Adviniacare Orchard, Llc
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
that on 9/20 and 9/21/2025, the resident was having pain when moving and complained of 10 out of 10 pain to his/her lower back. Additionally, the progress note revealed that the resident is not able to get out of bed or lift his/her head up without excruciating pain to the back area. His/her baseline is up and out of bed often.
The resident is almost in tears on exam from pain.Review of a progress note dated 9/21/2025 at 11:45 AM, authored by Licensed Practical Nurse, Staff A, revealed she overheard the resident screaming in his/her room. Upon entry, the resident stated that s/he had back pain. Staff A revealed that, .upon entering the room resident was lying in bed crying, reports pain localized to lower back rated 10/10. When asked what happened resident stated [s/he] had slipped and fell out of wheelchair Friday 9/19/25. Residents' roommate also stated ‘[s/he] fell out of [his/her] wheelchair the other day'. [range of motion] in lower extremities elicits pain/discomfort during flexion and extension. Redness and warmth area noted in lower back. No swelling or open areas noted.Review of a hospital Discharge summary dated [DATE REDACTED], revealed that the resident had a compression fracture (a type of break in the vertebrae that causes the bone to collapse) of the L2 vertebrae (a bone in your lumbar region). Further review of the discharge summary revealed that the cause of a compression fracture includes, but is not limited to, a fall or trauma.Record review revealed a physician's order dated 9/23/2025 for tramadol (a narcotic medication used for pain management) 25 mg, to be administered twice daily for pain for 1 week.Review of a statement provided by Nursing Assistant (NA), Staff B, revealed that Resident ID #2 fell on the floor on 9/19/2025 and she helped him/her up to his/her chair with another NA and nurse.During a surveyor interview on 9/24/2025 at 10:19 AM with Staff B, she revealed that on Friday, 9/19/2025, she was standing at the nurse's station when she heard screaming. She entered Resident ID #2's room and found him/her on the floor. The resident stated to Staff B that s/he had fallen and landed on his/her butt. The resident did not complain of pain at that time.During an interview on 9/24/2025 at 12:04 PM, with Registered Nurse, Staff C, she stated that she was the assigned nurse for Resident ID #2 on 9/19/2025. She reported that Staff B informed her the resident was found on the floor but claimed the resident had not fallen. When the surveyor asked whether she had questioned the resident about the incident, Staff C admitted she had not, noting that the resident was crying and appeared frightened. She further acknowledged that she did not perform an assessment or notify the provider regarding the incident.During a surveyor interview on 9/24/2025 at 12:56 PM, with the Director of Nursing Services, she revealed that regardless of if the resident fell from his/her wheelchair or was placed on the floor, that it is still considered a fall. Additionally, she was unable to provide evidence that the resident was evaluated following the fall on 9/19/2025, per the facility policy. Further, she was unable to provide evidence that the provider was notified of the resident's fall until the resident was observed in excruciating pain two days after the fall occurred.
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AdviniaCare Orchard, LLC in East Providence, RI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in East Providence, RI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AdviniaCare Orchard, LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.