Adviniacare Pawtucket Pleasant Rehab Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Pawtucket, Rhode Island.
- Location
- 544 Pleasant Street, Pawtucket, Rhode Island 02860
- CMS Provider Number
- 415027
- Inspections on file
- 46
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Adviniacare Pawtucket Pleasant Rehab Center, Llc during CMS and state inspections, most recent first.
A resident with hypo-osmolality, hyponatremia, and psychogenic polydipsia had physician and NP orders for a 1500 mL/day fluid restriction with specific allocations per meal and nursing shift, and instructions for staff to monitor and document daily fluid intake. NAs reported they did not document or communicate fluid amounts for residents, while an LPN indicated that intake was marked as completed in the TAR without recording actual volumes. Record review showed only check marks for completion of the fluid restriction order, with no per-shift intake amounts documented, contrary to the detailed physician order and the expectations of the Medical Director and Administrator.
A resident did not receive the specialized rehabilitative services required for their care, as the facility failed to provide or arrange for these necessary interventions according to the resident's care plan.
Nursing staff failed to demonstrate proper infection control practices for a resident requiring contact precautions due to an ESBL infection. Multiple staff members entered the resident's room without performing hand hygiene or using required PPE, and interviews revealed a lack of understanding about contact precaution protocols, despite having completed infection control competencies.
A nursing home area was found to have accident hazards and lacked adequate supervision, resulting in a deficiency for not preventing accidents as required.
A resident with ESBL in the urine had a physician's order for contact precautions, but a nursing assistant repeatedly entered the room without performing hand hygiene or donning required PPE, despite posted signage. The staff member was unaware of the precautions, and leadership confirmed the expectation for proper infection control measures.
A resident with dementia and malnutrition did not receive wound care services in accordance with professional standards, as required physician orders for wound treatments were missing, and wound dressings were not properly labeled with date or initials. Gaps in treatment documentation and order transcription were confirmed by nursing staff, resulting in missed or undocumented wound care for both a non-pressure wound and an unstageable pressure ulcer.
Surveyors identified widespread sanitation and maintenance deficiencies, including mold-like substances in shower stalls, persistent urine odors, stained toilets, and physical disrepair such as holes in walls and cluttered common areas. These issues were observed across all units and were confirmed by facility leadership during inspection.
A resident admitted with bacteremia missed four doses of the prescribed antibiotic Bactrim due to an incorrect transcription of the medication start date. The facility failed to notify a provider or use available Bactrim tablets from the Pyxis machine. The resident's condition worsened, leading to a hospital transfer for urosepsis treatment. Staff interviews revealed communication lapses and failure to address the medication error.
The facility failed to provide appropriate treatment for two residents with foley catheters. One resident, admitted with a UTI and sepsis, removed their catheter, and staff did not consistently document urinary output or notify a provider of low output until the resident's condition worsened. Another resident with neuromuscular bladder dysfunction had undocumented urinary output on several occasions. Staff interviews revealed an expectation for documentation, but it was not consistently followed.
The facility failed to accurately assess residents' tobacco use and range of motion. Four residents were documented as smokers, yet their MDS assessments incorrectly indicated no tobacco use. Additionally, a resident with a left-hand contracture was inaccurately assessed as having no range of motion impairments. The MDS Coordinator and DON could not provide evidence for the correct coding.
The facility failed to maintain an infection prevention and control program, as evidenced by residents with MDROs not being placed on necessary precautions, improper use of PPE during medication administration via a feeding tube, and improper storage of humidified oxygen. Additionally, a BiPAP machine was not cleaned according to policy, and the filter was missing.
A resident with Parkinson's disease and dysphagia was not positioned upright at 90 degrees during meals, contrary to a physician's order. Observations on multiple occasions confirmed this deficiency, and staff interviews acknowledged the oversight.
A facility failed to provide appropriate care for a resident with an indwelling foley catheter by not consistently measuring and recording urinary output. Despite the care plan's requirement, the facility missed 46 out of 51 opportunities to document this critical information, as confirmed by the DON during a surveyor interview.
A facility failed to ensure a resident receiving nutrition and medications via a g-tube received appropriate treatment to prevent complications. An LPN was observed administering medications without checking for proper g-tube placement, contrary to facility policy and a physician's order. The LPN acknowledged the oversight, and the DON could not provide evidence of appropriate treatment.
A facility failed to maintain a medication error rate below 5%, with a rate of 16.67% observed during a survey. An LPN was seen crushing and mixing medications for a resident and administering them via g-tube using a piston syringe, against facility policy. The medications included Nortriptyline, Cyanocobalamin, Cholecalciferol, Folic Acid, and Metoprolol Tartrate. The LPN admitted to not following the correct procedure, and the DNS confirmed the error without evidence of compliance with the required error rate.
