Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harris Health Care Center North during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, dementia, severe cognitive impairment (BIMS 99), and daily wandering behaviors was involuntarily secluded when an RN placed a medication cart in front of the resident’s doorway to prevent roaming while the resident had COVID-19. The DON documented that the cart blocked the room exit, and later interviews revealed the cart had been secured in place with a cord wrapped around a wall-mounted glove box, fully obstructing the resident’s ability to leave the room.
Failure to inform residents of the grievance process and to use the facility grievance policy was identified for 9 of 9 residents reviewed in Resident Council. Residents said they were unaware of how to file a grievance, the Activities Director confirmed she had not provided that information, and the Administrator acknowledged the grievance information had not been made available and that the grievance procedure was not being utilized as required.
Food storage and sanitation deficiencies were observed in the main kitchen. Surveyors found multiple opened or expired food items without discard dates, sticky and dirty juice equipment, residue on the coffee maker and stove, and a hood with heavy grease buildup. An open, unlabeled Lantus insulin pen belonging to the FSD was also stored in the refrigerator used for resident food.
QAPI Program Not Maintained for Trauma Informed Care and Kitchen Cleanliness: The facility failed to maintain an effective QAPI process for trauma informed care and kitchen cleanliness. After a prior CMS citation for trauma informed care, the QAPI binder showed only limited audits with no ongoing tracking, measurements, or documented improvement efforts. The dining department records also noted that daily cleaning duties were not being completed, but there was no evidence of ongoing audits or logs. Surveyors continued to find concerns in both areas, and the Administrator acknowledged there was no ongoing QAPI for either issue.
Infection control deficiencies were identified when a staff member's personal insulin pen was stored in the kitchen refrigerator used for resident food, a scabies cluster involving residents and staff was not reported to RIDOH, a housekeeper used a non-disinfectant cleaner on walls instead of an EPA-approved disinfectant, a nurse failed to change gloves and perform hand hygiene during wound care for a resident with DM2 and a sacral wound, and the facility could not show a water management program or flushing schedule for infrequently used fixtures.
Resident personal care information was posted on a supply closet door in a hallway where it could be seen by visitors, staff, and residents. The sign identified which residents were to use pull-ups versus briefs for 5 reviewed residents, and a resident stated privacy should be discrete. The DON acknowledged the posting contained personal information and did not maintain resident dignity.
Psychotropic Medication Monitoring and GDR Deficiency: A resident with dementia, behavioral disturbance, and major depressive disorder was receiving Quetiapine with a GDR in progress, but the record did not show monitoring of behaviors, mood changes, side effects, or the current GDR schedule. The care plan included psychotropic monitoring interventions, and the DON could not provide evidence that the resident’s behavior and mood were being monitored related to the psychotropic use and GDR. A facility-reported incident also documented a physical altercation involving the resident.
Failure to implement a prescribed UTI prevention medication for a resident with a urostomy. The resident returned from a cancer institute visit with a COC and Rx for methenamine 1 gram BID for UTI prevention, but the record showed no evidence the recommendation was reviewed with the MD or that the medication was started. An RN acknowledged the COC and Rx were received and that the resident was not started on methenamine, and the DON could not provide evidence of implementation.
Failure to Include Trauma History in Care Plans: The facility did not ensure that two residents with documented trauma histories received trauma-informed, culturally competent care. One resident with dementia and depression had PTSD screening that identified trauma related to the Korean War, and another resident with severe cognitive impairment had PTSD screening completed with family that identified trauma related to a roadside bomb during Army training. In both cases, the SW designee acknowledged the trauma information was not reflected in the care plan, and the DON and psych NP could not provide evidence of trauma-informed care plans.
A resident readmitted from home with bladder cancer lacked written physician approval for admission, and the record did not show admission orders, a summary of care, medication regimen, PASRR, or resident review for the new admission. Staff said they reinstated prior orders from a previous stay, but the DON could not provide evidence of a signed admission order, and 26 active physician orders were unsigned.
Unnecessary Antibiotic Administration and Order Mismatch: A resident with cellulitis was ordered Amoxicillin-Clavulanate, but the MAR showed amoxicillin was given instead for three doses, and then Amoxicillin-Clavulanate was continued beyond the ordered stop date for multiple additional doses. The DON acknowledged the wrong antibiotic and the extra doses, and the MD stated he did not order an extension beyond the original course.
Medication Administration Errors Exceeded Allowed Rate: Surveyors identified a 16% med error rate during observation, with errors affecting three residents. A CMT gave Magnesium Oxide instead of ordered Magnesium, two staff members administered Lactulose at 20 gm instead of the ordered 10 gm packet dose, and a CMT gave Acetaminophen as crushed tablets instead of the ordered liquid form. The DON acknowledged the meds were not given as ordered.
Significant Metoprolol Medication Error: A resident with HTN was admitted with hospital discharge orders to stop Metoprolol XL 25 mg daily and start Metoprolol Succinate 50 mg daily, but the MAR showed Metoprolol Tartrate 25 mg daily was given instead. The DON acknowledged the mismatch, and the Medical Director could not provide evidence that the ordered Metoprolol Succinate was administered.
