Adviniacare Newport, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Newport, Rhode Island.
- Location
- 398 Bellevue Avenue, Newport, Rhode Island 02840
- CMS Provider Number
- 415033
- Inspections on file
- 34
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Adviniacare Newport, Llc during CMS and state inspections, most recent first.
The facility did not follow physician orders for scheduled weights and failed to implement its own reweigh policy for significant weight changes in two residents. One resident with hemiplegia, hemiparesis, and adult failure to thrive did not have monthly weights obtained as ordered, and multiple documented weight losses were not rechecked within the required timeframe. Another resident with type 2 DM experienced repeated large weight gains without any documented confirmation weights, despite facility policy requiring reweighs for substantial changes. The Dietitian and DON acknowledged that ordered weights and required reweights were not completed or could not be verified in the clinical record.
Surveyors identified several deficiencies in dietary services, including unsanitary kitchen conditions, improper food cooling and storage, serving milk above safe temperatures, storing frozen supplements in the refrigerator, a malfunctioning dish machine, and failure of dietary staff to follow hand hygiene protocols after handling soiled equipment.
A survey revealed multiple deficiencies in food safety and cleanliness at a LTC facility. The dish machine was improperly sanitized due to incorrect test strips, and various kitchen areas had significant cleanliness issues. Additionally, improper food thawing and cold holding temperatures were observed, along with improper drying of meal trays and an unclean ice machine.
A resident with a history of pressure ulcers and other medical conditions developed an open wound on the right heel due to the facility's failure to conduct weekly skin checks and provide necessary treatment. The wound was not identified or treated until a surveyor's observation, and staff failed to notify the physician or apply appropriate care.
The facility failed to ensure that nursing staff, including two RNs and four NAs, had documented competencies necessary for providing adequate care. A review of records and staff interviews revealed no evidence of completed competencies for these staff members, and the Infection Preventionist could not provide documentation during a surveyor interview.
The facility failed to ensure menus met residents' nutritional needs according to national guidelines. The diet manual was outdated, and the menu lacked therapeutic exchanges for specific diets. Portion sizes did not match packaging labels, and there was no nutritional analysis for meals. The FSD could not provide evidence of standardized recipes or staff training on therapeutic diets. The Registered Dietitian was not involved in menu planning or review.
A facility failed to maintain an effective training program for its staff, as required by its own assessment. Training records for eight staff members, including RNs and NAs, showed significant gaps in areas such as abuse, resident rights, infection control, dementia care, and the QAPI program. The Director of Nursing was unable to provide evidence of completed in-services, indicating a systemic issue in the facility's training program.
The facility failed to apply hand splints as ordered for three residents with hemiplegia, leading to a deficiency in care. Despite physician orders for daytime use of resting hand splints, observations revealed the splints were not applied, and there was no documentation of resident refusal. The DNS and ADNS acknowledged the oversight but could not provide explanations.
A facility failed to adhere to its policy of replacing oxygen tubing weekly for a resident with COPD. Despite a physician's order for supplemental oxygen and a policy requiring weekly changes, surveyors observed the resident using discolored tubing dated over a month old. The DNS confirmed the expectation for weekly changes but could not explain the oversight.
The facility failed to properly store and secure medications, with expired drugs found in a medication room, unlocked and unattended medication carts, and medications left at the bedside of two residents. Staff acknowledged these lapses, and the DON emphasized the importance of proper medication handling.
The facility failed to accurately document medical records for three residents, leading to discrepancies in the application of prescribed devices. A resident with a stroke was found without a required hand splint, despite records indicating it was applied. Another resident with heart disease and pulmonary embolism was observed with only one TED stocking, contrary to physician orders. The DNS and staff were unable to explain these inaccuracies.
The facility failed to maintain a sanitary environment in the basement conference room due to water leakage from a ceiling light, caused by an overflowing toilet on the second floor. This issue had occurred previously, but the Assistant Director of Maintenance did not report it, believing it was resolved. The Administrator and DON were unaware of the problem, and the room's sanitation after previous incidents was not explained.
The facility failed to follow physician's orders for three residents, including not documenting weights for a dialysis-dependent resident, incorrect air mattress settings for a resident with Alzheimer's, and missing TED stockings for a resident with heart disease. Staff were unable to explain these discrepancies.
A resident with a gastrostomy tube was self-administering bolus feedings without proper checks for tube placement, contrary to facility policy. The resident and an LPN confirmed that tube placement was not consistently checked before feeding. The DON acknowledged the resident's self-administration but lacked evidence of a competency assessment for safe self-administration.
A pharmacist failed to report medication irregularities for a resident with type 2 diabetes mellitus. The resident's insulin was administered outside the ordered parameters multiple times in August 2024, but the pharmacist's report did not identify these issues, nor were they reported to the attending physician, Medical Director, or DON as required.
The facility failed to prevent significant medication errors for two residents. One resident with diabetes received incorrect insulin dosages, while another with schizophrenia missed doses of Quetiapine due to unavailability. The DON acknowledged these issues, highlighting a lapse in medication management.
A facility failed to provide a resident with food in the appropriate form as per their mechanical soft diet order. The resident's Salisbury Steak was cut into strips larger than the required size. A nursing assistant acknowledged cutting the steak incorrectly, and a speech-language pathologist confirmed the proper size was not adhered to.
A resident with severe cognitive impairment, including dementia and delusional disorder, eloped from a secured unit in an LTC facility due to inadequate supervision. Despite being redirected multiple times by staff during activities, the resident managed to leave the facility unsupervised. The facility's administrator acknowledged the resident's exit-seeking behavior as a change in condition but failed to ensure adequate supervision to prevent the incident.