A resident with specific dietary preferences for soft salad sandwiches did not receive them during lunch meals, despite these preferences being documented in their care plan and noted on their meal tray ticket. Observations and staff interviews confirmed the oversight, with staff unable to explain why the sandwiches were not provided, even though they were available.
A resident with multiple mental health diagnoses did not receive prescribed medications due to transcription errors, leading to worsening depression and anxiety. The facility failed to provide necessary behavioral health care, as staff were unaware of the medication errors.
A resident with severe cognitive impairment and on anticoagulant medication was found with bruises, but the physician was not notified. Hospice recommendations, including holding the anticoagulant and administering morphine, were implemented without physician approval. The facility's policy requires physician notification for changes in condition, which was not followed.
Failure to Monitor and Document Fluid Intake for Resident on Fluid Restriction
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with fluid restrictions received treatment and care in accordance with physician orders and professional standards. The resident was re-admitted in December 2025 with diagnoses including hypo-osmolality and hypernatremia, and had a care plan noting potential for fluid overload related to polydipsia and hyponatremia. A physician’s order dated 12/12/2025 directed staff to encourage the resident to limit fluid intake every shift for monitoring. After the resident was found on the bathroom floor with a large lump on the forehead and sent to the hospital, the hospital documented psychogenic polydipsia and hyponatremia with a sodium level of 119 and serum osmolality of 252, and recommended a 1500 mL fluid restriction. Following this, a 12/24/2025 physician order specified a 1500 mL/day fluid restriction with detailed allocations for dietary and nursing fluids per meal and per shift, and the NP reinforced the importance of adherence and instructed nursing staff to monitor daily fluid intake and report acute changes. Despite these orders, staff interviews revealed that NAs did not document or communicate the amount of fluids consumed for any residents, while an LPN stated that fluid intake for this resident was documented by NAs and signed off as completed in the TAR. Record review showed that the fluid restriction orders were only marked as completed with check marks, with no documentation of the actual amounts of fluid provided or consumed per shift as ordered. The Medical Director stated an expectation that intake amounts be monitored and documented per shift, and the Administrator acknowledged that the facility failed to monitor the resident’s fluid intake according to the physician’s order.
Failure to Provide Required Specialized Rehabilitative Services
Penalty
Summary
A resident did not receive specialized rehabilitative services as required for their care. The facility failed to provide or obtain these services, which are necessary to meet the resident's assessed needs. This inaction resulted in the resident not receiving the appropriate rehabilitative interventions as indicated in their care plan.
Failure to Ensure Staff Competency in Infection Control and Contact Precautions
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to prevent the transmission of communicable diseases and infections, specifically regarding contact precautions for a resident with an ESBL infection in the urine. Surveyor observations revealed that a nursing assistant entered the resident's room multiple times without performing hand hygiene or donning required personal protective equipment (PPE) such as gowns and gloves, despite clear signage indicating the need for contact precautions. The nursing assistant also entered another resident's room without performing hand hygiene in between. During interviews, the nursing assistant stated she was unaware of the contact precautions and misunderstood the requirements, believing PPE was only necessary when directly touching the resident. Further interviews with a certified medication technician and an LPN revealed similar gaps in knowledge, with both staff members unable to correctly describe when PPE should be used for residents on contact precautions. The Assistant Director of Nursing Services and Infection Preventionist confirmed that these staff members had completed infection control competencies but could not provide evidence that they demonstrated the necessary knowledge or skills for caring for residents on contact precautions. The deficiency was identified for three out of four nursing staff interviewed regarding contact precautions.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a nursing home area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and there was insufficient oversight to protect residents from potential accidents. This lack of proper supervision and the presence of hazards in the area directly contributed to the deficiency cited by surveyors.
Failure to Follow Contact Precautions for Resident with ESBL
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as required for residents with communicable diseases. Specifically, a resident with a diagnosis of ESBL in the urine had a physician's order for contact precautions, which included the use of gowns and gloves upon entering the resident's room. Surveyor observations revealed that a nursing assistant entered the resident's room on multiple occasions without performing hand hygiene and without donning the required gown and gloves, despite clear signage on the door indicating the need for contact precautions. The nursing assistant also entered another resident's room and then reentered the room of the resident on contact precautions, again without following proper infection control procedures. Interviews with the nursing assistant revealed a lack of awareness regarding the resident's contact precautions order and a misunderstanding of when to use personal protective equipment (PPE). The assistant director of nursing and the infection preventionist confirmed that the resident was actively being treated for ESBL and that staff were expected to perform hand hygiene and wear gowns and gloves upon entering the room. The failure to adhere to established infection control protocols was directly observed and acknowledged by staff during the survey.
