Adviniacare Providence Dodge Rehab Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Providence, Rhode Island.
- Location
- 135 Dodge Street, Providence, Rhode Island 02907
- CMS Provider Number
- 415038
- Inspections on file
- 36
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Adviniacare Providence Dodge Rehab Center, Llc during CMS and state inspections, most recent first.
A resident with end-stage renal disease, anemia, and full dependence for ADLs, but cognitively intact, was physically assaulted by a roommate with a known history of anxiety, delusional disorder, agitation, and aggressive behaviors. The aggressive resident had documented episodes of throwing meal trays, restlessness, and non-compliance with redirection and medications, and a physician’s order required behavior monitoring and shift-by-shift documentation. On the day of the incident, staff heard screaming and found one resident in a wheelchair with facial swelling and bloody, lacerated lips, while the roommate stood nearby holding a meal tray; both residents later confirmed that the roommate had punched the victim multiple times. Despite prior behavioral concerns and care plan interventions directing staff to intervene, monitor, and document behaviors, the behavior record for that day did not reflect the aggressive episode, and leadership and staff acknowledged awareness of the aggressor’s history of aggression and prior physical aggression toward the victim.
A resident with a history of an unwitnessed fall and confusion was evaluated for underlying causes, and after contaminated clean-catch urine specimens, a straight-catheter specimen confirmed a UTI with significant bacterial growth. The NP ordered IV vancomycin with trough monitoring before the fourth dose and a target range of 15–20 mg/L, but staff did not obtain trough levels at three ordered intervals, and the first level drawn was subtherapeutic, leading to a dose increase. The resident completed the antibiotic course and later experienced another fall with genital bleeding, altered status, and inability to stand, and was transferred to the hospital where sepsis with a urinary source was identified; the DON could not show evidence that appropriate treatment and services had been provided, and a pharmacy representative noted that subtherapeutic vancomycin levels increase the chance of not eradicating infection.
A resident with ESRD on hemodialysis and dependent on staff for all ADLs had a physician order for Sevelamer 3200 mg TID with meals to treat hyperphosphatemia, with the care plan directing coordination of medications with dialysis days. Over a three‑month period, MAR review showed 27 missed doses of Sevelamer. Lab results from the dialysis center documented rising phosphorus levels during this time. Facility nursing staff reported the drug was unavailable and placed on hold, and the DON was initially unaware that the medication supply came from the dialysis center. Dialysis center staff stated they were not informed the resident had run out of Sevelamer, despite being the supplier, and the NP attributed the increased phosphorus levels to the resident not receiving the medication.
A resident with sepsis, bacteremia, and a recent UTI was prescribed IV vancomycin 1 g every 12 hours for 12 days, for a total of 24 doses, under the facility’s antibiotic stewardship policy. An Antibiotic Time Out was completed by the IP and reviewed with the resident’s NP, but the December MAR showed the resident actually received 25 doses. In interviews, the NP reported being unaware of the extra dose, and the IP acknowledged that the antibiotic time out failed to identify the additional scheduled dose. This reflects a failure of the facility’s IPCP and antibiotic stewardship program to effectively monitor and control antibiotic use as ordered.
Surveyors found that food items in the main kitchen and two kitchenettes were not properly labeled or dated, as required by state food code and facility policy. Additional issues included a dusty kitchen fan blowing towards food being prepared and a dietary aide not fully covering his hair with a hair net. The Food Service Director acknowledged these failures during interviews.
The facility did not update care plans for two residents: one requiring increased assistance with eating due to dementia and failure to thrive, and another whose care plan still listed a fluid restriction after the physician's order was discontinued. Staff documentation and observations showed that the necessary care interventions were not consistently provided or reflected in the care plans.
A resident did not receive treatment and care in accordance with physician orders and their personal preferences and goals, resulting in a failure to meet the resident's individualized care needs.
A resident with COPD and a physician's order for oxygen therapy was found on multiple occasions with an empty portable oxygen cylinder and no documented monitoring of oxygen supply. The resident experienced critically low oxygen saturation levels, and staff failed to utilize available oxygen concentrators or adequately monitor the oxygen delivery, resulting in periods of hypoxia.
A resident with diabetes and multiple amputations did not receive the correct increased dose of Admelog insulin as ordered by an NP, due to the failure to update the physician's order in the record. The resident continued to receive the previous lower dose for two evenings, despite persistently high blood glucose levels, until the issue was identified by a surveyor.