Failure to Follow Physician Orders and Reweigh Policy for Significant Weight Changes
Penalty
Summary
The facility failed to meet professional standards of quality by not following physician orders and its own weight assessment policy for multiple residents. For one resident with hemiplegia, hemiparesis, and adult failure to thrive who was readmitted in October 2025, physician orders required monthly weights beginning in August 2025 and weekly weights for four weeks starting in January 2026. The clinical record showed weights documented in September, November, January, and February, but there was no evidence that weights were obtained in October and December as ordered. During interviews, the Dietitian and the Director of Nursing Services acknowledged that the ordered weights for this resident in October and December 2025 could not be verified. The facility also failed to follow its policy titled “Weight Assessment and Interventions,” which requires that any weight change of 5 lbs in a month or 3 lbs in a week be rechecked within 72 hours for confirmation and verified by nursing. For the first resident, the record showed a 13.4 lb loss between early November and early January, a 3.8 lb loss between early and mid-January, and a 4.2 lb loss between late January and mid-February, with no documentation that any of these weights were rechecked. For a second resident admitted in November 2025 with type 2 diabetes mellitus and ordered to have weekly weights for four weeks, the record showed multiple significant weight gains between early November and early February, including gains of 7.8 lbs, 10.4 lbs, 7.8 lbs, and 6 lbs between successive weigh dates, without evidence of required reweights. The Dietitian confirmed that reweights were not obtained per policy for these residents, and the Director of Nursing Services was unable to provide documentation of the required reweights.
Multiple Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
Surveyor observations and staff interviews revealed multiple deficiencies in the facility's food storage, preparation, and sanitation practices. The main kitchen was found to have significant accumulations of grease and grime on equipment such as the stove hood and tilt skillet, as well as debris and food crumbs on worktable shelves. The bottom shelf of a worktable storing the meat slicer was rusted. Additionally, a trash container was left uncovered at the entrance to the dish room while not in use. Improper cooling procedures were observed, including cooked chicken breasts left on a worktable at 98.1°F and chicken salad stored in the refrigerator at 68.7°F, with no cooling log in place. A carton of milk was served at 45.5°F, above the required cold holding temperature, and Magic Cup nutritional supplements, which require frozen storage, were found stored in the refrigerator instead of the freezer. Further deficiencies included a malfunctioning dish machine with a non-functioning Printed Circuit Board, resulting in the inability to verify proper wash temperatures. Infection control lapses were also observed, as a dietary aide donned gloves without washing hands, handled soiled equipment, and then proceeded to unload clean dishes without removing gloves or washing hands. The Food Service Director acknowledged the need for cleaning, proper trash receptacle use, correct food storage temperatures, and appropriate hand hygiene practices.
Food Safety and Cleanliness Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The dish machine in the main kitchen was converted from a high-temperature sanitizing machine to a chlorine-based sanitizing machine. However, the facility did not have the appropriate test strips to measure the chlorine concentration, and the concentration was found to be below the required level, indicating improper sanitization. Additionally, the facility's Food Service Director (FSD) was unable to provide evidence of monitoring the sanitizing solution's concentration or the availability of appropriate test strips. The survey also revealed several cleanliness issues in the main kitchen and a nursing unit kitchenette. There was an accumulation of dirt, food residue, and grime on various surfaces, including utility carts, the steam table, and kitchen equipment. The FSD could not provide evidence of a cleaning schedule for these areas. Furthermore, 22 red lip plates were found with heavy scoring and deep scratches, which could not be effectively cleaned and sanitized, and there was no evidence of purchase orders for their replacement. Additional deficiencies included improper thawing of beef stew meat at room temperature, cold holding temperatures for certain foods being above the acceptable range, and improper drying of meal trays with a napkin. The ice machine was also found to have an accumulation of a black and pink substance, indicating a need for cleaning and service. These deficiencies highlight the facility's failure to maintain food safety and cleanliness standards, potentially leading to foodborne illnesses.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident at risk for pressure ulcers, leading to the development of an open wound on the resident's right heel. The resident, who was readmitted with a stage 3 pressure ulcer and other medical conditions such as diabetes and Parkinson's Disease, was identified as being at risk for pressure ulcers based on a Braden Scale score of 16. Despite a care plan that included weekly skin checks, the facility did not complete the required body check on 8/29/2024, and the resident's right heel wound was not identified or treated until it was brought to the facility's attention by a surveyor on 9/5/2024. During the surveyor's observation, the wound was found to be open and without a dressing or treatment order. Staff B, a registered nurse, acknowledged the presence of the wound but failed to notify the physician or provide appropriate treatment, instead applying skin prep, which is not suitable for open wounds. The Director of Nursing Services confirmed the lack of awareness and treatment for the wound, acknowledging that the facility was unaware of the resident's condition until the surveyor's intervention.
Lack of Documented Competencies for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets to provide adequate nursing and related services, which are essential for ensuring resident safety and achieving or maintaining the highest practicable physical well-being of each resident. This deficiency was identified through a record review and staff interviews, which revealed that there was no evidence of completed competencies for two Registered Nurses (RNs), Staff B and Staff D, and four Nursing Assistants (NAs), Staff E, F, G, and H. During an interview with the Infection Preventionist, conducted as part of the Staffing Task, the surveyor found that the Infection Preventionist was unable to provide documentation of any completed nursing competencies for the aforementioned staff members.
