Harris Health Care Center North
For profit - Corporation
32 Beds
Independent
Data: November 2025
Trust Grade
63/100
#18 of 72 in RI
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Harris Health Care Center North has a Trust Grade of C+, indicating it is slightly above average but not without concerns. Ranking #18 out of 72 facilities in Rhode Island places it in the top half of the state's nursing homes, and #11 out of 41 in Providence County suggests only a few local options are better. Unfortunately, the facility is experiencing a worsening trend, with issues increasing from 8 in 2023 to 9 in 2024. Staffing is a relative strength, with a 3/5 star rating and 0% turnover, which is well below the state average of 41%, meaning staff tend to stay and know the residents well. However, the facility has incurred $10,033 in fines, which is average, and there are serious issues identified, such as a failure to provide necessary treatment for a resident's pressure ulcer and concerns about food safety practices in the kitchen.
- Trust Score
- C+
- In Rhode Island
- #18/72
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ⚠ Watch
- $10,033 in fines. Higher than 90% of Rhode Island facilities. Major compliance failures.
- Skilled Nurses ✓ Good
- Each resident gets 58 minutes of Registered Nurse (RN) attention daily — more than average for Rhode Island. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 25 deficiencies on record. Higher than average. Multiple issues found across inspections.
63/100
Top 25%
Needs review
8 → 9 violations
★★★★☆
4.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2023: 8 issues
2024: 9 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
Federal Fines: $10,033
Below median ($33,413)
Minor penalties assessed
The Ugly 25 deficiencies on record
1 actual harm
Oct 2024
8 deficiencies
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
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**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 necessary treat...
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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 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 with a pressure ulcer (a localized injury to the skin and/or underlying skin usually over a boney prominence), Resident ID #26.
Findings are as follows:
Record review of the facility policy titled, Skin Care Policy states in part, .This facility will follow appropriate standards of care as they relate to residents' skin care; identification of those at risk, weekly skin checks, and appropriate interventions and documentation .
4. The weekly skin assessments (documented in the treatment sheet record) will be done for every resident regardless of their risk score .
6. Monitoring: Weekly skin assessments will be done .
With each dressing change or at least weekly, the following documentation must be present:
-Location and staging;
-Size, depth .location .
-Exudate, if present; type, color, odor, and approximate amount .
-Wound bed: color and type of tissue/character .or necrosis (slough [non-viable tissue that is yellow, tan, gray, green or brown] or eschar [dead tissue that is hard or soft in texture; usually black, brown, or tan in color]; and
-Description of wound edges and surrounding tissue .
Record review revealed the resident was admitted to the facility in June of 2024 with a diagnosis including, but not limited to, paranoid schizophrenia.
Record review revealed an admission skin assessment dated [DATE], that indicated the resident did not have any impairments to his/her skin.
Record review of a Braden Scale for Predicting Pressure Score Assessment (a risk assessment tool that predicts the likelihood of developing a pressure injury) dated 6/21/2024, indicates the resident is at risk for developing pressure ulcers.
Record review failed to reveal evidence of weekly skin assessments for the weeks of 6/28, 7/5, 7/12, 7/19, 7/26, 8/2, 8/9 and 8/16/2024, indicating the resident's skin was not assessed for 8 consecutive weeks.
During a surveyor interview with the Director of Nursing Services (DNS) on 10/11/2024 at 10:36 AM, she revealed that she observed the resident's left heel a few days after his/her admission, and she described the left heel as mushy and asked the nurse to obtain an order for skin prep (a type of wound treatment that provides skin protection). The DNS also revealed the resident's heel was red and then turned black, at which time the wound was assessed by the Wound Physician on 8/19/2024.
Record review failed to reveal evidence of a wound assessment completed by the Director of Nursing Services, (DNS) of the resident's left heel, indicating that the left heel was noted to be mushy or that an order was implemented for skin prep in the month of June 2024.
Record review revealed the resident was assessed by the Wound Physician on 8/19/2024 and an unstageable (a wound that is covered with slough or eschar and the wound bed cannot be visualized and the depth of soft tissue damage cannot be determined), deep tissue injury (a purple or maroon area of discolored intact skin due to damage of underlying soft tissue, which may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) was identified to the resident's left heel.
Further review of the Wound Physician's assessment completed on 8/19/2024 revealed the left lateral heel wound was intact, with a purple/maroon discoloration. Additionally, the wound measured 3.5 centimeters (cm) in length x 2.9 cm in width with an undetermined depth. Additionally, a recommendation was made to start skin prep to the left heel twice daily. Lastly, there is a notation documented by the Wound Physician which states, per [DNS] at first heel was mushy on admission, then wound developed.
Record review revealed a physician's order dated 8/20/2024 for skin prep twice daily.
Record review revealed the Wound Physician reassessed the resident's wound on 9/3/2024, and determined that the left heel was unstageable, due to full thickness necrosis (a type of tissue death that occurs when damage extends below the epidermis and dermis into the subcutaneous tissue or beyond). The wound measured 1.9 cm in length x 3.2 cm in width, with an unmeasurable depth due to the presence of non-viable tissue and necrosis. The wound was draining a light serous (thin, clear or yellow in color) fluid and the wound bed was observed with 100% of thick, adherent black necrotic tissue. The resident's heel was surgically debrided (the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue). New recommendations were made to discontinue the skin prep and start Silver Sulfadiazine (Silvadene-a medication prescribed used to treat or prevent infections) daily and wrap with a gauze dressing.
Record review of the physician orders failed to reveal evidence that the skin prep was discontinued or that the Silvadene treatment was initiated as recommended on 9/3/2024.
During a surveyor interview on 10/11/2024 at 12:26 PM with Registered Nurse, Staff A, she acknowledged that she failed to transcribe the Silvadene order on 9/3/2024. She further revealed that prior to the 8/19/2024 skin prep order, the resident had a deep tissue injury and that the heel was closed. Additionally, Staff A was unable to explain why there was not a treatment ordered to treat the resident's deep tissure injury until 8/20/2024. Lastly, she was unable to provide evidence of wound measurements or a treatment order to the resident's left heel wound prior to 8/19/2024, as required per the facility's policy.
Further review of the physician orders revealed that the Silvadene order was not initiated until 9/11/2024, 8 days after the treatment was first recommended.
Record review revealed a physician's order dated 9/11/2024 to cleanse wound with Normal Saline, apply a small amount of Silvadene and cover with a border gauze. This order failed to include the location as to where the treatment was to be applied.
Additional record review of the skin assessments failed to reveal evidence that a skin assessment was completed for the week of 9/29/2024.
During a surveyor interview on 10/11/2024 at 10:12 AM with the resident's Physician, he revealed he follows the Wound Physician's recommendations as she is the expert in her field.
During the surveyor interview with the DNS on 10/11/2024 at 10:36 AM, she was unable to provide evidence that a treatment order was implemented for the resident's left heel prior to 8/19/2024. Additionally, she was unable to explain why the Silvadene order was not implemented on 9/3/2024, the day it was recommended by the wound physician, or that when the order was initiated on 9/11/2024, it included the location of where the treatment was to be applied. Lastly, the DNS was unable to provide evidence of a completed skin assessments for the for the weeks of 6/28, 7/5, 7/12, 7/19, 7/26, 8/2, 8/9 and 8/16/2024 or the week of 9/29/2024.
During a surveyor interview on 10/11/2024 at 1:10 PM with the resident, s/he acknowledged that s/he has a wound to his/her left heel, however s/he was unable to say when or how the wound developed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice for 1 of 2 residents reviewed relative to wound care, Resident ID #22 and 1 of 1 resident observed receiving medications, Resident ID #16.
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 physician's orders unless they believe the orders are in error or would harm the clients .
Record review revealed Resident ID #22 was admitted to the facility in January of 2022 with diagnoses including, but not limited to, cellulitis of the right and left lower extremities and non-pressure chronic venous ulcers (wounds to the lower extremities due to poor circulation of the blood).
Record review of a Braden Scale for Predicting Pressure Score Assessment (a risk assessment tool that predicts the likelihood of developing a pressure injury) dated 4/10/2024, indicates the resident is at risk.
Record review revealed the resident was hospitalized from [DATE] through 9/6/2024. Additionally, the resident was re-admitted to the facility on [DATE].
Record review revealed a physician's order dated 1/26/2023 to assess ulcer for location, stage, size including the length, width, and depth, presence/absence of granulation tissue (red tissue with cobblestone or bumpy appearance) and epithelialization (new skin that is light pink and shiny (even in persons with darkly pigmented skin) and condition of surrounding skin weekly.
