Saint Elizabeth Home East Greenwich
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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.
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Saint Elizabeth Home East Greenwich in East Greenwich, RI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in East Greenwich, RI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Saint Elizabeth Home East Greenwich or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.