Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Adviniacare Oakland Grove Llc during CMS and state inspections, most recent first.
A resident with a history of acute kidney failure experienced prolonged constipation after staff failed to initiate the facility's bowel management protocol, did not notify the provider of medication refusal or a new diagnosis of constipation, and neglected to update the care plan. These lapses resulted in severe fecal impaction, hospitalization, and the resident's subsequent decline and death.
Surveyors found that the walk-in freezer in the main kitchen was not maintaining a safe temperature, with several food items partially thawed and the ambient temperature at 28°F. The Food Service Director confirmed erratic freezer temperatures and acknowledged the need for replacement, following a complaint related to foodborne illness.
A resident with a cervical fracture did not receive a physician-ordered neck brace as required, due to the brace being unavailable and not applied over multiple shifts. Documentation confirmed the absence of the brace, and staff were unable to locate it, resulting in a failure to meet professional standards of quality.
The facility failed to ensure that two residents completed ordered specialist follow-up appointments. One resident, with DM and HTN, had a hospital discharge referral for outpatient cardiology after chest pain and SOB, but staff could not show that the appointment occurred. Another resident, with necrotizing fasciitis and a right foot wound, had an infectious disease follow-up scheduled, but the resident did not attend and staff were unaware of the appointment until it was identified during survey.
Medication Administration Errors: The facility failed to ensure that three residents received ordered medications as prescribed. One resident with chronic pain and moderately impaired cognition missed a buprenorphine patch dose, another resident being treated for C. diff missed multiple vancomycin doses, and a resident with Alzheimer’s disease and dementia missed scheduled Depakote doses. Documentation showed the medications were not administered as ordered, with notes indicating the patch was unavailable and Depakote was awaiting pharmacy delivery despite stock being available in the Pyxis.
Failure to Provide Timely Incontinence Care and Dignified Morning Care: A cognitively intact resident who was always incontinent of bowel repeatedly asked for brief care while staff delayed response, and the resident was observed sitting in soiled clothing before being changed. Another resident with severe cognitive impairment was found still in bed with stains on clothing and face, a urine odor in the room, and a wet bed and pants while morning care and incontinence care had not been completed before lunch was delivered.
A resident with MS and neurogenic bladder had a suprapubic catheter and a care plan to monitor catheter output for odor, color, consistency, amount, blood, and sediment. Review of the bladder continence task showed 10 of 30 days with no output documented. An NA stated catheter output is measured every shift and entered in the kiosk, an LPN acknowledged the missing documentation, and the DON could not provide evidence that the comprehensive care plan was followed.
An LPN failed to follow ordered wound care for a resident with multiple pressure wounds by applying collagen powder instead of collagen with silver to two wounds, and did not perform hand hygiene after removing gloves and before donning clean gloves during a dressing change for an open, draining heel wound. The wound physician and DON stated they expected staff to follow the ordered treatments and hand hygiene procedure.
Medication Storage and Labeling Deficiencies: On the 3rd floor, a CMT was observed pre-pouring multiple meds into labeled cups for residents who were unavailable, which the DON stated was against facility policy. Surveyors also found an expired Narcan bottle on the nurse med cart and an open, undated vial of tuberculin PPD in the med fridge, with no evidence of when it was opened or when it expired.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility did not ensure adequate safeguards against physical, mental, sexual abuse, physical punishment, or neglect by any individual.
A resident with Alzheimer's disease and a wrist fracture was returned to the facility with a volar splint, but there were no physician's orders for monitoring circulation, motion, sensation (CSM), or skin integrity as required by facility policy. Staff and the provider confirmed the absence of these orders, and the deficiency continued for nearly two weeks until identified during survey.
A resident with multiple medical conditions and full cognitive function experienced a fall and repeatedly requested hospital transfer due to pain. The facility did not honor these requests because there was no physician order, leading the resident to call 911 independently. The resident was subsequently diagnosed at the hospital with a lumbar vertebra and rib fracture.
A resident with diagnoses of hypernatremia, dehydration, and sepsis pneumonia did not receive prescribed antibiotic therapy due to unavailability, and the facility failed to monitor urine output as ordered. The resident's condition worsened, leading to hospitalization. Staff interviews revealed a lack of awareness and documentation regarding the resident's care.
A resident on Enhanced Barrier Precautions due to a gastrostomy tube and Foley catheter was not provided care in compliance with infection control protocols. Staff failed to wear required PPE during high-contact activities, and a tube feeding syringe was not replaced daily as ordered, with the last replacement recorded 10 days prior. Additionally, a nebulizer mask was improperly stored on the floor and not changed weekly as required.
A resident did not receive prescribed antibiotic therapy after hospital discharge due to unavailability of the medication. The MAR indicated the antibiotic was unavailable on two occasions, and an LPN could not recall administering it. The DNS confirmed the medication was not in the facility until the day after it was documented as given.
