Riverview Healthcare Community
For profit - Limited Liability company
190 Beds
MARQUIS HEALTH SERVICES
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
43/100
#43 of 72 in RI
Photo by Riverview Rehabilitation & Healthcare Center
Photo by Jean M Cean
Photo by Riverview Rehabilitation & Healthcare Center
1 / 5 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Riverview Healthcare Community has a Trust Grade of D, indicating below-average performance with some concerning issues. They rank #43 out of 72 facilities in Rhode Island, placing them in the bottom half of nursing homes in the state, and #5 out of 11 in Kent County, meaning only four local options are better. The facility is improving, as the number of issues reported decreased from 12 in 2024 to 6 in 2025. Staffing is average with a 3/5 rating and a turnover rate of 38%, which is slightly better than the state average. However, they have received significant fines totaling $48,617, and the RN coverage is concerning, being less than 77% of facilities in the state. Specific incidents reported include a critical failure to prevent medication errors affecting several residents on anticoagulants, concerns about food safety practices in the kitchen, and inadequate communication systems for residents to call for staff assistance. While there are some strengths, such as a strong quality measure rating of 4/5, families should weigh these concerns carefully when considering this facility.
- Trust Score
- D
- In Rhode Island
- #43/72
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 38% turnover. Near Rhode Island's 48% average. Typical for the industry.
- Penalties ○ Average
- $48,617 in fines. Higher than 71% of Rhode Island facilities. Some compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 34 minutes of Registered Nurse (RN) attention daily — about average for Rhode Island. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 46 deficiencies on record. Higher than average. Multiple issues found across inspections.
43/100
Bottom 41%
Review needed
12 → 6 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 12 issues
2025: 6 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (38%)
10 points below Rhode Island average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Rhode Island average (3.1)
Meets federal standards, typical of most facilities
Staff Turnover: 38%
Near Rhode Island avg (46%)
Typical for the industry
Federal Fines: $48,617
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: MARQUIS HEALTH SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 46 deficiencies on record
1 life-threatening
Jan 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure that the residents' environment remained as free of accident hazards as possible, relative to maintaining safe water temperatures for 3 of 3 floors observed.
Findings are as follows:
According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023, states in part, .Some States have regulations regarding allowable maximum water temperature .
According to TITLE 216 - DEPARTMENT OF HEALTH, CHAPTER 40 - PROFESSIONAL LICENSING AND FACILITY REGULATION, SUBCHAPTER 10 - FACILITIES REGULATION, PART 1 - Licensing of Nursing Facilities, .In resident areas, hot water temperatures shall not be less than one-hundred degrees Fahrenheit (100 ºF) nor exceed one-hundred- and eighteen-degrees Fahrenheit (118 ºF). Thermometers [accuracy of which can be plus or minus two degrees Fahrenheit (±2 ºF)] shall be provided in each residential area to check water temperature periodically on that unit and at each site where residents are immersed or showered .
Record review of a facility document titled, Water Temperatures, Safety of last revised 12/2009, states in part, Tap water in the facility shall be kept within a temperature range to prevent scalding of residents .Water temperature at point of service in the resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 ºF, or the maximum allowable temperature per state regulation .if at any time water temperatures feel excessive to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report finding to the immediate supervisor .
Record review of a facility document titled, .Water Temps, dated 1/13/2025 revealed the following temperatures that exceeded 120 ºF:
1/13/2025:
-First Floor- room [ROOM NUMBER] , sink 123.0 °F
-Third Floor- room [ROOM NUMBER], sink 121.0 °F
During a surveyor interview and observation on 1/28/2025 at 10:34 AM, with Resident ID #1, s/he revealed that the water gets very hot. S/he stated, put your hands under, they will burn. Further observation by the surveyor revealed the water became very hot to touch, reddening skin and steam was rising from the sink. Following this observation, the water temperature was obtained using a digital thermometer and recorded at a temperature of 125.1 °F.
Record review of a facility document dated 1/19/2025-1/28/2025 titled, Task: GG - Shower/Bathe Self for Resident ID #1, revealed s/he was documented by staff as independent for bathing and does not require staff assistance for 9 out of 13 opportunities.
During a surveyor interview and observation on 1/28/2025 at approximately 11:00 AM, with the Regional Maintenance Director, the following water temperatures were obtained and found to exceed 120 degrees °F:
-First Floor- room [ROOM NUMBER], sink 120.2 °F
-Second Floor- room [ROOM NUMBER], sink 121.8 °F
-Third Floor:
- room [ROOM NUMBER], sink 125.7 °F
- room [ROOM NUMBER], sink 122.6 °
- room [ROOM NUMBER], sink 121.6 °F
During a surveyor interview immediately following the above observation with the Regional Maintenance Director, he acknowledged the above temperatures exceeded 120 °F and further stated, there must be an issue with the mixing valve, that will need to be corrected immediately.
During a surveyor interview on 1/28/2025 at approximately 2:05 PM with the Administrator, she acknowledged the recorded temperatures in the Water Temps log on 1/13/2025 exceeded 120 °F and could not provide evidence that this was reported and corrected according to the facility policy.
During a surveyor interview on 1/28/2025 at approximately 2:21 PM, with the Administrator in the presence of the Director of Nursing Services, she acknowledged that water temperatures should not exceed 120 °F. Additionally, they were unable to provide evidence that the facility ensured the resident environment remained as free of accident hazards as possible.
Jan 2025
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on record review, surveyor observation, and staff interview, it has been determined that the facility failed to ensure that a resident is provided assistive devices to prevent accidents relative...
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Based on record review, surveyor observation, and staff interview, it has been determined that the facility failed to ensure that a resident is provided assistive devices to prevent accidents relative to smoking for 1 of 1 resident reviewed, Resident ID #41.
Findings are as follows:
Review of a facility policy revealed that a smoking assessment will be completed upon admission, quarterly, and when a resident chooses to change their smoking decision. Additionally, it reveals that the resident must be dressed appropriately per the care plan.
Record review revealed that the resident was admitted to the facility in April of 2023 with diagnoses including, but not limited to, traumatic brain injury, schizoaffective disorder, and epilepsy.
Review of a Smoking Evaluation dated 10/15/2024 revealed that the resident utilizes a smoking apron.
Review of a care plan dated 10/14/2024 revealed that the resident is a smoker with an intervention including, but not limited to, s/he is able to smoke safely with a smoking apron in place at times. Further review failed to reveal evidence when a smoking apron would need to be applied.
During a surveyor observation on 1/2/2025 at 10:38 AM in the presence of Registered Nurse (RN), Staff H, of the resident smoking, s/he was not wearing a smoking apron. During the observation the ashes from the resident's cigarette were observed to be landing on his/her pajama pants.
During a surveyor interview immediately following the above observation with Staff H, he acknowledged that the resident was not wearing a smoking apron and that the ashes had been landing on his/her pajama pants. Additionally, Staff H acknowledged that the resident's care plan revealed s/he is able to smoke safely with a smoking apron at times. Staff H, indicated they were not aware of when the resident should wear a smoking apron.
During a surveyor interview on 1/2/2025 at 11:06 AM with the Assistant Director of Nursing she acknowledged that the resident's smoking assessment revealed that s/he should be utilizing a smoking apron.
Record review revealed an order was put in place on 1/2/2025 to utilize a smoking apron with all smoking breaks after it was brought to the facility's attention by the surveyor.
During a surveyor interview on 1/2/2025 at 11:20 AM with the Director of Nursing Services (DNS) she acknowledged that the care plan and the most recent smoking assessment revealed the resident should be utilizing a smoking apron. The DNS further revealed that the resident refuses use of the smoking apron at times but was unable to provide evidence of the refusals.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
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 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 services being provided meet professional standards of practice for 2 of 2 residents observed for wound care, Resident ID #s 33 and 77, 1 of 2 residents reviewed for the utilization of a Freestyle Libre sensor (a continuous glucose monitoring system that is designed to replace finger sticks and lessen the need for test strips for people with diabetes), Resident ID #20, 1 of 1 resident reviewed for hand splints, Resident ID #33, and 1 of 1 resident reviewed for the use of a hot pack (a pack that delivers heat to relax the muscle), Resident ID #103.
Findings are as follows:
1. Record review for Resident ID #77 revealed that s/he was readmitted to the facility in December of 2024 with diagnoses including, but not limited to, Methicillin Resistant Staphylococcus Aureus (MRSA, an antibiotic resistant infection) and type 2 diabetes mellitus.
Review of the care plan revealed that the resident has bilateral foot wounds with an intervention to administer treatments, as ordered.
Record review revealed that Resident ID #77 had increased drainage to his/her left foot on 12/23/2024 and the physician was contacted. Additionally, an order was obtained to complete the wound dressing to the resident's left foot wounds twice a day.
Review of the resident's Minimum Data Set assessment dated [DATE] revealed a Brief Mental Status score of 15 out of 15, indicating intact cognition.
Review of the December 2024 Treatment Administration Record (TAR) revealed the wound dressing was not changed twice a day per the physician's order on 12/24/2024, 12/29/2024 and 12/30/2024.
During a surveyor observation and interview on 12/31/2024 at approximately 11:00 AM with Licensed Practical Nurse (LPN), Staff C and Unit Manager, Staff D, the left foot dressing was dated 12/30/2024 with the initials of LPN, Staff U. Staff C and D revealed, Staff U worked the first shift on 12/30/2024, indicating that this dressing was not changed on 12/30/2024 on the second shift, as ordered. Additionally, during this observation, the dressing had dried drainage on the outside of the dressing.
During a surveyor interview on 12/31/2024 at approximately 11:00 AM during the dressing change with Resident ID #77, the resident revealed to the surveyor that his/her dressing should be changed twice a day and that it has not been.
During a surveyor interview on 1/2/2025 at 1:21 PM with Nurse Practitioner, Staff B, she revealed that she would expect the dressing to be changed twice a day, per the physician's order.
During a surveyor interview on 1/2/2025 at 1:31 PM with the Director of Nursing Services (DNS), she revealed that she would expect the dressing to have been completed twice a day, per the physician's order. Additionally, she was unable to provide evidence that the physician's order was followed on 12/24/2024, 12/29/2024 and 12/30/2024.
2. Record review revealed Resident ID #33 was admitted to the facility in November of 2012 with a diagnosis including, but not limited to, persistent vegetative state.
Review of the care plan revealed that the resident has a stage 4 pressure ulcer (the most severe stage, with full-thickness tissue loss and exposed bone or muscle) to his/her coccyx (tailbone) with an intervention to administer treatments, as ordered.
Review of a physician's order dated 12/19/2024 revealed to wash his/her coccyx wound with vashe (wound cleanser) and allow it to soak for 5 minutes, followed by silvagel and calcium alginate with silver (wound treatments) followed by a silicone bordered gauze (wound dressing), twice daily.
During a surveyor observation of the resident's wound treatment on 12/31/2024 at 11:38 AM, with LPN, Staff A, she was observed to soak the wound with vashe for approximately 2 minutes, instead of allowing the vashe to soak for 5 minutes, as ordered.
During a surveyor interview following the above-observation with Staff A, she would not acknowledge that did she not follow the order.
Further record review revealed that the resident is followed by a wound physician for his/her coccyx wound. Additionally, the wound was reevaluated on 1/1/2025 with recommendations to continue with the 5-minute soak of vashe.
During a surveyor interview on 1/2/2025 at 1:10 PM with the Nurse Practitioner, Staff B, she indicated that she would expect that staff would follow the physician order and allow the wound to soak with vashe for the full 5 minutes.
During a surveyor interview on 1/2/2025 at 1:21 PM with the DNS, she indicated that she would expect the staff to follow the physician's order.
3. Record review revealed Resident ID #20 was readmitted to the facility in November of 2024 with diagnoses including, but not limited to, type 2 diabetes, and chronic kidney disease.
During a surveyor observation and interview on 1/2/2025 at approximately 12:00 PM, the resident was observed to have a freestyle libre2 system placed on his/her upper posterior (back) left arm. The resident indicated that it is used daily to check his/her blood glucose.
Record review of the physician's orders failed to reveal an order for the freestyle libre2, how often to change the device, or to monitor for any complications such as, infection or if the device is not working.
Record review of the care plan failed to reveal the use of the freestyle libre2 as the method of glucose (blood sugar) monitoring or any interventions to mitigate risk.
During a surveyor interview on 1/2/2025 at approximately 3:00 PM with the Assistant Director of Nursing Services, she acknowledged that the resident was utilizing a freestyle libre2 sensor for glucose monitoring and that there was no physician's order or a care plan in place.
4. Record review revealed Resident ID #33 was admitted to the facility in November of 2012 with a diagnosis including, but not limited to, persistent vegetative state.
Review of a physician's order dated 8/14/2024 revealed an order to apply resting hand splints to both hands with morning care and remove them during evening care, daily.
Surveyor observations revealed the resident was without either hand splint in place on the following dates and times:
-12/30/2024 at 11:10 AM
-12/31/2024 at 11:38 AM
-1/2/2025 at 9:11 AM and 11:34 AM
During a surveyor interview following the above observation on 1/2/2025 at 11:34 AM with Nursing Assistant (NA), Staff F, he acknowledged that the resident was not wearing either hand splint. He revealed that he was the NA assigned to his/her care that morning and revealed that he had already completed his/her morning care. Further, he acknowledged that both hand splints were observed on the nightstand and revealed that he was unsure if the resident utilizes them.
During a surveyor interview on 1/2/2025 at 11:37 AM with the LPN, Staff A, she revealed that the resident wears hand splints daily and that they should be on.
During a surveyor interview on 1/2/2025 at 1:21 PM with the DNS, she revealed that she would expect the staff to follow the physician's order.
5. Record review revealed Resident ID #103 was admitted to the facility in February of 2021 with diagnoses including, but not limited to, type 2 diabetes and pain.
Record review of a physician's order dated 12/10/2024 revealed to apply a hot pack for 15 minutes, as needed every 8 hours, for back pain.
During the Medication Administration Task on 1/2/2025 at 10:20 AM with the Certified Medication Technician, Staff G, she was observed applying the hot pack to the resident's back.
During further observation on 1/2/2025 at 12:07 PM, Staff G was observed entering the resident's room where she removed the hot pack from the resident's back, which was approximately two hours later.
During a surveyor interview with Staff G following the removal of the hot pack, she indicated that she placed the hot pack on the resident's back at 10:20 AM and that she does not know how long the hot pack was supposed to be applied for.
During a surveyor interview on 1/3/2025 at approximately 11:00 AM with the Director of Nursing Services, she indicated that she would expect the staff to follow the physician's order.
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 maintain an infection prevention and control program to help prevent the transmiss...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to contact precautions (a type of precaution utilized when a resident is known or suspected to be infected with a Multidrug Resistant Organism, MDRO, that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces in the resident's room) for 4 of 4 residents observed for contact precautions, Resident ID #s 77, 153, 330, and 332.
Findings are as follows:
Review of a facility policy titled Isolation-Categories of Transmission-Based Precautions revealed in part, Contact precautions .staff and visitors wear gloves (clean, non-sterile) when entering the room .Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potential contaminated surfaces with clothing after gown removed .
1. Record review for Resident ID #77 revealed that s/he was readmitted to the facility in December of 2024 with diagnoses including, but not limited to, Methicillin Resistant Staphylococcus Aureus (MRSA, an MDRO) and type 2 diabetes mellitus.
Record review revealed that the resident has wounds to his/her bilateral feet.
Record review revealed a physician's order dated 12/12/2024 for contact precautions for MRSA in the wounds.
Review of the signage posted outside of the resident's room on 12/30/2024 revealed the resident was on contact precautions and indicated to wear a gown and gloves prior to room entry.
During a surveyor observation on 12/30/2024 at 12:04 PM revealed Nursing Assistant, Staff P, enter Resident ID #77's room without wearing a gown and gloves prior to entering the room.
During a surveyor interview immediately following the above mentioned observation, Staff P acknowledged the signage outside of Resident ID #77's room and that she failed to wear a gown and gloves prior to entering the room.
2. Record review for Resident ID #153 revealed that s/he was admitted to the facility in June of 2024 with a diagnosis including, but not limited to, MRSA.
Record review revealed a physician's order dated 12/5/2024 for contact precautions for MRSA in the resident's urine.
Review of signage posted outside of the resident's room on 12/30/2024 revealed the resident was on contact precautions and indicated to wear a gown and gloves prior to entering the room.
During a surveyor observation on 12/30/2024 at 10:34 AM revealed Licensed Practical Nurse, Staff C, enter Resident ID #153's room without wearing a gown or gloves prior to entering the room.
During a surveyor interview immediately following the above mentioned observation, Staff C, acknowledged the signage posted outside of Resident ID #153's room and that she failed to wear a gown and gloves prior to entering the room.
3. Record review for Resident ID #330 revealed that s/he was admitted to the facility in December of 2024 with a diagnosis including, but not limited to, Extended-spectrum beta-lactamases (ESBL, an MDRO).
Record review revealed a physician's order dated 12/30/2024 for contact precautions for ESBL in the resident's urine.
Review of the signage posted outside of the resident's room on 12/30/2024 and 12/31/2024 revealed the resident was on contact precautions and indicated to wear a gown and gloves prior to entering the room.
During a surveyor observation on 12/30/2024 at 12:06 PM revealed Maintenance Staff, Staff Q, enter Resident ID #330's room without wearing a gown prior to entering the room and removed the resident's mattress from his/her bed.
During a surveyor interview immediately following the above mentioned observation, Staff Q acknowledged the signage posted outside of Resident ID #330's room and that he failed to wear a gown prior to entering the room.
During a surveyor observation on 12/31/2024 at 10:45 AM revealed an Occupational Therapist, Staff R, enter Resident ID #330's room without wearing gown or gloves prior to entering the room and placed her laptop on the resident's dresser in his/her room.
During a surveyor interview immediately following the above mentioned observation, Staff R acknowledged the signage posted outside of Resident ID #330's room but thought that it was only for direct contact and not upon room entry.
During a surveyor observation on 12/31/2024 at 11:00 AM revealed Activity Aide, Staff S, enter Resident ID #330's room without wearing a gown or gloves prior to entering the room.
During a surveyor interview immediately following the above mentioned observation, Staff S acknowledged the signage posted outside of Resident ID #330's room and that she failed to wear a gown and gloves prior to entering the room.
4. Record review for Resident ID #332 revealed that s/he was admitted to the facility in December of 2024 with a diagnosis including, but not limited to, MRSA.
Record review revealed a physician's order dated 12/24/2024 for contact precautions for MRSA in the resident's nares.
Review of signage posted outside of the resident's room on 12/30/2024 and 12/31/2024 revealed the resident was on contact precautions and indicated to wear gloves and a gown prior to entering the room.
During a surveyor observation on 12/31/2024 at 10:48 AM revealed Certified Occupational Therapy Assistant, Staff T, enter Resident ID #332's room without wearing a gown or gloves prior to entering the room.
During a surveyor interview immediately following the above mentioned observation, Staff T acknowledged the signage posted outside of Resident ID #332's room but thought that it was only for direct contact and not upon room entry.
During a surveyor interview with the Infection Preventionist on 1/2/2025 at 9:55 AM, she revealed that she would expect staff to put on a gown and gloves prior to entering a resident's room who is on contact precautions.
During a surveyor interview on 12/31/2024 at 2:24 PM with the Director of Nursing Services and the Administrator, they revealed they would expect staff to put on a gown and gloves prior to entering a resident's room who is on contact precautions.
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
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standar...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety relative to the main kitchen and 1 of 2 ice machines observed without an air gap (gap between the water supply inlet and the flood level rim of the plumbing fixture).
Findings are as follows:
1. Review of the Rhode Island Food Code 2018 Edition 2-402.11, states in part, .food employees shall wear hair restraints, beard restraints that are designed and worn to effectively keep their hair from contacting exposed food .
During a surveyor observation of the main kitchen on 12/30/2024 at approximately 8:25 AM, Dietary Aide, Staff I, and Cook, Staff J, were observed with full facial hair and not wearing a beard restraint while in the main kitchen. Additionally, Staff J was observed plating the breakfast meal for the residents.
During a surveyor interview following the above observation on 12/30/2024 with the Food Service Director (FSD), she acknowledged that Staff I and J were not wearing a beard restraint, as required.
2. Review of the Rhode Island Food Code 2018 Edition 5-202.13 states in part, .An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or non FOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25mm [millimeter] (1 inch) .
During a surveyor observation of the first-floor kitchenette on 1/2/2025 at 11:08 AM with the Director of Maintenance in the presence of the FSD, revealed an ice machine without an air gap.
During a surveyor interview directly following the above observation with the FSD, she acknowledged that the ice machine failed to have an air gap as outlined in the Rhode Island Food Code.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
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, staff and resident interview, it has been determined that the facility failed to b...
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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 be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 3 of 3 floors observed.
Findings are as follows:
During the resident council task completed on 12/31/2024 at approximately 1:00 PM multiple residents complained of waiting for long periods of time for their call lights to be answered due to the staff no longer carrying walkie talkies.
During surveyor observations of all the units from 12/30/2024 to 1/3/2025, revealed that not all resident rooms' call lights are visible from the nurse's station.
During a surveyor observation of the first floor on 1/3/2025 at approximately 10:20 AM, revealed lights above the resident doors signaling a call light had been engaged. Further observation failed to reveal that the call light relayed the call directly to staff members or to a centralized staff work area.