Failure to Ensure Wound Care Services Met Professional Standards
Penalty
Summary
The facility failed to ensure that wound care services provided to a resident met professional standards of practice, as evidenced by multiple deficiencies in the management and documentation of wound treatments. For a resident with dementia and moderate protein-calorie malnutrition, a wound physician recommended a specific treatment regimen for a non-pressure wound on the left anterior shin, including the application of a collagen sheet with calcium alginate and a gauze island dressing twice daily. However, there was no evidence of a physician's order in place for this treatment, and during observation, the dressing applied to the wound was not labeled with the date or initials as required by facility policy. Staff interviews confirmed the absence of the required order and proper labeling. Additionally, the same resident had an unstageable pressure wound on the left posterior calf. While there were physician orders for wound care, including the use of Santyl and later a collagen sheet with calcium alginate, record review showed gaps where no treatment order was in place for several shifts. The wound nurse acknowledged that orders from the wound physician are transcribed by nursing staff, but if received after hours, transcription may be delayed until the following day. The nurse also confirmed the lack of a treatment order for the non-pressure wound and the absence of documented treatment for the pressure ulcer on specific dates, as well as the failure to date and initial dressings per policy.
Widespread Sanitation and Maintenance Deficiencies in Resident Bathrooms and Shower Rooms
Penalty
Summary
Surveyor observations, record review, and staff interviews revealed that the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents across all three units. Multiple bathrooms and shower rooms were found with significant cleanliness and maintenance issues, including black and pink matter (suspected mold or mildew) in shower stalls, discolored and stained toilet bowls, and persistent strong odors of urine in several resident rooms and bathrooms. In one instance, a resident's room was reported to have an overwhelming urine odor that was not resolved despite a request for deep cleaning. Additionally, a shower stall was found to harbor multiple small flies, and urinals containing urine were left hanging on a resident's bed. Further deficiencies included physical disrepair such as a large hole in a bathroom wall, partially plastered walls with visible holes, and the storage of multiple wheelchairs, recliners, a bed frame, and a small table in a common area. These conditions were observed and acknowledged by facility leadership during the survey. The findings were substantiated by a community complaint and direct surveyor inspection, indicating a pattern of inadequate housekeeping and maintenance practices affecting resident comfort and sanitation.
Significant Medication Error Due to Missed Antibiotic Doses
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of an antibiotic, Bactrim, prescribed for bacteremia. The resident was admitted with diagnoses including urinary tract infection, bacteremia, and sepsis, and was to continue receiving Bactrim as per hospital discharge instructions. However, due to an incorrect transcription of the medication start date, the resident missed four consecutive doses of Bactrim. The error was not communicated to a provider, and the facility did not utilize available resources, such as substituting the liquid form of Bactrim with tablets from the Pyxis machine, to prevent the missed doses. The resident experienced a change in condition, including severe abdominal pain, increased weakness, difficulty urinating, chills, and abnormal vital signs, leading to a hospital transfer where the resident was treated for urosepsis. Interviews with staff revealed a lack of communication and failure to notify a provider about the missed doses or to explore alternative medication forms. The Director of Nursing Services and the Administrator acknowledged that they expected the resident to receive the medication as ordered or for a provider to be notified if it was not administered.
Failure to Monitor and Document Urinary Output for Residents with Foley Catheters
Penalty
Summary
The facility failed to provide appropriate treatment and services for two residents with indwelling catheters. Resident ID #1 was admitted with a urinary tract infection, bacteremia, and sepsis, and had a foley catheter in place. The resident accidentally removed the catheter, and although staff were instructed to monitor urinary output, documentation was incomplete and inconsistent. The resident's urinary output was not adequately recorded, and there was no evidence that a provider was notified of the low output until the resident's condition worsened, necessitating a hospital transfer. Resident ID #2, admitted with neuromuscular dysfunction of the bladder, also had a foley catheter and required monitoring of urinary output. However, the facility failed to document the resident's urinary output on several occasions as ordered. Interviews with staff revealed an expectation for urinary output to be measured and documented, yet this was not consistently done. The Director of Nursing Services did not acknowledge the need to notify a provider about Resident ID #1's low urinary output, indicating a lapse in communication and adherence to care protocols.
