiple times within a short period. Additionally, the facility did not adhere to proper labeling and storage protocols for medications on three of the four medication carts observed. Specifically, medications such as Nitroglycerin, Fluticasone Propionate and Salmeterol inhaler, Incruse Ellipta inhaler, and Trelegy Ellipta inhaler were either expired, opened and not dated, or improperly labeled. The surveyor's findings were confirmed through interviews with the staff members responsible for the medication carts. Staff I, J, and K acknowledged the issues with the medications and the unlocked cart. Furthermore, the Director of Nursing Services was unable to provide evidence that the medications were stored appropriately as required by the facility's policy. These deficiencies highlight a failure to comply with the facility's medication labeling and storage policy, which mandates that all medications and biologicals be stored in locked compartments and properly labeled with expiration dates.
Latest citations in Rhode Island
The facility failed to follow physician orders for post-fall care for three anticoagulated residents who experienced falls. One resident on a blood thinner with a head injury was ordered to be transferred to the ED after a telehealth evaluation, but an LPN did not send the resident, citing instructions to contact a supervisor first and inability to reach that supervisor. For two other residents on anticoagulants, providers ordered intensive neuro checks (every 15 minutes, then every 30 minutes, then hourly, then every 4 hours), but staff instead performed neuro checks only once per shift for 72 hours. The DON and Medical Director acknowledged that the transfer and monitoring orders were not implemented as written.
A resident with intact cognition and psychiatric diagnoses sustained a left eyebrow laceration when another resident with a documented history of escalating aggressive and threatening behaviors struck them with a cane during a hallway dispute. The aggressive resident had multiple prior documented incidents, including verbal threats to kill others, attacking a roommate with a cane over TV volume, throwing objects during activities, and throwing a lunch plate at staff. Despite these events, the care plan was not updated with interventions to address physical aggression toward other residents, and a psychiatric recommendation for PRN trazodone for agitation, anxiety, and insomnia was only implemented as PRN for insomnia. The failure to assess, monitor, and implement effective interventions for the aggressive resident’s behaviors led to the assault and injury and, per the report, placed this and other residents at risk of serious physical and psychosocial harm.
A resident with impulse disorder, mood and anxiety diagnoses, and a history of escalating verbal and physical aggression had multiple documented incidents of threats, object throwing, and assault with a cane. Despite a psychiatric consult recommending PRN trazodone for agitation, anxiety, and insomnia, the provider order listed insomnia only, and the care plan was not updated with specific interventions to address the resident’s physically aggressive behaviors after several documented events. Subsequently, the resident struck another resident with a cane, causing a facial laceration that required wound closure and ongoing treatment.
The facility failed to properly screen and document clearance for a NA with disqualifying criminal history information before hire, as required by its abuse, neglect, and exploitation policy. A BCI check showed disqualifying information, yet the NA was hired, completed orientation, and worked independently based only on verbal disclosure of an old drug-related charge, without written details or verification. Later, a staff member reported witnessing this NA grab a resident’s face and kiss the resident on the lips, and a community complaint alleged inappropriate interactions with the same resident, prompting involvement of local police.
A resident with anxiety disorder and PTSD was unable to attend meals and activities with peers because the facility lost the resident's clothing after it was sent to laundry. The resident was observed in a hospital gown with only a few clothing items in the room, and the record lacked an admission inventory of belongings. The DON/Administrator reported that laundry was handled by an outside vendor without a tracking system or item documentation.
A resident with dementia and severely impaired cognition was subjected to repeated non-consensual kissing on the lips by an NA, who entered the resident’s room during care, verbally expressed affection, and then kissed the resident on the mouth on at least two separate occasions witnessed by staff. One staff member delayed reporting the first incident due to fear of the NA. These actions occurred despite a facility policy defining sexual abuse as any non-consensual sexual act and requiring protections of residents’ rights and well-being.
Failure to investigate allegations of resident-to-resident sexual inappropriateness: A resident with dementia and TBI was documented as being inappropriate with another resident, and psych notes later described increased sexually inappropriate behaviors toward other residents. Staff interviews showed the resident had been observed touching others and needing frequent redirection, but the DON, ADON, and Administrator acknowledged the facility did not complete an investigation or recognize the allegation as possible abuse.