During a surveyor interview on 1/3/2025 at 10:29 AM with Licensed Practical Nurse (LPN), Staff K, she revealed that previously the call lights would communicate with walkie talkies carried by the Nursing Assistants (NA) but that they no longer work. Additionally, she acknowledged that the call lights do not call directly to a staff member or to a centralized staff work area.
During a surveyor interview on 1/3/2025 at 10:33 AM with Unit Manager, Staff D, she revealed that the NA's carry walkie talkies that the call lights communicate directly with. However, Staff D was unable to locate an NA that was carrying a walkie talkie and was unable to provide a functioning walkie talkie.
During a surveyor observation on 1/3/2025 at approximately 10:40 AM of the second floor, revealed a call light above room [ROOM NUMBER] engaged. Further surveyor observation of the unit failed to reveal an NA in the hallway at the time the light was engaged.
During a surveyor interview on 1/3/2025 at 10:42 AM with LPN, Staff A, she revealed that the NA's carry walkie talkies to alert them when a call light is engaged. During a follow up interview at approximately 10:50 AM Staff A, acknowledged that the staff no longer carry walkie talkies.
During a surveyor interview on 1/3/2025 at 10:45 AM with NA, Staff L, he revealed that he does not carry a walkie talkie and the only way he is aware a call light is engaged is by the light above the door.
During a surveyor interview on 1/3/2025 at 10:51 AM with NA, Staff M, she revealed that the staff do not utilize walkie talkies and there is no centralized staff area that the call lights alert to.
During a surveyor interview on 1/3/2025 at 11:09 AM with LPN, Staff N, she revealed that the staff on the third floor do not use walkie talkies and the call lights do not alert to a centralized location.
During a surveyor interview on 1/3/2025 at 11:10 AM with NA, Staff O, she acknowledged that the only way she is aware a call light is engaged is by the light above the door.
During a surveyor interview on 1/3/2025 at 12:33 PM with the Administrator, she acknowledged that the call lights in the facility do not communicate the call directly to a staff member or to a centralized staff work area.
May 2024
4 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0760
(Tag F0760)
Someone could have died · 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 7 of 8 residents reviewed receivi...
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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 7 of 8 residents reviewed receiving Coumadin (an anticoagulant medication that is used to prevent harmful blood clots from forming or growing larger), Resident ID #s 1, 4, 5, 6, 7, 8 and 9.
Findings are as follows:
1. Record review revealed Resident ID #1 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, atrial fibrillation (an irregular heartbeat often causing blood to flow inadequately through the heart) and long-term use of anticoagulants.
Record review revealed a physician's order dated 3/27/2024 for Coumadin 0.5 mg [milligrams] by mouth at bedtime for treating/preventing blood clots. Give with 1 mg tablet to equal 1.5 mg.
Record review of a laboratory report dated 4/8/2024 indicated the resident's INR (international normalized ratio-a blood test that measures how long it takes for your blood to clot and the results are used when dosing Coumadin) was elevated with a result of 4.5 (an INR between 2.0 and 3.0 is the therapeutic range for patients receiving Coumadin therapy. An INR greater than 3.0 poses a higher risk of bleeding). Further review at the bottom of the document revealed a hand-written order signed by the Registered Nurse Practitioner (RNP), Staff D, to Hold Coumadin 4/8 + 4/9 Recheck .INR on 4/10.
Record review revealed a nursing progress note dated 4/8/2024 at 2:44 PM which states, HOLD coumadin 4/8 and 4/9 re-check .INR on 4/10.
Further review of the record failed to reveal evidence of an order to hold the Coumadin on 4/8/2024 and 4/9/2024.
Record review of the April 2024 Medication Administration Record (MAR) revealed the Coumadin 0.5 mg was signed off as administered on 4/8/2024.
Additional record review of a nursing progress note dated 4/10/2024 at 2:58 AM, indicated the resident had an unwitnessed fall in his/her bedroom. Additionally, the on-call provider was contacted and ordered the resident to be sent to an acute care hospital for an evaluation due to the fall and that the resident was on Coumadin therapy.
Further record review revealed a progress note dated 4/10/2024, authored by RNP, Staff D, which states in part, .Returned from ER [emergency room] visit, review of discharge instructions .past medical history of a-fib on Coumadin .[resident] was sent to the hospital after an unwitnessed fall .[S/he] had an elevated INR of 10.7 [critically high value, indicating the blood is taking a long time to clot and there is a high risk for bleeding] in ER [4/10] and was given Vitamin K [a medication used to assist in normalizing an excessively elevated INR] 2.5mg PO [by mouth]. Instructed to hold Coumadin x 48 hrs [hours] and recheck INR on 4/12 .
During a surveyor interview on 4/25/2024 at 11:07 AM with RNP, Staff D, she acknowledged that she ordered to hold the resident's Coumadin on 4/8/2024 and 4/9/2024, and she was unaware that the resident had received Coumadin on 4/8/2024.
During a surveyor interview on 4/25/2024 at 11:50 AM with the Director of Nursing Services (DNS), she acknowledged that the order to hold Coumadin was not transcribed and that the medication should have been held on 4/8/2024, as ordered.
During a surveyor interview on 5/1/2024 at 12:06 PM with Registered Nurse, Staff G, she acknowledged that she received an order on 4/8/2024 to hold the resident's Coumadin on 4/8/2024 and 4/9/2024. Additionally, she was unable to explain why she did not transcribe to hold the Coumadin 0.5 mg order.
2. Record review revealed Resident ID #4 was admitted to the facility in November of 2022 with diagnoses including, but not limited to, atrial fibrillation and long-term use of anticoagulants.
Record review revealed a progress note dated 4/1/2024, authored by RNP, Staff F, states in part, .Assessment and Plan .NEW ORDER increase Coumadin to 4.5 mg NEW ORDER: repeat INR .1 week .
Record review revealed a physician's order dated 4/1/2024 for Coumadin 4.5 mg by mouth in the evening for 7 days. Further review of the order revealed the Coumadin start date was entered as 4/1/2024 at 8:00 PM and the Coumadin stop date was entered as 4/8/2024 at 7:59 PM, which was 1 minute prior to the 8:00 PM scheduled administration time on 4/8/2024, indicating a transcription error.
Further record review of the April 2024 MAR failed to reveal evidence of the scheduled order for an INR on 4/8/2024. Additional record review failed to reveal evidence that the Coumadin was administered to the resident on 4/8/2024, resulting in a missed dose.
Record review revealed an INR was completed on 4/9/2024, resulting in an INR of 2.0.
Record review of a provider progress note dated 4/9/2024, states in part, .INR reviewed Assessment and Plan .NEW ORDER Coumadin 5.0 mg po once a day thru end of 4/15 Recheck [INR] on 4/16 .
Record review revealed a physician's order dated 4/9/2024 for Coumadin 5 mg by mouth in the evening until 4/15/2024. Further review revealed an INR was completed on 4/16/2024 with an INR result of 2.5.
Record review of the laboratory report dated 4/16/2024 revealed a handwritten order at the bottom of the report, signed by RNP, Staff D which reads, Reviewed cont [continue] current dose of coumadin (5 mg po daily) Recheck .INR in 1 week .
Record review revealed a physician's order dated 4/16/2024 for Coumadin 5 mg by mouth in the evening .until 4/22/2024. Further review of the order revealed the Coumadin start date was entered as 4/17/2024 at 6:00 PM and not 4/16/2024 and the Coumadin stop date was entered as 4/22/2024 at 10 AM, which was 8 hours prior to the scheduled administration time of 6 PM, indicating a transcription error.
Record review of the April 2024 MAR failed to reveal evidence that the Coumadin was administered on 4/16/2024 and 4/22/2024, resulting in 2 missed doses.
During a surveyor interview on 5/2/2024 at 1:24 PM with Licensed Practical Nurse (LPN), Staff H, she was unable to explain why the resident was not administered his/her Coumadin on 4/8/2024, suggesting the order may have fallen off of the MAR. Additionally, she could not explain why the INR order was not transcribed on 4/8/2024.
3. Record review revealed Resident ID #5 was admitted to the facility in August of 2022 with diagnoses including, but not limited to, atrial fibrillation and prosthetic heart valve (an artificial valve that is implanted to replace their native heart valve).
Record review revealed a physician's order dated 3/27/2024 for Coumadin 5 mg by mouth in the evening for 5 days. Further review of the order revealed the Coumadin start date was entered as 3/27/2024 at 6:00 PM and the Coumadin stop date was entered as 4/1/2024 at 5:59 PM, which was 1 minute prior to the 6:00 PM scheduled administration time, indicating a transcription error.
Record review of a progress note dated 4/2/2024 and authored by RNP, Staff F, states in part, .Assessment and Plan .INR -2.0 NEW ORDER: increase coumadin to 5.5 mg once daily x 7 days and repeat .INR .7days .
Record review of the physician's orders failed to reveal a Coumadin order for 4/2/2024. Additional record review revealed an order for Coumadin 5 mg by mouth in the evening for 7 days with a start date of 4/3/2024 instead of 4/2/2024 and an incorrect Coumadin dose of 5 mg instead of Coumadin 5.5 mg daily, indicating a transcription error.
Record review of a provider progress note dated 4/10/2024 and authored by RNP, Staff F, states in part, .Assessment and Plan .INR -2.1 NEW ORDER: increase coumadin to 5.5 mg once daily x 7 days and repeat .INR .7 days .
Record review of a nursing progress note dated 4/10/2024 and authored by LPN, Staff B, states, INR reported, orders obtained to continue with 5 mg po qd [daily], recheck INR 4/17.
Record review revealed an order with a start date of 4/10/2024 for Coumadin 5 mg in the evening until 4/16/2024, instead of Coumadin 5.5 mg daily, indicating a transcription error.
Record review of the provider progress notes, revealed a note dated 4/24/2024 and authored by RNP, Staff F, states in part, .Assessment and Plan .INR -2.6 NEW ORDER: c/w coumadin 5.5 mg once daily x 7 days and repeat .INR .7 days .
Record review revealed two orders for Coumadin with a combined total dose of Coumadin 5.5 mg daily, with a start date of 4/24/2024 and a stop date of 4/29/2024, indicating the order was incorrectly transcribed for 6 days instead of the ordered 7 days.
Record review of the April 2024 MAR failed to reveal evidence that the Coumadin was administered on 4/1/2024, 4/2/2024 and 4/30/2024, indicating the resident missed 3 doses. Additional review of the MAR revealed the Coumadin 5 mg was signed off as administered daily, instead of the ordered 5.5 mg dose from 4/3/2024 through 4/16/2024, resulting in the resident receiving the incorrect dose of Coumadin for 14 days.
During a surveyor interview on 5/2/2024 at 2:40 PM with RNP, Staff F, after reviewing her written progress notes dated 4/3/2024 and 4/10/2024 and the transcribed orders with her, she revealed the orders were transcribed incorrectly, and she would have expected Resident ID #5 to receive Coumadin 5.5 mg daily as ordered on 4/3/2024 and 4/10/2024.
4. Record review revealed Resident ID #6 was admitted to the facility in April of 2024 with a diagnosis including, but not limited to, atrial fibrillation.
Record review revealed a physician's order dated 4/27/2024 at 9:24 AM to repeat INR today and hold the Coumadin until INR was rechecked.
Record review revealed a physician's order dated 4/27/2024 to obtain an INR.
Record review failed to reveal evidence of the INR results on 4/27/2024.
Further record review failed to reveal evidence of a physician's order to obtain an INR on 4/28/2024 or INR results for 4/28/2024.
Record review failed to reveal a Coumadin order for 4/27/2024 and 4/28/2024.
Record review of the April 2024 MAR failed to reveal evidence that the Coumadin was administered on 4/27/2024 and 4/28/2024, resulting in 2 missed doses.
During a surveyor interview on 5/2/2024 at 2:36 PM with the DNS, she was unable to provide evidence of the ordered INR results for 4/27/2024.
5. Record review revealed Resident ID #7 was admitted to the facility in June of 2021 with a diagnosis including, but not limited to, atrial fibrillation.
Record review revealed a physician's order dated 4/18/2024 at 6:05 PM for Coumadin 4 mg by mouth in the evening until 4/25/2024. Further review of the order revealed the Coumadin start date was entered incorrectly for 4/19/2024, instead of 4/18/2024, indicating a transcription error.
Record review of the April 2024 MAR failed to reveal evidence that the Coumadin was administered to the resident on 4/18/2024, resulting in a missed dose.
6. Record review revealed Resident ID #8 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, acute embolism (a foreign substance that moves in the blood stream until it blocks a vessel) and thrombosis (blood clot).
Record review revealed a physician's order dated 4/2/2024 for Coumadin 4 mg by mouth in the evening for 6 days. Further review of the order revealed the Coumadin start date was entered incorrectly for 4/3/2024 at 6:00 PM, instead of 4/2/2024, indicating a transcription error.
Further review of the orders revealed an order dated 4/9/2024 for Coumadin 4 mg by mouth in the evening for 6 days. Further review of the order revealed the Coumadin start date was entered as 4/9/2024 at 6:00 PM and the Coumadin stop date was entered as 4/15/2024 at 5:59 PM, which was 1 minute prior to the 6:00 PM scheduled administration time, indicating a transcription error.
Record review of the April 2024 MAR failed to reveal evidence that the Coumadin was administered on 4/2/2024 and 4/15/2024, resulting in 2 missed doses.
7. Record review revealed Resident ID #9 was admitted to the facility in June of 2023 with a diagnosis including, but not limited to, atrial fibrillation.
Record review revealed a physician's order dated 4/15/2024 to hold Coumadin on 4/15 and 4/16/2024, obtain the INR on 4/17/2024.
Record review of the laboratory report dated 4/17/2024 revealed a handwritten order at the bottom of the report, signed by RNP, Staff F, which reads, 1. Hold coumadin today 2. Repeat .INR tomorrow [4/18] .
Record review revealed a physician's order dated 4/18/2024 for Coumadin 3 mg by mouth in the evening. Further review of the order revealed the Coumadin start date was entered incorrectly as 4/19/2024 instead of 4/18/2024, indicating a transcription error.
Record review of the April 2024 MAR failed to reveal evidence that the Coumadin was administered on 4/18/2024, resulting in a missed dose.
During a surveyor interview on 5/2/2024 at 2:36 PM with the Administrator, Director of Nursing Services, Regional Director of Clinical Services and VP of Clinical Services, when the above-mentioned findings were reviewed, they acknowledged that the above-mentioned Coumadin and INR transcription errors resulted in significant medication errors.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote ...
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Based on record review and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 2 residents reviewed with pressure ulcers (a localized injury to the skin and/or underlying skin usually over a boney prominence), Resident ID #1.
Findings are as follows:
According to the State Operations Manual, Appendix PP Guidance to Surveyors for Long Term Care Facilities, revised 2/3/2023 states in part, A pressure ulcer/injury (PU/PI) can occur wherever pressure has impaired circulation to the tissue. A facility must .Identify whether the resident is at risk for developing or has a PU/PI upon admission and thereafter .Implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors .If a PU/PI is present, provide treatment and services to heal it and to prevent .It is important that each existing PU/PI be identified, whether present on admission or developed after admission .Any new PU/PI suggests a need to reevaluate the adequacy of prevention measures in the resident's care plan.
When assessing the PU/PI itself, it is important that documentation addresses:
- The type of injury (pressure-related versus non-pressure-related) because interventions may vary depending on the specific type of injury;
- The PU/PI's stage;
- A description of the PU/PI's characteristics;
- The progress toward healing and identification of potential complications;
- If infection is present;
- The presence of pain, what was done to address it, and the effectiveness of the intervention; and
- A description of dressings and treatments .
Record review revealed the resident was admitted to the facility in March of 2024 with diagnoses including, but not limited to, a Stage 2 pressure injury (shallow open ulcer) to the buttocks, adult failure to thrive and pneumonia.
Record review of the nursing progress notes revealed a note dated 4/1/2024, authored by Licensed Practical Nurse, Staff A, which states in part, .Skin/Wound : New changes in Skin Integrity resident has redness, non-blanchable [Stage 1 pressure injury-observable pressure related alteration of intact skin reddened areas of tissue that do not turn white or pale when pressed firmly with a finger or device] on right .heel encouraged heel to be elevated .
During a surveyor interview on 4/25/2024 at 9:44 AM with Staff A, she acknowledged that the resident had a Stage 1 pressure injury identified by her on 4/1/2024. When asked if she had notified the provider of the pressure injury, she could not say. Additionally, she was unable to explain why a treatment was not implemented for the resident's pressure injury.
Record review of the weekly skin checks dated 4/12/2024 and 4/19/2024 indicated the resident had a pressure injury to his/her right heel. Additionally, no further description of the wound was documented.
Record review of the physician's orders failed to reveal evidence of a treatment to the resident's Stage 1 pressure injury to his/her right heel.
During a surveyor interview on 4/25/2024 at 11:55 AM with the Director of Nursing Services, she revealed that she was unaware of a pressure injury to the resident's right heel. Additionally, she was unable to provide evidence that a treatment was implemented when the pressure injury was first identified.
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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who need respiratory care, are provided such care, consistent with professional sta...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who need respiratory care, are provided such care, consistent with professional standards of practice relative to 1 of 1 resident reviewed receiving oxygen therapy, Resident ID #2.
Findings are as follows:
Record review revealed the resident was admitted to the facility in October of 2023 with diagnoses including, but not limited to, traumatic brain injury, anxiety and s/he was diagnosed with Influenza (Flu) A virus on 4/18/2024.
Record review of a nursing progress note dated 4/19/2024 at 5:44 AM revealed the resident called 911 stating that s/he did not feel well and needed to go to the hospital. The resident was subsequently transferred to a local acute care hospital and returned to the facility that same day, 4/19/2024.
Review of the hospital continuity of care document dated 4/19/2024, revealed a chest x-ray was completed and was negative. Additionally, the document revealed recommendations included, O2 [oxygen] via NC [nasal cannula] 1-2 L [liters] to maintain sats [oxygen saturation-a measurement of the percent of oxygen in the blood, a normal reading for most people is 95-100%].
Record review revealed a physician's order dated 4/19/2024, Pt [patient] on 2L O2 via N/C, wean O2 to keep sats > [greater than] 91%, pulsox [pulse oximetry-an electronic device that measures the saturation of oxygen levels carried in your blood] qs [every shift] x 5 days.
Record review of the April 2024 Medication Administration Record (MAR) revealed the oxygen order was transcribed to start and end on 4/19/2024. Therefore, was no longer an active order after 4/19/2024. Additionally, the resident's O2 level that was documented within this order on 4/19/2024 (night shift) as 90%.
Record review of the nursing progress note dated 4/20/2024 at 10:57 AM, revealed the resident had fallen onto the floor and s/he was in distress, with increased anxiety, a rapid heart rate and excessive sweating. The resident's oxygen tubing was observed on the floor, wrapped in his/her clothing. Further assessment revealed the resident's oxygen saturation level was 86% at the time, the resident was placed back on his/her oxygen and given a nebulizer treatment and his/her oxygen saturation level increased to 90%. The provider was contacted and ordered to have the resident transferred to an acute care facility. The nurse called 911, upon EMS arrival, they assessed the resident and the resident refused to be transferred to the hospital for further evaluation.
During a surveyor interview with Licensed Practical Nurse (LPN), Staff B, she revealed that she was the nurse taking care of the resident on 4/20/2024. She revealed that she contacted the on-call provider to report the resident's fall and her assessment. She also revealed that she called EMS and when they arrived the resident refused to be transferred to the hospital. She further revealed that she and other staff continued to assess the resident frequently throughout the shift and to ensure the resident kept his/her oxygen on. During frequent checks of the resident, s/he was maintaining saturation levels of 90-92 % on oxygen and s/he was more relaxed and comfortable towards the end of the shift.
Record review revealed a subsequent order dated 4/20/2024 for a neurological assessment (sensory response and motor strength tests to evaluate functions associated with the spinal nerves), vital signs and oxygen saturation levels every shift for the unwitnessed fall on 4/20/2024.
Additional review of the MAR revealed the following oxygen saturation levels documented on 4/20/2024 which failed to indicate if the resident was receiving oxygen or not:
-7-3 shift: 90%
-3-11 shift: 90%
-11-7 shift: 88%
Further review of the record revealed the following oxygen saturation levels:
-4/20/2024 at 6:42 AM, 90% (room air)
-4/20/2024 at 2:35 PM, 94% (room air)
-4/20/2024 at 3:35 PM, 90% (Oxygen via NC)
-4/20/2024 at 9:04 PM, 90% (Oxygen via NC)
-4/21/2024 at 2:29 AM, 88% (Oxygen via NC)
During a surveyor interview on 4/25/2024 at 10:18 AM with LPN, Staff C, she revealed she and the nurse she was training were taking care of Resident ID #1 on 4/20/2024, during the 11-7 shift. Staff C revealed that frequent checks were made throughout the night and the resident was assessed to be alert and oriented, comfortable, and not short of breath. Towards the end of the shift, the resident had a fall and sustained swelling to his/her chin. Upon assessment after the fall, his/her oxygen saturation level was 80% on 2 L of oxygen. Additionally, Staff C was asked by this surveyor if she was aware of the resident's documented oxygen saturation level of 88% taken during her shift. She revealed that she was not aware of his/her prior oxygen level as the nurse that she was training did not inform her and Staff C further revealed that she would have contacted the provider prior if she had known. Lastly, she revealed 911 was called and the resident was transferred to an acute care hospital.
