Cra-Mar Meadows
For profit - Corporation
41 Beds
Independent
Data: November 2025
Trust Grade
60/100
#36 of 72 in RI
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Cra-Mar Meadows in Cranston, Rhode Island has a Trust Grade of C+, indicating it is slightly above average but not outstanding. It ranks #36 out of 72 facilities in the state, placing it in the top half overall, but #20 out of 41 in Providence County suggests that there are better local options available. The facility is experiencing a worsening trend, with issues increasing from 11 in 2024 to 16 in 2025. Staffing is a relative strength, with a 4 out of 5 star rating and a turnover rate of 32%, which is better than the state average. However, there have been significant concerns, including failures to ensure staff completed mandatory training in effective communication and quality improvement, as well as not providing the required in-service training for nurse aides. Despite having no fines and good RN coverage, the increasing number of issues and training deficiencies are important considerations for families.
- Trust Score
- C+
- In Rhode Island
- #36/72
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 32% turnover. Near Rhode Island's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Rhode Island facilities.
- Skilled Nurses ✓ Good
- Each resident gets 52 minutes of Registered Nurse (RN) attention daily — more than average for Rhode Island. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
60/100
Top 50%
No red flags
11 → 16 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 11 issues
2025: 16 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (32%)
16 points below Rhode Island average of 48%
Facility shows strength in staffing levels, 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: 32%
14pts below Rhode Island avg (46%)
Typical for the industry
The Ugly 33 deficiencies on record
May 2025
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on surveyor observation and staff interview, it has been determined that the facility failed to care for each resident in an environment that promotes maintenance of his/her quality of life rela...
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Based on surveyor observation and staff interview, it has been determined that the facility failed to care for each resident in an environment that promotes maintenance of his/her quality of life relative to maintaining residents' dignity during the dining experience for 3 of 6 residents observed who require assistance with eating, Resident ID #s 5, 9, and 10.
Findings are as follows:
During a surveyor observation of the main dining room on 5/19/2025 from approximately 11:30 AM to 12:00 PM the following was observed:
- Nursing Assistant, Staff E, was noted to be standing up and assisting Resident ID #5 with eating, while the resident was seated at the table.
- Speech Therapist, Staff C, was noted to be standing up and assisting Resident ID #10 with eating, while the resident was seated at the table.
- Nursing Assistant, Staff D, was noted to be standing up and assisting Resident ID #9 with eating, while the resident was seated at the table.
During a surveyor interview on 5/19/2025 at 12:12 PM, with Staff E, she acknowledged she was standing up while assisting Resident ID #5 with eating while s/he was seated at the table.
During a surveyor interview on 5/19/2025 at 12:16 PM with Staff C, she acknowledged she was standing up while assisting Resident ID #10 with eating while s/he was seated at the table.
During a surveyor interview on 5/19/2025 at 12:20 PM, with Staff D, she acknowledged she was standing while assisting Resident ID #9 with eating while s/he was seated at the table.
During a surveyor interview with the Director of Nursing Services on 5/21/2025 at approximately 1:45 PM, she acknowledged that staff will either sit or stand to feed residents, and indicated it was based on the staff's preference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0577
(Tag F0577)
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 protect the identifying information for a current resident, Resident ID #18, for o...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to protect the identifying information for a current resident, Resident ID #18, for one of one survey available for review in the facility's survey results binder.
Findings are as follows:
During a surveyor observation on 5/21/2025 at approximately 1:30 PM, the survey results binder for 2025 was observed to be in the main hallway of the facility, accessible to all.
Record review of the survey results binder revealed the following:
- Survey results for exit date 1/29/2025 with a staff/resident roster attached, identifying Resident ID #18.
During a surveyor interview with the Assistant Administrator on 5/21/2025 at approximately 1:54 PM, following the above observation, he acknowledged that the facility failed to protect the identifying information of Resident ID #18, who was listed on the staff/resident roster, located in the survey results binder.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan for each resident, to meet a resident's medical, nurs...
