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