Insufficient Food and Nutrition Staffing Competency: The facility failed to provide enough qualified support personnel to independently carry out food and nutrition services. The FSD reported working 7 days a week for all meals, while a Dietary Aid/Cook with only a Food Handlers Certification worked independently on multiple occasions. Two residents required modified diets, including one with CVA and dysphagia on a puree diet and another with muscle weakness on a ground diet, and the Administrator could not show that the staff member had the required competencies or Food Manager certification.
Improper Wound Dressing Application: A resident with type 2 DM and a sacral/coccyx wound received wound care that did not follow the physician order or product instructions. An RN applied calcium alginate over the wound and surrounding skin instead of directly in the wound base and did not cut it to fit the wound bed, despite the care plan calling for skin to be kept clean and dry and moisture exposure minimized.
Two residents had documented bleeding-related changes in condition, but the record did not show timely provider notification, ordered treatment, or complete follow-up. One resident had genital bleeding with a note to schedule urology, while another had hematuria and blood on the brief, with unclear lab follow-up, no documented urine specimen order, and incomplete monitoring documentation by nursing staff.
A resident with COPD and tracheostomy status had an order for O2 2-4 L PRN, but surveyors observed the resident on 2L via a discolored, undated nasal cannula. The TAR and nursing notes did not show the date, time, amount, or method of O2 administration, and there was no physician order for weekly tubing changes; the DON acknowledged the missing order and lack of documentation.
Improper Storage of Medications: Surveyors found an opened Lantus insulin pen in a med cart that had exceeded the manufacturer’s 28-day use period, and an inhaler was observed on a resident’s bedside table on multiple occasions. An RN and the DON acknowledged the insulin and inhaler were stored improperly.
Incomplete Medication Administration Documentation: A resident with diabetes, tracheostomy status, gait and mobility abnormalities, and schizophrenia had multiple ordered meds, including Eliquis, Gabapentin, Quetiapine, Amantadine, and Divalproex, that were not documented on the MAR for scheduled doses. An CMT stated she gave the meds but did not sign them off, and the DON stated administered meds should be documented in the MAR.
Incomplete Pneumococcal Documentation and Outdated Immunization Policy: The facility failed to document whether two residents received or declined pneumococcal vaccination, and one resident had only a prior PPSV23 record with no evidence of offer or receipt of newer PCV options. The DON/DNS also acknowledged that the facility’s flu and pneumonia vaccination policy was outdated and had not been reviewed or revised annually, leaving it inconsistent with current ACIP guidance.
A resident at risk for pressure ulcers did not receive timely skin assessments or treatment, leading to a deep tissue injury on the left heel. The facility failed to conduct weekly skin checks for eight weeks, and there was a delay in implementing the Wound Physician's treatment recommendations. Staff interviews revealed a lack of documentation and follow-through on treatment orders.
A facility failed to provide trauma-informed care to a resident with PTSD and a history of sexual abuse and childhood trauma. The resident's care plan lacked interventions to address trauma, and the PTSD screening was incomplete. Staff interviews revealed a lack of awareness and action regarding the resident's trauma history, with no evidence of further assessment or evaluation by a psychiatric provider.
The facility failed to document bowel movements for two residents with constipation. One resident, with multiple sclerosis, had no BM recorded for two extended periods, while another, with a history of stroke, had no BM documented for 24 days. Despite staff expectations to record BMs each shift, documentation was missing, and the residents experienced discomfort and required assistance.
The facility failed to create comprehensive care plans for two residents who are smokers. One resident, admitted with schizoaffective disorder and other conditions, lacked a smoking evaluation and care plan. Another resident, with anxiety disorder and vascular dementia, also had no care plan despite being identified as a smoker. Staff interviews confirmed the absence of these plans.
The facility failed to prevent significant medication errors for two residents. A resident with multiple sclerosis and other conditions missed several doses of Baclofen, with staff unable to explain the omissions. Another resident with cognitive impairment and anxiety did not receive a recommended gradual dose reduction of Quetiapine, as the evening dose was discontinued instead. The DNS acknowledged these issues without providing explanations.
The facility failed to meet professional standards in wound care and medication administration. A resident with chronic venous ulcers did not receive consistent weekly assessments as ordered by a physician, with missing documentation on several occasions. Additionally, a medication technician prepared medications for two residents at once, contrary to facility policy. Interviews with staff confirmed these deficiencies.
The facility did not follow its smoking policy for a resident with mental health diagnoses, failing to conduct required smoking evaluations upon admission and quarterly. Interviews with staff confirmed the absence of these assessments.
Surveyors found expired medications in the facility's storage room, including lactulose, carbamide peroxide, magnesium, loratadine, and simethicone. Staff acknowledged the oversight, and the DON expected proper disposal of expired items, but the facility's policy was not followed.
