The Dawn Hill Home for Rehab and Healthcare
For profit - Limited Liability company
133 Beds
GREEN TREE HEALTHCARE MANAGEMENT
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
38/100
#30 of 72 in RI
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Dawn Hill Home for Rehab and Healthcare has received a Trust Grade of F, which indicates significant concerns about the facility's quality and safety. It ranks #30 out of 72 nursing homes in Rhode Island, placing it in the top half, and #3 out of 5 in Bristol County, meaning only two local options are better. The facility is improving, with issues decreasing from 18 in 2024 to 5 in 2025, but it still has a concerning staff turnover rate of 57%, which is higher than the state average. There have been some serious incidents reported, including a failure to disinfect glucometers for blood glucose monitoring and a case where a resident did not receive critical medication after being readmitted from the hospital, which resulted in a return to the hospital. Despite these weaknesses, the facility has an overall star rating of 4 out of 5, with excellent quality measures, indicating some positive aspects to consider.
- Trust Score
- F
- In Rhode Island
- #30/72
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 57% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $44,425 in fines. Lower than most Rhode Island facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 44 minutes of Registered Nurse (RN) attention daily — more than average for Rhode Island. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
38/100
Top 41%
Review needed
18 → 5 violations
★★★★☆
4.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 18 issues
2025: 5 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 57%
11pts above Rhode Island avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $44,425
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: GREEN TREE HEALTHCARE MANAGEMENT
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (57%)
9 points above Rhode Island average of 48%
The Ugly 33 deficiencies on record
1 life-threatening 2 actual harm
Jun 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 2 of 3 residents reviewed receiving a...
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Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 2 of 3 residents reviewed receiving an antihypertensive (a medication prescribed to lower blood pressure) medication, Resident ID #s 1 and 2.
Findings are as follows:
1. Record review revealed Resident ID #1 was admitted to the facility with a diagnosis including, but not limited to, essential hypertension (high blood pressure).
Record review revealed a physician's order dated 5/27/2025 for Hydralazine 50 milligrams (mg) three times a day, give if the systolic blood pressure (SBP; refers to the top number of a blood pressure reading and indicates the pressure in your arteries when your heart contracts) is greater than 160.
Record review of the May and June 2025 Medication Administration Records (MARs) revealed on the following dates and times the Hydralazine was administered when the SBP was less than 160:
-5/27 at 2:00 PM, SBP of 118
-5/27 at 8:00 PM, SBP of 117
-5/28 at 9:00 AM, SBP of 132
-5/28 at 2:00 PM, SBP of 132
-5/28 at 8:00 PM, SBP of 132
-5/29 at 9:00 AM, SBP of 130
-5/29 at 2:00 PM, SBP of 118
-5/29 at 8:00 PM, SBP of 145
-5/30 at 9:00 AM, SBP of 128
-5/30 at 2:00 PM, SBP of 132
-5/30 at 8:00 PM, SBP of 126
-5/31 at 9:00 AM, SBP of 128
-5/31 at 2:00 PM, SBP of 118
-5/31 at 8:00 PM, SBP of 119
-6/1 at 9:00 AM, SBP of 138
-6/1 at 2:00 PM, SBP of 122
-6/1 at 8:00 PM, SBP of 133
-6/2 at 9:00 AM, SBP of 130
-6/2 at 2:00 PM, SBP of 130
-6/2 at 8:00 PM, SBP of 127
-6/3 at 9:00 AM, SBP of 118
-6/3 at 2:00 PM, SBP of 137
-6/3 at 8:00 PM, SBP of 127
During a surveyor interview on 6/5/2025 at 2:32 PM with Licensed Practical Nurse (LPN), Staff A, she acknowledged that Resident ID #1 was administered the Hydralazine medication when the resident's SBP was less than 160, indicating the resident received the medication when s/he should not have.
2. Record review revealed Resident ID #2 was admitted to the facility with a diagnosis including, but not limited to, essential hypertension.
Record review revealed a physician's order dated 8/6/2024 for Hydralazine 25 mg every 6 hours, hold for a SBP less than 110.
Record review of the May 2025 MAR revealed on the following dates and times the Hydralazine was administered when the SBP was less than 110:
-5/7 at 12:00 PM, SBP of 106
-5/14 at 12:00 AM, SBP of 88
-5/14 at 6:00 AM, SBP of 96
-5/16 at 12:00 PM, SBP of 106
-5/17 at 6:00 AM, SBP of 104
-5/23 at 12:00 PM, SBP of 105
-5/25 at 12:00 PM, SBP of 102
During a surveyor interview on 6/5/2025 at 2:55 PM with LPN, Staff B, she acknowledged that Resident ID #2 was administered the Hydralazine when the resident's SBP was less than 110, indicating the resident received the medication when s/he should not have.
During a surveyor interview on 6/5/2025 at 3:04 PM with the Director of Nursing Services, she was unable to provide evidence that the Resident ID #s 1 and 2 were free from unnecessary medications.
Mar 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that adequate pain managem...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review 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, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 residents reviewed for pain, Resident ID #1.
Findings are as follows:
Review of a community reported complaint submitted to the Rhode Island Department of Health on 3/12/2025 alleged in part that Resident ID #1 was discharged from a hospital at 11:00 AM and admitted to the facility on [DATE] after undergoing extensive back surgery. Additionally, the facility did not have any of his/her medications available, and s/he was subsequently transferred back to the hospital for pain management later that same day. Further, his/her neurosurgeon had ordered Decadron (a steroid medication prescribed to treat inflammation), however the nursing facility was unaware s/he was prescribed it.
1. Record review revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, fusion of the spine and radiculopathy (a condition caused by a pinched nerve in your spine).
Review of a care plan focus area dated 1/31/2025 revealed the resident has pain with a goal for the resident to verbalize adequate pain relief or the ability to cope with incompletely relieved pain.
a. Review of a hospital document titled, Continuity of Care [COC] - Post-Acute Facility dated 1/31/2025 revealed that the resident underwent spinal surgery and was to start taking oxycodone (an opioid medication proscribed to treat moderate to severe pain) one to two tablets every four hours as needed for pain (5 to 10 milligrams [mg]). Additionally, it indicated that his/her pain was well controlled with oral pain medications.
Review of a physician's order dated 1/31/2025 revealed to administer oxycodone, one tablet (5 mg), every 4 hours as needed for pain.
Additionally, record review failed to reveal evidence of an order for oxycodone, two tablets (10 mg), for pain, as indicated on the hospital COC form.
Review of a progress note dated 1/31/2025 at 10:20 PM revealed that the resident was admitted to the facility with his/her family member present (earlier in the day). Additionally, the resident presented with pain upon arrival, his/her pain was escalating after receiving 2 separate administrations of oxycodone 5 mg, and the provider gave a new order to administer oxycodone 10 mg for severe pain. S/he was subsequently transferred back to the hospital for pain management for 10 out of 10 pain (in the late evening).
Review of the January 2025 Medication Administration Record (MAR) revealed that the resident received only 5 mg of oxycodone on 1/31 at the following times:
- 1:00 PM for 8 out of 10 pain
- 5:36 PM for 9 out of 10 pain
During a surveyor interview on 3/13/2025 at 1:11 PM with Registered Nurse, Staff A, she revealed that when reviewing the hospital COC form upon admission, if there are orders to administer one to two tablets of a pain medication, she will verify that with the provider and document it. She further revealed that if a resident is admitted with an oxycodone order indicating to administer one to two tablets, the provider typically orders to administer one tablet for mild to moderate pain, and to administer two tablets for severe pain.
b. Additional review of a hospital document titled, Continuity of Care - Post-Acute Facility dated 1/31/2025 revealed that the resident was receiving Decadron 2 mg every 8 hours in the hospital and had an end date of 1/31/2025 at 9:59 PM. Additionally, it indicated that s/he was to receive another dose on 1/31/2025 at 2:00 PM according to page 11 of the document.
Record review failed to reveal evidence that the resident received the Decadron at 2:00 PM, that the medication had been transcribed to be administered as indicated in the hospital COC form, or that the medication was addressed with the provider.
During a surveyor interview on 3/13/2025 at 12:37 PM with Licensed Practical Nurse, Staff B, she revealed that she reviews the entire hospital COC form and will reference all pages to ensure accuracy and timely administrations of medications, and verifies all orders with the resident's provider.
During a surveyor interview on 3/13/2025 at approximately 1:00 PM with the Regional Director of Nursing Services, she acknowledged that the Decadron order was not listed in one section of the COC document, but was listed on page 11 of the document. Additionally, she revealed she would expect that the staff nurse would have addressed the Decadron order with the resident's provider and document the interaction in a progress note.
During a surveyor interview on 3/13/2025 at 1:54 PM with the Nurse Practitioner, she revealed that she was the provider who verified the resident's medications upon admission and does not recall staff addressing the Decadron medication. Additionally, she revealed that for oxycodone 1-2 tablet orders, she typically will order one tablet for mild/moderate pain and two tablets for severe pain. Further, she acknowledged that if the resident had received the two tablets of oxycodone initially for his/her severe pain, his/her pain may have been better controlled and s/he may not have required transport to the hospital for pain management.
Cross reference F 760 and F 842
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 3 residents reviewed for medication administration, Resident ID #1.
Findings are as follows:
Review of a community reported complaint submitted to the Rhode Island Department of Health on 3/12/2025 alleged in part that Resident ID #1 was discharged from a hospital at 11:00 AM and admitted to the facility on [DATE] after undergoing extensive back surgery. Additionally, the facility did not have any of his/her medications available, and s/he was subsequently transferred back to the hospital for pain management later that same day.
Review of an undated facility provided document titled, Medication Administration/Ordering Education states in part, .To avoid medications being unavailable it is important for nursing staff to order medications in a timely manner and/or utilize all other avenues of obtaining medication such as the Ekit [Emergency medication kit] and RXNow machine [Pyxis machine; an onsite medication dispensing system that securely stores commonly prescribed medications] .When a medication is due to be administered, and it is not in the cart to administer what should be done .Check all other carts/locations where the medication could have been placed. Other carts, all other drawers, med [medication] room, refrigerator, e-kit, RxNow machine. Call the pharmacy to inquire about the medication that is unavailable .Document conversation with pharmacy in a progress note .The MD/NP [Medical Director/Nurse Practitioner] must be made aware if the medication will not be administered timely. Ask provider for new orders .alternative medication or hold medication until ordered medication is available. Progress note must be written to reflect communication with provider .Please remember that medications are doctors orders and if a medication is not available to give then the MD must be made aware that the medication has not been administered so that an alternative may be ordered if appropriate.
1. Record review revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, fusion of the spine, radiculopathy (a condition caused by a pinched nerve in your spine), type II diabetes, high blood pressure, gastro-esophageal reflux disease (GERD), and hyperlipidemia (high fat levels in the blood).
a) Additional record review revealed the following physician's orders:
- 1/31/2025 Atorvastatin, give 10 milligrams (mg) at 4:00 PM for hyperlipidemia
- 1/31/2025 Calcium Carbonate, give 1200 mg at 7:00 AM and 4:00 PM for supplement
- 1/31/2025 Carvedilol, give 12.5 mg at 7:00 AM and 4:00 PM for high blood pressure
- 1/31/2025 Polyethylene Glycol powder, give 17 grams at 7:00 AM and 4:00 PM for constipation
- 1/31/2025 Metformin, give 1000 mg at 7:00 AM and 4:00 PM for diabetes type II
- 1/31/2025 Senna-Docusate Sodium, give 17.2-100 mg at 7:00 AM and 4:00 PM for constipation
Review of a progress note dated 1/31/2025 at 10:20 PM revealed that the resident was admitted to the facility with his/her family member present (earlier in the day). Additionally, the resident presented with pain upon arrival, was treated with several doses of pain relief medication, and was subsequently transferred back to the hospital for pain management (in the late evening) on the same day.
Record review revealed that s/he returned to the facility on 2/1/2025.
Review of the January 2025 Medication Administration Record (MAR) failed to reveal evidence that the resident received his/her Atorvastatin, calcium carbonate, carvedilol, polyethylene glycol, Metformin, or senna-docusate sodium medication on 1/31/2025 at 4:00 PM, when the resident was still present at the facility.
During a surveyor interview on 3/13/2025 at 11:38 AM with Registered Nurse, Staff A, she revealed that if a medication for a resident is unavailable or has yet to be delivered by the pharmacy, she will check the Pyxis machine to see if the medication is available. Additionally, she would notify the provider if a resident missed a medication administration and document it in his/her progress notes.
Record review failed to reveal evidence that the provider was notified of the above-mentioned missed medication administrations.
