Mount St Rita Health Centre

In the surveyor’s words

From the most serious findings on record at Mount St Rita Health Centre, in the surveyor’s own words.

• Immediate jeopardy, patternF684Aug 9, 2023

  Based on record review and staff interview, it has been determined that the facility failed to provide the necessary treatment and care in accordance with professional standards of practice relative to monitoring and obtaining orthostatic vital signs per a physician's order and as part of the post fall evaluation assessments, and completing fall risk assessments for 1 of 1 resident reviewed for a fall resulting in death, Resident ID #1. Additionally the facility failed to complete fall risk assessments and failed to complete post fall evaluation assessments relative to obtaining orthostatic blood pressures for 4 of 4 residents reviewed for falls, Resident ID #s 3, 4, 5, & 6. […]

• Immediate jeopardy, isolatedF742May 6, 2021

  Based on surveyor observation, record review, staff and family interview, it has been determined that the facility failed to ensure that a resident who displays or is diagnosed with a mental disorder of psychosocial adjustment difficulty, or who has a history of trauma, receives appropriate treatment and services to attain the highest practicable mental and psychosocial well-being relative to 1 of 1 resident reviewed for [CONDITION(S)], Resident ID #272. Findings are as follows: Review of the facility policy titled, Suicide Precautions, states in part, When a Resident expresses verbally or through behavioral symptoms, the thought that he/she no longer wishes to live and that he/ she will terminally harm themselves, the facility must initiate suicide precautions . 1. […]

• Actual harm, isolatedF700Jun 25, 2026

  Based on record review and staff interview, the facility failed to ensure the correct use and ongoing reassessment of bed siderails for one of one resident, Resident ID #1 reviewed for the use of bed siderails. The facility failed to reassess the continued need for and safety of the resident's bed siderails for approximately 15 months, despite the resident's severely impaired cognition, total dependence for bed mobility, and continued use of the device. Consequently, the facility failed to identify that the bed siderails had become unsafe and were no longer clinically appropriate. As a result, Resident ID #1 sustained a traumatic posterior (the back) dislocation of the right shoulder and significant bruising. […]

• Actual harm, isolatedF689Dec 30, 2025

  Based on surveyor observation, review of the clinical record, and staff interviews, the facility failed to ensure adequate supervision to prevent an accident for 1 of 1 resident reviewed. The resident disengaged the alarm system, exited the facility, remained outside for an unknown period of time, sustained an unwitnessed fall, and was unable to re-enter the building, resulting in hospital admission for treatment of frostbite to the resident's bilateral hands, Resident ID #1.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 12/29/2025, states in part, that a resident wandered outside of the facility during a snowstorm, believed to be outside for at least one hour, was found yelling for help while holding onto a… […]

• Actual harm, isolatedF699Oct 25, 2023

  Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors receive trauma informed care in accordance with professional standards of practice and accounting for the resident's experiences and preferences for 1 of 3 residents reviewed, Resident ID #23. Findings are as follows: Review of the resident record revealed s/he was admitted to the facility in August of 2021, with diagnoses including but not limited to: Alzheimer's disease, need for assistance with personal care, major depressive disorder, and anxiety. Review of a Minimum Data Set (MDS) Assessment, dated 8/23/2023, revealed his/her cognitive skills are severely impaired. […]