ABFGHI
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Facilityowner/operatorSurvey dateF-tagsDescriptionRIDOH Remedy
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links show last 36 months inspection reports/cms data
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Respiratory & RehabMayflower10/28/25F760, F726, F678CPR DONE INCORRECTLY(on bed, without backboard--3 staff involved, including RN, LPN, and RT) and Ambu-bag used incorrectly. Resident DIED.
MEDICATION ERROR: mis-transcribed as 3x/day instead of 3x/week, overlooked by supervisors--> resident unsupervised after med error discovered--> resident FELL, was on floor with condition declining but NOT GIVEN AID because staff were directed "not to move them until EMS arrives." Resident DIED.
6 other violations that don't constitute "immediate jeopardy" but include multiple bone fractures are included as well
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Heritage HillsMarquis9/18/25F689, F805ELOPEMENT: previous elopement, wanderguard not implemented per MD order; 2 residents' LIQUIDS NOT THICKENED per MD orders
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John Clarkenonprofit9/25/25F689ELOPEMENT: High risk, multiple previous elopements without additional safety measures
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Friendly HomeEden8/6/25F689ELOPEMENT: (+not wearing MD ordered post-craniectomy helmet)
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TrinityAllaire8/5/25F600NEGLECT: resident was left unattended outside of the facility for approximately 3 hours and 20 minutes during a heat advisory, resulting in CARDIAC ARREST
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Respiratory & RehabMayflower6/30/25F684, F760MEDICATION ERRORS: resident given another resident's antipsychotic medications, error detected, but physician not notified, resident not monitored for side effects (F684 QUALITY OF CARE) visiting family not notified and took resident on outing, resident became unresponsive--hospitalized as a result with toxic metabolic encephalopathy
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LincolnwoodMarquis7/18/25F710, F760MEDICATION ERRORS F 710 - failed to ensure that the resident's physician completed a medication reconciliation upon admission as a transcription error occurred and the physician failed to identify the error. As a result of this failure Resident ID #1 received a medication prescribed to treat seizures 18 times without a diagnosis of a seizure disorder. Additionally, the resident did not receive his/her ordered cardiac medication.
F 760 - Based on record review and staff interview it has been determined that the facility failed to keep all residents free from significant medication errors for 1 of 3 residents reviewed who received Dilantin (an antiseizure medication) in error, Resident ID #1.
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St. Antoinenonprofit3/24/25F756, F760MEDICATION ERRORS F 756 - failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for I of 3 residents reviewed,

F 760 - Based on record review and staff interview it has been determined that the facility failed to keep all residents free from significant medication errors for I of 3 residents reviewed
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TrinityJBF/Receivership3/3/25F584F584 failed to ensure that a resident's environment remains as free from accident hazards as possible related to unsafe water temperatures in hand sinks and showers that are accessible to residents for 4 of 4 facility floors observed.
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WestviewEden2/28/25F604failed to keep a resident free from a PHYSICAL RESTRAINT imposed for purposes of convenience and not required to treat the resident's medical symptoms.(2 incidents: one in which activity aide pushed a resident in their wheelchair aggressively, let go, and it hit the wall (NOT IJ); another where a resident was tied in bed with a bedsheet)
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ElmhurstMarquis1/21-28/25F756, 757, 842MEDICATION ERRORS F 756 - The facility failed to ensure that medication irregularities were identified by the pharmacist during the monthly drug regimen review for Resident ID #1.
F 757 - Failed to ensure that residents are free of significant medication errors for I of I resident who received another resident's cancer medication, Resident ID #I.
F 842 -The facility failed to ensure that resident records are maintained on each resident that are accurately documented in for resident who received another resident's medication for 13 days due to a transcription error.
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Silver CreekGreentree1/27/25F689F689- failed to ensure that the resident environment remains as free of accident hazards, relative to an actual fire that occurred at the facility on 1/24/2025.
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St. Elizabeth'snonprofit1/13/25F689Elopement: "Record review of a facility reported incident submitted to the Rhode Island Department of Health (RIDOH) on 1/2/2025 states in part, "Patient left facility without alerting staff. Patient was unable to re-enter the building and decided to walk. Passer by called 911 and patient was sent to ER [Emergency Room] for evaluation." Review of a community reported complaint submitted to the RIDOH on 1/2/2025 alleges that Resident ID #1 eloped from the facility and was found sitting on a main road and taken to the hospital at approximately 3:00 AM. It further revealed that the resident's family member was not notified by the facility that the resident was unable to be located during rounds until 7:14 AM. This was approximately 3 hours after the resident was found sitting in the road."
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Summit CommonsAthena1/3/25F760Medication errors: LPN administered the wrong Insulin medication to resident on 12/30, POC submitted 12/31 with training for all nurses, survey 1/3 revealed additional Insulin errors, new POC submitted, consulting pharmacy to do training
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DOP=Denial of Payment; DPOC=Directed Plan of Correction
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