A resident with a history of anxiety and mood disorders experienced a significant medication error when clonazepam was abruptly discontinued for several days during a gradual dose reduction process. The resident did not receive the medication as ordered, leading to increased anxiety and hand tremors. Facility staff and providers failed to ensure proper communication and follow-up regarding the medication changes, resulting in the resident not being free from significant medication errors.
A facility failed to follow a physician's order for a resident with congestive heart failure by not notifying the provider when the resident's weight exceeded 200 pounds on two occasions. Record reviews and staff interviews confirmed the oversight, as the Nurse Practitioner and DON were unaware of the weight changes.
The facility failed to accurately document weekly skin assessments for three residents. A resident with COPD, another with obesity, and a third with diabetes had physician's orders for weekly skin evaluations using a UDA. However, records showed assessments were documented as completed without evidence of actual completion. The DON could not provide evidence of accurate documentation.
The facility failed to protect residents from abuse, resulting in injuries from resident-to-resident altercations. A resident with PTSD was assaulted by another with dementia, leading to a fracture. Another resident with multiple sclerosis sustained a lip injury during an altercation with a resident with dementia. Staff acknowledged the facility's failure to prevent these incidents.
A facility failed to provide proper respiratory care for a resident with a tracheostomy. The resident, who was readmitted with acute respiratory failure, had no documented evidence of when to change or clean suction equipment, nor a current order for self-suctioning. Observations revealed undated suction equipment with secretions, and staff interviews confirmed the lack of documentation and assessment for the resident's self-suctioning.
A resident with pulmonary hypertension had physician orders for Isosorbide Mononitrate and Hydralazine, with instructions to hold if SBP was less than 110. However, records for July 2024 showed that blood pressure was not obtained before administering these medications, as required. The DON confirmed that staff were expected to document blood pressure prior to administration, but evidence was lacking, indicating potential unnecessary medication administration.
The facility failed to implement proper infection control measures for two residents. One resident with ESBL was not placed on required precautions, and another with an indwelling catheter had their urinary collection bag improperly placed on the floor and leaking. These deficiencies were confirmed by staff and observed by surveyors.
The facility failed to document the pneumococcal vaccination status for four residents, as their medical records lacked evidence of the vaccines being offered, received, or declined. This deficiency was identified during a record review and confirmed by the DON, who could not provide the necessary documentation until prompted by the surveyor.
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of an antibiotic review process for two residents prescribed antibiotics. The facility's tracking tool for antibiotic use was incomplete, and the DNS admitted it was filled out only after surveyor inquiry.
Failure to Protect Resident From Physical Abuse by Aggressive Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a roommate. The facility’s own policy, revised in October 2022, prohibits mistreatment and abuse and defines abuse as the willful infliction of injury resulting in physical harm, pain, or mental anguish. Despite this, an incident occurred in which two residents were heard screaming in their shared room, and staff who responded found one resident with blood on the upper and lower lips and later-documented facial injuries, including swelling to the eye, a lump on the cheek, bruising to the face, and lacerations to the lips. The injured resident, who was cognitively intact with a BIMS score of 15 and dependent on staff for all ADLs, reported being struck multiple times in the head and face while seated in a wheelchair after refusing a request from the roommate to close the bedroom door. The resident who committed the assault had a documented history of anxiety disorder, delusional disorder, and behavioral issues, including verbal aggression and increased agitation. The care plan for this resident, revised in August 2024, identified behaviors such as verbal aggression and agitation and included interventions for staff to intervene when the resident became agitated, document all behaviors, attempt to identify patterns, and encourage medication compliance. Nursing progress notes in December 2025 and early January 2026 documented an increase in agitation and aggressive behaviors, including repeatedly throwing meal trays on the hallway floor, being non-compliant with redirection and re-education regarding safety, and continued restlessness and agitation with care. A psychiatric evaluation noted ongoing behavior disturbance and non-compliance with medications. A physician’s order dated mid-December 2025 directed staff to monitor and document the aggressive resident’s behaviors and record the number of episodes every shift. However, the January 2026 Treatment Administration Record did not show evidence of behaviors on the date of the physical altercation, despite the documented violent incident that day. During interviews, the aggressive resident admitted to punching the roommate in the face, and the injured resident reported that the roommate had been physically aggressive in the past and that the facility was aware of this history. Staff and facility leadership also acknowledged the resident’s history of aggressive behaviors. The lack of effective monitoring, documentation, and intervention in response to the known behavioral history and physician’s order contributed to the failure to keep the injured resident free from physical abuse.