A resident was mistakenly administered Clozaril, intended for another resident, due to an LPN preparing medications for two residents simultaneously and being interrupted. The resident, with a history of cirrhosis and alcoholic cardiomyopathy, exhibited overdose symptoms and required critical care interventions after being transferred to a hospital. The facility's medication administration policy was not followed, leading to this significant error.
A resident with severe cognitive impairment was potentially given the wrong medication, Clozaril, instead of their prescribed medications, leading to a change in mental status. The LPN responsible for administering the medication did not immediately evaluate the resident or document follow-up evaluations, as required by facility policy. The resident was eventually transferred to a hospital, but the on-call provider was not contacted immediately after the error was suspected.
A resident with a history of paranoid personality disorder and anxiety reported non-consensual sexual contact with another resident, despite initially describing the relationship as consensual. The resident expressed discomfort to staff members, who failed to recognize the situation as potential abuse and did not take action to ensure the resident's safety. The resident was later treated for potential sexual assault, highlighting a deficiency in the facility's protection measures.
A facility failed to recognize and investigate potential abuse when a resident expressed discomfort and fear regarding a sexual relationship with another resident. Despite the resident's intact cognition, staff did not identify the situation as potential abuse and advised the resident to speak to the Director of Social Services later. This inaction led to further non-consensual encounters, resulting in the resident being treated for potential sexual assault. The facility administrator admitted the staff's failure to protect the resident and initiate an investigation.
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak. Employees and visitors were not screened for symptoms, and staff did not wear required N95 masks or conduct twice-weekly testing. Additionally, nursing students did not follow Enhanced Barrier Precautions for a resident with MRSA, failing to wear gowns during high-contact activities.
The facility failed to document intake and output (I&O) as ordered by physicians for four residents with conditions requiring close monitoring, such as suprapubic catheters and kidney disease. Records showed significant gaps in I&O documentation, and staff interviews confirmed the orders were not followed.
The facility failed to monitor and address significant weight changes in three residents, resulting in unreported and unverified weight loss or gain. A resident experienced severe weight loss without proper documentation or notification to the RD and physician. Another resident had a significant weight gain without a reweigh or communication to the RD and Nurse Practitioner. A third resident's weight loss was not reweighed, contrary to policy, indicating systemic issues in weight monitoring.
A facility failed to provide trauma-informed care to a resident with PTSD, bipolar disorder, and anxiety disorder. Despite the resident's intact cognition, the facility did not complete a comprehensive assessment to identify trauma history or preferences to mitigate triggers. Staff interviews revealed a lack of awareness about the resident's trauma history and potential triggers, and a recommendation to obtain psychiatric records was overlooked.
A facility failed to elevate a resident's head to the required 30-45 degrees for one hour after G-tube feeding, as per physician's orders. The resident, with dysphagia and Alzheimer's, was observed with their bed not elevated post-feeding. Both an LPN and the DON acknowledged the oversight, indicating non-compliance with the facility's enteral feeding policy.
A resident with rheumatoid arthritis did not receive Humira as prescribed on three occasions due to pharmacy delivery issues. The MAR showed missed doses, and there was no evidence that the physician was informed. The ADON and DON acknowledged the oversight during an interview.
A resident with a history of DVT and recent hip surgery experienced increased leg swelling, but the facility failed to monitor the condition or follow care plan interventions. Despite signs of excessive swelling and pain, an ultrasound to rule out DVT was delayed until recommended by the resident's surgeon. Additionally, the facility did not obtain the resident's weight as ordered, which could have helped monitor the condition. Staff interviews revealed a lack of documentation and monitoring, contributing to the deficiency.
The facility failed to protect residents from physical abuse, as evidenced by an incident where a resident with severe cognitive impairment and a history of aggression was found with their hands around another resident's neck. Despite previous incidents and care plan notes indicating potential aggression, the facility did not effectively prevent the assault, resulting in physical harm to the victim.
A facility failed to maintain an infection prevention and control program for a resident with a Multidrug-resistant Organism (MDRO). The resident was not placed on contact precautions in a timely manner, and there was no signage indicating the need for PPE during high-contact care activities until much later. The deficiency was identified through surveyor observations and staff interviews.
Failure to Follow Bowel Management Protocol and Notify Provider Leads to Resident Harm
Penalty
Summary
The facility failed to adhere to its established bowel management protocol for a resident who experienced prolonged constipation. According to the facility's policy, if a resident has no bowel movement for 9 consecutive shifts, a specific bowel protocol must be initiated, starting with Milk of Magnesia (MOM), followed by a Bisacodyl suppository, and then a Fleet enema if needed, with results documented and the provider notified if the protocol is ineffective. Record review showed that the resident went 15 consecutive shifts without a bowel movement, and the bowel protocol was not initiated as required. When MOM was eventually offered and refused by the resident, there was no evidence that this refusal was reported to the provider for further instruction or adjustment of the care plan. Further review revealed that after the resident was sent to the hospital for stroke-like symptoms and returned with a new diagnosis of constipation, the provider was not notified of this new diagnosis to allow for appropriate care plan adjustments. Documentation also failed to show timely reassessment or updates to the care plan in response to the resident's ongoing constipation and new medical findings. Staff interviews confirmed lapses in communication and monitoring, including failure to generate and pass along the required bowel management lists between shifts and lack of provider notification regarding medication refusal and significant changes in the resident's condition. As a result of these failures, the resident developed severe fecal impaction, abdominal distention, and was ultimately hospitalized with a diagnosis of constipation and stercoral colitis. The resident's condition deteriorated further during the hospital stay, leading to hypotension, hypoxia, and death. The facility was unable to provide evidence that its bowel management protocol was followed or that appropriate notifications and interventions were made in accordance with its own policies.
