Adviniacare Waterview Villas, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in East Providence, Rhode Island.
- Location
- 1275 South Broadway, East Providence, Rhode Island 02914
- CMS Provider Number
- 415042
- Inspections on file
- 30
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Adviniacare Waterview Villas, Llc during CMS and state inspections, most recent first.
A resident with RLS and seizures, who was cognitively intact, had a physician’s order for pramipexole twice daily that was not followed when nine doses were missed over several days because the medication was unavailable. The MAR documented multiple omitted morning and afternoon doses, and the resident reported going several days without the drug, experiencing leg discomfort, pain radiating to the back, and pacing due to inability to sit still. A provider note indicated the pharmacy failed to deliver the medication and that the resident requested ED transfer to obtain it. The DON acknowledged the medication was not given as ordered due to unavailability, and the pharmacy account manager reported that the facility did not submit the refill request until several days after doses began to be missed.
A resident with dementia and a history of colon cancer experienced worsening genital lesions and a herpes simplex outbreak. The facility failed to complete an ordered genital swab, delayed reporting a positive UTI result to the provider, and did not notify the responsible party of changes in condition or new medications. Staff interviews confirmed lapses in following up on diagnostic tests and communicating with the family, resulting in delayed treatment and more invasive interventions.
A resident with dementia and a history of falls experienced a significant decline after staff failed to update the care plan and implement recommended bed rail safety measures. Despite a physical therapy recommendation and physician order for side rails to assist with bed mobility, there was a delay in installation, and the resident fell out of bed, sustaining fractures that required surgery. Staff interviews confirmed the absence of side rails at the time of the fall and delays in pain management and diagnostic evaluation.
Garbage bags were left outside the dumpster and accumulated in the parking lot after the waste management company placed a hold on trash removal services due to nonpayment. This resulted in improper disposal of refuse, as confirmed by photographic evidence and staff interviews, and was reported to the Department of Health for attracting pests and creating a risk of disease.
A resident with significant medical needs, documented as requiring two staff for bed mobility and hygiene, was assisted by only one nursing assistant during care. The staff member, unaware of the two-person requirement, performed a bed bath alone, leading to the resident falling from bed and sustaining injuries that required hospital transfer. The DON did not acknowledge the documented two-person assistance requirement.
The facility failed to provide necessary ROM and mobility services to residents with contractures and limited mobility. A resident with anoxic brain damage had a contracted hand without interventions, while another with spinal stenosis had bilateral hand contractures and limited ROM, yet received no therapy. Additionally, a resident admitted for respite care was not provided with a wheelchair or therapy screen, remaining bedbound despite expressing a desire to get out of bed.
A resident admitted for respite care with reduced mobility and a history of poliomyelitis developed a pressure ulcer due to the facility's failure to provide necessary treatment and services. Despite the resident's intact cognition and desire to be out of bed, staff did not transfer the resident for 15 days, leading to a facility-acquired wound. The resident's wound care was inadequately managed, and new pressure areas were identified, indicating the development of pressure ulcers.
The facility was cited for deficiencies in food safety and storage practices. Surveyors observed grease accumulation on kitchen equipment and improper storage of farm eggs brought by a staff member, violating the Rhode Island Food Code. The administrator acknowledged the need for cleaning and proper food sourcing.
The facility failed to adhere to physician's orders for several residents, including medication refusals for a resident with Parkinson's and hypertension, improper use of straws for a resident with dysphagia, unreported high blood sugar levels for a diabetic resident, and delayed wound dressing changes. These issues were acknowledged by the DNS and staff, highlighting lapses in communication and adherence to care protocols.
A facility failed to monitor a resident with a history of mental disorders and suicidal ideations, as required for their mental and psychosocial well-being. Despite recommendations for monitoring, the care plan and records lacked interventions for suicidal ideation. Staff interviews confirmed the absence of monitoring, highlighting a deficiency in providing necessary behavioral health care.
A resident with mild communication deficit and major depressive disorder was not provided with an activity program aligned with their preferences, as documented in their care plan. Despite the resident's expressed interest in reading, music, and group activities, they were observed alone in their room without engagement. Staff interviews revealed that the activities department failed to visit the resident, and Nursing Assistants did not facilitate activities as expected.