Failure to Monitor Vancomycin Trough Levels and Provide Appropriate UTI Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services for a resident treated for a UTI with IV vancomycin, who later experienced a fall and was admitted to the hospital with sepsis. The resident had an unwitnessed fall and increased confusion in November 2025, prompting the NP to order blood work and a urine sample to evaluate for underlying causes. Two urine specimens collected by clean catch on consecutive dates were reported by the lab as suggestive of contamination, with instructions to repeat testing if clinically indicated. A subsequent provider order directed staff to obtain a urine specimen via straight catheterization every shift until obtained, and a specimen collected on 11/28/2025 later resulted positive for a UTI with two organisms at a colony count greater than 100,000. Following the positive urine culture, the resident was started on antibiotic therapy, including IV vancomycin. The NP ordered vancomycin 1 g IV twice daily for 12 days, with instructions to monitor vancomycin trough levels before the fourth dose and to maintain a target trough range of 15–20 mg/L. The December MAR showed the resident received vancomycin from early to mid-December with dose adjustments based on trough levels. However, record review did not show evidence that vancomycin trough levels were obtained prior to each fourth dose on three separate dates, representing three missed opportunities to monitor levels as ordered. The first trough level was not obtained until 12/10/2025, at which time the level was 12.1 mg/L, below the desired therapeutic range, and the dose was then increased from 1 g to 1,250 mg. Ten days after completion of the antibiotic course, progress notes documented that the resident sustained a fall, was bleeding from the genital area, appeared not at baseline, was shaky, unable to stand, and pale, and was transferred to an acute care hospital where the resident was admitted with sepsis. Hospital documentation indicated concern for sepsis with a urinary focus of infection, and the resident received broad-spectrum antibiotics, including vancomycin, along with fluids and blood. During interviews, the NP stated she expected staff to obtain vancomycin trough levels after the third dose and before the fourth dose to ensure therapeutic levels, acknowledged that trough levels were not completed on the three specified dates and that the 12/10/2025 trough was subtherapeutic. The DON was unable to provide evidence that the facility provided appropriate treatment and services for the resident diagnosed with a UTI who subsequently fell and was admitted for sepsis, and a pharmacy representative stated that subtherapeutic vancomycin trough levels increase the likelihood of failing to destroy an infectious organism.
Failure to Administer Ordered Sevelamer for Dialysis Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring dialysis received Sevelamer as ordered to manage hyperphosphatemia, consistent with professional standards of practice. The resident, who was readmitted with end stage renal disease and dependence on hemodialysis three times a week, was cognitively intact with a BIMS score of 15 and dependent on staff for all ADLs. The care plan included coordinating medications with dialysis days. A physician’s order dated 10/1/2025 prescribed Sevelamer 3200 mg three times daily with meals for elevated phosphorus levels. Review of the MARs for November and December 2025 and January 2026 showed that the resident did not receive 27 scheduled doses of Sevelamer across multiple dates and times. Laboratory results from the hemodialysis center showed the resident’s phosphorus level was elevated at 5.5 on 12/19/2025 and had further increased to 7.5 by 1/12/2026. During interviews, an RN at the facility stated that Sevelamer had not been available for a while and had been placed on hold due to unavailability, and that the medication was only recently received from the dialysis center. The dialysis center RN reported that Sevelamer was ordered three times daily with meals and that the center was unaware the resident had run out of the medication, as the facility had not communicated this, even though the dialysis center supplied it. The NP stated that the increased phosphorus levels were due to the resident not receiving Sevelamer. The DNS reported she was initially unaware that the resident’s Sevelamer supply came from the dialysis center and could not provide evidence that the medication had been administered as ordered.