Record review of the August, September and October 2024 Treatment Administration Records revealed the above mentioned order was initialed as completed of the following dates:
8/6/2024
8/13/2024
8/20/2024
8/27/2024
9/10/2024
9/17/2024
9/25/2024
10/1/2024
10/8/2024
Record review of the above-mentioned weekly skin assessments failed to reveal evidence of the wound measurements or description of his/her venous ulcers. Additional review of the record failed to reveal evidence that a weekly skin assessment had been completed on 8/27/2024, 9/10/2024 or on 9/6/2024 when s/he was re-admitted to the facility.
During a surveyor interview with the Director of Nursing Services (DNS) on 10/11/2024 at 10:36 AM, she acknowledged the wounds were not measured and described weekly as ordered. Additionally, she was unable to provide evidence that the weekly skin assessments were completed on 8/27/2024, 9/6/2024 and 9/10/2024.
During a surveyor interview on 10/11/2024 at 12:26 PM with Registered Nurse, Staff A, she was unable to provide evidence of the weekly skin assessments, including measurements and description of the venous ulcers.
During an attempt to interview the resident on 10/11/2024 at 1:20 PM, s/he did not want to answer any of the surveyors questions pertaining to his/her wounds.
2. According to Lippincott Nursing Center 2016 Medication Safety: Go beyond the basics states in part, .Prepare medications for one patient at a time .
Review of the policy titled, General Dose Preparation and Medication Administration provided by the facility states in part, .Only prepare medications for one resident at a time .Verify resident identification .
During a surveyor observation on 10/8/2024 at approximately 9:45 AM, Certified Medication Technician, Staff B, entered Resident ID #16's room with two medication cups and administered one of the cups of medications to the resident while holding the other.
During a surveyor interview immediately following the observation with Staff B, he indicated that one of the medication cups contained another resident's medications. Staff B further indicated that one of the residents was not in his/her room at the time that he prepared the medications, so he held onto the resident's medication cup and prepared Resident ID #16's medications. Additionally, Staff B indicated that he should only prepare medication for one resident at a time.
During a surveyor interview on 10/8/2024 at 9:47 AM with Resident ID #16, s/he indicated that s/he knew what his/her medications looked like and took the medications. Additionally, s/he indicated that the medication cup is usually labeled with his/her name.
During a surveyor interview on 10/8/2024 at 9:59 AM with Registered Nurse, Staff C, she indicated that medications should be administered to one resident at a time.
During a surveyor interview on 10/10/2024 at 10:12 AM with the DNS, she revealed that she would expect medications to be prepared and administered to one resident at a time.
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 F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 principles for 1 of 1 medication storage rooms observed.
Findings are as follows:
Review of a facility policy titled, .Storage and expiration dating of medication and biological's last revised on [DATE] states in part, .Facility should ensure that medications and biological's that .have an expired date on the label .have been retained longer than recommended by manufacturer or supplier guidelines .are stored separate from other medications until destroyed or returned to the pharmacy or supplier .
During a surveyor observation of the medication storage room on [DATE] at 10:43 AM, in the presence of the Certified Medication Technician, Staff B, the following was observed:
- Four, 16-ounce bottles of lactulose (a medication used to treat constipation) with a manufacturer's expiration date of 8/2024.
- Two sealed 0.5 fluid ounce bottles of carbamide peroxide 6.5% (a medication used to remove earwax) with a manufacturer's expiration date of 9/2024.
- One bottle of magnesium (a vitamin) 250 mg (milligrams) with a manufacturer's expiration date of 9/2024.
- One opened bottle of loratadine (a medication used to treat allergies) 10 mg, with 18 tablets remaining, with a manufacturer's expiration date of 5/2024.
- One bottle of simethicone (a medication used to relieve symptoms related to excess gas) 80 mg chewable tablets with a manufacturer's expiration date of 8/2024.
During a surveyor interview immediately following the above observations with Staff B, he acknowledged that the above-mentioned medications were stored beyond their manufacturer's expiration date and that they should be discarded.
During a surveyor interview on [DATE] at 12:51 PM with the Director of Nursing Services, she acknowledged that the above-listed medications were expired. She further revealed that she would expect the staff to discard them appropriately based on the manufacturer's instructions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Smoking Policies
(Tag F0926)
Could have caused harm · This affected 1 resident
Based on record review, staff and resident interview, it has been determined that the facility failed to implement their smoking policy in accordance with federal, state, and local laws for 1 of 2 res...
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Based on record review, staff and resident interview, it has been determined that the facility failed to implement their smoking policy in accordance with federal, state, and local laws for 1 of 2 residents reviewed for smoking, Resident ID #10.
Findings are as follows:
Review of the policy titled, Smoking Policy states in part, .Residents who wish to smoke are to be evaluated by the interdisciplinary team for their ability to smoke in a safe manner .on admission .at least quarterly .
Record review revealed Resident ID #10 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, schizoaffective disorder, bipolar type, anxiety disorder, and autistic disorder.
Record review of the list of smokers provided by the facility revealed the resident is a smoker.
Record review failed to reveal evidence of a smoking evaluation upon admission or quarterly.
During a surveyor interview on 10/10/2024 at 12:45 PM with the resident, s/he revealed that he is a smoker.
During a surveyor interview on 10/10/2024 at 12:51 PM with Registered Nurse, Staff A, she indicated that smoking evaluations should be completed on admission, quarterly, and annually. Additionally, she acknowledged the resident is a smoker and could not provide evidence that a smoking assessment had been completed.
During a surveyor interview on 10/10/2024 at 1:02 PM with the Director of Nursing Services, she indicated that smoking assessments are completed on admission and quarterly. Additionally, she could not provide evidence that a smoking assessment had been completed for the resident on admission or quarterly.
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on record review, staff interview and resident interview, it has been determined that the facility failed to develop and implement a comprehensive person-centered care plan for smoking for 2 of ...
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Based on record review, staff interview and resident interview, it has been determined that the facility failed to develop and implement a comprehensive person-centered care plan for smoking for 2 of 2 residents reviewed who are smokers, Resident ID #s 10 and 23.
Findings are as follows:
1. Record review revealed Resident ID #10 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, schizoaffective disorder, bipolar type, anxiety disorder, and autistic disorder.
Record review of the list of smokers provided by the facility revealed the resident is a smoker.
Record review failed to reveal evidence that a smoking evaluation was completed upon admission or quarterly.
Record review failed to reveal evidence of a comprehensive care plan that identifies the resident as a smoker which includes safety interventions.
During a surveyor interview on 10/10/2024 at 12:45 PM with Resident ID #10, s/he revealed that s/he is a smoker.
2. Record review revealed Resident ID #23 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, anxiety disorder, vascular dementia, and muscle weakness.
Record review of an admission smoking evaluation indicated the resident is a smoker.
Record review failed to reveal evidence of a comprehensive care plan that identifies the resident as a smoker, which includes safety interventions to be implemented.
During surveyor interviews on 10/10/2024 at 12:51 PM and again on 10/11/2024 at 12:15 PM with Registered Nurse, Staff A, she acknowledged that Resident ID #s 10 and 23 are smokers and that care plans had not been developed related to smoking.
During surveyor interviews on 10/10/2024 at 1:02 PM and again on 10/11/2024 at approximately 12:30 PM with the Director of Nursing Services (DNS), she indicated that she would expect that a care plan would be developed on admission related to smoking.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
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 who are trauma survivors, receive culturally competent, trauma-informed care in acc...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors, receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents experiences, and preferences, in order to eliminate, or mitigate triggers that may cause re-traumatization of the resident for 1 of 1 resident reviewed with a history of trauma, Resident ID #10.
Findings are as follows:
Review of the facility's form titled PC [Primary Care]-PTSD [Post Traumatic Stress Disorder]-5 states in part, .The primary PC-PTSD-5 is a 5-item screen designed to identify individuals with probable PTSD. Those screening positive require further assessment, preferably with a structured interview .
Record review revealed the resident was admitted to the facility in April of 2024 with diagnoses including, but not limited to, anxiety disorder, schizoaffective disorder, bipolar type, major depressive disorder, personality disorder and autistic disorder.
Review of the Primary Care PTSD Screen dated 4/25/2024 revealed the resident answered YES to the screening question In the past month, have you .tried hard not to think about event(s) or went out of your way to avoid situations that remind you of the event(s) . Further review revealed the screening was incomplete.
Review of the comprehensive care plan failed to include trauma informed care and interventions to eliminate or mitigate triggers that may cause re-traumatization of the resident.
Record review failed to reveal evidence that the resident had been evaluated by a psychiatric provider to address trauma.
During a surveyor interview on 10/9/2024 at 10:13 AM with the Administrator, he indicated that he was aware that the resident had a history of sexual abuse.