Deficiency in Nutritional Menu Planning and Oversight
Penalty
Summary
The facility failed to ensure that the menus met the nutritional needs of residents according to established national guidelines. The diet manual used by the facility was outdated, as it was based on guidelines from 2010 to 2015, while the current guidelines were revised in 2020. The facility's menu lacked evidence of therapeutic exchanges necessary for residents with specific dietary needs, such as Low Concentrated Sweets, low fat, cardiac, No Added Salt, renal, mechanical soft, and puree diets. During a surveyor observation, it was noted that the portion sizes served did not match the serving sizes indicated on packaging labels or recipes, and there was no nutritional analysis provided for the meals served. The Food Service Director (FSD) was unable to provide evidence of standardized recipes or the nutrient content of meals. Additionally, there was no documentation to support that dietary staff had been trained on therapeutic diets, despite their claims of having received such training. The Registered Dietitian revealed that she was not involved in menu planning and had not reviewed or signed off on the facility's menu to ensure its nutritional adequacy. These deficiencies indicate a lack of oversight and adherence to nutritional guidelines, potentially compromising the dietary needs of the residents.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for its staff, as required by its own facility assessment. The assessment, dated July 19, 2024, indicated that training and competencies should be completed upon hire, annually, and as needed. The required training areas included abuse, resident rights, infection control, dementia and Alzheimer's disease, behavioral health, communication, and the QAPI program. However, a review of training records for eight staff members, including registered nurses and nursing assistants, revealed significant gaps in their training. For instance, Staff B, a registered nurse hired in 2015, lacked training in communication and the QAPI program. Similarly, Staff D, another registered nurse hired in 2019, did not receive training in several critical areas, including communication, abuse, and dementia care. The deficiency was further highlighted during interviews with the Director of Nursing Services, who was unable to provide evidence that the required in-services were completed for the staff members in question. This lack of documentation and training was consistent across all eight employees reviewed, indicating a systemic issue in the facility's training program. The absence of training in essential areas such as infection control, resident rights, and behavioral health management suggests a failure to adhere to the facility's own standards and regulatory requirements, potentially impacting the quality of care provided to residents.
Failure to Apply Hand Splints as Ordered
Penalty
Summary
The facility failed to ensure that residents with limited range of motion received appropriate treatment to prevent further decline. Resident ID #18, who was readmitted with diagnoses including stroke and hemiplegia, had a physician's order for a left resting hand orthosis to be worn during the day. However, observations on multiple dates revealed the resident was without the splint, and there was no evidence in the nursing progress notes that the resident removed or refused to wear it. The Assistant Director of Nursing Services acknowledged the splint was not applied and admitted she could not locate it. Similarly, Resident ID #61, admitted with stroke and hemiplegia, had an order for a right resting hand splint to be worn during the day. Observations showed the resident without the splint, which was found on the window sill, and there was no documentation of refusal. The Director of Nursing Services confirmed the splint was not applied and could not explain the oversight. Resident ID #70, also with stroke and hemiplegia, had a similar order for a right resting hand splint, but was observed without it on several occasions. Again, there was no record of refusal, and the DNS acknowledged the splint was not applied without explanation.
Failure to Replace Oxygen Tubing Weekly
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident with chronic obstructive pulmonary disease (COPD). The resident was admitted in May 2023 and had a physician's order for supplemental oxygen at 1-2 liters/minute via nasal cannula as needed every shift. The facility's policy, revised in November 2020, required that the nasal cannula and tubing be replaced and dated weekly or when visibly soiled or damaged. However, during surveyor observations on multiple occasions in September 2024, the resident was seen using discolored oxygen tubing that was dated 7/18, indicating it had not been changed weekly as per policy. During an interview, the resident confirmed the use of oxygen nightly and as needed during the day. The Director of Nursing Services (DNS) acknowledged that the tubing should have been changed weekly according to the facility's policy but could not provide evidence explaining why the tubing was not replaced.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with accepted professional principles, as observed in one of two medication rooms, two medication carts, and two residents with medications at their bedside. In the basement medication storage room, six bottles of Calcium with Vitamin D and two bottles of Acetaminophen were found to be expired. The Medication Aide, Staff I, acknowledged the expired medications and indicated they should be discarded. Additionally, on the second floor, two medication carts were found unlocked and unattended, with one cart's drawer left half ajar. Staff J, a Medication Aide, confirmed the carts were left unattended and unlocked. Furthermore, two residents were observed with medications left at their bedside. Resident ID #63 had a plastic medication cup with five medications left unattended on the bedside table while the resident was asleep. Staff K, a Nursing Assistant, and Staff C, an LPN, acknowledged the unattended medications, with Staff C unable to identify the medications as she had not yet administered them. Resident ID #22's Spiriva inhaler was found on the bedside table instead of in the medication cart. Staff J admitted to possibly leaving the inhaler at the bedside after administering it the previous day. The Director of Nursing Services expressed that medications should not be left unattended at the bedside and that expired medications should be discarded.
Inaccurate Medical Record Documentation for Resident Care
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with professional standards for three residents. Resident ID #61, who was admitted with a stroke and hemiplegia, had a physician's order for a right resting hand splint to be applied during the day. However, during a surveyor observation, the resident was found without the splint, which was inaccurately documented as applied in the Treatment Administration Record (TAR). The Director of Nursing Services (DNS) could not explain the discrepancy. Similarly, Resident ID #67, with a history of arteriosclerotic heart disease and pulmonary embolism, had an order for TED stockings to be applied daily. Observations revealed the resident was only wearing one stocking, despite records indicating both were applied. The registered nurse acknowledged the error but could not explain the inaccurate documentation. Additionally, Resident ID #70, also with a stroke and hemiplegia, was observed without the ordered right hand splint, which was falsely signed off as applied in the TAR. The DNS was again unable to account for the inaccurate record-keeping.
