Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Pawtucket Falls Healthcare Center during CMS and state inspections, most recent first.
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 facility failed to provide adequate social services following a verbal altercation between a resident and a NA. The resident, with anxiety and major depressive disorders, felt threatened during the incident. The SW was aware but did not document or follow up, and the resident's care plan was not updated, leading to a deficiency in maintaining the resident's well-being.
A resident with Parkinson's disease and contractures did not receive prescribed devices to prevent further ROM decline. Despite orders for a carrot device and palm guards, observations showed these were not applied, and staff failed to document any refusals. An LPN admitted to signing off on the application without ensuring compliance, and the DON could not explain the oversight.
A resident with end-stage renal disease and a physician's order for a 1000 mL daily fluid restriction did not receive appropriate monitoring and documentation of fluid intake. Facility staff, including an Activities Aide and a Nursing Assistant, were unaware of the fluid restriction, and the resident was observed consuming fluids without restriction. The deficiency was identified during a surveyor's review, revealing a failure to adhere to the care plan and facility policy.
A resident experienced a fall resulting in a wrist fracture, but the facility failed to accurately document the incident and injury in the MDS assessment. Despite the resident's intact cognitive function and confirmation of the new injury, the MDS was initially incomplete and later revised without including the injury. Staff interviews revealed acknowledgment of the inaccurate coding by the nursing team.
A facility failed to follow a physician's order for a resident's orthostatic blood pressure checks, which were necessary due to the resident's recurrent falls and complaints of severe vertigo. Despite orders to check the blood pressure twice daily, the November MAR showed no evidence of these checks being completed. Interviews with the DNS and a Nurse Practitioner confirmed the expectation for these checks to be performed and documented.
A facility's administration failed in infection control by allowing a COVID-19 positive staff member to work as a cook without proper certification, leading to 26 residents testing positive for COVID-19. The Administrator was aware of the staff's COVID-19 status and directed her to work due to a lack of certified dietary staff.
A facility failed to maintain infection control by allowing a COVID-19 positive staff member to work in the kitchen during their isolation period, leading to an outbreak among residents. Despite testing positive, the staff member was directed by the Administrator to work due to staffing shortages, resulting in 26 residents contracting COVID-19.
A resident experienced complications due to incorrect placement of an indwelling urinary catheter by facility staff, who lacked documented competency training. The resident, admitted with urinary retention and other conditions, was transferred to a hospital after experiencing pain and blood in the urine. Interviews revealed that the involved LPN and other staff had not received necessary training, and the facility could not provide evidence of competency assessments.
The facility failed to have a Certified Food Protection Manager (CFPM) present during meal preparation and service on several occasions. The Director of Housekeeping, who was not certified, covered kitchen shifts due to a lack of available cooks, affecting meal preparation for residents, including those requiring mechanically altered diets. This deficiency was confirmed through staff interviews and record reviews.
A resident with multiple health conditions experienced significant medication errors due to the facility's failure to implement hospital medication orders upon admission. The resident missed several doses of prescribed medications and received incorrect dosages of others. The Director of Nursing was unable to explain the discrepancies, and the resident's physician was unaware of the errors until informed by surveyors.
The facility failed to maintain an effective training program for staff, with nine employees lacking required training in areas such as resident's rights, abuse, and infection control. Personnel files showed no evidence of training since hire, and the Staff Development Coordinator could not provide documentation of required education.
A facility failed to provide a resident with a written notice of the bed-hold policy before transferring them to the hospital. The resident, with multiple health conditions, was transferred due to a leaking PCN tube. The facility informed the hospital that the resident's bed was filled, and an email sent to the resident lacked crucial information about the bed-hold policy. The Admissions Director admitted the oversight and confirmed the facility's refusal to readmit the resident, citing unaddressed behavioral concerns.
A facility failed to develop a baseline care plan within 48 hours of admission for a resident with complex medical needs, including acute pyelonephritis and type 2 diabetes. The absence of a care plan meant there were no documented initial goals, physician orders, or therapy services to guide care. This deficiency was identified after the resident was discharged to the hospital without a bed hold, and the facility had filled the bed. The Director of Nurses Services acknowledged the oversight during a surveyor interview.
The facility failed to honor a resident's DNR request, leading to CPR being performed despite the resident's Advanced Directive. The resident's medical record contained two MOLST forms, one of which was improperly signed. Staff were unable to explain the discrepancies or the failure to follow the DNR order.