Failure to Monitor Antibiotic Use Resulting in Extra Vancomycin Dose
Penalty
Summary
The facility failed to establish and implement an Infection Prevention and Control Program (IPCP) that included an effective antibiotic stewardship program with protocols and a system to monitor antibiotic use. The facility’s own ANTIBIOTIC STEWARDSHIP policy, last revised in September 2025, required that antibiotics be prescribed and administered under the guidance of the stewardship program and that prescribers provide complete antibiotic orders, including duration of treatment, start and stop dates, and number of days of therapy. A resident with diagnoses including sepsis and bacteremia, who had recently completed a course of IV antibiotics for a UTI, was ordered vancomycin 1 gram every 12 hours for 12 days beginning on 12/2/2025, for a total of 24 doses. An Antibiotic Time Out assessment was completed by the Infection Preventionist (IP) for this vancomycin order and reviewed with the resident’s Nurse Practitioner. Record review showed that, despite the clear order for 24 doses, the December 2025 Medication Administration Record documented that the resident received 25 doses of vancomycin. During an interview, the Nurse Practitioner stated she was unaware that the resident had received an extra dose. In a separate interview, the IP, in the presence of the Director of Nursing Services, acknowledged completing the antibiotic time out for the vancomycin but failed to identify that the resident was scheduled to receive an additional, non-ordered dose. These actions and omissions demonstrated that the facility did not effectively monitor antibiotic use or ensure that the resident received only the prescribed number of antibiotic doses, as required by the facility’s antibiotic stewardship policy and IPCP requirements.
Food Storage, Sanitation, and Staff Hygiene Deficiencies Identified
Penalty
Summary
Surveyor observations and staff interviews revealed that the facility failed to store and distribute food in accordance with professional standards and the Rhode Island Food Code. Specifically, multiple food items in the main kitchen's walk-in refrigerator, such as opened butter, bowls of pudding, plates and bowls of lemon meringue pie, opened cheese, sliced tomatoes, cut lettuce, and ricotta cheese, were found without proper labeling or dating. Similar deficiencies were observed in the second- and third-floor kitchenettes, where resident food containers and other items were not labeled or dated as required by facility policy. Additionally, an opened butter was found stored in a biohazard bag in one kitchenette. The Food Service Director acknowledged these failures during interviews. Further deficiencies included a kitchen fan with visible dust accumulation blowing towards food being prepared, which was confirmed by the Food Service Director. Additionally, a dietary aide was observed not wearing a hair net that fully covered his hair while working, in violation of the food code's requirements for hair restraints. These findings collectively demonstrate a lack of adherence to food safety and sanitation standards in the facility's food service operations.
Failure to Revise and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement and revise comprehensive care plans for two residents with significant care needs. For one resident with dementia and adult failure to thrive, the care plan was not updated to reflect the resident's increased need for substantial or maximal assistance with eating, despite a significant change in condition documented in the MDS assessment. Staff continued to document the resident as eating independently, and multiple observations showed that the resident was not provided with the necessary assistance during meals. Interviews with staff and the MDS Coordinator confirmed that the care plan did not accurately reflect the resident's current needs, and staff were not consistently providing the required level of assistance. For another resident with chronic kidney disease and dependence on renal dialysis, the care plan was not revised to remove a fluid restriction after the physician's order for the restriction was discontinued. The care plan continued to indicate that the fluid restriction was in place, even though the order had been stopped. The MDS Coordinator acknowledged that the care plan should have been updated to reflect the change in the resident's treatment orders.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when appropriate treatment and care were not provided according to physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was delivered in alignment with the established plan, which is required to meet the individual needs and wishes of the resident. This lapse resulted in the resident not receiving care as intended, based on their documented preferences and medical orders.
Failure to Provide Safe and Consistent Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of non-ST elevation myocardial infarction and chronic obstructive pulmonary disease (COPD) was not provided with safe and appropriate respiratory care as required by professional standards. The resident had a physician's order for oxygen at 2 liters per minute via nasal cannula as needed. On two separate occasions, surveyor observations revealed that the resident's portable oxygen cylinder was empty, and there was no evidence in the medication and treatment administration records that the resident's oxygen supply was being monitored to ensure continuous delivery as ordered. During these times, the resident's oxygen saturation levels were found to be critically low, registering at 78% and later fluctuating between 85% to 86%, both well below the normal range. Staff interviews indicated a lack of awareness regarding the duration of oxygen cylinder supply and a failure to utilize available oxygen concentrators in the facility. The resident had been using portable oxygen cylinders exclusively, despite the availability of functional oxygen concentrators, and staff did not monitor the oxygen supply frequently enough to prevent depletion. The Director of Nursing Services confirmed that the resident should have been using an oxygen concentrator in the room and a portable cylinder only when out of the room, and that staff were expected to monitor the resident more closely when using portable oxygen. These failures resulted in the resident experiencing periods of hypoxia due to an empty oxygen supply.