Unsanitary Conditions Due to Recurring Toilet Overflow
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment in the basement conference room due to water leakage from the ceiling. This issue was observed by a surveyor who noted a significant amount of water pouring from a ceiling light onto a table, affecting a surveyor's computer, resident records, and personnel training records. The source of the water was identified as an overflowing toilet on the second floor, which had been clogged by a large bowel movement. This problem had occurred on two previous occasions the prior week, but the Assistant Director of Maintenance, Staff R, did not report it, believing he had resolved the issue by plunging the toilet. The Administrator and the Director of Nursing Services were unaware of the recurring issue with the overflowing toilet and the resulting unsanitary conditions in the basement conference room. The Director of Nursing Services could not explain how the room was sanitized after the previous incidents. Staff R later disclosed that the facility had purchased a new toilet for the resident's bathroom where the overflow occurred. The lack of communication and failure to address the recurring plumbing issue led to the unsanitary conditions observed by the surveyor.
Failure to Follow Physician's Orders for Residents
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by not following physician's orders for three residents. Resident ID #61, who has end-stage renal disease and is dependent on dialysis, had a physician's order to record weights on specific days. However, the facility did not document the resident's weights on multiple occasions between July and September 2024. This lack of documentation indicates a failure to adhere to the prescribed medical treatment plan. Resident ID #62, diagnosed with Alzheimer's Disease and a history of pressure injuries, had a physician's order for an air mattress to maintain skin integrity, with specific settings to be checked every shift. Observations revealed that the air mattress was set incorrectly, and staff could not explain the discrepancy. Additionally, Resident ID #67, with arteriosclerotic heart disease and pulmonary embolism, had orders for TED stockings to be applied daily. Observations showed that the resident was missing a TED stocking on multiple occasions, and staff were unable to provide an explanation for this oversight.
Failure to Ensure Safe Administration of Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving nutrition via a gastrostomy tube received appropriate treatment and services to prevent complications. The resident, who was readmitted to the facility with a diagnosis of dysphagia and gastrostomy, was found to be self-administering bolus feedings without proper checks for tube placement. The facility's policy on enteral feeding requires checking tube placement and residuals before feeding, but the resident reported that nurses did not check the tube placement before administration, and the resident also did not perform this check. Interviews with staff revealed that the Licensed Practical Nurse (LPN) sometimes did not check the tube placement before the resident administered the bolus feeding. The Director of Nursing Services acknowledged the resident's self-administration of the bolus but could not provide evidence of an assessment indicating the resident was competent to safely self-administer the feeding. This lack of oversight and failure to adhere to the facility's policy on enteral feeding contributed to the deficiency identified by the surveyors.
Pharmacist Fails to Report Insulin Administration Irregularities
Penalty
Summary
The deficiency involves a failure by the facility's pharmacist to report medication irregularities for a resident with type 2 diabetes mellitus. The resident was admitted in April 2023 and had a physician's order for Fiasp insulin with specific sliding scale instructions. However, the Medication Administration Record (MAR) for August 2024 showed that the insulin was administered outside the ordered parameters on multiple occasions between August 3 and August 13, 2024. The pharmacist's consultation report dated August 15, 2024, did not identify these irregularities, nor were they reported to the attending physician, the facility's Medical Director, or the Director of Nursing Services as required by the facility's policy. During an interview, the Regional Clinical Nurse confirmed that the pharmacist should have identified and reported these irregularities, but no evidence was provided to show that this was done.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of insulin and antipsychotic medications outside of prescribed parameters. Resident ID #59, who was admitted with type 2 diabetes mellitus, received Fiasp insulin inconsistently with the sliding scale orders on multiple occasions in August and September 2024. The insulin was administered in incorrect dosages based on the resident's blood sugar levels, which were documented in the Medication Administration Record (MAR). These errors included administering fewer units than prescribed for certain blood sugar ranges and failing to administer any insulin when it was required. Additionally, Resident ID #74, diagnosed with paranoid schizophrenia, did not receive the prescribed Quetiapine extended-release tablet on several occasions in September 2024 due to the medication being unavailable. The MAR indicated that the medication was not administered as ordered on four separate dates. During an interview, the Director of Nursing Services acknowledged the failure to administer the medications as ordered and stated that the expectation was for the physician to be notified if a medication was unavailable.
Failure to Provide Food in Appropriate Form for Resident
Penalty
Summary
The facility failed to ensure that a resident received food in the appropriate form as per their physician's diet order. The resident, admitted in January 2018 with a diagnosis including dementia, had a physician's order for a mechanical soft diet, which requires proteins to be ground or cut up. During a surveyor observation, it was noted that the resident's Salisbury Steak was cut into strips approximately 1 1/2 inch by 1 inch, instead of being cut into pieces less than 1/2 an inch as required for a mechanical soft diet. A nursing assistant admitted to cutting the steak into the incorrect size, and a speech-language pathologist confirmed the appropriate size for the diet was not followed.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent an accident involving a resident with severe cognitive impairment, who was able to elope from the facility unsupervised. The resident, diagnosed with dementia, delusional disorder, and paranoid personality disorder, was readmitted to the facility in May 2024. The resident's care plan indicated impaired cognitive skills, poor decision-making, and memory issues, with interventions including reporting changes in cognitive status and escorting the resident to activities. Despite residing on a secured unit, the resident attended an activity in a non-secured area and managed to leave the facility without staff supervision. On the day of the incident, the resident was observed to be exit-seeking and required redirection multiple times by staff. The resident expressed a desire to leave, mentioning being picked up by a spouse and wanting to go downtown. After attending activities, the resident was found outside the building unsupervised, stating confusion about the location. The facility's administrator acknowledged the resident's exit-seeking behavior as a change in condition and expected communication of such changes to the interdisciplinary team. However, there was no evidence provided that the facility ensured adequate supervision to prevent the elopement.
