St Antoine Residence

In the surveyor’s words

From the most serious findings on record at St Antoine Residence, in the surveyor’s own words.

• Immediate jeopardy, isolatedF756Mar 24, 2025

  Based on record review and staff interview, it has been determined that the facility failed to develop and maintain policies and procedures for the facility to act on pharmacy identified irregularities marked as Clinical Priority) for 1 of 1 resident reviewed for the use of Clozapine (Clozaril, an atypical antipsychotic medication prescribed for treatment-resistant schizophrenia, recurrent suicidal behavior in schizophrenia), Resident ID #1. Findings are as follows: Review of an article published by the National Library of Medicine, nlm.nih.gov dated 7/1/2019 reveals that abrupt discontinuation of Clozapine has the risk to cause seizures, rebound psychosis, cholinergic rebound (profuse sweating, headache, nausea, vomiting, and diarrhea), serotonin syndrome (agitation, insomnia, high blood… […]

• Immediate jeopardy, isolatedF760Mar 24, 2025

  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, Resident ID #1. Findings are as follows: Review of a policy titled Medication Reconciliation dated 5/13/2019 states in part, .Medication Reconciliation will occur for each patient/resident upon admission/re-admission or re-entry from the hospital to [Facility] to ensure safe and effective administration of medications .For a patient/resident who was sent to the hospital by [Facility] and is re-entering [Facility] after that hospital stay, the admitting nurse will: Review the Continuity of Care Form and clinical record from the discharging hospital and compare that Continuity of Care Form and clinical record… […]

• Actual harm, isolatedF580Jul 9, 2026

  Based on clinical record review and staff interview, the facility failed to ensure that the attending practitioner was immediately notified of a significant change in a resident's physical and clinical status for 1 of 1 resident reviewed with a change in condition, Resident ID #1. Specifically, nursing staff failed to notify the provider of Resident #1's acute decline in functional mobility (digressing from a 2-assist walker transfer to requiring the use of a mechanical lift for transfers) and multiple clinical manifestations of unmanaged pain (wincing, grimacing, heavy lateral leaning, and pointing to his/her right lower extremity) following consecutive falls on 6/16/2026 and 6/17/2026.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island… […]

• Actual harm, isolatedF684Sep 16, 2025

  Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed with a pre-cancerous lesion to the right temple, Resident ID #1.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 9/8/2025 alleges that the resident was transferred to an acute care hospital from the facility to be evaluated for a chronic malignant (cancerous) wound on his/her right scalp which was found to have maggots (worm-like creatures that feed on decaying organic matter) in it. […]

• Actual harm, isolatedF600Apr 8, 2025

  Based on record review and staff interview, it has been determined that the facility failed to keep a resident free from abuse for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health (RIDOH) on 3/31/2025, revealed in part, that Resident ID #1 became combative with staff and was escorted to his/her room and that the resident was held down in his/her bed to avoid him/her from falling. Additionally, the incident report dated 3/31/2025, revealed that a follow up call was placed from RIDOH to the facility, where the Director of Nursing Services (DNS), revealed that Registered Nurse (RN), Staff A, and Licensed Practical Nurse (LPN), Staff B, restrained Resident ID #1. […]