Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fairhaven Healthcare Center during CMS and state inspections, most recent first.
A resident with latent TB and prior hepatotoxicity from Rifampin was admitted with hospital documentation indicating Rifampin was to be stopped indefinitely and not administered. Facility policy required use of the final hospital discharge summary and two‑nurse verification for medication reconciliation, but the Nursing Supervisor relied on a preliminary discharge summary, entered Rifampin as an active order after calling the on‑call provider, and the second nurse did not verify orders against the final discharge summary. No staff documented review of the finalized discharge instructions or clarification of the Rifampin order, and the resident received two doses of Rifampin before being transferred back to the hospital with recurrent liver injury symptoms.
Failure to Follow Hypoglycemia Protocol and Heel Offloading Orders: A resident with diabetes had repeated blood sugar readings below 60 mg/dL, but nursing documentation did not show the required re-checks or provider notification after several episodes, and the MAR did not reflect completion of the ordered hypoglycemia protocol. A second resident with ESRD, DM2, and cognitive impairment was observed in bed with heels directly on the mattress despite orders for heel boots or floating booties while in bed; staff confirmed the heel devices were not in the room and the orders were not being followed.
Dignified Dining Experience: Two residents with severe cognitive impairment and dependence for eating were not provided a dignified mealtime. One resident was repeatedly left to eat non-finger foods with his/her hands without staff cueing or feeding assistance despite staff being present, while another resident was given covered meals and drinks out of reach and left waiting while tablemates were fed. Staff also referred to the second resident as a "feeder" instead of by name.
A resident with severe cognitive impairment, psychosis, and anxiety received PRN lorazepam over an extended period without a documented 14-day stop date. The MAR showed repeated Ativan use across multiple months, while BH recommendations and a consultant pharmacist note indicated the PRN psychotropic should have been reassessed and time-limited unless the prescriber documented justification for continued use.
A resident with dementia and moderate cognitive impairment, who was dependent on staff for eating, had a physician order for a double-handled mug with a red straw lid for all beverages with meals. During several observed meals, staff repeatedly placed two single-handled mugs with straws in front of the resident instead of the ordered mug, and staff interviews showed they were unaware of the order.
Failure to Update Care Plan After Hospice Enrollment: The facility did not review and revise a resident’s care plan after the resident started hospice and a SCSA was completed. The resident had severe cognitive impairment, a G tube, was NPO, and was receiving hospice services, but the current plan of care did not include hospice-related care. The UM said nursing updates care plans with significant changes, and the DON said she would expect the care plan to be updated when a resident starts hospice.
Failure to provide meal assistance during ADLs. A resident with severe cognitive impairment and diagnoses including Alzheimer’s disease and dementia was assessed as needing supervision and assistance with eating, yet was repeatedly observed in the dining room eating scrambled eggs, toast, salad, macaroni and cheese, oatmeal, butter, and jelly with his/her hands while staff were present but did not cue utensil use or offer feeding assistance. The NUM, CNA, and DON all stated the resident needed observation and assistance with meals as needed.
Two residents with indwelling urinary catheters did not receive care consistent with ordered catheter size, balloon volume, and drainage bag emptying frequency. One resident’s catheter was observed with a smaller balloon than ordered, while another resident’s Foley bag was found with a large urine volume and had not been emptied during the shift as expected. Staff stated catheter size orders should be checked and Foley bags emptied on the ordered schedule.
Missing Emergency Dialysis Supplies at Bedside: A resident with ESRD and severe cognitive impairment who was dependent on dialysis did not have the ordered non-serrated clamp or pressure dressing observed in the room despite physician orders and the care plan requiring them to be kept at the bedside, in the dialysis bag, and on the wheelchair for a tunneled hemodialysis catheter. The surveyor and an RN both did not see the supplies, and the RN, UM, and DON stated the clamp and pressure dressing should be at the bedside.
Failure to Complete Required AIMS Assessment for a Resident on Antipsychotics: A resident with dementia with psychotic disturbance and severe cognitive impairment was receiving quetiapine and Risperdal, but the medical record did not show the required AIMS assessment. Facility policy required a baseline AIMS when antipsychotics are started and every 6 months thereafter, and staff interviews showed confusion about who completed the assessment and that no system was in place for residents not seen by psych services.
Medication Error Rate Exceeded 5% Due to Incorrect Multivitamin and Eye Drops: A nurse made two medication errors during observation, resulting in a 7.69% error rate. A resident with cataracts and anemia received a multivitamin with minerals instead of the ordered multivitamin and refresh eye drops instead of the ordered Systane eye drops. The nurse said she was unaware of the difference between the products, and the DON confirmed the medications were not the same.
Unsecured Storage of Controlled Medication: Staff failed to keep two bottles of lorazepam, a Schedule IV controlled substance, in a separately locked compartment in the Pawtucket med room. Surveyors observed the compartment unlocked even though it had a lock, and an LPN acknowledged it should have been locked. The DON confirmed controlled meds such as lorazepam must be stored in a separately locked compartment.
Improper Hand Handling of Resident Food: On the Pawtucketville unit, two CNAs handled a resident’s toast with bare hands during breakfast, including tearing toast into oatmeal and moving toast to cover it with jelly. The facility’s Food Handling and Safety policy required hand hygiene and gloves when appropriate, and the CNA, NUM, and DON all stated staff should not handle resident food with bare hands.
The facility failed to follow physician orders for three residents, including incorrect wound care dressing, lack of hand rolls for a resident with contractures, and failure to conduct 15-minute safety checks for a resident with a history of falls and suicidal ideations. Staff were unaware or did not implement the necessary care, leading to deficiencies in meeting professional standards.