Resident Involuntarily Secluded by Medication Cart Blocking Room Exit
Penalty
Summary
Facility staff failed to protect a resident from involuntary seclusion when a medication cart was used to block the resident’s room exit. The resident had been admitted with Alzheimer’s disease and dementia and had a Minimum Data Set (MDS) assessment indicating severe cognitive impairment (BIMS coded 99) and daily wandering behaviors. A facility-reported incident documented that Registered Nurse Staff A placed a medication cart in front of the resident’s doorway, preventing the resident from leaving the room. A progress note by the Director of Nursing Services (DNS) recorded that the resident was found with the medication cart blocking the doorway. Further review of a statement from the DNS showed that Staff A admitted she positioned the cart to prevent the resident from roaming the facility while the resident had COVID-19. During an interview, the Maintenance Director reported that when he attempted to remove the cart, he observed a cord attached to the cart, with the other end wrapped several times around a wall-mounted glove box outside the door, securing the cart in place. In a surveyor interview, the DNS acknowledged that while assisting the Maintenance Director to remove the cart, it was determined that the cart had been tied in place, blocking the resident’s ability to leave the room.
Failure to Inform Residents of Grievance Procedure
Penalty
Summary
The facility failed to inform residents how to file a grievance or complaint and failed to implement its grievance policy to ensure prompt resolution of grievances for 9 of 9 residents reviewed during the Resident Council meeting, including Resident ID #s 4, 6, 9, 14, 20, 22, 24, 26, and 29. An undated grievance procedure/conflict resolution document stated that any person with a grievance, complaint, or concern could complete a grievance/complaint form available at each nurses' station or voice the concern directly to the Administrator/designee, and that the department head responsible would investigate and provide a written response within 3 business days. During the Resident Council meeting, the residents stated they were unaware of the grievance procedure and policy and reported that staff had not reviewed instructions with them on how to file a grievance verbally or in writing. The Activities Director, who assists with the Resident Council, stated she had not discussed or provided information to residents on how to file a grievance. The Administrator acknowledged that the facility had not made the grievance information available to residents and stated that the facility does not utilize the grievance procedure as required.
Food Storage, Sanitation, and Medication Storage Deficiencies in Main Kitchen
Penalty
Summary
The facility failed to ensure that food in the main kitchen was stored, dated, and distributed in accordance with professional food service standards. During the initial kitchen tour, surveyors observed multiple opened or stored food items without required discard dates, including an opened yogurt container, ready-to-use pie crusts, and several seasonings and dry goods with expired or illegible dates. In the dry storage area, surveyors also found multiple boxes of cranberry juice cocktail concentrate and orange juice concentrate with use-by dates from prior years, along with nectar thickened water with a later use-by date. The Food Service Director acknowledged that these items should have been dated, stored, and discarded as indicated. Surveyors also observed poor cleaning of kitchen equipment and surfaces. The three-burner coffee maker had food debris and a thick black residue, the shelf holding juice concentrate boxes had sticky substance, dirt, and food debris, the juice hoses and valve had dried concentrate buildup, the handheld juice dispenser had dark matter inside the nozzle, and the gas stove had black greasy residue on the knobs and exterior. The hood above the stove also had a black greasy residue and had last been cleaned and inspected one year earlier. The Food Service Director stated that equipment was cleaned quarterly by an outside company and that daily cleaning was not being conducted. In addition, a used, open, unlabeled, and undated Lantus insulin pen belonging to the Food Service Director was found stored on the top shelf of the refrigerator used for resident food, and he acknowledged that it was his personal pen and should not have been stored there.
QAPI Program Not Maintained for Trauma Informed Care and Kitchen Cleanliness
Penalty
Summary
The facility failed to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program focused on outcomes of care and quality of life related to trauma informed care and kitchen cleanliness. Review of the facility’s QAPI policy stated that the plan was intended to provide a planned, systemic, and ongoing quality improvement process to monitor and evaluate resident care and pursue organizational improvement. However, after the facility was cited for trauma informed care in a 10/11/2024 CMS 2567, the QAPI binder contained only three trauma informed care audits dated 10/9/2024, with no further audits, actions, measurements, or tracking documented in 2024 or 2025 to show ongoing improvement efforts. The QAPI binder for 2025 also contained dining department documents noting that daily cleaning duties were not being completed daily, with instructions to continue monitoring and auditing in later months, but there was no evidence of actions, measurements, or tracking related to kitchen cleanliness. During the 2025 recertification survey, surveyors continued to identify concerns with trauma informed care and the cleanliness of the kitchen. In interview on 12/5/2025, the Administrator acknowledged there was not an ongoing QAPI related to either issue and was unable to provide evidence of a good faith attempt to correct the trauma informed care concerns from the prior survey or daily cleaning logs or audits for the kitchen.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program when an open, unbagged personal Lantus insulin pen belonging to the Food Service Director was observed stored on the top shelf of the refrigerator used for resident food in the main kitchen. During interview, the Food Service Director acknowledged the insulin pen was his personal pen, that he had used it in the facility, and that it should not have been stored in the main kitchen refrigerator used for residents' food. The facility also failed to report a cluster of scabies to the Rhode Island Department of Health. Review of the scabies tracking list showed multiple residents and staff treated for scabies in September, October, and November 2025, including residents who received permethrin cream and a staff member who was treated with permethrin cream and ivermectin. The Director of Nursing acknowledged that there were confirmed scabies cases during those months and stated that the cluster was not reported to the Rhode Island Department of Health because she was unaware that notification was required. In addition, the facility failed to clean with an EPA-approved disinfectant and failed to prevent the spread of infection during wound care. A housekeeper was observed using Fabuloso, a multipurpose cleaner that was not identified as a disinfectant, to clean walls, despite the facility's room cleaning procedure calling for disinfectant cleaning. During wound treatment for a resident with type 2 diabetes and a sacral wound, a nurse cleansed the wound, applied silver sulfadiazine and calcium alginate, and then failed to remove soiled gloves and perform hand hygiene before moving from the soiled body site to the clean body site. The facility also failed to implement and document a water management program for Legionella prevention, as no evidence was provided of monitoring or flushing infrequently used fixtures, including the laundry room eye wash station.
