Saint Elizabeth Home East Greenwich
Saint Elizabeth Home East Greenwich in East Greenwich, RI — inspection on November 28, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
new findings. - 10/20/2025 at 4:26 PM, the Social Worker was aware that Resident ID #2 was involved in a resident-to-resident incident on 10/19.
Resident ID #2 was pleasant and smiling with no concerns relative to the incident. A stop sign and doorbell were in place in efforts to alert staff when other elders are entering his/her private room.Additional record review revealed physician's orders to plug in the motion sensor alarm at 6:00 AM and to unplug the motion sensor alarm at 10:00 PM.
Record review of the October 2025 Treatment Administration Record (TAR) failed to reveal evidence that the order to plug in the motion sensor at 6 AM was signed off as completed on 10/19/2025.During a surveyor interview with Nursing Assistant, Staff A, on 10/21/2025 at 11:39 AM, she revealed that on 10/19/2025, she started her shift at 7:00 AM and started to do rounds at approximately 7:15 AM when she noticed Resident ID #1 was not in his/her bed.
She indicated that s/he frequently wanders up and down the hallway, so she began checking other residents' rooms.
She revealed she found Resident ID #1 in Resident ID #2's bed, with Resident ID #2 making thrusting motions above Resident ID #1.
Additionally, she indicated that Resident ID #2 was undressed below the waist while Resident ID #1 had his/her pants on and brief intact.
Further, she indicated that Resident ID #2 has a motion alarm in his/her doorway that typically makes a sound when someone enters his/her room.
However, she indicated that it did not sound when she entered the room to separate the two residents.During a surveyor interview with Registered Nurse (RN), Staff B, on 10/21/2025 at 3:01 PM, she indicated that on 10/19/2025 at approximately 7:00 AM when she came in for her shift, she observed Resident ID #1 sitting in the small common area at the end of the hallway.
While she was receiving report from the third shift nurse, RN, Staff C, at the nurses' station, Staff A came and requested help in Resident ID #2's room.
She revealed that when they entered the room, Resident ID #2 was bare bottomed with no pants or brief on with Resident ID #1 beneath him/her fully clothed.
Additionally, she revealed that when they were walking in/out of the room, the sensor alarm on the door was not chiming.
She indicated the alarm can typically be heard a pretty good distance while in the hallway and in the common area.
Further, she indicated that the third shift nurse is responsible for plugging in the motion sensor and documenting it in the TAR.The surveyor attempted to contact RN, Staff C via phone on 10/21/2025 at 3:00 PM, 3:15 PM, and at 3:48 PM but was unsuccessful.During a surveyor interview with the Director of Nursing Services on 10/21/2025 at approximately 3:50 PM, she revealed that when Staff B and C went into Resident ID #2's room to address the incident, they did not observe the motion sensor on the door to be plugged in.
She indicated that she would expect the motion sensor on the door to be plugged in at 6:00 AM and documented in the TAR.
Additionally, she indicated that if the motion sensor was missing, broken, or not plugged in that it would be documented in the resident's record.
Further, she was unable to provide evidence that Resident ID #1 was kept free from abuse.
Facility ID:
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.