Two residents experienced significant weight loss due to the facility's failure to adhere to its policies on monitoring and addressing nutritional status. One resident with dementia and dysphagia lost 8 pounds in two weeks without proper re-weighing or intervention, while another resident with poliomyelitis and depression lost 1.3 pounds in 10 days without a nutritional care plan or assessment. The facility did not notify the interdisciplinary team or implement necessary interventions, leading to deficiencies in maintaining residents' nutritional health.
The facility failed to secure medication storage as required, with keys to medication carts and storage rooms being shared among staff, including non-licensed personnel, due to the bathroom key being on the same key ring. This breach was confirmed by staff interviews and acknowledged by the DON.
The facility failed to follow physician's orders and maintain accurate records for several residents. A resident with vascular dementia did not have their heels offloaded or heel protectors applied as ordered, and the TAR inaccurately showed completion. Another resident with muscle weakness also did not have their heels offloaded as required. Additionally, a resident with poliomyelitis did not receive a timely wound dressing change, despite the TAR indicating it was done. These deficiencies were acknowledged by nursing staff and the DON.
The facility failed to properly disinfect a glucometer used for multiple residents, contrary to both facility policy and manufacturer guidelines. A resident with type 2 diabetes mellitus had their blood sugar checked by a nurse who did not clean the glucometer before or after use. The Director of Nursing confirmed the expectation for proper disinfection, which was not met.
The facility did not notify residents receiving Medicaid benefits when their personal needs account balance approached the SSI resource limit, risking their Medicaid eligibility. This was identified for four residents with balances over $4,000, and the Account Receivable Assistant could not provide evidence of required notifications.
The facility failed to conduct weekly skin audits as per physician's orders for three residents, including those with severe protein calorie malnutrition and Alzheimer's disease. The audits were not performed for several weeks, and the DON could not provide evidence of compliance.
The facility failed to monitor and maintain the nutritional status of two residents. One resident was not consistently weighed on the same scale, and meal intakes were not recorded. Another resident, diagnosed with severe protein calorie malnutrition, was not weighed for a month, and meal intakes were frequently unrecorded. The resident also refused a nutritional supplement, but the provider was not notified. The DON could not provide evidence of proper monitoring or communication.
Failure to Ensure Timely Refill and Administration of Pramipexole for RLS
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of pramipexole for a resident with restless leg syndrome (RLS) and seizures. The resident was admitted in January 2026 and had intact cognition, as evidenced by a Brief Interview for Mental Status score of 15 out of 15. A physician’s order dated 1/23/2026 directed that pramipexole dihydrochloride 0.5 mg, two tablets by mouth twice daily, be administered for RLS. Review of the February 2026 Medication Administration Record showed that this medication was not administered as ordered on nine occasions between 2/8/2026 and 2/12/2026, with doses missed on multiple mornings and afternoons. The resident reported going about three days without receiving pramipexole because it was not available, and stated that this resulted in uncomfortable leg sensations, pain radiating to the back, and the need to pace around the unit due to discomfort when sitting still. A progress note dated 2/11/2026 documented that the pharmacy failed to deliver the ordered pramipexole and that the resident requested transfer to the Emergency Department to access the medication. During interviews, the Director of Nursing Services acknowledged that the medication was not administered as ordered on the identified dates because it was unavailable from the pharmacy, and the Pharmacy Account Manager stated that the refill request for pramipexole was not submitted by the facility until 2/12/2026.
Failure to Complete Diagnostic Testing, Report Lab Results, and Notify Responsible Party
Penalty
Summary
The facility failed to ensure that ordered diagnostic testing was completed and that significant laboratory results were reviewed and reported to the practitioner for a resident being treated for a herpes simplex outbreak. Specifically, a genital swab ordered by the nurse practitioner was documented as obtained, but there was no evidence that the swab was processed or that results were received or followed up on. Additionally, a urinalysis with culture and sensitivity (UA C&S) was ordered and resulted in a positive urinary tract infection (UTI), but the results were not reported to a provider until four days after they became available, delaying appropriate treatment. The resident involved had a history of dementia, malignant neoplasm of the colon, and was dependent on staff for activities of daily living, including incontinence care. The care plan identified the resident as being at risk for skin breakdown, with interventions to inspect the skin during care. Despite these risks, the resident experienced worsening genital lesions, swelling, and redness over several months, with multiple assessments and new orders for treatment, but without timely completion or follow-up of diagnostic tests as ordered by the practitioner. Furthermore, the facility did not ensure timely communication with the resident's responsible party regarding changes in condition, new diagnoses, or new medications prescribed. Interviews with staff and the Director of Nursing confirmed that the genital swab was not followed up on, the positive UA results were not promptly reported, and the resident's family was not notified of significant changes in the resident's condition. These failures collectively resulted in delays in treatment and the need for more invasive interventions.