During a surveyor interview on 10/9/2024 at 12:25 PM with the Director of Nursing Services (DNS), she indicated that she was aware that the resident had a history of trauma. She further indicated that she would expect the resident to have a trauma care plan in place.
During a surveyor interview on 10/9/2024 at 12:45 PM with the Social Services Designee, she indicated that she is responsible for completed the trauma assessments upon the residents' admissions. She further indicated that the resident indicated that he had childhood trauma, and that the trauma assessment was incomplete. Additionally, she could not provide evidence that interventions to eliminate or mitigate triggers that may cause re-traumatization of the resident were in place.
During a surveyor interview on 10/11/2024 at 11:18 AM with the Psychiatric Nurse Practitioner, she indicated that she was unaware that the resident had a history of childhood trauma, however she was aware of the resident's history of sexual abuse. Additionally, she indicated that she had not discussed the history of trauma with the resident.
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 F0760
(Tag F0760)
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 are free of any significant medication errors for 2 of 5 residents reviewed for unn...
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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 2 of 5 residents reviewed for unnecessary medications, Resident ID #s 1. Additionally, the facility failed to follow the pharmacy recommendation for a gradual dose reduction (GDR) (psychotropic medications are required by federal guidelines in skilled nursing facilities) for 1 of 2 residents reviewed, Resident ID #23.
Findings are as follows:
1a. Record review revealed that Resident ID #1 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, multiple sclerosis (a chronic disease damaging the central nervous system), bladder cancer, constipation and generalized muscle weakness.
Record review of the physician's orders revealed an order dated 8/1/2024 for Baclofen (a medication prescribed to treat muscle spasms) 10 milligrams (mg) tablets, take 2 tablets four times a day at 8 AM, 12 PM, 4 PM and 8 PM.
Record review of the August, September, and October 2024 Medication Administration Records (MARs) revealed the Baclofen was documented as MISSED with no additional notes on the following dates and times:
- 8:00 AM on 8/2, 8/5, 8/15, 8/16, and 8/30/2024.
- 4:00 PM on 8/5 and 8/26/2024
- 8:00 AM on 9/4/2024
- 4:00 PM on 9/4, 9/15, 9/16, 9/18 and 9/21/2024
- 8:00 AM on 10/9/2024
- 4:00 PM on 10/1, 10/2, 10/3, 10/4 and 10/8/2024
During a surveyor interview on 10/10/2024 at 9:52 AM with Registered Nurse (RN), Staff A, she acknowledged that the Baclofen was documented as missed on the above-mentioned dates and times and she could not explain why.
During a surveyor interview on 10/10/2024 at 10:35 AM with Certified Medication Technician (CMT), Staff B, he was unable to explain why the medications were documented as missed.
During a surveyor interview on 10/10/2024 at 3:10 PM with the Director of Nursing Services (DNS), she acknowledged that the Baclofen was marked as missed. Additionally, she was unable to provide evidence that the Baclofen was administered on the above-mentioned dates and times.
2a. Record review revealed Resident ID #23 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, complete traumatic amputation (an injury to a limb that results in immediate separation of the limb), mild cognitive impairment, chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breath), dementia, generalized muscle weakness and anxiety.
Record review revealed the following physician orders:
- Quetiapine (a medication prescribed to treat certain mood disorders) 12.5 mg in the morning
- Acetaminophen (a medication prescribed to relieve pain) 650 mg four times a day
- Aspirin (a medication prescribed to thin the blood) 81 mg once a day
- Gabapentin (a medication prescribed to relieve nerve pain) 300 mg three times a day
- Breztri Aerosphere (a medication prescribed to treat COPD) inhaler 160-9-4.8 microgram (mcg)/actuation, 2 puffs twice a day
- Cetirizine (a medication prescribed to treat allergy symptoms) 10 mg daily
Record review of the August 2024 Medication Administration Record (MAR) revealed the following medications were not administered as ordered on the following dates and times:
- Quetiapine, at 8:00 AM on 8/24, 8/29 and 8/30/2024
- Acetaminophen, at 8:00 AM on 8/15 ,8/24, 8/29 and 8/30/2024
- Aspirin, at 8:00 AM on 8/15, 8/24, 8/29 and 8/30/2024
- Gabapentin, at 8:00 AM on 8/15, 8/24, 8/29 and 8/30/2024
- Inhaler Breztri Aerosphere, at 8:00 AM on 8/15, 8/24, 8/29 and 8/30/2024
- Cetirizine, at 8:00 AM on 8/15, 8/24, 8/29, 8/30/ 2024
Record review of the September 2024 MAR revealed the following medications were not administered as ordered on the following dates and times:
- Quetiapine, at 8:00 AM on 9/4 and 9/5/2024
- Acetaminophen, at 8:00 AM on 9/4 and 9/5/2024
- Aspirin, at 8:00 AM on 9/4 and 9/5/2024
- Gabapentin, at 8:00 AM on 9/4 and 9/5/2024
- Inhaler Breztri Aerosphere, at 8:00 AM on 9/4 and 9/5/2024
- Cetirizine, at 8:00 AM on 9/4 and 9/5/2024
Record review of the October 2024 MAR revealed the following medications were not administered as ordered on the following dates and times:
- Quetiapine, at 8:00 AM on 10/9/2024
- Acetaminophen, at 4:00 PM on 10/4/2024 and 8:00 AM on 10/9/2024
- Aspirin, at 8:00 AM on 10/9/2021
- Gabapentin, at 8:00 AM on 10/9/2024
- Inhaler Breztri Aerosphere, at 8:00 AM on 10/9/2024
- Cetirizine, at 8:00 AM on 10/9/2024
During a surveyor interview on 10/11/2024 at 12:43 PM with the DNS, she was unable to provide evidence that the above medications were administered as ordered to Resident ID #23.
2b. Record review of Resident ID #23's pharmacy Consultant Report dated 8/16/2024 revealed a recommendation to attempt a gradual dose reduction for the evening dose of Quetiapine, from 25 mg to 12.5 mg in the evening. Further review of the report indicated that the resident's physician approved the recommendation on 9/19/2024.
Record review of the physician's orders failed to reveal evidence that the Quetiapine GDR was implemented, but rather the record indicated that the Quetiapine evening dose was discontinued on 9/3/2024.
During a surveyor interview on 10/11/2024 at 1:06 PM with the DNS, she acknowledged that the GDR recommendation for the Quetiapine was not implemented. Additionally, she was unable to explain why the evening Quetiapine dose was discontinued, and not gradually decreased to 12.5 mg as ordered by the physician.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple 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 accurately document bow...
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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 accurately document bowel movements (BM) in the resident's medical record for 2 of 2 residents reviewed for constipation, Resident ID #s 1 and 5.
Findings are as follows:
Review of the policy titled Bowel Function Management states in part, It is the facility's policy to manage each resident's bowel function in order to promote regular, voluntary, controlled bowel evacuation of normal consistency .Every resident's bowel function is to be monitored every day on every shift .The CNA [Certified Nursing Assistant] is responsible to document the resident's BMs in the resident's electronic medical record or in the CNA flow charts as appropriate .
1. Record review revealed Resident ID #1 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, multiple sclerosis (a chronic autoimmune disease that damages the protective coating around nerve fibers in the brain and spinal cord) and constipation.
Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15, indicating the resident's cognition is intact. Further review revealed the resident is incontinent of bowel and is dependent on staff for assistance with toileting.
Review of the BM output documentation in the electronic medical record failed to reveal evidence of a documented BM during the following time periods:
-From 9/7/2024 through 9/24/2024, 18 days.
-From 9/27/2024 through 10/2/2024, 6 days.
During a surveyor interview on 10/11/2024 at approximately 2:00 PM with the Director of Nursing Services (DNS), she was unable to provide evidence that there was any documentation of the resident's BMs during the above-mentioned time periods.
2. Record review revealed Resident ID #5 was admitted to the facility in August of 2018 with diagnoses including, but not limited to, transient cerebral ischemic attack (stroke) and major depressive disorder.
Review of an MDS assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating the resident's cognition is intact. Further review revealed the resident is incontinent of bowel and requires substantial assistance from staff for toileting.
Review of a care plan dated 6/9/2021 revealed the resident experiences bowel incontinence with an approach to ensure adequate bowel elimination.
Review of the BM output documentation in the electronic medical record revealed a BM had not been documented from 9/1/2024 until 9/24/2024.
During a surveyor interview on 10/9/2024 at 8:58 AM with Resident ID #5, s/he indicated that s/he sometimes has trouble having BMs and has belly discomfort. The resident further indicated that s/he is usually not offered medications for constipation and does not have a BM for a long time. Additionally, the resident indicated that s/he uses a commode and requires staff assistance.
