Adviniacare Orchard, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in East Providence, Rhode Island.
- Location
- 135 Tripps Lane, East Providence, Rhode Island 02915
- CMS Provider Number
- 415059
- Inspections on file
- 49
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 12 (3 serious)
Citation history
Health deficiencies cited at Adviniacare Orchard, Llc during CMS and state inspections, most recent first.
The facility failed to maintain a safe, functional, sanitary, and comfortable environment when roof leaks allowed brown water to penetrate ceiling tiles and overhead light fixtures on a second-floor care area. Towels, buckets, and laundry carts were placed in hallways and outside rooms to collect actively leaking water, leaving floors wet and slippery while many cognitively impaired residents sat or ambulated nearby. The Maintenance Assistant acknowledged the leak had started the prior day and that he had not yet removed snow from the roof as instructed, while the Administrator and Director of Operations confirmed awareness of the worsening leaks but could not show evidence of effective immediate interventions. Authorities later found water inside the second-floor fire panel, which appeared tampered with, and ordered evacuation of residents after determining the environment was unsafe.
Surveyors found that biohazardous waste and sharps were stored in unlocked, unsecured rooms throughout multiple units, including a secured memory care unit, and in a room off the back entrance with the door partially open. Boxes labeled as infectious or biohazard waste were overflowing with sharps containers and red biohazard bags, with some sharps containers open and needles and IV lines with visible blood exposed, while residents were observed moving near these areas. Staff, including the Administrator, DNS, and Assistant Maintenance Director, acknowledged that the rooms were unlocked, that biohazardous waste remained on the units, and that the contracted waste removal company had stopped pickups due to non-payment, with no evidence of proper biohazard disposal for an extended period.
Surveyors found that biohazardous waste and sharps were stored in unlocked, unsecured rooms throughout the facility, including a memory care unit, despite a policy requiring sharps to be kept in locked, designated containers and areas. A room off the back entrance contained overflowing boxes and bags of infectious and biohazard medical waste with the door left partially open, and facility leadership acknowledged the room was unlocked and filled with biohazardous waste. On multiple units, surveyors observed overflowing sharps containers, an open sharps container with exposed needles, sharps containers placed on the floor, and IV lines with visible blood hanging from sharps containers, while residents were ambulating nearby. Facility representatives and the contracted waste vendor reported that biohazard waste removal services had been on hold for months due to non-payment, and records showed no licensed biohazard waste removal since that time.
The facility failed to properly manage and dispose of garbage, allowing trash bags, including those containing PPE gowns, to accumulate along the back entrance shared with the main kitchen and block exit doors and an exit ramp. A complaint and accompanying photographs showed that the garbage covered the platform and extended to the ground, obstructing fire exits. Interviews with the contracted garbage removal company and facility staff revealed that weekly garbage pickups had been suspended for several weeks due to non-payment, during which time the trash accumulated and blocked exit routes, creating a hazardous condition for residents.
The governing body failed to ensure effective oversight of waste management policies, resulting in unsecured biohazardous waste and accumulated garbage throughout the facility. A complaint and surveyor observations confirmed large amounts of trash, including bags with PPE gowns, blocking back exit doors and ramps, and multiple unlocked rooms containing overflowing boxes of sharps containers, open sharps containers with exposed needles, and IV lines with visible blood. The Administrator, DNS, and maintenance staff acknowledged that biohazard and garbage removal services had been suspended for months due to non-payment, and vendor representatives confirmed that pickups had been on hold, while emails showed the governing body had been informed that these accounts were on credit hold.
A resident with a history of falls was not assessed or monitored after falling from a wheelchair, and the incident was not documented in the medical record. Staff failed to perform required post-fall evaluations, neurological checks, or notify a provider, despite the resident later developing severe pain and being diagnosed with a spinal fracture. The facility's policies for fall management and significant change were not followed.
Two residents with chronic kidney disease on dialysis did not consistently receive their prescribed Sevelamer Carbonate as ordered, and their fluid restrictions were not maintained according to physician orders. Medication records showed multiple missed doses and instances where fluid intake exceeded prescribed limits. Interviews confirmed the medication was not always given as scheduled, and facility leadership could not provide evidence of compliance.
A resident with dementia and mobility issues experienced an unwitnessed fall and showed signs of a possible hip fracture. Although a STAT right hip X-ray was ordered, the facility did not obtain the X-ray within the expected timeframe, and staff did not notify the provider of the delay. The resident's condition worsened, leading to hospitalization where a hip fracture was confirmed. Staff interviews confirmed expectations for timely STAT X-rays and provider notification in case of delays, and the DON acknowledged ongoing issues with radiology service timeliness.
A resident did not have daily weights recorded as ordered by the physician, and there was no documentation that the physician was notified of the missed weights. The DNS was unable to provide evidence that the required daily weights were obtained.
A resident with heart failure and fluid restrictions was not provided the physician-ordered low sodium diet and received excess fluids from dietary staff, as meal tickets and tray contents did not align with prescribed orders. The dietitian confirmed the errors in both diet and fluid provision.
A resident with heart failure and respiratory diagnoses had a physician-ordered fluid restriction, but the facility failed to document actual fluid intake and output per shift, and water containers were found at the bedside against policy. Additionally, the resident's behavioral concerns noted in the care plan were not addressed in the social worker's assessment or documented in the medical record, and staff were unaware of these concerns.
A cracked glass panel on the main vestibule's inner door, covered with medical tape, was observed by surveyors. The DON confirmed the damage had been present for several weeks and could not provide evidence of a repair plan, resulting in a deficiency for not maintaining a safe and functional environment.
Surveyors found that multiple residents across all units did not have functioning call lights and were instead given hand bells to request assistance. Staff, including the DON and maintenance director, confirmed the ongoing issue, citing discontinued parts and a lack of timely replacement. Documentation showed that over 20 occupied rooms lacked call lights, and staff were often unsure how long the deficiency had persisted.
A resident with a history of falls and dementia fell and complained of back pain. A physician ordered immediate x-rays of the lumbar and thoracic spine, but only a single view of the lumbar spine was obtained. The RN on duty reported the x-ray as negative without noting the missing views. The resident continued to experience severe pain and was sent to the hospital, where new compression fractures were diagnosed. The facility could not provide evidence that the ordered x-rays were completed.
A resident admitted with a UTI and dementia did not receive the prescribed antibiotic, cephalexin, as ordered. Despite confirmation of the order with an on-call provider, the medication was neither transcribed nor administered. Interviews with staff, including an LPN and the DON, confirmed the oversight and highlighted the expectation that physician's orders should be followed.
A resident with a history of dementia and depression attempted suicide in an LTC facility. Despite the facility's policy requiring one-to-one supervision, the resident was only placed on frequent checks, and necessary notifications were not made. The resident's room contained potential hazards, and they were observed leaving the facility unattended twice on the same day. Surveillance footage and staff interviews confirmed these deficiencies.
A resident with a history of depression and PTSD attempted suicide in an LTC facility. Despite the facility's policy requiring one-to-one supervision, the resident was not adequately monitored and was left unsupervised with ligature risks in their room. The resident was able to leave the facility twice without supervision on the same day, and the DON was not informed until hours later.
A resident with multiple pressure injuries did not receive necessary wound care treatments as recommended by a wound physician. The facility failed to implement treatment orders for the resident's left lateral lower leg, right great toe, and left buttocks wounds for several days, despite recommendations. Interviews with staff revealed a lack of explanation for the oversight, and the DON acknowledged the absence of treatment orders until the issue was highlighted by a surveyor.
A survey identified deficiencies in food safety practices at a facility, including unclean kitchen equipment, unlabeled and undated food items, and staff not wearing required beard restraints. In the nourishment areas, various food items were not labeled or dated, and some were past their use-by date. Staff interviews confirmed these practices did not meet professional standards.