Resident Personal Care Information Posted in Public View
Penalty
Summary
The facility failed to maintain resident dignity and privacy related to personal needs for 5 of 5 residents reviewed for the use of adult protective underwear, including residents ID #3, #16, #24, #28, and #31. Surveyor observation on 12/3/2025 at 12:17 PM found signage posted on the exterior door of the resident care supply closet in the first-floor main hallway that identified which residents were to use pull-ups and which residents were to use briefs. The posted information was visible in an area accessible to visitors, staff, and residents and contained personal information about the residents' use of adult protective underwear. During interview, a resident stated that privacy was important and that discussions related to health conditions should be discrete. The DON acknowledged that the signage was visible to visitors, staff, and residents, contained personal information, and did not maintain resident dignity.
Psychotropic Medication Monitoring and GDR Deficiency
Penalty
Summary
The facility failed to ensure psychotropic drug use was based on a comprehensive assessment for Resident ID #31 and failed to ensure the resident received monitoring and gradual dose reductions (GDR) for Quetiapine unless clinically contraindicated. Resident ID #31 was admitted with diagnoses including dementia with behavioral disturbance, mild neurocognitive disorder due to a known physiological condition with behavioral disturbance, and major depressive disorder, and was discharged from the facility on 11/28/2025. The resident had an order for Quetiapine 50 mg twice daily from 6/17/2025 through 11/25/2025, and the medication was being reduced as part of a GDR on 11/25/2025 to Quetiapine 25 mg once daily and Quetiapine 50 mg at bedtime. The resident’s care plan included a psychotropic drug usage focus area with interventions to monitor behaviors, mood, and side effects and to report changes to the doctor. However, review of the record did not reveal monitoring related to behaviors, mood changes, side effects, or the current GDR schedule of Quetiapine. During interview on 12/4/2025, the DON could not provide evidence that the resident’s behavior and mood were being monitored related to the psychotropic use and the GDR. The report also notes a facility-reported incident in which Resident ID #31 was trying to keep Resident ID #29 from speaking to a female resident and there was a physical altercation.
Failure to Implement UTI Prevention Medication for Resident With Urostomy
Penalty
Summary
Appropriate care for a resident with a urostomy was not provided when the facility failed to implement a recommendation for methenamine 1 gram twice a day for UTI prevention. Clinical record review showed the resident was readmitted in April 2025 with a diagnosis including malignant neoplasm of the bladder. A Continuity of Care Consultation and Referral form dated 10/8/2025 documented that the resident returned from an appointment at the Cancer Institute with a prescription and recommendation to start methenamine for UTI prevention. The resident's record did not show evidence that the recommendation was reviewed with the Medical Director or that the medication was started. During interview, an RN acknowledged that the COC form and prescription for methenamine were received on 10/8/2025 and that the resident was not started on the medication. The Medical Director stated that if he had been notified of the recommendation, he would have implemented the methenamine. The DON was unable to provide evidence that the resident was started on methenamine for UTI prevention per the COC.
Failure to Include Trauma History in Care Plans
Penalty
Summary
The facility failed to ensure that residents with a history of trauma received trauma-informed and culturally competent care in accordance with professional standards of practice. The facility’s policy stated that a trauma screening assessment would be completed as part of the admission social history and that the type and extent of trauma would be incorporated into culturally competent, resident-centered care to avoid re-traumatization, with a trauma-informed care plan developed as needed. However, for 2 of 3 residents reviewed with a history of trauma, Resident ID #3 and Resident ID #16, the trauma screening information was not reflected in their care plans. Resident ID #3 was readmitted with diagnoses including dementia with behavioral disturbance and depression. An undated Primary Care PTSD screen documented that the resident had experienced the Korean War and had nightmares, tried not to think about the events, and felt on guard, watchful, or easily startled, but the Social Worker designee acknowledged that this trauma information was not reflected in the care plan. Resident ID #16 was readmitted with diagnoses including alcohol dependence, major depressive disorder, and mood disorder due to known physiological condition with depressive features, and had severely impaired cognition on MDS assessment. An undated PTSD screen completed with a family member documented that the resident had experienced a roadside bomb during an Army drill, but the Social Worker designee acknowledged that this was also not reflected in the care plan. Review of the comprehensive care plans failed to include trauma-informed interventions to eliminate or mitigate triggers that may cause re-traumatization, and the DON and Psychiatric Nurse Practitioner were unable to provide evidence of trauma-informed care plans for these residents.