Failure to Maintain Walk-In Freezer in Safe Operating Condition
Penalty
Summary
Surveyor observation and staff interview revealed that the facility failed to maintain the walk-in freezer unit in the main kitchen in a safe operating condition. During the initial kitchen tour, the freezer was found to be holding at an ambient temperature of 28 degrees Fahrenheit, and several food items, including chicken wings, chicken tenders, lobster, and pork sausage patties, were observed in a partially thawed state. The Food Service Director acknowledged both the improper freezer temperature and the fact that the items were not frozen solid, further indicating that the freezer temperatures had been erratic recently and that the unit was in need of replacement. This deficiency was identified in connection with a community-reported complaint regarding concerns of foodborne illness among residents.
Failure to Provide Physician-Ordered Neck Brace
Penalty
Summary
A deficiency occurred when a resident with a type 2 odontoid fracture, admitted in October 2025, did not receive a physician-ordered neck brace as required. The physician's order specified that the neck brace should be applied at all times, but record review showed that the brace was not available and not applied during multiple shifts over two consecutive days. Documentation from the Treatment Administration Record confirmed the absence of the neck brace during these periods, and a Physical Therapy progress note indicated that the brace was not on the resident and could not be located by nursing staff. During an interview, the Director of Nursing Services acknowledged that her expectation was for the neck brace to be applied as ordered.
Missed Follow-Up Specialist Appointments
Penalty
Summary
The facility failed to ensure that two residents received treatment and care in accordance with professional standards related to follow-up physician appointments. Resident ID #11, who was readmitted with diagnoses including type II diabetes and hypertension, was transferred to the hospital for abdominal pain and vomiting and later had a discharge summary and progress note indicating a referral and need for outpatient cardiology follow-up for chest pain and shortness of breath. The record did not show evidence that the cardiology appointment occurred, and staff interviews showed the LPN, unit secretary, and DNS were unaware of the ordered follow-up or unable to provide evidence that it had been completed. Resident ID #85, admitted with diagnoses including necrotizing fasciitis and a right foot wound, had a follow-up appointment scheduled with infectious disease. The record did not show evidence that the resident attended the 9/29/2025 appointment. During interviews, the LPN acknowledged the resident did not go, the unit secretary stated she was unaware of the appointment and that the resident did not attend, and the infectious disease provider’s unit secretary confirmed the resident did not show up. The DNS was also unable to provide evidence that the ordered follow-up with infectious disease had occurred.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors for three residents reviewed. Resident #82 had diagnoses including low back pain and polyneuropathy, a BIMS score of 12 out of 15, and pain almost constantly. The care plan identified chronic left hip and back pain and polyneuropathy, with interventions to administer pain medications as ordered. The physician ordered a buprenorphine patch 10 microgram/hour to be applied once every seven days for pain, but the September 2025 MAR showed the patch was not administered on 9/3 and the next patch was not applied until 9/10. A progress note stated the patch was not available to be administered, and the DNS stated she would expect the patch to be available. Resident #85 was admitted with type II diabetes and was being treated with vancomycin for C. diff. The physician ordered vancomycin 50 mg/mL, 2.5 mL four times daily for 10 days, but the September 2025 MAR showed missed doses on 9/23 at 5:00 PM and 9:00 PM and on 9/25 at 9:00 AM. Resident #30 had diagnoses including Alzheimer's disease and dementia, with a care plan noting a history of agitation and physical aggression and an intervention to provide medication as ordered. The physician ordered divalproex sodium 125 mg, three capsules every 12 hours, but the October 2025 MAR showed the 8:00 AM dose was not given on 10/1 or 10/2. Progress notes stated Depakote was reordered and the facility was awaiting delivery from the pharmacy, while staff later stated the Pyxis machine stocked eight capsules of Depakote 125 mg and the DNS expected staff to check the Pyxis first and notify the provider if the medication was not received as ordered.