During a surveyor interview on 3/13/2025 at 12:30 PM with a Registered Pharmacist, he revealed that Atorvastatin, Carvedilol, and Metformin are all available in the Pyxis machine. Additionally, he revealed that calcium carbonate, polyethylene glycol, and senna-docusate sodium are over the counter medications and are available as facility stock.
b) Review of a physician's order dated 2/5/2025 revealed to inject Mounjaro 2.5 mg every Wednesday at 7:00 AM for diabetes type II.
Review of the February 2025 MAR revealed that Mounjaro was documented as 9 by Licensed Practical Nurse, Staff C, indicating Other / See Progress Notes.
Review of a progress note dated 2/5/2025 at 9:48 AM authored by Staff C, revealed that the Mounjaro was not available.
Record review failed to reveal evidence that the pharmacy was contacted or that the provider was notified that the resident's Mounjaro was unavailable to be administered.
During a surveyor interview on 3/13/2025 at 12:45 PM with Staff C, she acknowledged that the Mounjaro was unavailable to be administered and that she did not notify the resident's provider, and she should have.
During a surveyor interview on 3/13/2025 at approximately 1:00 PM with the Regional Director of Nursing Services, she revealed that she would expect the resident to have received the above-mentioned medications as ordered and would expect that staff would have contacted the provider and documented in the progress notes if the resident did not receive his/her medication.
During a surveyor interview on 3/13/2025 at 1:54 PM with the Nurse Practitioner, she revealed that she would expect staff to follow provider's orders and to notify her if a resident does not receive his/her medications.
Cross reference F 697 and 842
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to accurately maintain the resident'...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to accurately maintain the resident's medical record in accordance with accepted professional standards and practices for 1 of 1 newly admitted resident reviewed, Resident ID #1.
Findings are as follows:
Review of a community reported complaint submitted to the Rhode Island Department of Health on 3/12/2025 alleged in part that Resident ID #1 was discharged from a hospital at 11:00 AM and admitted to the facility on [DATE] after undergoing extensive back surgery. Additionally, the facility did not have any of his/her medications available, and s/he was subsequently transferred back to the hospital for pain management later that same day. Further, the resident's neurosurgeon had ordered Decadron (a steroid medication prescribed to treat inflammation), however the nursing facility was unaware s/he was prescribed it.
Record review revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, fusion of the spine and radiculopathy (a condition caused by a pinched nerve in your spine).
Review of a hospital document titled, Continuity of Care [COC] - Post-Acute Facility dated 1/31/2025 revealed that the resident underwent spinal surgery and was to start taking oxycodone (an opioid medication prescribed to treat moderate to severe pain) one to two tablets every four hours as needed for pain (5 to 10 milligrams [mg]).
Review of a physician's order dated 1/31/2025 revealed to administer oxycodone, one tablet (5 mg), every 4 hours as needed for pain.
Additionally, record review failed to reveal evidence of an order for oxycodone, two tablets (10 mg), for pain, as indicated in the hospital COC form, or that the order for multiple tablets was addressed with the provider.
Further review of the hospital COC form revealed that the resident was receiving Decadron 2 mg every 8 hours in the hospital and had an end date of 1/31/2025 at 9:59 PM. Additionally, it indicated that s/he was to receive another dose on 1/31/2025 at 2:00 PM according to page 11 of the document.
Record review failed to reveal evidence that the resident received the Decadron at 2:00 PM, that the medication was transcribed to be administered as indicated in the hospital COC form, or that the medication was addressed with the provider.
During a surveyor interview on 3/13/2025 at approximately 1:00 PM with the Regional Director of Nursing Services, she revealed that she would expect that staff would have addressed the Decadron medication and oxycodone order with the resident's provider and document the interaction in a progress note. Additionally, she was unable to provide evidence that the facility maintained medical records that are accurate.
Cross reference F 697 and 760
Jan 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to provide care consistent with professional standards of practice for 1 of 2 residents reviewed with an ost...
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Based on record review and staff interview, it has been determined that the facility failed to provide care consistent with professional standards of practice for 1 of 2 residents reviewed with an ostomy (colostomy/ileostomy; a surgical procedure that creates an opening (stoma) in the abdomen to divert waste products from the body to an external pouch), Resident ID #1.
Findings are as follows:
Record review of a community reported complaint allegation submitted to the Rhode Island Department of Health on 1/26/2025 alleges that the facility did not have appropriate ostomy bag or staff trained to care for a resident in need of ostomy care.
Review of a facility policy titled, Colostomy and Ileostomy Care last revised on 11/13/2024, states in part, .Applying or changing the pouch .Inspect the color and skin integrity of the stoma and peristomal skin .If applying a two-piece appliance with a separate skin barrier, peel off the paper backing of the prepared skin barrier, center the barrier over the stoma, and press gently to ensure adhesion .Document .type and size of appliance used .Appearance of the stoma and peristomal skin .Notification of physician .if applicable .patients response .
Record review revealed that Resident ID #1 was admitted to the facility in January of 2025 with a diagnosis including, but not limited to, ileostomy status.
Additional record review revealed that s/he has an ileostomy to his/her right lower abdomen. Furthermore, the record revealed a mid-abdominal wound and a group of surgical wounds to his/her left lower abdomen.
Record review revealed a progress note dated 1/26/2025 at 11:18 AM that revealed the resident's family member was requesting the resident to be transferred to the hospital due to concerns that he/she was not receiving appropriate care for the ostomy and the wounds.
Record review of a hospital document dated 1/26/2025 revealed that Resident ID #1 was transferred to the emergency room [ER] and was experiencing pain around the ostomy. Additionally, it revealed that the ostomy appliance(wafer) was not adhered to his/her skin and stool was leaking into a mid-abdominal incision (surgical wound). It further revealed that the facility did not have the correct ileostomy supplies.
Further record review failed to reveal evidence of the size and type of ostomy supplies to be used for the resident.
During a surveyor interview on 1/27/2025 at 12:50 PM with Licensed Practical Nurse (LPN), Staff A, she acknowledged that the wafer did not adhere to the resident's skin, and she needed to cut the wafer because the appliance that the facility had on hand was not the appropriate size. She also indicated that the peristomal skin appeared to have some redness from the leakage of stool as the appliance did not fit properly.
During a surveyor interview on 1/27/2025 at 2:04 PM with Registered Nurse, Staff B, she revealed that she assessed the residents' abdominal wounds on 1/26/2025 and that there was redness to the peristomal area. Additionally, she revealed that the ostomy wafer did not adhere to the resident's abdomen.
During a surveyor interview on 1/28/2025 at 11:08 AM, with the Wound Nurse, Staff C she revealed that she changed the resident's wafer (a device which is fitted or cut to the individual size of the stoma) on 1/24/2025 after being informed by a family member that it was leaking. The wound nurse acknowledged that the wafer did not adhere to his/her skin properly. She further revealed that she ordered a smaller size wafer that was to arrive the next day. She revealed that after she had changed the wafer on 1/24/2025 it held on for a few more hours and was then change again by another nurse because it was leaking.
During a surveyor interview on 1/28/2025 at approximately 11:30 AM with the Director of Nursing Services, she acknowledged that the resident did not receive the appropriate size ostomy supplies to prevent fecal leakage into the abdominal wound.
Dec 2024
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain professional standards of practice relative to a peripherally inserted ce...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain professional standards of practice relative to a peripherally inserted central catheter (PICC - a type of vascular access device [VAD] used to deliver medications directly to the large central veins near the heart) to 1 of 1 resident observed for intravenous (IV) antibiotic administration via a PICC line, Resident ID #321, and 1 of 3 residents reviewed who receive medication in crushed form, Resident ID #77.
Findings are as follows:
1) Review of a facility policy titled, SETTING UP A PRIMARY INFUSION (HYDRATION or MEDICATION) dated 8/2021 states in part, .Attach flush syringe, aspirate for a blood return to determine patency and then flush resident's IV catheter with appropriate flush solution as ordered .Scrub needleless connector on resident's catheter with antiseptic wipe .Attach primed IV tubing to the needleless connector .
Record review revealed Resident ID #321 was admitted to the facility in December of 2024 with a diagnosis including, but not limited to, bacteremia (bacteria in the blood).
Review of a care plan that was initiated on 12/5/2024, revealed that the resident has a PICC line to his/her right arm and receives IV antibiotics for bacteremia.
Record review revealed a physician's order dated 12/4/2024 for ampicillin (antibiotic) 2 grams to be given intravenously every 4 hours for a bacterial infection.
During a surveyor observation on 12/17/2024 at 12:06 PM of Licensed Practical Nurse, Staff A, he failed to assess for blood return prior to administering the ampicillin intravenously.
Additionally, Staff A disconnected the IV tubing due to the infusion pump alarming, and failed to scrub the needleless connector on the resident's catheter prior to reconnecting the IV tubing.
During a surveyor interview immediately following the above observation with Staff A, he acknowledged that he failed to assess for blood return prior to administering the ampicillin to the resident, and failed to scrub the needleless connector prior to reconnecting the IV tubing.
During a surveyor interview with the Director of Nursing Services on 12/17/2024 at 12:30 PM, she acknowledged that she would expect staff to assess the patency of the PICC line by flushing and assessing for blood return prior to infusing IV medication, and scrub the connector prior to connecting the IV tubing.
2) Record review revealed Resident ID #77 was admitted to the facility in March of 2021 with a diagnosis including, but not limited to, dysphagia (difficulty swallowing).
Record review of the face sheet and the care plan revealed special instructions to crush medications.
Record review revealed a physician's order with a start date of 9/5/2024 for Seroquel (a medication used to treat mental health disorders) 50 milligrams (mg) tablet and a 25 mg tablet, to be given together, for a total dose of 75 mg twice daily.
During a surveyor observation on 12/18/2024 at 11:39 AM of Certified Medication Technician, Staff B, she administered both tablets of Seroquel to the resident whole with cranberry juice, not in crushed form, as indicated in the special instructions.
During a surveyor interview immediately following the above observation with Staff B, she acknowledged that she failed to crush the resident's Seroquel per the special instructions.
During a surveyor interview with the Director of Nursing Services on 12/18/2024 at 2:13 PM, she revealed that she would expect the staff to have crushed the resident's Seroquel tablets prior to administering them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide appropriate treatment and services to 1 of 2 residents reviewed with a Sup...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide appropriate treatment and services to 1 of 2 residents reviewed with a Suprapubic Catheter (SPC) (a flexible plastic tube inserted into your bladder via a surgical opening in the abdomen), Resident ID #67.
Findings are as follows:
Record review revealed that the resident was admitted to the facility with a diagnosis including, but not limited to, obstructive and reflux uropathy (condition in which urine flows backward from the bladder to one or both kidneys).
Record review of the textbook, Lippincott Nursing Procedures, 9th Edition, pages 432-33 states in part, Catheter care .Keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder, which increases the risk of CAUTI [A catheter-associated urinary tract infection caused by germs entering the urinary tract through a catheter].
Record review revealed a physician's order dated 7/27/2024 for catheter care to be provided every shift and as needed relative to the SPC tube.
Record review of a care plan dated 7/27/2024 revealed a focus of potential for infection related to SPC with an intervention to maintain the catheter bag below bladder level.
During surveyor observations on 12/17/2024 at 8:43 AM and 9:37 AM, revealed the resident was lying in bed with the catheter bag lying flat on the mattress next to him/her.
During a surveyor interview at 9:37 AM immediately following the above observation with the resident, s/he stated that s/he doesn't know who put the catheter bag on the mattress.
Additional surveyor observations on 12/17/2024 at 9:57 AM and 10:12 AM revealed Nursing Assistants, Staff C and D, entering the resident's room and failing to move the catheter bag below bladder level per the resident's care plan.
During a surveyor interview at 10:12 AM, immediately after the above observation, with Licensed Practical Nurse (LPN), Staff A, he acknowledged that the catheter bag should have been placed lower than the resident's bladder level.
Further surveyor observations on 12/18/2024 at 8:45 AM and 8:52 AM, revealed the catheter bag was lying flat on top of the mattress, next to the resident.
During a surveyor interview on 12/18/2024 at 8:52 AM, immediately following the above observation, the Assistant Director of Nursing Services, acknowledged that the catheter bag was lying on top of the mattress next to the resident. Additionally, she revealed that she would expect staff to maintain the catheter bag below the resident's bladder level, per his/her plan of care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to maintain medical records that are...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to maintain medical records that are complete and accurately documented on each resident, in accordance with accepted professional standards and practices, for 1 of 4 residents reviewed related to urinary catheter (a flexible tube inserted into the bladder to drain urine), and for 1 of 3 residents reviewed related to advance directives, Resident ID #105.
Findings are as follows:
Record review revealed the resident was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, urinary retention.
