Inspection Reports for Adviniacare Pawtucket Pleasant Rehab LLC
544 PLEASANT STREET, PAWTUCKET, RI, 02860
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
13.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
291% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
84% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 2, 2025
Visit Reason
A follow-up to a previous Recertification survey and a follow-up to a previous Life Safety Code survey were conducted at the facility to verify correction of prior deficiencies.
Findings
All previous deficiencies were corrected and no new deficiencies were identified during both the Recertification and Life Safety Code follow-up surveys.
Inspection Report
Plan of Correction
Census: 109
Capacity: 130
Deficiencies: 6
Date: Aug 15, 2025
Visit Reason
A recertification and complaint investigation survey was conducted to determine compliance with Long Term Care Facilities regulations, including state licensure and emergency preparedness.
Findings
Deficiencies were identified related to quality of care, free of accident hazards, competent nursing staff, infection prevention and control, and life safety code compliance. The facility submitted a Plan of Correction (POC) addressing these deficiencies with immediate actions and system changes including staff education, audits, and monitoring.
Deficiencies (6)
Failed to provide treatment and care in accordance with professional standards for 2 of 3 residents relative to skin conditions.
Failed to ensure a resident received adequate supervision and assistance devices to prevent accidents related to elopement risk.
Failed to have sufficient nursing staff with appropriate competencies and skills to provide nursing and related services.
Failed to establish and maintain an infection prevention and control program including proper PPE use and handwashing.
Life Safety Code deficiencies related to kitchen fire suppression system maintenance and fire alarm system testing.
Failed to maintain the emergency power supply system generator in accordance with regulations.
Report Facts
Census: 109
Total Capacity: 130
Deficiencies cited: 6
RN coverage days missed: 16
Residents reviewed for skin conditions: 3
Residents reviewed for elopement risk: 1
Residents reviewed for nursing staff competency: 2
Residents reviewed for rehab services: 2
Residents reviewed for infection control: 1
Residents reviewed for fire safety: 109
Inspection Report
Annual Inspection
Census: 109
Capacity: 129
Deficiencies: 9
Date: Aug 15, 2025
Visit Reason
A recertification and complaint investigation survey was conducted from 08/12/2025 through 08/15/2025 to determine compliance with federal regulations for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Complaint Details
The survey included a complaint investigation based on intake reference number 2580692. The complaint involved concerns about quality of care related to skin conditions and supervision of residents at risk for elopement. The complaint was substantiated as deficiencies were identified.
Findings
Deficiencies were identified related to quality of care, free of accident hazards, competent nursing staff, infection prevention and control, and life safety code violations including fire safety and emergency power supply. Specific issues included failure to provide treatment for skin conditions, inadequate supervision for a resident at risk of elopement, insufficient nursing staff competencies, failure to maintain infection control precautions, and failure to maintain fire alarm and sprinkler systems.
Deficiencies (9)
Quality of care deficiency related to failure to provide treatment and care for skin conditions in 2 of 3 residents reviewed.
Failure to ensure a resident at risk for elopement received adequate supervision and assistive devices.
Failure to have sufficient nursing staff competencies and skills to prevent transmission of communicable diseases.
Failure to provide specialized rehabilitative services as required for 2 of 2 residents reviewed.
Failure to maintain kitchen hood suppression system in accordance with NFPA 101 Life Safety Code.
Failure to maintain fire alarm system in accordance with NFPA 101 Life Safety Code.
Failure to maintain sprinkler system and conduct required quarterly testing.
Failure to maintain emergency power supply system generator and conduct required monthly testing.
Failure to maintain infection prevention and control program including proper use of PPE and isolation precautions.
Report Facts
Census: 109
Total Capacity: 129
Deficiencies cited: 9
Nursing staff coverage: 24
Nursing staff coverage failures: 16
Open wound size: 3
Open wound size: 2
Skin alteration measurements: 5
Skin alteration measurements: 2
Skin alteration measurements: 13
Skin alteration measurements: 5
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 6, 2024
Visit Reason
An off-site desk audit was conducted on September 6, 2024, to review all previous deficiencies cited on July 19, 2024.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Census: 118
Capacity: 129
Deficiencies: 13
Date: Jul 19, 2024
Visit Reason
A recertification survey and complaint investigation survey were conducted at Oak Hill Health and Rehabilitation Center from 7/16/2024 through 7/19/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Complaint Details
The survey included a complaint investigation with ACTS Reference Numbers 96565 and 96691. Deficiencies were substantiated as a result of the complaint investigation.
Findings
Deficiencies were cited in multiple areas including accuracy of assessments, comprehensive care plans, bowel/bladder incontinence, tube feeding management, medication errors, behavioral health services, infection prevention and control, resident care services staffing, environmental and maintenance services, and life safety code compliance. The facility failed to meet several regulatory requirements and corrective actions were planned.
Deficiencies (13)
Facility failed to ensure assessment accurately reflected resident status for tobacco use and limited range of motion.
Facility failed to provide treatment and care in accordance with professional standards for assistance with meals for one resident.
Facility failed to provide appropriate treatment and services to maintain continence for residents with urinary and bowel incontinence.