The facility failed to implement proper infection control measures, including Enhanced Barrier Precautions (EBP), for residents with multidrug-resistant organisms (MDROs). Staff were observed not using appropriate PPE, and necessary signage and precaution bins were missing. Additionally, improper handling of soiled linens was noted, contributing to the deficiency.
The facility failed to follow physician's orders for obtaining weekly weights for two residents, one with dysphagia and severe protein calorie malnutrition, and another with weakness and diabetes mellitus. Weights were not obtained on several occasions, and the Director of Nursing Services could not provide explanations or evidence for the missing weights.
A resident with a history of DVT experienced new symptoms of pain and swelling in the left leg. Despite a STAT order for a venous doppler, the procedure was not completed, and the provider was not notified of the delay. Staff interviews revealed communication lapses, and the resident was eventually sent to the emergency department, where a hematoma or small abscess was found.
A resident with pressure ulcers did not receive wound care as ordered, leading to a deficiency. The LPN applied barrier cream instead of medihoney and failed to change dressings daily, as required by the physician's orders. The DON confirmed that orders should be followed.
A facility failed to communicate a resident's critically low potassium levels to the dialysis center, resulting in continued hypokalemia. The resident, with chronic kidney disease, was receiving hemodialysis. Despite a physician's order for STAT labs and potassium, the LPN did not include this information in the communication sheet due to unawareness of lab results. The DON could not provide evidence of communication to the dialysis center before surveyor intervention.
The facility did not complete annual performance reviews for several nurse aides as required. A review of personnel records showed that 4 out of 7 nurse aides did not have documented evaluations within the past 12 months. The DON could not provide evidence of these evaluations during an interview.
The facility failed to timely address pharmacy recommendations for two residents, resulting in deficiencies in medication management. One resident's Pravastatin dosage reduction was delayed over two months, and a Risperdal discontinuation trial was not implemented. Another resident's Valproic Acid serum level test was delayed, revealing a subtherapeutic level. The DON acknowledged these delays, which violated the facility's 14-day policy.
A resident with intact cognition was physically abused by their roommate, who had a history of behavioral issues and moderately impaired cognition. The incident involved biting and slapping, resulting in injury and required medical treatment. Staff intervened but the facility failed to provide evidence of sufficient protective measures to prevent the abuse.
The facility did not post the most recent survey results in an accessible area for residents, staff, and the public. Residents were aware of the State Inspection results but had concerns about accessing them. A sign indicated the survey book was available upon request, but the binder was outdated, missing the latest survey from April 2024. The Regional Director confirmed the oversight and acknowledged the need for updating and relocating the binder.
A resident with a history of mental health disorders and cognitive impairments successfully eloped from a facility multiple times due to inadequate supervision and failure to assess elopement risks. The facility did not follow its own policies on elopement and AMA discharge, resulting in a lack of proper documentation and interventions. The resident's care plan was not updated to reflect these incidents, and the physician was not informed in a timely manner.
Roof Leaks, Water Intrusion, and Compromised Fire Panel Create Unsafe Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment when active water leaks from the roof penetrated ceiling tiles and electrical fixtures on the second floor. Surveyors observed multiple areas on two second-floor units with towels on the floor that were saturated with brown-colored water, as well as waste and laundry baskets and buckets placed in hallways and outside resident rooms to collect water from active leaks. Water was seen leaking from ceiling tiles and overhead light fixtures, with visible water staining on numerous ceiling tiles and wall surfaces. Floor surfaces were wet and slippery, particularly around the water collection buckets. Many residents, including those with mild to severe cognitive impairments, were observed sitting or ambulating near the active leaks and containers collecting water. During interviews, the Maintenance Assistant acknowledged the roof leak, stated it had started the day prior, and reported he had been instructed to remove snow from the roof to prevent continued leaking but had not yet done so. The Administrator acknowledged that the leaks had become progressively worse throughout the morning and that the facility was in the process of obtaining a quote to repair the roof. The Director of Operations confirmed awareness that the leaking water was coming from the roof and that a contractor had been called to assess and fix the damage, but he could not provide evidence of any immediate interventions implemented to ensure a safe, functional, sanitary, and comfortable environment. Subsequent evaluations by external authorities identified water inside the second-floor fire panel, which appeared to have been tampered with, and led to the establishment of a fire watch and orders to evacuate first the second floor and then the entire facility due to the water damage, active leaks, and compromised conditions.
Unsecured Biohazardous Waste and Sharps Stored on Resident Units and at Facility Entrance
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible related to the storage and management of biohazardous waste and sharps. A community complaint reported that trash and biohazardous waste were blocking the back entrance and that such waste was stored in unlocked, unsecured rooms. Surveyors observed a room off the back entrance with the door half open containing multiple boxes labeled “Infectious Waste” and “Biohazard Medical Waste,” overflowing with sharps containers and red biohazard bags filled with sharps containers, with additional red bags on the floor extending to the doorway and visible from outside the room. These observations were repeated later the same morning, again with the door half open and the same unsecured biohazardous waste present. Further observations on resident units showed that biohazardous waste and sharps were stored in unlocked and unsecured rooms where residents resided, including a secured memory care unit. On one unit, a box was overflowing with sharps containers, with five additional sharps containers on top, including one open container with exposed needles and other sharp objects. On another unit, boxes were overflowing with sharps containers with nine additional containers on top. On a third unit, fourteen sharps containers were observed on the floor, along with multiple IV lines visibly containing blood hanging from the sharps containers. On the memory care unit, a box was overflowing with sharps containers with five additional containers on top. During these observations, multiple residents were seen ambulating and self-propelling near these unsecured rooms. Interviews confirmed that the rooms were unlocked and contained biohazardous waste and sharps, and that the waste had not been removed from the units. The Assistant Maintenance Director acknowledged that the back entrance room was filled with biohazardous waste and unlocked, and stated that the contracted biohazard waste removal company had not picked up waste due to non-payment. A representative from the waste removal company reported that services had been on hold since non-payment and that the last pickup occurred months earlier, which was consistent with facility records showing no biohazardous waste removal since that time. The Administrator stated she was aware of the biohazardous waste disposal issues upon being hired and acknowledged that waste was not disposed of appropriately due to non-payment, and was unable to provide evidence that the residents’ environment remained as free of accident hazards as possible related to the storage of biohazardous materials.
Unsecured and Improperly Stored Biohazardous Waste and Sharps
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program related to the storage, security, and disposal of biohazardous waste and sharps. A community complaint reported that trash and biohazardous waste were blocking the back side of the building and that such waste was stored in unlocked, unsecured rooms. Surveyors observed, off the back entrance, a room with the door half open containing multiple boxes labeled "Infectious Waste" and "Biohazard Medical Waste" overflowing with sharps containers and red biohazard bags, with additional red bags and sharps containers on the floor extending to the doorway and visible from outside the room. The facility’s policy on storage of sharps required all sharps to be stored and secured in designated locked containers and areas at all times when not in use, and not to be handled by residents with functional or cognitive limitations. During subsequent observations, in the presence of the Administrator and the Assistant Maintenance Director, the same back entrance room was again found half open and filled with biohazardous waste, and both individuals acknowledged that the room was unlocked and contained biohazardous waste. The Assistant Maintenance Director stated that the contracted biohazard waste removal company had not picked up the waste due to non-payment by the facility. A representative from the contracted biohazard waste removal company confirmed that services had been placed on hold months earlier due to non-payment and that the last biohazardous waste removal had occurred in late May of the previous year. Review of facility records did not show evidence of any licensed biohazardous waste removal company being on site for waste removal and disposal since that time. Surveyors also observed unsecured biohazardous waste and sharps containers on multiple resident units, including a secured memory care unit. On one unit, a box was overflowing with sharps containers, with additional sharps containers on top, including one open container with exposed needles and other sharp objects. On another unit, boxes were overflowing with sharps containers, with multiple additional containers stacked on top. On the Cortland Unit, fourteen sharps containers were observed on the floor, along with multiple IV lines visibly containing blood and hanging from the sharps containers. On the memory care unit, a box was overflowing with sharps containers with additional containers on top. The DNS acknowledged that these unit rooms were unlocked and contained sharps containers with biohazardous waste and could not provide evidence that sharps containers were stored in secured areas not accessible to residents. During these observations, multiple residents were seen ambulating and self-propelling near the unsecured rooms, including on the secured memory care unit housing residents with cognitive impairment.