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Based on record review and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan for each resident, to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 1 resident reviewed with a suprapubic catheter (SP catheter, a flexible tube inserted into your bladder via a surgical opening in the abdomen), Resident ID #8.
Findings are as follows:
Record review revealed the resident was readmitted to the facility in May of 2022 with diagnoses including, but not limited to, multiple sclerosis (MS, a chronic, disabling neurological disease that can affect any part of the body including the bladder) and neuromuscular dysfunction of the bladder (a problem in your brain, spinal cord, or central nervous system makes you lose control of your bladder).
Review of a care plan focus area initiated 11/3/2021 revealed that the resident has an SP catheter due to a neurogenic bladder relative to MS with an intervention to provide indwelling catheter care with hygiene and as needed.
Additional review of the care plan revealed a problem start date of 5/1/2025 indicating that s/he is experiencing symptoms of an acute urinary tract infection as evidenced by a change in mental status and foul-smelling urine with sediment.
Record review failed to reveal evidence that SP catheter care was being completed per the care plan.
During a surveyor interview on 5/20/2025 at 9:58 AM, with Nursing Assistant, Staff E, she revealed that when she assists with routine hygiene care, she does not provide any catheter care and stated, we don't touch it.
During a surveyor interview on 5/20/2025 at 10:29 AM, with the Director of Nursing Services, she revealed that she would expect catheter care to be completed daily by using soap and water to cleanse around the insertion site. She further revealed that she expects the nursing assistants to complete catheter care while providing assistance with hygiene however would not expect them to document it. When questioned by the surveyor how she can ensure catheter care is being conducted routinely, she was unable to explain or provide evidence that the resident is receiving routine catheter care per the care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed for a change in condition, Reside...
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Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed for a change in condition, Resident ID #8.
Findings are as follows:
According to www.health.harvard.edu last edited April 2022 revealed that there are two main allergic rashes that may happen after taking a drug, one that occurs within hours, but also a delayed rash that may appear four to 14 days after starting a medication that may appear as pink and red bumps on a person's chest and back and could spread. Additionally, with the delayed type of rash, common triggers include antibiotics.
Record review revealed the resident was readmitted to the facility in May of 2022 with a diagnosis including, but not limited to, multiple sclerosis (MS, a chronic, disabling neurological disease that can affect any part of the body including the bladder).
Record review revealed that the resident was treated for a suspected urinary tract infection and received ciprofloxacin (an antibiotic) 500 milligrams twice daily from 5/1/2025 through 5/6/2025 (a total of 11 doses).
Review of a progress note dated 5/15/2025 at 10:37 AM authored by Registered Nurse, Staff F, revealed she was called into the resident's room and noted the resident to be diaphoretic (excessive sweating due to an underlying condition or medication) indicating that s/he was soaking wet. Additionally, the resident was noted to have a rash to his/her torso with red/pink lines all over .like [s/he] scratched [him/herself] . but is physically unable to due to his/her condition.
Additional record review failed to reveal evidence that the provider was made aware that the resident was diaphoretic and had developed a rash.
During a surveyor interview on 5/20/2025 at 11:20 AM with Staff F, she revealed that she was called into the room and noted the resident to be very sweaty and had a rash from his/her waist to his/her collar bone. She revealed that she went to notify the Director of Nursing Services (DNS), and by the time she returned with the DNS, the rash had already begun to disappear. She further revealed that she did not notify the provider of the resident's change in condition.
During a surveyor interview on 5/20/2025 at 11:38 AM, with the DNS, she revealed that she would consider the resident's sweating and rash to be a change in condition and would only notify the provider if the rash persisted. She indicated that when she entered the resident's room, the resident had red lines on his/her torso but could not recall the amount of time that elapsed from when the rash first developed. Further, she indicated that she reviewed the resident's medication regimen, and failed to identify that the resident was recently treated with antibiotics because she only reviewed his/her current medications.
During a surveyor interview on 5/20/2025 at 2:46 PM with the resident's physician, he indicated that he would consider the resident's rash and sweating to be a change in condition and would typically expect to be notified.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 3 residents reviewed for ...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 3 residents reviewed for a medication with parameters, Resident ID #18.