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in oxygen therapy and CPAP/BiPAP equipment management. A resident received oxygen without necessary filters, while another had a dusty concentrator and dirty CPAP machine. A third resident had outdated equipment and a dirty BiPAP facemask. Staff were unclear about maintenance schedules, contributing to inadequate care.
The facility failed to follow infection control practices, including improper hand hygiene and PPE use in Enhanced Barrier Precaution rooms, unsanitized glucometer use between residents, and inadequate wound care procedures. Staff acknowledged these lapses, which were observed by surveyors.
A resident's dignity was compromised when their urinary catheter bag was repeatedly left uncovered, making it visible from the hallway. Despite the facility's policy requiring privacy bags, observations showed the catheter bag was not covered, and staff confirmed it should have been.
The facility failed to develop care plans for two residents, one at risk for pressure ulcers and another with a cardiac pacemaker. Despite assessments indicating the need for a pressure ulcer care plan for a resident with incontinence, none was created. Similarly, a resident with a pacemaker lacked a comprehensive care plan, contrary to facility policy. Staff interviews confirmed the necessity of these care plans.
A resident with dysphasia and failure to thrive was left unsupervised during meals, despite being dependent on staff for all functional tasks. Observations revealed the resident attempting to eat without assistance, contrary to the care plan requiring supervision. Staff interviews confirmed the need for help, yet the resident was left alone, indicating a failure in following care protocols.
The facility failed to provide necessary treatment for two residents with pressure ulcers. One resident did not have the required soft booties on their feet as per the care plan, often due to them being in the laundry. Another resident did not receive the correct wound treatment as recommended by the wound physician, with staff unaware of the specific treatment order. These deficiencies indicate lapses in following prescribed care plans and treatment protocols.
A resident with a history of burns from hot coffee was repeatedly observed without a lid on their coffee cup, despite care plan requirements for covered cups. Staff interviews revealed a lack of communication and adherence to the care plan, resulting in a deficiency in maintaining the resident's safety.
A resident with adult failure to thrive and type 2 diabetes was admitted as continent but later became frequently incontinent. The facility failed to conduct necessary evaluations or develop a care plan for the resident's bladder incontinence, despite policy requirements. Staff confirmed the resident's incontinence and lack of a toileting plan, highlighting a deficiency in care.
A resident with dementia and lactose intolerance experienced significant weight loss over six months. Despite the dietitian's recommendations for dietary interventions, including Mighty Shakes, these were not implemented promptly. The facility's failure to follow its weight policy and communicate effectively led to continued weight loss.
A facility failed to provide appropriate dialysis care for a resident with end-stage renal disease. The resident's care plan lacked specific interventions for the dialysis access site, and there were no emergency supplies, such as a non-serrated clamp, at the bedside. Additionally, communication between the facility and the dialysis center was inconsistent, with missing entries in the resident's communication book. Staff were unaware of the need for an emergency plan or supplies, and the care plan did not specify the location of the dialysis access site.
The facility exceeded a 5% medication error rate when two nurses made errors affecting two residents. One nurse withheld medications without physician orders, and another crushed a medication against instructions. Both actions violated facility policy requiring adherence to prescriber orders.
The facility failed to ensure medications were labeled with open dates and outdated medications were not available for administration on two resident care units. Observations revealed several medications, including inhalers and nasal sprays, were opened and undated, making it impossible to determine expiration dates. Interviews with nursing staff confirmed the requirement for medications to be labeled and dated when opened.
A resident with missing teeth and difficulty eating was not provided the prescribed Mechanical Soft (Dental) Ground texture diet. Observations showed the resident received meals inconsistent with the diet order, such as toast and an uncut grilled cheese sandwich. The facility's therapeutic diets did not include ground textures, and the resident had not been screened by Speech Therapy upon admission, leading to the deficiency.
A facility failed to maintain an accurate medical record for a resident with a pressure ulcer. The resident's air mattress, ordered to be set at 165 lbs, was observed at 180 lbs on two occasions, while the Treatment Administration Record inaccurately documented it as 165 lbs. Interviews confirmed the mattress should match the resident's weight, which was 178 lbs, and highlighted incorrect documentation.
The facility failed to support residents' right to self-determination by requiring them to eat in the dining room and not delivering meals to their rooms, causing distress and difficulty for residents who preferred or needed to eat in their rooms. This policy change led to safety concerns and challenges for residents who had to transport their meals independently.
Failure to Reconcile Hospital Discharge Orders Leads to Administration of Discontinued Rifampin
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when admission medications were not accurately reconciled and transcribed. Facility policy required that all physician and authorized practitioner orders be accurately transcribed, verified by a second licensed nurse, and reconciled with the physician upon admission and after hospitalization, with discrepancies clarified immediately. Another policy required use of the official, final hospital discharge document for medication reconciliation, with the admitting nurse resolving discrepancies prior to order entry and a second nurse confirming accuracy before activating orders in the EMR. Resident #1 was admitted with diagnoses including latent tuberculosis, anemia, muscle wasting, diabetes mellitus, and acute kidney failure. The preliminary hospital discharge summary indicated a discharge diagnosis of hepatotoxicity secondary to Rifampin and stated that Rifampin was stopped due to toxicity and to remain off it indefinitely. The finalized hospital discharge summary explicitly directed that Rifampin 150 mg capsules and Ibuprofen 600 mg tablets were not to be administered. A physician’s progress note in the resident’s record also stated that the resident was to remain off Rifampin indefinitely due to hepatotoxicity. Despite these documented instructions, the resident’s MAR contained an active order for Rifampin 150 mg, three capsules once daily, and the medication was documented as administered on two days. Interviews and record review showed that the Nursing Supervisor used the preliminary discharge summary sent to the admission coordinator, saw Rifampin listed as a current medication, called the on‑call provider, verbally reviewed and reconciled the medication list, and then entered the orders into the EMR without using the finalized discharge paperwork that accompanied the resident on the actual admission date. The second nurse responsible for double‑checking admission orders did not verify the medication orders against the final discharge summary. There was no documentation that nursing staff reviewed the finalized discharge summary or clarified discrepancies related to Rifampin with the provider. The Unit Manager reported being unaware that the medications were not reconciled or transcribed accurately upon admission, even though she stated that medication reconciliation should always be completed by two nurses using the final hospital discharge summary. As a result of these failures, the resident received two doses of Rifampin after it had been discontinued at the hospital, and the resident was subsequently transferred back to the hospital with recurrent symptoms related to liver injury.