Record review of the subsequent nursing progress note dated 4/21/2024 at 1:50 PM, indicated that the resident was admitted to the local hospital and currently intubated (a medical procedure where a tube is inserted into the body for ventilation). The resident was diagnosed with acute respiratory failure and needed to be transferred to the only trauma hospital in the state.
Record review of a nursing progress note dated 4/22/2024 at 2:19 PM revealed the resident has been diagnosed with Pyothorax (a condition that occurs when there is a build-up of pus or fluid in the chest cavity).
During a surveyor interview on 4/25/2024 at 11:18 AM with the Registered Nurse Practitioner, Staff D, she revealed she was unaware that the oxygen order was no longer active after 4/19/2024. Additionally, she would expect that nursing would have called the provider if the resident's oxygen saturation level was less than 91%.
During a surveyor interview on 4/24/2024 at 4:10 PM with the Director of Nursing Services, she acknowledged the oxygen order was transcribed incorrectly, with a start and stop date of 4/19/2024 and not for the full 5 days as ordered. Additionally, she revealed she would expect that the provider would have been notified when the resident's oxygen saturation level was 90% and below.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to maintain medical records for each ...
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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 for each resident that are accurately documented, in accordance with accepted professional standards and practices for 1 of 3 residents reviewed for skin observations, Resident ID #2.
Findings are as follows:
Record review revealed the resident was admitted to the facility in October of 2023 with diagnoses including, but not limited to, traumatic brain injury, anxiety and s/he was diagnosed with Influenza (Flu) A virus on 4/18/2024.
Record review revealed a weekly skin assessment dated [DATE] indicating a new small open [area] to coccyx area was identified.
During a surveyor interview on 4/24/2024 at 3:23 PM with Registered Nurse, Staff E, she acknowledged that she was the nurse that completed the skin assessment report, however she revealed that the resident did not have an open area and she had documented this in error.
During a surveyor interview on 4/25/2024 at approximately 11:30 AM with the Director of Nursing Services, she revealed that Staff E documented an open area to the resident's coccyx in error on 4/19/2024. Additionally, she was unable to explain why the resident's medical record was inaccurate.
Apr 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and resident and staff interview, it has been determined the facility failed to ensure that services pro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and resident and staff interview, it has been determined the facility failed to ensure that services provided by the facility meet professional standards of quality for 1 of 1 resident reviewed relative to the monitoring of daily weighs, Resident ID #1.
Findings are as follows:
Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients .
Record review of a community reported complaint sent to the Rhode Island Department of Health on 4/9/2024 alleges that Resident ID #1 was not receiving appropriate medical care at the facility.
1a. Record review revealed that the resident was readmitted to the facility in February 2024 with diagnoses including, but not limited to, congestive heart failure (when the heart cannot pump or fill adequately), type 2 diabetes mellitus, and major depressive disorder.
Record review of a quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15 indicating that his/her cognition is intact.
Review of a physician order dated 3/26/2024 revealed Weigh daily in the morning. Report to physician and complete SBAR [situation, background, assessment and recommendation] for a weight gain of 3 lbs. [pounds] overnight or weight loss/gain of 5 lbs. in one week.
Review of the daily weights from March 26, 2024, to April 11, 2024 failed to reveal evidence that the resident's weight was obtained.
- 3/28/2024 at 0600 [6 AM]
- 3/29/2024 - 6 AM
- 4/1/2024 - 6 AM
- 4/3/2024 - 6 AM
- 4/4/2024 - 6 AM
- 4/5/2024 - 6 AM
- 4/10/2024 - 6 AM
- 4/11/2024 - 6 AM
This indicates that the resident's weight was not obtained for 8 of 18 opportunities.
Additional record review revealed that the electronic medical record (EMAR) was marked 2 indicating the resident refused to have her/his weight obtained.
- 3/26/2024
- 3/30/2024
- 4/8/2024
- 4/9/2024
- 4/12/2024
This indicates that the resident's weight was documented as refused for 5 out of 18 opportunities.
1 b. Record review revealed the following documented weights for Resident ID #1.
- 3/27/2024 345 lbs.
- 3/31/2024 345 lbs.
- 4/2/2024 345.2 lbs.
- 4/6/2024 354.6 lbs.
- 4/7/2024 354.4 lbs.
This indicates that between 4/2/2024 and 4/6/2024, the resident gained 9.2 pounds.
Further record review failed to reveal evidence that the provider was notified, the SBAR for the weight gain was completed or any interventions were implemented for the weight gain.
During a surveyor interview on 4/12/2024 at 1:30 PM with the resident, s/he revealed that s/he was not aware that a daily weight needed to be obtained. S/he further indicated that s/he has not refused to be weighted.
During a surveyor interview on 4/12/2024 at approximately 3:00 PM with Licensed Practical Nurse, Staff A, she revealed that she is the resident's primary 11 PM to 7 AM Nurse and she indicated that she goes to the resident's room at 4:00 AM to obtain the weight but s/he is fast asleep and documents this as a refusal. Additionally, Staff A acknowledged that she did not notify the provider of the resident's weight gain of 9.2 lbs. on 4/6/2024 or when she does not obtain his/her weight.
During a surveyor interview on 4/12/2024 at 3:10 PM with the Director of Nursing Services in presence of the Administrator, she indicated that she would expect the nurses to follow the physician's order and she indicated that the provider should have been notified about the resident's 9.2 lb. weight gain and the weights that were not obtained.
During a surveyor interview on 4/12/2024 at 3:45 PM with the Nurse Practitioner, she revealed that she was aware that the resident can be noncompliant at times, but she was not made aware this his/her daily weighs were not being obtained. She further indicated that she was not aware of the resident's 9.2 lb. weight gain. She indicated that she would have expected to be notified so she could implement interventions to address the weight gain.
Jan 2024
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
**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 develop an...
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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 develop and implement a baseline care plan for each resident within 48 hours of a resident's admission, that includes the minimum healthcare information necessary to properly care for a resident including but not limited to, initial goals based on admission orders, physician orders, dietary orders, and therapy services, for 1 of 3 residents reviewed, Resident ID #578.
Findings are as follows:
Record review of Appendix PP, the State Operations Manual for Long Term Care, last revised on 2/3/2023, states in part, Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission .
Record review revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, vascular dementia, type 2 diabetes, cerebral infarction (stroke), and urinary incontinence.
Record review revealed the resident had the following a physician orders:
- 1/19/2024 for a foley catheter (a tube inserted into the bladder to drain urine)
- 1/19/2024 for speech therapy
- 1/19/2024 for a pureed texture diet
- 1/20/2024 for occupational therapy
- 1/20/2024 for physical therapy
Review of the baseline care plan initiated on 1/19/2024 failed to reveal evidence that it included initial goals based on the resident's admission orders, physician orders, dietary orders or therapy services.
During a surveyor interview with the Director of Nursing Services on 1/25/2024 at 12:44 PM she was unable to provide evidence that a baseline care plan was developed for the above-mentioned resident within 48 hours of admission, to include instructions needed to provide effective and person-centered care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that pain management was provided to a resident who required such services ...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that pain management was provided to a resident who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for 1 of 2 residents observed during a dressing change, Resident ID #89.
Findings are as follows:
Record review revealed the resident was admitted to the facility in April of 2021 with diagnoses including, but not limited to, dependence on renal dialysis (treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) and bilateral below the knee amputations.
Review of a care plan dated, 1/17/2024 revealed that the resident has skin breakdown including a Stage 4 Pressure Ulcer (the most serious pressure wound that extends below the subcutaneous fat into deep tissues, including muscle, tendons, ligaments and can extend as far down as the bone) to his/her sacrum with interventions including, but not limited to, evaluate for the presence of pain and to administer pain medication as ordered to promote comfort and to monitor for side effects and effectiveness.
Review of a Wound Evaluation and Management Summary dated 1/24/2024 revealed that the resident has a stage 4 pressure wound of the posterior sacrum measuring, 5.7 centimeter (cm) x 4.5 cm x 1.7 cm with a 23.85 cm surface area.
Further record review revealed the resident has the following orders for pain management:
- Oxycodone (pain medication) 5 milligram (mg) Give 5 mg by mouth every 6 hours as needed for pain.
- Acetaminophen 325 mg, give 3 tabs as needed once daily for pain.
During a surveyor observation on 1/25/2024 at 9:31 AM with Licensed Practical Nurse (LPN), Staff E, of the resident's wound dressing change, revealed the following:
-Prior to the dressing change the resident stated, I'm in a lot of pain, I just want to get this over with.
-While the nurse was repositioning the resident s/he grimaced and revealed that s/he was in a lot of pain.
-While cleaning the wound and applying skin prep to the skin surrounding the wound, the resident continued to complain of pain and stated what are you doing.
During a surveyor interview after the above observation at 9:45 AM with Staff E, she acknowledged the resident was in pain during the wound dressing change and that the resident does have a PRN (as needed) pain medication available. Additionally, she acknowledged that she did not offer or administer pain medication to the resident prior to the dressing change or at any point during the dressing change.
During a surveyor interview with the Director of Nursing Services on 1/25/2024 at 9:55 AM, when made aware of the above-mentioned observation, she acknowledged that Staff E, should have stopped the dressing change and offered the resident pain medication prior to continuing the dressing change. Additionally, she was unable to provide evidence that the facility ensured Resident ID #89 was provided or offered with the as needed pain management medication when s/he was expressing that s/he was experiencing pain.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of significant medication errors for 1 of 4 residents reviewed who receive...
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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 significant medication errors for 1 of 4 residents reviewed who receive Coumadin (a blood thinner), 1 of 5 residents reviewed who receive a psychotropic medication, Resident ID #170 and 1 of 6 residents reviewed who receive insulin, Resident ID #34.
Findings are as follows:
Review of the facility's policy titled, Administering Medications states in part, Medications are administered in a safe and timely manner, and as prescribed.
1a. Record review revealed Resident ID #170 was admitted to the facility in December of 2023 with diagnoses including but not limited to, fracture of right humerus with surgical repair, artificial heart valve and unspecified psychosis with delusions.
Record review revealed the resident is to receive Coumadin therapy daily to prevent his/her blood from clotting as s/he has an artificial heart valve, which places him/her at a high risk for experiencing a stroke due to a blood clot. The dosage of the Coumadin is determined by obtaining a prothrombin time (PT, a laboratory value used to determine dose Coumadin).
Review of the December 2023 and January 2024 Medication Administration Records (MAR) failed to reveal evidence that the resident received Coumadin on the following dates:
- 12/7/2023
- 12/13/2023
- 12/19/2023
- 12/26/2023
- 1/17/2024
1b. Review of physician orders revealed an order dated 12/7/2023 for clonazePAM Oral
Tablet 1 MG Give 1 mg by mouth at bedtime for sleep.
Review of the December 2023 and January 2024 MARs failed to reveal evidence that the resident received clonazePAM as ordered on the following dates:
- 12/23/2023
- 12/30/2023
- 1/18/2024
Record review revealed the following progress notes:
- 12/23/2023 at 11:10 PM .Needs script for clonazepam for dose tonight .medication ordered clonazepam 1 mg PO [by mouth] .Medication sent electronically .
- 12/30/2023 at 9:16 PM .Medication on order .
- 1/18/2024 at 10:56 PM, .Resident has no more tablets of clonazepam 1mg .Medication ordered clonazepam 1mg PO x 1 tonight. Medication sent electronically .
Review of an untitled document provided by the facility, revealed that clonazepam was available in the Pyxis machine (secured medication dispensing machine).
Review of a document titled Item Transaction Log (a document which shows which medication was removed from the Pyxis machine, including when the item was removed and for which resident) failed to reveal evidence that the clonazepam was removed on the above-mentioned dates from the Pyxis machine for this resident.
During a surveyor interview on 1/24/2024 at 12:46 PM, with the Director of Nursing Services, she acknowledged that the Coumadin and Clonazepam were not administered to this resident, as ordered. Additionally, she was unable to provide evidence that the resident was free from any significant medication errors.
2. Record review revealed Resident ID #34 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, type II diabetes and diabetic neuropathy (nerve damage).
Record review revealed an order dated 1/13/2024 for Insulin Glargine-yfgn 100 unit/ml (milliliter) solution pen injector, inject 10 units subcutaneously (beneath the skin) at bedtime.
Review of the January 2024 MAR failed to reveal evidence that the above order was administered to the resident on the following dates:
- 1/13/2024
- 1/14/2024
Further record review revealed an order dated 1/22/2024 for Insulin Glargine-yfgn 100-units/ml solution pen injector, Inject 20 units subcutaneously at bedtime.
Review of the January 2024 MAR failed to reveal evidence the above order was administered on the 1/22/2024.
During an interview with the DNS on 1/24/2024 at 12:46 PM, she was unable to provide evidence that the resident received the required doses of insulin. Additionally, she was unable to provide evidence that the resident was free from any significant medication errors.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and pra...
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Based on record review and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 5 residents reviewed for psychotropic medication, Resident ID #103.
Findings are as follows:
Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
Record review revealed the resident was admitted to the facility in March of 2023 with a diagnosis that includes, but is not limited to, unspecified dementia with behavioral disturbances.
Review of a document titled, Supportive Care Your Behavioral Health Partner PHYSICIAN ORDERS & RECOMMENDATIONS dated 12/11/2023, revealed an order/recommendation to discontinue Seroquel 75 mg every evening and start Seroquel, 50mg every evening.
Review of physician's orders revealed an order with a start date of 12/11/2023 which states in part, QUEtiapine Fumarate (Seroquel) 25 MG .Give 2 tablet by mouth in the evening related to UNSPECIFIED DEMENTIA, MODERATE, WITH MOOD DISTURBANCE .GIVE 3 TABS TOTAL DOSE 75 MG.
Review of the January 2024 Medication Administration Record revealed the above order was documented as being administered daily.
During a surveyor interview on 1/25/2024 at 11:12 AM, with Licensed Practical Nurse, Staff F, she acknowledged that the Seroquel order listed two different dosage amounts and indicated that she was unsure how much she would administer to the resident. She further revealed that she would have to contact the provider for clarification before administering the medication.
During a surveyor interview on 1/25/2024 at 11:15 AM, with Nurse Practitioner, Staff C, she indicated that the two dosages listed in the Seroquel order might have been a transcription error and indicated the order should be changed to state, administer 2 tablets equaling 50mg, per recommendation.
Record review revealed a physician's order dated 1/25/2024, after it was brought to the facility's attention by the surveyor, for Seroquel, 25 mg with instructions to give 2 tablets, equaling 50 mg, by mouth every evening.
During a surveyor interview on 1/25/2024 at 11:56 AM, with the Director of Nursing Services, she acknowledged that the 12/11/2023 Seroquel order listed two different dosage amounts and revealed that she was unsure what dosage was being administered to the resident. Further, she was unable to provide evidence that the facility maintained accurate medical records in accordance with professional standards and practices.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
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 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 residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 2 residents observed during a dressing change, Resident ID #34.
Findings are as follows:
a. According to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities last revised on 2/3/2023 states in part, .Stage 2 Pressure Ulcer [PU]: Partial-thickness loss .of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough [non-viable yellow, tan, gray, green or brown tissue] and eschar [dead or devitalized tissue that] are not present .Stage 3 Pressure Ulcer: Full-thickness skin loss .in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible .With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the PU/PI should be documented. At a minimum, documentation should include the date observed and .Size (perpendicular measurements of the greatest extent of length and width of the PU/PI), depth; and the presence, location and extent of any undermining or tunneling/sinus tract .
Record review revealed that the resident was admitted to the facility in December of 2023 with diagnoses including, but not limited to, type 2 diabetes and peripheral vascular disease (blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm).
Record review revealed a care plan initiated on 12/13/2023, which states in part, I have impaired skin integrity r/t [related to] decreased mobility .Stage II .
Record review revealed an order dated 12/13/2023 which states in part, Santyl External Ointment 250 [wound ointment] UNIT/GM (gram) (Collagenase) Apply to right buttock/coccyx topically every shift for wound care .
Record review revealed the resident was hospitalized on [DATE] and returned to the facility on [DATE].
Record review failed to reveal evidence of orders to treat the wound to the right buttocks upon the resident's return from the hospital from [DATE] through 12/29/2023.
Record review revealed the resident was rehospitalized on [DATE] and returned to the facility on 1/2/2024.
Review of the hospital Continuity of Care (COC) form dated 1/2/2024 revealed the resident continued with a stage 2 PU to his/her right buttocks/coccyx.
Record review revealed the resident was again rehospitalized from [DATE] and returned to the facility on 1/9/2024.
Record review failed to reveal evidence of an order for wound care for the right buttocks stage 2 PU from 1/9/2024 through 1/11/2024.
Record review revealed a physician's order dated 1/12/2024 which states in part, Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to right buttock, coccyx topically one time a day .
Record review revealed the following progress note:
-12/13/2023 at 12:12 PM .open area to bottom .
-12/14/2023 5:07 PM .Stage 2 ulcer on .Buttocks, no dranage [sic], noted granulation tissue. No S/S [signs and symptoms] of infection or psin [sic] noted .
-12/16/2023 at 11:45 AM .small open area to buttocks was cleaned with NS [normal saline] and wound gel [type of wound treatment] applied before bordered gauze. Area remains free of s/s [signs and symptoms] of infection .
-12/26/2023 at 8:31 PM .wound on [his/her] coccyx/buttock (stage 2). some redness in groin area. treatments are in place. coccyx/ right buttock wound. treatment in place .
-12/28/2023 12:29 PM .no changes to wound .
-1/10/2024 at 4:40 PM .Stage 2 to buttocks shows no S/S of infection. no drainage noted .
-1/11/2024 at 1:25 PM .Stage 2 to buttocks shows no S/S of infection. no drainage noted .
-1/12/2024 .Skin: coccyx wound .
-1/13/2024 .Stage 2 to buttocks shows no S/S of infection. no drainage noted, wound bed noted to have slough edges and granulation in middle of wound .
-1/15/2024 at 3:47 PM .Stage 2 to buttocks shows no S/S of infection. no drainage noted, wound bed noted to have slough edges and granulation in middle of wound .
-1/17/2024 at 4:52 PM .Stage 2 to buttocks shows no S/S of infection. no drainage noted, wound bed noted to have slough edges and granulation in middle of wound .
-1/19/2024 at 6:23 PM .pressure wound on buttocks cleaned with normal saline, covered with border gauze. Pt [patient] tolerates treatment well .
-1/22/2024 at 7:38 PM .Stage 2 to R buttock shows no drainage or S/S of infection. Wound bed noted to have slough edges and granulation in middle of wound .
-1/23/2024 at 12:32 PM .Stage 2 to R buttock shows min [minimal] sero-sang [watery, clear, or slightly yellow/tan/pink fluid] drainage & no S/S of infection. Wound bed noted to have slough edges and granulation in middle of wound .
Record review failed to reveal evidence of weekly wound measurements for the right buttocks stage 2 PU wound while the resident was in the facility.
During a surveyor interview on 1/24/2024 at 11:47 AM with Licensed Practical Nurse (LPN), Staff A at 11:47 AM, she revealed that the resident was admitted to the facility with the wound on his/her bottom. She further revealed that she was unable to locate measurements of the wound in the resident's record.
During a surveyor interview with the Infection Preventionist on 1/25/2024 at 9:55 AM, she revealed that she follows the wounds in the facility. She further revealed that she had not assessed or measured this resident's wound until after it was brought to her attention by the surveyor. Furthermore, she revealed that the wound is possibly a stage 3.
During a surveyor observation at 1/25/2024 at 11:00 AM of the resident's wound care, in the presence of Staff, A, two wounds were observed on the resident, one in the right inner gluteal fold and the other on the right glute. Staff A described the two wounds as having slough as the wounds presented with yellow tissue on the wound beds.
During a surveyor interview on 1/25/2024 at 11:17 AM with the Director of Nursing Services, she was unable to provide evidence that weekly wound measurements were obtained for the resident's stage 2 PUs. Additionally she indicated, after she was informed that the wound bed now had slough, that the wound had progressed to a stage 3 PU. Furthermore, she was unable to provide evidence of documentation or a treatment for the 2nd wound observed on the resident's right inner gluteal fold.
b. Review of a facility policy titled Dressing, Dry/Clean states in part, .steps in the procedure .2. Place the clean equipment on the clean field. Arrange the supplies so they can be easily reached .6. Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull glove over dressing and discard into plastic or biohazard bag 8. Wash and dry your hands thoroughly .
During a surveyor observation at 1/25/2024 at 11:00 AM of the resident's wound care in the presence of Staff, A, she removed her scissors from her pocket and placed them on the clean field without first sanitizing them. She proceeded to remove the old dressing, cleansed and dried the wound, failing to perform hand hygiene or changing her gloves in between. She then applied the Santyl to the wound bed, cut the calcium alginate (wound treatment) to the wound size, dated the wound dressing and covered the wound with the dressing, again without ever performing hand hygiene or changing her gloves.
During a surveyor interview on 1/25/2024 at 11:12 AM with Staff A, she acknowledged that she removed her scissors from her pocket and placed them on the clean field without sanitizing them first. She further acknowledged that she did not change her gloves or perform hand hygiene while providing the resident with wound care, per the facility policy.