Facility failed to ensure proper administration and documentation of enteral tube feeding medications.
Facility failed to ensure medication error rates were below 5 percent for residents receiving g-tube medications.
Facility failed to provide necessary behavioral health services to maintain highest practicable mental and psychosocial well-being for residents.
Facility failed to maintain infection prevention and control program to prevent spread of communicable diseases including MDROs.
Facility failed to maintain sufficient qualified nursing staff to meet resident care needs.
Facility failed to maintain quarterly evaluations for Certified Medication Technicians.
Facility failed to maintain Emergency Operations Plan (EOP) available to staff on all units.
Facility failed to maintain required fire safety standards including means of egress and fire door functionality.
Facility failed to maintain infection prevention and control for residents on isolation and enhanced barrier precautions.
Facility failed to maintain oxygen humidifiers properly and failed to provide food preferences for residents.
Report Facts
Census: 118
Total Capacity: 129
Medication error rate: 16.67
Medication error opportunities: 30
Medication errors: 5
Fire/smoke zones: 14
Fire drills: 1
Staffing coverage days reviewed: 21
Medication technician evaluations reviewed: 2
Fire door inspections: 4
Audits for oxygen concentrator placement: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Olivia Russo | LNHA | Signed as Laboratory Director or Provider/Supplier Representative |
| Staff A | Licensed Practical Nurse | Named in medication administration and tube feeding medication findings |
| Staff B | Licensed Practical Nurse | Named in medication administration and oxygen humidifier cleaning findings |
| Staff C | Nursing Assistant | Named in feeding assistance and meal preference findings |
| Staff D | Licensed Practical Nurse | Named in feeding assistance, oxygen humidifier, and infection prevention findings |
| Director of Nursing Services | Interviewed regarding MDS assessments and medication administration | |
| Administrator | Interviewed regarding staffing and emergency preparedness | |
| Director of Maintenance | Named in fire safety and emergency preparedness findings | |
| Registered Dietitian | Named in food preference and meal service findings | |
| Infection Preventionist | Named in infection prevention and control findings |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 16, 2022
Visit Reason
An off-site desk audit was conducted on June 16, 2022, to review all previous deficiencies cited on May 11, 2022.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Census: 95
Capacity: 129
Deficiencies: 12
Date: May 11, 2022
Visit Reason
A Recertification Survey was conducted at Oak Hill Health & Rehabilitation Center from 05/09/2022 through 05/11/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were cited in multiple areas including employee immunization and screening, resident rights, activities of daily living, treatment and prevention of pressure ulcers, foot care, medication administration, food safety, and staff competencies. The facility failed to provide evidence of required immunizations for staff and had multiple resident care deficiencies related to wound care, medication errors, and documentation.
Deficiencies (12)
Employee Immunization & Screening - Facility failed to obtain evidence of immunity for all health care workers as required.
Resident Rights - Facility failed to ensure residents' rights to request, refuse, and discontinue treatment and to formulate advance directives.
Activities of Daily Living - Facility failed to provide necessary care and services to maintain residents' abilities in activities of daily living.
Treatment/Services to Prevent/Heal Pressure Ulcers - Facility failed to provide necessary treatment and services to prevent and heal pressure ulcers for residents.
Foot Care - Facility failed to provide proper foot care and treatment to maintain mobility and good foot health for residents.
Sufficient/Competent Staff Behavioral Health Needs - Facility failed to ensure sufficient competent staff to meet residents' behavioral health needs.
Drug Regimen Review - Facility failed to ensure monthly drug regimen reviews by a licensed pharmacist for all residents.
Competent Staff - Facility failed to ensure nursing staff had the specific competencies and skills sets necessary to provide nursing and related services.
Food Procurement, Store, Prepare, Serve - Facility failed to ensure food safety requirements including proper cleaning and sanitation of food service equipment.
Resident Records - Facility failed to maintain medical records in compliance with regulations including documentation of air mattress use and wound care.
Abuse, Neglect, and Exploitation Training - Facility failed to provide training to staff on abuse, neglect, exploitation, and dementia management.
Medication Administration - Facility failed to ensure residents were free from significant medication errors and failed to audit medication administration properly.
Report Facts
Census: 95
Total Capacity: 129
Staff Members: 120
Licensed Nurses: 17
Nursing Assistants: 38
Residents Reviewed: 9
Residents with Pressure Ulcers Reviewed: 8
Residents with Foot Care Reviewed: 3
Residents with Behavioral Needs Reviewed: 8
Residents with Weight Reviewed: 12
Residents with Medication Errors Reviewed: 9
Residents with Psychotropic Drug Orders Reviewed: 9
Residents with Abuse Training Reviewed: 120
Report
Aug 15, 2025
Report
Apr 7, 2025
Report
Mar 27, 2025
Report
Oct 2, 2024
Report
Jul 19, 2024
Report
Jul 19, 2024
Report
Jun 6, 2024
Report
Oct 5, 2023
Report
Sep 13, 2023
Report
Jun 19, 2023
Report
May 24, 2023
Report
Feb 8, 2023
Report
Viewing
Loading inspection reports...