Latest citations in Rhode Island
A cognitively impaired resident with dementia and severe BIMS impairment, care planned and ordered to wear a wander guard with regular placement and function checks, eloped from the facility after being last seen in an activity room with a visitor. Staff later could not locate the resident for dinner, and searches were initiated while the resident’s whereabouts were unknown for several hours. Witnesses, including the Activities Director, Receptionist, another resident’s family member, and the visitor, reported that the resident and visitor exited through the main entrance without a wander guard alarm sounding and without use of a door code. The visitor admitted driving the resident to the spouse’s home without notifying staff. EMS and hospital records documented that the resident had been missing for several hours, was confused, could not recall events, and reported severe throat and chest pain, arriving at the hospital with an ankle monitoring device in place. Upon the resident’s return, the facility discarded the original wander guard without testing its functionality and could not provide evidence of consistent monitoring per policy and physician orders, resulting in an Immediate Jeopardy situation.
A resident with Alzheimer’s disease, dementia, severe cognitive impairment, documented exit-seeking behavior, and a care plan identifying high elopement risk and the use of a wander guard was inadequately supervised. Earlier in the day, an LPN observed the resident attempting to open an exit door and redirected the resident, who was later last seen in their room. The resident subsequently exited a secured unit through a stairwell door that only briefly alarmed and was not connected to the wander guard system, descended to a basement level, and left through an exterior door. Because wander guard sensors were only placed at elevators and not at exit doors or stairwells, the resident’s departure went undetected until a Code Orange was called and the elopement protocol initiated, after which staff located the resident off premises and returned the resident to the facility.
A cognitively intact resident with spinal stenosis and post-stroke hemiplegia/hemiparesis was discharged from the hospital with documented referrals to a spine center for evaluation and possible spinal steroid injections, which were reiterated in a later provider note citing ongoing lower extremity weakness. Despite these physician-ordered referrals and the resident’s repeated attempts to reach the appointment scheduler, the facility did not schedule or facilitate the neurosurgical consultation. The unit secretary, who was responsible for scheduling, reported being unaware of the referrals, and neither she nor the DON could provide any evidence that efforts were made to arrange the appointment, leading to a prolonged delay in the resident’s surgical follow-up.
A resident with dysphagia, autonomic dysfunction, seizure disorder, a G-tube, and dependence on staff for feeding had physician orders and a care plan requiring a minced and moist diet with thin liquids given by spoon only while upright. Video from a room camera showed a nurse providing thin liquids through a straw while the resident was lying down and continuing despite the resident coughing. Additionally, a physician ordered every-shift monitoring and documentation of vital signs, including lung sounds, O2 saturation, temperature, and signs of aspiration for seven days, but the MAR showed that required vital signs were not obtained on multiple shifts. The DON confirmed these deviations from physician orders and expected practice.
A resident with intact cognition and a history of hypertension used the call light for toileting assistance when a CNA entered the room and yelled statements such as not "playing games" and telling the resident to wait, causing the resident to become upset. A nursing supervisor heard the CNA yelling, went to the room, and observed the resident visibly upset, while an LPN’s written statement described the CNA’s tone as very rude and yelling about having been with another resident. The CNA later acknowledged speaking loudly to the resident, and during interviews, the administrator and DON could not demonstrate that the resident had been free from verbal abuse as required by the facility’s abuse prohibition policy.
A resident with Alzheimer’s disease receiving hospice services was observed by an RN to be grimacing, with swelling and bruising of the right ankle, and an x-ray later confirmed displaced fractures of the medial and lateral malleolus. Facility policy required that responsible family or legal representatives be notified within 24 hours of significant condition changes or injuries and that this notification be documented in the medical record. A NP documented the fracture findings and ordered that hospice and the resident’s representative be contacted, but there was no documentation that the representative was notified. In interviews, the resident’s representative reported learning of the injuries from hospice staff, the RN acknowledged not notifying the representative, and the DON could not provide evidence that immediate notification occurred, resulting in a deficiency for failure to notify the representative of a significant change in condition.
A resident with Alzheimer's disease, severe cognitive impairment, and non-ambulatory status, receiving hospice care, was found grimacing with swelling and bruising to the right ankle after being brought to the dining room. An x-ray later confirmed acute to subacute displaced fractures of both the medial and lateral malleolus, with no cause identified in the record, making it an injury of unknown origin. A hospice aide reported that during care, the resident became agitated and flailed while two CNAs held the resident's arms and legs, but care was not stopped and the nurse was not notified of the behavior. The RN on duty could not show that the injury of unknown origin was reported to RIDOH, and the DON acknowledged that the incident was not reported, resulting in a failure to report an alleged violation and injury of unknown origin as required.
A non-ambulatory hospice resident with severe cognitive impairment developed swelling and bruising of the right ankle after being taken to the dining room and receiving care in the room, during which the resident became agitated and flailed while a hospice aide and two CNAs continued care and physically held the resident’s arms and legs. An RN later noted the ankle changes, obtained an x-ray order from a provider, and imaging confirmed acute to subacute displaced fractures of both the medial and lateral malleolus. The clinical record and interviews with the RN, DON, and NP showed that no thorough investigation was conducted into the origin of the injury, no potential causes were documented or identified, and no interventions to prevent further or potential injury were documented, despite regulatory requirements and a community complaint alleging lack of notification and unclear cause of the injury.
A resident with CHF, afib, moderate cognitive impairment, and low body weight was mistakenly given another resident’s clozapine 150 mg and melatonin 3 mg by a CMT who entered the wrong room and failed to verify identity, contrary to facility policy requiring multiple resident-identification checks. The resident did not receive ordered warfarin and metoprolol during this pass. Subsequently, the resident was found unresponsive with abnormal respirations, tachycardia, and hypoxia, required EMS intervention with suctioning, high-flow oxygen via BVM, and IV emergency cardiac medication, and was admitted to the hospital with altered mental status, profound hypothermia, pleural effusion, and aspiration pneumonia, later transitioning to comfort care and expiring. The DON was unable to show the resident was kept free from significant medication errors, and the Medical Director stated she expected correct medications to be given to the correct resident.