Failure to Manage Garbage Resulting in Blocked Exit Routes
Penalty
Summary
The facility failed to ensure proper disposal and management of garbage, resulting in a significant accumulation of trash at the back of the building that obstructed exit routes. A community-reported complaint to the Rhode Island Department of Health alleged that large amounts of trash were blocking the entire back side of the facility, including exit doors used as fire exits. Photographs from the complainant showed multiple black and white trash bags, including bags containing yellow personal protective gowns, piled along the back entrance shared with the main kitchen. The garbage covered the entire platform surface, extended to the ground below, and blocked the exit ramp, with multiple large garbage bins filled to capacity. Interviews and record review revealed that the contracted garbage removal company had placed services on hold after non-payment by the facility, with the last pickup occurring in late November and not resuming until early January. The representative from the garbage removal company confirmed that weekly Thursday pickups had been suspended due to non-payment. The Assistant Director of Maintenance acknowledged that garbage had not been picked up during this period and confirmed that the photographs accurately depicted the accumulation of garbage and blocked exit routes. The Administrator also acknowledged the photographs showing the large accumulation of garbage at the back entrance. When the surveyor later observed the back entrance, no garbage accumulation was present and exit routes were unobstructed, leading to a determination of past noncompliance.
Governing Body Failure to Ensure Safe Biohazard and Garbage Management
Penalty
Summary
The governing body failed to ensure effective implementation and oversight of policies for waste management and overall facility operations, resulting in serious deficiencies in the disposal and management of biohazardous waste and general garbage. The facility assessment stated that the physical environment and resources, including waste and hazardous waste management, were to be reviewed to ensure resident safety and well-being. However, a community complaint reported that large amounts of biohazardous waste were stored in unsecured rooms and that garbage was blocking the entire back side of the facility, including exit doors, making fire exits unavailable for residents in an emergency. Surveyor observations confirmed extensive accumulations of garbage and unsecured biohazardous waste. Photographs from the complainant showed large amounts of trash bags, including bags containing yellow personal protective gowns, blocking exit doors at the back entrance shared with the main kitchen, covering the entire platform, extending to the ground, and obstructing the exit ramp. On-site, surveyors observed a room off the back entrance with the door half open, containing multiple boxes labeled "Infectious Waste" and "Biohazard Medical Waste" overflowing with sharps containers and red biohazard bags, with additional red bags and sharps containers on the floor extending to the doorway and visible from outside the room. The Administrator and Assistant Maintenance Director acknowledged that the room was unlocked, filled with biohazardous waste, and that the contracted biohazard waste removal company had not removed the waste due to non-payment by the facility. Further observations on multiple units, in the presence of the DNS, revealed additional unsecured storage of biohazardous waste and sharps containers. On one unit, a box was overflowing with sharps containers, with several more on top, including one open container with exposed needles and other sharps. On other units, boxes were overflowing with sharps containers, and on one unit fourteen sharps containers were on the floor, with IV lines visibly containing blood hanging from the containers. The DNS acknowledged that these rooms were unlocked and contained biohazardous waste that had not been removed due to non-payment to the waste removal company by the facility owner. Representatives from the contracted biohazard and garbage removal companies confirmed that services had been placed on hold months earlier due to non-payment, and records showed no biohazardous waste removal since May of the prior year and no garbage removal for several weeks. Email communications showed the Administrator had informed the Regional Director of Operations that both accounts were on credit hold, and the Administrator acknowledged that the corporate governing body, which authorizes payments, was aware that these services were suspended due to non-payment.
Failure to Assess and Document Post-Fall Care
Penalty
Summary
A resident with a history of unsteadiness and falls was involved in an incident where they fell from their wheelchair to the floor. The fall occurred on a Friday, and both the resident and a nursing assistant confirmed the event. Despite this, there was no documentation of the fall in the resident's medical record, nor was there evidence of an assessment, initial or ongoing vital signs, neurological checks, or monitoring for latent injury as required by facility policy. The assigned nurse did not question the resident about the incident, did not perform an assessment, and did not notify the provider. The resident began experiencing significant pain the day after the fall, which escalated to severe back pain by Sunday. The resident was eventually sent to the hospital, where a compression fracture of the L2 vertebrae was diagnosed. Documentation showed that the resident received pain medication for increasing pain, but there was no record of post-fall evaluation or provider notification until the resident's pain became excruciating and they were unable to get out of bed. Interviews with staff and the Director of Nursing confirmed that the incident met the facility's definition of a fall and that required post-fall procedures were not followed. The facility was unable to provide evidence of any evaluation or provider notification following the fall, in direct violation of their fall management and significant change policies.
Failure to Administer Dialysis Medications and Enforce Fluid Restrictions
Penalty
Summary
The facility failed to ensure that residents requiring dialysis received services consistent with professional standards of practice, specifically regarding the administration of Sevelamer Carbonate and adherence to fluid restrictions. For two residents with chronic kidney disease on dialysis, physician orders specified Sevelamer Carbonate to be administered three times daily with meals and set strict daily fluid restrictions. Medication Administration Records (MAR) revealed multiple missed doses of Sevelamer for both residents, often documented as the resident being absent or with no evidence of administration at the scheduled times. Additionally, records showed that both residents exceeded their prescribed fluid intake on several occasions, surpassing the limits set by their physicians. Resident interviews confirmed that the medication was not consistently administered as ordered, with one resident stating that Sevelamer was usually not given before meals as prescribed. The Director of Nursing Services was unable to provide evidence that the medication was administered as ordered or that fluid restrictions were consistently followed. These findings were based on record reviews, resident and staff interviews, and direct observation of facility documentation.
Failure to Obtain Timely STAT X-ray Following Resident Fall
Penalty
Summary
The facility failed to provide or obtain timely radiology services for a resident who sustained an unwitnessed fall and exhibited symptoms suggestive of a hip fracture, including right groin pain and a leg length discrepancy. A STAT right hip X-ray was ordered by the provider, and the resident was placed on bed rest pending results. Despite the STAT order, the X-ray was not performed within the expected timeframe, and the contracted radiology company did not provide a technician promptly. Nursing staff communicated with the resident about the pending X-ray and contacted the radiology company, but the X-ray was still not completed. Over the following day, the resident developed additional symptoms, including malaise, fever, and hypoxia, and experienced significant pain during care. The provider was updated about the resident's deteriorating condition, and the resident was eventually sent to the hospital, where a hip fracture was confirmed. Interviews with staff revealed that a STAT X-ray should be performed within four hours and that the provider should be notified if there are delays. The DON acknowledged that staff did not notify the provider of the delay in obtaining the X-ray, resulting in prolonged pain and hospitalization, and also stated that timeliness of X-ray services had been an ongoing issue with the contracted company.
Failure to Follow Physician's Order for Daily Weights
Penalty
Summary
The facility failed to meet professional standards of quality by not following a physician's order to obtain daily weights for a resident. The physician's order, which began on 3/27/2025, required daily weights to be recorded. However, there was no documentation of weights being taken from 3/28/2025 through 4/1/2025. Additionally, there was no evidence that the physician was notified about the missed weights. During an interview, the Director of Nursing Services was unable to provide documentation that the daily weights had been obtained during this period.