Failure to Provide Timely Incontinence Care and Dignified Morning Care
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity related to incontinence care for 2 of 3 residents reviewed. Resident ID #2 was re-admitted in March 2025 with diagnoses including hemiplegia and hemiparesis affecting the right dominant side and benign prostatic hyperplasia with lower urinary tract symptoms. An annual MDS assessment showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact, and the resident was always incontinent of bowel and dependent on staff for toileting. During surveyor interviews and continuous observation on 9/30/2025, Resident ID #2 reported being soiled and needing assistance after a staff member said she would help but did not return. The resident’s call light was observed on, and the resident repeatedly told staff that a brief change was needed. An activity aide brought the lunch tray and told the resident to tell the nurse; later, the resident again asked a staff member to be changed, but the staff member left after saying, "Just give me a minute." At 12:29 PM, the resident was observed during incontinence care to have had a large bowel movement. The nursing assistant later acknowledged that waiting 45 minutes to be changed was unacceptable and that the call light should have been answered faster, while the DNS stated the call light should be answered within about 5 to 10 minutes and the resident should have been changed before being served the meal. Resident ID #90 was admitted in May 2025 with dementia with behavioral disturbance and had a quarterly MDS showing a BIMS score of 2 out of 15, indicating severe cognitive impairment. The resident required substantial to maximal assistance with toileting and personal hygiene. During a family member interview and immediate observation on 10/2/2025, the resident was found still in bed with a brown stain on the shirt, dried brown liquid on the side of the mouth, unkempt hair, pajamas still on, a strong urine odor in the room, and lunch being delivered before morning care was completed. When the resident stood with help from the family member, there was a large wet stain on the backside of the pants and a large yellow stain on the bed. The assigned NA stated she had not performed morning care or incontinence care and was unaware the resident was incontinent of urine, and the LPN acknowledged the stains and that morning care had not been done. The DNS stated residents should be toileted prior to being served a meal and was unable to provide evidence that each resident was treated with respect and dignity.
Failure to Document Catheter Output
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for Resident ID #16 related to a suprapubic urinary catheter. The resident was admitted in August 2016 with diagnoses including multiple sclerosis and neurogenic dysfunction of the bladder. A care plan focus area dated 9/18/2024 stated that the resident had a suprapubic catheter with an intervention to monitor output for odor, color, consistency, amount, blood, and sediment. However, review of the Bladder Continence Task showed that catheter output was not documented on 10 of the last 30 days. During interviews, a Nursing Assistant stated that catheter output is measured every shift and documented in the kiosk, and an LPN stated that Nursing Assistants measure the output every shift and report it to the nurse; the LPN acknowledged the missing documentation. The DON also acknowledged the missing days of output documentation and was unable to provide evidence that the facility followed the comprehensive care plan for the resident.
Failure to Follow Ordered Wound Treatments and Hand Hygiene During Dressing Changes
Penalty
Summary
The facility failed to ensure that a resident with multiple pressure wounds received the ordered wound treatments and services. The resident was admitted with diagnoses including type I diabetes and pressure wounds to the left heel, right foot, right hip, and sacrum. The care plan stated that the resident had multiple pressure wounds and was seen by the wound physician weekly, with wounds to be treated as ordered. The physician orders included collagen with silver for the right hip and coccyx wounds, skin prep and foam dressing for the right lateral foot, xeroform and a bordered dressing for the right heel, and skin prep for the left heel. During surveyor observation, an LPN applied collagen powder instead of the ordered collagen with silver to the right hip wound and again to the coccyx wound before covering each with a foam dressing. The LPN then cleansed the left heel wound, removed gloves, and put on new gloves without performing hand hygiene before applying a clean dry dressing to a wound that was observed to be open and draining. The LPN acknowledged not using collagen with silver for the two wounds and not performing hand hygiene between glove changes. The wound physician stated she would expect staff to use collagen with silver as ordered, and the DON stated she would expect staff to follow the wound treatment orders and perform hand hygiene between glove changes.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles on the 3rd floor. During observation of the 3rd Floor Northwest CMT medication cart, three medication cups labeled with residents’ room numbers were found containing multiple medications in each cup. The CMT stated that he had pre-poured the residents’ medications because the residents were unavailable when the medications were prepared. The DNS stated that pre-pouring medications was against facility policy and that medications should be disposed of if residents were unavailable. Additional medication storage issues were observed on the 3rd Floor Northwest Nurse medication cart and in the medication refrigerator. A bottle of Narcan was found with a manufacturer expiration date of 6/2025, and the LPN acknowledged that it was expired and should have been removed from the cart. The medication refrigerator also contained an open, undated vial of Tuberculin Purified Protein Derivative, with no evidence of when it was opened or when it expired. Manufacturer instructions reviewed during the survey indicated the open medication should be discarded after 30 days, and the LPN acknowledged that the vial was open and undated and could not identify when it expired.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Ensure Splint Care Met Professional Standards
Penalty
Summary
The facility failed to ensure that a resident with a volar splint received care in accordance with professional standards and the facility's own policy. The resident, who had Alzheimer's disease and sustained a distal radial (wrist) fracture following a physical altercation, was admitted with a splint on the left wrist. Facility policy required that residents with splints have their affected extremity monitored for circulation, motion, and sensation (CSM), as well as for signs of edema, redness, irritation, or pressure areas, at least every shift. However, record review showed there were no physician's orders in place for monitoring CSM and skin integrity for this resident after the splint was applied. Surveyor observations and staff interviews confirmed that neither the LPN nor the DON were aware of any such orders being in place, despite acknowledging that they should have been. The resident's provider also confirmed the absence of orders for monitoring CSM and skin integrity, although she would not confirm if CSM monitoring was necessary per policy. The deficiency persisted for 13 days after the resident returned to the facility with the splint, until it was identified by the surveyor.