Findings are as follows:
Review of a facility policy titled, Medication Administration dated 2017, states in part, .Medications are administered in accordance with written orders of the attending physician or physician extender .
Record review revealed the resident was readmitted to the facility in January of 2025 with diagnoses including, but not limited to, hypertensive (relating to high blood pressure) heart disease with heart failure and repeated falls.
Review of a physician's order dated 1/10/2025 revealed to administer metoprolol tartrate (a medication prescribed to treat high blood pressure) 25 milligrams twice daily. Additionally, the special instructions indicated to hold the medication for a systolic blood pressure (the top number of the blood pressure reading) of less than 110.
Review of the April and May 2025 Medication Administration Records (MARs) revealed that the resident received the medication when it was indicated to be held, per the physician's order on the following dates and times:
- 4/8 4:00 - 9:00 PM with a documented Blood Pressure (BP) of: 108/62
- 4/16 7:00 - 11:00 AM with a documented BP of: 104/60
- 5/11 4:00 - 9:00 PM with a documented BP of: 106/74
- 5/13 7:00 - 11:00 AM with a documented BP of: 107/65
During a surveyor interview on 5/21/2025 at 12:54 PM with the Director of Nursing Services, she acknowledged that the resident received the blood pressure medication on the above-mentioned dates and times and revealed that it should have been held, as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5...
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Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 25 opportunities for error observed during the medication administration task, there were 2 errors resulting in an error rate of 8% affecting Resident ID #s 1 and 24.
Findings are as follows:
Review of a facility policy titled, Medication Administration dated 2017, states in part, .Medications are administered in accordance with written orders of the attending physician or physician extender .The personnel administering the medication is to check the label on the medication against the order in the EMAR [Electronic Medication Administration Record] for accuracy. This is to prevent medication errors .
1a. Record review revealed Resident ID #24 has a physician's order for Flonase allergy spray 50 micrograms per spray with instructions to administer two sprays to each nostril once daily.
During a surveyor observation during the medication administration task on 5/21/2025 at approximately 9:25 AM with Certified Medication Technician, Staff B, she was observed to administer one spray of Flonase to each nostril.
1b. Record review revealed Resident ID #1 has a physician's order for Benefiber sugar-free fiber supplement with instructions to give one gram (approximately one teaspoon) in eight ounces of water once daily.
Additional record review revealed that the resident has a diagnosis of type II diabetes.
During a surveyor observation during the medication administration task on 5/21/2025 at approximately 9:40 AM with Staff B, she was observed to use Psyllium Fiber Powder, a non-sugar-free fiber supplement that contains four grams of sugar in one teaspoon, and added one teaspoon into eight ounces of water and administered it to the resident.
During a surveyor interview on 5/21/2025 at approximately 11:45 AM with Staff B, she acknowledged administering only one spray of Flonase to each nostril for Resident ID #24 and that the order indicates to provide 2 sprays for each nostril. Additionally, she acknowledged that she administered a non-sugar free fiber supplement to Resident ID #1 and that the order indicates to administer a sugar-free fiber supplement. Further, she revealed that she is unsure if the facility has a sugar-free fiber supplement in stock and the non-sugar-free fiber supplement that she used is the one she typically uses for all residents.
During a surveyor interview on 5/21/2025 at 12:20 PM with the Director of Nursing Services, she indicated that she would expect medications to be administered as ordered.
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 a resident's drug regimen is free from significant medication errors, for 1 of 1 resident reviewed...
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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 1 of 1 resident reviewed with a respiratory infection, Resident ID #24.
Findings are as follows:
Record review revealed the resident was admitted to the facility in November of 2023 with a diagnosis including, but not limited to, systolic congestive heart failure.
Record review revealed a progress note dated 5/19/2025 which revealed Nurse Practitioner, Staff G, gave the following new orders:
- azithromycin (an antibiotic medication) 500 milligrams (mg), by mouth, for a one-time dose, in the evening of 5/19/2025 and then administer 250 mg daily for four days starting 5/20/2025
- prednisone (a steroid medication) 40 mg, by mouth, for a one-time dose, in the evening of 5/19/2025 and then administer 20 mg daily for 3 days starting 5/20/2025.