Failure to Provide Physician-Ordered Therapeutic Diet and Fluid Restriction
Penalty
Summary
A resident admitted with acute and chronic respiratory failure and diastolic heart failure had a physician order for a Low Sodium Diet (2-4 grams of sodium) and a 2000 ml daily fluid restriction, with dietary staff to provide only 830 ml of that total. On review, the resident was served a lunch meal containing a double portion of ham, despite the tray ticket specifying 'No Ham' and a low sodium diet. The dietitian confirmed that the prescribed diet was not served and that the resident should have received baked chicken instead. Additionally, the resident's meal tickets for the day indicated that the dietary department provided a total of 1320 ml of fluids, exceeding the 830 ml limit set by the physician's order. The beverages listed and served at each meal surpassed the allowed dietary fluid allotment. The dietitian acknowledged that the dietary staff provided beverages as listed on the meal tickets, resulting in the resident receiving more fluids than prescribed.
Failure to Maintain Accurate Medical Records and Fluid Restriction Protocol
Penalty
Summary
The facility failed to maintain medical records in accordance with professional standards for a resident with a physician-ordered fluid restriction. Despite a clear order specifying the daily fluid limit and its distribution across nursing shifts and meals, surveyor observation found multiple water containers at the resident's bedside, contrary to facility policy prohibiting water pitchers at the bedside for residents on fluid restriction. Review of the Medication Administration Records (MAR) for the relevant months did not show documentation of the actual fluid amounts consumed per shift, only check marks, and the Director of Nursing Services (DNS) confirmed that intake and output were not accurately recorded as required by policy. The DNS was also unable to explain the presence of water containers at the bedside. Additionally, the facility did not ensure that the resident's medical record accurately reflected behavioral concerns identified in the care plan. While the care plan noted verbal expressions of anger and accusatory behaviors, the social worker's assessment did not address these issues, and there was no evidence in the record that these concerns were followed up on. Interviews with staff revealed a lack of awareness of the resident's behavioral concerns, and the DNS could not provide documentation that the medical record was complete or accurate regarding these issues.
Failure to Maintain Safe and Functional Entrance Door
Penalty
Summary
Surveyor observation revealed that the lower glass panel of the main vestibule's inner door was damaged, with approximately eight one foot by one-foot cracked glass segments. The cracked areas were covered with white medical tape. During an interview, the DON acknowledged the damage and stated that it had occurred three to four weeks prior to the survey. No evidence of a plan to repair the door was provided at the time of the survey. These findings indicate that the facility failed to maintain a safe, functional, and comfortable environment for residents, staff, and the public, as required.
Failure to Provide Functioning Call Light System for Residents
Penalty
Summary
The facility failed to ensure that a functioning call system was available in each resident's bathroom and bathing area, as required. Surveyor observations, record reviews, and staff interviews revealed that approximately 30 residents did not have functioning call lights and were instead provided with hand bells to communicate their needs to staff. This issue was confirmed by the Director of Nursing Services, who provided documentation indicating that 25 rooms were labeled as having no call light (NCL), with 21 of those rooms currently occupied. Multiple staff members across all four units acknowledged the absence of call lights in specific resident rooms and were either unaware of how long the issue had persisted or stated it had been ongoing for at least a month. Further investigation showed that the problem had been ongoing for months, with the Director of Maintenance confirming that the call light system required replacement due to discontinued parts and that call lights continued to fail one by one. Although a quote to replace the call light system on one unit had been approved, there was no evidence of a contract or project start date. The Administrator also acknowledged the ongoing nature of the issue and the fact that multiple residents were without call lights at the time of the survey.
Failure to Follow Physician's Orders for X-rays After Resident Fall
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 orders for x-rays after a fall. The resident, who had a history of dementia, unsteadiness, and falls, fell and complained of lower back pain. A physician ordered immediate x-rays of the lumbar and thoracic spine, but only a single frontal view of the lumbar spine was obtained. The lateral view of the lumbar spine and the two views of the thoracic spine were not completed, and this information was not communicated to the provider. The RN on duty read the incomplete radiology report to the provider, indicating the x-ray was negative, without mentioning the missing views. The facility later reported to the on-call provider that the x-rays were obtained as ordered and were negative. The resident continued to experience severe pain and was eventually sent to the hospital, where a CT scan revealed new compression fractures. The facility was unable to provide evidence that the ordered x-rays were obtained, and the Radiological Technologist later stated he was unable to complete all the x-rays as ordered.
Failure to Administer Prescribed Antibiotic
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the administration of a prescribed antibiotic. The resident, who was a new admission with diagnoses including a urinary tract infection (UTI) and dementia, was supposed to receive cephalexin (Keflex) 500 mg twice a day for two days as per the hospital's Continuity of Care document. This order was confirmed with the on-call provider, and a new order was obtained. However, the October 2024 Medication Administration Record did not show that the Keflex was transcribed or administered to the resident as ordered. During interviews, a Licensed Practical Nurse (LPN) acknowledged that the resident did not receive the antibiotic as ordered. A Nurse Practitioner indicated that she would expect the order to be completed if given by an on-call provider. The Director of Nursing Services also acknowledged that the physician's order for Keflex had not been transcribed or administered as ordered, and she expressed an expectation that physician's orders should be followed. This oversight represents a failure to adhere to professional standards of practice in medication administration.
Neglect Following Resident's Suicide Attempt
Penalty
Summary
The facility failed to protect a resident from neglect following a suicide attempt. The resident, who had a history of vascular dementia, depression, and PTSD, attempted suicide by wrapping a belt around their neck. Despite the facility's policy requiring one-to-one supervision and immediate notification of the physician and nursing administration, the resident was only placed on frequent checks, and the necessary notifications were not made. The family was also not informed until they called the facility after speaking with the resident. Staff interviews revealed that the resident was restless and awake during the night of the incident, and the belt was removed with the help of three staff members. However, the resident was not placed under one-to-one supervision as required by the facility's policy. Additionally, the resident's room contained potential hazards such as belts and cords, which were not removed despite the recent suicide attempt. The resident was observed leaving the facility unattended twice on the same day as the suicide attempt, indicating a failure to monitor their whereabouts. Surveillance footage confirmed these events, and staff interviews corroborated the lack of supervision and failure to follow the facility's policy. The DON was not informed of the incident until several hours later and was unaware of the policy requirements and the unsafe items in the resident's room.
Inadequate Supervision Following Resident's Suicide Attempt
Penalty
Summary
The facility failed to provide adequate supervision to a resident who attempted suicide, as evidenced by multiple lapses in following their own policy. The resident, who had a history of major depression, PTSD, and moderate cognitive impairment, attempted to hang themselves with a belt. Despite the facility's policy requiring one-to-one supervision following a suicide attempt, the resident was not placed under such supervision. Instead, staff only conducted frequent checks, which were not documented, and the resident was left unsupervised in their room with accessible ligature risks. The incident occurred during the early morning hours, and staff members, including the Night RN/Nursing Supervisor and Nursing Assistant, failed to implement the required one-to-one supervision. The resident was found with a belt around their neck, and it took three staff members to remove it. Despite this serious incident, the resident was not continuously monitored, and the facility's policy was not followed, as the charge nurse did not notify the physician or nursing administration immediately. Further failures were observed when the resident was able to leave the facility unsupervised twice on the same day. Surveillance footage showed the resident exiting the facility without staff supervision, indicating a lack of monitoring of their whereabouts. The Director of Nursing was not informed of the incident until several hours later, and there was no evidence of the facility taking immediate action to ensure the resident's safety, such as removing unsafe items from the resident's room or notifying the family promptly.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to provide necessary treatment and services to promote wound healing and prevent new ulcers from developing for a resident with multiple pressure injuries. The resident was readmitted to the facility with diagnoses including sepsis, pressure injuries to the left lateral lower leg, left buttocks, right great toe, osteomyelitis, and muscle wasting. A wound physician recommended daily treatment for the resident's left lateral lower leg pressure wound, but the facility did not implement this treatment for 19 days. Additionally, two new deep tissue injuries were identified on the resident's right great toe and left buttocks, with treatment recommendations made by the wound physician. However, these recommendations were not acted upon for 12 days. Interviews with facility staff revealed a lack of implementation of the wound physician's recommendations. The resident's physician stated that wound recommendations are typically followed, while the wound nurse, responsible for entering the recommendations into the system as orders, could not explain why the treatments were not implemented. The Director of Nursing Services acknowledged the absence of treatment orders for the resident's wounds until the surveyor brought it to the facility's attention.