Failure to Follow Hypoglycemia Protocol and Heel Offloading Orders
Penalty
Summary
The facility failed to follow a physician-ordered hypoglycemic protocol for a resident with type 2 diabetes and moderate cognitive impairment. The resident had multiple blood sugar readings below 60 mg/dL, including 56 mg/dL on 8/7/25 and 8/28/25, 53 mg/dL on 9/1/25, and 56 mg/dL on 9/11/25. The physician order required a carbohydrate snack, re-checking blood sugar every 15 minutes until it was greater than 70 mg/dL, and notifying the MD for blood sugar less than 60 mg/dL. For the low blood sugar episodes on 8/7/25 and 8/28/25, Nurse #1 documented that orange juice was given, but the record did not show that the blood sugar was re-checked in 15 minutes or that the physician was notified. For the 9/1/25 episode, Nurse #3 documented that orange juice was given and that the blood sugar was re-checked and within normal limits, but the record did not show that the physician was notified. For the 9/11/25 episode, the medical record did not show that orange juice was provided, that the blood sugar was re-checked, or that the physician was notified. The MAR also did not show the hypoglycemic protocol order as completed after these low readings. The facility also failed to follow physician orders for heel offloading for another resident with end stage renal disease, muscle weakness, type 2 diabetes, and moderate cognitive impairment. The resident had orders to off-load the heels with floating booties or heel boots while in bed, and the care plan included applying heel booties when in bed. Surveyors observed the resident lying in bed with the heels directly on the mattress on 9/24/25, 9/25/25, and 9/26/25. During the observation, the resident stated the heel boots had not been worn since the heel wounds healed. Staff interviews confirmed the resident did not have heel booties in the room and that the orders should have been followed.
Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for two residents. Resident #49 had diagnoses including Alzheimer's disease, dementia without behavioral disturbance, and osteoarthritis of the shoulders. The most recent MDS indicated the resident was rarely understood, had severely impaired cognition, and required set-up or cleaning assistance with eating. The care plan and nutrition assessment described continual supervision and assistance with meals as the resident allowed, and the quarterly functional assessment indicated dependence on staff for eating. During multiple dining room observations, Resident #49 was repeatedly served meals and left without cueing or assistance while eating non-finger foods with his/her hands. The resident was observed eating scrambled eggs, salad, macaroni and cheese, butter, and jelly with his/her hands, licking food from his/her fingers, and at times attempting to use a spoon but dropping food onto the table. Staff were present in the dining room during these observations, but no one offered feeding assistance, cueing to use utensils, or an alternative meal such as finger foods. The Nurse Unit Manager, CNA, and DON each stated that staff should intervene when the resident struggles to eat and that it is not a dignified dining experience when the resident is eating non-finger foods with his/her hands. Resident #107 had diagnoses including Alzheimer's disease, epilepsy, and weakness. The MDS indicated the resident rarely is understood, has severely impaired cognition, and is dependent on staff for eating assistance. The functional assessment and care plan also identified the resident as requiring assistance with eating. During dining room observations, staff repeatedly placed covered plates and drinks in front of the resident and walked away, leaving food and beverages out of reach while the resident watched tablemates being fed. On one occasion, a CNA referred to the resident as a "feeder" and staff discussed placing all "feeders" together. At another point, a CNA fed the resident while laughing and talking to another staff person. The Nurse Unit Manager and DON stated that residents needing feeding assistance should not have food placed in front of them until staff are ready to assist, should not have to watch others eat while waiting, and should be referred to by name rather than by care need.
Unnecessary PRN Lorazepam Use Without Required Stop Date
Penalty
Summary
The facility failed to ensure one resident was free from unnecessary psychotropic medication. The resident was admitted in July 2023 with diagnoses including alcoholic cirrhosis of the liver, psychosis, and anxiety, and the most recent MDS dated 6/19/25 showed severe cognitive impairment with a BIMS score of 5 out of 15. Physician orders showed PRN lorazepam started on 11/6/24 at 0.5 mg by mouth every 8 hours as needed for anxiety, then increased on 12/9/24 to 1 mg by mouth every 8 hours as needed for anxiety. The record did not indicate that a 14-day stop date had been initiated for the PRN lorazepam order. The MAR from November 2024 through September 2025 showed repeated administration of Ativan, including multiple doses in several months. Behavioral Health Group recommendations on 11/5/24 indicated lorazepam liquid 0.5 mg every 8 hours PRN for anxiety for 30 days then reassess, and a 12/3/24 recommendation increased the dose to 1 mg every 8 hours for anxiety. A consultant pharmacist note dated 7/19/25 stated the resident was receiving PRN Ativan and noted PRN psychotropic medications require re-evaluation after the initial 14 days of therapy and documentation of medical justification if continued beyond 14 days. A physician progress note dated 7/25/25 stated the resident would continue to receive lorazepam as needed because staff reported no concerns. Staff interviews indicated PRN psychotropics should be ordered for one to two weeks and reassessed, and the DON stated a PRN psychotropic should have a 14-day stop date unless the physician documents a reason to extend use.