During a surveyor interview on 10/9/2024 at 9:05 AM with Nursing Assistant (NA), Staff D, she indicated that the NAs are expected to document BMs in the electronic medical record each shift.
During a surveyor interview on 10/10/2024 at 9:17 AM with Registered Nurse, Staff A she indicated that BMs, or the lack there of, should be documented in the electronic medical record each shift by the NAs. She further indicated that Resident ID #5 typically doesn't have BMs for 3-4 days and that s/he requires staff to assist him/her to the commode.
During a surveyor interview on 10/10/2024 at 10:03 AM with the DNS, she indicated that she would expect NAs to document BMs on each shift. She further indicated that the resident regularly does not have a BM for 3 to 5 days. Additionally, she acknowledged that a BM for the resident had not been documented from 9/1/2024 until 9/25/2024, a total of 24 days.
Jan 2024
1 deficiency
MINOR
(C)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Deficiency F0638
(Tag F0638)
Minor procedural issue · This affected most or all residents
Based on record review and staff interview, it is has been determined that the facility failed to assess residents using the quarterly review instrument specified by the State and approved by Centers ...
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Based on record review and staff interview, it is has been determined that the facility failed to assess residents using the quarterly review instrument specified by the State and approved by Centers for Medicare & Medicaid Services (CMS) not less frequently than once every 3 months.
According to the, State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last revised in February of 2023 states in part, .DEFINITIONS §483.20(c) 'Quarterly Review Assessment' is an OBRA ' 87-required, non-comprehensive assessment that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all Minimum Data Set (MDS) items appear on the Quarterly assessment .
1. Record review for Resident ID #1 revealed a Quarterly MDS assessment with a start date of 11/16/2023 and a required completion date of 11/30/2023. Further record review revealed, that as of 1/25/2024, the resident's assessment was not completed and was 57 days overdue.
2. Record review for Resident ID #2 revealed a Quarterly MDS assessment with a start date of 12/23/2023 and a required completion date of 1/06/2024. Further record review revealed, that as of 1/25/2024, the resident's assessment was not completed and was 21 days overdue.
3. Record review for Resident ID #3 revealed a Quarterly MDS assessment with a start date of 12/30/2023 and a required completion date of 1/13/2024. Further review revealed, that as of 1/25/2024, the resident's assessment was not completed and was 12 days overdue.
During surveyor interview with the Director of Nursing on 1/25/2024 at 3:30 PM, she was unable to provide evidence that the Quarterly MDS assessments were completed as required for the above-mentioned residents.
Nov 2023
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
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 develop and implement a baseline care plan for each resident within 48 hours of a r...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to develop and implement a baseline care plan for each resident within 48 hours of a resident's admission, that includes the instructions needed to provide effective and person-centered care for the resident that meets professional standards of quality care relative to bilateral lower extremity edema (swelling caused due to excess fluid accumulation in the body tissues) for 1 of 2 new admissions, Resident ID #179.
Finding are as follows:
Record review revealed the resident was admitted to the facility in November of 2023 with diagnoses including, but not limited to, hypertension (high blood pressure) and atrial fibrillation (irregular heartbeat).
During a surveyor observation on 11/14/2023 at 9:25 AM, the resident was observed to have bilateral lower extremity edema.
Review of the resident admission document tilted admission Observation dated 11/10/2023 states in part .left foot 2+ pitting edema (indentation that remains in the edematous area after pressure is applied) .
Record review of the baseline care plan initiated on 11/10/2023 failed to reveal evidence of a plan of care that includes interventions or treatments for bilateral lower extremity edema.
During a surveyor observation and interview on 11/16/2023 at 2:14 PM with the Director of Nursing Services, she acknowledged that the resident has bilateral lower extremity edema and that a baseline care plan was not developed to address, monitor or treat the resident's edema.
See F684
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, surveyor observation and staff interview it has been determined that the facility failed to ensure that ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, surveyor observation 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 and the comprehensive person-centered care plan, for 1 of 3 residents reviewed for COVID-19, Resident ID #28, and 1 of 2 residents reviewed for new admissions, Resident ID #179.
Findings are as follows:
1. Review of a facility policy titled Care of the COVID-19 Positive Resident/Patient last updated [DATE] states in part, .The residents care plan will be revised to reflect the infection status and care of the individual resident's needs .
Closed record review revealed that Resident ID #28 was readmitted to the facility in September of 2021 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD, lung disease) and type II diabetes mellitus.
Review of a progress note dated [DATE] states, Resident at baseline, coughing more than usual. Positive covid at this shift. Plan of care modified, ongoing assessments.
Review of a care plan dated [DATE] revealed s/he has COPD with interventions including, but not limited to, monitor and document respiratory status. Further review of the care plan failed to reveal a care plan for COVID-19 infection status or care of the individual resident's needs.
Record review failed to reveal evidence of an assessment of the resident's respiratory status. Further record review failed to reveal evidence of a complete set of vital signs obtained to include, blood pressure, pulse, oxygen saturation and respiratory rate.
Review of a progress note dated [DATE] revealed the resident was more lethargic than usual and refused to eat the breakfast meal. Additionally, it revealed that the resident expired on the same day.
During a surveyor interview on [DATE] at 11:54 AM with Registered Nurse (RN), Staff A, she revealed that the resident tested positive for COVID-19 on [DATE]. Additionally, she was unable to provide evidence of why an assessment or a complete set of vital signs was not obtained after the resident tested positive on [DATE] and before s/he expired on [DATE].
During a surveyor interview on [DATE] at 11:30 AM with the Director of Nursing Services (DNS) she acknowledged that a complete set of vital signs and an assessment was not completed for Resident ID #28 once s/he tested positive for COVID-19. Additionally, she revealed that she would expect that an assessment and a complete set of vital signs was obtained every shift. The DNS further acknowledged that there was not a care plan put in place for COVID-19. She was unable to provide evidence that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan.
2. Record review revealed that Resident ID #179 was admitted to the facility in November of 2023 with diagnoses including, but not limited to, hypertension (high blood pressure) and atrial fibrillation (irregular heartbeat).
Record review of an admission assessment dated [DATE] revealed that s/he has left lower extremity edema (swelling caused due to excess fluid accumulation in the body tissues) graded at 2+ (indentation that remains in the edematous area after pressure is applied). The assessment failed to reveal evidence of edema to the right lower extremity.
During a surveyor observation on [DATE] at 9:25 AM the resident was noted to have bilateral lower extremity edema. Additionally, his/her legs were noted to not be elevated.
Record review failed to reveal evidence of an assessment or care plan in place for the resident's edema.
During a surveyor observation and interview on [DATE] at 1:20 PM with Registered Nurse, Staff B, she acknowledged that the resident had bilateral lower extremity edema. Additionally, she revealed that the right lower extremity edema was approximately 3+ (moderate deep pitting, 6 mm indent for 30 seconds) and the left lower extremity was approximately 4+ edema (severe very deep pitting, 8 mm indent, greater than 30 seconds to return to normal). Staff B indicated she was going to report the increased edema to the Medical Director.
During a surveyor observation on [DATE] at 8:10 AM the resident was observed to have bilateral lower extremity edema and his/her legs were noted not to be elevated.
Record review failed to reveal evidence of Staff B's assessment of the edema on [DATE] and failed to reveal evidence that the Medical Director was notified of the increased edema.
During a surveyor interview on [DATE] at 11:16 AM with the Medical Director he revealed that he was not notified regarding the resident's increased edema on [DATE]. Additionally, he revealed that he would have ordered the nurse to elevate the resident's legs and assess his/her respiratory status if he had been made aware.
During a surveyor interview on [DATE] at 2:14 PM with the DNS she acknowledged that the resident has increased bilateral lower extremity edema. Additionally, she acknowledged there was no evidence that the staff assessed the increased edema or reported the change to the physician. The DNS was unable to provide evidence that the residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
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 the irregularities identified by the Clinical Consultant Pharmacist during the monthly pharma...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that the irregularities identified by the Clinical Consultant Pharmacist during the monthly pharmacist Medication Regimen Review (MRR) were acted upon for 1 of 5 residents reviewed, Resident ID #24.
Findings are as follows:
Record review for the resident revealed that s/he was admitted to the facility in July of 2023 with diagnoses including, but not limited to, fusion of spine (neurosurgical or orthopedic surgical technique that joins 2 or more vertebrae), type 2 diabetes mellitus, and hypertension (high blood pressure).
