Adviniacare Orchard, LLC

Inspectors wroteBased on surveyor observations and staff interviews between 1/22/2026 and 1/23/2026, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for all residents, staff, and the public. Active water leaks from the roof penetrated ceiling tiles and electrical fixtures on the second floor, causing brown water to pool on floors, collect in hallways accessible to cognitively impaired residents, and infiltrate the fire alarm panel. Despite awareness from maintenance, administration, and operations staff, no effective mitigation measures were implemented. These failures resulted in slippery, hazardous conditions, compromised life safety systems, and necessitated an evacuation directed by The Rhode Island Department of Health, placing 125 residents at immediate risk for serious harm or death.

Inspectors wroteBased on surveyor observation, record review, and staff interview, the facility failed to ensure the residents' environment remained as free of accident hazards as possible related to the storage and management of biohazardous waste (any material contaminated with infectious agents or potentially infectious substances that pose a risk to health, including blood and body fluids) and sharps (any instruments or devices with sharp points or edges that can puncture or cut skin, posing risks of injury and disease transmission). This failure resulted in unsecured, unlocked, and accessible biohazardous waste and sharps on four (4) of four (4) units observed, including a secured memory care unit, placing residents at risk for exposure to bloodborne pathogens, infectious disease, and physical injury.

Inspectors wroteBased on surveyor observation, record review, and staff interview, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the transmission of communicable diseases and infections. Specifically, the facility failed to properly store, secure, and dispose of biohazardous waste (any material contaminated with infectious agents or potentially infectious substances that pose a risk to others) and overfilled sharps containers (used for the safe disposal of used needles, syringes, and other sharp medical items to prevent needlestick injuries and the spread of infection) in unsecured and unlocked areas on four (4) of four (4) units observed, including a secured memory care unit. [...]

Inspectors wroteBased on surveyor observation, record review, and staff interview, the facility failed to ensure the proper disposal and management of garbage, resulting in an accumulation of garbage at the back of the facility that obstructed exit routes and posed an immediate hazard to residents' safety. This failure placed residents at risk in the event of an emergency evacuation. The facility was found to be in past noncompliance.

Inspectors wroteBased on surveyor observation, record review, and staff interview, the facility's governing body failed to ensure the effective implementation and oversight of policies related to the management and operation of the facility. Specifically, the governing body failed to ensure the proper disposal and management of biohazardous waste and garbage, resulting in unsecured biohazardous waste stored in the facility and an accumulation of garbage at the back of the building that obstructed exit routes and posed an immediate hazard to the residents' safety.

Inspectors wroteBased on record review, resident, family, and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed who sustained a fall, Resident ID #2.

Inspectors wroteBased on record review, resident and staff interviews, it has been determined that the facility failed to ensure that residents who require dialysis (a treatment that filters waste and excess fluid from your blood when your kidneys are failing) receive services consistent with professional standards of practice, for 2 of 2 residents reviewed who receive dialysis, Resident ID #s 1 and 3.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to provide or obtain radiology services to meet the needs of its residents relative to obtaining a STAT (diagnostic or therapeutic procedure that is to be performed immediately) X-ray for 1 of 1 resident reviewed, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to ensure that residents are free from significant medication errors for 1 of 1 resident reviewed for the use of methadone (a medication prescribed to reduce cravings and withdrawals from opiates and to treat chronic and severe pain), Resident ID #330.

Inspectors wroteBased on surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed in accordance with professional standards for food service safety, relative to the main kitchen.

Inspectors wroteBased on staff interview and record review, it has been determined that the facility failed to maintain an effective pest control program so that the facility is free of pests.

Inspectors wroteBased on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to ensure that the resident's environment remained as free of accident hazards as possible for 3 of 4 shower rooms observed relative to safety rails (rails that provide a sturdy handhold to help users maintain balance and avoid slips and falls, especially on wet or slippery surfaces).