During a surveyor interview on 1/25/2024 at 11:17 AM with the Director of Nursing Services, she was unable to provide evidence that the resident's pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Additionally, she was unable to provide evidence that appropriate wound care was provided to prevent infections.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide ap...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 4 residents reviewed with an indwelling catheter (a tube inserted into the bladder to drain urine), Resident ID #165.
Findings are as follows:
Review of the Minimum Data Set (MDS) Resident Assessment Instrument Manual (v)1.18.11 dated October of 2023, states in part, Indwelling catheters should not be used unless there is valid medical justification. Assessment should include consideration of the risk and benefits of an indwelling catheter, the anticipated duration of use, and consideration of complications resulting from the use of an indwelling catheter. Complications can include an increased risk of urinary tract infection [UTI] .Incontinence also may lead to the potentially troubling use of indwelling catheters, which can increase the risk of life threatening infections .Because of the risk of substantial complications with the use of indwelling urinary catheters, they should be used for appropriate indications and when no other viable options exist.
According to the American Urological Association, prolonged indwelling catheter use is associated with extended hospitalization and catheter associated urinary tract infections. Additionally, if a patient fails trial of void they should follow up with a Genitourinary specialist (i.e. urology) within 5-14 days.
Record review revealed the resident was admitted to the facility in October of 2023 and readmitted in December of 2023 with diagnoses including, but not limited to, UTI and extended spectrum beta lactamase (ESBL) resistance.
Review of an MDS assessment dated [DATE] revealed the resident has an indwelling catheter.
Review of the resident's care plan revealed a focus initiated on 10/9/2023 which states, I have an indwelling urinary catheter r/t [related to] urine retention-Failed trial void in hospital -Colonized ESBL -Trial void 10/19/23-Monitor - re-admitted with Foley 11/7/23 -TRIAL VOID 12/16/23-MONITOR-Failed -Foley still remains in place 1/19/24.
Review of a provider note dated 10/24/2023, authored by Nurse Practitioner (NP), Staff C states in part, .[S/he] also failed trial void and continues to have foley catheter .Assessment and Plan .Continue foley catheter. Urology consult .
Record review revealed a urine culture, obtained on 11/16/2023 which revealed the resident did not have any abnormalities in his/her urine.
Review of a provider note dated 11/20/2023, authored by Staff C, states in part, .[S/he] continues to have foley catheter and will need urology consult-Discussed with Dr .
Record review revealed a urine culture, obtained on 12/4/2023, which states in part, .SOURCE FOLEY CATHETER .POSITIVE FOR ESBL .
Review of progress notes revealed the following:
- 12/7/2023 at 11:18 AM, states in part, .lab called to notify this writer that pt [patient] U/a [urine analysis] collected on 12/4 resulted positive for ESBL. NP .notified. PER NP NO [new order] Midline for IV [intravenous] for IV abx.[antibiotics]. NO Etrapenem [antibiotic] 500mg [milligram] daily x [times] 14 days .
- 12/7/2023 at 10:44 PM, states in part, Upon 10pm rounds, pt was unresponsive to verbal commands and stimuli .pt has a new onset UTI and has been hypotensive [low blood pressure] .
- 12/8/2023 revealed the resident was admitted to the hospital for urosepsis (a life-threatening condition that occurs when a UTI spreads to the bloodstream and causes sepsis, a severe inflammatory response), hypotension and was positive for ESBL in urine.
- 12/13/2023 revealed the resident was readmitted to the facility from the hospital after being admitted for urosepsis, where s/he completed a course of antibiotics and steroids.
Review of a provider note dated 12/26/2023, authored by Staff C states in part, .Assessment and Plan .Urology f/u [follow up] as patient has failed multiple trial voids .
Record review failed to reveal evidence that the facility made an attempt to schedule a urology appointment, 3 months after the initial recommendation was made by the NP and following a recent hospitalization for urosepsis, until it was brought to the facilities attention by the surveyor.
During a surveyor interview on 1/24/2024 at 10:54 AM with Unit Manager, Staff D, she revealed the resident has not attended a urology consult and acknowledged the NP notes indicate the need for a urology appointment, since the resident's admission to the facility.
During a follow up interview on 1/24/2024 at 12:09 PM, with Staff D, she revealed when the resident returned to the facility in December of 2023, following a hospitalization, a request was made to follow up with urology.
During a surveyor interview on 1/24/2024 at 12:45 PM, with the Director of Nursing Services, she was unable to provide evidence the facility attempted to arrange for a urology appointment for the resident, until the surveyor brought this concern to the facility's attention. Furthermore, she was unable to provide evidence that the facility provided appropriate treatment and services for Resident ID #165 relative to a foley catheter.
During a surveyor interview on 1/25/2024 at 12:22 PM, with NP, Staff B and Staff C, they revealed that they would have expected the urology appointment to have been scheduled, before it was brought to the facility's attention by the surveyor.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
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 maintain a...
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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 maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections for 4 of 6 resident's reviewed for Multidrug-resistant Organisms (MDRO), Resident ID #s 88, 89, 156, and 165.
Findings are as follows:
Review of the CDC's (Centers for Disease Control and Prevention) document titled, Multidrug-resistant organisms management states in part, .For ill residents (e.g., those totally dependent upon healthcare personnel for healthcare and activities of daily living .) .use Contact Precautions [use of gown and gloves when entering a resident's room] in addition to Standard Precautions .For MDRO colonized or infected patients without draining wounds, diarrhea, or uncontrolled secretions, establish ranges of permitted ambulation, socialization, and use of common areas based on their risk to other patients and on the ability of the colonized or infected patients .
Review of a facility policy titled Isolation - Categories of Transmission-Based Precautions states in part, .Contact precautions are also used in situations when a resident is experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environment contamination and risk of transmission of a pathogen, even before specific organism has been identified .Contact precautions are used for residents infected or colonized [If you are colonized with an MDRO, these germs are living on or in your body. You may not be sick with an infection, but you can spread the germs] with MDROs in the following situations .when a resident has wounds, secretions, or excretions that are unable to be covered or contained .the individual on contact precautions is placed in a private room if possible. If a private room is not available the infection preventionist will assess various risks associated with other resident placement options (e.g., cohorting, placing with a low risk roommate) .
Review of a document titled, Rhode Island Department of Health, Guidelines for the Management of Methicillin Resistant Staphylococcus aureus in Rhode Island Long Term Care Facilities (2007) states in part, . Contact precautions may be discontinued when there is documentation of two (2) consecutive negative MRSA screens from previously positive sites. Screens should be obtained no sooner than 72 hours after completion of decolonization and/or treatment of infection.
1. Record review revealed that Resident ID #88 was admitted to the facility in January of 2024 with diagnoses including, but not limited to, carrier or suspected carrier of methicillin resistant staphylococcus aureus (MRSA) and acute respiratory failure with hypoxia.
Review of the resident's discharge Continuity of Care form (COC) dated 1/1/2024 reveals that the resident was discharged to the facility on isolation precautions for Covid-19 and MRSA.
Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed s/he requires moderate to maximum assistance to complete activities of daily living (ADLs).
Review of the progress notes revealed the following:
1/23/2024 states in part, .pt [patient] does have a productive cough, and is getting out clear sputum .
1/22/2024 states in part, .cough present .
1/18/2024 states in part, .+ [positive] cough .CARRIER OR SUSPECTED CARRIER OF METHICILLIN RESIS STAPH-Infectious precautions per protocol .
Record review failed to reveal evidence of a re-culture for MRSA.
During surveyor observations from 1/22/2024 through 1/25/2024 failed to reveal evidence that the resident was on contact precautions for MRSA, although s/he was noted to have respiratory symptoms.
During a surveyor interview on 1/25/2024 at 10:14 AM with the Infection Preventionist (IP), she acknowledged that Resident ID #88 was not on contact precautions for MRSA although s/he has a cough.
2. Record review revealed that Resident ID #89 was re-admitted to the facility in March of 2023 with diagnoses including, but not limited to, dependence on renal dialysis (treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) and bilateral below the knee amputations.
Review of a Wound Evaluation and Management Summary dated 1/24/2024 revealed that the resident has a stage 4 pressure wound (the most serious pressure wound that extends below the subcutaneous fat into deep tissues, including muscle, tendons, ligaments and can extend as far down as the bone) of the posterior sacrum measuring, 5.7 centimeter (cm) x 4.5 cm x 1.7 cm with 23.85 cm surface area. Further review revealed the wound had moderate serous drainage (thin, clear or yellow fluid).
Review of a care plan for pressure ulcers initiated on 3/10/2023 revealed s/he tested positive for MRSA in his/her sacral wound on 10/15/2023.
Review of a wound culture dated 10/15/2023 revealed s/he is positive for MRSA in his/her wound.
Review of a progress note dated 11/2/2023 authored by Nurse Practitioner (NP), Staff G, revealed that the resident had a recent wound culture positive for MRSA that was sensitive to Vancomycin (antibiotic) and would start treatment of intravenous Vancomycin 3 times a week for 6 weeks.
Review of a progress note dated 12/12/2023 revealed that the resident will receive his/her last dose of antibiotics on 12/14/2023.
Record review failed to reveal evidence of a re-culture to determine if the wound continued to be positive for MRSA, once the antibiotic was completed.
During a surveyor observation of the resident's dressing change on 1/25/2024 at 9:35 AM with Licensed Practical Nurse (LPN), Staff E, failed to reveal evidence of the resident being on contact precautions.
During a surveyor interview on 1/25/2024 at 10:19 AM with the IP, she revealed that the provider did not re-culture the wound after completion of the antibiotic. Additionally, she acknowledged that the resident is not on contact precautions.
3. Record review revealed that Resident ID #156 was re-admitted to the facility in January of 2024 with diagnoses including, but not limited to, diverticulitis (inflammation or infection of the pouches formed in the colon) and vancomycin resistance.
Review of a 5 Day MDS assessment dated [DATE] revealed s/he required moderate to dependent assistance to complete ADLs.
Review of a Nurse to Nurse Report Checklist revealed that Resident ID #156 has a significant history of Vancomycin Resistant Enterococci (VRE).
During surveyor observations on 1/23/2024 revealed that the resident was incontinent of loose stools three times on the 7 AM - 3 PM shift. The staff was observed to be providing incontinent care without the use of personal protective equipment.
Record review failed to reveal evidence that the facility obtained a re-culture for VRE.
During surveyor observations on 1/22/2024 and 1/23/2024 (when the resident was transferred to the hospital), s/he was not on contact precautions.
Record review revealed that Resident ID #156 shares a room with Resident ID #158 who requires dialysis.
During a surveyor interview on 1/25/2024 at 10:06 AM with the IP, she revealed that the resident has chronic diarrhea. Additionally, she acknowledged that the resident was not on precautions prior to being transferred to the hospital on 1/23/2024. Additionally, she acknowledged that the resident shares a room with a clinically compromised resident who requires dialysis.
4. Record review revealed that Resident ID #165 was readmitted to the facility in December of 2023 with diagnoses including, but not limited to, extended spectrum beta lactamase (ESBL) and urinary tract infection.
Review of a Quarterly MDS assessment dated [DATE] revealed s/he is totally dependent on staff for toileting.
Review of a urine culture dated 12/4/2023 revealed s/he is positive for ESBL.
Record review failed to reveal evidence of a re-culture for ESBL following antibiotic treatment.
Review of a care plan initiated on 10/9/2023 revealed s/he has an indwelling urinary catheter and has colonized ESBL.
During surveyor observations from 1/22/2024 through 1/25/2024 revealed the resident was not on contact precautions.
During a surveyor interview on 1/25/2024 at 10:12 AM with the IP, she revealed that the facility did not re-culture to rule out ESBL following antibiotic treatment. Additionally, she acknowledged that the resident was not on contact precautions.
During a surveyor interview on 1/25/2024 at 11:17 AM with the Director of Nursing Services, she acknowledged that the above residents were not on contact precautions per the CDC, Rhode Island Department of Health and the facility policy. Additionally, she was unable to provide evidence that the facility maintained an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to MDROs.
Jul 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to protect the resident's right to be...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to protect the resident's right to be free from sexual abuse for 1 of 2 residents reviewed, Resident ID #' 7.
Findings are as follows:
Record review of a facility reported incident submitted to the Rhode Island Department of Health on 7/27/2023 alleges that Resident ID #8 was found with his/her mouth on the chest of Resident ID #7.
The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023, states in part, .sexual contact is nonconsensual if the resident .lacks the cognitive ability to consent .
Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated October 2022, states in part, .Residents have the right to be free from abuse .This includes but is not limited to freedom from .sexual .abuse .
1. Record review revealed Resident ID #7 was admitted to the facility in February of 2023 with diagnoses that include but are not limited to, dementia, and depression.
Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating severely impaired cognition.
Record review revealed a care plan dated 2/25/2023 indicating the resident has impaired thought processes related to dementia. Interventions include to cue, reorient, and supervise as needed.
Additional record review revealed a care plan dated 7/27/2023 indicating the resident has a behavior problem related to disinhibition behavior with sexual tendencies.
Record review of a social services progress note dated 7/27/2023 at 3:27 PM indicates, Nursing Assistant (NA), Staff B, found Resident ID #7 with his/her shirt up while in bed with another resident.
2. Record review revealed Resident ID #8 was admitted to the facility in July of 2023 with a diagnosis that includes, but is not limited to, dementia.
Record review of a 7/20/2023 admission MDS Assessment revealed a BIMS score of 6 out of 15 indicating severely impaired cognition.
Record review revealed a care plan dated 7/21/2023 indicating the resident has impaired thought processes relative to dementia. Interventions include to cue, reorient, and supervise as needed.
Further review revealed a care plan dated 7/27/2023 indicating s/he has a behavior problem related to disinhibition behavior with sexual tendencies.
Record review of a social services progress note dated 7/27/2023 at 3:27 PM, revealed Resident ID #8 was found in bed with another resident (Resident ID #7) on 7/25/2023. Additionally, the note indicates Resident ID #8 was clothed, however the other resident's shirt was up. Resident ID #8 was unable to recall the incident.
Additional record review revealed a nurse practitioner progress note dated 7/27/2023 at 8:10 PM, which indicates the resident was evaluated by the NP related to the 7/25/2023 incident. The note further indicates that Resident ID #8 denied being in a room with another resident. The note states in part, .[S/he] does report that another resident has been persistent and trying to hold [his/her] hand .
During a surveyor interview on 7/28/2023 at 11:10 AM, with Social Worker, Staff A, she revealed that on 7/25/2023, Staff B found Resident ID #'s 7 and 8 in bed in another resident's room. She indicated that the two residents have a friendly relationship and often sit close together in the common area.
During a surveyor interview on 7/28/2023 at 1:00 PM, with Staff B, she revealed that on 7/25/2023 around 3:00 PM, she witnessed Resident ID #'s 7 and 8 in another resident's room. She indicated that she saw Resident ID #7 with his/her shirt up and Resident ID #8 with his/her mouth on Resident ID #7's unclothed chest.
During a surveyor interview on 7/28/2023 at 3:10 PM, with NA, Staff C, she revealed that she worked on 7/25/2023 on the 7:00 AM - 3:00 PM shift and indicated she was present when Staff B informed her and the nurse of an incident with two above-mentioned residents. She further indicated that she was concerned when Staff B named the two residents because she had witnessed them cuddling in the common area earlier in the day.
During a surveyor interview on 7/28/2023 at approximately 3:00 PM, with the Assistant Director of Nursing Services, she revealed the incident occurred on 7/25/2023 however management was not aware of the incident until 7/27/2023. Additionally, she was unable to provide evidence that Resident ID #'s 7 was kept free from sexual abuse.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on surveyor observations, record review, resident and staff interview, it has been determined that the facility failed to ensure a resident's environment remains as free of accident hazards as p...
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Based on surveyor observations, record review, resident and staff interview, it has been determined that the facility failed to ensure a resident's environment remains as free of accident hazards as possible relative to smoking hazards for 2 of 2 residents reviewed, Resident ID #'s 1, and 5.
Findings are as follows:
Record review of facility reported complaints submitted to the Rhode Island Department of Health on 7/22/2023 and 7/27/2023 revealed Resident ID #'s 1 and 5 were involved in resident-to-resident incidents.
Review of the facility policy titled, Tobacco-Restrictive Policy Acknowledgement, revised March 2021, states in part, .The purpose of restricting smoking at the facility is to reduce the effect of smoking to residents who do not smoke .to reduce the risk of passive smoke, and to reduce the risk of fire .Procedure .All cigarettes, lighters and any other smoking materials will be kept at the nurses' station .
1. Record review revealed Resident ID #1 was admitted to the facility in July of 2023 with diagnoses including, but not limited to, bipolar disorder, and major depressive disorder.
Record review revealed a care plan dated 7/18/2023 indicating the resident is a smoker. Interventions include that the facility will store his/her nicotine products and lighter for safety. The care plan also indicates that s/he wears a smoking apron.
Additional record review revealed the resident signed the facility smoking policy acknowledgement form on 7/18/2023.
During a surveyor observation on 7/28/2023 at 1:15 PM and 1:30 PM, Resident ID #1, was observed lying in bed in his/her room. A lighter was observed on the floor near the bed, one pack of cigarettes was observed on the bed, and one pack of cigarettes on the bedside table. During a surveyor interview immediately following the above-mentioned observation with Resident ID #1, s/he revealed that his/her cigarettes and lighter are kept in his/her possession.
During a surveyor interview on 7/28/2023 at approximately 1:20 PM, with Agency Licensed Practical Nurse (LPN), Staff D. She acknowledged that the resident's lighter and two packs of cigarettes were in the resident's room. Additionally, she indicated that the residents are allowed to keep the above-mentioned items.
Record review of a progress note dated 7/28/2023 at 2:15 PM, authored by Staff D, indicates that the resident was educated on returning the lighter after smoking, after it was brought to the facility's attention by the surveyor.
2. Record review revealed Resident ID #5 was admitted to the facility in June of 2023 with diagnosis including but not limited to, cerebral infarction (stroke).
Record review revealed a care plan dated 6/29/2023 indicating that the resident is a smoker. Interventions include that the facility will store his/her nicotine products and lighter for safety.
Additional record review revealed the resident signed the facility smoking policy acknowledgement form on 7/1/2023.
During a surveyor observation and interview with Resident ID #5, on 7/28/2023 at 1:45 PM, s/he was observed in the common area and revealed that s/he had a lighter and pack of cigarettes in his/her pants pocket. Additionally, the resident indicated that the smoking materials remain in his/her possession and not at the nurses' station.
During a surveyor interview on 7/28/2023 at approximately 2:00 PM, with the Assistant Director of Nursing Services (ADNS), she indicated that she expects all resident cigarettes and lighters to be kept at the nurses' station and not in the resident's possession per the facility policy.
Jun 2023
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to protect the resident's right to be...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to protect the resident's right to be free from sexual abuse from Resident ID #1, for 2 of 6 residents reviewed, Resident ID #'s 5 and 6.
Findings are as follows:
Record review of a community reported complaint submitted to the Rhode Island Department of Health on 6/22/2023 alleges in part, [Resident ID #1] demonstrated inappropriate 'consensual sexual behavior with another patient' .
According to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023, states in part, .sexual contact is nonconsensual if the resident .lacks the cognitive ability to consent .
1. Record review revealed Resident ID #1 (perpetrator) was admitted to the facility in August of 2022 with diagnoses that include but are not limited to, dementia, major depressive disorder, and anxiety.
Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating intact cognition.
Additional record review revealed that the resident resided on the secured memory care unit.
Record review of a care plan with a revision date of 2/10/2023 revealed that the resident was watching a sexually inappropriate movie in the common area on 10/16/2022.
Record review of a care plan initiated on 3/27/2023 revealed that the resident has a behavior problem of entering other resident rooms and demonstrating inappropriate touching. Interventions include to monitor boundaries.
Record review revealed the following progress notes which state in part:
- 12/12/2022 at 2:30 AM, At approximately 2:00 a.m. resident was found in room .with a .resident .refused to relocate back to [his/her] room .
- 12/14/2022 at 9:02 PM, Resident was found in another residents bed .resident tried to get other residents to come to [his/her] room .
- 12/29/2022 at 3:08 AM, .observed in another pt [patient] bed .difficult to redirect .
- 1/15/2023 at 9:28 PM, Resident found in .residents bed, reluctant to go to [his/her] own room .
- 1/18/2023 at 7:25 AM, Around 4AM .resident was found .with another .resident .redirected back to [his/her] room .
- 2/12/2023 at 4:15 PM, .restorative therapy session on this date .[Resident ID #1] displayed sudden inappropriate verbal and physical behavior, attempting to hold this writer's shoulders and pull mask off saying, 'I just want to have a kiss, please please.' .Nursing aware
- 3/25/2023 at 12:55 PM, Resident had .resident in room lying in bed with [him/her] .
- 3/25/2023 at 1:32 PM, Resident asked about entering a .residents room .stated [s/he] was 'invited in' .Educated and redirected on not entering any other rooms that are not [his/hers]. Resident in agreement and stated [s/he] understood .
2. Record review for Resident ID #5 (victim) revealed that s/he was admitted to the facility in July of 2020 with diagnoses that include but are not limited to, dementia and major depressive disorder.
Record review of an annual MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15 indicating severely impaired cognition.