Failure to Honor Resident's Request for Hospital Transfer After Fall
Penalty
Summary
A resident with a history of stroke, renal disease, and diabetes, who was cognitively intact and required a walker, experienced an unwitnessed fall in their room. Following the fall, the resident repeatedly requested to be transported to the hospital due to pain. Nursing progress notes indicate that the Medical Director was notified of the fall but did not provide an order for hospital transfer. Despite the resident's continued requests for hospital evaluation, the facility did not honor these requests because there was no physician order. Subsequently, the resident used their personal cell phone to call 911 and was transported to the hospital by Emergency Medical Services, where they were diagnosed with a closed fracture of the first lumbar vertebra and a rib fracture. The Director of Nursing Services confirmed during an interview that the expectation is to contact the physician if a resident complains of pain and acknowledged that she would have called for a hospital evaluation in such a case. However, she was unable to provide evidence that the facility honored the resident's request for transfer.
Failure to Administer Antibiotics and Monitor Urine Output
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the administration of prescribed antibiotic therapy and monitoring of urine output. The resident, who had been hospitalized multiple times within a month, was readmitted to the facility with diagnoses of hypernatremia, dehydration, and sepsis pneumonia. Upon readmission, there was a physician's order to continue antibiotic therapy with Amoxicillin-Pot Clavulanate, which was not administered as prescribed due to the medication being unavailable. The medication was documented as unavailable for administration on two occasions, and the physician was not informed promptly to consider alternative treatment options. Additionally, the facility failed to monitor the resident's urine output as per the physician's order and facility policy. The resident had an indwelling foley catheter, and there was an order to document intake and output every shift for 72 hours. However, there was no evidence of such documentation from the time of the resident's readmission. Interviews with staff confirmed the lack of documentation and monitoring of the resident's urine output. The deficiency was further highlighted by the resident's deteriorating condition, as noted in a hospital assessment, which indicated lethargy, non-responsiveness, and laboratory results showing hypernatremia and acute kidney injury. The assessment also noted the possibility of incomplete treatment of pneumonia due to missed antibiotic doses. Interviews with the facility's physician and Director of Nursing Services revealed a lack of awareness and uncertainty regarding the administration of the antibiotic and monitoring of the resident's condition.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. A resident, who was readmitted with conditions including hypernatremia, dehydration, and sepsis pneumonia, was placed on Enhanced Barrier Precautions (EBP) due to the presence of a gastrostomy tube and an indwelling Foley catheter. Despite signage indicating the need for gown and gloves during high-contact care activities, a nursing assistant was observed providing care without wearing a gown on two separate occasions. The Director of Nursing Services acknowledged the expectation for staff to adhere to the facility's EBP policy. Additionally, the facility failed to adhere to physician orders regarding the replacement of a tube feeding syringe. A surveyor observed an undated syringe with dry, crusted debris on the resident's side table, which had been used to administer medications. The last recorded replacement of the syringe was approximately ten days prior, contrary to the expectation of daily replacement. The Director of Nursing Services confirmed the expectation for the syringe to be changed every 24 hours. Furthermore, the resident's nebulizer mask was found on the floor, with tubing dated 13 days prior, indicating it had not been changed weekly as required. The staff acknowledged the mask should not have been on the floor and should have been stored properly. The Director of Nursing Services confirmed the expectation for the nebulizer mask and tubing to be changed every seven days.
Failure to Administer Prescribed Antibiotic and Maintain Accurate Records
Penalty
Summary
The facility failed to maintain the resident's medical record in accordance with accepted professional standards and practices for one resident. The issue was identified through a review of two community-reported complaints submitted to the Rhode Island Department of Health, which alleged that the resident did not receive prescribed antibiotic therapy after being discharged from the hospital. The resident was readmitted to the facility with diagnoses including hypernatremia, dehydration, and sepsis pneumonia. A hospital Continuity of Care document indicated a physician's order for Amoxicillin-Pot Clavulanate to be administered twice daily for three days. However, the facility's Medication Administration Record (MAR) showed that the medication was unavailable for administration on two occasions. During interviews, a Licensed Practical Nurse (LPN) was unable to recall administering the antibiotic as documented, and the Director of Nursing Services (DNS) confirmed that the medication was not available in the facility until the day after it was supposedly administered. This discrepancy indicates a failure in maintaining accurate medical records and ensuring the availability of prescribed medications, leading to the deficiency noted in the report.