Failure to Provide Ordered Adaptive Dining Equipment
Penalty
Summary
Resident #28, who was admitted in April 2024 and had diagnoses including dementia without behavioral disturbance and major depressive disorder, was assessed as rarely/never understood, moderately cognitively impaired, without behaviors, and dependent on staff for eating. The resident had an active physician order dated 1/30/25 to use a double-handled mug with a red straw lid for all beverages with all meals. The resident’s care plans also referenced adaptive equipment for meals, including a cup with lid for all beverages and a mug with lid and straw. During multiple meal observations on 9/24/25, 9/25/25, and 9/26/25, the resident was repeatedly provided two single-handled mugs with straws instead of the ordered double-handled mug with a red straw lid. Staff observed the resident leaning forward to drink from the straw and attempting but being unable to pick up one of the mugs, yet the incorrect mugs were not replaced during the observed meals. Interviews with CNA #1 and Nurse Unit Manager #3 showed they were not aware of the double-handled mug order, and the DON stated that if there was a physician order for double-handed mugs with meals, they should be provided.
Failure to Update Care Plan After Hospice Enrollment
Penalty
Summary
The facility failed to review and revise the care plan for Resident #102 after the resident started hospice and a comprehensive assessment for significant change in status was completed. The facility policy titled, Updating Care Plans Following Significant Changes in Resident Condition, dated April 2025, stated that significant changes may include a substantial decline in physical, mental, or psychosocial status or new physician orders impacting care, and that the interdisciplinary team will immediately review the resident’s condition and revise the care plan to reflect updated goals, interventions, and outcomes within the regulatory timeframe, generally within 7 days of identifying the change. Resident #102 was admitted in October 2024 with diagnoses including dysphagia, protein calorie malnutrition, and a G tube. The MDS showed a BIMS score of 7 out of 15, indicating severe cognitive impairment, and also indicated that the resident had a G tube, was NPO, and was receiving hospice services. The census showed hospice admission on 8/20/25, social service notes documented hospice sign-on and that the resident was admitted to hospice, and a later note identified a significant change with the resident signed on with hospice. Review of the current plan of care showed no care related to hospice. During interviews, the Unit Manager stated care plans are updated by nursing with significant changes in status, and the DON stated she would expect nursing to update the care plan when a resident starts hospice.
Failure to Provide Meal Assistance During ADLs
Penalty
Summary
The facility failed to ensure assistance with ADLs was provided for a resident who was unable to eat independently. Resident #49 was admitted with diagnoses including Alzheimer's disease, dementia without behavioral disturbance, and osteoarthritis of the shoulders. The most recent MDS indicated the resident was rarely understood, had severely impaired cognition, and required set-up or cleaning assistance with eating. The nutrition risk assessment stated the resident ate with continual supervision and assistance as he/she allowed, and the care plan directed continual supervision with assistance as the resident allowed, task segmentation, privacy and dignity, and the amount of staff intervention needed for task completion. During multiple dining room observations, Resident #49 was repeatedly seen eating non-finger foods with his/her hands while staff were present but did not provide feeding assistance or cueing to use utensils. On 9/24/25, the resident ate scrambled eggs and toast with jelly using his/her hands, had jelly on his/her hands, and licked his/her fingers while staff in the dining room assisted other residents and did not intervene. Later that day, the resident ate salad with his/her hands while staff were present and no assistance was offered. On 9/25/25, the resident was observed eating scrambled eggs, toast, a cinnamon bun, oatmeal, and macaroni and cheese with his/her hands, including licking food from his/her fingers, while staff nearby did not cue utensil use or offer assistance. On 9/26/25, the resident again ate breakfast items with his/her hands, including picking up butter and jelly containers and licking the food from his/her fingers, while multiple staff were present and no cueing or assistance was provided. The Nurse Unit Manager stated the resident had variable ability to self-feed and staff should observe meals and offer assistance as needed. The CNA stated the resident sometimes needed help because he/she tires and staff should help or give a spoon if the resident used his/her hands. The DON stated it was her expectation that staff provide meal assistance as needed and intervene if a resident was struggling to eat or eating non-finger food with his/her hands.
Indwelling Catheter Orders Not Followed
Penalty
Summary
The facility failed to provide treatment and services related to indwelling urinary catheters for two residents. Resident #3, admitted with diagnoses including benign hyperplasia with lower urinary tract symptoms and neuromuscular dysfunction of the bladder, had an MDS indicating moderately impaired cognition and required an indwelling catheter. On observation, the resident’s catheter was seen as size 16 Fr with a 5 mL balloon, while the physician’s order directed insertion of a 16 Fr catheter with a 10 mL balloon. The resident’s care plan also referenced a Foley catheter with a 14 Fr, 10 cc setup and directed catheter and bag changes per MD order. The TAR showed the catheter was changed on 9/17/25. Staff interviews indicated nurses should follow the ordered catheter size and check the order before changing the Foley. Resident #92, admitted with diagnoses including retention of urine, UTI, and neuromuscular dysfunction of the bladder, had an MDS indicating moderately impaired cognition and required an indwelling catheter. On observation, the resident’s Foley drainage bag contained 1,400 mL of urine, and later the same day the nurse observed the bag contained 1,600 mL and stated it had not yet been emptied that shift. The nurse said the CNAs were supposed to change the Foley bag at the beginning and end of the shift. The resident’s orders directed Foley catheter care every shift, emptying the Foley bag two times a shift for prevention of irritation/urine backflow, and insertion of a 20 Fr catheter with a 10 mL balloon. The care plan identified a 14 Fr, 10 mL balloon catheter and stated catheter care every shift and as needed. Staff interviews confirmed the resident’s catheter was emptied twice per shift because of high urine output, and the DON stated nurses should follow the physician order for correct catheter size and that Foley catheters are emptied every shift and as needed.