Deficiencies in Food Safety Practices
Penalty
Summary
The facility was found to have several deficiencies in food safety practices during a survey. In the main kitchen, a chef's knife and a can opener were observed with dried food residue, indicating they were not cleaned according to professional standards. Additionally, refrigerated ready-to-eat foods such as applesauce and mixed fruit were not labeled or dated, which is a requirement under the Rhode Island Food Code. Staff members in the kitchen were also observed handling food without wearing required beard restraints, which is necessary to prevent contamination. In the nourishment areas of different units, similar issues were identified. On the A Unit, a toaster was found with dried food debris, and several containers of thickened lemon-flavored water were open and undated, contrary to the manufacturer's instructions. On the B Unit, various food items, including a cheeseburger and burger patties, were not labeled or dated, and some shakes were past their use-by date. The C Unit also had undated food items and expired shakes, indicating a widespread issue with food labeling and storage across the facility. Interviews with staff members, including a Registered Dietitian and a supervisor, confirmed that the observed practices did not meet the facility's policies or professional standards. They acknowledged that all food and beverages should be dated when opened, expired foods should be discarded, and food equipment should be clean. The lack of adherence to these standards led to the deficiencies noted in the survey.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of Enhanced Barrier Precautions (EBP) for four residents. Resident ID #84, who was diagnosed with MRSA, had wound care supplies improperly handled by an LPN, who used contaminated gloves to touch various items and intended to reuse these supplies for other residents. The Director of Nursing Services acknowledged that these supplies should not have been removed from the resident's room or reused. Resident ID #28, with a history of ESBL infection, did not have the required precaution signage or PPE bin outside their room. Staff members were observed providing care without the necessary PPE, and one staff member was unaware of the resident's need for enhanced precautions. The Infection Preventionist and DNS confirmed that enhanced barrier precautions should have been in place. Resident ID #42, with pressure ulcers, had signage and a bin for EBP, but a nursing assistant attempted to provide care without wearing a gown. The DNS confirmed that staff should wear appropriate PPE. Additionally, Resident ID #163, with a gastrostomy tube, lacked precaution signage and a PPE bin, and staff were unaware of the need for EBP. The facility also failed to follow proper infection control practices for handling soiled linens, as observed with Resident ID #92, where soiled linens were placed on the floor instead of in a bag.
Failure to Obtain and Document Weekly Weights
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice by not following physician's orders for obtaining weekly weights for two residents. Resident ID #53, who was readmitted with diagnoses including dysphagia and severe protein calorie malnutrition, had a physician's order for weekly weights starting in early May 2024. However, the facility did not obtain weights on several occasions, specifically on 5/14/2024, 5/21/2024, and 6/3/2024. The nursing progress note for 5/14/2024 indicated that the weight was not obtained, but did not provide a reason or document any further attempts to obtain the weight. During an interview, the Director of Nursing Services (DNS) could not explain the lack of documentation or provide evidence of the missing weights. Similarly, Resident ID #96, who was readmitted with diagnoses including weakness and diabetes mellitus, had a physician's order for an admission weight and weekly weights for four consecutive weeks. The facility failed to obtain weights on 6/10/2024 and 6/17/2024. The DNS was unable to provide evidence of these missing weights and acknowledged that staff should have followed the physician's orders. These failures indicate a lack of adherence to professional standards of practice in obtaining and documenting required resident weights.
Failure to Timely Execute STAT Order for Resident with DVT History
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with a history of deep vein thrombosis (DVT). The resident, who was readmitted with a diagnosis of acute embolism and thrombosis of deep veins in the right lower extremity, reported new symptoms of pain, redness, and warmth in the left leg. Despite these symptoms and a physician's order for a STAT venous doppler, there was no evidence that the provider was notified of the change in condition on the day it occurred, nor was the venous doppler completed as ordered. Interviews with staff revealed that the order for the venous doppler was not transcribed as STAT, and the provider was not informed of the delay. The resident's condition was not communicated to the nurse practitioner until two days later, and the medical director confirmed that a STAT order should have been completed the same day. The director of nursing services acknowledged the oversight only after it was brought to their attention by the surveyor. The resident was eventually sent to the emergency department, where a small complex fluid collection, likely a hematoma or small abscess, was found in the calf.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice to promote wound healing and prevent new ulcers from developing for a resident with pressure ulcers. The resident, who was admitted with Alzheimer's disease and pressure ulcers on the coccyx and left heel, had specific physician's treatment orders for wound care. These orders included applying medihoney followed by calcium alginate and covering with foam dressing for the left heel, and applying medihoney and bordered foam dressing for the coccyx, both to be done every evening shift. During a surveyor observation, it was found that the wound care was not performed as ordered. The LPN, identified as Staff E, removed a soiled dressing from the coccyx, cleansed the wound with normal saline, and applied barrier cream instead of medihoney, failing to cover the wound with the bordered foam dressing as ordered. Additionally, the dressings were not changed daily as required, as evidenced by the dressings being dated two days prior. Staff E admitted to being uncertain of the treatment order before providing care, and the Director of Nursing Services confirmed that physician's orders should be followed.
Failure to Communicate Critical Lab Values for Dialysis Resident
Penalty
Summary
The facility failed to ensure proper communication and management of a resident's dialysis care, leading to a deficiency in providing safe and appropriate dialysis services. The resident, who was readmitted with acute kidney failure and chronic kidney disease, was receiving hemodialysis three times a week. A physician's order for STAT labs revealed a critically low potassium level, which was communicated to the physician, resulting in an order for a STAT dose of potassium. However, the communication of these critical lab values and the resident's change of condition was not effectively relayed to the dialysis center or nephrology, as evidenced by the Hemodialysis Communication Sheet. During the survey, it was discovered that the Licensed Practical Nurse responsible for completing the communication sheet was unaware of the resident's lab results and the Nurse Practitioner's progress note, leading to the omission of critical information. The Director of Nursing Services was unable to provide evidence that the facility had communicated the resident's critically low potassium level to the dialysis center before the surveyor's intervention. This lack of communication and coordination between the facility and the dialysis center resulted in continued hypokalemia for the resident.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete an annual performance review for every nurse aide at least once every 12 months, as required. This deficiency was identified during a record review and staff interview, which revealed that 4 out of 7 nurse aide personnel records lacked evidence of a completed annual performance evaluation. The affected staff members included Staff F, G, H, and I, with hire dates ranging from 2013 to 2022. During an interview with the Director of Nursing Services, conducted on June 26, 2024, at 10:45 AM, she was unable to provide documentation of a completed performance evaluation within the last 12 months for these employees. This indicates a lapse in the facility's adherence to regulatory requirements for staff performance evaluations.