1. Record review of the resident's physician order list revealed the following conflicting orders related to the size of catheter being utilized for the resident:
- Change the resident's foley catheter monthly and as needed with 16 Fr (French sizing system - measurement of the urinary catheter based on its outer diameter) with 10 mL (milliliter) balloon as needed with a start date of [DATE].
- Change the resident's foley catheter monthly and as needed with 16 Fr, 10 mL balloon every day shift every 30 days for catheter care with a start date of [DATE].
- Change the resident's foley catheter monthly and as needed with 18 Fr, 5 mL balloon for urinary retention every day shift every 30 days with a start date of [DATE].
- Change the resident's foley catheter monthly and as needed with 18 Fr, 5 mL balloon with a start date of [DATE].
During a surveyor interview on [DATE] at 10:28 AM with Licensed Practical Nurse (LPN), Staff G, in the presence of the Regional Director of Sales and Marketing, LPN Staff H, she revealed that the resident's current catheter size is 18 Fr.
Further surveyor interview on [DATE] at 11:20 AM with Staff H, he revealed that the resident's physician order for 16 Fr should have been discontinued, and his/her most recent physician order is for an 18 Fr.
2. Record review of the resident's advanced directives revealed that s/he is a Do Not Resuscitate (a medical order that instructs health care providers not to perform cardiopulmonary resuscitation (CPR) if a patient's heart stops or breathing stops) and No Artificial Nutrition (a medical order to stop or not start providing artificial nutrition and hydration (ANH) to a patient).
Review of the resident's record revealed that another resident's advance directives were uploaded on his/her miscellaneous documents on [DATE] which indicates a Full Code Status (the healthcare team will perform all possible resuscitation procedures to try and save their life, including CPR, defibrillation, and other life-saving measures) and to Administer Artificial Nutrition Via Feeding Tube.
During a surveyor interview on [DATE] at 10:28 AM with Staff H, he asked Staff G to delete the other resident's advance directive uploaded in Resident ID #105's record.
During a surveyor interview on [DATE] at 12:17 PM with the Director of Nursing Services, she acknowledged there were multiple orders for the resident's foley catheter size that did not match. Additionally, she was unable to provide evidence that the resident's medical record was maintained accurately related to his/her advance directives.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to be adequat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 for 1 of 3 residents reviewed related to calling for assistance for pain, Resident ID #75.
Findings are as follows:
Record review of the policy titled Call Bell Policy revealed that the staff should ensure the resident is safe and the call bell is within reach.
Record review of the Minimum Data Set assessment dated [DATE] revealed a Brief interview for Mental Status score of 15 of 15, indicating intact cognition.
During a surveyor observation on 12/17/2024 from 12:28 PM through 12:50 PM, the resident was noted to be yelling out for help asking for assistance related to his/her pain for the past half hour.
During a surveyor interview on 12/17/2024 at 12:55 PM with Nursing Assistant, Staff C, she acknowledged that the resident's call bell was on the ground and failed to be within reach of the resident.
During a surveyor interview on 12/17/2024 at 1:01 PM with the resident, s/he revealed that his/her call bell fell on the floor and has been yelling for help.
During a surveyor interview on 12/17/2024 at 1:38 PM with the Director of Nursing Services, she revealed that she would expect the resident's call bell to be placed within the resident's reach.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional standards...
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Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional standards for 2 of 3 medication storage rooms observed.
Findings are as follows:
Record review of a facility policy titled Medication Storage, last revised on 2/4/2022 states in part, .Medications and biologicals labeled in accordance with currently accepted professional principles, and include:
-Appropriate accessory and cautionary instructions .
-Expiration date, when applicable .
Multi-dose vials which have been opened or accessed (e.g. needle punctured) should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.
During a surveyor observation of the North Medication Storage Room on 12/18/2024 at 10:30 AM, in the presence of Licensed Practical Nurse (LPN), Staff E, 1 vial of Tuberculin Purified Protein Derivative (tuberculin skin test solution) opened and not dated. Staff E acknowledged that the vial should have been dated when opened. Additionally, the manufacturer instructions indicated to discard the vial after 30 days of opening.
During a surveyor observation of the East Medication Storage Room on 12/18/2024 at 11:24 AM, in the presence of LPN, Staff F, one bottle of Ativan Intensol (medication for anxiety) was observed opened and not dated. Staff F acknowledged the vial should have been dated when opened. Additionally, the instructions on the bottle indicated to discard after 90 days of opening.
During a surveyor interview with the Director of Nursing Services on 12/18/2024 at 2:13 PM, she revealed that she would expect that the medication bottles be dated once opened, and that both the Ativan Intensol and Tuberculin should be discarded.
Dec 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based 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, r...
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Based 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 orders for obtaining weights for 2 of 3 residents reviewed, Resident ID #s 1 and 2.
Findings are as follows:
According to Mosby's 4th Edition, Fundamentals of Nursing page 314, states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients.
1. Record review revealed Resident ID #1 was admitted to the facility in December of 2024 with diagnoses including, but not limited to, atherosclerotic heart disease (artery is narrowed or clogged and it is unable to bring enough blood to organs and tissues) with unstable angina pectoris (chest pain), and congestive heart failure.
Record review of a care plan dated 12/4/2024 revealed the resident is at risk for complications related to congestive heart failure with interventions including, but not limited to, weight monitoring as ordered.
Record review of a physician's order dated 12/4/2024 revealed an order for daily weights to be obtained every day shift for monitoring. The order also included instructions to notify the Physician (MD) or Nurse Practitioner (NP) of a weight gain of 3 pounds (lbs.) in one day or 5 lbs. in one week.
Record review of the December 2024 Medication Administration Record (MAR) revealed the daily weights were not obtained on the following dates:
-12/5/2024
-12/6/2024
-12/9/2024
Review of the progress notes failed to reveal evidence that the above weights were obtained or that the MD or NP were notified that they were not obtained.
2. Record review revealed Resident ID #2 was admitted to the facility in November of 2024 with diagnoses including, but not limited to, congestive heart failure, and supraventricular tachycardia (an irregular fast heartbeat).
Record review of a care plan dated 11/23/2024 revealed the resident is at risk for complications related to congestive heart failure with interventions including, but not limited to, weight monitoring as directed.
Record review of a physician's order dated 11/25/2024 revealed an order for daily weights to be obtained every day shift for monitoring. The order also included instructions to notify the MD or NP of a weight gain of 3 lbs. in 1 day or 5 lbs. in one week.
Record review of the November and December MARs revealed the daily weights were not obtained on the following dates:
11/26/2024
11/27/2024
11/28/2024
11/29/2024
11/30/2024
12/1/2024
12/2/2024
12/3/2024
12/4/2024
12/5/2024
12/7/2024
12/9/2024
Review of the progress notes failed to reveal evidence that the above weights were obtained or that the MD or NP were notified that they were not obtained.
During a surveyor interview on 12/10/2024 at approximately 1:15 PM with Licensed Practical Nurse (LPN), Staff A , she acknowledged that she documented that the weights were unable to be obtained on several of the dates above. She revealed that recently the nursing assistants have not been getting the weights. She further revealed that she did not report to the MD or NP that they were unable to obtain the resident's weights, because she was unaware that she was supposed to.
During a surveyor interview on 12/10/2024 at approximately 1:54 PM with LPN, Staff B, he acknowledged that he documented that weights were unable to be obtained on some of the dates above. Additionally, he stated that if he notified the MD or NP that the weights were not obtained, he would have noted it in his progress notes.
During a surveyor interview on 12/10/2024 at approximately 2:00 PM with NP, Staff C , she revealed that orders for daily weights are usually put in place for cardiac reasons. Additionally, she revealed that she was not notified the daily weights for the above residents were not being obtained.
During a surveyor interview on 12/10/2024 at approximately 2:30 PM with the Director of Nursing Services, she revealed that she would expect the daily weights to be obtained per the physician's order. She further revealed that she would expect the next shift to try and obtain the weights if the day shift was unable to obtain them. Additionally, she would expect the nurse to report it to the MD or NP if the weights were unable to be obtained.
Oct 2024
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0635
(Tag F0635)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to obtain complete admission orders ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to obtain complete admission orders for the resident's immediate care for 1 of 1 resident reviewed who was not administered the prescribed medications after being readmitted to the nursing facility from the hospital, Resident ID #1.
Findings are as follows:
Record review of a community reported complaint submitted to the Rhode Island Department of Health on 10/29/2024 alleges that the resident was not administered the prescribed amiodarone (a medication that treats a fast or irregular heart rhythm by reducing symptoms and helps avoid life-threatening complications) on his/her readmission to the facility from the hospital on [DATE]. Additionally, the allegation indicates that the failure resulted in his/her return to the hospital.
Record review revealed that Resident ID #1 was initially admitted to the facility on [DATE] with diagnoses including, but not limited to, congestive heart failure (CHF, a condition that happens when a person's heart can't pump blood well enough to give the body a normal supply. Blood and fluids collect in the lungs and legs over time) and persistent atrial fibrillation (A-fib, a serious fast and irregular heart rhythm that requires medical intervention. If left untreated, a person is placed at risk of developing blood clots that can lead to heart attack or stroke).
Further record review revealed that the resident transferred from the facility to the hospital on 9/28/2024 and subsequently transferred to a different hospital for further management of difficulty breathing and an irregular heart rhythm. S/he was readmitted to the facility on [DATE].
Record review revealed that 22 files containing hospital documents, labeled admission Documents were scanned into the resident's electronic medical record on 10/11/2024.
Additional record review revealed that one of the 22 files contained a 7-pages long document dated 10/9/2024 titled, Patient Information. Page 2 of this document revealed a section titled, Patient's Medications Prior To Admission.
Further record review failed to reveal evidence of a hospital continuity of care form or discharge summary which would include the medication's Resident ID #1 should receive upon readmission to the facility. Additionally, the record failed to reveal evidence of a physician's order for amiodarone dated 10/11/2024.
During a surveyor interview on 10/29/2024 at 2:16 PM, with Registered Nurse, Staff A, she revealed that she was Resident ID #1's Unit Manager. Additionally, she was unable to provide evidence of a hospital discharge summary or continuity of care form that included medications the resident was to receive upon readmission to the facility on [DATE]. Additionally, she acknowledged that the 7-page document revealed a list of medications the resident was on prior to admission to the hospital and did not indicate what s/he was to receive after readmission to the facility.
During a surveyor interview on 10/29/2024 at 2:19 PM, with the Director of Nursing Services (DNS), she revealed that Resident ID #1's medication orders upon readmission to the facility on [DATE] were transcribed from the document titled Patient's Medications Prior To Admission. She indicated that those were the documents the admitting nurse received from the hospital upon the resident's readmission. She indicated that she was made aware of the missed medications concerns after the resident was sent back to the hospital on [DATE]. At this time the facility obtained the DISCHARGE SUMMARY form from the 10/11/2024 hospital discharge which included the medications the resident was prescribed to take.
A telephone interview was attempted with the admitting nurse, Licensed Practical Nurse, Staff B on 10/30/2024 at 9:35 AM, however she was unable to be reached. A voicemail was left, and a return telephone call has not been received.
Further record review of the hospital document dated 10/11/2024 titled, DISCHARGE SUMMARY revealed that Resident ID #1 should start taking the following medications on 10/11/2024:
- amiodarone 400 milligrams (mg) one tablet by mouth three times a day for 2 days, then one tablet once daily for 90 days until s/he follows up with his/her heart specialist.
- Anora Ellipta (inhaler medication used to help improve difficulty with breathing) 62.5-25 micrograms, one puff by mouth once daily.
- furosemide (water pill, used to treat patients diagnosed with heart failure by removing excessive water from the body) 20 mg once daily.
Further record review failed to reveal evidence of physician's orders for the amiodarone, Anora Ellipta, or furosemide dated 10/11/2024 which indicates s/he was not administered the above medications for a total of 16 days.
Additional record review revealed that Resident ID #1 was transferred back to the hospital on [DATE] due to complaints of difficulty breathing.
Review of the hospital Emergency Department (ED) document dated 10/26/2024 revealed that his/her treatment plan includes admission for management of conditions including, but not limited to, A-fib with rapid ventricular rate (a type of irregular heart rhythm, when the heart doesn't have a normal signaling process telling the heart when to beat) CHF and possible aspiration pneumonia. Additionally, the document indicates that the hospital contacted the nursing facility concerning the missed discharge orders from 10/11/2024.
During a surveyor interview with Resident ID #1's physician on 10/30/2024 at 11:30 AM, he indicated that he would expect that the nurse would have contacted the hospital and request the correct continuity of care form and follow the instructions.