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to staff wearing the appropriate personal protective equipment (PPE), for 1 of 1 resident observed on neutropenic precautions (a set of measures taken to prevent infections for individuals with neutropenia, a condition where there is an abnormally low number of white blood cells, increasing the risk of infection), Resident ID #2, and for 1 of 1 resident reviewed who was readmitted to the facility with an order for Enhanced Barrier Precautions (EBP; infection control measures which require putting on a gown and gloves during high-contact resident care activities), Resident ID #43.

Inspectors wroteBased on surveyor observation and staff interview, it has been determined that the facility failed to maintain all mechanical, electrical, and patient care equipment in a safe operating condition for the exhaust hood in the main kitchen.

Inspectors wroteBased on surveyor observation and staff interview, it has been determined that the facility failed to have handrails securely affixed to the walls on 3 of 4 units in the facility.

Inspectors wroteBased on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to ensure that adequate pain management was provided to a resident who required such services, for 1 of 1 resident reviewed for pain, Resident ID #330.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident relative to 1 of 1 resident reviewed with an order for methadone (a medication prescribed to reduce cravings and withdrawals from opiates and to treat chronic and severe pain), Resident ID #330.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality, relative to following a physician's order to obtain daily weights for 1 of 1 resident reviewed, Resident ID #1.

Inspectors wroteBased on record review, surveyor observation, and staff interview, it has been determined that the facility failed to ensure a resident received a therapeutic diet as ordered by the physician for 1 of 2 residents reviewed who had orders for a therapeutic diet, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to maintain medical records in accordance with professional standards and practices for 1 of 1 resident reviewed for a fluid restriction and for a complete and accurate medical record, Resident ID #1.

Inspectors wroteBased on surveyor observation, resident and staff interview, it has been determined that the facility failed to maintain a safe, functional, and comfortable environment for residents, staff, and the public, relative to a cracked glass panel on the inner door of the facility's entrance.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area directly from each resident's bedside for 4 of 4 units reviewed, affecting Resident ID #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following physician's orders for 1 of 1 resident reviewed relative to X-ray orders, Resident ID #1.

Inspectors wroteBased on record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to physician's orders for 1 of 1 resident reviewed who was a new admission, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to keep a resident free from neglect for 1 of 1 resident reviewed who attempted suicide, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review and staff interview it has been determined that the facility failed to ensure that residents receive adequate supervision for 1 of 1 resident reviewed who attempted suicide, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 1 resident reviewed, who has an actual pressure injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence), Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to prepare, store, and distribute food according to professional standards of food service safety, relative to the main kitchen and 3 of 4 nourishment areas observed.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections due to the facility's failure to utilize appropriate Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes), for 4 of 8 residents reviewed, Resident ID #s 84, 28, 42, and 163. Additionally, the facility failed to conduct appropriate infection control practices relative to the handling of soiled linen.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to keep a resident free from physical abuse for 1 of 3 residents reviewed, Resident ID #45.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice relative to following physicians orders for 2 of 4 residents reviewed relative to obtaining weekly weights, Resident ID #s 53 and 96.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed with a history of a deep vein thrombosis (DVT), Resident ID # 36.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 3 residents reviewed for pressure ulcers (a localized injury to the skin or underlying tissue due to pressure), Resident ID #42.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a blood purifying treatment given when kidney function is not optimum) receive such services consistent with professional standards of practice for 1 of 1 resident reviewed for dialysis, Resident ID #36.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to complete an annual performance review for every nurse aide (nursing assistant; NA), at least once every 12 months, for 4 of 7 NA personnel records reviewed, Staff F, G, H, I.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to address pharmacy recommendations in a timely manner for 2 of 5 residents reviewed for unnecessary medications. Resident ID #s 22 and 97.

Inspectors wroteBased on record review and staff, and resident interview, it has been determined that the facility failed to post the results of the most recent survey in a readily accessible area for the residents, staff, and public.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure a resident receives adequate supervision to prevent accidents for 1 of 4 residents reviewed who successfully eloped from the facility and for whom interventions and assessments were not implemented, Resident ID #4.