Failure to Update Insulin Order Results in Missed Dosage Change
Penalty
Summary
A deficiency occurred when a resident with diabetes mellitus, diabetic neuropathy, and bilateral leg amputations did not receive the correct insulin dosage as ordered. The Nurse Practitioner (NP) reviewed the resident's labs and provided a new order to increase the evening dose of Admelog insulin from 14 units to 18 units. However, the physician's order was not updated in the resident's record to reflect this change. As a result, the Medication Administration Record (MAR) showed that the resident continued to receive 14 units of Admelog on two consecutive evenings instead of the newly ordered 18 units. The resident's blood sugar levels remained significantly elevated during this period, with documented readings of 420 mg/dL and 400 mg/dL. The NP confirmed her expectation that the increased dose should have been administered, and the Director of Nursing Services acknowledged that the order was not updated until the surveyor brought it to her attention. This failure resulted in the resident missing two doses of the correct insulin dosage as ordered by the NP.
Abrupt Discontinuation of Clonazepam Results in Significant Medication Error
Penalty
Summary
A deficiency occurred when a resident with a history of bipolar disorder and major depressive disorder, who had been receiving clonazepam for anxiety, did not receive the medication for several days due to abrupt discontinuation. The resident's medication orders were changed multiple times as part of a gradual dose reduction (GDR) plan, but after the last order was discontinued, there was a gap from the evening of 5/16/2025 through 5/19/2025 during which the resident did not receive any clonazepam. The resident reported increased anxiety and worsening hand tremors during this period. Interviews with facility staff and medical providers revealed a lack of clear communication and follow-up regarding the GDR plan and the resident's medication needs. The psychiatric provider who initiated the GDR was no longer assigned to the resident and did not reassess the resident after the dose reduction. The medical director was not notified of the missed doses until several days later, at which point a new order for a lower dose was provided. The facility was unable to provide evidence that the resident remained free from significant medication errors, as the abrupt discontinuation of clonazepam occurred without appropriate oversight or a proper GDR process.
Failure to Notify Provider of Resident's Weight Exceeding Physician's Order
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following a physician's order. The resident, who was readmitted to the facility with a diagnosis of congestive heart failure, had a physician's order to notify the provider if their weight exceeded 200 pounds. Record reviews showed that the resident's weight was over 200 pounds on two occasions in January 2025. However, there was no evidence that the provider was notified of these weight measurements as required by the physician's order. Interviews with the Nurse Practitioner and the Director of Nursing Services confirmed that the provider was not informed of the resident's weight on the specified dates.
Inaccurate Documentation of Weekly Skin Assessments
Penalty
Summary
The facility failed to accurately document weekly skin assessments in the medical records of three residents. Resident ID #2, who was readmitted with chronic obstructive pulmonary disease, had a physician's order for weekly skin assessments using a user-defined assessment (UDA). However, the records for November, December, and January showed that the assessments were documented as completed on several dates, but there was no evidence that the UDAs were actually completed on those dates. Similarly, Resident ID #3, admitted with obesity, had a physician's order for a weekly skin evaluation using a UDA, but the January records showed the assessment was documented as completed on one date without evidence of completion. Resident ID #4, admitted with diabetes, also had a physician's order for weekly skin assessments, but the January records showed the assessment was documented as completed on one date without evidence of completion. During an interview, the Director of Nursing Services was unable to provide evidence that the UDAs were accurately documented in the medical records.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in injuries to two residents due to resident-to-resident altercations. Resident ID #1, who had a history of PTSD and anxiety disorder, was assaulted by Resident ID #2, who had dementia with behavioral disturbances. Despite being aware of Resident ID #2's aggressive behavior, including a history of homicidal ideation and striking out against others, the facility did not adequately prevent the assault. Resident ID #1 sustained a nondisplaced right maxillary bone fracture after being hit with a commode cover by Resident ID #2. In another incident, Resident ID #3, who had multiple sclerosis and anxiety disorder, was involved in an altercation with Resident ID #4, who had dementia and delusional disorder. Resident ID #4 entered Resident ID #3's room and refused to leave, leading to a physical altercation that resulted in Resident ID #3 sustaining a skin tear on the lower lip. Despite Resident ID #4's known impulsive and aggressive behavior, the facility failed to prevent the altercation. Interviews with staff and the Director of Nursing Services revealed acknowledgment of the facility's failure to protect residents from physical abuse. The Director of Nursing Services admitted that Resident ID #2 was not suitable for the facility and should have been placed in a memory care unit. The facility's inability to manage residents with known aggressive behaviors contributed to the incidents of abuse and injury.