Failure to Implement Timely Bed Rail Safety Measures Results in Resident Injury
Penalty
Summary
The facility failed to ensure that staff updated and implemented proper safety measures, specifically regarding the use of bed rails, which resulted in a preventable fall and significant injury to a resident. The resident, who had a history of dementia, left hip fracture, and previous falls, was readmitted to the facility and experienced a decline in mobility after a fall while ambulating. Physical therapy evaluated the resident and recommended the use of side rails to assist with bed mobility and transfers, with the plan of care signed by a physician. However, the care plan was not updated to reflect the need for side rails, and there was a delay of approximately 20 days before the side rails were installed on the resident's bed. On the day of the incident, the resident fell out of bed and was found on the floor by a nursing assistant, complaining of back and leg pain. Progress notes indicated ongoing pain and a lack of effective pain management, with a delay in obtaining an X-ray to assess the extent of the injury. The X-ray, when finally completed, revealed a left femoral neck fracture and pelvic fracture, requiring the resident to be sent to the emergency department and subsequently undergo surgery. The resident, who had previously been ambulatory with a walker, now required a wheelchair and assistance from two staff members for mobility. Interviews with staff confirmed that the resident did not have side rails in place at the time of the fall, despite the physical therapy recommendation and physician's order. The Director of Nursing and other staff acknowledged the absence of side rails and the delay in their installation. The failure to update the care plan and implement the recommended safety measures directly contributed to the resident's fall, resulting in significant injury and a marked decline in functional status.
Improper Disposal of Garbage and Refuse Due to Lapsed Trash Removal Services
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse in accordance with professional food safety standards. Surveyor observation, record review, and staff interviews revealed that garbage bags were left outside the dumpster, which is not compliant with the 2022 FDA Food Code requirements for refuse storage and removal. Specifically, the code prohibits the outside storage of refuse in unprotected bags and requires removal at a frequency that prevents the attraction or harboring of pests. A community complaint reported to the Rhode Island Department of Health alleged that overflowing garbage was attracting pests and creating a risk of disease. Photographic evidence provided by the complainant showed multiple garbage bags accumulated next to the dumpsters. An email from the facility Administrator confirmed that the waste management company had placed a hold on trash removal services due to nonpayment, resulting in trash bags accumulating in the parking lot. During an interview, the Administrator acknowledged that the trash removal company had stopped pickups without notice, leading to the accumulation of garbage on the premises.
Failure to Provide Required Two-Person Assistance During Resident Care Results in Fall and Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for bed mobility and personal hygiene and required the assistance of two staff members during care, was provided care by only one nursing assistant. The resident had significant medical conditions, including anoxic brain damage, seizures, and diabetes, and was documented in both the Minimum Data Set (MDS) and care card as needing two staff for bed mobility and hygiene tasks. Despite these documented requirements, the nursing assistant performed a full bed bath and attempted to change the resident alone, during which the resident rolled out of bed and sustained injuries, including a facial laceration and abrasions, necessitating immediate transfer to the hospital. Interviews with staff revealed that the nursing assistant was unaware of the documented requirement for two-person assistance and typically worked alone with the resident. The Director of Nursing Services also did not acknowledge the two-person requirement, despite its presence in the resident's care documentation. As a result of the failure to follow the care plan and MDS directives, the resident experienced a fall with multiple injuries and required hospitalization.
Failure to Provide Appropriate ROM and Mobility Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to residents with limited range of motion (ROM) and contractures, as well as to a resident with limited mobility. Resident ID #67, who was admitted with anoxic brain damage and muscle wasting, was observed to have a contracted left hand without any interventions in place to prevent further decrease in ROM. Despite the resident's severe cognitive impairment, staff interviews revealed that no physical or occupational therapy was being provided, and the care plan did not address the contracture or include interventions to prevent further decline. Resident ID #79, admitted with spinal stenosis and peripheral autonomic neuropathy, was also found to have bilateral hand contractures and limited ROM, yet was not receiving therapy services. The care plan failed to document these issues, and no evidence was found of a therapy evaluation or interventions to prevent further decline. Staff interviews indicated a lack of awareness of the resident's condition and the absence of necessary therapy evaluations and interventions. Resident ID #272, admitted for respite care with reduced mobility and a history of poliomyelitis, had not been out of bed since admission and lacked a wheelchair. Despite the resident's expressed desire to get out of bed, staff had not facilitated this, and no therapy screen had been conducted to assess the need for adaptive equipment. It was only after surveyor intervention that a therapy screen was completed, revealing the resident required assistance for transfers and needed a wheelchair.