The facility failed to ensure that a CMT had demonstrated competency in resident identification during medication administration and did not complete the required quarterly medication aide evaluations. Despite only one documented evaluation and no evidence of competency in verifying resident identity, the CMT was scheduled to pass medications and entered the wrong room, administering clozapine 150 mg and melatonin 3 mg intended for another resident to a frail, elderly resident with CHF and Afib. The resident, who weighed 79.2 pounds, subsequently developed tachycardia, shortness of breath, altered mental status, profound hypothermia, a small pleural effusion, and aspiration pneumonia, was admitted to the hospital for comfort measures only, and later died. The DON acknowledged that quarterly evaluations were required and could not provide evidence that the CMT had demonstrated competency in medication administration per state requirements.
Elopement of Cognitively Impaired Resident Despite Wander Guard Device
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary supervision and maintain an effective elopement prevention system for a cognitively impaired resident identified as an elopement risk. The resident had diagnoses including dementia, cognitive communication deficit, and anxiety disorder, and a Quarterly MDS showed a BIMS score of 4/15, indicating severe cognitive impairment. The resident’s care plan, initiated after prior attempts to leave the facility, required use of a wander guard bracelet, weekly assessment of the device’s functioning and battery status, and visual checks or supervision for safety. Physician orders directed staff to check placement of the Tektone wander guard bracelet every shift and to check its functionality weekly. Documentation on the March Treatment Administration Record indicated the device was in place on the day of the incident and that its functionality had been checked and found operational several days earlier. On the day of the elopement, staff observed the resident wearing the wander guard bracelet in the activities room during a bingo activity in the mid-afternoon. An LPN reported last seeing the resident in the activity room seated with a visitor and wearing the wander guard. Later, when the LPN attempted to escort the resident to dinner, the resident could not be located, and a subsequent call to the resident’s spouse confirmed that the spouse did not have the resident and was unaware the resident was missing. The facility’s elopement protocol was then initiated, and staff, along with law enforcement, conducted searches of the building and surrounding community. During this time, staff and management did not know the resident’s whereabouts for several hours. Interviews and witness accounts established that the resident exited the facility through the main entrance with a visitor. The Activities Director stated that she did not see the resident or visitor leave and did not hear a wander guard alarm at the exit. The Receptionist reported seeing the resident and a visitor walking toward the main entrance and also did not hear an alarm. A visitor later admitted that she removed the resident from the facility at the resident’s request to go home, drove the resident to the spouse’s house, dropped the resident off, and left without notifying staff; she stated that the wander guard alarm did not sound when they exited and that she had never been given a door code. A family member of another resident reported seeing the visitor leave with the resident through the main entrance without hearing an alarm or seeing a code entered. The resident ultimately arrived at the spouse’s home with a sandwich in hand, appeared confused, and could not explain how they had gotten there. EMS and hospital records documented that the resident had been missing from the facility for several hours, could not recall their whereabouts, and reported severe throat and chest pain; the hospital record also noted that the resident arrived with an ankle monitoring device in place. Following the resident’s return, the facility did not evaluate or test the wander guard device that had been in use at the time of the elopement. A Regional Nurse documented that a new wander guard device was applied to the resident’s left ankle, and later acknowledged in interview that the original device had been discarded without assessment. The Regional Administrator and Regional Nurse were unable to provide evidence that the previous device had been checked or tested for functionality upon the resident’s return. The Administrator stated that it was unclear whether the wander guard system had failed, whether an alarm had sounded without staff response, or whether a visitor had entered a door code, and confirmed that visitors should not have the door code. The facility was also unable to provide documentation confirming that staff consistently monitored the resident in accordance with facility policy and physician orders. These failures resulted in the resident leaving the facility unsupervised for approximately six hours while staff were unaware of the resident’s whereabouts, placing the resident at risk for serious injury, serious harm, serious impairment, or death, and constituted a situation of Immediate Jeopardy.
Failure of Elopement Prevention and Supervision for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and maintain an effective elopement prevention system for a resident assessed as a high elopement risk. The resident had Alzheimer’s disease, dementia, severe cognitive impairment (BIMS score of 00), a documented history of exit-seeking behaviors, and a care plan identifying high elopement risk, prior elopements, recent attempts to leave, verbalizations about leaving, and wandering behavior requiring a wander guard. On the morning of the incident, an LPN observed the resident attempting to open the unit exit door at approximately 9:30 AM; the resident was redirected and escorted back to the dining room. The resident was last seen in their room at approximately 10:00 AM. Despite residing on a secured unit and wearing a wander guard, the resident eloped from the unit via a stairwell door that alarmed when opened but stopped alarming after the door closed and after a period of time. The wander guard system was configured so that sensors were only located at the elevators and did not detect the resident at the unit exit doors or stairwell. The resident used the stairwell to descend several flights to the basement level and exited through a basement exterior door, leaving the building undetected. A Code Orange was not called and the elopement protocol not initiated until approximately 11:20 AM, at which time the resident had already traveled off premises and was later observed walking along a main road and crossing a four-lane street before being located and returned to the facility at approximately 11:45 AM.