Additional record review revealed that the resident resided on the secured memory care unit.
Record review of a progress note dated 3/25/2023 at 1:12 PM indicates that Resident ID #5 came out to the common area to report that Resident ID #1 entered his/her room and tried to touch his/her chest. The note also indicates that Resident ID #5's family member was contacted and asked the staff members not to discuss the situation with the resident due to his/her past traumas.
During a surveyor interview on 6/28/2023 at 9:53 AM with Nursing Assistant (NA), Staff A, she revealed that Resident ID #1 was the resident who entered Resident ID #5's room and attempted to touch his/her chest area.
3. Record review for Resident ID #6 (victim) revealed s/he was admitted to the facility in February 2023 with diagnoses that include but are not limited to, dementia, and depression.
Record review of an admission MDS assessment dated [DATE] revealed a BIMS score of 8 out of 15 indicating moderately impaired cognition.
Additional record review revealed that the resident resided on the secured memory care unit.
Record review of a care plan dated 2/25/2023 revealed that the resident has impaired cognitive function and impaired thought processes related to the diagnosis of dementia. Interventions include, supervise as needed.
Record review of a document titled, Social Services Assessment dated 3/9/2023 at 11:27 AM and signed on 5/16/2023 at 7:59 PM, revealed that the resident has a history of Post-Traumatic Stress Disorder.
Record review revealed a progress note dated 3/25/2023 at 1:35 PM which indicates Resident ID #6 was found in Resident #1's room, in bed with him/her. Resident ID #6 was noted to be fully dressed while Resident ID #1 was clothed in an under-garment brief and no shirt. The note further indicates that Resident ID #6 was fondling Resident ID #1's sexual organ.
During a surveyor telephone interview on 6/28/2023 at 1:21 PM, with the Social Worker, Staff B, she revealed that Resident ID #1 was moved off of the secured memory care unit after s/he was involved in two separate incidents on 3/25/2023 with Resident ID #'s 5 and 6.
During a surveyor interview on 6/28/2023 at 11:22 AM and 1:06 PM, with the Administrator, she revealed that Resident ID #1 initially resided on the secured dementia unit and described him/her as being high functioning. She indicated Resident ID #1 was moved off of the secured memory care unit after s/he asked to touch the chest of Resident ID #5. Additionally, she was unable to provide evidence that the residents were kept free from sexual abuse.
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 F0675
(Tag F0675)
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 provide services to attain and ma...
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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 provide services to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing for 1 of 6 residents reviewed, Resident ID #2.
Findings are as follows:
Record review of a community reported complaint submitted to the Rhode Island Department of Health on 6/23/2023 alleges in part, .[S/he] presented to the ED [emergency department] .on 6/21/23 .[resident's] wheelchair broke & alleges 'they left [him/her] in bed for 2 weeks .
Record review revealed that the resident was readmitted to the facility in October of 2021 with diagnoses including, but not limited to, traumatic brain injury (TBI), aphasia (inability to speak), paraplegia (paralysis), major depressive disorder and anxiety.
Record review of an annual Minimum Data Set (MDS) assessment dated [DATE], section F0400 titled Interview for Daily Preferences, revealed the resident indicated that it is very important to do things with groups of people and go outside to get fresh air when the weather is good.
Record review of a quarterly MDS assessment dated [DATE] revealed that the resident does not walk, requires the total dependence of two or more staff members for transferring, and utilizes a wheelchair for mobility.
Record review revealed a document dated 6/2/2023 titled, Occupational Therapy OT Evaluation & Plan of Treatment, states in part, .Pt [patient] wheelchair [w/c] footrest is broken .
Record review revealed a document dated 6/4/2023 titled, Nursing Therapy Communication Change of Status Form, which indicates that the resident is unable to get out of bed and sit in his/wheelchair because the footrest is broken. The document also indicates that an occupational therapy evaluation was completed and indicates a wheelchair is required.
Further record review of the document titled, Occupational Therapy Treatment Encounter Note(s), revealed the following notes in part:
- 6/9/2023, .Pt received sitting up in bed .
- 6/11/2023 .Pt [patient] received laying .in bed with R [right] lateral contracture to neck .Pt positioned in bed for breakfast .
- 6/12/2023, .attempt to achieve an improve head position in bed .
During a surveyor telephone interview on 6/27/2023 at 9:28 AM, with the resident's family member, they indicated that about 2 weeks ago the resident's wheelchair broke and since then s/he has not been able to get out of bed.
During a surveyor interview on 6/27/2023 at 10:14 AM, with Nursing Assistant (NA), Staff C, she revealed that she was the resident's assigned NA about two weeks ago and s/he had to stay in bed because his/her wheelchair was broken. Staff C further indicated that the resident enjoyed spending time out of his/her room.
During a surveyor interview on 6/27/2023 at 11:54 AM, with Certified Occupational Therapy Assistant (COTA), Staff D, revealed that the resident had remained in bed for 7-14 days because his/her wheelchair was broken. Staff D also indicated that the resident was less cooperative with treatment when working with him/her in bed versus when s/he was able to sit in the wheelchair.
During a surveyor interview on 6/28/2023 at 11:36 AM, with the Director of Maintenance, he revealed that he was notified by staff that the resident was unable to get out of bed because his/her wheelchair was broken on 6/19/2023. He also indicated that a rental chair was delivered to the facility on 6/20/2023.
Record review of documents titled, Southwest Medical dated 6/19/2023 and H&R HEALTHCARE LP dated 6/20/2023, indicates a rental wheelchair was delivered to the facility on 6/20/2023, which was approximately 18 days after the facility was made aware that the resident's wheelchair was broken and resulted in him/her remaining in bed for approximately 7-14 days.
During a surveyor interview on 6/27/2023 at 3:05 PM, with the Assistant Director of Nursing Services, she acknowledged that the resident was unable to sit in his/her wheelchair because it was noted to be broken on approximately 6/4/2023 . Furthermore, she was unable to explain why the resident was not provided with a rental wheelchair to attain and maintain his/her highest practicable physical, mental, and psychosocial wellbeing until 6/20/2023.
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
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 and staff interview, it has been determined that the facility failed to ensure that a resident received t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of care relative to 1 of 1 residents reviewed for constipation, Resident ID #2.
Findings are as follows:
Record review of a community reported complaint submitted to the Rhode Island Department of Health on 6/23/2023 alleges in part, .presented to the ED [emergency department] .on 6/21/23 due to .poor intake .in the setting of severe volume depletion .[resident] .has not been provided drinks (water) as often as they should .not [him/herself] .distended (bloated) stomach and no appetite .
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 orders unless they believe the orders are in error or would harm the clients.
Record review of the facility policy titled, Bowel Elimination, dated February 2023, states in part, .Nursing service shall be responsible for monitoring bowel functions of patients .and assist the patient with elimination .
Record review revealed that the resident was readmitted to the facility in October of 2021 with diagnoses including, but not limited to, traumatic brain injury (TBI), paraplegia (paralysis), dysphagia (difficulty swallowing), and constipation.
Record review of a quarterly Minimum Data Set assessment dated [DATE] revealed that the resident requires the total dependence of two or more staff members for toileting needs.
Record review of a care plan dated 3/3/2023 revealed a constipation focus area. Interventions include, to follow the bowel regime as ordered and monitor and record bowel movements (BM) every shift.
Additional record review revealed a progress note dated 6/6/2023 at 7:33 PM, which indicates that an abdominal x-ray was ordered after the resident was noted with a distended abdomen and vomiting. The note also indicates that the x-ray results revealed an ileus (lack of movement in the intestines) and the physician gave orders to monitor for gas and bowel movements.
Record review failed to reveal evidence that the resident was monitored for gas except for on 6/7, 6/13, and 6/20/2023.
Furthermore, the record failed to reveal evidence that a bowel movement was recorded every shift per the care plan on the following dates:
7:00 AM - 3:00 PM shift on 6/2 and 6/10/2023
3:00 PM - 11:00 PM shift on 6/11/2023
11:00 PM - 7:00 AM shift on 6/9, 6/11, 6/13, 6/18, and 6/20/2023.
Record review of the June 2023 Medication Administration Record revealed that the following ordered medications were documented as not administered on 6/20/2023 at 9:00 PM; Gas relief 80 milligrams (MG), senna 8.6 MG 2 tablets (laxative), stool softener 100 mg (laxative), and Constulose solution 30 milliliters on 6/16 and 6/20/2023 at 9:00 PM.
Record review revealed that the resident was documented as having no bowel movements on 6/18, 6/19, and 6/20/2023.
The record further revealed that the resident was transferred to the emergency department on 6/21/2023 with diagnoses including, constipation, fecal impaction and required manual disimpaction (removal of stool from the colon).
During a surveyor interview on 6/28/2023 at 11:40 AM, with the Assistant Director of Nursing Services (ADNS), she revealed that her expectation is for staff to initiate the bowel regime after three days with no bowel movement. She also indicated that she would have expected staff to document a bowel assessment which would include listening for bowel sounds, when a resident has abdominal distention and entering and following the physician's order to monitor for gas and BM. Furthermore, she was unable to provide evidence that the resident received treatment and care in accordance with professional standards of care relative to constipation.
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 F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident is offered...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident is offered sufficient fluid intake to maintain proper hydration and health for 1 of 1 residents reviewed, Resident ID #2.
Findings are as follows:
Record review of a community reported complaint submitted to the Rhode Island Department of Health on 6/23/2023 alleges in part, .[S/he] presented to the ED [emergency department] from .Nursing home on 6/21/23 due to .poor PO [by mouth] intake and was found to have .sodium level of 183 [normal range is 135 - 146] .in the setting of severe volume depletion. Resident's [family member] alleges that .has not been provided drinks (water) as often as they should .Resident's [family member] stated when [s/he] visits, 'there is sometimes a small cup of water near [him/her], but [s/he] can't drink it [him/herself] .Resident's attending [physician] at [hospital] stated that this patient presented .with clear clinical signs of severe dehydration .
Record review revealed that the resident was readmitted to the facility in October of 2021 with diagnoses including, but not limited to, traumatic brain injury (TBI), paraplegia (paralysis) and dysphagia (difficulty swallowing).
Record review of a quarterly Minimum Data Set assessment dated [DATE] revealed that the resident requires the extensive assistance of one staff member for drinking.
Record review of a facility document dated 6/5/2023 titled Nutritional Risk Assessment indicates that the resident's estimated fluid needs are 2275 - 2730 cc (cubic centimeters) per day.
Record review of a nutrition care plan initiated on 6/5/2023 revealed interventions that include, but are not limited to, monitor and record intake at meals.
Additional record review failed to reveal evidence of documented fluid intake during meals, therefore the facility was unable to determine if the resident met the above-mentioned estimated fluid needs daily.
Record review of an Occupational Therapy treatment note dated 6/11/2023 indicated that the resident required maximum assistance for eating due to increased lethargy and fatigue.
Record review revealed that the resident was transferred to the hospital on 6/21/2023 due to a change in mental status, decreased oral intake, and a critically elevated sodium level of 179.
Record review of the hospital documents dated 6/22/2023, titled Progress Notes, and 6/23/2023, titled, Nutrition assessment, indicates that the resident presented with hypernatremia in the setting of poor oral intake and dry mucus membranes. The documents also revealed the treatment plan included intravenous fluids and the placement of a naso-gastric tube (a tube inserted through the nose, down the throat and esophagus, and into the stomach) for hydration.
During a surveyor interview on 6/26/2023 at 1:41 PM, with the Registered Dietitian, she acknowledged that she documented the resident's estimated daily fluids as 2275 - 2730 cc and was unable to provide evidence that the resident received this amount daily.
During a surveyor interview on 6/27/2023 at 9:28 AM, with the resident's family member, they indicated that during visits the resident would have full cups of fluids around his/her room, however s/he is unable to pick up the cups to drink the fluid without staff assistance.
During a surveyor interview on 6/27/2023 at 11:44 AM, with the Nurse Practitioner (NP), she revealed that she was alerted to the resident's change in mental status and poor intake on 6/20/2023 and ordered STAT (immediate) blood work. The NP also indicated that she gave an order to have the resident transferred to the emergency department the morning of 6/21/2023 after being notified of the resident's critical blood work results. Additionally, she stated that a sodium of 179 does not occur overnight, and indicated that she would have expected to have the resident's fluid intake tracked because '[s/he] is so compromised.
During a surveyor interview on 6/27/2023 at 11:54 AM, with Certified Occupational Therapy Assistant (COTA), Staff D, he revealed that he works with the resident for self-feeding during the evening meal and indicated that he noticed the resident was abnormally sweaty, not him/herself, and was drinking less.
During a surveyor interview with the Assistant Director of Nursing Services (ADNS) on 6/27/2023 at 3:05 PM, she was unable to provide evidence that the resident received adequate fluids to maintain health.
Jun 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that all alleged violation...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to other officials (Department of Health), in accordance with State law for 1 of 1 residents reviewed for abuse, Resident ID #2.
Findings are as follows:
Record review of a community reported complaint submitted to the Rhode Island Department of Health on 5/25/2023 alleges in part, .The patient .presented to the emergency department via EMS [Emergency Medical Services] with a chief complaint of altered mental status .history is obtained by speaking to the patient's [family member] .stated that the patient was involved in an altercation with another resident at .Nursing Home where [s/he] resides .
Record review of the undated facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, states in part, .All reports of resident abuse .and reasonable suspicions of crimes against residents are reported to local, state and federal agencies .and thoroughly investigated by facility management. Findings of all investigations are documented and reported .'Immediately' is defined as .within two hours if the events that cause the allegation involve abuse .Follow-Up Report .Within five (5) business days of the incident, the administrator will provide a follow-up investigation report .Corrective Actions .The resident's care plan is revised if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident or abuse .
Record review revealed that the resident was readmitted to the facility in May of 2023 with diagnoses including, but not limited to, hyponatremia (condition where the blood level of sodium is low) and lack of coordination.
Record review of a quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15 indicating intact cognition.
Further record review revealed a progress note authored by Licensed Practical Nurse, Staff A, dated 5/20/2023 at 10:09 AM and was struck out on 5/23/2023 at 11:01 AM. The note states in part, .RESIDENT TO RESIDENT: Resident was interviewed r/t [related to] incident .Resident stated one [sic] of the residents .hit [him/her] on the R [right] arm but is unable to identify who it was .facility manager on call notified. MD [medical doctor] notified . Additionally, the record revealed that the note was struck out due to Incorrect Documentation.
During a surveyor interview and observation on 6/7/2023 at 2:25 PM with the resident in his/her room, s/he revealed an incident occurred sometime last month while s/he was using the bathroom, another resident entered through the door from the adjoining room and hit him/her on the right arm. Additionally, the resident indicated that s/he almost fell off of the toilet and it caused him/her to experience pain.
During a surveyor observation of the resident's bathroom, during the above interview revealed the resident's the shared bathroom consists of a toilet and the door to the alleged perpetrator's room would be to the right if the resident was sitting on the toilet.
Additional record review revealed a physician's order with a start date of 3/15/2023 for Acetaminophen (Tylenol) two 325 milligrams tablets to be administered orally every 6 hours as needed for pain.
Review of the May 2023 Medication Administration Record (MAR) revealed that the resident received Acetaminophen for a pain level of 5 out of 10 on 5/20/2023 at 10:13 AM. The MAR failed to reveal the location of the resident's pain.
During a surveyor interview with Staff A on 6/7/2023 at 1:50 PM, she acknowledged that she was the author of the above-mentioned progress note dated 5/20/2023. Furthermore, Staff A revealed that she was the weekend supervisor at the facility on 5/20/2023. She also indicated that during the 7:00 AM - 3:00 PM shift a Nursing Assistant, who she was unable to recall the name of, alerted her to the resident's allegation of resident-to-resident abuse. Staff A indicated that she documented her findings in the medical record after she interviewed the resident. She further indicated that the two residents from the other room were interviewed by her and denied having any knowledge of the allegation. Staff A also indicated that she called the resident's family member and informed them of the incident. She further indicated that the resident was noted with increased confusion and the physician gave an order for the resident to be transferred to the hospital for evaluation on 5/21/2023 at 1:09 PM due to abnormal blood work. Staff A also indicated that the Assistant Director of Nursing Services (ADNS) told her to strike the note out.
Further record review revealed a hospital document titled Discharge Summary, dated 5/26/2023 which states in part, .Diagnoses .2. Acute metabolic encephalopathy [a problem in the brain caused by a chemical imbalance in the blood] .Resolved. Most likely psychological trauma from recent altercation .
During a surveyor interview with the ADNS on 6/7/2023 at 2:50 PM, she was unable to provide evidence that the resident's allegation of resident-to-resident abuse was reported to local, state and federal agencies per the facility policy.
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
Investigate Abuse
(Tag F0610)
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 provide evidence that all alleged...
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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 provide evidence that all alleged violations were thoroughly investigated for 1 of 1 residents reviewed for allegations of abuse, Resident ID #2.
Findings are as follows:
Record review of an undated facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, states in part, .All reports of resident abuse .and reasonable suspicions of crimes against residents are reported to local, state and federal agencies .and thoroughly investigated by facility management. Findings of all investigations are documented and reported .'Immediately' is defined as .within two hours if the events that cause the allegation involve abuse .Follow-Up Report .Within five (5) business days of the incident, the administrator will provide a follow-up investigation report .
Record review revealed that the resident was readmitted to the facility in May of 2023 with diagnoses including, but not limited, hyponatremia (condition where the blood level of sodium is low) and lack of coordination.
Record review of a quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition.
Further record review revealed a progress note authored by Licensed Practical Nurse (LPN), Staff A, and dated 5/20/2023 at 10:09 AM was struck out on 5/23/2023 at 11:01 AM. The note states in part, .RESIDENT TO RESIDENT: Resident was interviewed r/t [related to] incident .Resident stated one [sic] of the residents .hit [him/her] on the R [right] arm but is unable to identify who it was .facility manager on call notified. MD [medical doctor] notified . Additionally, the record revealed that the note was struck out due to Incorrect Documentation.
During a surveyor interview with Staff A on 6/7/2023 at 1:50 PM, she revealed that she was the weekend supervisor and author of the above-mentioned progress note dated 5/20/2023. She indicated that during the 5/20/2023 7:00 AM - 3:00 PM shift a Nursing Assistant (NA) notified her of the resident's allegation of resident-to-resident abuse. Staff A indicated she was unable to recall the name of the NA. Staff A further indicated that she documented her findings in the medical record after she interviewed the resident. She also revealed that she interviewed the two residents from the room next door and they denied having any knowledge of the allegation. She further indicated that the resident was noted with increased confusion and the physician gave an order for the resident to be transferred to the hospital for evaluation on 5/21/2023 at 1:09 PM due to abnormal bloodwork. She further indicated that the progress note was struck out on 5/23/2023 at the request of the Assistant Director of Nursing Services (ADNS).
During a surveyor interview on 6/7/2023 at 2:25 PM with the resident in his/her room, s/he revealed that an incident occurred sometime last month while s/he was using the bathroom. S/he indicated that while seated on the toilet in the bathroom in his/her room, another resident entered through the door from the next room, yelled and hit him/her on the right arm. The resident further indicated that the door was closed when a resident entered from his/her right side, began to yell and tell him/her to get off of the toilet and struck his/her right arm. The resident further indicated that s/he almost fell off of the toilet and that s/he experienced pain as a result.
During a surveyor observation of the resident's bathroom, during the above interview revealed the resident's the shared bathroom consists of a toilet and the door to the alleged perpetrator's room would be to the right if the resident was sitting on the toilet.
Additional record review revealed a physician's order with a start date of 3/15/2023 for Acetaminophen (Tylenol) two 325 milligrams tablets to be administered orally every 6 hours as needed for pain.
Review of the May 2023 Medication Administration Record (MAR) revealed that the resident received Acetaminophen for a pain level of 5 out of 10 on 5/20/2023 at 10:13 AM. The MAR failed to reveal the location of the resident's pain.
Further record review revealed the resident was transferred to the emergency department and admitted on [DATE]. Record review also revealed a hospital document titled Discharge Summary, dated 5/26/2023 which states in part, .Diagnoses .2. Acute metabolic encephalopathy [a problem in the brain caused by a chemical imbalance in the blood] .Resolved. Most likely psychological trauma from recent altercation .
During a surveyor interview with the ADNS on 6/7/2023 at 2:50 PM, she indicated that the resident's allegation of resident-to-resident abuse was not witnessed and therefore, she revealed that this is why the allegation of resident to resident abuse was not thoroughly investigated.
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
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, resident and staff interview, it has been determined that the facility failed to provide a safe, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, resident and staff interview, it has been determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public relative to 4 resident rooms observed on the first floor.
Findings are as follows:
Record review of an anonymous community reported complaint submitted to the Rhode Island Department of Health on 6/14/2023 alleges in part, .doesn't have .cleaning supplies. The first floor has a smell of urine .
Record review of an undated facility policy titled, Cleaning and Disinfection of Environmental Surfaces states in part, .Environmental surfaces will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection of healthcare facilities .Housekeeping surfaces .floors .will be cleaned on a regular basis, when spills occur, and when surfaces are visibly soiled .Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g. daily, three times per week) and when surfaces are visibly soiled .