Missing Emergency Dialysis Supplies at Bedside
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for one resident who required renal dialysis. The resident was admitted with end stage renal disease and was dependent on dialysis. The most recent MDS indicated severe cognitive impairment, with a BIMS score of 5 out of 15. The resident’s physician orders directed that non-serrated clamps be kept at bedside and on the person, and the plan of care stated that if bleeding occurred, a pressure dressing should be applied and 911 called, with a non-serrated clamp kept at bedside, in the dialysis bag, and on the wheelchair to clamp the chest port catheter in the event of bleeding. During observations on 9/25/25, the resident was seen sitting on the edge of the bed and later walking around the room, and the surveyor did not observe emergency clamps or pressure dressings in the room. During an observation and interview, Nurse #1 also did not observe the emergency clamp and pressure dressing in the resident’s room and stated they should be there. The Unit Manager stated the emergency clamp should be in the resident’s room next to the bed, and the DON stated residents with tunneled dialysis catheters should have emergency clamps and pressure dressing at the bedside.
Failure to Complete Required AIMS Assessment for Resident on Antipsychotics
Penalty
Summary
The facility failed to ensure that an Abnormal Involuntary Movement Scale (AIMS) assessment was completed for one resident receiving antipsychotic medications. Facility policy titled Psychotropic Medication Management, dated October 2023, required a baseline AIMS assessment upon initiation of any antipsychotic medication and every six months thereafter. Resident #13 was admitted in November 2024 with diagnoses including dementia with psychotic disturbance, and the MDS dated 7/31/25 showed severe cognitive impairment and that the resident was receiving an antipsychotic. Resident #13’s physician orders showed quetiapine fumarate ER 600 mg at bedtime and later Risperdal 0.5 mg twice daily. Consultant pharmacy recommendations noted that the resident was receiving Risperdal and that an AIMS assessment was required every 6 months, and later noted Seroquel XR 600 mg at bedtime and Risperdal 1 mg daily with a recommendation for periodic dose evaluation. Review of the medical record failed to show that an AIMS assessment was completed as required. During interviews, a nurse stated she was not aware who completed the AIMS assessment or how often it needed to be completed, the unit manager stated the assistant director of nursing completes it, and the DON stated AIMS should be completed upon admission and every six months for residents receiving antipsychotic medications, but there was no system in place to complete AIMS assessments for residents not being seen by psych services.
Medication Error Rate Exceeded 5% Due to Incorrect Multivitamin and Eye Drops
Penalty
Summary
The facility failed to ensure it was free from a medication error rate of 5% or greater. Based on observations, interviews, and record review for one resident out of three residents observed, one of three nurses observed made two errors out of 26 opportunities, resulting in a medication error rate of 7.69%. During observation, Nurse #4 administered the incorrect type of multivitamin and the incorrect type of eye drops to Resident #62. Resident #62 was admitted with diagnoses including bilateral cataracts and anemia and was cognitively intact with a BIMS score of 15 out of 15. The resident’s physician’s orders directed a multivitamin tablet once daily and Systane 0.3%-0.4% eye drops, one drop in both eyes four times a day. The surveyor observed Nurse #4 give a multivitamin with minerals tablet and refresh eye drops instead. During interview, Nurse #4 stated she was unaware there was another multivitamin available and was unsure whether refresh eye drops were the same as Systane eye drops. The Unit Manager and DON stated that multivitamin with minerals should only be given if specifically ordered and that refresh eye drops are different from Systane eye drops.
Unsecured Storage of Controlled Medication
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with accepted professional principles when two bottles of lorazepam oral concentrate 2 mg/ml, a Schedule IV controlled substance, were found in an unlocked compartment in the Pawtucket medication room. The compartment had a lock, but it was not engaged and the door could be opened without a key. The facility policy titled Medication Storage Policy, dated March 2024, stated that controlled medications are to be stored in a separately locked compartment within the medication cart or storage room. During interview, Nurse #2 stated the compartment should have been locked because it contained controlled substances and acknowledged that he did not lock it. The DON also stated that controlled medications such as lorazepam must be stored in a separately locked compartment and that Nurse #2 should have locked the compartment.
Improper Hand Handling of Resident Food
Penalty
Summary
The facility failed to ensure proper food handling on 1 of 4 resident units, the Pawtucketville unit. During breakfast observation, a CNA sat beside a resident in the dining room, picked up the resident’s toast with bare hands, tore it into pieces, and placed it in the resident’s oatmeal. On a separate breakfast observation the next day, another CNA sat beside a resident in the dining room, picked up the resident’s toast with bare hands, and moved it on the plate to cover it with jelly. The facility policy titled Food Handling and Safety, dated April 2024, stated that all staff handling food must wash hands thoroughly before and after handling food and wear gloves when appropriate, and that staff will receive ongoing education on food safety and infection control practices. During interview, CNA #2 stated staff should always wear gloves when handling food items such as a resident’s toast. The Nurse Unit Manager #3 stated staff should not handle resident food with bare hands because it is an infection control issue and said she has a lot of new staff that still need education. The DON also stated staff should not be handling resident food with their bare hands.
Failure to Follow Physician Orders for Resident Care
Penalty
Summary
The facility failed to meet professional standards of quality care for three residents, as observed by surveyors. For one resident, the facility did not apply the correct wound care dressing as per physician orders. The resident, who was at risk of developing pressure ulcers and dependent on staff for daily living activities, was observed with an incorrect silicone foam dressing instead of the prescribed collagen and bordered gauze dressing. The nurse acknowledged the error, and the Assistant Director of Nursing confirmed that staff should follow physician orders and facility protocols for wound care. Another resident, diagnosed with quadriplegia and contractures, was not provided with hand rolls as ordered by the physician. The resident's care plan did not include the use of bilateral hand rolls, and staff were unaware of the requirement. Observations showed the resident without hand rolls during the night, despite a sign indicating their necessity. Interviews with staff revealed a lack of awareness and implementation of the physician's orders regarding the hand rolls. A third resident, with a history of major depressive disorder and recent falls, was not monitored with 15-minute safety checks as ordered. The resident, who had moderate cognitive impairment and a history of suicidal ideations, was observed without staff conducting the required checks. The facility's documentation did not reflect the implementation of these checks, and staff interviews confirmed the oversight. The Director of Nursing emphasized the importance of following physician orders for the resident's safety.