Failure to Arrange Neurosurgical Follow-Up for Resident With Spinal Stenosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services were provided in accordance with professional standards of quality for a resident admitted with spinal stenosis and post-stroke hemiplegia/hemiparesis. The resident was admitted in October 2025 with diagnoses including spinal stenosis and left-sided weakness following a stroke. A Continuity of Care - Post-Acute Facility document dated 10/24/2025 indicated that, upon hospital discharge, a referral to a spine center was placed to evaluate the need for spinal steroid injections. A subsequent provider progress note dated 11/17/2025 documented the resident’s ongoing chronic lower extremity weakness related to lumbar disc protrusions and reiterated the need for outpatient neurosurgical follow-up, with an additional referral placed at that time. Record review and interviews showed that, despite these clear and repeated physician-ordered referrals, the facility did not schedule or facilitate the required neurosurgical consultation. The resident, who had a Brief Interview for Mental Status score of 14/15 indicating cognitive intactness and ability to express needs, reported making multiple unsuccessful attempts to contact the facility’s appointment scheduler to obtain the neurosurgical consultation for spinal injections. During an interview, the Unit Secretary responsible for scheduling appointments stated she was unaware of the referrals, and neither she nor the Director of Nursing Services could provide evidence that any efforts were made to arrange the neurosurgical appointment. A community complaint alleged that the resident waited approximately five months without resolution of the needed surgical follow-up appointment.
Failure to Follow Physician Orders for Dysphagia Management and Vital Sign Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of practice and followed physician orders for a resident with significant swallowing difficulties and other complex medical conditions. The resident, admitted with diagnoses including seizure disorder, autonomic dysfunction, presence of a gastrostomy tube, bilateral upper extremity contractures, and dysphagia, was dependent on staff for eating. A physician’s order dated 1/6/2026 specified a house diet with minced and moist texture and thin liquids to be provided by spoon only. The care plan initiated on 12/4/2024 also identified swallowing difficulty and included an intervention to provide thin liquids via spoon. A community complaint and video footage from the resident’s room showed that during an overnight shift, a nurse gave the resident a drink using a straw while the resident was lying down and continued to provide liquids while the resident was coughing, contrary to the physician’s order and care plan. The DON confirmed, after reviewing the video, that the nurse provided thin liquids with a straw while the resident was not upright and continued despite the resident’s coughing. The facility also failed to follow a physician’s order related to monitoring for possible aspiration. A physician’s order dated 3/19/2026 directed staff to obtain and document the resident’s vital signs, including lung sounds, oxygen saturation, temperature, and signs and symptoms of aspiration such as coughing or runny nose, every shift for seven days. Review of the March 2026 Medication Administration Record showed that vital signs were not obtained during the 3:00 PM–11:00 PM and 11:00 PM–7:00 AM shifts on 3/23/2026, and the 11:00 PM–7:00 AM shift on 3/24/2026. In an interview, the DON stated she expected vital signs to be obtained and documented each shift as ordered and acknowledged that the facility failed to ensure physician orders were followed for this resident.
Failure to Protect a Resident From Verbal Abuse by Nursing Assistant
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a nursing assistant. The resident was admitted with diagnoses including hypertension and had an admission MDS Brief Interview for Mental Status score of 15/15, indicating intact cognition. On the evening in question, after the resident used the call light for toileting assistance, Nursing Assistant Staff A entered the room and yelled, "I'm not playing games with you tonight, you keep pressing the call light, and I told you to wait." The resident reported being upset by this interaction. A Nursing Supervisor, Staff B, who was on duty at the time, responded to the resident’s room after hearing Staff A yelling and observed the resident to be visibly upset. An LPN, Staff C, provided a written statement indicating she heard Staff A speaking in a very rude tone and yelling, "I told you to wait, I was with another resident." Staff A’s own written statement acknowledged that she spoke back to the resident loudly. During an interview with the Administrator and the Director of Nursing Services, they acknowledged the findings and were unable to provide evidence that the resident was free from verbal abuse during this incident, in contrast to the facility’s abuse prohibition policy defining verbal abuse as disparaging or derogatory oral, written, or gestured language within a resident’s hearing.
Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s representative of a significant change in condition, specifically an injury of unknown origin resulting in right ankle fractures. The facility’s policy dated 10/19/2023 requires responsible family members or legal representatives to be notified as soon as possible, or within 24 hours, of any changes in the resident’s condition, including significant physical changes and any accidents resulting in injury, with documentation of such notification in the medical record. The resident, admitted in October 2025 with Alzheimer’s disease and receiving hospice services, was observed on 3/9/2026 by an RN to be grimacing after being brought to the dining room, and further assessment revealed swelling and bruising of the right ankle. An x-ray was ordered and later confirmed acute to subacute fractures of the medial malleolus with displacement and a moderately displaced fracture of the lateral malleolus. A subsequent progress note by a nurse practitioner documented the fracture findings and included an order to contact hospice and the resident’s representative to review the results. However, record review did not show any evidence that the resident’s representative was notified by the facility of the injuries, nor was there documentation of such notification in the medical record as required by policy. During interviews, the resident’s representative stated that they were not notified by the facility and instead learned of the injuries from hospice staff. The RN who first identified the bruising and swelling acknowledged that she did not notify the resident’s representative. The Director of Nursing Services was unable to provide evidence that the resident’s representative was immediately notified when the injuries were identified, confirming the failure to follow the facility’s notification policy.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the Rhode Island Department of Health (RIDOH) for a resident with Alzheimer's disease who was non-ambulatory, dependent on staff for all transfers, and had severe cognitive impairment. The resident, who was on hospice services, was brought to the dining room by staff and was later observed grimacing, with swelling and bruising to the right ankle. An x-ray obtained that evening confirmed acute to subacute fractures of both the medial and lateral malleolus with displacement. A subsequent nurse practitioner note documented the fracture findings and included an order to contact hospice and the resident's representative, but the clinical record did not identify a cause for the injury, classifying it as an injury of unknown origin. Record review also failed to show that this injury of unknown origin was reported to RIDOH. During interviews, a hospice aide reported that after lunch she provided care to the resident in the room, accompanied by two CNAs. She stated the resident was not in discomfort before care, but became agitated during care and flailed upper and lower extremities, while one CNA held the resident's legs and another held the resident's arms; she did not stop care or notify the nurse of the resident's behavior. After care, the resident was transferred to a chair and returned to the dining room, and the aide later learned of the swollen ankle after returning from lunch, without knowing how the injury occurred. The RN on duty at the time of injury identification was unable to provide evidence that the injury of unknown origin was reported to RIDOH, and the Director of Nursing Services acknowledged that the facility did not report the injury to RIDOH, confirming the failure to report the alleged violation and injury of unknown origin as required.