Inspectors wroteBased on record review and staff interview if has been determined that the facility failed to promptly identify and intervene during an acute change in a resident's condition, related to a mental status change and a fall, for 1 of 1 resident reviewed for a change in condition, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined the facility failed to develop and implement a baseline care plan for each resident within 48 hours of a resident's admission, that includes the instructions needed to provide effective and person-centered care for 3 of 3 residents reviewed. Resident ID #s 1, 2, and 3.

Inspectors wroteBased on surveyor observations, record review, staff and resident interview, it has been determined the facility failed to treat each resident with respect and dignity, and is cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life relative to assistance with eating during meals for 1 of 1 hospice resident reviewed, Resident ID #5.

Inspectors wroteBased on surveyor observations, record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 1 hospice resident reviewed for the breakfast meal, Resident ID #5.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that a resident's environment remains as free of accident hazards as possible for 1 of 3 residents reviewed for falls, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, and staff and resident interviews, it has been determined that the facility failed to ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene for 1 of 3 residents reviewed for showers, Resident ID #2.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to a nurse transcribing an order for NPO (nothing by mouth) without a physician's order and discontinuing a medication without physician authorization for 1 of 1 resident reviewed, Resident ID #99. Additionally, the facility failed to follow a physician's order for 1 of 3 residents reviewed for blood sugar monitoring, and for 1 of 2 residents observed for wound care, Resident ID #11.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative for 1 of 4 residents reviewed for hospice services, Resident ID #99. Additionally, the facility failed to follow physician's recommendations for 2 of 3 residents reviewed for wounds, Resident IDs #8 and 330, and not following the comprehensive care plan for 1 of 1 resident reviewed for the use of arm sleeves, Resident ID #82.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that a resident is offered sufficient fluid intake to maintain proper hydration and health for 1 of 1 residents reviewed for hydration, Resident ID #99.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure the medical care of each resident is supervised by a physician for 1 of 4 residents reviewed for end-of-life care, Resident ID #99.

Inspectors wroteBased on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to ensure that each resident receives adequate supervision to prevent accidents relative to smoking for 4 of 4 residents reviewed, Resident ID #s 26, 78, 103, 112; 1 of 1 resident reviewed relative to the water temperature for bathing, Resident ID #55; 1 of 1 resident reviewed relative to wandering, Resident ID #5; and 1 of 1 resident reviewed for supervision while eating, Resident ID #8.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors receive trauma informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences for 5 of 5 residents reviewed, Resident ID #s 5, 11, 50, 76 and 86.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored, served and distributed, in accordance with professional standards for food service safety relative to the main kitchen and nursing unit kitchenettes.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections relative to the handling of a multi-use glucometer for 2 of 2 residents observed, Resident ID #s 333 and 8; and 1 of 1 residents reviewed, Resident ID #7, with a positive wound culture for Methicillin-Resistant Staphylococcus Aureus (MRSA) who was not on proper precautions, and relative to improper technique for a clean dressing change.

Inspectors wroteBased on surveyor observation, record review, resident, staff, and resident representative interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 4 residents reviewed with an indwelling catheter, Resident ID #57.

Inspectors wroteBased on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to ensure that self-administration of medications was clinically appropriate for 1 of 3 residents observed with medications at bedside, Resident ID #74.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that the assessment accurately reflected the resident's status for 1 of 1 resident assessed for physical restraints/alarms, Resident ID #5, 1 of 1 resident assessed for weight gain; Resident ID #36, and 1 of 1 resident reviewed for special treatment/procedures, Resident ID #79.

Inspectors wroteBased on record review, staff and resident interview, it has been determined that the facility failed to ensure that a resident receives proper treatment to maintain vision abilities for 1 of 1 resident reviewed, Resident ID #5.

Inspectors wroteBased on surveyor observation, record review, and staff interview it has been determined that the facility failed to meet professional standards of practice for care related to a peripherally inserted central catheter (PICC) for 1 of 1 residents reviewed for PICCs, Resident ID #330.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 1 of 6 medication carts reviewed and 1 of 3 resident rooms reviewed relative to medication storage for self-administration, Resident ID #74.