Failure to Prevent Pressure Ulcers in Resident with Reduced Mobility
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent new pressure ulcers from developing for a resident admitted for respite care. The resident, who had reduced mobility and a history of poliomyelitis, was admitted without any wounds. However, within six days, the resident developed a facility-acquired wound on the right buttocks. The resident's care plan indicated a risk for skin breakdown due to impaired mobility, and a Norton Assessment identified the resident as being at moderate risk for developing pressure ulcers. Despite the resident's intact cognition and expressed desire to be out of bed, staff did not transfer the resident out of bed for 15 consecutive days. The resident was observed lying flat on their back during multiple surveyor observations, and staff interviews revealed a lack of awareness and action regarding the resident's mobility needs. The resident's care card indicated a need for assistance from two staff members for bed mobility and transfers, yet this was not implemented. The resident's wound care was also inadequately managed, as evidenced by a soiled dressing not being changed as ordered. The wound nurse identified new pressure areas with non-blanchable redness, indicating the development of pressure ulcers. The Director of Nursing Services acknowledged that staff should have offered to transfer the resident out of bed, highlighting a failure in the facility's care practices that led to the resident developing a pressure ulcer.
Deficiencies in Food Safety and Storage Practices
Penalty
Summary
The facility was found to have deficiencies in food storage, preparation, distribution, and service according to professional standards. Surveyor observations on multiple dates revealed significant grease accumulation on various kitchen equipment, including the steamer, food warmer, stove, and food meal delivery carts. Additionally, the utility cart storing spice containers was noted to have crumbs and debris in the corners. In the main dining room, the steam table was observed with grease accumulation on the knobs and food spills on the front of the unit. These observations indicate a failure to maintain nonfood contact surfaces free of dirt, dust, food residue, and other debris as required by the Rhode Island Food Code 2018 Edition. Furthermore, the facility failed to procure food from approved sources. During a surveyor observation, a dozen eggs with a use-by date of 12/14/2024 were found stored in a gray egg container in the main kitchen's reach-in refrigerator. These eggs were revealed to be fresh farm eggs brought in by a staff member from his farm-raised chickens, which is not compliant with the Rhode Island Food Code 2018 Edition that mandates food to be obtained from sources that comply with the law. The facility administrator acknowledged the need for cleaning the food service equipment and the improper storage of eggs brought from home.
Failure to Follow Physician's Orders and Medication Refusals
Penalty
Summary
The facility failed to meet professional standards of quality by not following physician's orders for several residents. One resident with Parkinson's disease and hypertension refused medications multiple times throughout January 2025, including Amlodipine, Lisinopril, Metoprolol, Multivitamin, and Carbidopa-Levodopa. The facility did not notify the provider of these refusals, as confirmed by the Director of Nursing Services and the Nurse Practitioner during interviews. Another resident with dysphagia and dementia had a dietary order to avoid straws with liquids, yet surveyor observations noted the presence of straws on multiple occasions. Staff members, including a Registered Nurse and a Nursing Assistant, were unaware of the order until informed by the surveyor. The Director of Nursing Services acknowledged the oversight and confirmed the expectation that straws should not be provided to the resident. Additionally, a resident with Diabetes Mellitus Type 2 had blood sugar readings exceeding 400 on several occasions, but the provider was not notified as required by the physician's order. Furthermore, a resident with a wound on the right buttocks did not receive timely dressing changes as ordered, with a dressing observed to be overdue for change. These deficiencies were acknowledged by the Director of Nursing Services, who confirmed the expectation for adherence to physician orders.