Record review of the document titled [Pharmacy] Consultation Report revealed that on August 28, 2023, the following laboratory tests were recommended to be obtained for the resident:
- Monitor A1C (glycohemoglobin - a test used to monitor how well a person's blood sugar level is being managed).
- Monitor fasting lipid panel (a blood test that measures the amount of certain fat molecules called lipids in the blood).
- Monitor serum creatinine (a blood test that measures how well your kidneys are performing their job of filtering waste from the blood).
Further record review revealed that the physician accepted and authorized the above laboratory tests on September 6, 2023.
Review of the resident's record failed to reveal evidence that the above-mentioned blood tests were obtained.
Record review of the resident's pharmacy MRR for September 29, 2023, and October 30, 2023, revealed that the above stated laboratory tests were continued to be recommended but were not completed.
During a surveyor interview with the Director of Nursing Services on 11/15/2023 at 11:14 AM, she was unable to provide evidence that the above-mentioned blood tests were completed and acknowledged that it should have been completed as soon as the physician authorized the recommendations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
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 each resident's medication regimen is free from a medication error rate of ...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 25 opportunities observed during the medication administration task, there were 2 errors resulting in an error rate of 8%.
Findings are as follows:
1. Record review revealed Resident ID #3 has a physician's order dated 8/17/2018 for Lactulose (a medication used to treat constipation) Oral Solution 10 GM (gram)/15 ML (milliliter), administer 30 ml by mouth twice a day, every morning and evening.
During a surveyor observation of the medication administration task with Certified Medication Technician (CMT), Staff C, on 11/15/2023 at 9:15 AM, revealed she administered 22 ml of Lactulose instead of 30 ml as ordered by the physician.
During a surveyor interview immediately following the above observation with Staff C, she acknowledged she did not administer the Lactulose as ordered. Staff C stated I can't see very good.
2. Record review revealed Resident ID #5 has a physician's order dated 3/15/2022 for Omeprazole (a medication used to treat acid reflux, ulcers) capsule delayed release, 20 milligrams, administer 1 capsule by mouth, once a day at 7:00 AM.
Review of the medication blister package revealed an instruction on the package which indicates to administer before meals.
During a surveyor observation of the medication administration task with Staff C on 11/15/2023 at 8:22 AM revealed she administered the Omeprazole to the resident after the resident already had his/her breakfast.
During a surveyor interview immediately following this observation with Staff C, she acknowledged she did not administer the above medication as ordered.
During a surveyor interview with the Director of Nursing Services on 11/15/2023 at 9:30 AM, she acknowledged the above-mentioned errors. Additionally, she indicated she would expect that the staff would administer medications as ordered and to follow the instructions on the blister package.
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 on each r...
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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 on each resident that are accurately documented for 1 of 3 residents reviewed for COVID-19, Resident ID #28.
Findings are as follows:
a. Record review revealed that the resident was readmitted to the facility in September of 2021 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD, lung disease) and type II diabetes mellitus.
Record review revealed that the resident expired on [DATE].
Review of the banner on the electronic medical record revealed that the resident's advanced directives were full code (wants resuscitation and all life saving measures performed in a medical emergency).
Review of the resident's closed medical record revealed a signed Advanced Directive for Do Not Resuscitate (DNR) and comfort measures (CMO).
During a surveyor interview on [DATE] at 11:54 AM with Registered Nurse (RN), Staff A, she revealed that the resident's signed advanced directive was DNR/CMO and life saving measures were not performed prior to him/her expiring.
During a surveyor interview on [DATE] at 8:55 AM with the Director of Nursing Services she acknowledged that the banner on the resident's electronic medical record did not match his/her signed advanced directives.
b. Record review revealed that the resident expired on [DATE].
Review of the [DATE] Vital Signs report revealed an entry for the resident's temperature of 98.2 degrees on [DATE] at 9:29 AM.
During a surveyor interview on [DATE] at 8:55 AM with the Director of Nursing Services she was unable to explain why a temperature was recorded in the resident's medical record a day following his/her death. Additionally, she was unable to provide evidence that the facility maintained accurately documented medical records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on surveyor observation and staff interview, it has been determined that the facility failed to follow standard precautions (basic level of infection control that should be used at all times, ex...
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Based on surveyor observation and staff interview, it has been determined that the facility failed to follow standard precautions (basic level of infection control that should be used at all times, example: hand hygiene) to prevent the spread of infection relative to hand washing during the Medication Administration task for Resident ID #s 3, 5, 18 and 180 and placement of a glucometer supply basket during the morning blood glucose monitoring for Resident ID #s 13, 24, 79 and 129.
Findings are as follows:
Review of a facility policy titled General and Medication Administration .Procedure states in part, .2. Prior to preparing or administering medications, authorized and competent Facility staff should follow facility's infection control policy (e.g., handwashing) .
1. During a surveyor observation on 11/15/2023 of the Medication Administration task with Certified Medication Technician, Staff C, she was observed administering medication to the following residents without performing hand hygiene between residents at the following times:
- 8:22 AM - Resident ID #5 - 8:41 AM - Resident ID #180 - 9:09 AM - Resident ID #18 - 9:15 AM - Resident ID #3
Additionally, Staff C was observed at 8:41 AM, wearing gloves and then she was observed to touch the kitchen door keypad and wiping the table with her gloved hands. She then proceeded to administer Resident ID #180's eye drops without changing her gloves or performing hand hygiene.
During a surveyor interview following this observation, she acknowledged that she failed to perform hand hygiene throughout the Medication Administration task. Additionally, she indicated that she failed to change her gloves after she touched the door keypad and wiped the table.
During a surveyor interview on 11/15/2023 at approximately 10:00 AM with the Director of Nursing Services (DNS), she indicated that she expects Staff C to follow standard precautions while administering the residents' medication.
2. During a surveyor observation on 11/15/2023 at 7:43 AM, Registered Nurse, Staff B ,was observed taking the glucometer supply basket to Resident ID #13's room and placed it on the bed while she was checking his/her blood glucose.
During further surveyor observation, Staff B was observed at 7:55 AM taking the same glucometer supply basket that has not been sanitized to the dining room and placed it on a table while she checked Resident ID #22's blood glucose.
During additional surveyor observations on 11/15/2023, Staff B was observed placing the same glucometer basket that had not been sanitized on the following residents' beds.
- 8:05 AM - Resident ID #24 - 8:12 AM- Resident ID #79 - 8: 18 AM- Resident ID #129
During a surveyor interview immediately following the above-mentioned observations, Staff B acknowledged taking the same basket to multiple rooms without sanitizing it.
During a surveyor interview on 11/15/2023 at approximately 10:00 AM with the DNS, she indicated that Staff B should not have brought a basket of supplies from one room to another without sanitizing it in between.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors, receive culturally competent, traum...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors, receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents experiences, and preferences, in order to eliminate, or mitigate triggers that may cause re-traumatization of the resident for 2 of 5 residents reviewed for Trauma Informed Care, Resident ID #s 12 and 21.
Findings are as follows:
Review of the Centers for Medicare and Medicaid Services (CMS) State Operations Manual, Appendix PP Guidance to Surveyors for Long Term Care Facilities, last updated 2/3/2023 states in part, .'Trauma' results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being . 'Trauma-informed care' is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization .
Review of the facility's form titled PC [Primary Care]-PTSD [Post Traumatic Stress Disorder]-5 states in part, .The primary PC-PTSD-5 is a 5-item screen designed to identify individuals with probable PTSD. Those screening positive require further assessment, preferably with a structured interview .
1. Record review revealed Resident ID #12 was admitted to the facility in December of 2022, with diagnoses including, but not limited to, major depressive disorder and anxiety disorder.
Review of the facility's form titled PC-PTSD-5 dated 12/2/2022 indicates that the resident has a trauma history-experiencing a traumatic event over the course of their life . This form further indicates the following:
-has nightmares about the event(s) or thought about the event(s) when s/he did not want to
-tried hard not to think about the event or went out of his/her way to avoid situations that reminded him/her of the events
-felt numb or detached from people, activities, or his/her surroundings
Further record review failed to reveal a comprehensive assessment for trauma was completed. Additionally, review of a care plan dated 12/2/2022 revealed Psychosocial well-being PTSD with only one intervention provide validation and support surrounding trauma Once A Day; 05:00 PM.
During a surveyor interview with the Director of Nursing Services (DNS) on 11/17/2023 at 9:20 AM, she was unable to provide evidence that a comprehensive assessment for trauma was completed. Furthermore, she acknowledged that the above mentioned care plan was not individualized to include trauma informed care and interventions to eliminate, or mitigate triggers that may cause re-traumatization of the resident.