Record review revealed the following physician's orders:
- azithromycin, 250 mg, with instructions to administer two tablets, once a day at 6:00 PM, with a start date of 5/19/2025 and an end date of 5/20/2025.
- azithromycin, 250 mg, with instructions to administer one tablet, once daily, with a start date of 5/20/2025
- prednisone, 20 mg, with instructions to administer two tablets, once a day at 6:00 PM, with a start date of 5/19/2025 and an end date of 5/20/2025.
- prednisone, 20 mg, with instructions to administer one tablet, once daily, with a start date of 5/20/2025.
Review of the May 2025 Medication Administration Record (MAR) revealed the resident was administered 500 mg of azithromycin and 40 mg of prednisone on 5/19/2025 and 5/20/2025. Further review revealed s/he was administered 250 mg of azithromycin and 40 mg of prednisone on 5/20/2025, indicating that s/he received an additional 500 mg dose of azithromycin and a 40 mg dose of prednisone on 5/20/2025, in error.
During a surveyor interview on 5/22/2025 at 9:58 AM, with Registered Nurse, Staff H, she revealed that the resident was only supposed to receive 500 mg of azithromycin and 40 mg of prednisone on 5/19/2025, as a one-time dose, but acknowledged that the MAR reflected that the resident was administered an additional 500 mg dose of azithromycin and a 40 mg dose of prednisone, in the evening of 5/20/2025, due to a transcription error. Further, she revealed that she was unaware the resident had received the appropriate dose of azithromycin and prednisone in the morning of 5/20/2025.
During a surveyor interview on 5/22/2025 at 10:09 AM, with Certified Medication Technician, Staff B, she acknowledged that she administered 40 mg of prednisone to the resident on 5/20/2025, but revealed that she only administered one tablet, 250 mg of azithromycin in the evening of 5/20/2025.
During a surveyor interview on 5/22/2025 at 10:20 AM, with NP, Staff G, she revealed that she was unaware of the medication errors, until it was brought to her attention by the surveyor. She further revealed that she would expect staff to transcribe the orders accurately and as written.
During a surveyor interview on 5/22/2025 at 10:28 AM, with the Director of Nursing Services, she revealed that the medication errors were due to a transcription error and indicated that she would expect staff to transcribe the orders accurately.
Cross reference F842
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0839
(Tag F0839)
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 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 staff are licensed, certified, or registered in accordance with applicable state laws, for 1 of 2 Certified Medication Technicians (CMT) reviewed, Staff A.
Findings are as follows:
According to 216-RICR-40-05-22, titled 216-Department of Health, Chapter 40-Professional Licensing and Facility Regulation, Subchapter 05 Part 22, Nursing Assistant, Medication Aide and the Approval of Nursing Assistants and Medication Aide Training Programs, states in part no person shall be employed as a Nursing Assistant or Medication Aide unless s/he holds license.
Review of Staff A's personnel file revealed she was hired on [DATE]. Further review revealed Staff A holds two certifications as a CMT and a Nursing Assistant, which both expired on [DATE].
During a surveyor observation on [DATE] at approximately 10:09 AM, Staff A was observed administering medications to residents in the activity room.
During a surveyor interview on [DATE] at 11:58 AM with Staff A, she revealed that she is a part time staff member and works two days a week in the facility. Staff A further revealed that she was not aware that her certifications had expired and acknowledged that she has been passing medications and caring for residents in the facility.
During a surveyor interview on [DATE] at approximately 12:00 PM with the Director of Nursing Services (DNS), she revealed that it is the responsibility of the employee to ensure that their certification is current. Additionally, the DNS revealed that the facility does not have a process for tracking employee certifications at this time, and did not know that Staff A had been working at the facility with expired certifications.
During a surveyor interview on [DATE] at approximately 12:08 PM with the Administrator, he revealed that the facility will periodically check the Rhode Island Department of Health's website for certification verification, but revealed that they do not have a formal process.