During a surveyor interview on 10/31/2024 at 10:51 AM, with the DNS, she stated that the admitting nurse transcribed the orders from the document she received upon the resident's admission and acknowledged that the documents were not the discharge orders. Additionally, she stated that she would have expected that the nurse would have requested the correct discharge documents. She also acknowledged that the resident missed 16 days of his/her Anora Ellipta and furosemide.
Oct 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to treat each resident with respect and dignity in an environment that promotes maintenance of his or her qu...
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Based on record review and staff interview, it has been determined that the facility failed to treat each resident with respect and dignity in an environment that promotes maintenance of his or her quality of life for 1 of 3 residents reviewed, Resident ID #1.
Findings are as follows:
Review of a community reported complaint submitted to the Rhode Island Department of Health on 10/10/2024 alleged that Resident ID #1 was found by his/her family on 10/6/2024, in bed, covered in large amount of dried blood and feces.
Additional review of the complaint revealed a photograph of Resident ID#1 lying in bed with dark brown matter, which appeared to be dry and cracking on both of his/her legs, on the bed sheet and on his/her shirt.
During a surveyor interview on 10/11/2024 at 11:42 AM with the complainant, s/he stated that when a family member arrived on 10/6/2024 the resident was found in bed with his/her legs covered in stool. The complainant stated the stool was so dry it was cracking on his/her skin.
Record review revealed the resident was readmitted to the facility in September of 2024 with diagnoses including, but not limited to, presence of joint implant (hip replacement), diabetes mellitus, and congestive heart failure. The resident was receiving hospice care.
The resident was unable to be interviewed because s/he passed away on 10/7/2024.
During a surveyor interview on 10/11/2024 at approximately 1:00 PM with Licensed Practical Nurse, Staff A, she revealed that she was called to the resident's room on 10/6/2024 and found the resident's legs covered in what they thought was feces. She revealed 2 nursing assistants (NA) cleaned the resident up in bed. Additionally, she revealed that after the resident was cleaned up in bed, she and a NA took the resident to have a shower. During the shower Staff A realized that it was blood and not feces. Staff A stated to this surveyor, That's why it was drying like that because it was blood.
During a surveyor interview on 10/15/2024 at 9:45 AM with NA, Staff B, she revealed that a family member approached her at approximately 4:30 or 5:00 PM on 10/6/2024 and asked to speak to a supervisor. Staff B revealed she followed the family member to the resident's room, and when she entered the room, she observed that the resident had a large amount of stool that was dried and stuck to him/her. Staff B further revealed that it took 3 staff members to clean the resident. Additionally, Staff B revealed that the resident was on her assignment, but this was the first time she had seen the resident during that shift.
During a surveyor interview on 10/15/2024 at 1:45 PM, with the Director of Nursing Services, she revealed that usually the NA's complete rounds to check on the residents at the start of the shift, around dinner time, and around 10:00 PM. She was unable to provide evidence that the resident was checked on at the start of the shift.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed for insu...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed for insulin use, Resident ID #1.
Findings are as follows:
Review of a community reported complaint submitted to the Rhode Island Department of Health on 10/10/2024 alleged that the failed to manage the resident's insulin.
Record review revealed the resident was readmitted to the facility in September of 2024 with diagnoses including, but not limited to, presence of joint implant (hip replacement), type 2 diabetes mellitus, and congestive heart failure. The resident was receiving hospice care.
Record review of a physician's order dated 9/27/2024 for Humalog (insulin) 50/50 kwikpen 100 units/milliliter, inject 6 units at bedtime for diabetes mellitus.
Record review of the Medication Administration Record failed to reveal evidence that the resident received his/her Humalog on 9/27, 9/28, 9/29, and 9/30/2024. It was documented that the insulin was unavailable.
Further record review failed to reveal evidence that the provider was notified that the resident failed to receive his/her Humalog on 9/27, 9/28, 9/29, and 9/30/2024.
During a surveyor interview on 10/11/2024 at 12:25 PM, Licensed Practical Nurse, Staff C, who signed off that the Humalog was unavailable on 9/28/2024,revealed that she didn't remember if she called the pharmacy or the provider to notify them that the Humalog was unavailable.
During a surveyor interview on 10/15/2024 at 12:36 PM with the Nurse Practitioner, she revealed that she was unaware that the Humalog was unavailable on 9/27, 9/28, 9/29, and 9/30/2024. She indicated that she would have expected the nurse to notify the pharmacy that the medication was unavailable and notify the provider.
During a surveyor interview on 10/15/2024 at approximately 1:45 PM with the Director of Nursing Services, she revealed that if the insulin hadn't come from the pharmacy her expectation would be that the nurses call the pharmacy to order the medication and the provider notified. She stated that the facility has an insulin emergency kit, and the order could have been changed if the Humalog kwikpen was unavailable. She could not provide evidence that the pharmacy or the provider were notified that the Humalog was unavailable on 9/27, 9/28, 9/29, and 9/30/2024.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to maintain medical records on each resident that are complete and accurately documented, in accordance with...
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Based on record review and staff interview, it has been determined that the facility failed to maintain medical records on each resident that are complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 3 residents reviewed, Resident ID #1.
Findings are as follows:
Record review revealed the resident was readmitted to the facility in September of 2024 with diagnoses including, but not limited to, presence of joint implant (hip replacement), diabetes mellitus, and congestive heart failure. The resident was receiving hospice care.
Record review of a Health Status Note dated 9/30/2024 written by the Nurse Practitioner reveals in part, .Hospice level of care- Focus on comfort .use Ativan for anxiety. The note indicated that the resident continued to have an order for Ativan.
Record review of the Health Status Note dated 10/4/2024 written by the Nurse Practitioner reveals in part, .Hospice level of care- Focus on comfort .use Ativan for anxiety. The note indicated that the resident continued to have an order for Ativan.
Record review failed to reveal an order for Ativan at the time of the above documentation by the Nurse Practitioner on 9/30 and 10/4/2024. The resident's Ativan order was discontinued on 9/13/2024 and the Ativan wasn't reordered for the resident until 10/6/2024.
During a surveyor interview on 10/15/2024 at 12:36 PM with the Nurse Practitioner, she revealed that when she wrote the above notes, she would have expected the resident to be on Ativan because s/he was on hospice. She acknowledged that the resident failed to have an order for Ativan at the times of her notes.
During a surveyor interview on 10/15/2024 at 1:45 PM, with the Director of Nursing Services, she revealed that she would expect the Nurse Practitioner to complete a review of the resident's current medication as a part of her visit.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that hospice services meet professional standards of principles that apply to individuals providin...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that hospice services meet professional standards of principles that apply to individuals providing services in the facility for 1 of 2 residents reviewed who are receiving hospice services, Resident ID #1.
Findings are as follows:
Record review revealed a physician's order dated 9/27/2024 for Hospice Evaluation and admit as indicated.
Further record review of the Hospice Certification and Plan of Care revealed the resident had a start of care date of 9/28/2024. It reveals that the resident will be seen by the Nurse 3 times a week for the first week, then 1 time a week for the next 10 weeks. It further reveals the Hospice nurse will observe and assess signs and symptoms of declining status and imminent death and coordinate plan of care with facility staff.
Review of the Hospice paperwork provided by the facility failed to reveal evidence of the Hospice Recommendation forms for all hospice nursing visits. These forms are used by hospice to communicate recommendations and resident assessments completed by the hospice nurse.
The resident was unable to be interviewed because s/he passed away on 10/7/2024.
During surveyor interviews on 10/11/2024 and 10/15/2024 with Hospice Nurse, Staff D, she revealed that the resident was seen by another hospice nurse on 10/6/2024, the day before s/he passed away. She further revealed that she had seen the resident on 9/30/2024 and could not explain why the facility did not have a copy of the Hospice Recommendation forms.
During a surveyor interview on 10/15/2024 at approximately 10:00 AM with Hospice Nurse, Staff E, she revealed that she was the nurse on call on 10/6/2024. She came to the facility to assess the resident after s/he had an episode of bleeding. She said she spoke to the nurse and gave them the Hospice Recommendation form. She could not explain why the facility did not have the form on file.
During a surveyor interview on 10/15/2024 at approximately 12:36 PM with the Nurse Practitioner, she revealed that she reviews the Hospice Recommendation forms during her record review. She further reviewed she was unable to review all the visits because they were unavailable. Additionally, she stated she would expect the hospice documentation to be complete so she could review their notes.
During a surveyor interview on 10/15/2024 at approximately 1:45 PM with the Director of Nursing Services, she revealed that she would expect the hospice notes for each visit to be in the resident's hospice binder.
Jul 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure residents are free from ab...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure residents are free from abuse for 1 of 3 residents reviewed, Resident ID # 1.
Findings are as follows:
According to State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last revised 2/2023, .Abuse is the willful infliction of injury .with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .
Resident to Resident Abuse of Any Type
A resident to resident altercation should be reviewed as a potential situation of abuse .Also, when investigating an allegation of abuse between residents, the surveyor should not automatically assume that abuse did not occur, especially in cases where either or both residents have a cognitive impairment or mental disorder. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. In determining whether F 600-Free from Abuse and Neglect should be cited in these situations, it is important to remember that abuse includes the term 'willful'. The word 'willful' means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach .The facility may provide evidence that it completed a resident assessment and provided care planning interventions to address a resident's distressed behaviors such as physical, sexual or verbal aggression. However, based on the presence of resident to resident altercations, if the facility did not evaluate the effectiveness of the interventions and staff did not provide immediate interventions to assure the safety of residents, then the facility did not provide sufficient protection to prevent resident to resident abuse. For example, redirection alone is not a sufficiently protective response to a resident who will not be deterred from targeting other residents for abuse once he/she has been redirected .
Record review of a facility reported incident received by the Rhode Island Department of Health on 7/10/2024 indicated that an incident occurred on 7/10/2024 at approximately 6:20 PM in the hallway. The report alleges that Nursing Assistant, Staff A, witnessed Resident ID #2, push Resident ID # 1 into a precaution bin. Then Resident ID #1 fell to the floor. Resident ID #1 complained of pain to the left arm and face and an X-ray was ordered that showed a dislocation of the left shoulder.
Record review revealed that the alleged victim, Resident ID #1, was admitted to the facility in March of 2021 with diagnoses that include, but are not limited to, Alzheimer's Disease, and anxiety.
Review of the Minimum Data Set Assessment (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3 of 15, which indicates the resident has impaired cognition.
Record review revealed that the alleged perpetrator, Resident ID #2, was admitted to the facility in March of 2022 with diagnoses that include, but are not limited to, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
Review of the MDS, dated [DATE], revealed a BIMS score of 7 of 15, which indicates the resident has impaired cognition.
Record review of the facility's internal investigation revealed that on 7/10/2024 Staff A witnessed Resident ID #2 push Resident ID #1 resulting in Resident ID #1 sustaining a dislocated left shoulder.
During an interview with the Administrator and the Director of Nursing Services on 7/19/2024 at 12:30 PM, they acknowledged that Resident ID #2 pushed Resident ID #1 which resulted in Resident ID #2 dislocating Resident ID #1's left shoulder. They were unable to provide evidence that Resident ID #1 was kept free from abuse.
Jan 2024
6 deficiencies
1 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected 1 resident
Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to provide a safe and sanitary environment to help prevent the transmission of infec...
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Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to provide a safe and sanitary environment to help prevent the transmission of infections relative to disinfecting glucometers (a device used to monitor blood glucose) for 3 of 4 residents observed who require blood glucose monitoring, Resident ID #s 43, 317 and 108.
Findings are as follows:
1. According to the facility's policy last revised in March of 2015 titled, diabetes-care of equipment states in part, .5. If a glucometer is to be used for one resident and then reused for another, the device must be cleaned and disinfected between uses. Directions vary between manufacturers and even between models within brands. Follow the glucometer manufacturer's recommendations for cleaning .