Delayed Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to address pharmacy recommendations in a timely manner for two residents, leading to deficiencies in medication management. For one resident, a recommendation to reduce Pravastatin dosage was made on April 9, 2024, but was not signed by the provider until June 20, 2024, and was not implemented until the surveyor's intervention. Additionally, a recommendation to trial discontinuation of Risperdal was signed on June 11, 2024, but was not acted upon. For another resident, a recommendation to obtain a Valproic Acid serum level within two weeks was signed on June 11, 2024, but the test was not conducted until June 26, 2024, after the surveyor's notice. The lab report indicated a subtherapeutic level of Valproic Acid, which was significantly below the therapeutic range. The Director of Nursing Services acknowledged the delay in addressing these recommendations, which were expected to be completed within 14 days according to facility policy.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving two residents. Resident ID #45, who was cognitively intact with a BIMS score of 15, was assaulted by their roommate, Resident ID #81, who had a moderately impaired cognition with a BIMS score of 11. The incident occurred when Resident ID #81, who had a history of behavioral problems, including swearing, agitation, and combativeness, bit Resident ID #45 on the cheek. This altercation was reported to the Rhode Island Department of Health, and the facility's records confirmed the occurrence of the abuse. The incident was documented in the facility's progress notes and investigation statements. Staff members, including a Nursing Assistant and a Licensed Practical Nurse, intervened to separate the residents during the altercation. Despite these efforts, Resident ID #81 continued to attempt to hit Resident ID #45. The facility's records indicated that Resident ID #45 experienced pain and required medical treatment for the bite injury, which included antibiotics and topical care. The Director of Nursing Services acknowledged the assault and the resulting injury to Resident ID #45. However, the facility was unable to provide evidence that they had effectively protected Resident ID #45 from abuse, as required by regulations. The lack of sufficient protective measures and the failure to evaluate the effectiveness of interventions for Resident ID #81's behavioral issues contributed to the deficiency in ensuring resident safety.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to post the results of the most recent survey in a readily accessible area for residents, staff, and the public. During a resident council task, residents expressed awareness of the State Inspection results but raised concerns about their accessibility. A surveyor observed a sign near the front desk indicating that the Department of Health Survey Book was available upon request in the receptionist's office. However, upon reviewing the facility's survey results binder, it was found that the last entry was from a survey conducted in December 2023, and it did not include the most recent survey results from April 2024. The Regional Director of Clinical Services confirmed that the binder was not updated to include the most recent surveys for 2024 and acknowledged that the survey results binder should be updated and placed in a readily accessible location.
Failure to Prevent Resident Elopement and Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and assessment for a resident, identified as Resident ID #4, who successfully eloped from the facility on multiple occasions. The resident, who has a history of schizoaffective disorder, adjustment disorder, traumatic brain injury, developmental delay, mild intellectual disability, and type 2 diabetes mellitus, was not properly assessed for elopement risks, nor were appropriate interventions implemented. On one occasion, the resident eloped from a behavioral health appointment, and the facility assumed the resident left against medical advice (AMA) without following the proper discharge procedures. The facility's policy on elopement and AMA discharge was not adhered to, as evidenced by the lack of an elopement assessment and the absence of an AMA discharge order or documentation in the resident's clinical record. The resident's care plan did not reflect any assessment for elopement risks or interventions following the incidents. Additionally, the facility staff, including the Director of Nursing Services and the Regional Director of Nursing, were unable to provide evidence of a completed AMA discharge or an elopement risk assessment after the resident's unsupervised departure from the community provider's office. Further incidents occurred when the resident eloped from the facility on two consecutive days, following a verbal altercation with another resident. Despite these events, the facility failed to analyze the incidents or update the resident's care plan to address elopement behaviors. The resident's physician was not informed of these incidents until much later, and the facility did not conduct the necessary elopement behavior assessments, placing the resident at risk for serious injury, harm, impairment, or death.
Latest citations in Rhode Island
The facility failed to follow physician orders for post-fall care for three anticoagulated residents who experienced falls. One resident on a blood thinner with a head injury was ordered to be transferred to the ED after a telehealth evaluation, but an LPN did not send the resident, citing instructions to contact a supervisor first and inability to reach that supervisor. For two other residents on anticoagulants, providers ordered intensive neuro checks (every 15 minutes, then every 30 minutes, then hourly, then every 4 hours), but staff instead performed neuro checks only once per shift for 72 hours. The DON and Medical Director acknowledged that the transfer and monitoring orders were not implemented as written.
A resident with intact cognition and psychiatric diagnoses sustained a left eyebrow laceration when another resident with a documented history of escalating aggressive and threatening behaviors struck them with a cane during a hallway dispute. The aggressive resident had multiple prior documented incidents, including verbal threats to kill others, attacking a roommate with a cane over TV volume, throwing objects during activities, and throwing a lunch plate at staff. Despite these events, the care plan was not updated with interventions to address physical aggression toward other residents, and a psychiatric recommendation for PRN trazodone for agitation, anxiety, and insomnia was only implemented as PRN for insomnia. The failure to assess, monitor, and implement effective interventions for the aggressive resident’s behaviors led to the assault and injury and, per the report, placed this and other residents at risk of serious physical and psychosocial harm.
A resident with impulse disorder, mood and anxiety diagnoses, and a history of escalating verbal and physical aggression had multiple documented incidents of threats, object throwing, and assault with a cane. Despite a psychiatric consult recommending PRN trazodone for agitation, anxiety, and insomnia, the provider order listed insomnia only, and the care plan was not updated with specific interventions to address the resident’s physically aggressive behaviors after several documented events. Subsequently, the resident struck another resident with a cane, causing a facial laceration that required wound closure and ongoing treatment.
The facility failed to properly screen and document clearance for a NA with disqualifying criminal history information before hire, as required by its abuse, neglect, and exploitation policy. A BCI check showed disqualifying information, yet the NA was hired, completed orientation, and worked independently based only on verbal disclosure of an old drug-related charge, without written details or verification. Later, a staff member reported witnessing this NA grab a resident’s face and kiss the resident on the lips, and a community complaint alleged inappropriate interactions with the same resident, prompting involvement of local police.
A resident with anxiety disorder and PTSD was unable to attend meals and activities with peers because the facility lost the resident's clothing after it was sent to laundry. The resident was observed in a hospital gown with only a few clothing items in the room, and the record lacked an admission inventory of belongings. The DON/Administrator reported that laundry was handled by an outside vendor without a tracking system or item documentation.
A resident with dementia and severely impaired cognition was subjected to repeated non-consensual kissing on the lips by an NA, who entered the resident’s room during care, verbally expressed affection, and then kissed the resident on the mouth on at least two separate occasions witnessed by staff. One staff member delayed reporting the first incident due to fear of the NA. These actions occurred despite a facility policy defining sexual abuse as any non-consensual sexual act and requiring protections of residents’ rights and well-being.
Failure to investigate allegations of resident-to-resident sexual inappropriateness: A resident with dementia and TBI was documented as being inappropriate with another resident, and psych notes later described increased sexually inappropriate behaviors toward other residents. Staff interviews showed the resident had been observed touching others and needing frequent redirection, but the DON, ADON, and Administrator acknowledged the facility did not complete an investigation or recognize the allegation as possible abuse.
A resident with dementia and a hearing deficit did not receive ear care as ordered because the chart lacked the Debrox order and the ear was flushed before the intended Debrox course was completed. In a separate incident, staff witnessed inappropriate kissing of a resident with dementia, but the allegation was not reported to the provider and the care plan was not updated. A third resident’s wound care was also not completed as ordered when an RN used normal saline instead of the prescribed Vashe wound wash.
A resident with migraines and chronic pain did not receive timely pain management after repeatedly reporting a migraine and appearing in visible distress. An NA notified an LPN, an RN said she could not access the med cart, and the resident continued waiting while the LPN was off the unit; the PRN migraine medication was not given until 40 minutes after the first complaint. The DON acknowledged the resident should not have waited that long for pain medication.
A resident missed 6 doses of a prescribed antibiotic, and the MAR did not show that the provider was notified. The RN acknowledged the missed doses and said they should have been reported, while the Medical Director stated she was unaware of the missed doses and would have extended the antibiotic course if informed. The DON also confirmed the missed doses and expected provider notification for any missed antibiotic dose.