1. During a surveyor interview on 6/15/2023 at approximately 11:50 AM with Resident ID #6, s/he revealed that the bathroom in his/her room had not been cleaned for days and as a result his/her family member purchased cleaning supplies and applied some cleaning powder to the floor to help make it easier for staff to clean when they come.
Record review revealed Resident ID #6 a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition.
During a surveyor observation immediately following the above-mentioned interview and again at 12:50 PM, revealed the resident's private bathroom with a toilet, sink, and shower stall. Various bottles of household cleaning products including but not limited to, Clorox toilet bowl cleaner, Comet cleaning powder and Pinesol. were observed on the floor near the toilet. The floor was observed to have white powder scattered throughout the floor around the toilet and at the shower entrance. The powder was observed to be covering dark discolored matter on the floor. Additionally, solid brown matter was observed on the floor in the shower.
During a subsequent surveyor interview on 6/15/2023 at approximately 12:00 PM, with Resident ID #6, s/he indicated that the shower had not been utilized on that date. S/he further indicated that their family member brought the supplies in the day before.
During a surveyor observation of Resident ID #6's bathroom on 6/15/2023 at 12:50 PM, that it had not been cleaned and the white powder was still on the floor and the brown matter remained in the shower.
During a surveyor interview on 6/15/2023 at 1:09 PM, with the Director of Maintenance (DOM), he revealed that he manages the housekeeping department. Additionally, he revealed that every resident room including floors are expected to be cleaned daily.
During a surveyor observation of Resident ID #6's bathroom, on 6/15/2023 at 1:15 PM, in the presence of the DOM, he acknowledged the above mentioned observations and indicated the brown matter appeared to be feces. Furthermore, he indicated that he would have expected the bathroom to be cleaned.
2. During a surveyor observation of Resident ID #11's room on 6/15/2023 at 12:20 PM revealed a private bathroom in the resident's room. Additionally, the bathroom was observed to have dark discolored matter around the base of the toilet and the shower was observed to have scattered dark pink/orange matter on the floor.
During a surveyor interview and observation of the resident's bathroom on 6/15/2023 at approximately 1:20 PM, with the DOM, he acknowledged the above observation.
3. During a surveyor observation of Resident ID #8's room on 6/15/2023 at 12:40 PM revealed the bathroom to have dark discolored matter around the base of the toilet. Additionally, the shower was observed to have black and pink matter scattered on the walls and the floor of the shower.
During a surveyor observation of the resident's bathroom on 6/15/2023 at approximately 1:23 PM in the presence of the DOM, he acknowledged the above observations.
4. During a surveyor observation of Resident ID #'s 9 and 10's room on 6/15/2023 at 12:43 PM revealed the bathroom had a foul-smelling odor and brown matter was on the floor of the shower.
During a surveyor interview with Resident ID #8 immediately following the above-mentioned observation, s/he indicated that s/he took a shower with assistance from a staff member that morning around 8:00 AM.
During a surveyor interview with Resident ID #9 on 6/15/2023 at approximately 12:45 PM, revealed that s/he took a shower with assistance from a staff member that morning around 9:30 AM.
During a surveyor interview with Housekeeper, Staff B, on 6/15/2023 at 1:35 PM, she revealed that nursing staff are responsible for cleaning any bodily fluids or excrement. Additionally, she indicated that after nursing staff cleans, then housekeeping staff disinfects.
During a surveyor interview on 6/15/2023 at approximately 1:45 PM, with Nursing Assistant, Staff C, she indicated that she assisted the residents with showers and acknowledged the above observation and indicated that the brown matter appeared to be feces.
During a surveyor interview on 6/15/2023 at 3:25 PM with the Infection Preventionist, she revealed that her expectation is that resident rooms and bathrooms are to be cleaned daily. Additionally, she indicated that she would expect staff to clean any fecal matter then disinfect immediately after assisting a resident with a shower.
During a surveyor interview on 6/15/2023 at approximately 3:30 PM, with the DOM he indicated that a work order was requested on 6/15/2023 to address the above mentioned observations, after the surveyor brought these concerns to the facility's attention.
Apr 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and resident interviews it has been determined that the facility failed keep resident free from s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and resident interviews it has been determined that the facility failed keep resident free from sexual abuse for 1 of 1 resident reviewed for sexual abuse, Resident ID #1.
Findings are as follows:
Record review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated October 2022 states in part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to .sexual or physical abuse .
Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/10/2023 revealed that on 4/10/2023 the resident reported that the Physical Therapist Assistant (PTA) grabbed his/her right chest last Thursday 4/6/2023.
Record review revealed that Resident ID #1 was admitted to the facility in February of 2023 with diagnoses including, but not limited to: schizophrenia, personal history of malignant neoplasm of breast (breast cancer), and major depressive disorder.
Record review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status assessment score of 15 out of 15, indicating the resident is cognitively intact.
Record review revealed a Physical Therapy Treatment Encounter Note(s) dated 4/6/2023 revealing that PTA, Staff A provided service to the resident.
Review of a statement provided by the Director of Social Services, indicated that Staff A was behind the resident and took his hand and grabbed the resident chest and the resident reenacted the actions. Additionally, the statement revealed the resident did not say anything to Staff A during this incident but rather the next day. Furthermore, the statement revealed that the resident feels that this was intentional.
During a surveyor interview on 4/11/2023 at 8:34 AM with the resident s/he revealed that s/he did not want to talk about what had occurred anymore.
During a surveyor interview on 4/11/2023 at 11:23 AM with Staff A, he revealed that he brought the resident back to his/her room he gave him/her a hug and then he touched the resident's chest. Surveyor queried if the touching of the resident's chest was an accident or intentional. Staff A responded, No it was pretty intentional, I don't know what I was thinking.
During a surveyor interview with the Administrator on 4/11/2023 at 2:10 PM, she acknowledged that the incident did occur, and that the PTA admitted he did intentionally touch the resident's chest. Additionally, she was unable to provide evidence that the facility kept this resident free from sexual abuse.
Feb 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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, and staff and resident interviews, it has been determined that the facility failed to ensure that reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff and resident interviews, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to 1 of 1 resident reviewed for urinary tract infections (UTIs), Resident ID #1.
Findings are as follows:
Record review of a community reported complaint received by the Rhode Island Department of Health on 2/23/2023 indicates that the resident's family member contacted the case manager at the hospital alleging that the resident had been neglected and abused at the nursing home.
During a surveyor interview on 2/27/2023 at 12:56 PM with the resident's family member, s/he revealed that the resident has a history of UTIs. S/he further revealed that on 2/17/2023 the resident was very confused. S/he indicated that when the resident becomes confused this is the first sign that s/he has a UTI. Additionally, she indicated that the resident had a urinalysis ordered on 2/16/2023. When the family member called the facility on 2/19/2023 to obtain the results of the urinalysis s/he discovered the urine sample had not been collected. The family member further revealed the urine sample was obtained after s/he brought it to the facility's attention, three days after the urinalysis was ordered.
Review of the resident's record revealed s/he was admitted to the facility in September of 2022 with diagnoses including, but not limited to, urinary tract infection and urinary retention.
Record review of the resident's care plan dated 1/30/2023 revealed the resident is at risk for urinary tract infections secondary to a history of indwelling foley catheter (drains urine from your bladder into a bag outside your body) use due to neurogenic bladder (a lack of bladder control, common symptoms; UTI, urinary frequency and urgency) and history of UTIs. Interventions include, but are not limited to: Assess for UTI (burning, pain w/urination, urgency, frequency, bladder cramps/spasms, low back pain, flank pain, malaise, nausea, vomiting, pain/tenderness over the bladder, chills, fever, foul odor of urine, concentrated urine, blood in urine, confusion) and labs per MD [medical doctor] orders .
Review of the resident's progress notes revealed the following entries:
-9/12/2023, Resident was admitted to the hospital with diagnoses of acute kidney injury, bladder infection, and acute bladder retention.
-9/29/2022, Resident complained of vaginal discomfort, U/A (urinalysis) results positive. Resident to start on Cipro 500mg twice a day for 7 days.
-10/25/22, New order for UA/CS (culture sensitivity) for increased confusion and back pain.
-10/28/22, UA results reviewed, resident to start on Macrobid (used to treat UTIs) 100mg twice a day.
-10/30/22, Resident on Macrobid for UTI and VRE (vancomycin-resistant Enterococci, can cause infections of the urinary tract)
-11/18/2022, Resident returned from [NAME] Hospital 14Fr foley catheter in place draining clear yellow urine, + UTI, po [by mouth] abx [antibiotic] Cefdinir 300mg po Q 12 hours x 6 days. [Resident] failed trial void in hospital and new catheter was placed on 11/16 .
-11/28/2022, Resident with increase confusion from baseline, stated, I just don't feel right .
-12/2/2022, u/a reviewed by [Nurse Practitioner] new order to start CIPRO [antibiotic] 250 MG bid x7 Days.
-1/10/2023, Resident c/o [complained of] dysuria [painful or difficult urination], history of UTI, stated it feels like I have a UTI, seen by [nurse practitioner]- new order UTI protocol .
-1/13/2023, Resident has ESBL (Extended-spectrum beta-lactamases are enzymes that confer resistance to most antibiotics) in the urine. New order for Levaquin 500 mg daily x7days.
-2/16/2023, Resident complaining of weakness, pain during urination, and feeling cloudy new order for UA .
-2/19/2023, [family member] called .inquired about urine culture. New U/A successfully collected via straight cath, urine dark, thick and foul smelling .
-2/20/2023, Resident with slight confusion from baseline .
-2/21/2023, 6:09 AM, Resident with some confusion, urinalysis pending.
-2/21/2023, 7:51 AM, Resident presents with increase confusion, unable to finish sentence, color pale, hands with tremors, VS [vital signs]: 89/49-74-24- 98.4- spo2[oxygen saturation is a measurement of how much oxygen your blood is carrying as a percentage of the maximum it could carry] 91% RA [room air], FS [fasting sugar]118, Oxygen @ [at] 2L [liter] placed on resident, called .NP [Nurse Practitioner] and reported assessment, new order to send to ER for Evaluation .
2/21/2023, 10:58 PM, resident admitted to the hospital with a UTI diagnosis.
Record review of the physician orders revealed an order dated 2/16/2023 for Cultures-Urine Analysis; Urine Analysis; Once- One Time Shift 2
Record review failed to reveal evidence that a urine was obtained until 2/19/2023, after the family called the facility and inquired about the test results.
During a surveyor interview with Registered Nurse, Staff A, on 2/27/2023 at 11:50 AM, she revealed that when an order is written it is expected to be followed. She further revealed that if the urinalysis had been unsuccessful then the nurse would document the failed attempt and report it to the physician. She was unable to provide evidence that the urine sample was obtained until 2/19/2023.
During a surveyor interview with the Nurse Practitioner, Staff B, on 2/27/2023 at 1:28 PM, she revealed she would expect her orders to be carried out as ordered, if not, she would expect to be notified within that shift and no later than the next shift.
During a surveyor interview with the Director of Nursing Services (DNS), on 2/27/2023 at 12:12 PM, she revealed that the nurse that took the order failed to assign it, therefore the order did not show up on the treatment administration record to be obtained.
During a subsequent surveyor interview the DNS at 2:25 PM, she further revealed she would have expected the urine culture to be obtained when the order was given. She further revealed that if the urine culture could not be obtained then there should be a documented reason as to why and the physician should be notified. She could not provide evidence that the urine culture was obtained on 2/16/2023 or that the physician was notified on 2/16/2023 as to why the urine sample was not obtained.
Feb 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 and staff interview it has been determined that the facility failed to ensure that residents receive trea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive care plan relative to surgical wound care for 1 of 2 residents reviewed for wounds, Resident ID #1.
Findings are as follows:
Record review revealed the resident was admitted to the facility in January of 2023 with diagnoses including, but not limited to, orthopedic aftercare following surgical amputation and acquired absence of the right leg below the knee.
Record review of the admission skin assessment dated [DATE] failed to reveal evidence of any impairments to the resident's skin.
Record review of the admission nursing progress note dated 1/26/2023 at 9:24 PM states in part, .skin is free from bruises or redness .BKA [below the knee amputation] wrapped c/d /i [clean/dry/intact] .
Record review of the physician's orders revealed an order with a start date of 1/27/2023 and a discontinue date of 1/30/2023 for the following:
-Right knee amp: ioban wrap [antimicrobial wound treatment to help reduce the risk of surgical site infections and stops the growth of microorganisms] Once a Day Monitor for signs and symptoms of infection.
Record review of the January Treatments Administration History revealed the following:
-1/27/2023 at 1:20 PM Not Administered: Due to Condition
-1/29/2023 at 10:25 AM Not Administered: Due to Condition Comment: UNTENABLE
Review of the additional comments on the treatment record revealed the following:
Record review of the nursing progress notes revealed the following:
-1/29/2023 at 12:58 PM states in part, .Treatment IOBAN WRAP for BKA not available .
-1/30/2023 at 4:38 PM states in part, .Treatment dressing to right amp was applied, staples in place with small area 1 cm x 2 cm open. Xeroform applied and fluff with king [sic] and bandage. Stump is red, no signs of infection .
Record review of a subsequent physician's order dated 1/30/2023 revealed the following treatment order was implemented after an open area was identified to the resident's surgical wound incision line:
-Right knee amp: xeroform, fluff and kerlix and wrap with ace bandage once a day Monitor for signs and symptoms of infection.
Further review of subsequent nursing progress notes revealed the following:
-2/3/2023 at 5:12 PM states in part, SIGNIFICANT CHANGE SURGICAL SITE BKA RIGHT/During treatment change noted/Stump warm to touch/oozing drainage left side of surgical site/boggy at base of stump/patient screamed/states extremely painful when dressing removed/new behavior during change of dressing/Assured patient MD would be notified of significant change .
-2/3/2023 at 6:34 PM which states in part, Resident stump site noted warm, reddened, purulent drainage and extremely tender to touch during dressing change, Got a call back from Dr. [name redacted] with order to send resident to [hospital] ASAP, Resident sent via rescue .
During a surveyor interview on 2/22/2023 at approximately 3:30 PM with the Director of Nursing Services, she was unable to explain why the resident did not receive the ordered wound treatments to the surgical incision site until 1/30/2023.
During an interview on 2/22/2023 at 3:42 PM with the Licensed Practical Nurse, Staff A, she revealed that she had called the resident's surgeon on 1/27/2023 to clarify the ordered Ioban wrap for the resident, as the facility did not have that treatment avilable. Staff A further revealed that she obtained a treatment order from the surgeon on 1/27/2023 for a Xeroform dressing. Additionally, she was unable to explain why the Xeroform order was not implemented until 1/30/2023, which was 3 days after receiving the order.
Record review, completed on 2/23/2023, of the hospital emergency department admission document dated 2/3/2023 states in part, .Patient now presenting from SNF [skilled nursing facility] with peri-incisional pain, drainage, and staple-line dehiscence [surgical complication where the wound ruptures along the surgical line] at R [right] below-knee amputation site, consistent with stump infection. Will admit for IV [intravenous] antibiotics and wound care .
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 F0694
(Tag F0694)
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 parenteral fluid is administered consistent with professional standards of practice and in ac...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that parenteral fluid is administered consistent with professional standards of practice and in accordance with physician orders for 1 of 1 resident reviewed with a PICC (peripherally inserted central catheter) line, Resident ID #2.
Findings are as follows:
Record review revealed the resident was admitted to the facility in January of 2023 with a diagnosis including, but not limited to, MRSA bacteremia (a multi drug resistant organism blood infection).
Record review revealed the following physician orders:
-1/21/2023 which states in part, PICC: Measure circumference of upper arm (10 cm [centimeters] above insertion site) when clinically to assess for the presence of edema and possible deep vein thrombosis once a Day on Wed [Wednesday] .
-1/21/2023 which states in part, .Midline-PICC: Change transparent dressing and measure external length of PICC catheter starting with the 0 mark to the insertion site weekly and when clinically indicated (when no 0 mark exists, measure from the hub) .
Record review of the January 2023 Medication Administration Record (MAR) revealed the nurse initialed both of the above-mentioned orders on 1/25/2023, but she failed to document the measurements of the external catheter length or the upper arm circumference.
During a surveyor interview on 2/22/2023 at approximately 3:30 PM with the Director of Nursing Services, she was unable to provide evidence of the measurements of the external catheter length or the upper arm circumference.
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 a resident's drug regimen is free from significant medication errors for 2 of 2 resident's reviewe...
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Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from significant medication errors for 2 of 2 resident's reviewed for medication administration, Resident ID #1 and 2.
Findings are as follows:
1. Record review revealed Resident ID #1 was admitted to the facility in January of 2023 with diagnoses including, but not limited to, orthopedic aftercare following surgical amputation, acquired absence of right leg below knee and difficulty in walking.
Record review of the physician's orders revealed the following:
-1/26/2023, Xarelto tablet; 20 mg [milligram]; Amount to Administer: 20 mg; oral once daily in the evening.
-1/26/2023, Gabapentin capsule; 300 mg; Amount to Administer: 600 mg; oral four times daily.
-1/26/2023, Symbicort aerosol inhaler; 80-4.5 mcg/actuation; Amount to Administer: 2 puffs; inhalation twice daily.
A review of the January 2023 Medications Administration History revealed the following:
Gabapentin 600 mg capsule was signed off by the nurse on 1/26/2023 at 7:15 PM and 9:10 PM. Additional documentation for both administration times indicated the medication was Not Administered: Drug/item unavailable.
Xarelto 20 mg tablet was signed off by the nurse on 1/26/2023 at 7:15 PM. Additional documentation for that administration time stated the medication was, Not Administered: Drug/item unavailable.
Symbicort aerosol inhaler was signed off by the nurse on the following dates and times:
-1/26/2023 at 7:15 PM, with additional documentation for that administration time which stated the medication was, Not Administered: Drug/item unavailable.
-1/27/2023 at 9:57 AM, with additional documentation for that administration time which stated the medication was, Not Administered: Other Comment: on order awaiting pharmacy.
-1/27/2023 at 8:06 PM, with additional documentation for that administration time which stated the medication was, Not Administered: Other Comment: waiting to be delivered.
-1/28/2023 at 10:24 AM, with additional documentation for that administration time which stated the medication was, Not Administered: Drug/item unavailable.
-1/28/2023 at 7:03 PM, with additional documentation for that administration time which stated the medication was, Not Administered: Drug/item unavailable.
Further record review failed to reveal evidence that the medications were administered to the resident or that the provider was contacted to be made aware that the medications were not available to administer to the resident.
Record review of an email correspondence dated 2/22/2023 between the Administrator and the pharmacy revealed Symbicort was not filled by the pharmacy and the generic Advair was dispensed as a global authorization substitution.
Further record review of the physician's orders and the January 2023 Medications Administration History failed to reveal evidence of an Advair order.
2. Record review revealed Resident ID #2 was admitted to the facility in January of 2023 and had a medical diagnosis including, but not limited to, a urinary tract infection (UTI).
Record review of a nursing progress note dated 2/3/2023 states in part, .pt [patient] oncology Dr. [doctor] would like pt to d/c [discontinue] clindamycin [antibiotic] and Nursing continue .Cipro [antibiotic] .order clarified with NP [nurse practitioner] NO [new order] cipro 500 mg BID [twice daily] for 7 days orders placed.
Record review of the physician's orders revealed the following:
-2/3/2023, Cipro (ciprofloxacin hcl) tablet; 500 mg; Amount to Administer: 1 tab [tablet] = 500mg; oral .twice a day for UTI/Cellulitis .
Record review of the February 2023 Medications Administration History revealed the order for Cipro was ordered on 2/3/2023. Further record review revealed the medication was signed off as administered twice daily from 2/3/2023 through 2/10/2023, indicating the resident received the antibiotic for 8 days instead of 7 and received 2 additional doses.
During an interview on 2/22/2023 at approximately 3:30 PM with the Director of Nursing Services, she was unable to explain why the above-mentioned medications were not administered to Resident ID #'s 1 and 2 as ordered.
Nov 2022
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure the resident has the right to a clean environment relative to clean drinking cups and straw...
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Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure the resident has the right to a clean environment relative to clean drinking cups and straws for Resident ID #113.
Findings are as follows:
Surveyor observations revealed two pink plastic cups with straws at the resident's bedside table. One straw was observed with brown tinged staining and the other straw was observed with pink tinged staining on the following dates and times:
-11/28/2022 at 10:37 AM
-11/29/2022 at 1:15 PM
-11/30/2022 at 9:02 AM
During a surveyor interview and simultaneous observation on 11/30/2022 at 9:08 AM with Licensed Practical Nurse, Staff A, she acknowledged both cups had straws that were discolored with brown and pink tinged staining.
During a surveyor interview with the Assistant Director of Nursing Services on 11/30/2022 at approximately 11:00 AM, she revealed would expect staff to provide clean drinking cups and straws to the residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to address the needs of every resident, including but not limited to, the resident at risk or already experi...
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Based on record review and staff interview, it has been determined that the facility failed to address the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range related to weight monitoring for 2 of 6 sample residents reviewed for nutrition, Resident ID #s 2 and 67.
Findings are as follows:
Record review of a facility policy titled Weight Loss/Gain Protocol and Heights, states in part, .POLICY: All residents are to be weighed upon admission and at least monthly; so as to monitor for weight loss or gain .PROCEDURE: The resident will be weighed on the day of admission .The resident will then be weighed weekly x3. After the first 4 weeks of admission, the frequency of weights will then be decided by the interdisciplinary team (weekly or monthly thereafter) based on the resident's individual needs .
