Deficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
47% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 7
Sep 5, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of care, resident preferences, medication administration, infection control, and staff training as part of the annual survey.
Findings
The facility was found deficient in multiple areas including failure to follow physician orders for offloading devices, lack of person-centered care for a non-English speaking resident, failure to follow specialist treatment recommendations, medication errors exceeding 5%, inadequate infection control practices, and insufficient staff training on trauma informed care, QAPI, and effective communication.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure residents receive treatment and care in accordance with professional standards related to the utilization of a heel offloading device for Resident ID #3. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to honor each resident's preferences, choices, values and beliefs for Resident ID #63 who is unable to speak or understand English and speaks Cantonese. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and care according to orders and specialist recommendations for Resident ID #40 regarding Prostate-Specific Antigen testing. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate of 7.14% observed during medication administration affecting Residents ID #2 and #64. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain an infection prevention and control program related to staff not wearing appropriate PPE when handling soiled linen. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop, implement, and maintain an effective training program for new and existing staff on abuse, infection control, dementia behavioral health management, trauma informed care, and QAPI. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide mandatory effective communication training for direct care staff regarding Resident ID #63 who only speaks Cantonese. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication administration opportunities observed: 28
Medication errors: 2
Medication error rate: 7.14
Physician order date: Aug 26, 2024
Physician order date: May 13, 2023
Physician order date: Aug 20, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Acknowledged failure to offload Resident ID #3's right heel and ankle as ordered and inability to provide evidence of PSA lab results |
| Staff B | Nursing Assistant | Acknowledged that the offloading device was not placed on Resident ID #3's right ankle |
| Director of Nursing Services | Expressed expectation for proper offloading device placement, acknowledged lack of interpreter services, and lack of staff training | |
| Staff C | Registered Nurse | Unable to identify Chinese language spoken by Resident ID #63 and unaware of interpreter services |
| Staff D | Activity Director and Activity Aide | Unaware of Chinese language spoken by Resident ID #63 and interpreter services |
| Staff E | Nursing Assistant | Unaware of language spoken by Resident ID #63 and use of translating cards |
| Staff F | Nursing Assistant | Unaware of language spoken by Resident ID #63 and interpreter services |
| Staff G | Medication Technician | Unaware of language spoken by Resident ID #63 and interpreter services; mixed medication in incorrect fluid amount |
| Staff H | Certified Medication Technician | Administered incorrect dose of medication to Resident ID #64 |
| Staff I | Laundry Aide | Observed handling soiled linen without appropriate PPE |
| Staff J | Laundry Aide | Unaware that gown or apron should be worn when handling soiled linens |
| Staff K | Licensed Practical Nurse | Lacked evidence of annual education on Trauma Informed Care and effective communication training |
| Staff L | Certified Medication Technician | Lacked evidence of annual education on Trauma Informed Care, QAPI, and effective communication training |
| Staff M | Nursing Assistant | Lacked evidence of annual education on Trauma Informed Care, QAPI, and effective communication training |
| Staff N | Registered Nurse | Lacked evidence of annual education on Trauma Informed Care, QAPI, and effective communication training |
| Staff O | Nursing Assistant | Lacked evidence of annual education on Infection Control, Abuse, Dementia behavioral health management, Trauma Informed Care, QAPI, and effective communication training |
| Staff P | Dietary Aide | Lacked evidence of effective communication training |
| Staff Q | Nursing Assistant | Lacked evidence of effective communication training |
Inspection Report
Complaint Investigation
Deficiencies: 2
Dec 16, 2024
Visit Reason
The inspection was conducted following a community-reported complaint alleging that a resident on oxygen was found without oxygen when EMS arrived, resulting in hypoxia and hospitalization.
Findings
The facility failed to ensure proper oxygen administration during an acute medical event for one resident, including failure to monitor oxygen saturation after oxygen was applied and lack of nursing staff competencies related to oxygen therapy. The resident's oxygen was found off upon EMS arrival, and the nurse did not reevaluate the resident after placing oxygen.