Failure to Follow Post-Fall Physician Orders for Anticoagulated Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for post-fall care, including hospital transfer and neurological monitoring, for residents on anticoagulant therapy. One resident with atrial fibrillation on Xarelto experienced an unwitnessed fall with a scalp laceration and head lump. The on-call provider, after a telehealth evaluation, ordered transfer to the ED and wrote an order directing that the resident be sent to the hospital. The resident was not transferred as ordered, and an additional order for vital signs and neuro checks every shift for 72 hours after the fall was not completed as ordered on one of the shifts. The LPN caring for this resident stated she did not send the resident to the ED because she had been instructed to call a supervisor before sending residents out, and she was unable to reach the supervisor during the shift. A second resident, also with atrial fibrillation and on Xarelto, had an unwitnessed fall with injury. The on-call provider was notified and ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, then every four hours for an additional 24 hours. A physician’s order reflecting this schedule was scanned into the EMR. However, the neuro checks were not completed as ordered; instead, they were performed only once per shift for 72 hours. The RN who authored the progress note documented the fall and the resident’s anticoagulant use, and later stated she could not remember why she did not transcribe and complete the neuro checks as ordered. A third resident with atrial fibrillation on Apixaban had a non-injury fall after attempting to walk independently. The on-call provider ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, and then every four hours for an additional 24 hours, and this order was scanned into the EMR. The record did not show that these neuro checks were completed as ordered; instead, neuro checks were documented only once per shift for 72 hours. The Medical Director stated he would have expected the first resident to be transferred to the ED as ordered and that the facility should not override a provider’s order. The DON acknowledged that the transfer order and the ordered monitoring for the first resident were not followed as written, and that for the second and third residents, staff performed only once-per-shift neuro checks instead of the more frequent monitoring ordered by the providers.
Failure to Manage Escalating Aggression Leading to Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident, Resident ID #1, from abuse by another resident with a known history of escalating aggression, Resident ID #2. Resident ID #1 was admitted in October 2025 with diagnoses including paranoid schizophrenia and adjustment disorder with mixed anxiety and depressed mood, and had a BIMS score of 14/15, indicating intact cognition. On 4/27/2026, progress notes documented that Resident ID #1 was on the receiving end of a physical altercation with another resident and was found with a deep bleeding abrasion to the left eyebrow. A subsequent nursing note described a new laceration to the left eyebrow measuring 0.5 cm by 2.0 cm by 0.1 cm, related to a resident-to-resident incident, for which wound closure strips were applied. Resident ID #1 requested police involvement and a police report, and refused transfer to the hospital for sutures. Resident ID #2 had been admitted in December 2024 with multiple psychiatric and behavioral diagnoses, including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed a BIMS score of 13/15 and documented both physical and verbal behaviors during the look-back period. Progress notes over several months recorded a pattern of escalating aggressive and threatening behaviors: on 9/13/2025, Resident ID #2 threatened to slit another resident’s throat and made additional threats toward staff; on 11/7/2025, the resident was involved in a verbal dispute with raised voice, name-calling, and verbal threats; on 12/28/2025, after another resident struck Resident ID #2 with a helmet, Resident ID #2 was overheard threatening to kill that resident if touched again. On 2/21/2026, the on-call provider documented that Resident ID #2 attacked a roommate with a cane over TV volume and required ER transfer for psychiatric evaluation. Subsequent notes on 3/9/2026 and 4/10/2026 described the resident throwing poker chips on the floor, yelling and swearing at staff and residents, and throwing a lunch plate across the nurses’ station at a nursing assistant due to dissatisfaction with portion size. Despite this documented pattern, the care plan for Resident ID #2, dated 1/16/2025, only indicated a behavior problem of being verbally aggressive toward staff with resident-to-resident altercations on 12/28/2025, 2/21/2026, and 4/27/2026, and record review failed to show added interventions to mitigate the risk of physical aggression toward other residents after the 2/21/2026 cane attack and the object-throwing incidents on 3/9/2026 and 4/10/2026. A psychiatric evaluation on 4/23/2026 recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order entered on 4/24/2026 specified trazodone 25 mg twice daily as needed only for insomnia, and record review did not show that agitation and anxiety were included as indications for use. During interviews, the RNP and the DON stated it was their expectation that agitation and anxiety would have been included in the trazodone order, and the DON was unable to provide evidence that the care plan had been updated with interventions to address Resident ID #2’s physically aggressive behaviors documented on 2/21/2026, 3/9/2026, and 4/10/2026. On 4/27/2026, the DON documented that Resident ID #2 was ambulating down the hall toward his/her room while Resident ID #1 was walking in the opposite direction, and the two residents began a verbal dispute. Before staff could intervene, Resident ID #2 used his/her cane to make contact with Resident ID #1, resulting in the eyebrow laceration that required steri-strips and ongoing wound treatment. A police incident report recorded that Resident ID #1 stated being struck with a walking cane, wanted to press charges, and that Resident ID #2 admitted to striking Resident ID #1, leading to an arrest on one count of felony assault with a dangerous weapon. The facility’s failure to assess, monitor, and implement effective interventions for Resident ID #2’s known and escalating aggressive behaviors, including failure to update the care plan after prior incidents and failure to fully implement psychiatric recommendations, resulted in this resident-to-resident altercation and injury, and the report states that this failure placed Resident ID #1 and other residents at risk of serious physical and psychosocial harm.
Failure to Implement Psychiatric Recommendations and Update Behavior Care Plan Leading to Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health services and care planning for a resident with a documented history of psychiatric conditions and aggressive behaviors. The resident was admitted in December 2024 with diagnoses including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed intact cognition with a BIMS score of 13/15 and documented physical and verbal behaviors during the look-back period. Over time, multiple behavioral incidents were recorded, including threats to slit another resident’s throat during a smoking session, verbal disputes with name-calling and threats, and a statement to another resident that if touched again the resident would be killed. Further documentation showed escalating behaviors, including an incident where the resident attacked a roommate with a cane over television volume and required ER transfer for psychiatric evaluation, throwing poker chips and yelling when not winning at Bingo, causing the roommate to avoid the shared bathroom due to inappropriate comments and frustration over the light being turned on at night, and throwing a lunch plate across the nurses’ station at a nursing assistant over portion size. The care plan, initiated in January 2025 for verbal aggression and resident-to-resident altercations, did not contain added interventions to address the resident’s physically aggressive behaviors toward others after the incidents on 2/21/2026, 3/9/2026, and 4/10/2026. The DNS later could not provide evidence that the care plan had been updated with interventions to mitigate the risk of these physically aggressive behaviors or to guide staff in ensuring the safety of other residents. On 4/23/2026, a psychiatric evaluation recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order dated 4/24/2026 implemented trazodone 25 mg twice daily as needed for insomnia only, and the record lacked evidence that agitation and anxiety were included as indications for use as recommended by the consulting psychiatrist. Both the RNP and the DNS stated it was their expectation that the trazodone order would have included agitation and anxiety. Following this incomplete implementation of the psychiatric recommendation and the lack of updated behavioral interventions in the care plan, a resident-to-resident altercation occurred on 4/27/2026 in which the resident struck another resident with a cane, causing a laceration to the left eyebrow that required closure with steri-strips and ongoing wound treatment.
Failure to Properly Screen and Clear NA with Disqualifying Criminal History
Penalty
Summary
The facility failed to ensure that a prospective employee was properly screened and cleared for a history of abuse, neglect, exploitation, or misappropriation of resident property before hire. A nursing assistant, identified as Staff A, was hired on 11/18/2025 and was working independently as a NA. Prior to hire, a Bureau of Criminal Identification (BCI) check dated 11/6/2025 showed that Staff A had disqualifying information under federal and state law. Surveyor review after discovery of the positive BCI revealed that Staff A had an extensive criminal history. Despite this, the facility proceeded with the hire and allowed Staff A to complete orientation and work independently without obtaining or maintaining documentation specifying the nature of the disqualifying information, contrary to the facility’s Abuse, Neglect and Exploitation Policy, which requires screening and documentation of proof that such screening occurred. Subsequently, a facility-reported incident submitted on 4/17/2026 documented that a staff member reported witnessing Staff A grab a resident’s face and kiss the resident on the lips. A community-reported complaint submitted on 4/22/2026 alleged inappropriate interactions between the same NA and the same resident, and included a local police incident report indicating the resident’s family intended to pursue charges related to the incident. During interviews, the Human Resource Director stated that Staff A had disclosed disqualifying information related to a prior drug-related charge from about ten years earlier, but acknowledged there was no documentation specifying the nature of the disqualifying information and that this was known only by word of mouth. The Administrator stated she was aware that the BCI contained disqualifying information and that she exercised her own judgment in proceeding with the hire, and further acknowledged she did not receive documentation detailing the disqualifying information until it was brought to her attention by the surveyor.