A resident with dementia and a hearing deficit did not receive ear care as ordered because the chart lacked the Debrox order and the ear was flushed before the intended Debrox course was completed. In a separate incident, staff witnessed inappropriate kissing of a resident with dementia, but the allegation was not reported to the provider and the care plan was not updated. A third resident’s wound care was also not completed as ordered when an RN used normal saline instead of the prescribed Vashe wound wash.
A resident with migraines and chronic pain did not receive timely pain management after repeatedly reporting a migraine and appearing in visible distress. An NA notified an LPN, an RN said she could not access the med cart, and the resident continued waiting while the LPN was off the unit; the PRN migraine medication was not given until 40 minutes after the first complaint. The DON acknowledged the resident should not have waited that long for pain medication.
A resident missed 6 doses of a prescribed antibiotic, and the MAR did not show that the provider was notified. The RN acknowledged the missed doses and said they should have been reported, while the Medical Director stated she was unaware of the missed doses and would have extended the antibiotic course if informed. The DON also confirmed the missed doses and expected provider notification for any missed antibiotic dose.
Failure to Follow Post-Fall Physician Orders for Anticoagulated Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for post-fall care, including hospital transfer and neurological monitoring, for residents on anticoagulant therapy. One resident with atrial fibrillation on Xarelto experienced an unwitnessed fall with a scalp laceration and head lump. The on-call provider, after a telehealth evaluation, ordered transfer to the ED and wrote an order directing that the resident be sent to the hospital. The resident was not transferred as ordered, and an additional order for vital signs and neuro checks every shift for 72 hours after the fall was not completed as ordered on one of the shifts. The LPN caring for this resident stated she did not send the resident to the ED because she had been instructed to call a supervisor before sending residents out, and she was unable to reach the supervisor during the shift. A second resident, also with atrial fibrillation and on Xarelto, had an unwitnessed fall with injury. The on-call provider was notified and ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, then every four hours for an additional 24 hours. A physician’s order reflecting this schedule was scanned into the EMR. However, the neuro checks were not completed as ordered; instead, they were performed only once per shift for 72 hours. The RN who authored the progress note documented the fall and the resident’s anticoagulant use, and later stated she could not remember why she did not transcribe and complete the neuro checks as ordered. A third resident with atrial fibrillation on Apixaban had a non-injury fall after attempting to walk independently. The on-call provider ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, and then every four hours for an additional 24 hours, and this order was scanned into the EMR. The record did not show that these neuro checks were completed as ordered; instead, neuro checks were documented only once per shift for 72 hours. The Medical Director stated he would have expected the first resident to be transferred to the ED as ordered and that the facility should not override a provider’s order. The DON acknowledged that the transfer order and the ordered monitoring for the first resident were not followed as written, and that for the second and third residents, staff performed only once-per-shift neuro checks instead of the more frequent monitoring ordered by the providers.
Failure to Manage Escalating Aggression Leading to Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident, Resident ID #1, from abuse by another resident with a known history of escalating aggression, Resident ID #2. Resident ID #1 was admitted in October 2025 with diagnoses including paranoid schizophrenia and adjustment disorder with mixed anxiety and depressed mood, and had a BIMS score of 14/15, indicating intact cognition. On 4/27/2026, progress notes documented that Resident ID #1 was on the receiving end of a physical altercation with another resident and was found with a deep bleeding abrasion to the left eyebrow. A subsequent nursing note described a new laceration to the left eyebrow measuring 0.5 cm by 2.0 cm by 0.1 cm, related to a resident-to-resident incident, for which wound closure strips were applied. Resident ID #1 requested police involvement and a police report, and refused transfer to the hospital for sutures. Resident ID #2 had been admitted in December 2024 with multiple psychiatric and behavioral diagnoses, including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed a BIMS score of 13/15 and documented both physical and verbal behaviors during the look-back period. Progress notes over several months recorded a pattern of escalating aggressive and threatening behaviors: on 9/13/2025, Resident ID #2 threatened to slit another resident’s throat and made additional threats toward staff; on 11/7/2025, the resident was involved in a verbal dispute with raised voice, name-calling, and