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 Provide Adequate Social Services After Staff-Resident Altercation
Penalty
Summary
The facility failed to provide medically-related social services to help a resident achieve the highest possible quality of life. This deficiency was identified following an incident involving a verbal altercation between a resident and a nursing assistant (NA). The resident, who was admitted to the facility with anxiety disorder and major depressive disorder, had an intact cognitive status as indicated by a perfect score on the Brief Interview for Mental Status. During the altercation, the resident told the NA to shut up, to which the NA responded with 'make me!' The resident reported feeling physically threatened as the NA walked towards them. The social worker (SW) was aware of the incident but did not document the conversation with the resident or follow up after the altercation. The Director of Nursing Services confirmed that the altercation was substantiated and that the NA was re-educated and disciplined. However, the SW did not update the resident's care plan or document any follow-up actions, which contributed to the facility's failure to provide adequate social services to maintain the resident's well-being.
Failure to Apply Prescribed Devices for Resident with Contractures
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received appropriate treatment and services to prevent further decrease in ROM. The resident, who was readmitted to the facility with a diagnosis of Parkinson's disease, was observed multiple times without the prescribed carrot device in their left hand and bilateral palm guards, which were part of their care plan to prevent contractures. Despite a physician's order for the carrot to be applied every shift, surveyor observations on several occasions revealed that the device was not in place, and there was no documentation of the resident refusing the device. Interviews with staff, including an LPN responsible for applying the carrot, revealed a lack of awareness and adherence to the care plan. The LPN admitted to signing off on the application of the carrot without ensuring it was in place and was unaware of the requirement for bilateral palm guards. The Director of Nursing Services could not provide evidence as to why the resident's contractures were not being addressed and stated that staff should document any refusals of the devices by the resident, which was not done.
Failure to Monitor Fluid Restrictions for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received appropriate care consistent with professional standards. The resident, who was admitted with end-stage renal disease and cerebral infarction, had a physician's order for a daily fluid restriction of 1000 mL. However, the facility did not document this fluid restriction in the Medication Administration Records (MAR) for November and December 2024, as required by their policy. During a surveyor observation, the resident was seen consuming fluids without any apparent monitoring or restriction, and staff members, including an Activities Aide and a Nursing Assistant, were unaware of the resident's fluid restriction order. Interviews with the Unit Manager and the Director of Nursing Services revealed that the facility did not monitor or document the resident's daily fluid intake as per the physician's order. The Director of Nursing Services acknowledged that it was expected for staff to be aware of and monitor residents with fluid restriction orders. The deficiency was identified when the surveyor brought it to the facility's attention, indicating a lapse in adherence to the prescribed care plan and facility policy for managing the resident's fluid intake.
Inaccurate Resident Assessment Following Fall with Injury
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the resident's status for a resident who experienced a fall with injury. The resident, identified as having intact cognitive function, was readmitted to the facility with a diagnosis of an unspecified fracture of the lower end of the left radius. On September 18, 2024, the resident was found on the floor complaining of pain and swelling in the left wrist, and x-rays confirmed a possible fracture. The resident was later sent to the hospital due to increased confusion and an irregular cardiac rhythm, returning with a soft cast and instructions for non-weight bearing on the left upper extremity. The Quarterly Minimum Data Set (MDS) assessment for the resident failed to document the fall and subsequent injury as required. During interviews, both a registered nurse and the Director of Nursing Services acknowledged that the MDS assessment was inaccurately coded, omitting the fall and the injury sustained. Although the MDS was later revised to include the fall, it still did not document the injury. The resident confirmed that the wrist fracture was a new injury resulting from the fall, contradicting the initial assessment documentation.
Failure to Follow Physician's Order for Orthostatic Blood Pressure
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following a physician's order for obtaining orthostatic blood pressure measurements. The resident, who was admitted with diagnoses including dementia and repeated falls, had a physician's order to have orthostatic blood pressure checked twice daily due to recurrent falls and complaints of severe vertigo. However, a review of the November 2024 Medication Administration Record (MAR) revealed no evidence that these vital signs were completed as ordered. Interviews with the Director of Nursing Services (DNS) and a Nurse Practitioner confirmed the expectation that the resident's orthostatic blood pressure should have been obtained and documented. The DNS indicated that the orthostatic blood pressures were ordered due to the resident's recurrent falls, while the Nurse Practitioner noted that the order was given because the resident had complained of severe vertigo, which had resulted in multiple falls. Despite these orders and expectations, the facility did not document the completion of the orthostatic blood pressure checks, leading to a deficiency in the care provided to the resident.