Review of the glucometer manufacturer's User Instruction Manual Reference titled, Assure Prism Multi Blood Glucose Monitoring System, states in part, .Cleaning and Disinfecting: The disinfection procedure is needed to prevent transmission of blood-borne pathogens. The meter should be cleaned and disinfected after use on each patient. This Blood Glucose Monitoring System may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed. We have validated Clorox Healthcare Bleach Germicidal Wipes, dispatch Hospital Cleaner Disinfectant Towels with Bleach, Cavi Wipes1 and PDI Super Sani-Cloth Germicidal Disposable wipe for disinfecting the Assure Prism multi meter .Only wipes with Environmental Protection Agency [EPA] registration numbers listed in the previous tables have been validated for use in cleaning and disinfecting the meter. Any disinfectant product containing these EPA registration numbers may be used on this device .
a) Record review revealed Resident ID #43 was readmitted to the facility in December of 2023 with diagnoses including, but not limited to, type II diabetes. Additionally, review of the Medication Administration Record (MAR) revealed the resident's blood sugars are documented as monitored daily at the following times: 6:30 AM, 8:00 AM, 4:30 PM and at bedtime.
b) Record review revealed Resident ID #317 was admitted to the facility in January of 2024 with a diagnosis including, but not limited to, type II diabetes. Additionally, review of the MAR revealed the resident's blood sugars are documented as monitored daily at the following times: 7:30 AM, 8:00 AM, 11:30 AM and 4:30 PM.
c) Record review revealed Resident ID #108 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, type 2 diabetes mellitus, unspecified viral Hepatitis B (a virus that is passed from person to person through blood), and Syphilis (an infection caused by bacteria that is most often sexually transmitted). Additionally, review of the MAR revealed the resident's blood sugars are documented as monitored daily at the following times: 6:30 AM, 7:30 AM, 9:00 AM, 11:30 AM, 1:30 PM and 4:30 PM.
During surveyor observations on 1/18/2024 during the medication administration task with Licensed Practical Nurse (LPN), Staff D, the following observations were made:
- 10:46 AM, Staff D cleansed the Assure Prism multi glucometer with an alcohol prep pad then obtained Resident ID #43's blood sugar. Staff D then used an alcohol prep pad to clean the glucometer. Staff D did not utilize a validated disinfectant wipe to disinfect the glucometer as per the manufacturer's guidelines, prior to placing the glucometer into a basket containing clean blood glucose supplies and returning it to the cart.
- 11:35 AM ,Staff D obtained Resident ID #317's blood sugar with the same glucometer used for Resident ID #43. Staff D again cleansed the Assure Prism Multi glucometer with an alcohol prep pad prior to entering the room. This surveyor stopped Staff D when she indicated that she was ready to obtain the resident's blood sugar and asked to speak with her for a minute in the hallway.
During a surveyor interview, immediately following the above observation, Staff D stated that she always uses Alcohol prep pads to cleanse the glucometer. She further indicated that she was unaware that this was an improper disinfection practice. Staff D was asked about the manufacturer's instruction manual, she then returned with the appropriate disinfectant wipes, and obtained the blood sugar.
During a surveyor observation on 1/18/2024 with LPN, Staff E, the following was revealed:
12:14 PM, Staff E entered Resident ID #108's room and obtained his/her blood sugar with an Assure Prism Multi glucometer. After obtaining the blood sugar, Staff E wiped the glucometer with an alcohol prep pad, exited the resident's room and placed the glucometer in a plastic basket on the nurse's cart containing clean blood glucose supplies.
During a surveyor interview with Staff E immediately following the above observation he acknowledged that he wiped the glucometer with an alcohol prep pad after obtaining the residents blood sugar. He further revealed that using an alcohol prep pad to disinfect the glucometer after use was his common practice.
During a subsequent interview on 1/18/2024 at 1:43 PM with Staff E he indicated that the glucometer used in the above observation is used for multiple residents on the unit. Additionally, he indicated that he did not have the appropriate sanitizing wipes in the nurse's cart he was using.
During a surveyor interview on 1/18/2024 at 4:19 PM with the Director of Nursing Services (DNS), in the presence of an additional surveyor, she revealed that she would expect that the manufacturer's instructions would be followed for disinfecting the glucometer.
As a result of the facility's failure to follow its own diabetes-care of equipment policy relative to glucometers, and more specifically, the glucometer's reference manual specific to the cleaning and disinfection process, placed all residents who require blood glucose monitoring at an increased risk for the transmission of blood borne pathogens.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of qualit...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality for 1 of 1 resident reviewed relative to the use of an upper extremity splint and for 1 of 5 residents reviewed for offloading heels while in bed, Residents ID #s 13 and 24.
Findings are as follows:
Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
1. Record review of Resident ID #13 revealed s/he was admitted to the facility in May of 2023 with diagnoses including, but not limited to, cerebrovascular disease affecting left non-dominant side (stroke) and contractures of muscle of left upper arm.
Further record review revealed a physician's order dated 5/19/2023 for a blue splint to the left hand during the day then remove at night before applying the white splint. Additionally, review of a physician's order dated 9/23/2023 revealed a left upper extremity elbow splint daily for 4 hours as tolerated.
During a surveyor interview on 1/16/2024 at 10:13 AM with the resident, s/he stated that staff assist him/her with the left hand splint only at night.
During surveyor observations on the following dates and times, there was no evidence of a hand and elbow splint applied:
1/16/2024 at 10:13 AM 1/16/2024 at 12:19 PM 1/16/2024 at 2:32 PM 1/17/2024 at 9:22 AM 1/17/2024 at 10:20 AM 1/17/2024 at 11:48 AM 1/17/2024 at 1:02 PM 1/17/2024 at 2:20 PM
Additional record review failed to reveal evidence that the resident could not tolerate the left elbow splint.
During a surveyor observation of the resident and interview on 1/17/2024 at 2:59 PM with the Licensed Practical Nurse, Staff A, she acknowledged that the resident was not wearing the left elbow or the left hand splint.
2. Record review of Resident ID #24 revealed s/he was readmitted to the facility in January of 2015 with diagnoses including, but not limited to, cerebrovascular disease affecting left non-dominant side and heart failure.
Further record review revealed a physician's order dated 10/13/2022 to float heels while the resident is in bed as tolerated.
During surveyor observations on the following dates and times, the resident failed to have her/his heels offloaded while in bed as ordered:
1/16/2024 at 11:08 AM 1/16/2024 at 12:48 PM 1/16/2024 at 1:50 PM 1/16/2024 at 2:39 PM 1/17/2024 at 10:20 AM 1/17/2024 at 12:21 PM 1/17/2024 at 1:44 PM 1/17/2024 at 2:30 PM 1/18/2024 at 10:23 AM 1/18/2024 at 10:54 AM
Additional record review failed to reveal evidence that the resident could not tolerate his/her feet being offloaded.
During a surveyor interview on 1/18/2024 at approximately 11:00 AM with the resident, s/he revealed that s/he would like his/her feet elevated but the staff don't assist him/her.
During a surveyor observation of the resident and simultaneous interview on 1/18/2024 at 11:04 AM with the Regional Director of Nursing and the Medication Administration Aide, Staff B, they acknowledged that the resident's heels were not offloaded as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide food prepared in a form designed to meet individual needs for 1 of 2 reside...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide food prepared in a form designed to meet individual needs for 1 of 2 residents reviewed for foods being served in a form to meet their individual nutritional needs. Resident ID #62.
Findings are as follows:
Record review of The International Dysphagia Diet Standardization Initiative(IDDSI), reads in part, ice cream is only allowed if the person can tolerate thin liquids .
Record review revealed that the resident was admitted to the facility in March of 2021 with a diagnosis that included but not limited to dysphagia (difficulty swallowing).
Further record review revealed a current physician's order that reads in part .Regular diet, Pureed texture, Honey/Moderately Thick consistency .
During a surveyor observation on 1/17/2024 at approximately 12:15 PM, the resident received ice cream for dessert. Additionally, the soup on her/his lunch tray was thickened with a packet that reads in part, .Hormel Thick & Easy Instant Food & Beverage Thickener, Nectar Consistency/mildly thick .
During a surveyor interview on 1/18/2024 at approximately 2:30 PM with the Administrator she was unable to provide evidence that the resident received food in the appropriate form.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide special adaptive eating equipment and utensils for 2 of 5 residents review...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide special adaptive eating equipment and utensils for 2 of 5 residents reviewed who require special eating equipment, Resident ID #s 60 and 11.
Findings are as follows:
1. Record review revealed that Resident ID #60 was admitted to the facility in October of 2022 with diagnoses including, but not limited to, unspecified macular degeneration (a disease that affects a person's central vision), legal blindness, and dysphagia (difficulty swallowing).
Record review revealed a physician order dated 11/10/2022, which states Divided lip plate with all meals as needed.
Surveyor observations during the lunch meal on 1/17/2024, 1/18/2024, and 1/19/2024 revealed the resident did not receive the divided lip plate as ordered.
During a surveyor interview on 1/19/2024 at approximately 12:45 PM, with Resident ID #60, s/he acknowledged that s/he needs the divided plate due to his/her visual impairment.
During a surveyor interview on 1/19/2024 during the lunch meal service with Licensed Practical Nurse (LPN), Staff A, she acknowledged the resident did not receive the adaptive equipment as ordered.
2. Record review revealed Resident ID #11 was admitted to the facility in October of 2019 with diagnoses including, but not limited to, dysphagia, unspecified lack of coordination, and Bell's palsy (an unexplained episode of facial muscle weakness or paralysis).
Record review revealed a physician's order to, Provide divided lip plate, two handled sip cup, and a built-up spoon for all meals as tolerated.
Surveyor observations of the resident's lunch meal trays on 1/16/2024, 1/17/2024, and 1/18/2024, revealed that s/he did not receive a two handled sip cup for all beverages served.
During a surveyor interview on 1/17/2024 at approximately 12:50 PM with Resident ID #11, s/he revealed in order for him/her to be able to drink hot and cold beverages, s/he needs a two handled sip cup. Further observation revealed the resident did not drink his/her coffee provided as it was not served as ordered in a two handled sip cup.
During a surveyor interview on 1/19/2024 at approximately 2:00 PM, with LPN, Staff C, she acknowledged the resident did not receive the two handled sip cups as ordered by the physician.
During a surveyor interview with the Administrator on 1/19/2024 at approximately 3:00 PM, she was unable to explain why the residents did not receive adaptive eating equipment as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance wi...
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Based on surveyor observation, record review, resident, 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 2 of 6 residents reviewed for inaccurate documentation, relative to the usage of an upper extremity splint and offloading heels while in bed, Residents ID #s 13 and 24.
Findings are as follows:
1. Record review for Resident ID #13 revealed s/he was admitted to the facility in May of 2023 with diagnoses including, but not limited to, cerebrovascular disease affecting left non-dominant side (stroke) and contractures of muscle of left upper arm.
Further record review revealed a physician's order dated 5/19/2023 for a blue splint to the left hand during the day then remove at night before applying the white splint. Additionally, review of the physician's order dated 9/23/2023 revealed a left upper extremity elbow splint daily for 4 hours as tolerated.
During a surveyor observation and interview on 1/16/2024 at 10:13 AM with the resident, s/he stated that staff assist him/her with a hand and elbow splint only at night.
During surveyor observations on the following dates and times, failed to reveal evidence that a hand or elbow splint were applied.
1/16/2024 at 10:13 AM 1/16/2024 at 12:19 PM 1/16/2024 at 2:32 PM 1/17/2024 at 9:22 AM 1/17/2024 at 10:20 AM 1/17/2024 at 11:48 AM 1/17/2024 at 1:02 PM 1/17/2024 at 2:20 PM
Review of the January 2024 Treatment Administration Record (TAR) revealed that the Nurse documented that both the left hand and left elbow splints were applied on the following dates:
1/16/2024 AM 1/17/2024 AM
During a surveyor interview on 1/17/2024 at 2:59 PM with the Licensed Practical Nurse (LPN), Staff A, she acknowledged that the resident was not wearing the left hand and left elbow splints as ordered. Additionally, she acknowledged documenting that they were applied when they were not.
2. Record review of Resident ID #24 revealed s/he was readmitted to the facility in January of 2015 with diagnoses including, but not limited to, cerebrovascular disease and heart failure.
Further record review revealed a physician's order dated 10/13/2022 to float heels while the resident is in bed as tolerated.
During surveyor observations on the following and dates and times, the resident failed to have her/his heels offloaded while in bed as ordered:
1/16/2024 at 11:08 AM 1/16/2024 at 12:48 PM 1/16/2024 at 1:50 PM 1/16/2024 at 2:39 PM 1/17/2024 at 10:20 AM 1/17/2024 at 12:21 PM 1/17/2024 at 1:44 PM 1/17/2024 at 2:30 PM - 1/18/2024 at 10:23 AM 1/18/2024 at 10:54 AM
Review of the January 2024 TAR revealed that the Nurse documented that the resident's heels were offloaded on the following dates:
1/16/2024 AM 1/17/2024 AM
During a surveyor interview on 1/19/2024 at approximately 10:00 AM with Staff A, she acknowledged documenting in the resident's medical record that the resident's heels were offloaded when they were not.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure tha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings are as follows:
1) The Rhode Island Food Code 2018 Edition 4-601.11 states in part, .nonfood contact surfaces of equipment shall be kept free of an accumulation of dirt .and other debris .