Missing physician admission order and unsigned orders
Penalty
Summary
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care was not met for one resident who was readmitted to the facility from home with a diagnosis including malignant neoplasm of the bladder. The resident had previously been discharged home in December 2024 and was readmitted in April 2025. Review of the medical record did not reveal a written recommendation for admission for the April 2025 readmission, including admission orders, a summary of care, medication regimen, preadmission screening, or a resident review. The physician's orders also included an unsigned order to admit the resident from a prior 2023 admission. The record further showed that 26 active physician orders for the resident were not signed by a provider. During interviews, the Social Worker designee and DNS stated they were unsure what documents the resident arrived with and believed the facility reinstated orders from December 2024 for the April 2025 admission. The Social Worker designee stated the resident's representative reported no medication changes in the community. The DNS was unable to provide evidence of written physician approval for the April 2025 admission, confirmed there was no active or signed physician admission order in 2025, and acknowledged there was no evidence of a new Preadmission Screening and Resident Review for the April admission.
Unnecessary Antibiotic Administration and Order Mismatch
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary drugs for Resident ID #7, who was readmitted in October 2025 with a diagnosis that included cellulitis of the left upper limb. An acute care hospital discharge summary documented an order for Amoxicillin-Clavulanate 875-125 mg twice daily for seven days, from 10/4/2025 through 10/10/2025. However, the October 2025 MAR showed an order for amoxicillin 875 mg twice daily with a start date of 10/4/2025 and a discontinue date of 10/6/2025, and the resident received three doses of amoxicillin from 10/5/2025 through 10/6/2025 instead of the ordered Amoxicillin-Clavulanate. The October 2025 MAR also showed an order for Amoxicillin-Clavulanate 875-125 mg twice daily for seven days with a start date of 10/6/2025 and a discontinue date of 10/27/2025. The resident received 11 additional doses of Amoxicillin-Clavulanate after 10/10/2025 on 10/11, 10/12, 10/13, 10/14, 10/17, 10/18, 10/19, 10/25, and 10/26. During interview, the DNS acknowledged the resident received the wrong antibiotic for three doses and additional doses of Amoxicillin-Clavulanate beyond the ordered stop date, and the Medical Director acknowledged he did not give an order to extend Amoxicillin-Clavulanate beyond 10/10/2025.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure each resident's medication regimen was free from a medication error rate of 5% or greater. During surveyor observation of medication administration, 4 errors were identified during 25 opportunities, resulting in a 16% error rate and affecting Resident IDs #2, #5, and #10. For Resident #2, the record showed an order for Magnesium 200 mg, 2 tablets daily, but Staff C administered 1 tablet of Magnesium Oxide 400 mg and stated, "that's what I always give." For Resident #5, the record showed an order for Lactulose 10 gm packet, 30 mL three times daily, but Staff C and Staff D both prepared and administered liquid Lactulose 10 gm/15 mL, 30 mL, which equaled 20 gm rather than the ordered 10 gm; Staff C stated she did not know whether the resident was supposed to receive 10 gm or 20 gm, and Staff D stated she followed the instructions to give 30 mL and was unsure if it should be 10 gm or 20 gm. For Resident #10, the record showed an order for Acetaminophen liquid 500 mg/15 mL, 1000 mg, but Staff C administered 1000 mg as crushed tablets instead of the ordered liquid form and acknowledged the facility did not have liquid Acetaminophen. The DON acknowledged the medications were not administered as ordered and stated staff should obtain clarification if an order is unclear or the medication form is unavailable.
Significant Metoprolol Medication Error
Penalty
Summary
The facility failed to ensure a resident was free from a significant medication error involving metoprolol. The resident was admitted with a diagnosis including hypertension, and hospital discharge orders dated 10/9/2025 directed discontinuation of Metoprolol XL 25 mg daily and initiation of Metoprolol Succinate 50 mg daily. However, a physician order with a start date of 10/9/2025 listed Metoprolol Tartrate 25 mg daily instead, and the Medication Administration Record from 10/9/2025 through 12/4/2025 showed the resident received Metoprolol Tartrate 25 mg daily rather than the ordered Metoprolol Succinate 50 mg daily. During interview, the DON acknowledged the resident should have received Metoprolol Succinate 50 mg daily and could not provide evidence explaining why the order was not changed, and the Medical Director also could not provide evidence that the resident received Metoprolol Succinate 50 mg as ordered.