Medication Error Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving the administration of Clozaril, an antipsychotic medication, to the wrong resident. Resident ID #1, who did not have a physician's order for Clozaril, was mistakenly given the medication intended for Resident ID #2. This error occurred when Licensed Practical Nurse (LPN) Staff A prepared medications for both residents simultaneously and was interrupted by another resident, leading to the administration of the wrong medication. Resident ID #1, who had a history of cirrhosis and alcoholic cardiomyopathy, was admitted to the facility with severely impaired cognition. After receiving the incorrect medication, Resident ID #1 exhibited symptoms of a medication overdose, including difficulty arousing, low blood oxygen levels, and respiratory distress. The resident was transferred to an acute care hospital, where they required critical care interventions, including intubation and treatment for acute toxic encephalopathy and acute respiratory failure. The facility's medication administration policy, which requires verifying medication orders, identifying residents, and avoiding distractions, was not followed by Staff A. The Director of Nursing Services acknowledged that the policy was not adhered to, as Staff A prepared and administered medications for more than one resident at a time. This failure to follow protocol resulted in a significant medication error, placing Resident ID #1 at risk for serious harm.
Failure to Evaluate Resident After Suspected Medication Error
Penalty
Summary
The facility failed to meet professional standards of quality by not evaluating a resident immediately after a suspected medication error. Resident ID #1, who has a history of cirrhosis and alcoholic cardiomyopathy, was potentially given Clozaril, an antipsychotic medication intended for another resident, leading to a change in mental status. The incident was reported to the Rhode Island Department of Health, and the resident was transferred to an acute care hospital. The facility's policy requires an immediate evaluation of the resident in relation to the nature of the error, but there was no evidence that such an evaluation occurred. Staff A, an LPN, was responsible for administering medications to Resident ID #1 and another resident. During the medication pass, she was interrupted and suspected that she might have administered the wrong medication. Although she checked on the resident several times and took vital signs, there was no documentation of an immediate evaluation or follow-up evaluations. The Nurse Practitioner confirmed that the on-call provider was not contacted immediately after the error was suspected, and the Director of Nursing Services could not provide evidence of the required evaluations.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by the events involving Resident ID #1 and Resident ID #2. Resident ID #1, who was admitted with diagnoses including paranoid personality disorder and anxiety, initially reported a consensual relationship with Resident ID #2. However, Resident ID #1 later reported non-consensual sexual contact occurring over several days. Despite having a BIMS score indicating intact cognition, Resident ID #1 expressed feeling unsafe and uncomfortable with the relationship. On the morning of 9/30/2024, Resident ID #1 reported to the Director of Social Services that sexual activity had occurred without consent. Prior to this, on 9/29/2024, Resident ID #1 had expressed discomfort to staff members, including a laundry aide and a nursing assistant, about the pace of the relationship with Resident ID #2. Both staff members encouraged Resident ID #1 to speak with the Director of Social Services but did not recognize the situation as potential abuse. The concerns were communicated to an LPN, who also did not investigate further. The facility's failure to act on Resident ID #1's expressed concerns resulted in a lack of intervention to ensure safety. Resident ID #1 was later transferred to a hospital for evaluation related to genital pain and reported being treated for potential sexual assault. The facility's staff did not initiate any interventions from the time they were made aware of the resident's discomfort until the allegations of sexual assault were made, indicating a deficiency in protecting the resident from abuse.
Failure to Recognize and Investigate Allegations of Abuse
Penalty
Summary
The facility failed to recognize and investigate allegations of potential abuse involving a resident who expressed concerns about a consensual sexual relationship with another resident. Despite the resident's intact cognition, as indicated by a BIMS score of 14 out of 15, staff members did not identify the resident's discomfort and fear as potential abuse. The resident reported feeling uncomfortable and pressured by the other resident, but staff members, including a laundry aide and a nursing assistant, did not take immediate action to investigate or report the concerns to the appropriate authorities. Instead, they advised the resident to speak to the Director of Social Services the following day. The facility's inaction resulted in the resident experiencing further non-consensual sexual encounters, leading to a visit to the emergency room for potential sexual assault. The resident reported being penetrated with an object and experienced symptoms such as dysuria, pelvic pain, and anxiety. The facility administrator acknowledged that the staff did not recognize the situation as potential abuse and failed to protect the resident from further harm during the investigation. The facility did not initiate an investigation to determine if abuse had occurred, nor did they provide evidence of measures taken to prevent further incidents.