Failure to Monitor Suicidal Ideation in Resident
Penalty
Summary
The facility failed to ensure that a resident with a history of mental disorders and suicidal ideations received appropriate treatment and services to maintain their mental and psychosocial well-being. The resident, admitted in January 2025, had diagnoses including suicidal ideations, bipolar disorder, and PTSD. Despite being cognitively intact, the resident showed signs of moderately severe depression. A consult service document highlighted the resident's chronic risk of suicide ideation, recommending monitoring for suicidal ideation and discussing a behavioral plan with staff. However, the care plan dated 1/8/2025 did not include interventions for monitoring suicidal ideation, nor was there evidence of a behavioral plan related to this issue. The January 2025 Treatment Administration Record and nursing progress notes lacked documentation of behavioral monitoring for suicidal ideation. During interviews, both a registered nurse and the Director of Nursing Services were unable to provide evidence of monitoring the resident's behavior related to suicidal ideation, indicating a lapse in the facility's responsibility to provide necessary behavioral health care and services.
Failure to Provide Resident-Centered Activity Program
Penalty
Summary
The facility failed to provide an ongoing activity program tailored to a resident's preferences and needs, as identified in their comprehensive assessment and care plan. The resident, who was readmitted in September 2024 with diagnoses including mild communication deficit and major depressive disorder, expressed a strong preference for activities such as reading, listening to music, and participating in group activities. Despite these preferences being documented in the resident's care plan, observations on multiple dates revealed that the resident was left alone in their room without engagement in any activities, such as watching television or listening to music. Interviews with staff members revealed a lack of adherence to the resident's care plan. A Nursing Assistant indicated that the resident preferred to stay in their room and was supposed to receive visits from the activities department for in-room activities. However, the assigned Activities Aide admitted to not visiting the resident on the observed dates. Additionally, the Director of Nursing Services expected Nursing Assistants to facilitate the resident's engagement with television or music, as per the care plan, but this was not done. This lack of action resulted in the resident not participating in any activities, contrary to their documented preferences and care plan interventions.
Failure to Maintain Residents' Nutritional Status
Penalty
Summary
The facility failed to ensure that residents maintained acceptable nutritional status, as evidenced by significant weight loss in two residents. Resident ID #52, who was readmitted with dementia and dysphagia, experienced an 8-pound weight loss over two weeks. The facility's policy required weekly weights for residents with significant weight changes, but weights were not obtained for Resident ID #52 during the weeks of 12/29/2024 through 1/4/2025. Additionally, there was no evidence of re-weighing or further interventions after the weight loss was documented on 1/6/2025, until the issue was identified by the surveyor. Resident ID #272, admitted with poliomyelitis and depression, also experienced weight loss, losing 1.3 pounds in 10 days. The facility failed to obtain weekly weights as per policy, and there was no evidence of a nutritional care plan or an admission nutritional assessment by the dietitian. Although the dietitian assessed the resident on 1/20/2025 and recommended a nutritional supplement, there was no documentation of this assessment or communication of the recommendation to the facility. Interviews with the dietitian and the Director of Nursing Services (DNS) revealed that the facility did not follow its policy of notifying the interdisciplinary team, dietitian, physician, and family of significant weight loss. The DNS acknowledged the expectation for re-weighing and notification but could not provide evidence of these actions for either resident. The lack of adherence to the facility's policies and procedures contributed to the deficiency in maintaining the residents' nutritional status.
Medication Storage Security Breach
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with accepted professional principles, as observed during a survey. The facility's policy requires that medications be stored in a locked mobile medication cart accessible only to licensed nursing personnel, and other medications be stored in a locked medication room. However, during a medication administration pass, it was observed that the keys to the medication cart and storage room were on the same key ring as the only key to the unit's bathroom. This key ring was shared among staff members, including non-licensed personnel, to access the bathroom, which compromised the security of the medication storage. During interviews, staff members, including a Certified Medication Technician (CMT), a Licensed Practical Nurse (LPN), and a housekeeper, confirmed that the medication technician's key ring was used by various staff members to access the bathroom. The Director of Nursing Services acknowledged that the bathroom key should be separate from the medication storage keys and could not provide evidence that the medication storage areas were only accessible to licensed nurses or medication technicians, as required by the facility's policy.