Infection Control Breach Due to COVID-19 Positive Staff Working
Penalty
Summary
The facility was found to be deficient in its administration, particularly in infection control, leading to immediate jeopardy for F 880. The Administrator directed a staff member, who was COVID-19 positive, to work as a cook in the main kitchen despite not having a Food Safety Manager Certification. This decision was made due to a lack of available certified dietary staff. The staff member, identified as the Director of Housekeeping, tested positive for COVID-19 on 7/31/2024 and was instructed to work on 8/3/2024 and 8/4/2024. During this period, the staff member worked while COVID-19 positive, which was acknowledged by the Administrator during a surveyor interview. The report indicates that prior to the COVID-19 positive staff member working, there were no residents with COVID-19. However, following the staff member's shifts, 26 residents tested positive for COVID-19 over the subsequent days. The Administrator was aware of the staff member's COVID-19 status and still directed her to cover the shifts, as evidenced by text message exchanges. This action directly contributed to the spread of COVID-19 within the facility, compromising the health and safety of the residents.
Infection Control Breach Leads to COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain an effective infection control program, allowing a staff member who tested positive for COVID-19 to work in the kitchen during their isolation period. The staff member, who was the Housekeeping Director, tested positive on 7/31/2024 and was instructed by the Infection Preventionist to isolate and return to work only after a negative test. Despite this, the Administrator directed the staff member to work as a cook on 8/3/2024 and 8/4/2024 due to a lack of kitchen staff, during which time the staff member did not wear a mask. This breach in protocol led to a COVID-19 outbreak within the facility, with 26 residents testing positive shortly after the staff member worked while infected. Prior to this incident, there were no COVID-19 positive residents in the facility. The Administrator was aware of the staff member's positive status and their presence in the kitchen, contradicting the facility's infection control policies and CDC guidelines.
Deficiency in Nursing Competency for Catheter Insertion
Penalty
Summary
The facility failed to ensure that licensed nurses possessed the necessary competencies and skills to care for residents with indwelling urinary catheters. A community-reported complaint alleged that a resident's urinary catheter was incorrectly placed at the facility. The resident, who was admitted with conditions including urinary retention, chronic kidney disease, and encephalopathy, experienced pain and swelling after the initial catheter was removed. A new catheter was placed following a provider's order, but the resident subsequently experienced pain and blood in the urine, leading to a hospital transfer. Hospital documentation confirmed that the catheter had been incorrectly placed in the urethra instead of the bladder. Interviews and record reviews revealed that the staff involved, including a newly hired LPN and other nursing staff, had not received training or competency assessments for catheter insertion. The facility's assessment indicated that urinary catheter care was a required competency, yet personnel files for the involved staff lacked evidence of such training. The Staff Development Coordinator was unable to provide documentation of completed training or competency evaluations for the staff members involved in the incident.
Lack of Certified Food Protection Manager During Meal Preparation
Penalty
Summary
The facility failed to comply with professional standards for food service safety by not having a Certified Food Protection Manager (CFPM) available during the preparation and serving of meals on multiple occasions. Specifically, the facility did not have a CFPM present during evening meals on 7/1, 7/7, 7/15, 7/20, and 8/3/2024, as well as during all meals on 8/4/2024. This deficiency was identified through record reviews and staff interviews, which revealed that the Director of Housekeeping, who was not a certified food protection manager, was acting as the Food Service Director and was responsible for cooking and overseeing the kitchen operations during these times. The absence of a CFPM was further corroborated by a community-reported complaint and interviews with staff members, including the Dietary Aide and the Director of Human Resources. The Director of Housekeeping, Staff A, admitted to covering the kitchen shifts due to a lack of available cooks, despite not having the necessary certification. This situation affected the preparation of meals for residents, including those requiring mechanically altered diets, as 31 out of 89 residents needed such diets. The Regional Director of Operations acknowledged the lack of a CFPM during the specified times, confirming the facility's failure to meet the required food safety standards.