Insufficient Food and Nutrition Staffing Competency
Penalty
Summary
The facility failed to provide sufficient support personnel with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service for residents receiving modified diets. During an initial tour of the main kitchen on 12/3/2025, the Food Service Director stated that he worked 7 days per week to provide all three meals and averaged 60 to 65 hours per week, and that he received some assistance from a Dietary Aid/Cook, Staff E. The Food Service Director also stated that Staff E had a Food Handlers Certification, not the Food Managers Certification required to work independently and safely carry out food and nutrition services. Record review showed Staff E worked independently and performed all functions of food and nutritional services on multiple dates in November 2025. The facility had two residents on modified diets. Resident ID #13 was admitted in October 2024 with diagnoses including cerebral infarction and dysphasia, and had a physician order for a puree texture diet with gravy on the side. Resident ID #15 was admitted in July 2024 with diagnoses including muscle weakness and the need for assistance, and had a physician order for a ground texture diet. During interview, the Administrator was unable to provide evidence that Staff E had the competencies and skill sets required to safely and effectively carry out the food and nutrition service independently, and was also unable to provide evidence that Staff E held a Food Manager's Certification.
Improper Wound Dressing Application
Penalty
Summary
Services provided by the nursing facility did not meet professional standards of quality during wound care for Resident ID #5, who was readmitted in June 2025 with a diagnosis including type 2 diabetes. The resident had a physician's order dated 12/2/2025 to cleanse the sacral/coccyx wound with wound wash, apply silver sulfadiazine to the open area, and then apply calcium alginate dressing. The resident's care plan, last revised on 6/17/2025, identified pressure ulcers or vascular wounds to the buttocks and included interventions to keep the skin clean and dry as possible and minimize skin exposure to moisture. During observation of the wound care treatment on 12/5/2025, Registered Nurse Staff A applied a square of calcium alginate over the wound and surrounding skin instead of directly in the base of the wound, and did not cut the dressing to fit the size of the wound. The package instructions for the calcium alginate directed that the dressing be applied to the wound and loosely fill the wound. In an immediate interview, Staff A acknowledged that she failed to cut the dressing to the size of the wound bed. The Director of Nursing Services later stated she was unable to provide evidence that Staff A cut the calcium alginate to the size of the wound bed to keep the skin dry and minimize skin exposure to moisture, per the manufacturer's instructions and care plan.
Failure to Respond to Residents’ Bleeding and Hematuria
Penalty
Summary
The facility failed to provide appropriate treatment and services for two residents who had changes in condition related to bleeding. One resident, admitted with diagnoses including obstructive and reflux uropathy and thrombocytopenia, was documented on a progress note as bleeding from the genitalia, with a note that a urology appointment should be scheduled. The record did not show that the provider was notified, that any treatment was started, or that a urology consult was scheduled. The Medical Director stated he did not remember being notified and would have expected the resident to be scheduled for a urology appointment after the bleeding was identified, while the DON could not provide evidence that the bleeding was reported or that an appointment was obtained. A second resident, readmitted with diagnoses including dementia with behavioral disturbance and a personal history of infectious and parasitic diseases, was noted by nursing staff to have hematuria and blood on the brief. A urine specimen had been obtained, but the note stated there was no confirmation the lab picked it up and no documentation in the lab’s electronic system regarding the specimen. Staff documented attempts to contact the lab and the Medical Director, and a nurse order was entered to monitor vital signs until further orders were obtained, but the record did not show returned calls, any provider orders, or further documentation about the bleeding. The physician order record did not show an order to obtain a urine specimen, and the TAR contained repeated entries for monitoring for bruising or bleeding related to aspirin use, with several dates documenting only the word monitoring and no indication whether bleeding was present.
Failure to Document and Maintain Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident with diagnoses including COPD and tracheostomy status. The resident had a physician’s order dated 10/9/2025 for oxygen 2-4 liters as needed. During surveyor observations on 12/3/2025 and 12/4/2025, the resident was seen receiving 2L of oxygen via a nasal cannula that was discolored throughout, and the tubing was not dated. Record review of the Treatment Administration Record for 10/9/2025 through 12/4/2025 and the nursing progress notes did not show the date, time, amount, or method of oxygen administration, as required by the facility’s policy. Additional review also did not reveal a physician’s order to change the oxygen tubing weekly. During interview, the DON stated she would expect the oxygen tubing to be changed weekly and acknowledged there was no order in place to change the tubing, and she could not provide evidence that staff were documenting oxygen administration as required.
Improper Storage of Medications
Penalty
Summary
Drugs and biologicals were not stored in accordance with currently accepted professional principles. Surveyor observation of a medication cart with a registered nurse present found a Lantus insulin pen that had been opened and dated 10/1, even though manufacturer instructions indicate the pen should be discarded 28 days after opening. During an immediate interview, the nurse acknowledged that the insulin should have been discarded. Surveyors also observed Resident ID #1's bedside table on two occasions and found a Furoate/Vilanterol Ellipta inhaler stored there. During a later observation with staff present, the inhaler was again on the bedside table. The nurse acknowledged that the inhaler was on the resident's bedside table and stated it should not have been stored there. The Director of Nursing Services also acknowledged that the inhaler should not have been stored on the bedside table, and acknowledged the insulin pen was stored in the medication cart and dated 10/1.