During a surveyor observation, in the presence of the Food Service Director (FSD) on 1/16/2024 during the initial walk through of the main kitchen at approximately 10:15 AM the following was observed:
- a build up of a crusted black substance along the inner rim of the stove hood
- liquid spills along the back side of the stove hood
- food accumulation in the drain spout of the steamer
- dust accumulation in the side vents of the steamer
- the convection oven had a build up of grease and grime in the corners of the unit
- the reach in refrigerator unit had black substance on the back wall of the unit
2) The Rhode Island Food Code 2018 Edition 3-501.1 reads in part, .Ready to Eat, Time/Temperature Control for Safety Food, Date Marking reads in part, may not exceed the manufacturer's use by date .
During a surveyor observation of the walk in refrigerator, in the presence of the FSD, on 1/16/2024 at approximately 10:30 AM two 5 pound containers of sour cream revealed a use by date of 1/2/2024.
3) The [NAME] Food Code 2018 Edition 3-501.18 reads in part, .the food shall have an initial temperature of 57 degrees C(Celsius),135 degrees F(Fahrenheit) when removed from hot holding temperature control .
During a surveyor observation on 1/18/2024 at approximately 8:45 AM, a fried egg was being served to Resident #13 with a hot holding temperature of 105.7 degrees F.
4) The Rhode Island Food Code 2018 Edition 4-703.11 reads in part, .hot water mechanical operations by being cycled through equipment that is set up and achieving a utensil surface temperature of 71 degrees C (160 F) as measured by an irreversible registering temperature indicator(temperature once indicated cannot be reversed) .
During a surveyor observation, in the presence of the FSD, on 1/16/2024 at approximately 10:15 AM the irreversible registering temperature indicator that was being used by the facility was a sanitizing temperature strip, not a strip measuring the surface temperature of a utensil.
The FSD revealed to the surveyor that the sanitizing test strip is the test strip that is used by the facility, not the surface utensil test strip.
5) The Rhode Island Food Code 4-501.11 reads in part, .equipment shall be maintained in a state of repair .
During a surveyor observation, in the presence of the FSD , on 1/16/2024 at approximately 10:15 AM the dish machine was not registering 180 degrees per the sanitizing strip the FSD provided to the surveyor.
Additionally, the Eco Lab representative was contacted, and he revealed the spray arms are not spraying on to the surface of the utensils to achieve the proper temperature.
6) The Rhode Island Food Code 5-501.113 reads in part, .covering receptacles .contain food residue and are not in continuous use .
During surveyor observations on the following dates and times the trash receptacles by the dessert/ snack work station were uncovered, when not in use:
1/16/2024 at 10:30 AM
1/17/2024 at approximately 2:15 PM
1/18/2024 at 12:50 PM
1/20/2024 at 11:45 AM
During a surveyor interview with the FSD on 1/16/2024 at approximately 10:45 AM he acknowledged the outdated sour cream, the above mentioned equipment which was in need of cleaning, the dishmachine was in disrepair, and that he was unaware that the surface utensil test strips were to be utilized per the RI Food Code.
During a surveyor interview on 1/20/2024 at approximately 2:30 PM with the Administrator, she was unable to provide evidence that the fried eggs were served within the appropriate temperature ranges and that the trash was covered when not in use. Additionally, she acknowledged the dish machine was in disrepair.
Dec 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to protect the resident's right to be...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to protect the resident's right to be free from physical abuse for 1 of 4 resident's reviewed, Resident ID #2.
Findings are as follows:
Record review of a facility reported incident submitted to the Rhode Island Department of Health on 12/26/2023 indicated that on 12/22/2023, Resident ID #2 (victim) revealed to a staff member that s/he was choked by their roommate, Resident ID #1 (perpetrator).
Review of the facility policy titled, Abuse Prohibition states in part, It is the policy of this facility to ensure that all residents are treated with respect and dignity and that all residents are free from abuse .Definitions: Abuse = [equals] willful infliction of injury .
1) Record review revealed Resident ID #1 was admitted to the facility in May of 2021 with a diagnosis including, but not limited to, unspecified dementia without behavioral disturbance. Record review of his/her quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment.
Record review of the resident's care plan initiated on 5/9/2022 revealed the resident can often feel anxious and become easily agitated due to his/her diagnoses of bipolar disorder, depression, adjustment disorder, and dementia. Interventions include, but are not limited to, monitor and record mood to determine if problems seem to be related to external causes; monitor, record, and report to the physician as needed mood patterns signs and symptoms of depression, anxiety, observe for signs and symptoms of increased irritability, frequent mood changes and agitation.
Record review of the Treatment Administration Record (TAR) revealed an order dated 6/26/2023 to monitor for the following targeted behaviors such as hallucinations, paranoia, aggression, anxiety and document + [positive] if present - [negative] if not present every shift for monitoring.
Further record review of the TAR revealed the resident did not have any documented behaviors on 12/22/2023.
Record review of the progress note dated 12/22/2023 authored by the physician, revealed that the resident is aggressive, combative, reportedly attempted choking [his/her] roommate on the neck per roommate's statement.
2) Record review revealed Resident ID #2 was admitted to the facility in June of 2023 with a diagnosis including, but not limited to, Schizophrenia. Record review of his/her Quarterly MDS assessment dated [DATE] revealed a BIMS score of 6, indicating severe cognitive impairment.
Record review of a progress note dated 12/23/2023 authored by the physician, revealed that the resident was examined and appeared confused and anxious. Additionally, a small area on his/her lower neck revealed mild redness.
Record review of a statement dated 12/22/2023 for Nursing Assistant, Staff A, indicated that Resident ID #1 had placed his/her hands on Resident #2's chest area while saying, are you afraid to die?
During a surveyor interview on 12/27/2023 at 8:14 AM with the Director of Nursing Services (DNS), she revealed that the second shift supervisor determined that this incident wasn't reportable since there was no intent or harm.
During a surveyor interview on 12/27/2023 at 9:57 AM with Staff A, in the presence of the DNS, she revealed while taking Resident ID #2 to the bathroom on 12/22/2023 she indicated the resident appeared afraid. She further revealed that Resident ID #2 indicated to her that his/her roommate seemed agitated and stated, don't leave me alone, stay with me. Staff A revealed that she did not let anyone know that Resident ID #2 was afraid of Resident ID #1 and told the resident not to worry. Additionally, she revealed later that evening she was walking the hallway and heard two residents arguing, she went into their room and saw Resident ID #2 yelling from the bed. Resident ID #1 stated, are you afraid of dying because I am going to choke you. Staff A revealed s/he looked mad and furious and demonstrated how Resident ID #1 had his/her hands on Resident ID #2, one hand was on the resident's lower neck and the other hand was on his/her shoulder, holding the resident down.
During a surveyor interview on 12/27/2023 at approximately 2:30 PM with the DNS in the presence of the Administrator, they were unable to provide evidence that the facility kept Resident ID #2 free from physical abuse.
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based 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 o...
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Based 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 for pressure ulcers, Resident ID #1.
Findings are as follows:
According to the 1/30/2020 Center for Disease Control (CDC) document titled, Hand Hygiene Guidance, it states in part, .Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications .Before moving from work on a soiled body site to a clean body site on the same patient .after contact with blood, body fluids, or contaminated surfaces .immediately after glove removal .
Review of the facility policy titled, Clean Dressing Technique, revealed in part, .PROCEDURE .1. Check the physician order for current, correct treatment .
Review of the resident's record revealed s/he was admitted to the facility in July of 2023 with diagnoses including, but not limited to, osteomyelitis of vertebra sacral and sacrococcygeal region (infection of the bone in the portion of the spine between the lower back and the tail bone), pressure ulcer of the left and right heels, and pressure ulcer of the left buttock.
Review of the resident's care plan, revised on 7/21/2023, revealed s/he was admitted to the facility with a stage 4 (a deep wound that may impact muscle, tendons, ligaments and bone) sacral pressure ulcer, a stage 3 (ulcers that affect the top two layers of skin as well as fatty tissue) posterior thigh pressure ulcer, and suspected deep tissue injuries (DTI- an injury to underlying tissue below the skin surface that results from prolonged pressure in an area of the body) to both the left and right heels with an intervention to provide wound care per the treatment order.
Review of a document titled, Order Summary Report, revealed the following physician's orders, dated 8/2/2023:
- Cleanse the coccyx (tailbone) with normal saline or wound wash, damp to dry using calcium alginate (an absorbent wound dressing) dampened with ¼ strength Dakin's Solution (broad spectrum antimicrobial cleanser) and dry clean dressing twice daily for wound care
- Cleanse left thigh with normal saline or wound wash, damp to dry using calcium alginate dampened with ¼ strength Dakin's Solution and dry clean dressing twice daily for wound care
- Cleanse right heel with Vasche (saline based wound cleanser that contains hypochlorous acid as a preservative that inhibits microbial contamination), apply Santyl (ointment that removes dead tissue from the wound) to the wound bed, then calcium alginate followed by bordered foam twice daily for wound care
- Apply skin prep (protective wipe that forms a barrier to help preserve skin integrity) to left heel twice daily for wound care
During a surveyor observation on 8/8/2023 at approximately 12:00 PM with Licensed Practical Nurse, Staff A, she was observed applying Santyl to the wound beds, then applying a dry calcium alginate dressing, followed by a Dakin's-soaked gauze when providing wound treatments to the coccyx and thigh sites.
Surveyor observation of the right heel treatment revealed Staff A did not apply Santyl to the wound bed and applied betadine (antiseptic used for skin disinfection before and after surgery) after applying skin prep to the left heel DTI.
Additionally, surveyor observation revealed when Staff A cleaned the coccyx, thigh, and right heel sites, she did not perform hand hygiene when changing her gloves before she continued to complete the wound treatments and applying a clean dressing to all three sites. Furthermore, she failed to perform hand hygiene after removing her gloves and prior to applying a new pair of gloves when working from a soiled wound site and moving to a clean wound site per the facility's policy.
During a surveyor interview on 8/8/2023 at approximately 1:00 PM with Staff A, she acknowledged that she did not follow the physician's treatment orders or perform hand hygiene when changing her gloves while providing the wound treatments to the resident.
During a surveyor interview on 8/8/2023 at 1:40 PM with the Director of Nursing Services (DNS), she indicated that her expectation would be that the nurse would follow the physician's wound treatment orders. Additionally, she indicated that after the surveyor's wound treatment observations were brought to her attention, she realized the wound physician's recommendations were incorrectly transcribed by the wound care nurse.
During a surveyor interview on 8/8/2023 at 2:48 PM with the physician, he indicated that his expectation would be that staff would perform hand hygiene as indicated by the CDC guidelines. Additionally, he stated the procedure for following recommendations from providers outside of the facility is that they are reviewed by either himself, or another facility provider, before the orders are implemented.
During a surveyor interview on 8/8/2023 at 3:30 PM with the Nurse Practitioner, she indicated that it is her practice to follow the Wound Care Physician's recommendations. Additionally, she reviewed the orders that were transcribed into the resident's record by the Wound Care Nurse and revealed that she did not provide those orders to treat the resident's wounds and would have expected the Wound Care Physician's recommendations to have been entered into the resident's record and those orders to be followed.
Record review of a progress not dated 8/2/2023, authored by the Wound Care Nurse, states in part, patient seen for wound round by wound md [medical doctor] orders modified from last wound assessment and approved by N.P [Nurse Practitioner] .
Apr 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record review, resident and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to following physician's orders for 1 of 3 resi...
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Based on record review, resident and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to following physician's orders for 1 of 3 residents reviewed, Resident ID #1 relative to medication management.
Findings are as follows:
Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
Record review of a community reported complaint sent to the Rhode Island Department of Health on 4/15/2023 alleges that Resident ID #1 was not given his/her medications.
Record review revealed that the resident was admitted to the facility in January of 2023 with diagnoses that include, but are not limited to, acute pyelonephritis (a bacterial infection causing inflammation of the kidneys), osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) and hypertension (high blood pressure).
Record review of the 5-day Minimum Data Set (MDS) Assessment completed in January of 2023 revealed a Brief Interview for Mental Status Score of 13 out of 15 revealing the resident is cognitively intact.
During a surveyor interview on 4/18/2023 at 10:09 AM with the resident, s/he revealed that s/he wasn't provided with all of his/her medication while at the facility.
Record review of the physician's orders revealed the following:
- Fosamax oral tablet 70 mg (milligrams). Give 1 tablet by mouth one time a day every Saturday for osteoarthritis with a start date on 1/14/2023 at 7:00 AM\
- Estrace vaginal cream 0.1 mg/gm (gram). Insert 1 suppository vaginally at bedtime every Thursday and Saturday for estrogen therapy with a start date on 1/12/2023 at 7:00 PM.