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 ensure that resident records are complete and accurately documented, relative to medication administratio...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that resident records are complete and accurately documented, relative to medication administration, for 1 of 1 resident reviewed with a respiratory infection, Resident ID #24.
Findings are as follows:
Record review revealed the resident was admitted to the facility in November of 2023 with a diagnosis including, but not limited to, systolic congestive heart failure.
Record review revealed a progress note dated 5/19/2025 which revealed Nurse Practitioner, Staff G, gave the following orders:
- azithromycin (an antibiotic) 500 milligrams (mg), by mouth, for a one-time dose, in the evening of 5/19/2025
- prednisone (a steroid) 40 mg, by mouth, for a one-time dose, in the evening of 5/19/2025
Record review revealed the following physician orders:
- azithromycin, 250 mg, with instructions to administer two tablets, once a day at 6:00 PM, with a start date of 5/19/2025 and an end date of 5/20/2025 at 6:51 PM.
- prednisone, 20 mg, with instructions to administer two tablets, once a day at 6:00 PM, with a start date of 5/19/2025 and an end date of 5/20/2025 at 6:51 PM.
Further review of the above physician's orders indicate that the above medication orders were transcribed to be administered on two days, rather than one day as ordered.
Review of the May 2025 Medication Administration Record (MAR) revealed the resident was administered 500 mg of azithromycin and 40 mg of prednisone at 6:00 PM on 5/19/2025 and 5/20/2025.
During a surveyor interview on 5/22/2025 at 9:58 AM, with Registered Nurse, Staff H, she revealed that the resident was only supposed to receive 500 mg of azithromycin and 40 mg of prednisone on 5/19/2025, but acknowledged that the MAR reflected that the resident was administered an additional dose of 500 mg of azithromycin and 40 mg of prednisone, on the evening of 5/20/2025, due to a transcription error, as the order was entered with an end date of 5/20/2025.
During a surveyor interview on 5/20/2025 at 10:09 AM, with Certified Medication Technician, Staff B, she acknowledged that she administered 40 mg of prednisone to the resident on 5/20/2025 but revealed that she only administered one, 250 mg tablet, of azithromycin on the evening of 5/20/2025, indicating the resident received an additional dose of 250 mg tablet, of azithromycin on 5/20/2025.
During a surveyor interview on 5/22/2025 at 10:28 AM, with the Director of Nursing Services, she acknowledged the transcription errors, and indicated that she would expect staff to transcribe orders accurately.
Cross reference F760
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performan...
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Based on record review and staff interview, it has been determined that the facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life relative to making a good faith attempt to correct medication errors.
Findings are as follows:
Record review of a 2567 (Centers for Medicare & Medicaid Services statement of deficiencies) dated 1/30/2025 revealed that the facility was cited for a significant medication error. Additional review of the 2567 revealed the facility submitted a plan of correction to the Rhode Island Department of Health on 2/17/2025 that states in part .Nurses and CMTs [Certified Medication Technician] that are directly employed as staff for the facility will receive 2 in-service/education with testing yearly .This will be discussed at the next QAPI meeting .
Record review of a document titled, QAPI Report Nursing Department states in part, .DNS [Director of Nursing Services] has completed overhaul of Medication Policy and Procedure for the facility in January .
Review of the QAPI binder for 2025 failed to reveal evidence of any actions, measurements, or tracking to ensure efforts for improvements of identified problem areas within the facility, including medication errors.
During a surveyor interview with the Director of Nursing Services on 5/22/2025 at 10:10 AM, she was unable to provide evidence of an ongoing and comprehensive QAPI program and that any good faith attempts were made by the facility regarding mitigating future medication errors.
Cross Reference F760.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiot...
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Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 2 of 2 residents reviewed for antibiotic use, Resident ID #s 8 and 24.
Findings are as follows:
According to the Centers for Disease Control and Prevention (CDC) document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes states in part, Perform antibiotic 'time outs.' .Nursing homes should have a process in place for a review of antibiotics by the clinical team two to three days after antibiotics are initiated to answer these key questions:
· Does this resident have a bacterial infection that will respond to
antibiotics?