Incomplete Medication Administration Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for one resident reviewed for medication administration. The resident was admitted in October 2025 with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, tracheostomy status, abnormalities of gait and mobility, and schizophrenia. Physician orders in the record included Amantadine HCl 100 mg twice daily, Divalproex delayed release 250 mg daily, Divalproex delayed release 500 mg daily, Eliquis 5 mg twice daily, Gabapentin 600 mg three times daily, and Quetiapine 400 mg twice daily. Review of the January 2026 MAR showed that the resident was not documented as receiving the scheduled 8:00 AM doses of these medications on 1/14/2026. During a telephone interview, the CMT stated that she administered the medications to the resident but did not sign them off on the MAR. The DON stated that if medications were administered, she would expect them to be documented as such in the MAR.
Incomplete Pneumococcal Immunization Documentation and Outdated Vaccination Policy
Penalty
Summary
The facility failed to ensure that the medical records for 2 of 5 residents reviewed, Resident ID #6 and Resident ID #27, included documentation showing that the residents either received the pneumococcal vaccination or did not receive it because of a medical contraindication or refusal. Resident ID #6 was readmitted to the facility in August 2023, and the immunization record showed a PPSV23 vaccine in November 2020, but there was no evidence that the resident was offered, received, or declined PCV13, PCV15, PCV20, or PCV21. Resident ID #27 was admitted in March 2023, and the immunization record contained no evidence that the resident was offered, received, or declined PCV13, PCV15, PPSV23, PCV20, or PCV21. The facility also had an outdated Resident Vaccination (Flu and pneumonia) policy dated 3/2020. The policy stated that vaccinations were to be provided according to the most recent ACIP guidelines, but it still reflected 2019 pneumonia vaccination guidance and did not include current pneumococcal recommendations. During interview, the DNS acknowledged that the policy in use was out of date and had not been reviewed or revised annually as required.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote wound healing and prevent new ulcers for a resident with a pressure ulcer. The resident, who was admitted with a diagnosis including paranoid schizophrenia, was identified as at risk for developing pressure ulcers according to a Braden Scale assessment. However, the facility did not conduct weekly skin assessments for eight consecutive weeks, as required by their policy. This lack of monitoring led to the development of a deep tissue injury on the resident's left heel, which was not properly documented or treated in a timely manner. The Director of Nursing Services (DNS) observed the resident's left heel as mushy shortly after admission and requested a skin prep order, but there was no evidence of a wound assessment or treatment order until two months later. The wound was eventually assessed by a Wound Physician, who identified it as an unstageable deep tissue injury and recommended treatment. However, the recommended treatment was not initiated promptly, and there was a delay in implementing the physician's orders, including the use of Silvadene, which was not started until eight days after it was recommended. Interviews with staff revealed a lack of documentation and follow-through on treatment orders. The DNS and a registered nurse were unable to provide evidence of wound measurements or treatment orders prior to the Wound Physician's assessment. Additionally, there was a failure to document the location of the treatment application in the physician's orders. The resident acknowledged having a wound on the left heel but was unable to recall when or how it developed.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to a resident with a history of trauma, specifically sexual abuse and childhood trauma. The resident, admitted with multiple psychiatric diagnoses including anxiety disorder, schizoaffective disorder, bipolar type, major depressive disorder, personality disorder, and autistic disorder, was not given a comprehensive care plan that addressed trauma-informed care. The Primary Care PTSD Screen conducted on the resident was incomplete, and there was no evidence of further assessment or evaluation by a psychiatric provider to address the resident's trauma. Interviews with facility staff revealed a lack of awareness and action regarding the resident's trauma history. The Administrator and Director of Nursing Services acknowledged the resident's history of trauma but failed to ensure a trauma care plan was in place. The Social Services Designee admitted to incomplete trauma assessments and the absence of interventions to mitigate triggers for re-traumatization. Additionally, the Psychiatric Nurse Practitioner was unaware of the resident's childhood trauma and had not discussed it with the resident, despite being aware of the sexual abuse history.
Failure to Document Bowel Movements for Residents with Constipation
Penalty
Summary
The facility failed to accurately document bowel movements (BM) in the medical records of two residents, both of whom were reviewed for constipation. Resident ID #1, admitted with multiple sclerosis and constipation, showed no documented BM in the electronic medical record for two significant periods: 18 days and 6 days. Despite the resident's intact cognition and dependency on staff for toileting, the Director of Nursing Services (DNS) could not provide evidence of BM documentation during these periods. Similarly, Resident ID #5, with a history of transient cerebral ischemic attack and major depressive disorder, had no BM documented for 24 days. The resident, who is bowel incontinent and requires substantial assistance, reported experiencing discomfort and not being offered medications for constipation. Interviews with staff, including a Nursing Assistant and a Registered Nurse, confirmed the expectation to document BMs each shift, yet acknowledged the lack of documentation for this resident. The DNS also confirmed the absence of documentation and the resident's regular pattern of not having BMs for 3 to 5 days.