Infection Control Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak. Despite the facility's policy to follow CDC and local public health authority guidelines, surveyors observed that employees and visitors were not screened for COVID-19 symptoms upon entering the building. Interviews with staff confirmed that screening had not been conducted for several weeks. Additionally, the facility did not adhere to the local public health authority's recommendations, which included screening, wearing N95 masks in resident care areas, and conducting COVID-19 testing twice a week for staff and residents. Further deficiencies were noted in the use of Personal Protective Equipment (PPE). A nursing assistant was observed entering a COVID-19 positive resident's room wearing two surgical masks instead of the required N95 mask, despite clear signage indicating the necessary PPE. The facility's Director of Nursing Services and other staff acknowledged the failure to follow the facility's policy and public health recommendations, including the lack of evidence for twice-weekly COVID-19 testing for staff. The facility also failed to implement Enhanced Barrier Precautions for a resident with a history of Methicillin-resistant Staphylococcus aureus (MRSA). Nursing students were observed assisting the resident with high-contact activities without wearing gowns, contrary to the facility's policy and posted signage. The Infection Preventionist confirmed the expectation for staff and visitors to adhere to infection control practices, including wearing all required PPE for rooms under isolation precautions.
Failure to Document Intake and Output as Ordered
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by not following physicians' orders for documenting intake and output (I&O) for four residents. Resident ID #26, who was readmitted with a suprapubic catheter, had a physician's order to document I&O every shift, but records from September 1 to September 10, 2024, showed that documentation was missing for 27 out of 30 opportunities. The Director of Nursing Services (DNS) could not provide evidence that the order was followed. Similarly, Resident ID #30, with a suprapubic catheter and chronic conditions, had a physician's order for I&O documentation every shift, but records showed missing documentation for 26 out of 30 opportunities. Resident ID #61, also with a suprapubic catheter, had no I&O documentation for 30 out of 30 opportunities. Lastly, Resident ID #104, with acute kidney injury and chronic kidney disease, had incomplete I&O documentation, with missing entries for 9 out of 10 opportunities on the night shift. Staff interviews confirmed the failure to follow physician's orders for I&O documentation.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to ensure that residents maintained acceptable nutritional status, as evidenced by significant weight loss or gain in three residents. Resident ID #76 experienced a severe weight loss of 11.89% within a month, with missing weight documentation for two weeks in August 2024. The Licensed Practical Nurse (LPN) and Registered Dietitian (RD) were not informed of the weight loss, and the physician was also unaware until the surveyor's intervention. The Director of Nursing Services (DNS) confirmed the lack of evidence for weekly weights and the absence of reweighs following significant weight changes. Resident ID #96 showed a significant weight gain of 10.55% in less than 30 days, with no reweigh conducted as per facility policy. The weight gain was not reported to the RD or the Nurse Practitioner, indicating a communication breakdown in the facility's weight monitoring process. The nurse responsible for documenting and reporting weight changes could not provide evidence of compliance with the policy. Resident ID #104 experienced a weight loss of 17.1 lbs. in less than a month, with no reweigh conducted to verify the change. The LPN and DNS acknowledged the failure to obtain a reweigh, and the RD expected staff to follow the policy for significant weight changes. These deficiencies highlight a systemic issue in the facility's adherence to its weight monitoring policy, resulting in unaddressed significant weight changes in residents.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to a resident with a history of PTSD, bipolar disorder, and anxiety disorder. The resident, who was admitted in October 2023, had an intact cognition score of 14 out of 15 on the Minimum Data Set assessment. Despite this, the facility did not complete a comprehensive assessment to identify the resident's specific trauma history or preferences to mitigate triggers that could cause re-traumatization. The Social Service Trauma-Informed Care Screening Tool used did not specify the type of trauma experienced by the resident or the necessary preferences to avoid triggers. Interviews with staff, including a Medication Technician, LPNs, and the Social Worker, revealed a lack of awareness regarding the resident's trauma history and potential triggers. Additionally, the Social Worker was unaware of a recommendation from Optum Behavioral Health to obtain the resident's outpatient psychiatric records. The Director of Nursing Services expressed an expectation for a completed Trauma-Informed Care Assessment for residents with PTSD, which was not fulfilled in this case.
Failure to Elevate Resident's Head Post-Feeding
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube (G-tube) received appropriate treatment and services to prevent complications. The resident, who was readmitted to the facility in February 2024 with diagnoses including dysphagia and Alzheimer's disease, had a physician's order to have their head elevated 30-45 degrees during feeding and for one hour after gravity feeds. Additionally, the resident was to be elevated at all times with continuous feeding. However, during a surveyor observation on September 11, 2024, it was noted that the resident's head of the bed was not elevated to the required position for one hour after receiving therapeutic nutrition. The surveyor's interview with a Licensed Practical Nurse (LPN) revealed that the resident completed their therapeutic nutrition at approximately 8:30 AM, but the head of the bed was not elevated as ordered. The Director of Nursing Services also acknowledged that the resident's head of the bed should have been elevated to 30-45 degrees for one hour after receiving the nutrition. This oversight indicates a failure to adhere to the physician's orders and the facility's policy on enteral feeding, potentially compromising the resident's care.