verbal threats; on 12/28/2025, after another resident struck Resident ID #2 with a helmet, Resident ID #2 was overheard threatening to kill that resident if touched again. On 2/21/2026, the on-call provider documented that Resident ID #2 attacked a roommate with a cane over TV volume and required ER transfer for psychiatric evaluation. Subsequent notes on 3/9/2026 and 4/10/2026 described the resident throwing poker chips on the floor, yelling and swearing at staff and residents, and throwing a lunch plate across the nurses’ station at a nursing assistant due to dissatisfaction with portion size. Despite this documented pattern, the care plan for Resident ID #2, dated 1/16/2025, only indicated a behavior problem of being verbally aggressive toward staff with resident-to-resident altercations on 12/28/2025, 2/21/2026, and 4/27/2026, and record review failed to show added interventions to mitigate the risk of physical aggression toward other residents after the 2/21/2026 cane attack and the object-throwing incidents on 3/9/2026 and 4/10/2026. A psychiatric evaluation on 4/23/2026 recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order entered on 4/24/2026 specified trazodone 25 mg twice daily as needed only for insomnia, and record review did not show that agitation and anxiety were included as indications for use. During interviews, the RNP and the DON stated it was their expectation that agitation and anxiety would have been included in the trazodone order, and the DON was unable to provide evidence that the care plan had been updated with interventions to address Resident ID #2’s physically aggressive behaviors documented on 2/21/2026, 3/9/2026, and 4/10/2026. On 4/27/2026, the DON documented that Resident ID #2 was ambulating down the hall toward his/her room while Resident ID #1 was walking in the opposite direction, and the two residents began a verbal dispute. Before staff could intervene, Resident ID #2 used his/her cane to make contact with Resident ID #1, resulting in the eyebrow laceration that required steri-strips and ongoing wound treatment. A police incident report recorded that Resident ID #1 stated being struck with a walking cane, wanted to press charges, and that Resident ID #2 admitted to striking Resident ID #1, leading to an arrest on one count of felony assault with a dangerous weapon. The facility’s failure to assess, monitor, and implement effective interventions for Resident ID #2’s known and escalating aggressive behaviors, including failure to update the care plan after prior incidents and failure to fully implement psychiatric recommendations, resulted in this resident-to-resident altercation and injury, and the report states that this failure placed Resident ID #1 and other residents at risk of serious physical and psychosocial harm.
Failure to Implement Psychiatric Recommendations and Update Behavior Care Plan Leading to Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health services and care planning for a resident with a documented history of psychiatric conditions and aggressive behaviors. The resident was admitted in December 2024 with diagnoses including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed intact cognition with a BIMS score of 13/15 and documented physical and verbal behaviors during the look-back period. Over time, multiple behavioral incidents were recorded, including threats to slit another resident’s throat during a smoking session, verbal disputes with name-calling and threats, and a statement to another resident that if touched again the resident would be killed. Further documentation showed escalating behaviors, including an incident where the resident attacked a roommate with a cane over television volume and required ER transfer for psychiatric evaluation, throwing poker chips and yelling when not winning at Bingo, causing the roommate to avoid the shared bathroom due to inappropriate comments and frustration over the light being turned on at night, and throwing a lunch plate across the nurses’ station at a nursing assistant over portion size. The care plan, initiated in January 2025 for verbal aggression and resident-to-resident altercations, did not contain added interventions to address the resident’s physically aggressive behaviors toward others after the incidents on 2/21/2026, 3/9/2026, and 4/10/2026. The DNS later could not provide evidence that the care plan had been updated with interventions to mitigate the risk of these physically aggressive behaviors or to guide staff in ensuring the safety of other residents. On 4/23/2026, a psychiatric evaluation recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order dated 4/24/2026 implemented trazodone 25 mg twice daily as needed for insomnia only, and the record lacked evidence that agitation and anxiety were included as indications for use as recommended by the consulting psychiatrist. Both the RNP and the DNS stated it was their expectation that the trazodone order would have included agitation and anxiety. Following this incomplete implementation of the psychiatric recommendation and the lack of updated behavioral interventions in the care plan, a resident-to-resident altercation occurred on 4/27/2026 in which the resident struck another resident with a cane, causing a laceration to the left eyebrow that required closure with steri-strips and ongoing wound treatment.