Inaccurate Resident Assessments for Tobacco Use and Range of Motion
Penalty
Summary
The facility failed to ensure accurate assessments of residents' tobacco use and range of motion, as required by the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual. For four residents reviewed for tobacco use, the facility's records indicated that they were independent smokers, yet their Minimum Data Set (MDS) assessments inaccurately coded them as non-users of tobacco products. This discrepancy was identified through a review of progress notes and a facility document titled Quality Review - Smoking Program, which confirmed the residents' tobacco use. The MDS Coordinator admitted to not interviewing residents about their smoking status and could not provide evidence to justify the incorrect coding. Additionally, the facility failed to accurately assess a resident's range of motion. A resident with a left-hand contracture was documented in their care plan, but their MDS assessment inaccurately indicated no impairments to their range of motion. During interviews, both the MDS Coordinator and the Director of Nursing Services were unable to provide evidence that the MDS assessments for the residents in question were completed accurately, highlighting a failure in the facility's assessment processes.
Infection Control and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. Two residents with Multi-drug Resistant Organisms (MDROs) were not placed on Contact or Enhanced Barrier Precautions as required by the facility's policy and CDC guidelines. Resident ID #17, diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA), and Resident ID #86, diagnosed with MRSA and Extended-spectrum beta-lactamase (ESBL), were not observed to be on the necessary precautions during the survey dates. Additionally, there was no evidence that Resident ID #86 was retested for MRSA or ESBL before removing the precautions. Another deficiency was noted with Resident ID #38, who had a gastrostomy tube and required Enhanced Barrier Precautions. A Licensed Practical Nurse (LPN) was observed administering medications via the feeding tube without wearing a gown, despite signage indicating the need for gown use during such procedures. The Director of Nursing Services (DNS) confirmed that the nurse should have worn a gown during the medication administration. Further deficiencies were identified in the storage of humidified oxygen for two residents, ID #45 and ID #58, where the oxygen humidifier containers were placed on the floor instead of the shelf of the oxygen concentrator. Additionally, Resident ID #11's Bilevel Positive Airway Pressure (BiPAP) machine was not cleaned according to the facility's policy, and the filter was missing. The LPN admitted to documenting the cleaning without actually performing it, and the DNS could not provide evidence of the BiPAP's cleaning as per the policy.
Failure to Position Resident Upright During Meals
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident who required assistance with meals. The resident, admitted in October 2021, had diagnoses including Parkinson's disease, dysphagia, and contractures of both hands. The care plan, last revised in August 2022, indicated the resident had a nutritional problem related to obesity and required physical assistance for meals and fluids. A physician's order from July 2022 specified that the resident should receive one-to-one assistance with feeding and be positioned upright at 90 degrees during meals. Surveyor observations revealed that the resident was not positioned upright at 90 degrees during meals on multiple occasions. Specifically, the resident was not properly positioned during meals observed on July 17 and July 18, 2024. Interviews with staff, including a Nursing Assistant and an LPN, confirmed the failure to adhere to the physician's order. The Director of Nursing Services was unable to provide evidence that the resident was positioned correctly during mealtimes as required by the physician's order.
Failure to Monitor Urinary Output for Resident with Foley Catheter
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with an indwelling foley catheter. The resident, who was readmitted to the facility with acute heart failure and obstructive uropathy, required monitoring of urinary output as part of their care plan. Despite this requirement, the facility did not measure and record the resident's urinary output consistently, with 46 out of 51 opportunities missed between July 1, 2024, and July 17, 2024. The Director of Nursing Services confirmed during an interview that it was expected for urinary output to be documented every shift for residents with a foley catheter. However, the facility was unable to provide evidence of such documentation, indicating a failure to monitor and assess the resident's renal function adequately. This deficiency was identified during a surveyor's review of the resident's records and interviews with facility staff.
Failure to Ensure Proper G-Tube Placement Check
Penalty
Summary
The facility failed to ensure that a resident receiving nutrition and medications via a gastrostomy tube (g-tube) received appropriate treatment and services to prevent complications. The deficiency was identified during a surveyor observation, record review, and staff interview. The facility's policy on Enteral Tube Medication Administration, dated December 2019, requires checking for proper tube placement using air and auscultation and checking gastric content for resident feeding. A physician's order dated July 21, 2023, also mandated checking g-tube placement every shift before and after any feeds and before and after any medication administration. During a medication administration task observed by a surveyor on July 18, 2024, a Licensed Practical Nurse (LPN), identified as Staff A, was seen disconnecting the resident's feeding, administering medications, and reconnecting the tube feeding without checking for proper g-tube placement. Staff A acknowledged during an interview that she did not check for proper g-tube placement at any time during the medication administration task and did not follow the physician's order. The Director of Nursing Services was unable to provide evidence that the resident received the appropriate treatment and services to prevent complications related to checking for placement of the tube prior to medication administration.