Failure to Provide Proper Respiratory Care for Resident with Tracheostomy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident with a tracheostomy. The resident, who was readmitted to the facility with acute respiratory failure and a history of malignant neoplasm of the larynx, had a physician's order for tracheostomy suctioning as needed. However, the facility's records did not include evidence of when to change, clean, or replace the suction equipment, nor was there a current order for the resident to perform self-suctioning. Additionally, there was no assessment conducted to determine if the resident was safe to self-suction following their readmission. During a surveyor observation, it was noted that the suction machine in the resident's room had a canister filled with secretions and floating sediment, which was undated. Interviews with nursing staff revealed that the resident had been self-suctioning for months without a current physician order or documented assessment of safety. The staff also acknowledged the lack of documentation regarding the dating and maintenance of the suction equipment, including when the canister was last emptied or changed.
Failure to Monitor Blood Pressure Before Administering Medications
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically concerning blood pressure medications. The resident, who was readmitted in August 2023 with a diagnosis of pulmonary hypertension, had physician orders for Isosorbide Mononitrate and Hydralazine, both with specific instructions to hold the medication if the systolic blood pressure (SBP) was less than 110. However, a review of the Medication Administration Record and vital sign summary report for July 2024 revealed that the resident's blood pressure was not obtained for 30 out of 30 opportunities before administering Isosorbide Mononitrate and for 60 out of 90 opportunities before administering Hydralazine, as per the physician's orders. During an interview with the Director of Nursing Services, it was confirmed that staff were expected to obtain and document the resident's blood pressure prior to administering these medications. The Director was unable to provide evidence that the resident's blood pressure was monitored, indicating that the medications may have been administered unnecessarily. This oversight highlights a failure in adhering to physician orders and ensuring the resident's drug regimen was free from unnecessary medications.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of appropriate precautions for residents with specific medical conditions. One resident, who was admitted with diagnoses including dementia and type 2 diabetes mellitus, tested positive for Extended-spectrum beta-lactamase (ESBL) in March 2024. Despite the facility's policy and the resident's care plan indicating the need for Contact Precautions, surveyor observations over several days revealed that the resident was not placed on any precautions. This oversight was acknowledged by the Director of Nursing Services during an interview. Additionally, another resident with an indwelling catheter was observed with their urinary collection bag on the floor on multiple occasions, contrary to the facility's policy and the resident's care plan. The catheter guidelines specify that the collection bag should not be on the floor and should be changed if leaking. However, surveyor observations noted the bag on the floor and leaking, forming a puddle, without evidence of it being changed. This was confirmed by a Registered Nurse and the Director of Nursing Services, indicating a failure to adhere to aseptic techniques and infection control measures.
Failure to Document Pneumococcal Vaccination Status
Penalty
Summary
The facility failed to ensure that the medical records of four residents included documentation regarding the administration or refusal of pneumococcal vaccinations. Specifically, the records for Residents ID #17, #63, #73, and #106 did not contain evidence that the pneumococcal vaccines PVC13, PVC15, PCV20, or PPSV23 were offered, received, or declined. This deficiency was identified during a record review and confirmed through an interview with the Director of Nursing Services. The Director of Nursing Services was unable to provide documentation that these residents' medical records included information on whether they received the pneumococcal immunization or did not receive it due to medical contraindications or refusal. This issue was only brought to the facility's attention by the surveyor, indicating a lapse in the facility's vaccination documentation process for these residents.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an effective Infection Prevention and Control Program (IPCP) that includes an antibiotic stewardship program with protocols and a system to monitor antibiotic use. This deficiency was identified for two residents, who were prescribed antibiotics without evidence of an antibiotic review process to determine if the antibiotics were still indicated or if adjustments were necessary. Resident ID #17 was prescribed Amoxicillin for 21 days following a tooth extraction, and Resident ID #54 was prescribed Cipro for a urinary tract infection. In both cases, there was no documentation of an antibiotic review process being implemented. The facility's Quality Assurance and Performance Improvement (QAPI) plan indicated that data collection for infection control and antibiotic stewardship was to be conducted weekly. However, the facility's tracking tool for antibiotic use was found to be incomplete for the month of July 2024, with no evidence of tracking or trending of antibiotic use, including for the two residents in question. During interviews, the Director of Nursing Services (DNS) admitted that the antibiotic tracker was filled out only after the surveyor's inquiry, and there was no evidence that the tracking system was completed as required by regulations.
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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