Deficiencies in Respiratory Care Services
Penalty
Summary
The facility failed to provide appropriate respiratory care services for three residents, leading to deficiencies in the management of oxygen therapy and CPAP/BiPAP equipment. Resident #317, who was admitted with acute and chronic respiratory failure and type 2 diabetes mellitus, was observed multiple times receiving oxygen via nasal cannula without the necessary external filters on the oxygen concentrator. Despite the physician's order for continuous oxygen therapy, the staff, including the Unit Manager and Assistant Director of Nursing (ADON), were initially unaware of the requirement for filters, which was later confirmed by the oxygen concentrator's manual and a representative from the oxygen supply company. Resident #77, who was moderately cognitively impaired and dependent on a CPAP machine, was found to have a thick layer of dust on the oxygen concentrator filter, and the CPAP machine was visibly dirty. The oxygen tubing was undated, and the CPAP mask was improperly stored. Despite physician orders for nightly CPAP use, the staff, including Nurse #1 and Unit Manager #1, were unclear about the frequency of cleaning and changing the equipment, leading to inadequate maintenance of the respiratory equipment. Resident #42, who was cognitively intact and dependent on a BiPAP machine, was observed with outdated oxygen tubing and sterile water, a dusty concentrator filter, and a visibly dirty BiPAP facemask. The resident's physician orders required regular cleaning and changing of the equipment, but the Treatment Administration Record (TAR) showed inconsistencies in documentation and adherence to these orders. Interviews with staff, including a Certified Nursing Assistant (CNA) and Unit Manager #4, revealed a lack of compliance with the prescribed maintenance schedule, contributing to the deficiency in respiratory care for this resident.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control practices, as observed by surveyors. In one instance, a housekeeper entered and exited rooms requiring Enhanced Barrier Precautions without performing hand hygiene. The housekeeper also changed trash and swept floors without using gloves appropriately. Additionally, two CNAs were observed in a resident's room, who required Enhanced Barrier Precautions, without wearing the necessary gloves and gowns while providing care. The facility also failed to sanitize shared medical equipment, specifically a glucometer, between residents. A nurse was observed using the glucometer on multiple residents without cleaning it between uses, despite the facility's policy requiring sanitization after each use. Both the nurse and the Assistant Director of Nursing acknowledged that the glucometer should be sanitized after each use. During a wound dressing change, a nurse did not perform hand hygiene after removing gloves and placed dressing supplies on a resident's bed. The nurse also stored unused dressing supplies in the resident's personal drawer and wrote on the resident's dressing while it was on their body. The nurse admitted to not following proper hand hygiene and wound care protocols, which was confirmed by the Assistant Director of Nursing.
Failure to Use Privacy Bag for Urinary Catheter
Penalty
Summary
The facility failed to provide a dignified existence for a resident by not utilizing a privacy bag for the resident's urinary catheter bag, which was visible and in use. The resident, who was admitted with acute and chronic respiratory failure with hypoxia and type 2 diabetes mellitus, had intact cognition and was dependent on staff for toileting hygiene. Observations made by the surveyor on multiple occasions revealed that the urinary catheter bag, containing visible yellow urine, was hanging from the resident's bed or clipped to the wheelchair armrest and could be seen from the hallway. Despite the presence of a privacy bag next to the catheter bag on one occasion, it was not in use. Interviews with facility staff, including a nurse and the Assistant Director of Nursing, confirmed that the urinary catheter bags should have been covered with a privacy bag to prevent them from being visible from the hallway. The facility's policy on resident rights, which guarantees a dignified existence, was not adhered to in this instance, as the resident's urinary catheter bag was repeatedly left uncovered, compromising the resident's dignity.
Failure to Develop Care Plans for Pressure Ulcer and Pacemaker Management
Penalty
Summary
The facility failed to develop and implement person-centered care plans with measurable goals and individualized interventions for two residents. Resident #58, who was admitted in June 2024 with diagnoses including adult failure to thrive and type 2 diabetes mellitus, was observed without sheets on the bed and reported incontinence. Despite being at risk for pressure ulcers, as indicated by the Minimum Data Set (MDS) and Care Area Assessment (CAA), no care plan was developed to address this risk. Interviews with staff confirmed the resident's incontinence and the need for a care plan to prevent pressure injuries. Resident #94, admitted in August 2023 with a cardiac pacemaker, also lacked a comprehensive care plan for pacemaker management. The facility's policy required documentation of pacemaker details upon admission, but the resident's medical record did not reflect this. Interviews with the Unit Manager and Assistant Director of Nursing confirmed that a care plan should have been developed for the pacemaker, highlighting a lapse in care planning for this resident as well.
Failure to Provide Meal Supervision for a Resident
Penalty
Summary
The facility failed to provide necessary supervision during meals for a resident who was dependent on staff for all functional tasks. The resident, admitted with diagnoses including dysphasia and failure to thrive, was observed on multiple occasions attempting to eat meals without staff assistance. During these observations, the resident was not visible from the hallway, and no staff were present in the room to assist or supervise. The resident's care plan indicated a need for supervision with a 1:8 ratio and occasional assistance, yet this was not adhered to, as evidenced by the resident being left alone during meal times. The resident's care plan and CNA care card indicated the need for assistance with eating, including setting up meals and providing reminders. However, staff failed to follow these directives, as observed by the surveyor. Interviews with staff, including a CNA and the Director of Nursing, confirmed that the resident required help with eating and that staff were expected to follow the care plan. Despite these expectations, the resident was left unsupervised, highlighting a deficiency in the facility's adherence to care plans and supervision protocols.