1. Record review revealed Resident ID #2 was readmitted to the facility in July of 2021 with a diagnosis including, but not limited to paraplegia (loss of muscle function to the lower half of the body).
Record review revealed an order dated 8/26/2021 which states in part, Obtain Weekly weight Once A Day on Mon [Monday]Weekly .
Record review failed to reveal evidence that weekly weights were obtained on 10/17/2022 and 11/14/2022.
During a surveyor interview on 11/30/2022 at 12:02 PM with the Registered Dietitian (RD), she was unable to provide evidence that the resident's weight was obtained on the above-mentioned dates. Additionally, she revealed she would expect staff to have obtained the resident's weekly weights as ordered.
2. Record review revealed Resident ID #67 was admitted to the facility in April of 2022 with a diagnosis including, but not limited to, multiple sclerosis (a chronic disease impacting the central nervous system).
Record review of a document titled Nutritional Evaluation Assessment dated 7/6/2022 authored by the RD which states in part, .Will proceed to care plan to monitor intakes, weight trends .
Record review of the resident care plan for nutrition status with a start date of 7/6/2022 revealed interventions including, .Monitor/record weight as ordered .Obtain dietary consult .
Record review failed to reveal evidence of an order to monitor or record the resident's weights per the care plan. Additional record review failed to reveal evidence that a dietary consult or a nutritional assessment had completed for this resident since 7/6/2022.
During a surveyor interview on 11/30/2022 at 11:53 AM with the RD she revealed that she should have conducted a nutritional assessment for the most recent quarter on 9/22/2022 and updated the care plan accordingly. Additionally, she was unable to provide evidence that a dietary consult or nutritional assessment was completed after 7/6/2022 or that a weight was obtained for the month of October 2022. She further acknowledged there was no order to obtain weights and revealed she would expect for the resident to have monthly weights obtained.
During a surveyor interview on 11/30/2022 at 2:27 PM with the Assistant Director of Nursing Services she was unable to provide evidence that the resident's weight was obtained in October and she would expect the RD to assess the residents quarterly.
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 pharmacy written reports are sent to the attending physician and director of nursing when irr...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that pharmacy written reports are sent to the attending physician and director of nursing when irregularities have been identified, for 2 of 10 residents reviewed for unnecessary medications, Resident ID #s 4 and 18.
Findings are as follows:
Review of the facility's Policy and Procedure titled MEDICATION REGIMEN REVIEW AND REPORTING states in part, Policy .The MRR [Medication Regimen Review] includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities .
Procedure .
6. Resident-specific MRR recommendations and findings are documented and acted upon by the nursing care center and/or physician.
7. A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable format to nurse, physicians and the care planning team within 48 hours of MRR completion.
8. The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days .
1. Record review for Resident ID #4 revealed s/he was admitted to the facility in April of 2022 with diagnoses including, but not limited to mental illness, acute respiratory distress, heart failure, and chronic kidney disease.
Record review revealed Consultants - Pharmacy Drug Regimen Review reports dated 9/27/2022 and 10/29/2022 which indicated .rec [recommendation] - see report .
Further record review failed to reveal evidence of readily available reports for 9/27/2022 and 10/29/2022.
During a surveyor interview with the Administrator on 11/29/2022 at approximately 2:30 PM, she was unable to provide evidence that the above-mentioned reports were available at the facility.
During a subsequent interview on 11/29/2022 at approximately 3:00 PM, the Administrator revealed that she requested the pharmacy reports to her. The Administrator further revealed the only report she received from the pharmacist was a report dated 10/31/2022.
Review of the pharmacy report dated 10/31/2022 revealed several recommendations including, but not limited to .Please clarify the Spiriva [medication used to treat lung disease] order to read to inhale entire amount of capsule, to ensure delivery of entire contents of each capsule exhale and inhale 2nd time .Ventolin [medication used to treat wheezing and shortness of breath] add to wait at least 1 minute in between puffs and clarify the PRN [as needed] indication for use .
Record review failed to reveal evidence that the above recommendations were acted on by the physician.
During a surveyor interview with the Acting Director of Nursing Services (DNS) and the Assistant Director of Nursing Services (ADNS) on 11/30/2022 at 9:16 AM, they were unable to provide evidence that the pharmacy recommendations dated 10/31/2022 were acted upon by the resident's physician.
2. Record review for Resident ID #18 revealed s/he was admitted to the facility in April of 2022 with diagnoses including, but not limited to, liver failure, heart disease, and chronic obstructive pulmonary disease.
Record review revealed a Consultants - Pharmacy Drug Regimen Review report dated 9/25/2022 which indicated .rec [recommendation] - see report .
Further record review failed to reveal evidence of the consultant pharmacy report.
During an interview with the Acting DNS and ADNS on 11/30/2022 at approximately 9:30 AM, they were unable to provide evidence of the pharmacy report dated 9/25/2022.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to assist residents in obtaining routine and emergency dental care for 1 of 3 residents reviewed, Resident ID #140.
Findings are as follows:
Record review revealed the resident was readmitted to the facility in July of 2022 with diagnoses including, but not limited to, diabetes and dysphagia (difficulty swallowing).
Record review of a quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15 indicating s/he has intact cognition.
During a surveyor interview with the resident on 11/28/2022 at 11:08 AM, s/he revealed s/he has broken bottom teeth to the back of his/her mouth which cause discomfort and prevent him/her from eating certain foods. The resident further revealed that s/he needs some teeth extracted and new full upper and partial lower dentures, but has not had a follow up appointment since his/her last dental consult in October of 2022 at the facility. Additionally, s/he was told that s/he would have an appointment scheduled.
Record review of the progress notes dated 7/1/2022 through 11/30/2022 revealed the following:
-7/14/2022 10:36 AM Nutrition Note .reports problem with chewing .
-7/14/2022 1:54 PM .complained of mouth pain, was seen by Hygienist onsite today .resident needs referral for Dental Consult .
-7/21/2022 11:19 AM
.tooth pain .
-8/22/2022 12:40 PM
.Resident c/o [complained of] oral pain .Resident on list to see Dentist.
Additional record review revealed the resident did not have a dental consult until 10/21/2022, approximately 3 months after reporting mouth pain and a problem with chewing.
Further record review of the dental consult document dated 10/21/2022 states in part, .Full upper denture .Patient states lower left rear broken tooth, needs to be extracted and also lower right fragment bothers [him/her]. Clinically Th [tooth] #18 root fragment remains and lower right appears maybe piece of TH #30 .Will send over oral surgery referral to facility. Upper denture causing some sores for patient .after extractions on lower and healing will move forward to fabricate new FU [full upper] and PL [partial lower] dentures .
Additional record review failed to reveal evidence of an oral surgery consult after recommendations were made on 10/21/2022.
During a surveyor interview with Licensed Practical Nurse, Staff A, on 11/30/2022 at 9:46 AM, she acknowledged that the resident was seen by the dentist on 10/21/2022 and was unable to provide evidence of an oral surgeon appointment.
During a surveyor interview with the transportation/appointment scheduler, Staff L, on 11/30/2022 at 2:11 PM, she revealed she received an email from the dental provider on 11/30/2022 and would be scheduling the resident's oral surgery appointment. She further revealed that she did not receive the referral until brought to the attention of the facility by the surveyor.
During a follow up surveyor interview with the Assistant Director of Nursing Services on 11/30/2022 at approximately 10:45 AM, she was unable to provide evidence that the resident was assisted in obtaining dental services relative to an oral surgeon appointment.
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 ensure that medical records for e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that medical records for each resident are maintained in accordance with professional standards and practices that are complete and accurately documented relative to a resident who was transferred to an acute care facility and admitted , Resident ID #108.
Findings are as follows:
Record review for Resident ID #108 revealed s/he was readmitted to the facility after a hospital stay in November of 2022 with medical diagnoses including, but not limited to acute respiratory failure with hypoxia (lack of oxygen to the tissues).
Review of the resident census information revealed the resident was discharged from the facility on 11/1/2022 at 4:11 AM and was expected to return.
Review of a progress note dated 11/21/2022 at 11:22 PM stated in part, Res [resident] was re-admitted to the facility at 6.05pm [6:05 PM] today from [the hospital] .admitted .for respiratory distress .
Further review of the progress notes revealed a nursing note dated 10/29/2022 at 12:21 PM which states in part, .No issues or concerns at this time . This was the last health status progress note in the resident's record prior to the resident's discharge to the hospital on [DATE].
Additional review of the record failed to reveal evidence or any documentation related to the hospitalization on 11/1/2022.
During a surveyor interview on 11/30/2022 at 11:13 AM with the Assistant Director of Nursing Services, she revealed the resident was hospitalized on [DATE] and was unable to provide any evidence or documentation regarding the resident's hospitalization.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 2 of 6 residents reviewed, Resident ID #s 86 and 98.
Findings are as follows:
Review of the facility policy titled, Call System, Resident states in part, .Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station .If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided .
1. Record review revealed Resident ID #86 was readmitted to the facility in June of 2020 with diagnoses including, but not limited to, dementia, anxiety, and repeated falls.
Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated s/he is cognitively impaired. Further review revealed s/he requires total assistance of two or more staff members for transfers and locomotion.
Additional record review revealed a care plan dated 4/15/2022 which indicates the resident is at risk for falling. Interventions include but are not limited to, .Keep call light in reach when in [his/her] room .
Surveyor observations revealed the following:
-11/28/2022 at 9:48 AM The resident was observed sitting in a wheelchair in his/her room yelling out with the call light out of his/her reach.
-11/28/2022 at 10:16 AM The resident was observed sitting in a wheelchair in his/her room with the call light placed between the resident's bed and night stand out of his/her reach.
-11/28/2022 at 10:54 AM The resident was observed sitting in a wheelchair in his/her room asking to use the bathroom with his/her call light out of reach.
-11/28/2022 at 12:57 PM The resident was observed calling out while in room with his/her call light out of reach.
During a surveyor interview with the resident immediately following the observation on 11/28/2022 at 10:16 AM, revealed s/he was unable to access the call light. Additionally, s/he was observed to be in his/her wheelchair and unable to independently move the wheelchair to the location of his/her call light.
During a surveyor interview with Nursing Assistant, Staff N, on 11/28/2022 at 12:57 PM she acknowledged the residents call light was not within his/her reach.
2. Record review revealed Resident ID #98 was admitted to the facility in March of 2019 with diagnoses including, but not limited to, diabetes, anxiety, and pain.
Review of a significant change MDS assessment dated [DATE] revealed a Brief Interview for Mental Status score of 9 out of 15 indicating s/he has moderately impaired cognition. Further review revealed s/he requires extensive assistance of two or more staff members for bed mobility, transfers, and toileting needs.
Additional record review revealed a care plan dated 2/3/2022 which indicates the resident is at risk for falling. Interventions include but are not limited to, .Keep call light in reach when in [his/her] room .
Surveyor observations on 11/28/2022 and 11/29/2022 revealed the following:
-11/28/2022 at 10:56 AM The resident was observed to be yelling out for help from his/her room. S/he was lying in bed with the call light out of reach.
-11/29/2022 at 9:19 AM The resident was observed lying in bed with the call light out of reach.
-11/29/2022 at 9:43 AM The resident was observed lying in bed with the call light out of reach.
During a surveyor interview with the resident at the time of the observation on 11/29/2022 at 9:19 AM, revealed s/he wanted help with repositioning in bed and indicated that s/he could not reach the call light.
During a surveyor observation of the medication administration task with Certified Medication Technician, Staff O, on 11/29/2022 at 9:39 AM, a resident was heard calling out for help. Staff O, acknowledged hearing a resident calling out, however she did not respond to the resident's call for help.
During a surveyor interview with Resident ID # 98 on 11/29/2022 at 9:43 AM, revealed s/he was lying in bed calling out for help. S/he indicated that s/he needed help with repositioning in bed. Additionally, his/her call light was observed out of reach. The call light was observed wrapped and hanging from the wall out of the resident's reach.
During a surveyor observation and interview with Staff O on 11/29/2022 at 9:44 AM, she acknowledged that the resident's call light was out of reach. Staff O placed the call light next to the resident and when prompted by the surveyor to access the call light, the resident was unable to. Additionally, the call light was placed in the resident's hand by Staff O and the resident was unable to press the call light button.
During a subsequent surveyor observation on 11/30/2022 at 8:58 AM revealed that the resident's call light was replaced with an adaptive touch pad call device allowing him/her to utilize the call system more easily only after it was brought to the facility's attention by the surveyor.
During a surveyor interview with the Assistant Director of Nursing Services on 11/30/2022 at approximately 2:30 PM, she indicated that all call lights are to be in reach and accessible by all residents.
CONCERN
(E)
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 surveyor observation, record review and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan for 2 of 5 residents relative t...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan for 2 of 5 residents relative to falls, Resident ID #64 and 110, and 1 of 6 residents relative to range of motion (ROM), Resident ID #42.
Findings are as follows:
1. Record review revealed Resident ID #64 was readmitted to the facility in October of 2022 with a diagnosis including, but not limited to, Alzheimer's disease.
Record review of a care plan for falls dated 10/6/2021 and last revised on 11/14/2022 states in part, .[resident] is at risk for falling secondary to h/o [history of] falling, impaired safety awareness, unsteady balance and gait and potential medication side effects . Further record review revealed interventions including, but not limited to, .Non skid strips on the floor at [his/her] left bedside .
Surveyor observation of the resident's room failed to reveal nonskid strips on the floor to the left side of the resident's bed on the following dates and times:
-11/29/2022 at approximately 2:30 PM
-11/30/2022 at 12:40 PM and 2:10 PM
During a surveyor interview and simultaneous observation on 11/30/2022 at 2:28 PM with Nursing Assistant, Staff B, she acknowledged that the non skid strips were not on the floor at the left side of the resident's bed.
2. Record review revealed Resident ID #110 was admitted to the facility in September of 2019 with a diagnosis including, but not limited to, dementia.
Record review of a nursing progress note dated 8/13/2022 at 6:45 AM, states in part, .[resident] ambulating to the bathroom was found on the floor face first on the ground with seizure activity and laceration to the head and nose followed by a nose bleed. open areas to the mouth .
Additional record review revealed the resident was sent to the hospital and returned to the facility with .suture on left forehead, and bruising around eyes and nose .
Record review of a document titled Fall Risk Observation dated 10/6/2022 revealed the resident had one fall in the past 3 months and has unsteady gait. Further record review revealed the resident is at high risk for falls.
Record review revealed the resident has a care plan initiated on 7/30/2021 and last revised on 10/27/2022 which states in part, .[resident] presents at risk for falls secondary to h/o [history of] falling, potential medication side effects, impaired safety awareness, impaired vision and unsteady balance and gait . Further record review revealed interventions including, but not limited to, .Nonskid strips on the floor in the bathroom in front of the toilet .
Surveyor observations failed to reveal nonskid strips to the resident's bathroom floor on the following dates and times:
-11/28/2022 at approximately 12:30 PM
-11/29/2022 at 10:28 AM and 3:55 PM.
During a surveyor observation and simultaneous interview on 11/29/2022 at 3:58 PM with Registered Nurse, Staff C, he acknowledged that the nonskid strips were not on the floor in front of the resident's toilet as per the resident's plan of care.
3. Record review revealed Resident ID #42 was readmitted to the facility in June of 2021 with diagnoses including, but not limited to anoxic (lack of oxygen) brain damage and persistent vegetative state (a state of coma that lacks both awareness and wakefulness).
Record review of a care plan dated 8/6/2021 states in part, .[s/he] has impaired ROM to bilateral upper extremities . Further record review revealed interventions including, but not limited to, .ROM to arms and legs during AM and PM care .
Further record review revealed a physician's order dated 6/13/2021 for General ROM to arms and legs during AM, and PM care twice a day .
Review of the November 2022 Treatment Administration Record failed to reveal evidence that the order for ROM to the resident's arms and legs was provided per the physician's order.
During a surveyor interview on 11/30/2022 at 3:16 PM with the Assistant Director of Nursing Services, she was unable to provide evidence that the above order for ROM was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to not following physician's orders, for 1 of 1 resident ...
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Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to not following physician's orders, for 1 of 1 resident reviewed for bowel movements, Resident ID #108, 1 of 3 residents reviewed for weekly skin assessments, Resident ID #42 and 1 of 2 residents receiving enteral nutrition (nutrition delivered directly to the stomach via a tube), Resident ID #153.
Findings are as follows:
A. 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 .
1. Record review revealed Resident ID #153 was admitted to the facility in September of 2022 with diagnoses including, but not limited to dysphagia (difficulty swallowing), and cerebral infarction (stroke).
Record review of the physician's orders revealed the following:
-9/29/2022 Flush g-tube [gastrostomy tube, a tube that is placed in the stomach for nutrition] with at least 30 ml [milliliters] of distilled water before medication administration dilute each med [medication] with @ [at] least 15 ml of distilled water and flush tubing with @ least 15 ml of distilled water between meds. After all meds administered flush tube with at least 30 ml of distilled water.
-10/3/2022 .enter amount of fluid and supplement resident received on each shift .Every Shift .Supplement = amount of Jevity1,2, Fluids = amount of water with flushes Q [every] hour and with meds.
-11/10/2022 GIVE JEVITY [tube feeding] 1.2 CAL [calorie] 60 ML/HR [per hour] CONTINUOUS WITH FLUSHES 23 CC [cubic centimeters] Q HOUR .Every shift
Record review of the November 2022 Medication Administration Record (MAR) failed to reveal evidence that the tube feeding and fluid intake were recorded accurately, every shift with a numeric value.
Further review of the MAR revealed that the tube feeding was recorded as a percentage on the following dates and times:
-11/18/2022 5:23 AM
Supplements: 26-50%
-11/18/2022 8:00 AM
Supplements: 51-75%
-11/18/2022 9:33 PM
Supplements 76-100%
-11/19/2022 6:19 AM
Supplements 76-100%
-11/19/2022 3:48 PM
Supplements 76-100%
-11/20/2022 6:46 AM
Supplements 76-100%
-11/20/2022 1:59 AM
Supplements 76-100%
-11/20/2022 3:31 PM
Supplements 76-100%
-11/21/2022 5:39 AM
Supplements: 76-100%
-11/21/2022 3:34 PM
Supplements: 76-100%
-11/21/2022 6:05 PM
Supplements: 76-100%
-11/22/2022 9:02 AM
Supplements: 26-50%
-11/22/2022 8:04 PM
Supplements: 26-50%
-11/23/2022 4:58 PM
Supplements: 76-100%
-11/23/2022 2:29 PM
Supplements: 76-100%
-11/23/2022 3:23 PM
Supplements: 76-100%
-11/24/2022 1:59 AM
Supplements: 76-100%
-11/24/2022 11:01 AM
Supplements: 76-100%
-11/24/2022 8:28 PM
Supplements: 76-100%
-11/25/2022 6:02 AM
Supplements: 76-100%
-11/25/2022 5:40 PM
Supplements: 26-50%
-11/26/2022 4:14 AM
Supplements: 76-100%
-11/27/2022 4:00 PM
Supplements: 76-100%
-11/28/2022 5:01 AM
Supplements: NPO [nothing by mouth]
-11/28/2022 9:28 AM
Supplements: 26-50%
During a a surveyor interview on 11/30/2022 at approximately 4:00 PM with the Acting Director of Nursing (DNS), in the presence of the Administrator, she acknowledged that the above mentioned fluid intake was not recorded as ordered by the physician.
B. Review of the facility policy titled, Bowel Function Management revealed after 72 hours (On day 4) without a resident having had a bowel movement, the following should be implemented:
- 7-3 (1st shift) Offer 90-120mL (milliliters) of prune juice
- 3-11 (2nd shift) Offer 30mL of Milk of Magnesia (laxative) if the prune juice was not effective
- 11-7 (3rd shift) Offer a Dulcolax suppository (laxative) if the Milk of Magnesia was not effective
- In the event the Dulcolax suppository was not effective, a fleet enema (laxative) is to be given by 1st shift on Day 5
2. Record review completed on 11/30/2022 of the bowel documentation for Resident ID #108 revealed the resident had a bowel movement on 11/24/2022. Further record review failed to reveal evidence of a subsequent bowel movement since 11/24/2022.
Record review revealed the following physician orders:
-11/21/2022 Milk of Magnesia 30 ml for symptoms of constipation or per patient preference once a day as needed
-11/22/2022 Bisacodyl suppository; 10 mg; 1 suppository per rectum QD (every day as needed)
-11/21/2022 Fleet enema 1 daily PRN to treat constipation If no effect from Dulcolax, or per patient preference.
Further review of the November 2022 MAR failed to reveal evidence that the above medications were administered per the order or facility policy.
During a surveyor interview on 11/30/2022 at 3:12 PM with the Assistant Director of Nursing Services, she revealed that the bowel protocol is initiated after two days without a bowel movement. Additionally, she was unable to provide evidence that the above medications were administered.
3. Record review revealed Resident ID #42 was readmitted to the facility in June of 2021 with diagnoses including, but not limited to anoxic (lack of oxygen) brain damage, persistent vegetative state (a state of coma that lacks both awareness and wakefulness), and pressure ulcer of sacral region, stage 4 (pressure ulcer with exposed bone, tendon, or muscle).