Failure to Properly Screen and Clear NA with Disqualifying Criminal History
Penalty
Summary
The facility failed to ensure that a prospective employee was properly screened and cleared for a history of abuse, neglect, exploitation, or misappropriation of resident property before hire. A nursing assistant, identified as Staff A, was hired on 11/18/2025 and was working independently as a NA. Prior to hire, a Bureau of Criminal Identification (BCI) check dated 11/6/2025 showed that Staff A had disqualifying information under federal and state law. Surveyor review after discovery of the positive BCI revealed that Staff A had an extensive criminal history. Despite this, the facility proceeded with the hire and allowed Staff A to complete orientation and work independently without obtaining or maintaining documentation specifying the nature of the disqualifying information, contrary to the facility’s Abuse, Neglect and Exploitation Policy, which requires screening and documentation of proof that such screening occurred. Subsequently, a facility-reported incident submitted on 4/17/2026 documented that a staff member reported witnessing Staff A grab a resident’s face and kiss the resident on the lips. A community-reported complaint submitted on 4/22/2026 alleged inappropriate interactions between the same NA and the same resident, and included a local police incident report indicating the resident’s family intended to pursue charges related to the incident. During interviews, the Human Resource Director stated that Staff A had disclosed disqualifying information related to a prior drug-related charge from about ten years earlier, but acknowledged there was no documentation specifying the nature of the disqualifying information and that this was known only by word of mouth. The Administrator stated she was aware that the BCI contained disqualifying information and that she exercised her own judgment in proceeding with the hire, and further acknowledged she did not receive documentation detailing the disqualifying information until it was brought to her attention by the surveyor.
Failure to Maintain Resident Clothing and Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when the resident was unable to attend meals and activities with other residents because of a lack of appropriate clothing. The resident was admitted in May 2025 with diagnoses including anxiety disorder and post-traumatic stress disorder, and a care plan revised on 8/25/2025 described the resident as highly social and willing to participate in a variety of activities, with an intervention to provide reminders of scheduled events. During observation on 4/29/2026, the resident was found in the room wearing a hospital gown while other residents were in the dining room for lunch. Only one pair of pants and two T-shirts were observed in the room. The resident stated that the facility lost all of the resident's clothing, including shirts, pants, shorts, and socks, after they were sent to laundry services several months earlier and were never returned. The resident reported that the Administrator was told about the missing clothing, but no follow-up occurred and the clothing was neither located nor replaced. The record did not contain an admission inventory list of the resident's belongings, and the Administrator stated that laundry was handled by an outsourced company without a tracking system or documentation identifying which items belonged to which resident.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse when a nursing assistant (NA) was observed kissing the resident on the lips on more than one occasion. The resident, identified as having dementia and a Brief Interview for Mental Status (BIMS) score of 0/15 indicating severely impaired cognition, had been admitted in March 2026. On one occasion, a Certified Medication Technician (CMT) reported that while she was assisting the resident with breakfast, the NA entered the room, verbally expressed affection for the resident, made a kissing noise, leaned forward, and kissed the resident on the lips. This incident made the CMT uncomfortable, and she later discussed it with another NA. A separate staff member, another NA, reported that two days earlier she had observed the same NA enter the resident’s room while morning care was being provided, ask the resident if they remembered her, state that she loved the resident, then lean toward the resident, make a kissing sound, and kiss the resident on the mouth with full lip-to-lip contact. This second NA did not report the incident at the time because she was fearful of the NA involved and only came forward after learning of the later incident. The facility’s abuse, neglect, and exploitation policy defined sexual abuse as a non-consensual sexual act of any type with a resident and required protections for each resident’s health, welfare, and rights, as well as screening of potential employees for a history of abuse. Despite this policy, the resident with severely impaired cognition was subjected to repeated non-consensual kissing by the NA.
Failure to Investigate Allegations of Resident-to-Resident Sexual Inappropriateness
Penalty
Summary
The facility failed to ensure that allegations made by residents were recognized as possible abuse by staff and that all allegations were investigated for Resident ID #41, who was admitted with diagnoses including dementia and traumatic brain injury. A facility policy titled, Abuse, Neglect and Exploitation, stated that an immediate investigation is warranted when suspicion of abuse, neglect, exploitation, or reports of abuse, neglect, or exploitation occur. A progress note written by an RN documented that a resident reported Resident ID #41 was being inappropriate with another resident. Subsequent records included psychiatric evaluations stating the resident was being seen due to increased sexually inappropriate behaviors toward other residents and that sexual impulses may present an unsafe environment for other patients in the facility. Staff interviews revealed that Resident ID #41 had been observed touching other residents' shoulders and hands and required frequent redirection. The RN who documented the incident stated the behavior involved an attempted hug without contact and that both residents were separated and assessed, while the ADON and DON acknowledged they were unaware of the behavior or that the facility had not investigated the allegations. The Administrator also acknowledged that an investigation had not been completed to determine what sexually inappropriate behavior had occurred and that staff did not identify the allegation as possible abuse or investigate it immediately.