Significant Medication Errors in Resident Care
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. The resident, who was admitted in July 2024, had multiple diagnoses including acute respiratory failure with hypoxia, atrial fibrillation, alcohol dependence, urinary retention, and hypertension. Upon admission, the resident's medication orders from the hospital were not properly implemented. The resident did not receive Aspirin, Vitamin B-12, Folic acid, or Lasix for 24 days, and Flomax was not initiated until after a urology evaluation, resulting in nine missed doses. Additionally, there were errors in the administration of Metoprolol tartrate, where the resident received an extra 50 mg on the first day and an extra 100 mg for 22 days. The resident also continued to receive Heparin injections for 23 days despite orders to discontinue. The Director of Nursing Services was unable to explain why the medication orders were not followed, and the resident's physician was unaware of the discrepancies until informed by the surveyor.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for both newly hired and existing staff members. This deficiency was identified through record reviews and staff interviews, revealing that nine staff members, including a Director of Housekeeping, Registered Nurse, Licensed Practical Nurses, Housekeeper, Cook, and Nursing Assistants, did not receive required training. The training topics that were not covered included resident's rights, abuse, dementia and behavioral health management, trauma-informed care, infection control, and QAPI, as outlined in the facility's assessment dated November 15, 2023. The personnel files of these staff members lacked evidence of training since their respective hire dates, some dating back several years. During an interview, the Staff Development Coordinator was unable to provide documentation that these staff members had received the necessary education and training annually or upon hire, as required by the facility's assessment. This lack of training affects the staff's ability to perform their roles effectively, particularly in areas critical to resident care and safety.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide a written notice of the bed-hold policy to a resident or their representative prior to the resident's transfer to the hospital. This deficiency was identified during a review of a community-reported complaint. The resident, who had been admitted to the facility with multiple diagnoses including acute pyelonephritis, morbid obesity, type 2 diabetes mellitus, major depressive disorder, and post-traumatic stress disorder, was transferred to the hospital non-emergently due to a leaking PCN tube. Despite the transfer, the facility did not provide the resident with a bed-hold form before leaving the facility. Upon the resident's transfer to the hospital, the facility informed the hospital case manager that the resident had not placed a bed hold and that the bed had already been filled. An email sent to the resident by the Admissions Director included a document titled 'Bed Hold Policy,' but it failed to provide essential information such as the duration of the bed-hold, the daily room rate, and the policy for the resident's return to the facility. The Admissions Director acknowledged during an interview that the facility did not provide the required written information prior to the resident's transfer and confirmed that the facility had bed availability when contacted by the hospital. However, the facility declined to accept the resident back, citing concerns with behaviors that were not previously addressed or disclosed to the resident.
Failure to Implement Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident, identified as Resident ID #2, which is a requirement to ensure effective and person-centered care. The resident was admitted with multiple diagnoses, including acute pyelonephritis, morbid obesity, type 2 diabetes mellitus, major depressive disorder, and post-traumatic stress disorder. Despite these complex medical needs, there was no evidence of a baseline care plan from the time of admission on 4/22/2024 until 4/29/2024. This lack of a care plan meant that there were no documented initial goals, physician orders, dietary orders, therapy services, social services, or PASARR recommendations, if applicable, to guide the resident's care. The deficiency was identified following a community-reported complaint to the Rhode Island Department of Health, which revealed that the resident was discharged to the hospital on 5/2/2024 without a bed hold, and the facility had already filled the resident's bed. During a surveyor interview, the Director of Nurses Services, in the presence of the Administrator, acknowledged the absence of a baseline care plan for the resident prior to discharge. This oversight indicates a failure to provide necessary instructions for effective and person-centered care, which is essential for meeting the resident's immediate health and safety needs.
Failure to Honor Resident's DNR Request
Penalty
Summary
The facility failed to honor a resident's Advanced Directive requesting to refuse lifesaving treatment. The resident, who had diagnoses including gangrene and chronic obstructive pulmonary disease, was admitted in February 2024. On the date of the incident, the nursing progress notes indicated that the resident was evaluated by staff, a Code Blue was initiated, and CPR was started. Emergency Medical Services (EMS) were called and continued CPR, eventually transporting the resident to the hospital. However, the resident's face sheet and Medical Orders for Life Sustaining Treatment (MOLST) indicated that the resident wished to be a Do Not Resuscitate (DNR). One MOLST form was signed by the resident's representative but lacked a qualified medical professional's signature, while a second MOLST was properly signed by both a Nurse Practitioner and the resident's representative. During interviews, the Medical Records Supervisor and the Director of Nursing Service were unable to explain why there were two different MOLST forms in the resident's record or why CPR was initiated despite the DNR order. The discrepancy in the documentation and the failure to follow the resident's DNR wishes led to the deficiency identified by the surveyors.
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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.
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Nursing homes near Pawtucket
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Adviniacare Pawtucket Pleasant Rehab Center, Llc | 1.6 mi | ★★★★★ | 14 | 0 |
| Adviniacare Summit Commons, Llc | 2.2 mi | ★★★★★ | 15 | 2 |
| Mansion Nursing And Rehab Center | 2.4 mi | ★★★★★ | 3 | 0 |
| Jeanne Jugan Residence | 2.4 mi | ★★★★★ | 3 | 0 |
| Bethany Home Of Rhode Island | 2.8 mi | ★★★★★ | 7 | 0 |
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