- Meloxicam oral tablet 7.5 mg by mouth one time a day for pain and discomfort with a start date on 1/11/2023 at 7:00 AM
- Azelastine HCL ophthalmic solution 0.05%. Instill 1 drop in both eyes two times a day with a start date on 1/11/2023 at 8:00 AM
- Methenamine Hippurate oral tablet 1 gm. Give 1 tablet by mouth two times a day for prevention of a urinary tract infection with a start date on 1/11/2023 at 8:00 AM
- Metoprolol Succinate Extended Release (ER) 50 mg tablet. Give 1 tablet by mouth two times a day for hypertension with a start date on 1/11/2023 at 8:00 PM
Record review of the Janaury Electronic Medication Administration Records (EMAR) revealed the following:
- on 1/14/2023 (Saturday) at 7:00 AM, Fosamax was coded as not being in the facility
- on 1/12/2023 (Thursday) at 8:00 PM, Estrace vaginal cream was not checked off as given
- on 1/11/2023 at 7:00 AM, Meloxicam was coded as not being in the facility
- on 1/11/2023 and on 1/12/2023 at 8:00 AM, Azelastine HCL was coded as not being in the facility
- on 1/11/2023 at 8:00 AM, Methenamine Hippurate was coded as not being in the facility
- on 1/15/2023 at 8:00 PM, Metoprolol Succinate was coded as not being in the facility.
During a surveyor interview with the Director of Nursing Services on 4/18/2023 at approximately 2:45 PM, she was unable provide evidence that the medications listed above were administered to the resident as ordered.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview, it has been determined that the facility failed to provide a dietary menu ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview, it has been determined that the facility failed to provide a dietary menu that meets the nutritional needs of residents in accordance with established national guidelines and that was reviewed by a clinically qualified nutritional professional as evidenced by a planned menu which failed to follow the facility diet manual.
Findings are as follows:
Record review of the facility's diet manual titled, Maryland Department of Health and Mental Hygiene Diet Manual for long term care residents 2014 Edition, reveals in part, the regular diet is designed for residents who do not require any dietary restrictions.
The Dietary Guidelines for Americans, 2010 and My Plate for Older Adults 2011 have been used as the basis for this and all other diets and menus in this edition. The regular diet reveals 2 or more servings of fruits daily.
Record review of the Dietary Guidelines for Older Adults established by the USDA (US Department of Agriculture) for 2020-2025, revealed the daily dietary guidelines include, but are not limited to: .2 cups of fruit ., for older adults [AGE] years of age and older.
Record review of a community reported complaint sent to the Rhode Island Department of Health on 4/15/2023 reveals that Resident ID #1 alleges that the food was inedible.
Record review revealed that the resident was admitted to the facility in January of 2023 with diagnoses that include, but are not limited to, acute pyelonephritis (a bacterial infection causing inflammation of the kidneys), osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) and hypertension (high blood pressure).This resident was discharged in January of 2023.
During a surveyor interview with Resident ID #1 on 4/18/2023 at 10:06 AM, s/he revealed that s/he likes fresh fruit and did not receive any while at the facility.
Record review of the facility's planned menus failed to reveal 2 servings of fruit for week 1 on Sunday, Monday, and Wednesday, for week 2 on Monday and Thursday, for week 3 on Wednesday, and for week 4 on Sunday. Additionally, all 4 weeks of menus failed to reveal any fresh fruit.
During a surveyor interview on 4/18/2023 at 11:25 AM with Resident ID #2, s/he revealed that s/he has not received any fresh fruit and would like it to be offered to him/her.
During a surveyor interview with Resident ID #3 on 4/18/2023 at 12:30 PM, s/he revealed that s/he would like fresh fruit like apples and oranges, and that s/he has not received any fresh fruit.
During a surveyor interview on 4/18/2023 at 12:45 PM with the facility's Registered Dietitian, she revealed that she was not involved in planning the menu. Additionally, she acknowledged the menu is nutritionally inadequate.
Apr 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on record review, resident representative interview, and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors f...
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Based on record review, resident representative interview, and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 2 residents reviewed, Resident ID #2.
Findings are as follows:
Review of a community reported complaint submitted to the Rhode Island Department of Health on 3/30/2023, alleges that the resident may have missed doses of insulin and hydralazine (a blood pressure medication) while at this facility.
During a surveyor telephone interview on 3/31/2023 at 12:45 PM with the resident's family member, s/he questioned if the resident received all of his/her insulin since his/her blood sugar was high shortly after s/he was admitted . S/he further indicated that s/he felt the resident did not receive all of his/her hydralazine doses due to the amount that was left and was provided to him/her at discharge.
Record review revealed the resident was admitted to the facility in March of 2023 with a diagnosis of Type 2 Diabetes Mellitus with Ketoacidosis (a serious diabetic complication where the body produces excess blood acids and ketones. This occurs when there is not enough insulin in the body).
Record review revealed a physician's order for insulin glargine solution 100 units/milliliter. Inject 40 units subcutaneously one time a day for diabetes with a start date of 3/10/2023 at 8:00 AM.
Record review of the March 2023 Medication Administration Record (MAR) failed to reveal evidence that the resident received his/her insulin on 3/10/2023 at 8:00 AM.
Additional review of the MAR revealed that on 3/11/2023 at 8:00 AM the resident had a blood sugar reading of 577 mg/d (milligrams per deciliter; a blood sugar level reading of 70 mg/dl to 140 mg/dl is a normal blood sugar reading).
Further record review revealed a physician's order for guaifenesin extended release, 1 tablet by mouth every 12 hours for congestion to start on 3/9/2023 and an order for hydralazine HCL 10 mg by mouth four times a day for hypertension (high blood pressure) to start on 3/9/2023.
Further review of the March 2023 MAR failed to reveal evidence that the resident received the following medications:
- hydralazine HCL oral tablet 10 mg on 3/9/2023 at 9:00 PM
-guaifenesin ER tablet extended release on 3/9/2023 at 8:00 PM and 3/10/2023 morning dose
During a surveyor interview with the Director of Nursing Services on 4/3/2023 at 10:31 AM she was unable to provide evidence that the resident received the above mentioned medications.
Feb 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident receive...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for falls, Resident ID #7.
Findings are as follows:
Record review of a facility policy and procedure document titled Falls Reduction Program states in part, .establish a care plan that identifies risk factors exhibited by the resident and which directs employees regarding measures to be taken to mitigate or eliminate those risk factors .The at-Risk Committee is responsible to review the resident record, perform in-depth analysis of each event .to assure that .interventions are in place to reduce risk of future falls .9. Evaluate .interventions already put into place to reduce each resident's risk of falls .Develop action plans for facility interventions related to risk reduction .
Record review of a facility reported incident submitted to the Rhode Island Department of Health on 1/30/2023 states in part, Patient sustained unwitnessed fall .sent to hospital .admitted to [hospital] .
Review of hospital documentation dated 1/29/2023 states in part,
.SNF [Skilled Nursing Facility] found this morning, trying to get to bathroom w/o [without] walker, tripped and fall .Patient states that [s/he] tripped on [his/her] way to the bathroom and was unable to get up .Patient also with 2 parietal occipital [back of the head] scalp hematomas [abnormal collection of blood outside of a blood vessel due to disease or trauma] .left-sided fifth or seventh rib fractures, ninth and 10th rib fractures, and a questionable eighth rib fracture. Humerus [bone of upper arm] fracture confirmed .Reportedly, often ambulates to bathroom without [his/her] walker .
Record review revealed the resident was admitted to the facility in March of 2022 with diagnoses including, but are not limited to, metabolic encephalopathy (disturbed brain function from diseases or toxins in the body), chronic obstructive pulmonary disease (lung disease), difficulty in walking, and dementia.
Review of a facility assessment titled, MORSE FALL SCALE dated 3/30/2022 revealed the resident was a high fall risk.
Review of the Minimum Data Set Assessment (MDS) dated [DATE] revealed the resident has long and short-term memory problems and s/he has severely impaired cognitive skills for daily decision making.
Further review of the MDS Assessment indicated the resident had repeated falls, utilizes a walker and requires a one-person physical assist for transfers, walking within the room, and toileting.
Review of a care plan focus area dated 4/11/2022 states in part, [Resident] is at risk for falls related to difficulty in walking .patient ambulating without AD [assistive device].
Further review of the care plan dated 1/30/2023 revealed the resident fell 8 times between 8/30/2022 through 1/29/2023. Additionally, interventions relative to falls included, but are not limited to:
-Assist the resident with early get-up if awake.
-Reinforce teaching regarding calling for assistance when s/he wants to get up.
-Anticipate and meet needs.
-Monitor gait and balance.
-PT [physical therapy] screen for walker with oxygen, dated 12/31/2022.
Record review failed to reveal evidence the above-mentioned interventions were implemented or followed. Additionally, the resident was not currently receiving therapy services including, PT/OT [occupational therapy] between 12/27/2022 through 1/29/2023, the day the resident was sent to the hospital for evaluation after sustaining a fall on 1/29/2023.
Record review revealed the following progress notes:
-12/31/2022 at 7:11 PM .resident attempt to stand .lost [his/her] balance and landed on [his/her] buttocks .
-1/17/2023 at 3:39 PM Authored by the Physician, .Routine Encounter .ongoing .PT/OT .no acute concerns at this time .Resident States [s/he] is feeling well .no complaints .Promote fall and safety precautions .
-1/27/2023 at 11:47 AM .Resident fell .
-1/29/2023 at 6:54 AM .Noted to be on the ground .R [right] Arm appears to be broken .911 called .
-1/31/2023 at 2:17 PM .contacted residents POA [power of attorney] informed writer that [s/he] is unable to be stabilized at this time and is actively dying .
During a surveyor interview on 2/9/2023 at 12:14 PM with the resident's POA, she revealed the resident had passed away on 2/2/2023.
Review of a facility incident report conducted after the resident fell on 1/29/2023 revealed the resident's room was poorly lit. Additionally, it revealed the resident was confused and had a gait imbalance.
During a surveyor interview on 2/8/2023 at 11:58 AM with Registered Nurse, Staff A, she revealed the resident uses a 3 wheeled walker and is on continuous oxygen therapy. She further revealed the resident is impulsive and forgetful, and often goes to the bathroom without his/her walker.
During a surveyor interview on 2/8/2023 at 12:16 PM with Licensed Practical Nurse, Staff B, she acknowledged she was the nurse on duty when the fall occurred. She revealed she entered the resident's room at approximately 6:25 AM to administer morning medications to his/her roommate and noted Resident ID #7 seated upright on his/her bed. She further revealed the room was dark and the resident's walker was noted by the dresser which was out of the resident's immediate reach. At approximately 6:45 AM, Nursing Assistant, Staff C, alerted her the resident was noted on the ground in front of the roommate's bureau (which is right before the bathroom door.) Additionally, Staff B revealed she was unaware of the interventions in the resident's care plane that indicated staff were to assist the resident with early get-up if awake and to anticipate his/her needs.
During a surveyor interview on 2/9/2023 at 12:58 PM with the Assistant Director of Nursing Services, she revealed residents who are identified as fall risks are discussed during the weekly at-Risk meetings held on Wednesdays. Additionally, residents are also added to the at-Risk report after sustaining a fall. She further revealed appropriate interventions are formulated during the post-fall assessment and the care plan is updated. She was unable to provide evidence the resident was identified and discussed during the weekly at-Risk meetings. She revealed she would expect the care plan to be updated and the interventions followed per the plan of care. Furthermore, she was unable to provide evidence the facility ensured and promoted the safest environment for the resident to prevent or mitigate accidents.
Dec 2022
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and servic...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 1 residents reviewed with pressure ulcers/injury, Resident ID #2.
Findings are as follows:
Record review of the facility's policy titled Prevention of Pressure Ulcer/Injuries states in part, .Support Surfaces and Pressure Redistribution Select appropriate surfaces based [on] the resident's mobility .body size, weight .
Record review revealed the resident was admitted to the facility in November of 2022 with diagnoses that include but are not limited to, end stage renal (kidney) disease, dependence on renal dialysis (a procedure that removes waste products and excess fluid from the blood when kidneys stop working properly), and peripheral vascular disease (a disease that causes decreased blood flow to the legs).
Record review of a care plan initiated on 11/23/2022 states in part, .at risk for developing pressure injuries due to limitations in mobility and urinary incontinence. admitted with DTIs [deep tissue injury, pressure ulcers that are caused by damage of underlying soft tissue from pressure] to .heels .toes and abrasion to L [left] buttocks .
Interventions include but are not limited to the following:
-
Initiated on 11/23/2022 .Provide pressure relieving and positioning devices as ordered .