Complaint Details
Complaint submitted on 2024-12-13 alleged the resident was on oxygen but it was not on when EMS arrived, leading to hypoxia and hospital admission. The complaint was substantiated by record review and staff interviews.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure residents receive treatment and care in accordance with professional standards of practice relative to oxygen administration during an acute medical event. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure nursing staff have appropriate competencies and skill sets to provide nursing and related services, specifically related to oxygen therapy. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Oxygen saturation: 85
Oxygen saturation: 84
Oxygen saturation: 95
Oxygen flow: 2
Hire date: Jun 25, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Nurse responsible for resident care during oxygen administration incident and acknowledged failure to reevaluate resident after oxygen application |
| Staff B | Nursing Assistant | Observed resident on oxygen and reported concentrator issues to nurse |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding expectations for oxygen administration and nursing competencies |
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 29, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Elmwood Nursing and Rehabilitation Center following a survey completed on 08/29/2024.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 7, 2023
Visit Reason
The inspection was conducted following a complaint investigation regarding alleged involuntary seclusion of a resident by staff at the facility.
Findings
The facility failed to ensure residents were free from abuse related to involuntary seclusion for one resident. Staff acknowledged restraining the resident by holding the door closed with a towel, preventing the resident from leaving the room without consent.
Complaint Details
The complaint investigation was substantiated based on record reviews and staff interviews confirming involuntary seclusion of Resident ID #1 by staff using a towel to hold the door closed.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect resident from abuse related to involuntary seclusion by restraining the resident in their room against their wishes. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Practical Nurse | Acknowledged holding the door closed, preventing the resident from exiting the room. |
| Staff A | Scheduler | Reported seeing the towel on the door handle and reported the incident to the Director of Nursing Services. |
| Staff B | Nursing Assistant | Provided towel to nurse and confirmed hearing banging on the door until the resident was let out. |
Inspection Report
Deficiencies: 5
Sep 21, 2023
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality, resident safety, trauma-informed care, and proper medical record maintenance at Elmwood Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to maintain proper positioning of a resident per physician orders, inadequate supervision of an elopement risk resident, improper administration of IV antibiotics via PICC line, failure to provide trauma-informed care and assessments for multiple residents, and failure to maintain accurate medical records for an elopement risk resident.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure services met professional standards of quality for positioning of Resident ID #25, including not elevating the head of bed as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure adequate supervision and wanderguard placement for elopement risk Resident ID #516. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to properly assess PICC line patency by checking for blood return prior to IV antibiotic administration for Resident ID #520. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide trauma-informed care and complete trauma screening assessments for multiple residents, including Resident ID #4 who was re-traumatized. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain accurate medical records and documentation regarding wanderguard placement for Resident ID #516. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for positioning: 5
Residents reviewed for elopement supervision: 4
Residents reviewed for trauma informed care: 17
Residents reviewed for elopement medical record accuracy: 4
Wanderguard non-compliance observations: 6
PICC antibiotic administration days: 35
PICC flush volume: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Technician | Acknowledged resident had eaten lunch and should not be lying flat in bed |
| Staff B | Registered Nurse (RN) | Acknowledged resident's bed was not elevated as ordered and resident requires elevation due to dysphasia and aspiration history |
| Staff C | Nursing Assistant | Acknowledged resident is an elopement risk and did not have wanderguard on |
| Staff D | Registered Nurse | Observed flushing PICC line without assessing blood return and acknowledged this was not done |
| Staff E | Licensed Practical Nurse (LPN) | Authored progress note regarding Resident ID #4's refusal to shower due to past trauma |
| Staff F | Licensed Practical Nurse (LPN) | Revealed resident often refuses showers and was unaware of past trauma until incident |
| Staff G | Nursing Assistant | Indicated resident refuses showers sometimes and was unaware of trauma history |
| Director of Nursing Services | Director of Nursing Services | Acknowledged physician orders and expected staff compliance for bed elevation and wanderguard placement; expected trauma screenings and care plans |
| Social Worker | Social Worker | Responsible for trauma screening assessments; acknowledged assessments were not completed for some residents |
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