· If so, is the resident on the most appropriate antibiotic(s), dose,
and route of administration?
· Can the spectrum of the antibiotic be narrowed or the duration of
therapy shortened (i.e., de-escalation)?
· Would the resident benefit from additional infectious disease/
antibiotic expertise to ensure optimal treatment of the suspected
or confirmed infection .
1. Record review revealed that Resident ID #8 was readmitted to the facility in May of 2022 with a diagnosis including, but not limited to, neuromuscular dysfunction of the bladder (a problem in your brain, spinal cord, or central nervous system that makes you lose control of your bladder).
Record review revealed a physician's order for Ciprofloxacin (an antibiotic) tablet 500 milligrams (mg) twice daily from 5/1/2025 through 5/6/2025.
Review of an Infection Control-Infection Tracker revealed a question, Antibiotic Reassessment (Antibiotic Time Outs) Performed? With the answer checked as no.
Additional record review failed to reveal evidence an antibiotic time out or a review at day three was conducted.
2. Record review revealed that Resident ID #24 was admitted to the facility in November of 2023 with a diagnosis including, but not limited to, type II diabetes.
Record review revealed a physician's order with a start date of 5/19/2025 for Azithromycin (an antibiotic) 250 mg daily for 4 days.
Record review failed to reveal evidence of a completed Infection Control-Infection Tracker for the use of the antibiotic.
Additional record review failed to reveal evidence an antibiotic time out or a review at day three was conducted.
During a surveyor interview on 5/21/2025 at 10:23 AM with the Director of Nursing Services she acknowledged that the facility does not perform antibiotic timeouts or reviews for residents receiving antibiotics.
Cross reference F-882
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected 1 resident
Based on staff interview, it has been determined that the facility failed to ensure that the Infection Preventionist completed specialized training in infection prevention and control.
Findings are as...
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Based on staff interview, it has been determined that the facility failed to ensure that the Infection Preventionist completed specialized training in infection prevention and control.
Findings are as follows:
Review of the facility assessment last updated 4/30/2025 revealed that the Director of Nursing Services (DNS), will complete the Infection Preventionist course.
During the Infection Control Task with the DNS on 5/21/2025 at 10:03 AM, she revealed that she is the Infection Preventionist (IP) for the facility. Additionally, she was unable to provide evidence that she completed the specialized training in infection prevention and control, as required. The DNS further indicated that the Minimum Data Set (MDS) Nurse, Staff I, is certified in infection control.
During a telephone interview on 5/21/2025 at 11:00 AM with Staff I, she revealed that she does not assist with infection prevention and control in the facility. Additionally, she revealed that she has not worked in the capacity of the facility's IP since April of 2024.
During a follow up interview on 5/21/2025 at approximately 11:30 AM with the DNS she acknowledged that she did not complete the infection preventionist training since taking over as the facility's IP, 1 year ago.
Cross reference F-880, F-881 and F-883
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 record review, surveyor observation and staff interview it has been determined that the facility failed to establish and maintain an infection prevention and control program designed to provi...
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Based on record review, surveyor observation and staff interview it has been determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents reviewed with wounds and the use of Enhanced Barrier Precautions (EBP; refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and glove use during high contact resident care activities), Resident ID #s 2 and 11, and for 1 of 2 residents reviewed for use of a continuous positive airway pressure machine (CPAP, a device used to keep your airways open while you sleep so you can receive the oxygen you need), Resident ID #20.
Findings are as follows:
Review of an undated facility policy titled, Enhanced Barrier Precautions states in part, .Resident that meets criteria for the requiring EBP are: Any resident with open chronic wound that requires applying a dressing places them at risk for infection (e.g. Pressure ulcers, diabetic foot ulcers, un-healed surgical wound, or venous stasis ulcers) .
1a. Record review revealed that Resident ID #2 was readmitted to the facility in April of 2023 with diagnoses including, but not limited to, dementia and difficulty walking.