Failure to Develop Smoking Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents who are smokers. Resident ID #10 was admitted in April 2024 with diagnoses including schizoaffective disorder, bipolar type, anxiety disorder, and autistic disorder. Despite being identified as a smoker, there was no evidence of a smoking evaluation completed upon admission or quarterly, nor was there a comprehensive care plan addressing smoking safety interventions. During an interview, the resident confirmed being a smoker. Similarly, Resident ID #23, admitted in August 2024 with anxiety disorder, vascular dementia, and muscle weakness, was identified as a smoker through an admission smoking evaluation. However, there was no comprehensive care plan in place to address smoking safety interventions. Interviews with a registered nurse and the Director of Nursing Services confirmed the absence of care plans related to smoking for both residents, acknowledging the expectation that such plans should have been developed upon admission.
Medication Administration Errors and Non-Compliance with GDR
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the missed administration of prescribed medications for two residents. Resident ID #1, who was admitted with multiple sclerosis, bladder cancer, constipation, and generalized muscle weakness, had several doses of Baclofen missed over the course of August, September, and October 2024. Despite the documentation of these missed doses, staff members, including a registered nurse and a certified medication technician, were unable to provide explanations for the omissions. The Director of Nursing Services (DNS) also acknowledged the missed doses and could not provide evidence that the medication was administered as ordered. Additionally, the facility did not follow the pharmacy's recommendation for a gradual dose reduction (GDR) of Quetiapine for Resident ID #23, who had diagnoses including complete traumatic amputation, mild cognitive impairment, COPD, dementia, generalized muscle weakness, and anxiety. The pharmacy consultant recommended reducing the evening dose of Quetiapine, which was approved by the resident's physician. However, the facility failed to implement this GDR, and instead, the evening dose was discontinued without a gradual reduction. The DNS confirmed that the GDR was not implemented and could not explain the discontinuation of the evening dose.
Deficiencies in Wound Care and Medication Administration
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for wound care and medication administration. For Resident ID #22, who was admitted with cellulitis and non-pressure chronic venous ulcers, the facility did not adhere to the physician's order to conduct weekly assessments of the ulcers, including measurements and descriptions. The Treatment Administration Records indicated that these assessments were not consistently documented, and there was no evidence of assessments on specific dates, including the resident's readmission date. The Director of Nursing Services and a Registered Nurse confirmed the lack of documentation and adherence to the physician's orders during interviews. In a separate incident, the facility did not follow its policy for medication administration. A Certified Medication Technician was observed preparing medications for two residents simultaneously, which is against the facility's policy and professional standards. The technician admitted to holding medications for another resident while administering medications to Resident ID #16. Interviews with the resident and nursing staff confirmed that medications should be prepared and administered to one resident at a time, and the Director of Nursing Services acknowledged the expectation for compliance with this policy.
Failure to Implement Smoking Policy for Resident
Penalty
Summary
The facility failed to implement its smoking policy in accordance with federal, state, and local laws for a resident identified as a smoker. The policy requires that residents who wish to smoke be evaluated by the interdisciplinary team for their ability to smoke safely upon admission and at least quarterly. However, there was no evidence of a smoking evaluation for the resident upon admission or quarterly, despite the resident being admitted with diagnoses including schizoaffective disorder, bipolar type, anxiety disorder, and autistic disorder. Interviews with the resident, a registered nurse, and the Director of Nursing Services confirmed the absence of the required smoking assessments.
Expired Medications Found in Storage Room
Penalty
Summary
The facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles, as observed during a surveyor inspection of the medication storage room. The surveyor, accompanied by a Certified Medication Technician, identified several expired medications, including four 16-ounce bottles of lactulose, two sealed 0.5 fluid ounce bottles of carbamide peroxide 6.5%, one bottle of magnesium 250 mg, one opened bottle of loratadine 10 mg with 18 tablets remaining, and one bottle of simethicone 80 mg chewable tablets. These medications were found to be stored beyond their manufacturer's expiration date. During interviews with the staff, both the Certified Medication Technician and the Director of Nursing Services acknowledged the presence of expired medications. The Director of Nursing Services expressed that she expected the staff to discard expired medications appropriately, following the manufacturer's instructions. However, the facility's policy on the storage and expiration dating of medications and biologicals was not adhered to, leading to the retention of expired medications in the storage room.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 761 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Central Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mansion Nursing And Rehab Center | 0.8 mi | ★★★★★ | 3 | 0 |
| Grandview Center | 0.9 mi | ★★★★★ | 6 | 0 |
| Jeanne Jugan Residence | 2.1 mi | ★★★★★ | 3 | 0 |
| Adviniacare Pawtucket Pleasant Rehab Center, Llc | 2.2 mi | ★★★★★ | 14 | 0 |
| Adviniacare Summit Commons, Llc | 2.7 mi | ★★★★★ | 15 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.