Failure to Administer Humira as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the administration of Humira, a medication used to treat rheumatoid arthritis. The resident, who was admitted in March 2024 with diagnoses including infection following a surgical procedure, rheumatoid arthritis, and diabetes, had physician orders for Humira to be administered subcutaneously every two weeks. However, the Medication Administration Records (MAR) for March, April, May, and June 2024 revealed that the resident did not receive the medication on three occasions: March 29, April 12, and June 13, 2024. The progress notes indicated that on the dates the medication was missed, staff documented that they were waiting for the pharmacy to deliver the medication. There was no evidence in the records that the physician was informed about the missed doses. During an interview with the Assistant Director of Nursing and the Director of Nursing Services, it was acknowledged that the resident did not receive Humira as prescribed, and it was expected that the nurses should have notified the physician of the missed doses.
Failure to Monitor Resident's Condition and Follow Care Plan
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. The resident, who had a history of deep vein thrombosis (DVT) and recent surgery for a left hip fracture, exhibited increased swelling in the left leg. Despite this, the facility did not adequately monitor the resident's condition or follow physician's orders for weekly weight checks. The resident's care plan included interventions such as applying compression stockings and monitoring for signs of DVT, but there was no evidence that these measures were implemented. The resident was readmitted to the facility with severe non-pitting edema in the left leg. Over several days, physical therapy notes indicated excessive swelling and pain, yet the facility did not conduct an ultrasound to rule out DVT until it was recommended by the resident's surgeon. The resident's condition worsened, leading to a positive DVT diagnosis and transfer to an acute care hospital for further treatment. Interviews with staff revealed a lack of documentation and monitoring, with the nurse practitioner acknowledging the delay in ordering an ultrasound despite the resident's history and symptoms. Additionally, the facility failed to obtain the resident's weight as ordered, which could have assisted in monitoring the resident's condition and the effectiveness of prescribed medication. The Assistant Director of Nursing and Medical Director both acknowledged the expectation for nursing staff to monitor the resident's weight and condition as per the care plan. The lack of adherence to the care plan and physician's orders contributed to the deficiency in the resident's care.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect and keep residents free from physical abuse, as evidenced by an incident involving two residents. A nursing assistant observed Resident ID #1 with their hands around Resident ID #5's neck. The residents were immediately separated, and Resident ID #1 was sent to the hospital for evaluation. Resident ID #5 was later found with a bruise on their left shoulder and superficial nail marks on their neck. The facility's policy on abuse prevention was not effectively implemented to prevent this incident. Resident ID #1, who has severe cognitive impairment due to Alzheimer's disease, generalized anxiety disorder, and major depressive disorder, had a history of physical aggression. Despite being followed by psychiatric services and having medication adjustments, Resident ID #1's care plan noted the potential for physical aggression. The resident had previously been involved in an incident with Resident ID #5, leading to their separation into different rooms. However, on the day of the incident, Resident ID #1 entered Resident ID #5's room and physically assaulted them. Resident ID #5, who also has severe cognitive impairment and is dependent on assistance for most functional abilities, was unable to defend themselves. The Director of Nursing Services acknowledged that Resident ID #5 was not kept free from abuse, as required by the facility's policy. The incident highlights a failure in monitoring and ensuring the safety of residents with known aggressive behaviors, leading to physical harm to Resident ID #5.
Failure to Maintain Infection Control for MDRO
Penalty
Summary
The facility failed to maintain an infection prevention and control program to prevent the transmission of communicable diseases and infections for a resident diagnosed with a Multidrug-resistant Organism (MDRO). The resident, who was readmitted to the facility with multiple diagnoses including Alzheimer's disease and metastatic colon cancer, was found to be positive for Extended-spectrum beta-lactamase (ESBL) in the urine. Despite the CDC guidelines and the facility's own policy requiring contact precautions for residents with MDRO, the resident was not placed on contact precautions until a day after starting antibiotics, and there was no signage indicating the need for personal protective equipment (PPE) during high-contact care activities until much later. Surveyor observations revealed that the resident's room lacked appropriate signage for contact or enhanced precautions, and the resident's physician was not consulted regarding the removal of these precautions. The Infection Preventionist acknowledged that the resident was no longer on contact precautions despite the ongoing risk. It was only after the surveyor's intervention that the resident was placed on Enhanced Barrier Precautions, with proper signage and PPE availability at the doorway. This delay in implementing and maintaining appropriate infection control measures led to the deficiency noted in the report.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 812 citations issued within 25 miles in the last 12 months — including the 23 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Woonsocket
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woonsocket Health Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Cedar Haven Operations Holding Llc Valley View Hea | 0.8 mi | ★★★★★ | 0 | 0 |
| Holiday Retirement Home Inc | 2.2 mi | ★★★★★ | 9 | 0 |
| The Friendly Home | 2.3 mi | ★★★★★ | 13 | 0 |
| St Antoine Residence | 2.6 mi | ★★★★★ | 4 | 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.