2. Record review revealed Resident ID #21 was admitted to the facility in May of 2009, with diagnoses including, but not limited to major depressive disorder, anxiety and depressed mood and schizophrenia (mental illness).
Review of the facility's form titled PC-PTSD-5 dated 10/1/2022 indicates that the resident has a trauma history-experiencing a traumatic event over the course of their life .
Further record review failed to reveal a comprehensive assessment for trauma was completed.
Additional record review failed to reveal evidence of a trauma informed care plan with interventions to eliminate, or mitigate triggers that may cause re-traumatization of the resident.
During a surveyor observation and interview on 11/14/2023 at 11:28 AM, the resident was crying with his/her right hand shaking. During the interview, the resident revealed s/he is afraid that someone will hurt him/her. The resident further revealed s/he does not sleep well at night because s/he is afraid.
During an interview with the admission Coordinator, who is the Social Worker Designee, on 11/15/2023 at 11:58 AM, she revealed that the facility's social worker informed her that there was trauma in [the resident's] life but she does not know the details of the trauma.
During a telephone interview with the facility's Social Worker on 11/16/2023 at 11:43 AM, she revealed the resident has a trauma history but she was unsure of the specific trauma or how it affects the resident. The Social Worker further revealed that the resident is very anxious and fearful, especially with authority (ex: police officers and immigration). Additionally, the Social Worker revealed she does not know who performs the comprehensive assesment for trauma or develops the trauma informed care plan.
During a surveyor interview with the Minimum Data Set Assessment Coordinator on 11/16/2023 at 12:10 PM, she was unable to provide evidence of a trauma informed care plan with interventions to eliminate, or mitigate triggers that may cause re-traumatization of the resident.
During a surveyor interview with on 11/17/2023 at 9:20 AM, with the DNS, she acknowledged that the comprehensive assessments for trauma were not completed and that the trauma informed care plans were not implemented for the above-mentioned residents.
Oct 2023
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
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to conduct periodic accurate, comprehensive, standardized reproducible assessment of each resident's functio...
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Based on record review and staff interview, it has been determined that the facility failed to conduct periodic accurate, comprehensive, standardized reproducible assessment of each resident's functional capacity for 3 of 4 residents reviewed, Resident IDs #2, 3, and 4.
Findings are as follows:
1. Record review for Resident ID #2 revealed s/he was admitted to the facility in June of 2023. Further record review failed to reveal evidence that a quarterly assessment was completed in September.
2. Record review for Resident ID #3 revealed s/he was admitted to the facility in September of 2023. Further record review failed to reveal evidence that an admission assessment was completed.
3. Record review for Resident ID #4 revealed s/he was admitted to the facility in June of 2020. Further record review failed to reveal evidence that a quarterly assessment was completed in July of 2023.
During a surveyor interview with the Minimum Data Set (MDS) Assessment Coordinator on 10/18/2023 at 1:43 PM, she acknowledged that the above assessments were incomplete.
During a surveyor interview with the Admissions Director in the presence of the Administrator and the Director of Nursing on 10/18/2023 at 2:30 PM, she could not provide evidence that the MDS for the above residents were completed as required.
Sept 2022
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
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 each resident is offered the COVID-19 vaccine unless the immunization is medically contraindi...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident has already been immunized for 1 of 7 residents reviewed, Resident ID #3.
Findings are as follows:
According to the Center for Disease Control and Prevention dosing schedule states in part, .Anyone wanting protection due to high levels of community transmission, people ages 65 years and older, or people who are more likely to get very sick from COVID-19 should get the second dose of: Pfizer-BioNTechCOVID-19 vaccine 3 weeks (or 21 days) after the first dose .
Record review revealed the resident was admitted to the facility in June of 2022 with diagnoses that include, but are not limited to, type 2 diabetes mellitus, vascular dementia without behaviors, and malignant neoplasm of unspecified site.
Record review of the resident's Preventative Health documentation revealed a vaccination for COVID-19 was received in the facility on 6/29/2022 and documented as booster 2.
Further record review failed to reveal evidence that the resident recieved his/her primary vaccination series and the first booster.
Further record review failed to reveal evidence that the resident's medical record includes documentation that indicates, at a minimum, each dose of COVID-19 vaccine administered to the resident; or if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal.
Additionally, the record failed to reveal evidence that the Covid-19 primary series second dose was administered 3 weeks or 21 days following the initial dose from the facility in accordance with the dosing schedule.
During a surveyor interview on 9/1/2022 at approximately 2:30 PM with the Director of Nursing Services and the Administrator, they were unable to provide evidence of the residents primary vaccination series and first booster dose for COVID-19.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
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 ensure that...
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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 services provided by the facility meet professional standards of quality relative to following physician's orders for 1 of 1 resident reviewed for supervised meals, Resident ID #2 and for 10 of 12 residents reviewed for appropriate bowel regimen, Resident ID #'s 1, 2, 3, 9, 13, 19, 20, 23, 24 and 227.
Findings are as follows:
According to 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.
A. Record review revealed Resident ID #2 was admitted to the facility in January of 2018 with diagnoses including, but not limited to; muscle weakness, nutritional deficiency, and adjustment disorder with mixed anxiety and depressed mood.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed an unscored Brief Interview for Mental Status, indicating the resident is cognitively impaired. Further review of the MDS revealed the resident has short term and long-term memory problems.
Record review revealed a physician's order dated 6/23/2018 for [House Consistent Carbohydrate] HCC with food cut up, supervision during meals, aspiration precautions of sitting upright at 90 degrees during meals and for 30 minutes after meals and beverages to alternate [with] bites/sips.
The following observations revealed the resident was not being supervised with meals:
- On 8/29/2022, 8/30/2022, and 8/31/2022 the resident was not supervised by staff during his/her lunch meal.
- On 9/1/2022 the resident was not supervised by staff during his/her breakfast.
Further observation on the above dates and meals, the resident was noted to not be alternating between solids and liquids, as per his/her physician's diet order.
Review of a quarterly progress note by the Registered Dietitian, dated 7/14/2022, revealed in part, .Diet per SLP [Speech Language Pathologist]: HCC [House Carbohydrate Consistent] with food cut up, supervision during meals, aspiration precautions of sitting upright at 90 degrees during meals and for 30 minutes after meals and beverages to alternate bites/sips .
During a surveyor interview with Certified Nursing Assistant (CNA), Staff A, on 8/31/2022 at 12:31 PM, she was unable to provide evidence that the resident received supervision during meals per the physician order.
During a surveyor interview on 8/31/2022 at 12:37 PM with the Infection Preventionist, she revealed that she was unaware of the physician's order for the resident to have supervision during meals.
During a surveyor interview with the Director of Nursing Services on 9/1/2022 at 10:15 AM, she acknowledged that the resident should be supervised during meals.
B. Review of a facility policy titled, Bowel Function Management Procedure: which states in part, 1. Every resident's bowel function is to be monitored every day on every shift. 2. The CNA is responsible to document the resident's BM [bowel movement] in the resident's electronic medical record or in the CNA flow charts as appropriate 3. The Charge nurse is responsible to monitor the resident's Bowel records on a daily basis .Routine Bowel Protocol- 1. In the event that the resident has not had a BM for 72 hours-90ml[milliliters] of prune juice is to be administered by the first 7-3 shift staff member after the 72 hours who is responsible for administering medications. 2. In the event that the resident does not have a BM by the end of that 7 -3 shift, 30 ml of MOM [Milk of Magnesium] is to be administered by the 3-11 shift staff member responsible for administering medications. 3. In the event the resident has not had a BM by the end of the 3 to 11 shift, a Dulcolax suppository is to be administered by the 11-7 staff member who is responsible for administering such medication. 4. In the event that the resident has not had a BM within 8 hours (by the end of the 11-7 shift on the next day), a fleets enema is to be given by the 7-3 shift. 5. Any further lack of BM is to be reported to the attending physician immediately .
1. Record review for Resident ID #1's bowel elimination flow sheet revealed that s/he did not have documentation for a bowel movement on the following dates:
- 8/3/2022 through 8/7/2022, a total of 5 days
- 8/9/2022 through 8/13/2022, a total of 5 days
- 8/17/2022 through 8/30/2022, a total of 14 days.
Indicating 3 missed opportunities to initiate the routine bowel protocol.
2. Record review for Resident ID #2's bowel elimination flow sheet revealed that s/he did not have documentation for a bowel movement on the following dates:
- 8/6/2022 through 8/10/2022, a total of 5 days
- 8/19/2022 through 8/23/2022, a total of 5 days
- 8/27/2022 through 8/30/2022, a total of 4 days
Indicating 3 missed opportunities to initiate the routine bowel protocol.