Failure to Follow Physician's Orders and Maintain Accurate Records
Penalty
Summary
The facility failed to maintain accurate medical records and adhere to physician's orders for several residents. Resident ID #83, who was readmitted with conditions including contracture of the right knee and vascular dementia, was identified as being at high risk for pressure ulcers. Despite physician's orders to offload the resident's heels and apply heel protectors every shift, surveyor observations revealed these orders were not followed on multiple occasions. The Treatment Administration Record (TAR) inaccurately indicated that these orders were completed, which was acknowledged by Registered Nurse, Staff G. Similarly, Resident ID #46, with diagnoses including muscle weakness and major depressive disorder, had orders to offload heels every shift. Observations showed these orders were not followed, and Registered Nurse, Staff F, confirmed the inaccuracy in the TAR. Additionally, Resident ID #272, diagnosed with poliomyelitis, had a physician's order for a specific wound dressing change that was not completed as required. The dressing was not changed on the specified date, despite the TAR indicating otherwise. This was confirmed by Registered Nurse, Staff B, and acknowledged by the Director of Nursing Services, who expected adherence to physician's orders and accurate documentation.
Inadequate Disinfection of Glucometer
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the disinfection of a glucometer used for multiple residents. The facility's policy, revised in October 2018, required that blood glucose monitoring equipment be cleaned with bleach wipes before and after use, or as per manufacturer guidelines. However, the manufacturer's instructions for the Embrace Pro glucometer specified cleaning with a moist cloth or tissue using isopropyl alcohol or mild detergent with water. During an observation, a registered nurse did not clean the glucometer before or after obtaining a resident's blood sugar, nor did she disinfect it before returning it to the medication cart. The resident involved was readmitted to the facility in July 2023 with a diagnosis of type 2 diabetes mellitus and had a physician's order for Humalog insulin to be administered based on blood sugar readings. During an interview, the registered nurse acknowledged her failure to clean the glucometer as required. The Director of Nursing Services confirmed that the expectation was for the glucometer to be cleaned with a bleach wipe before and after use. This deficiency was identified during a surveyor observation and interview process.
Failure to Notify Residents of Medicaid Eligibility Risk
Penalty
Summary
The facility failed to notify residents or their representatives who receive Medicaid benefits when their personal needs account balance reached $200 less than the Social Security Income (SSI) resource limit. This deficiency was identified for four residents, each with account balances exceeding $4,000. According to the Title 210-Executive Office of Health and Human Services, Chapter 50-Medicaid Long-Term Services and Supports (LTSS), facilities are required to provide written notification to residents when their account balance approaches the resource eligibility guideline to prevent jeopardizing Medicaid eligibility. During a survey, the Account Receivable Assistant was unable to provide evidence of such notifications being issued to the affected residents.
Failure to Conduct Weekly Skin Audits
Penalty
Summary
The facility failed to meet professional standards of quality by not adhering to physician's orders for weekly skin audits for three residents. Resident ID #3, admitted with severe protein calorie malnutrition, had a physician's order for weekly skin checks, but the last recorded audit was on 5/27/2024, indicating no assessments were conducted in June and July 2024. Similarly, Resident ID #4, also diagnosed with protein calorie malnutrition, had a physician's order for weekly skin checks, but the last audit was recorded on 6/30/2024, showing no assessments in July 2024. Resident ID #5, diagnosed with Alzheimer's disease, had a physician's order for weekly body audits, but the last recorded audit was on 7/5/2024, indicating a lapse of three consecutive weeks without assessment. During an interview, the Director of Nursing Services could not provide evidence that the required weekly skin audits were completed for these residents, as per the physician's orders.
Failure to Monitor Nutritional Status and Record Meal Intakes
Penalty
Summary
The facility failed to adequately monitor and maintain the nutritional status of two residents, leading to deficiencies in their care. For Resident ID #1, the facility did not consistently use the same scale for weighing, as required by their policy, and failed to obtain a reweigh after a significant weight change. Additionally, there were numerous instances where meal intakes were not recorded, making it difficult to assess the resident's nutritional intake accurately. The Director of Nursing Services was unable to provide evidence of consistent weighing practices or complete meal intake records during the surveyor interview. For Resident ID #3, the facility did not obtain a weight measurement for the entire month of June, despite the resident's diagnosis of severe protein calorie malnutrition. The resident's care plan required monitoring of food and fluid intake, but meal intakes were frequently not recorded. Furthermore, the resident refused the prescribed nutritional supplement, Ensure Clear, on multiple occasions, yet there was no evidence that the provider or dietician was notified of these refusals. The Director of Nursing Services could not provide evidence of meal intake monitoring or communication with the provider regarding the supplement refusals.
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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