Failure to Follow Orders, Report Abuse, and Perform Ordered Wound Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for a resident with dementia and anxiety disorder who had a hearing deficit and complained of right ear wax buildup. The medical record showed an order for Debrox ear drops and a separate order to flush the right ear with warm water two times a day following Debrox usage for 5 days, but the record did not include a physician order for the Debrox solution. The April 2026 MAR showed the resident’s right ear was flushed six times, and the resident stated that the right ear still felt blocked. The RN acknowledged flushing the ear and was unaware whether Debrox had been given, while the DON stated the order had been entered incorrectly and that the ear should not have been flushed before Debrox administration. The NP stated the intended order was for Debrox twice daily for five days before irrigation and that she would not have ordered daily ear flushing. The facility also failed to report an allegation of abuse and failed to update the care plan for a resident with dementia after staff reported inappropriate interactions with a nursing assistant. A community complaint and police incident report indicated the family wanted to press charges, and the Administrator and DON confirmed that staff had reported witnessing the nursing assistant kiss the resident on two occasions. The record did not show that the allegation was reported to the provider, and the comprehensive care plan was not updated to reflect the allegation or any interventions related to the incident. The NP stated she was unaware of the incident and would have expected to be notified, and the ADNS acknowledged that the provider had not been notified and the care plan had not been updated. The facility further failed to follow a wound care order for a resident readmitted with peripheral vascular disease and cellulitis of the lower limb. The physician ordered cleansing open areas on the left lower leg with Vashe wound wash, applying xeroform to the wound bed, and wrapping with kling. During observation, the RN performing wound care did not use Vashe wash and instead cleansed the wound with normal saline. The RN acknowledged using normal saline rather than the ordered cleanser, and the DON stated she would expect the nurse to follow the wound orders as written.
Delayed Pain Medication for Resident with Migraine
Penalty
Summary
Safe, appropriate pain management was not provided for Resident ID #17, who was admitted with diagnoses including migraines and chronic pain. The resident’s care plan dated 4/20/2026 included a goal for the resident to verbalize adequate pain relief and an intervention to respond immediately to any complaint of pain. The physician ordered Butalbital-APAP-Caffeine 50-300-40 mg, 1 capsule every 12 hours as needed for migraine pain. On 4/29/2026 at 10:30 AM, the resident was observed in the hallway complaining of a migraine, moaning in pain, and holding his/her head. At 10:34 AM, an NA reported to an LPN that the resident wanted pain medication, and at 10:37 AM the resident continued to complain of migraine pain and told an RN about the pain, but the RN stated she did not have keys to the medication cart and could not get any pain medication. The resident continued to complain of severe head pain, returned to the room to lie down at 10:40 AM, and the LPN was still off the unit at 10:42 AM. The resident was not assessed when the LPN returned, and the medication was not administered until 11:10 AM, 40 minutes after the initial complaint. The resident later reported pain rated 7 out of 10, and the DON acknowledged that a resident should not wait 40 minutes for pain medication.
Missed Antibiotic Doses Not Reported to Provider
Penalty
Summary
The facility failed to ensure that Resident ID #17 was free from significant medication errors when the resident missed 6 doses of a prescribed antibiotic. The resident was admitted in April 2026 with diagnoses including surgical aftercare and complication of surgical and medical care, and had a physician order dated 4/3/2026 for Cefadroxil 500 mg by mouth twice daily for 14 days. Review of the April 2026 MAR showed missed doses on 4/3 at 8:00 PM, 4/6 at 8:00 PM, 4/11 at 8:00 PM, 4/12 at 8:00 AM, 4/14 at 8:00 PM, and 4/17 at 8:00 AM. The record did not show that the provider was notified of the missed antibiotic doses. During interview, the RN acknowledged the 6 missed doses and stated they should have been reported to the provider. The Medical Director stated she was unaware of the missed doses and said she would have extended the antibiotic course if she had known. The DON also acknowledged the missed doses and stated she would expect the provider to be informed if a resident misses any dose of an antibiotic.
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