3. Record review for Resident ID #3's bowel elimination flow sheet revealed that s/he did not have documentation of a bowel movement on the following dates:
- 8/6/2022 through 8/14/2022, a total of 9 days
- 8/22/2022 through 8/27/2022, a total of 6 days.
Indicating 2 missed opportunities to initiate the routine bowel protocol.
4. Record review for Resident ID #9's bowel elimination flow sheet revealed that s/he did not have documentation of a bowel movement from 8/26/2022 through 8/30/2022, a total of 5 days.
Indicating 1 missed opportunity to initiate the routine bowel protocol.
5. Record review for Resident ID #13's bowel elimination flow sheet revealed that s/he did not have documentation of a bowel movement from 8/4/2022 through 8/20/2022, a total of 17 days.
Indicating 1 missed opportunity to initiate the routine bowel protocol.
6. Record review for Resident ID #19's bowel elimination flow sheet revealed that s/he did not have documentation of a bowel movement from 8/26/2022 through 8/30/2022, a total of 5 days.
Indicating 1 missed opportunity to initiate the routine bowel protocol.
7. Record review for Resident ID #20's bowel elimination flow sheet revealed that s/he did not have documentation of a bowel movement from 8/15/2022 through 8/28/2022, a total of 14 days.
Indicating 1 missed opportunity to initiate the routine bowel protocol.
8. Record review for Resident ID #23's bowel elimination flow sheet revealed that s/he did not have documentation of a bowel movement from 8/3/2022 through 8/19/2022, a total of 16 days.
Indicating 1 missed opportunity to initiate the routine bowel protocol.
9. Record review for Resident ID #24's bowel elimination flow sheet revealed that s/he did not have documentation of a bowel movement on the following dates:
- 8/1/2022 through 8/13/2022, a total of 13 days
- 8/15/2022 through 8/23/2022, a total of 9 days.
Indicating 2 missed opportunities to initiate the routine bowel protocol.
10. Record review for Resident ID #227 bowel elimination flow sheet revealed that s/he did not have documentation of a bowel movement on the following dates:
- 8/6/2022 through 8/17/2022, a total of 12 days
- 8/19/2022 through 8/23/2022, a total of 5 days.
Indicating 2 missed opportunities to initiate the routine bowel protocol.
During a surveyor interview with the Director of Nursing Services on 8/31/2022 at 12:57 PM, she was unable to provide evidence that the above resident's bowels were documented every shift or that the routine bowel protocol was initiated per facility policy when needed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
Based on surveyor observation, 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 1 of 7 residen...
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Based on surveyor observation, 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 1 of 7 residents reviewed for unnecessary medications, Resident ID #15.
Findings are as follows:
Record review revealed that the resident was admitted to the facility in September of 2022 with diagnoses that include, but are not limited to, acute kidney injury and type 2 diabetes mellitus with diabetic neuropathy (Tingling pins and needles or numbness, especially in the hands and feet).
Record review revealed a physician's order dated 9/21/2020 for Pepto-Bismol (bismuth subsalicylate) 262 mg (milligram)/15 mL (milliliter); amt (amount): 15 ml; oral, once a day at 5:00 PM with special instructions that state may have daily as needed for upset stomach.
Record review of the resident's discharge summary from the hospital from September of 2020 revealed an order that states, bismuth subsalicylate (Peptic Relief 262 mg/15 mL oral suspension) 262 mg, by mouth, once a day, As needed discomfort.
During a surveyor interview on 8/31/2022 at approximately 1:00 PM with the Infection Preventionist, she revealed that the order was transcribed incorrectly from the discharge paperwork from the hospital. She further acknowledged that the resident has received the medication on a daily schedule and not as needed as per physician's order since September of 2020.
During a subsequent surveyor interview on 9/1/2022 at 10:10 AM with the Infection Preventionist, she acknowledged that the order was not corrected until after the surveyor had brought it to the facility's attention and the resident did receive an additional dose on 8/31/2022 at 6:12 PM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each resident's medication regimen is free from medication error rate ...
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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's medication regimen is free from medication error rate of 5% or greater. Based on 25 opportunities for error observed during the medication administration task, there were 5 errors resulting in an error rate of 20% involving Resident ID #'s 1, 3, 11, 16, and 17.
Findings are as follows:
1. Record review revealed Resident ID #16 had a physician's order for Aspirin [OTC] [over the counter] tablet, delayed release (DR [delayed release]/EC [enteric coated]; 81 mg [milligram]; 1 TAB [tablet] .oral once a day .07:30 AM - 10:00 AM .
During an observation of the medication administration task on 8/31/2022 at 8:15 AM with Certified Medication Technician (CMT) Staff C, she administered one Aspirin 81 mg chewable tablet to the resident.
During a surveyor interview immediately following the observation with CMT Staff C, she acknowledged that the resident was supposed to receive Aspirin DR/EC and not the chewable version. She further indicated that the Aspirin DR/EC was on back order from the pharmacy.
2. Record review revealed Resident ID #11 had a physician's order for Meloxicam tablet ; 15 mg [milligram] ; amt [amount]: 1 tab; oral .once a day .9:00 AM .
During an observation of the medication administration task on 8/31/2022 at 8:23 AM with CMT Staff C, she administered the Meloxicam tablet to the resident and the resident immediately laid down after taking his/her medications.
Review of the pharmacy medication card for the Meloxicam stated in part, .avoid laying down x 10 minutes after .
During a surveyor interview immediately following the observation with Staff C, she acknowledged that the resident was not supposed to lay down for 10 minutes after taking the medication.
3. Record review revealed Resident ID #1 had a physician's order for Novolog Flexpen U-100 Insulin (insulin aspart u-100) insulin pen; 100 unit/mL [milliliter] (3mL) .three times a day .
During an observation of the medication administration task on 8/31/2022 at 11:37 AM with the Infection Preventionist, she administered the insulin into the resident's arm without performing an air shot or while administering, slowly counting to 10 before taking the needle out of the skin.
4. Record review revealed Resident ID #3 had a physician's order for Novolog Flexpen U-100 Insulin (insulin aspart u-100) insulin pen; 100 unit/mL (3 mL) .before meals .
During an observation of the medication administration task on 8/31/2022 at 11:39 AM with the Infection Preventionist, she administered the insulin into the resident's arm without performing an air shot or while administering, slowly counting to 10 before taking the needle out of the skin.
5. Record review revealed Resident ID #17 had a physician's order for Novolog Flexpen U-100 Insulin aspart u-100) insulin pen; 100 unit/mL (3 mL); amt: 15 units; subcutaneous .three times a day .
During an observation of the medication administration task on 8/31/2022 at 11:42 AM with the Infection Preventionist, she administered the insulin into the resident's arm without performing an air shot or while administering, slowly counting to 10 before taking the needle out of the skin.
Manufacturer's instructions for the Novolog Flexpen state in part, .Step 3 Perform an air shot .For each injection: 1. Select a dose of 2 units .3. With the pen pointing up, tap the insulin to move the air bubbles to the top 4. Press the button all the way in and make sure insulin comes out of the needle -Repeat up to two more times with the same needle if needed .Step 5 Inject the dose .10. Keep the button pressed and slowly count to 10 before taking the needle out of the skin .
During a surveyor interview with the Infection Preventionist immediately following the three above mentioned insulin administrations, she revealed that she was unaware that the Novolog Flexpen's are supposed to have an air shot performed prior to injection administration to a resident or that she was supposed to count to 10 before taking the needle out of the resident's skin during the insulin administration.
During a surveyor interview with the Director of Nursing Services (DNS) on 8/31/2022 at approximately 1:00 PM, she acknowledged that the facility should have had Aspirin DR/EC in stock and that the resident should not have laid down for 10 minutes after taking the Meloxicam. The DNS further indicated that manufacturer's instructions should be followed when administering Flexpen insulin to the resident's.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide a safe, sanitary and comfortable environment and to help prevent the devel...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents observation during insulin administration, Resident ID #'s 1, 3, and 17.
Findings are as follows:
Review of the facility policy titled Safe Injection Practices SECTION: Infection Control, Safety Program . states in part, .POLICY: This facility is committed to providing safe, healthful work environment for our entire staff and recognize Unsafe injection practices can lead to infections and even disease outbreaks .PROCEDURE: .2. Injections are prepared using aseptic technique .4. The rubber septum on a medication vial is disinfected with alcohol prior to piercing .The following are unsafe practices and should never be done: .Improperly cleaning and disinfecting multiple-use equipment. Failing to follow basic safe injection practices .Use aseptic technique to avoid contamination of sterile injection equipment .