Failure to Implement Pressure Ulcer Care Plans
Penalty
Summary
The facility failed to provide necessary treatment and services for two residents with pressure ulcers. Resident #37, who has a history of chronic obstructive pulmonary disease, moderate protein calorie malnutrition, and other conditions, was observed without the required soft booties on both feet as per the medical plan of care. Despite having orders for soft booties to be worn every shift, observations showed the resident's feet were often on a pillow or directly on the mattress without the booties. Interviews with staff revealed that the booties were sometimes unavailable due to being in the laundry, indicating a lapse in ensuring the resident's care plan was followed. Resident #61, admitted with diagnoses including heart failure and chronic respiratory failure, was not receiving the correct wound treatment as recommended by the wound physician. The physician had advised using collagen with silver for a stage 3 pressure ulcer on the coccyx, but the treatment administered was collagen without silver. The discrepancy was noted during a surveyor's observation, and interviews with the nursing staff revealed a lack of awareness about the specific treatment order and its importance. The Assistant Director of Nursing acknowledged the oversight and the antimicrobial benefits of the silver in the collagen, which were not being utilized. These deficiencies highlight a failure in the facility's adherence to prescribed treatment plans and protocols for pressure ulcer management. The lack of proper implementation of care plans and treatment orders for residents at risk of or with existing pressure ulcers indicates a need for improved communication and adherence to medical directives within the facility.
Failure to Implement Safety Interventions for Resident with Burn History
Penalty
Summary
The facility failed to implement safety interventions for a resident who had previously suffered burns from spilled hot coffee. The resident, who has intact cognition and requires setup assistance with meals, was observed multiple times without a lid on their coffee cup, despite a care plan indicating the necessity of using a covered cup to prevent further burns. The resident's care plan and incident report both specified that hot liquids should be served in a covered cup, yet during several meal observations, the resident was given a mug without a lid, and no cup holder was attached to their wheelchair. Staff interviews revealed that the resident's diet slip did not indicate the need for lids with coffee, and there was a lack of communication between nursing and dietary services regarding this requirement. The Unit Manager, Assistant Director of Nursing, and Director of Nursing all acknowledged the need for lids on the resident's coffee due to their history of burns, but the necessary precautions were not consistently implemented. This oversight in following the care plan and ensuring proper communication led to the deficiency in maintaining the resident's safety.
Failure to Implement Continence Care Plan
Penalty
Summary
The facility failed to provide appropriate services to maintain continence for a resident, identified as Resident #58, who was admitted in June 2024. The resident, who has diagnoses including adult failure to thrive and type 2 diabetes mellitus, was initially assessed as continent of bladder upon admission. However, subsequent assessments indicated a decline in urinary continence, with the resident becoming frequently incontinent. Despite this change, the facility did not conduct further evaluations or develop a person-centered care plan with individualized interventions for the resident's bladder incontinence. Observations and interviews revealed that Resident #58 was often found incontinent and without a proper toileting program in place. The resident expressed that they wore briefs and did not always recognize the urge to urinate. Staff members, including CNAs and nurses, confirmed the resident's incontinence and lack of a toileting plan. The facility's policy required a 3-day observation tool and a Bladder and Bowel Evaluation to be completed upon admission, annually, quarterly, and when significant changes occur, but these were not implemented for Resident #58. Interviews with facility staff, including the Director of Nursing, indicated that the necessary assessments and care plans were not completed as required. The DON acknowledged that a new assessment should have been triggered after admission and that a quarterly evaluation and a 3-day bladder voiding trial should have been conducted to determine the type of incontinence and the potential benefit of a toileting plan. The lack of these evaluations and an individualized care plan for urinary incontinence constituted a deficiency in the facility's care for Resident #58.
Failure to Implement Dietary Interventions for Resident's Weight Loss
Penalty
Summary
The facility failed to implement necessary interventions for a resident experiencing significant weight loss. Resident #13, who was admitted with diagnoses including dementia and lactose intolerance, experienced a weight loss of 16.61% over six months. Despite the dietitian's recommendations for dietary interventions, including the use of Mighty Shakes twice daily, these were not implemented in a timely manner. The resident's weight continued to decline, and the dietitian's recommendations were not acted upon until a month later, when the order for Mighty Shakes three times daily was finally initiated. The deficiency was identified through observations, record reviews, and interviews. The facility's weight policy required reweighing and notifying the interdisciplinary team for significant weight changes, but these steps were not effectively followed. Interviews with staff, including the CNA, physician, dietitian, unit manager, and DON, revealed a lack of awareness and communication regarding the implementation of the dietitian's recommendations. This oversight contributed to the resident's continued weight loss, highlighting a failure in the facility's process for addressing significant weight changes in residents.
Deficiency in Dialysis Care and Communication
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident who required such services. The resident, who was admitted with end-stage renal disease and dependent on renal dialysis, had a chest port for dialysis access. The facility did not adhere to emergency care practices for the use of a venous catheter, as there were no emergency items, including a non-serrated clamp, in the resident's immediate area. The resident was unaware of any supplies for emergency care of the chest catheter, and the facility staff, including the nurse and unit manager, were not aware of the need for an emergency plan or supplies at the bedside. The facility also failed to have a person-centered care plan with individualized interventions for the resident. The care plan did not indicate the location of the resident's dialysis access site or include interventions related to the access site, such as having non-serrated clamps bedside for emergencies. Additionally, the physician's orders did not include the requirement for non-serrated clamps for emergencies related to the venous catheter access site. Furthermore, the facility did not ensure consistent communication between the facility and the dialysis treatment center according to the medical plan of care. The resident's communication book, which was supposed to document vital signs and any changes in condition, was missing entries for several dates in August, September, and October. The Assistant Director of Nursing acknowledged that staff should send the resident with a completed communication document for each dialysis treatment and that the dialysis care plan should specify the location of the dialysis access site.