Medication Administration Errors via G-Tube
Penalty
Summary
The facility failed to ensure that each resident's medication regimen was free from a medication error rate of 5% or greater. During a survey, it was observed that there were 5 errors out of 30 opportunities, resulting in a medication error rate of 16.67%. The errors were specifically related to the administration of enteral medications via a gastrostomy tube (g-tube). The facility's policy on enteral tube medication administration requires that each medication be administered separately and that the tubing be flushed between each medication. Additionally, medications should be allowed to flow by gravity. During the survey, a Licensed Practical Nurse (LPN), identified as Staff A, was observed crushing and mixing all prescribed medications together and administering them via a g-tube using a piston syringe, contrary to the facility's policy. The medications included Nortriptyline, Cyanocobalamin, Cholecalciferol, Folic Acid, and Metoprolol Tartrate. Staff A acknowledged during an interview that she did not administer each medication separately, did not flush the tubing between medications, and did not allow the medication to flow by gravity. The Director of Nursing Services (DNS) confirmed that the expected procedure was not followed and could not provide evidence that the facility ensured a medication error rate below 5% for each resident.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate a resident's food preferences, as observed by surveyors. The resident, who was admitted in October 2021 with diagnoses including Parkinson's disease, dysphagia, and contractures of both hands, had a care plan indicating a nutritional problem related to obesity and required staff assistance for meals. The care plan included an intervention to identify and honor food preferences. A progress note from the Registered Dietitian dated July 18, 2024, stated that the resident preferred soft salad sandwiches for lunch and dinner, which was noted on the resident's tray ticket. However, during surveyor observations, it was found that the resident did not receive the preferred sandwich on two consecutive days. On July 17, 2024, the sandwich was crossed off the tray ticket, and on July 18, 2024, the sandwich was listed but not provided. Interviews with staff confirmed the oversight, with a Licensed Practical Nurse unable to explain the omission and a Nursing Assistant continuing to feed the resident chicken despite the resident's expressed preference for a sandwich. The Registered Dietitian confirmed that sandwiches were available and should have been provided, and the Administrator could not provide evidence that the resident received meals according to their preference.
Failure to Provide Prescribed Behavioral Health Medications
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, as required to maintain their highest practicable physical, mental, and psychosocial well-being. The resident, admitted in March 2023, had diagnoses including post-traumatic stress disorder, bipolar disorder, major depressive disorder, and anxiety disorder. A psychiatric evaluation on March 26, 2024, recommended increasing buspirone to 15 mg twice daily and adding hydroxyzine 25 mg as needed for anxiety. However, the physician's order was incorrectly transcribed, resulting in the resident receiving buspirone only once daily and hydroxyzine for just one day. This error was not identified or corrected, leading to the resident not receiving the prescribed treatment. The resident's mental health condition deteriorated, as evidenced by increasing scores on the Patient Health Questionnaire (PHQ-9), indicating worsening depression. Progress notes documented ongoing anxiety and depressive symptoms, including difficulty sleeping, anxiety related to medical procedures, and requests for psychiatric support. Despite these documented needs, the facility did not ensure the resident received the prescribed medications. Interviews with the Director of Nursing Services and the psychiatric provider revealed a lack of awareness and oversight regarding the medication errors, contributing to the deficiency in care.
Failure to Notify Physician and Unauthorized Implementation of Hospice Recommendations
Penalty
Summary
The facility failed to meet professional standards of practice by not notifying the physician of a change in condition and implementing hospice recommendations without physician approval for a hospice resident. The resident, who had severe cognitive impairment and required maximum assistance, was found to have bruises on the genital area and inner thigh. Despite the facility's policy requiring physician notification for changes in condition, the physician was not informed of the bruising or the hospice recommendations. The hospice nurse recommended holding the anticoagulant medication and administering morphine, but these actions were taken without physician authorization. The resident had a history of dementia with behavioral disturbance, thrombophilia, anxiety disorder, and hypertension, and was on Rivaroxaban, an anticoagulant. The nurse on duty did not notify the physician of the bruising or the hospice recommendations, and entered these recommendations as orders in the electronic medical record without provider authorization. The Nurse Practitioner and Director of Nursing Services confirmed that the provider should have been notified of the resident's condition and the hospice recommendations before they were implemented.
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.
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