Failure to Maintain Resident Clothing and Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when the resident was unable to attend meals and activities with other residents because of a lack of appropriate clothing. The resident was admitted in May 2025 with diagnoses including anxiety disorder and post-traumatic stress disorder, and a care plan revised on 8/25/2025 described the resident as highly social and willing to participate in a variety of activities, with an intervention to provide reminders of scheduled events. During observation on 4/29/2026, the resident was found in the room wearing a hospital gown while other residents were in the dining room for lunch. Only one pair of pants and two T-shirts were observed in the room. The resident stated that the facility lost all of the resident's clothing, including shirts, pants, shorts, and socks, after they were sent to laundry services several months earlier and were never returned. The resident reported that the Administrator was told about the missing clothing, but no follow-up occurred and the clothing was neither located nor replaced. The record did not contain an admission inventory list of the resident's belongings, and the Administrator stated that laundry was handled by an outsourced company without a tracking system or documentation identifying which items belonged to which resident.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse when a nursing assistant (NA) was observed kissing the resident on the lips on more than one occasion. The resident, identified as having dementia and a Brief Interview for Mental Status (BIMS) score of 0/15 indicating severely impaired cognition, had been admitted in March 2026. On one occasion, a Certified Medication Technician (CMT) reported that while she was assisting the resident with breakfast, the NA entered the room, verbally expressed affection for the resident, made a kissing noise, leaned forward, and kissed the resident on the lips. This incident made the CMT uncomfortable, and she later discussed it with another NA. A separate staff member, another NA, reported that two days earlier she had observed the same NA enter the resident’s room while morning care was being provided, ask the resident if they remembered her, state that she loved the resident, then lean toward the resident, make a kissing sound, and kiss the resident on the mouth with full lip-to-lip contact. This second NA did not report the incident at the time because she was fearful of the NA involved and only came forward after learning of the later incident. The facility’s abuse, neglect, and exploitation policy defined sexual abuse as a non-consensual sexual act of any type with a resident and required protections for each resident’s health, welfare, and rights, as well as screening of potential employees for a history of abuse. Despite this policy, the resident with severely impaired cognition was subjected to repeated non-consensual kissing by the NA.
Failure to Investigate Allegations of Resident-to-Resident Sexual Inappropriateness
Penalty
Summary
The facility failed to ensure that allegations made by residents were recognized as possible abuse by staff and that all allegations were investigated for Resident ID #41, who was admitted with diagnoses including dementia and traumatic brain injury. A facility policy titled, Abuse, Neglect and Exploitation, stated that an immediate investigation is warranted when suspicion of abuse, neglect, exploitation, or reports of abuse, neglect, or exploitation occur. A progress note written by an RN documented that a resident reported Resident ID #41 was being inappropriate with another resident. Subsequent records included psychiatric evaluations stating the resident was being seen due to increased sexually inappropriate behaviors toward other residents and that sexual impulses may present an unsafe environment for other patients in the facility. Staff interviews revealed that Resident ID #41 had been observed touching other residents' shoulders and hands and required frequent redirection. The RN who documented the incident stated the behavior involved an attempted hug without contact and that both residents were separated and assessed, while the ADON and DON acknowledged they were unaware of the behavior or that the facility had not investigated the allegations. The Administrator also acknowledged that an investigation had not been completed to determine what sexually inappropriate behavior had occurred and that staff did not identify the allegation as possible abuse or investigate it immediately.
Failure to Follow Orders, Report Abuse, and Perform Ordered Wound Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for a resident with dementia and anxiety disorder who had a hearing deficit and complained of right ear wax buildup. The medical record showed an order for Debrox ear drops and a separate order to flush the right ear with warm water two times a day following Debrox usage for 5 days, but the record did not include a physician order for the Debrox solution. The April 2026 MAR showed the resident’s right ear was flushed six times, and the resident stated that the right ear still felt blocked. The RN acknowledged flushing the ear and was unaware whether Debrox had been given, while the DON stated the order had been entered incorrectly and that the ear should not have been flushed before Debrox administration. The NP stated the intended order was for Debrox twice daily for five days before irrigation and that she would not have ordered daily ear flushing. The facility also failed to report an allegation of abuse and failed to update the care plan for a resident with dementia after staff reported inappropriate interactions with a nursing assistant. A community complaint and police incident report indicated the family wanted to press charges, and the Administrator and DON confirmed that staff had reported witnessing the nursing assistant kiss the resident on two occasions. The record did not show that the allegation was reported to the provider, and the comprehensive care plan was not updated to reflect the allegation or any interventions related to the incident. The NP stated she was unaware of the incident and would have expected to be notified, and the ADNS acknowledged that the provider had not been notified and the care plan had not been updated. The facility further failed to follow a wound care order for a resident readmitted with peripheral vascular disease and cellulitis of the lower limb. The physician ordered cleansing open areas on the left lower leg with Vashe wound wash, applying xeroform to the wound bed, and wrapping with kling. During observation, the RN performing wound care did not use Vashe wash and instead cleansed the wound with normal saline. The RN acknowledged using normal saline rather than the ordered cleanser, and the DON stated she would expect the nurse to follow the wound orders as written.
Delayed Pain Medication for Resident with Migraine
Penalty
Summary
Safe, appropriate pain management was not provided for Resident ID #17, who was admitted with diagnoses including migraines and chronic pain. The resident’s care plan dated 4/20/2026 included a goal for the resident to verbalize adequate pain relief and an intervention to respond immediately to any complaint of pain. The physician ordered Butalbital-APAP-Caffeine 50-300-40 mg, 1 capsule every 12 hours as needed for migraine pain. On 4/29/2026 at 10:30 AM, the resident was observed in the hallway complaining of a migraine, moaning in pain, and holding his/her head. At 10:34 AM, an NA reported to an LPN that the resident wanted pain medication, and at 10:37 AM the resident continued to complain of migraine pain and told an RN about the pain, but the RN stated she did not have keys to the medication cart and could not get any pain medication. The resident continued to complain of severe head pain, returned to the room to lie down at 10:40 AM, and the LPN was still off the unit at 10:42 AM. The resident was not assessed when the LPN returned, and the medication was not administered until 11:10 AM, 40 minutes after the initial complaint. The resident later reported pain rated 7 out of 10, and the DON acknowledged that a resident should not wait 40 minutes for pain medication.
Missed Antibiotic Doses Not Reported to Provider
Penalty
Summary
The facility failed to ensure that Resident ID #17 was free from significant medication errors when the resident missed 6 doses of a prescribed antibiotic. The resident was admitted in April 2026 with diagnoses including surgical aftercare and complication of surgical and medical care, and had a physician order dated 4/3/2026 for Cefadroxil 500 mg by mouth twice daily for 14 days. Review of the April 2026 MAR showed missed doses on 4/3 at 8:00 PM, 4/6 at 8:00 PM, 4/11 at 8:00 PM, 4/12 at 8:00 AM, 4/14 at 8:00 PM, and 4/17 at 8:00 AM. The record did not show that the provider was notified of the missed antibiotic doses. During interview, the RN acknowledged the 6 missed doses and stated they should have been reported to the provider. The Medical Director stated she was unaware of the missed doses and said she would have extended the antibiotic course if she had known. The DON also acknowledged the missed doses and stated she would expect the provider to be informed if a resident misses any dose of an antibiotic.
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