Record review revealed a physician's order dated 6/28/2021 for Complete weekly Full Body Assessment; document in Observations Once A Day on Fri [Friday] .3:00 PM - 11:00 PM.
Review of the October 2022 and November 2022 Treatment Administration Record revealed that the weekly body assessment order was signed off as completed.
Further review of the record failed to reveal evidence that a weekly full body assessment was completed and documented in observations per the order on the following dates:
-
10/7/2022
-
10/21/2022
-
11/4/2022
-
11/11/2022
-
11/18/2022
-
11/25/2022
During a surveyor interview on 11/30/2022 at 3:16 PM with the Assistant Director of Nursing Services, she was unable to provide evidence that the weekly full body assessments were completed and documented as per the order for the above-mentioned dates.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple 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 ensure that a resident with press...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 5 residents reviewed for pressure ulcers, Resident ID #94.
Findings are as follows:
Record review revealed the resident was admitted to the facility in April of 2021 with diagnoses including, but not limited to, pressure ulcer of left heel, stage 4 (pressure ulcer with exposed bone, tendon, or muscle), acute osteomyelitis (bone infection) of left ankle and foot-left heel, and hemiparesis (paralysis on one side of the body) affecting left non-dominant side.
Review of the Skin Ulcer Documentation document dated 8/24/2022, revealed a stage 4 pressure ulcer to the left heel with necrotic tissue (death of cells in an organ or tissue that is black, brown, or tan that adheres firmly to the wound bed or edges) measuring 8 cm (centimeters) in length x 4.9 cm in width.
Review of the quarterly Minimum Data Set assessment dated [DATE] revealed the resident has a stage 4 pressure ulcer.
Record review of the physician's order revealed the following order dated 9/15/2022:
Left foot wound: Apply abd [dressing], then kerlix [dressing], then flexinex [wrap] or ace wrap .Once A Day Every 5 Days
Review of several progress notes on the following dates and times revealed the following:
-8/24/2022 at 1:00 PM Wound Rounds: Stage IV Pressure Wound of the Left Heel .
-9/9/2022 at 12:57 PM .[s/he] left around 12:30pm to see dr [community Doctor] to assess .left heel wound; will continue to monitor
-9/30/2022 at 9:51 PM .seen by [Dr.] for wound f/u [follow up]. MD aware of nursing concerned about necrotic tissue .continue current dsg [dressing] order; ABD/Kerlix [wound treatment dressings] q [every] 5 days. f/u 6 weeks .
Further record review failed to reveal evidence of documentation for the left heel pressure ulcer including, but not limited to, measurements, exudate (drainage), description and characteristics of wound bed, edges, and surrounding tissues since 8/24/2022.
During a surveyor interview on 11/30/2022 at 10:48 AM with the Wound Nurse, she revealed the left heel wound is a pressure wound. She further revealed the resident is followed by a doctor in the community and that s/he is the only resident she does not follow weekly for wound rounds.
During a surveyor interview on 11/30/2022 at 11:18 AM with the Assistant Director of Nursing Services, she acknowledged the resident is followed by a doctor in the community, but not on a weekly basis. She was unable to provide evidence of weekly pressure wound assessments including, but not limited to, measurements, exudate, description and characteristics of wound bed, edges, and surrounding tissues since 8/24/2022.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
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 respiratory care consistent with professional standards of practice for 3 ...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 3 of 6 residents reviewed for oxygen therapy, Resident ID #s 42, 108 and 113.
Findings are as follows:
A. According to Brunner and Sudarth's textbook, Medical and Surgical Nursing, 7th Edition, 1992, p. 524, as with other medications, oxygen is administered with care, and its effects on each patient are carefully assessed. Oxygen is a drug and except in emergency situations is prescribed by a physician.
1. Record review revealed Resident ID #42 was readmitted to the facility in June of 2021 with a diagnosis including, but not limited to anoxic brain injury (complete lack of oxygen to the brain).
Surveyor observations revealed the following:
-11/28/2022 at 10:52 AM, the resident was receiving humidified oxygen at 35% via tracheostomy mask.
-11/29/2022 at 12:55 PM, the resident was receiving humidified oxygen at 35% via tracheostomy mask.
-11/30/2022 at 10:38 AM, the resident was receiving humidified oxygen at 35% via tracheostomy mask.
During a subsequent observation and simultaneous interview on 11/30/2022 at approximately 3:40 PM, with Registered Nurse, Staff D, in the presence of the Assistant Director of Nursing Services (ADNS), revealed the resident was receiving humidified oxygen at 35% via tracheostomy mask. Staff D revealed that the resident should be receiving humidified oxygen at 28%, not 35%. When Staff D was asked about the order specifying the humidified oxygen, she was unable to provide evidence of the oxygen order.
Further record review failed to reveal evidence of a physician's order for humidified oxygen therapy.
2. Record review revealed Resident ID #108 was readmitted to the facility in November of 2022 with diagnoses including, but not limited to acute respiratory failure with hypoxia, chest pain on breathing, and hypertensive heart disease with heart failure.
Surveyor observations revealed the following:
-11/28/2022 at 2:53 PM the resident was observed on 2 liters of oxygen via nasal cannula.
-11/29/2022 at 12:46 PM the resident was observed on 2 liters of oxygen via nasal cannula.
-11/30/2022 at 8:51 AM the resident was observed on 1.5 liters of oxygen via nasal cannula.
Record review of a care plan dated 7/19/2022 states in part, At risk for alteration in respiratory status which revealed an intervention for O2 .as ordered.
Further record review failed to reveal evidence of a physician's order for oxygen therapy.
During surveyor interviews on 11/30/2022 at 11:13 AM and 3:16 PM with the ADNS, she was unable to provide evidence of an oxygen order for Resident ID #s 42 and 108.
B. According to Basic Nursing, Mosby's, 3rd edition after administering a drug, the nurse records it immediately on the appropriate record form. Recording the drug includes .exact time of administration.
3. Record review revealed Resident ID #113 was readmitted to the facility in December of 2020 with diagnoses including, but not limited to, chronic respiratory failure and chronic obstructive pulmonary disease.
Surveyor observations of the resident revealed the following:
-11/28/2022 at 10:28 AM the resident was observed on 4 liters of oxygen via nasal cannula.
-11/29/2022 at 9:08 AM the resident was observed on 4 liters of oxygen via nasal cannula.
-11/30/2022 at 9:03 AM the resident was observed on 4 liters of oxygen via nasal cannula.
Record review revealed a physician's order dated 10/14/2021 which states in part, Oxygen @ 2 liters via NC [nasal cannula] per resident's request Every Shift - PRN [as needed] Offer for Shortness of breath or per resident request. Maintain SpO2 [oxygen saturation level] > 88% on 2-4 L [liter] .
Record review of the Vitals Report for November 2022 revealed documentation that the resident was receiving oxygen on the following dates and times:
-11/7/2022 at 8:23 PM
-11/14/2022 at 9:38 PM
-11/28/2022 at 5:33 PM
Record review of the November 2022 Treatment Administration Record failed to reveal evidence that the oxygen was signed off as administered.
During a surveyor interview on 11/30/2022 at 10:53 AM with the ADNS she revealed she would expect the oxygen PRN order would be signed off when the oxygen was administered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
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 have sufficient nursing...
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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 have sufficient nursing staff to provide nursing and related services to assure residents receive care as determined by the residents' individual plan of care for 4 residents related to showers, Resident ID #s 2, 33, 45 and 113.
Findings are as follows:
1. Record review revealed Resident ID #2 was readmitted to the facility in July of 2021 with a diagnosis including, but not limited to, paraplegia (loss of muscle function to the lower half of the body).
Record review revealed an order dated 11/7/2022 which states in part, Resident to receive shower Special Instructions: Document in progress note if resident refuses. Once A Day on Mon [Monday] .
Record review of the November 2022 Treatment Administration Record (TAR) revealed on 11/24/2022 the resident's shower order was signed off as Not Administered: Due to condition.
During a surveyor interview on 11/30/2022 at 12:54 PM with Licensed Practical Nurse, Staff A, she revealed the resident did not receive a shower on 11/24/2022 due to not having enough staff.
2. Record review revealed Resident ID #33 was readmitted to the facility in June of 2021 with a diagnosis including, but not limited to, multiple sclerosis (a chronic disease impacting the central nervous system).
Further record review revealed a quarterly Minimum Data Set assessment dated [DATE], with a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition.
Record review revealed an order dated 6/15/2022 which states in part, Resident to receive shower Once A Day on Tue [Tuesday], Sat [Saturday] .
Record review of the November 2022 TAR revealed that on 11/26/2022 the shower order was signed off as Not Administered: Refused.
During a surveyor interview on 11/29/2022 at 4:20 PM with the resident, s/he revealed s/he did not receive a shower on 11/26/2022 due to there not being enough staff. Additionally, the resident further indicated that the resident did not refuse a shower.
During a surveyor interview on 11/30/2022 at 12:40 PM with Nursing Assistant (NA), Staff E, she revealed she was instructed not to provide showers if only two NAs are scheduled. She further revealed that on 11/26/2022 only two NAs and a trainee were scheduled. Additionally, she revealed the resident did not receive a shower on 11/26/2022.
3. Record review revealed Resident ID #45 was readmitted to the facility in September of 2022 with diagnoses including, but not limited to encephalitis (inflammation of the brain tissue caused by an infection).
Record review revealed an order dated 3/2/2022 which states,Resident to receive a shower once a day on Sunday, weekly 07:00 AM - 03:00 PM.
Further record review of a progress note dated 11/27/2022 at 3:15 PM, states in part, .Shower was not given due to staffing constraints .
During an interview with the Administrator on 11/29/2022 at approximately 3:30 PM, she was unable to provide evidence that the resident received a shower on 11/27/2022.
4. Record review revealed Resident ID #113 was readmitted to the facility in December of 2020 with a diagnosis including, but not limited to, multiple sclerosis.
Record review revealed an order dated 12/15/2020 which states in part, Resident to receive shower Once A Day on Wed [Wednesday], Sat [Saturday] .
Record review of the November 2022 TAR revealed the shower order marked as Not Administered: Due to condition on 11/26/2022.
During a surveyor interview on 11/30/2022 at 12:44 PM with Licensed Practical Nurse, Staff F, she revealed that on 11/26/2022 she informed the resident that they would not receive a shower due to only having two NAs on the unit.
During a surveyor interview on 11/30/2022 at 2:22 PM with the Assistant Director of Nursing Services, she was unable to provide evidence that the above-mentioned residents received their weekly showers as ordered.
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 record review and staff interviews, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 9 residents reviewed, Resident ...
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Based on record review and staff interviews, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 9 residents reviewed, Resident ID #94.
Findings are as follows:
Record review revealed the resident was admitted to the facility in April of 2021 with diagnoses including, but not limited to, hypertension (high blood pressure), end stage renal (kidney) disease, and dependence on renal dialysis.
Record review revealed a physician's order dated 8/18/2022 for, doxazosin [medication used to treat hypertension] tablet; 2 mg [milligrams] .Twice A Day .hold AM DOSE on dialysis days.
Further record review revealed the resident receives dialysis treatments on Tuesday, Thursday, and Saturday.
Review of the Medication Administration Records for October 2022 and November 2022 revealed the resident was administered doxazosin 2 mg prior to receiving his/her dialysis treatment on the following dates:
-10/1, 10/4, 10/8, 10/15, 10/27, 10/29, 11/5, 11/10, 11/12, 11/19, 11/21, and 11/29.
During a surveyor interview on 11/30/2022 at 11:04 AM with the Assistant Director of Nursing Services, she was unable to provide evidence that the doxazosin medication was held before dialysis as ordered on the above-mentioned dates.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**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 2 of 4 medication storage rooms and 5 of 5 medication carts observed.
Findings are as follows:
Review of the facility policy titled, Medication Storage states in part, .It is the policy of this facility that medication and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration .Insulin products should be stored in the refrigerator until opened .The refrigerator should be kept clean and frost-free .Outdated .discontinued .medications .are immediately removed from stock, disposed of according to procedures .
1. Surveyor observation on [DATE] at 9:40 AM of the Second floor, South Medication Cart, in the presence of Licensed Practical Nurse, Staff G, revealed the following:
- One Fluticasone Propionate and Salmeterol inhalation powder 250 mcg/50 mg, with 30 doses remaining on the counter, was open and not dated. Manufacturer's instructions read to discard the inhaler 1 month after opening.
- One Trelegy Ellipta 100 mcg/62.5 mcg/25, with 14 doses remaining on the counter. Manufacturer's instructions read to discard 6 weeks after opening.
- Two Lorazepam Intensol liquid bottles, located in the nurses locked box which were open and not dated. Additionally, manufacturer's instructions read, to refrigerate and discard after 90 days.
During a surveyor interview on [DATE] at 9:50 AM with Staff G revealed the above-mentioned medications should be dated when opened. Additionally, she acknowledged the Lorazepam should be refrigerated.
2. During a surveyor observation on [DATE] at 9:55 AM of the Second floor, North Medication Cart, in the presence of Licensed Practical Nurse, Staff H, revealed the following:
- One Breo Ellipta Inhaler 100/25 30 dose with 13 doses remaining in counter. Manufacturer's instructions read to discard 6 weeks after opening.
- One Pataday (Olopatadine Ophthalmic Solution 0.2%) open and not dated. Manufacturer's instructions read to discard 4 weeks after opening.
- One Tresiba Flex Touch pens 200 units/ml, unopened and not in use. Manufacturer's instructions read to store unused Tresiba FlexTouch pens and vials in the refrigerator at 36°F to 46°F.
- One Lorazepam Intensol liquid, located in the nurse's locked box, open and not dated. Additionally, manufacturer's instructions read, to refrigerate and discard after 90 days.
During a surveyor interview on [DATE] at the time of the observations with Staff H, revealed she could not explain why the above-mentioned medications were not dated when opened. Additionally, she acknowledged the Lorazepam should be refrigerated and could not explain why it was located in the nurse's cart.
3. During a surveyor observation on [DATE] at approximately 10:25 AM of the 3 South medication cart in the presence of Licensed Practical Nurse, Staff A, revealed the following:
- One Breo Ellipta inhaler opened and undated. Manufacturer's guidance read date when open foil tray and discard after 6 weeks or counter reads '0'
- Two Incruse Ellipta inhalers open and undated. Manufacturer's guidance states in part, .Date when foil tray opened and discard after 6 weeks or counter reads '0' .
- One bottle of Oyster shell vitamin with expiration date of 6/2022
- One opened and undated empty box for Trelegy inhaler.
During a surveyor interview with Staff A on [DATE] during the observation, she indicated that the resident's medication is stored in his/her room. During a surveyor observation on [DATE] at approximately 10:30 AM, of Resident ID #114's room revealed Trelegy inhaler opened and undated. Manufacturer's guidance reads date when foil tray opened and discard after 6 weeks.
During a surveyor interview on [DATE] immediately following this observation with Staff A, she acknowledged the above stated findings and was unable to answer why the medications were not dated or expired medication not discarded.
4. During a surveyor observation on [DATE] at 11:03 AM of the 1 North medication cart in the presence of Licensed Practical Nurse, Staff I, revealed the following:
- One Trelegy Ellipta inhaler opened and undated. Manufacturer's guidance reads date when opened and discard after 6 weeks.
- One Symbicort inhaler opened and undated. Manufacturer's guidance reads date after opening the foil and discard after 3 months.
During a surveyor interview immediately following this observation with Staff I, she acknowledged the above findings as stated and was unable to answer why the medications were not dated.
5. During a surveyor observation of the 1 North/South medication room on [DATE] at 11:10 AM in the presence of Staff I revealed the following:
- The refrigerator was observed to have frost protruding out from the freezer which prevented the freezer door from closing completely.
- One bottle of Lorazepam Oral Solution opened and dated [DATE]. Manufacturer's guidance states date when opened and discard 90 days after opening.
During a surveyor interview with Staff I immediately following the observations, she acknowledged the findings.
6. During a surveyor observation on [DATE] at 11:21 AM of the 1 South medication cart in the presence of Licensed Practical Nurse, Staff J, revealed the following:
- One bottle of Zinc 50 mg with an expiration date of 8/2022
- One Fluticasone inhaler opened and dated [DATE]. Manufacturer's guidance reads date when removed from foil pouch and discard 1 month after remove from foil or counter reads 0
- One bottle of Normal Saline open and dated [DATE], manufacturer's storage guidelines indicate discard unused portion immediately after initial use.
- One bottle of Morphine Sulfate oral solution open and undated. Manufacturer's guidance indicates discard after 1 year.
- One opened and undated empty box for Incruse Ellipta inhaler for Resident ID #58. During a surveyor interview with Staff J at the time of the observation she indicated that the resident's inhaler is kept at his/her bedside. During a surveyor observation in the presence of Staff J of the resident's medication at the bedside revealed the Incruse Ellipta inhaler was opened and undated. Manufacture's guidance reads date when opened and discard after 6 weeks or when the counter reads 0.
7. During a surveyor observation of the 1 East medication room on [DATE] at 11:03 AM in the presence of Registered Nurse, Staff K, revealed the following:
- One vial of Tuberculin solution, opened and undated. Manufacturer's guidance reads date when opened and discard unused portion after 30 days.
During a surveyor interview with Staff K immediately following the observation, she acknowledged the findings.
During a surveyor interview on [DATE] at 10:44 AM with the Assistant Director of Nursing Services, she was unable to explain why the Lorazepam Intensol bottles were not stored in the refrigerator. Additionally, she could not explain why the above-mentioned medications were open and not dated. She also indicated that the expectation is for refrigerators to be kept free from frost.
Nov 2022
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to not following a physician's order for 1 of 3 residents...
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Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to not following a physician's order for 1 of 3 residents reviewed, Resident ID #2.
Findings are as follows:
According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients .
Review of the record revealed the resident was admitted to the facility in September of 2012 with a diagnosis of type 2 diabetes mellitus.
Record review of the 9/9/2022 care plan, states in part, .Has a potential for alteration in blood sugars related to diabetes mellitus .monitor blood glucose [blood test that screens for diabetes by measuring the level of glucose (sugar) in a person's blood] .check MAR [Medication Administration Record] for finger sticks .
Review of a current physician's order, dated 9/9/2022, states in part, .Blood sugar check Special Instructions: Call Optum [primary care provider] if < [less than] 70, or > [greater than] 350 .Before Meals on Fri [Friday]; 07:30 AM, 11:30 AM, 4:30 PM .
Review of the documentation relative to blood sugars, progress notes and the Medication and Treatment Administration Records, from 9/9/2022 through 11/4/2022, failed to reveal evidence that the resident's blood sugar was monitored on the following dates and times (for 22 out of 24 opportunities):
- 9/9/2022: 4:30 PM meal
- 9/16/2022: all meals
- 9/23/2022: all meals
- 9/30/2022: all meals
- 10/7/2022: all meals
- 10/14/2022: 11:30 AM and 4:30 PM meals
- 10/21/2022: all meals
- 10/28/2022: all meals
- 11/4/2022: 7:30 AM meal
During a surveyor interview with Registered Nurse, Staff A, on 11/4/2022 at approximately 10:00 AM, she acknowledged that she had not obtained a blood sugar on 11/4/2022 at 7:30 AM for the resident. Additionally, she indicated she was unaware of the physician's order to obtain blood sugar checks before meals.
During a surveyor interview with the Director of Nursing, on 11/4/2022 at approximately 11:00 AM, she was unable to provide evidence that the blood sugars were monitored as ordered and stated her expectation is that the blood sugars should have been obtained per the physician order.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 38% turnover. Below Rhode Island's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), $48,617 in fines. Review inspection reports carefully.
- • 46 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $48,617 in fines. Higher than 94% of Rhode Island facilities, suggesting repeated compliance issues.
- • Grade D (43/100). Below average facility with significant concerns.
Bottom line: Trust Score of 43/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Riverview Healthcare Community's CMS Rating?
CMS assigns Riverview Healthcare Community an overall rating of 3 out of 5 stars, which is considered average nationally. Within Rhode Island, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Riverview Healthcare Community Staffed?
CMS rates Riverview Healthcare Community's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 38%, compared to the Rhode Island average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Riverview Healthcare Community?
State health inspectors documented 46 deficiencies at Riverview Healthcare Community during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 45 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Riverview Healthcare Community?
Riverview Healthcare Community is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by MARQUIS HEALTH SERVICES, a chain that manages multiple nursing homes. With 190 certified beds and approximately 169 residents (about 89% occupancy), it is a mid-sized facility located in Coventry, Rhode Island.
How Does Riverview Healthcare Community Compare to Other Rhode Island Nursing Homes?
Compared to the 100 nursing homes in Rhode Island, Riverview Healthcare Community's overall rating (3 stars) is below the state average of 3.1, staff turnover (38%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Riverview Healthcare Community?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Riverview Healthcare Community Safe?
Based on CMS inspection data, Riverview Healthcare Community has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Rhode Island. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Riverview Healthcare Community Stick Around?
Riverview Healthcare Community has a staff turnover rate of 38%, which is about average for Rhode Island nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Riverview Healthcare Community Ever Fined?
Riverview Healthcare Community has been fined $48,617 across 1 penalty action. The Rhode Island average is $33,565. 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 Riverview Healthcare Community on Any Federal Watch List?
Riverview Healthcare Community 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.