-
Initiated on 12/5/2022 .Prevalon boots (cushioned boots that help keep the feet floating to reduce
pressure) when in bed as tolerated .
Record review of the December 2022 Treatment Administration Record (TAR) revealed an order for Prevalon boots on while in bed as tolerated every shift for wound prevention/healing with a start date of 12/5/2022. Additionally, the order was observed to be signed off as administered for the evening and night shift on 12/5/2022 and the day shift on 12/6/2022.
During a surveyor observation on 12/6/2022 at 10:53 AM, revealed the resident lying in bed with his/her feet exposed without wearing Prevalon boots. Furthermore, the Prevalon boots were not observed in the resident's room. The resident was also observed to by lying on an air mattress with the weight set at 280 pounds (lbs).
During a surveyor interview with the Wound Nurse on 12/6/2022 at 3:18 PM, she was unable to provide evidence of an order for the air mattress. Additionally, she was unable to answer why the air mattress was set at 280 lbs despite the resident's documented weight of 145.4 lbs on 11/29/2022. Furthermore, she indicated that she would expect there to be an order in place for the air mattress with settings by weight or comfort as tolerated.
During a surveyor interview with Nursing Assistant (NA), Staff A, on 12/6/2022 at approximately 12:55 PM she indicated that she was the resident's assigned NA. Additionally, when asked why s/he was not wearing Prevalon boots while in bed she indicated that she was unaware that the resident had an order for special boots to be worn while in bed.
Record review of a document titled Resident Care Card failed to reveal evidence of instructions for positioning devices until after the surveyor requested a copy of the document.
During a surveyor interview with Registered Nurse (RN), Staff B, on 12/6/2022 at approximately 1:00 PM in the presence of the North Unit secretary, she was unable to state why the resident was not wearing Prevalon boots while in bed during the surveyor's observation despite signing the TAR as administered for 12/6/2022 day shift. Additionally, she could not answer why the boots were not visible in his/her room. Furthermore, the North Unit Secretary indicated that the boots were in the resident's room in a bag.
During a surveyor interview with the Director of Nursing Services on 12/6/2022 at 1:18 PM, she indicated that the wound nurse received the Prevalon boots on 12/5/2022 and that she would expect staff to apply them as ordered and document accurately on the TAR.
During a surveyor observation and interview with RN Staff C on 12/6/2022 at 1:24 PM, she revealed the Prevalon boots were in the resident's room closet sealed in the plastic manufacturer's bag.
Additionally, Staff C acknowledged the above-mentioned findings and indicated she would expect the boots to be removed from the plastic bag and applied to the resident's feet while in bed as ordered.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each resident receives care to prevent accidents for 1 of 2 residents ...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each resident receives care to prevent accidents for 1 of 2 residents reviewed for falls, Resident ID #2.
Findings are as follows:
Record review of a facility policy titled Safe Resident Handling states in part, .It is the policy of this facility to ensure that our residents are cared for safely .Direct resident care employees are to assess all resident handling tasks in advance to determine the safest way to accomplish them .approved resident handling aids are to be used to prevent manual lifting and handling of residents .which will prevent .injuries to residents which result from manual lifting, transferring and positioning .
Record review of the facility nursing assistant education meeting dated 10/26/2022 states in part .Safe transfers .
Further review revealed a document titled .Assisted Sit-Pivot Transfers .To and From a Wheelchair . states in part, .Your caregiver will help you .and grab your transfer belt .
Record review revealed the resident was admitted to the facility in November of 2022 with diagnoses that include but are not limited to osteoarthritis, end stage renal (kidney) disease, and dependence on renal dialysis (a procedure that removes waste products and excess fluid from the blood when the kidneys stop working properly).
Record review of a care plan initiated on 11/23/2022 indicates the resident has an AV fistula (a connection that is made between an artery and a vein for dialysis access) to his/her left arm.
Record review of a resident safe handling evaluation dated 12/1/2022 revealed that the resident requires the assistance of two staff members for transfers to and from the toilet.
Further record review of the December 2022 Treatment Administration Record (TAR) revealed an order with a start date of 11/23/2022 which states in part, upper extremity restrictions r/t [related to] AV fistula to both arms .
During a surveyor observation on 12/6/2022 at 1:02 PM in the presence of the resident's family member revealed Nursing Assistant, Staff D and Registered Nurse, Staff C assisting the resident with transferring from his/her wheelchair to the toilet. Staff D and C were observed to place a gait belt around the resident's waist prior to transferring him/her. Staff D was then observed to grab the resident by his/her left arm and not the gait belt. The resident's family member intervened and informed Staff D to be careful of his/her fistula.
During a surveyor interview with Staff D at 1:08 PM she indicated that it was the first time she had assisted in the resident's care and was unaware of his/her order for restrictions to the upper extremities related to the AV fistula.
Review of the Resident Care Card failed to reveal evidence of the resident's upper extremity restrictions related to the AV fistula until after the surveyor's interview with Staff D, which was approximately 2 weeks after the resident was admitted to the facility.
During a surveyor interview with the Director of Nursing Services on 12/6/2022 at 3:09 PM she indicated that her expectations are for staff to hold the gait belt during transfers and not the resident's arm. Additionally, she acknowledged that the Resident Care Card did not have the information regarding the resident's upper extremity restrictions related to AV fistula prior to 12/6/2022.
Nov 2022
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility has failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent wit...
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Based on record review and staff interview, it has been determined that the facility has failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 7 residents, Resident ID #46.
Findings are as follows:
Record review revealed the resident was admitted to the facility in December of 2021 with a diagnosis to include but not limited to heart failure.
Record review of a care plan initiated on 1/26/2022 and revised on 8/22/2022 for .is at risk for alteration in skin integrity r/t [related to] impaired mobility, incontinence, and impaired nutrition .Administer skin treatments as ordered by physician .
Record review of Skin/Wound Note dated 10/20, 11/10 and 11/16/2022 revealed recommendations to apply skin prep to the right heel daily by the Wound Consultant, Staff A.
Record review failed to reveal evidence that the skin prep was applied to the resident's right heel since it was recommended by the wound specialist on 10/20, 11/10 and 11/16/2022.
Further record review failed to reveal evidence that the resident's primary physician was notified of the wound specialists wound treatment recommendations to the right heel.
During a surveyor interview with Licensed Practical Nurse, Staff B on 11/17/2022 at 1:41 PM she was unaware of the treatment recommendations made by the Wound Consultant and was unable to provide evidence that the wound treatment was provided to the resident's right heel.
During a telephone interview with Staff A on 11/17/2022 at 2:20 PM, she revealed she recommended skin prep to the right heel to provide protection to the skin and wound.
During a surveyor interview with the Director of Nursing on 11/17/2022 at 2:25 PM, she was unable to provide evidence that the skin prep was provided to the resident's right heel or that the resident's physician was notified of the wound treatment recommendations.
During a telephone interview with the resident's physician on 11/17/2022 at 2:31 PM, he revealed he would have approved the recommendation to apply skin prep to the right heel for skin and wound protection.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 3 of 5 residents reviewed for oxygen therapy, Resident ID #s 273, 79, and 80.
Findings are as follows:
According to Brunner and Sudarth's textbook, Medical and Surgical Nursing, 7th Edition, 1992, p. 524, as with other medications, oxygen is administered with care, and its effects on each patient are carefully assessed. Oxygen is a drug and except in emergency situations is prescribed by a physician.
According to Fundamentals of Nursing, Concepts, Process, and Practice, Sixth Edition, 2000, the five guidelines to ensure safe drug administration include the right drug, the right dose, the right client, the right route and the right time.
1) Record review revealed that Resident ID #273 was admitted to the facility in November of 2022 and has since passed away. S/he had diagnoses including, but not limited to, acute and chronic respiratory failure with hypercapnia [presence of higher than normal level of carbon dioxide in the blood] and hypoxia [below-normal level of oxygen in the blood], chronic obstructive pulmonary disease [disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough] with acute exacerbation, solitary pulmonary nodule [single abnormality in the lung that is smaller than 3 centimeters in diameter], hypertension, and pulmonary fibrosis [a disease in which the lungs become scarred].
Record review revealed a physician's order dated 11/10/2022 which states, May titrate O2 [oxygen] with a goal of 88% RA [room air].
Further record review failed to reveal evidence that the physician's order dated 11/10/2022 for oxygen included an oxygen flow rate [the percentage or concentration of oxygen that a person inhales.)
Review of the resident's record revealed a nursing progress note dated 11/10/2022 at 9:36 PM which revealed in part, .Now on 5 L [liters] at 92% .
2) Record review revealed that Resident ID #79 was admitted to the facility in October of 2022 and had a diagnosis including, but not limited to, pneumonia.
Surveyor observations of the resident revealed the following:
-11/15/2022 at 9:16 AM, the resident was receiving oxygen therapy at 0.5 liter per minute via nasal cannula.
-11/16/2022 at 9:28 AM, the resident was receiving oxygen therapy at 1 liter per minute via nasal cannula.
Record review revealed a physician's order dated 10/25/2022 which states, May titrate O2 [oxygen] via nasal cannula to maintain O2 sat [Saturation] greater than 92% with a goal of R/A every shift.
Further record review failed to reveal evidence that the physician's order dated 10/25/2022 for oxygen included an oxygen flow rate.
During a surveyor interview with the resident at the time of the above observation s/he revealed that s/he wears oxygen all the time.
3) Record review revealed that Resident ID #80 was admitted to the facility in October of 2022 and has a diagnosis including, but not limited to, unspecified asthma,
Record review revealed a physician's order dated 10/24/2022 which states, May titrate O2 via nasal cannula to maintain O2 sat greater than 92% with a goal of R/A every shift.
Further record review failed to reveal evidence that the physician's order dated 10/24/2022 for oxygen included an oxygen flow rate.
Review of the Medication Administration Record revealed documentation that the resident received oxygen at 2 liters per minute on the night shift of 11/10/2022 and on the evening shift of 11/11/2022.
During a surveyor interview on 11/17/2022 at 10:30 AM with the Director of Nursing, she acknowledged that the oxygen orders for Resident ID #s 273, 79 and 80 do not have a flow rate, because the nurses use their judgement.
During a surveyor interview on 11/17/2022 at 2:45 PM with the residents' physician, he acknowledged that the orders do not specify a flow rate as the nurses use their judgement.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 2 harm violation(s), $44,425 in fines, Payment denial on record. Review inspection reports carefully.
- • 33 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $44,425 in fines. Higher than 94% of Rhode Island facilities, suggesting repeated compliance issues.
- • Grade F (38/100). Below average facility with significant concerns.
Bottom line: Trust Score of 38/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is The Dawn Hill Home For Rehab And Healthcare's CMS Rating?
CMS assigns The Dawn Hill Home for Rehab and Healthcare an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Rhode Island, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is The Dawn Hill Home For Rehab And Healthcare Staffed?
CMS rates The Dawn Hill Home for Rehab and Healthcare's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 57%, which is 11 percentage points above the Rhode Island average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 63%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at The Dawn Hill Home For Rehab And Healthcare?
State health inspectors documented 33 deficiencies at The Dawn Hill Home for Rehab and Healthcare during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 30 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates The Dawn Hill Home For Rehab And Healthcare?
The Dawn Hill Home for Rehab and Healthcare is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GREEN TREE HEALTHCARE MANAGEMENT, a chain that manages multiple nursing homes. With 133 certified beds and approximately 123 residents (about 92% occupancy), it is a mid-sized facility located in Bristol, Rhode Island.
How Does The Dawn Hill Home For Rehab And Healthcare Compare to Other Rhode Island Nursing Homes?
Compared to the 100 nursing homes in Rhode Island, The Dawn Hill Home for Rehab and Healthcare's overall rating (4 stars) is above the state average of 3.1, staff turnover (57%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting The Dawn Hill Home For Rehab And Healthcare?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.
Is The Dawn Hill Home For Rehab And Healthcare Safe?
Based on CMS inspection data, The Dawn Hill Home for Rehab and Healthcare has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Rhode Island. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at The Dawn Hill Home For Rehab And Healthcare Stick Around?
Staff turnover at The Dawn Hill Home for Rehab and Healthcare is high. At 57%, the facility is 11 percentage points above the Rhode Island average of 46%. Registered Nurse turnover is particularly concerning at 63%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was The Dawn Hill Home For Rehab And Healthcare Ever Fined?
The Dawn Hill Home for Rehab and Healthcare has been fined $44,425 across 3 penalty actions. The Rhode Island average is $33,523. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is The Dawn Hill Home For Rehab And Healthcare on Any Federal Watch List?
The Dawn Hill Home for Rehab and Healthcare is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.