Review of the manufacturer's instructions for the Novolog Flexpen (insulin aspart injection) 100 units/mL [milliliter] reveal in part, .Step 2 Attach The Needle 5. Wipe the pen tip with an alcohol pad .Step 5 Inject The Dose 7. Clean the injection site with an alcohol swab and wait for it to dry .
1. Record review revealed Resident ID #1 had a physician's order for Novolog Flexpen U-100 Insulin (insulin aspart u-100) insulin pen; 100 unit/mL [milliliter] (3mL) .three times a day .
During an observation of the medication administration task on 8/31/2022 at 11:37 AM with the Infection Preventionist, she failed to wipe the pen tip with alcohol and failed to clean the injection site with an alcohol swab prior to administrating the insulin injection.
2. Record review revealed Resident ID #3 had a physician's order for Novolog Flexpen U-100 Insulin (insulin aspart u-100) insulin pen; 100 unit/mL (3 mL) .before meals .
During an observation of the medication administration task on 8/31/2022 at 11:39 AM with the Infection Preventionist, she failed to wipe the pen tip with alcohol and failed to clean the injection site with an alcohol swab prior to administrating the insulin injection.
3. Record review revealed Resident ID #17 had a physician's order for Novolog Flexpen U-100 Insulin aspart u-100) insulin pen; 100 unit/mL (3 mL); amt: 15 units; subcutaneous .three times a day .
During an observation of the medication administration task on 8/31/2022 at 11:42 AM with the Infection Preventionist, she failed to wipe the pen tip with alcohol and failed to clean the injection site with an alcohol swab prior to administrating the insulin injection.
During a surveyor interview with the Infection Preventionist on 8/31/2022 immediately following the above observations, she revealed that she was unaware that she had to wipe the pen tip with alcohol prior to insulin administration and indicated that she has never cleaned the injection site with an alcohol swab prior to an insulin injection administration.
During a surveyor interview with the Director of Nursing Services (DNS) on 8/31/2022 at approximately 1:00 PM, she acknowledged that the insulin pen tip should be wiped with an alcohol swab prior to insulin administration. The DNS further indicated that the insulin injection site should be cleaned with an alcohol swab prior to insulin administration to prevent infection.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on surveyor observation and staff interview, it has been determined that the facility failed to maintain a sanitary and comfortable environment relative to shower rooms for 1 of 2 shower rooms o...
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Based on surveyor observation and staff interview, it has been determined that the facility failed to maintain a sanitary and comfortable environment relative to shower rooms for 1 of 2 shower rooms observed.
Findings are as follows:
Review of the facility policy titled Housekeeping Department Infection Control Guidelines states in part, .Policy: It is the policy of this facility to maintain a clean and sanitary environment in order to preserve the health and safety of the residents, staff and visitors. For this reason, the following guidelines are to be scrupulously carried out by all members of the housekeeping department .Procedure: Routine Cleaning of Horizontal Surfaces: .All horizonal surfaces such as .counters, sinks, tubs, shower floors are to be cleaned daily with an acceptable hospital grade disinfectant/germicide .friction (scrubbing) will be used in addition to a germicide to remove surface dirt .
Surveyor observations on 8/30/2022 at 10:00 AM and 2:07 PM, of the second-floor shower room, revealed a shower stall with speckles of black matter lining the silicone on the floors, the base of the wall, the silicone around the handle to turn on and off the shower and along the entrance of the shower.
Additional observations of this shower stall on 8/31/2022 at 9:17 AM and 11:11 AM revealed the black speckles on the above-mentioned surfaces.
During a surveyor interview on 8/31/2022 at 11:24 AM with the Director of Nursing Services (DNS), she indicated that she was unaware of the black matter of the above mentioned shower stall.
During a surveyor interview with the Administrator and the DNS on 9/1/2022 at approximately 2:35 PM, they acknowledged the black matter in the showers and that it should have been cleaned.
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 the facility stores, distributes, and serves food in accordance with professional standards for food service safety relative to the main kitchen and the food pantry.
Findings are as follows:
The State of Rhode Island Food Code 2018 edition, titled 4-601.11 Equipment, Food-Contact Surfaces, Non-Food-Contact Surfaces, and Utensils states in part, .(B) The food-contact surfaces of cooking equipment .shall be kept free of encrusted grease deposits and other soil accumulations .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.
1. During the initial tour of the main kitchen on 8/29/2022 at 8:20 AM revealed the following observations:
A. Three dessert bowls with dried up matter on the inside that were stacked and ready for use.
B. Three juice cups with dried up matter on the inside and edge of the cups that were stacked and ready for use.
C. One opened carton of [NAME] Ready Care Thickened Water 46 oz dated 8/17 in the refrigerator. The carton states, Refrigerate after opening and use within 7 days.
D. An accumulation of grease on the metal slats within the exhaust hood, located behind the stove. There was also an accumulation of grease and debris in the oven and on the stove top.
2. The refrigerator in the pantry contained a roll of defrosted ground meat, not dated, on a cracked bottom shelf. The inside of the refrigerator also had dried liquid matter on the inside door and bottom shelf.
3. On 8/30/2022 at 11:01 AM the refrigerator behind the nurse's station contained a posting which states, This refrigerator is for: Resident's food (If coming in from the outside must have residents name & date of arrival. It can only be held for 3 days) . Inside the refrigerator contained the following:
A. A blueberry pie not labeled or dated, 1/4 gone.
B. A half of a chicken salad sandwich and a bowl of greenbeans on a plate not labeled or dated.
C. A 20 oz bottle of Sprite, 1/2 empty, no label.
During a surveyor interview immediately following the above-mentioned observations with Staff Nurse B, on 8/30/2022 at 11:23 AM, she acknowledged that all of the above items in the refrigerator should be labeled and dated.
4. On 8/31/2022 at 8:39 AM the ice machine was observed to contain black matter on the inside walls.
During a surveyor interview with the Food Service Director on 8/29/2022 at approximately 8:30 AM and on 8/31/2022 at 8:39 AM he revealed that he would expect all the food items in the refrigerator to be labeled and dated, that dinnerware is to be clean of food and debris when served, and that food contact equipment and non-food contact equipment to be free of grease and mold [black matter].
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected most or all residents
**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 have a tracking mechanism that ide...
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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 have a tracking mechanism that identified each staff 's role, assigned work area, and how they interact with residents for individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement.
Findings are as follows:
Review of the facility's COVID-19 policy and procedure book and the Staff COVID-19 vaccination tracking document failed to reveal evidence of COVID-19 vaccination tracking documentation for individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement, including, but not limited to the following individuals or contacted companies:
1. [NAME] Hospice aid Staff D
2. Nurse Practitioner, Staff E
3. Any names of staff members from Preventative Diagnostic (X-Ray company)
4. Any names of staff members from East Side Clinical Laboratory
During an interview with the Director of Nursing Services and the Administrator on 9/1/2022 at approximately 2:10 PM they were unable to provide evidence of a COVID-19 vaccination tracking document that included the above-mentioned individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement.
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
- "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
- • 25 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $10,033 in fines. Above average for Rhode Island. Some compliance problems on record.
Bottom line: Mixed indicators with Trust Score of 63/100. Visit in person and ask pointed questions.
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About This Facility
What is Harris Health Care Center North's CMS Rating?
CMS assigns Harris Health Care Center North 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 Harris Health Care Center North Staffed?
CMS rates Harris Health Care Center North's staffing level at 3 out of 5 stars, which is average compared to other nursing homes.
What Have Inspectors Found at Harris Health Care Center North?
State health inspectors documented 25 deficiencies at Harris Health Care Center North during 2022 to 2024. These included: 1 that caused actual resident harm, 23 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Harris Health Care Center North?
Harris Health Care Center North is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 32 certified beds and approximately 29 residents (about 91% occupancy), it is a smaller facility located in Central Falls, Rhode Island.
How Does Harris Health Care Center North Compare to Other Rhode Island Nursing Homes?
Compared to the 100 nursing homes in Rhode Island, Harris Health Care Center North's overall rating (4 stars) is above the state average of 3.1 and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Harris Health Care Center North?
Based on this facility's data, families visiting should ask: "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?" "Can I speak with family members of current residents about their experience?"
Is Harris Health Care Center North Safe?
Based on CMS inspection data, Harris Health Care Center North has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Rhode Island. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Harris Health Care Center North Stick Around?
Harris Health Care Center North has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Harris Health Care Center North Ever Fined?
Harris Health Care Center North has been fined $10,033 across 1 penalty action. This is below the Rhode Island average of $33,179. 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 Harris Health Care Center North on Any Federal Watch List?
Harris Health Care Center North 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.