Failure to Investigate Injury of Unknown Origin and Identify Cause of Ankle Fractures
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an injury of unknown origin for a non-ambulatory resident with Alzheimer’s disease who was dependent on staff for all transfers and had severe cognitive impairment. The resident, who was on hospice services, was brought to the dining room by staff and later exhibited grimacing, with swelling and bruising noted to the right ankle. An x-ray obtained the same day confirmed acute to subacute displaced fractures of both the medial and lateral malleolus. Although the nurse on duty notified the provider and obtained the x-ray order, the clinical record lacked documentation of any investigation into how the injury occurred, any determination or discussion of potential causes, or identification of the origin of the fractures. Surveyor interviews revealed that a hospice aide, accompanied by two CNAs, had taken the resident to the room after lunch to provide care. During care, the resident, who had not shown discomfort beforehand, became agitated and flailed upper and lower extremities while one CNA held the resident’s legs and another held the resident’s arms; care was continued despite the agitation, and the nurse on duty was not notified of this behavior. After care, the resident was transferred to a chair and returned to the dining room, and the hospice aide later learned of the swollen ankle but did not know how the injury occurred. The RN who discovered the swelling and bruising, the DON, and the NP all acknowledged there was no thorough investigation, no documentation establishing the origin of the injuries, and no evidence of implemented measures to prevent further or potential injury, and the facility could not provide investigative findings or evidence of required reporting.
Fatal Medication Error Due to Failure to Verify Resident Identity
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a Certified Medication Technician (CMT) administered another resident’s medications without verifying identity. On the evening medication pass, the CMT, identified as Staff A, entered the wrong room and gave clozapine 150 mg and melatonin 3 mg, which were prescribed for a different resident, to Resident ID #1. This administration occurred despite a facility policy requiring staff to verify resident identity using methods such as checking an identification band, reviewing a photograph attached to the medical record, and, if necessary, confirming identity with other personnel. All patient identifiers were missed, and the resident did not receive his or her regularly scheduled medications, including warfarin 0.5 mg and metoprolol 12.5 mg. Resident ID #1 had been admitted in October 2025 with diagnoses including congestive heart failure and atrial fibrillation and was over a specified advanced age. A recent MDS assessment showed moderately impaired cognition with a Brief Interview for Mental Status score of 10 out of 15. The resident weighed 79.2 pounds, and the provider documented that the clozapine dose administered in error was a significant concern given the resident’s small body habitus. Record review confirmed there were no physician orders for clozapine 150 mg or melatonin 3 mg for this resident. Following the medication error, progress notes documented that late on the night of the error, the LPN (Staff B) recorded that the resident had received another resident’s medications and had missed his or her own scheduled warfarin and metoprolol. The next morning, staff found the resident unresponsive with abnormal breathing, pale skin, a heart rate of 136 bpm, and an oxygen saturation of 90%, prompting transfer via EMS. EMS records described the resident as unresponsive with audible gurgling, excessive oral secretions requiring suctioning, a fast and irregular heart rate between 150–190 bpm, and severely depressed respirations requiring bag-valve-mask support and IV emergency heart medication. Hospital records documented elevated heart rate, shortness of breath, altered mental status, profound hypothermia, a chest x-ray showing a small left pleural effusion and aspiration pneumonia, and subsequent transition to end-of-life care, with the resident expiring several days later. During interviews, the DON could not demonstrate that the resident was kept free from significant medication errors, and the Medical Director stated she would have expected the correct medications to be administered to the right resident.
Failure to Ensure CMT Medication Competency and Required Quarterly Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a Certified Medication Technician (CMT) had the required competencies and quarterly evaluations to safely administer medications, as required by Rhode Island regulations. State regulations mandate that medication technicians must complete a State‑approved course, demonstrate competency in drug administration, and receive quarterly evaluations by the Director of Nursing (DON) or RN designee, with documentation placed in personnel files. The facility’s own assessment stated that department‑specific training and competencies are completed throughout employment to ensure staff can safely and competently provide the required care. However, review of the CMT’s personnel record showed she was hired as a CMT/Nursing Assistant and had only one medication administration evaluation since hire, with no evidence of the four required quarterly evaluations. Record review of the CMT’s “Medication Administration Competency” document showed no evidence that she had demonstrated competency in identifying a resident prior to medication administration. Despite this, she was scheduled to administer medications periodically. On the evening in question, the CMT entered the wrong room and administered medications intended for another resident to Resident ID #1, without verifying the resident’s identity and missing all patient identifiers. The medications administered in error included clozapine 150 mg and melatonin 3 mg, which were prescribed for another resident. Resident ID #1 had been admitted in October 2025 with diagnoses including congestive heart failure and atrial fibrillation and was over a specified advanced age. Following the medication error, a provider note documented that the CMT had administered the wrong medications by entering the wrong room and failing to verify identity, and that the clozapine dose was of significant concern given the resident’s low body weight of 79.2 pounds. The resident subsequently presented to the hospital with elevated heart rate, shortness of breath, and altered mental status, was found to have profound hypothermia, a small left pleural effusion, and aspiration pneumonia, and was admitted for inpatient comfort measures only. The resident later expired. The DON acknowledged that medication aide evaluations are required at least quarterly and was unable to provide evidence that the CMT had demonstrated competency in medication administration per state requirements.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