Medication Administration Errors Exceed 5% in Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as observed during a survey. Two nurses were involved in medication administration errors affecting two residents. Nurse #3 did not administer Amlodipine and Lasix to a resident with primary pulmonary hypertension due to low blood pressure, despite lacking physician orders to withhold these medications. This decision was made without consulting a physician, which is against the facility's policy that requires medications to be administered according to prescriber orders. Nurse #4 crushed and administered Aripiprazole to a resident, despite the medication card's instructions not to crush or chew the tablet. The resident had requested the medication to be crushed, but Nurse #4 acknowledged that a physician's order is necessary for such modifications. The Unit Manager and the Assistant Director of Nursing confirmed that medication administration should adhere to physician orders and pharmacy guidelines, emphasizing the need for physician approval for any changes in medication administration.
Medication Labeling and Expiration Deficiency
Penalty
Summary
The facility failed to ensure that medications were properly labeled with open dates and that outdated medications were not available for administration on two of four resident care units. During an observation of the [NAME] Unit medication Cart One, several medications, including ProSource Liquid Protein, fluticasone nasal spray, saline nasal spray, and various inhalers, were found opened and undated, making it impossible to determine their expiration dates. Manufacturer instructions for these medications specified discard dates after opening, which were not adhered to, indicating a lapse in following proper medication storage protocols. Similarly, on the Centerville Unit medication Cart One, additional medications such as Budesonide inhaler, ipratropium Bromide and albuterol sulfate, Dorzolamide eye solution, and Tuberculin Purified Protein Derivative were also found opened and undated. Interviews with nursing staff, including a nurse, a unit manager, and the Director of Nursing, confirmed that medications should be labeled and dated when opened, and expired medications should not be present in the medication cart. This oversight in medication management reflects a failure to comply with the facility's policy on medication storage and preparation.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide the prescribed therapeutic diet for a resident who was admitted with diagnoses including acute and chronic respiratory failure with hypoxia and type 2 diabetes mellitus. The resident was prescribed a Mechanical Soft (Dental) Ground texture diet due to missing teeth and difficulty eating certain foods. However, the resident did not receive the appropriate ground textures during meals, as observed by the surveyor. The resident expressed difficulty eating bread due to missing teeth, and the surveyor noted that the resident's breakfast included toast, which the resident could not eat. Further observations revealed that the resident's lunch included an uncut grilled cheese sandwich with crust, which was not in line with the prescribed ground texture diet. The facility's Food Service Director and Registered Dietitian confirmed that the meal did not meet the ground texture requirement. The facility's therapeutic diets did not mention ground textures, and there was confusion about the resident's diet order. The resident had not been screened by Speech Therapy upon admission to the facility, which contributed to the oversight in providing the correct diet.
Inaccurate Medical Record and Equipment Setting
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident who was admitted in July 2023 with a diagnosis that included a pressure ulcer in the sacral region. The resident's Minimum Data Set (MDS) indicated moderate impaired cognition and the presence of a pressure ulcer. Physician orders from December 2023 required a specialty air mattress to be set at 165 lbs and checked every shift to aid in wound healing. However, observations on two consecutive days in October 2024 revealed the air mattress was set at 180 lbs, contrary to the physician's orders. Despite this discrepancy, the Treatment Administration Record (TAR) for October 2024 showed that nurses inaccurately documented the mattress setting as 165 lbs. Interviews with the Unit Manager and Assistant Director of Nursing confirmed that the mattress should be set according to the resident's weight, which was 178 lbs, and that the documentation in the TAR was incorrect.
Failure to Support Resident Self-Determination in Meal Choices
Penalty
Summary
The facility failed to support residents' right to self-determination by not facilitating their choice to eat meals in their rooms. A notification letter was issued to all residents, indicating that they were required to eat in the dining room unless they were ill or had approval from nursing staff. Additionally, the letter stated that nursing staff would no longer deliver meal plates to residents' rooms, forcing some residents to transport their meals themselves, even if they had approval to eat in their rooms. This policy change was not communicated in a timely manner, causing distress among the residents who felt their rights were being infringed upon. During a tour, a surveyor observed a resident using a rolling walker to transport a meal plate to their room, without any assistance from the nursing staff present in the hallway. The resident expressed difficulty and frustration with this process, citing challenges in balancing hot food items and beverages on the walker. Another resident, who preferred to eat in their room due to anxiety, also had to transport their meal using a cane, which they found hard but necessary to avoid the dining room. Both residents were independent in mobility and eating but faced significant challenges due to the facility's policy. Interviews with staff, including the Director of Nursing (DON) and the Director of Social Services, revealed concerns about the safety and homelike environment of the facility. The DON acknowledged that residents should feel at home and have the right to eat their meals wherever they choose. However, the facility's administration implemented the policy to address pest control issues, as reported by their pest control company. The administration's decision to require residents to transport their meals independently, even if they had approval to eat in their rooms, led to the observed deficiencies in supporting residents' rights and ensuring their safety and comfort during mealtimes.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,092 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lowell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| D'youville Senior Care | 0.9 mi | ★★★★★ | 6 | 0 |
| Northwood Rehabilitation & Healthcare Center | 1 mi | ★★★★★ | 50 | 0 |
| Regalcare At Lowell | 1 mi | ★★★★★ | 21 | 1 |
| D'youville Care For Advanced Therapy | 1.1 mi | ★★★★★ | 0 | 0 |
| Palm Springs Post Acute | 2.1 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.