Review of a document titled, Wound Evaluation and Management Summary dated 5/14/2025 revealed Resident ID #2 has a stage 4 pressure ulcer (the most severe type of pressure ulcer with tissue damage that extends to the muscle, tendon, ligament, cartilage or bone) to his/her coccyx (tailbone) measuring 2.5 centimeters (cm) X 1.3 cm X 0.3 cm with a duration of greater than 156 days. Additionally, the record revealed wound care orders to apply a dressing every other day.
During surveyor observations on all days of the survey from 5/19 to 5/22/2025, failed to reveal evidence that Resident ID #2 was on EBP, despite having a chronic wound requiring a dressing.
During a surveyor observation on 5/20/2025 at 4:00 PM with Registered Nurse (RN), Staff H, revealed she did not wear a gown while performing wound care for the resident.
During a surveyor interview directly following the above observation with Staff H, she acknowledged that Resident ID #2 was not on EBP although the resident does have a wound.
1b. Record review revealed Resident ID #11 was readmitted to the facility in December of 2024 with diagnoses including, but not limited to, type II diabetes and disorder of the skin.
Review of a document titled, Wound Evaluation and Management Summary dated 5/14/2025 revealed that Resident ID #2 has the following wounds:
- A non-pressure wound of the right buttock measuring 2.5 cm X 1.5 cm X 0.2 cm with a duration of greater than 113 days. Additionally, the record revealed wound care orders to apply a dressing 3 times a week.
- A non-pressure wound of the left first toe measuring 0.4 cm X 0.4 cm X 0.1 cm with a duration of greater than 53 days. Additionally, the record revealed wound care orders to apply a dressing three times a week.
During surveyor observations on all days of the survey from 5/19 to 5/22/2025, failed to reveal evidence that Resident ID #11 was on EBP despite having two chronic wounds that required a dressing.
During a surveyor observation on 5/20/2025 at 10:37 AM with RN, Staff F, revealed that she did not wear a gown while performing wound care for the resident.
During a surveyor interview on 5/21/2025 at 10:23 AM with the Director of Nursing Services (DNS), she acknowledged that Resident ID #s 2 and 11 were not on EBP as required by the facility policy and the regulation.
During a surveyor observation on 5/22/2025 at 9:56 AM, after this concern was brought to the attention of the facility by the surveyor, Resident ID #s 2 and 11 were not on EBP.
2. Record review revealed that Resident ID #20 was admitted to the facility in March of 2025 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and obstructive sleep apnea (a sleep disorder in which breathing repeatedly stops and starts).
Record review revealed a physician's order for a CPAP machine at bedtime.
Review of the May 2025 Medication Administration Record revealed the CPAP was documented as being in use on multiple nights.
Record review failed to reveal evidence of the CPAP machine or its accessories being cleaned.
During a surveyor interview on 5/20/2025 at 10:34 AM with RN, Staff F, she was unable to provide evidence of when the CPAP machine and its accessories were cleaned.
During a surveyor interview on 5/20/2025 at 10:54 AM with the DNS she acknowledged that the CPAP mask should be cleaned daily and the machine weekly. The DNS was unable to provide evidence that the CPAP machine for Resident ID #20 was cleaned.
Following the above interview, the DNS provided a policy dated 2025, titled, Cleaning a CPAP Machine that states in part, To ensure the safety and effectiveness of CPAP therapy, the CPAP machine, mask, tubing, and related accessories must be cleaned regularly according to manufacture guidelines and infection control standards.
Cross reference F-882
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
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 the resident's medical rec...
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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 the resident's medical record includes documentation that the resident either received the pneumococcal vaccination or did not receive the vaccination due to medical contraindications or refusal, for 4 of 5 residents reviewed, Resident ID #s 2,7, 8 and 11. Additionally, the facility failed to have updated policies regarding immunizations.
Findings are follows:
According to the Centers for Disease Control and Prevention (CDC), pneumococcal vaccination for all adults 19 through [AGE] years old who have certain chronic medical conditions or 65 years or older who have only received PPSV23 [a type of pneumococcal conjugate vaccination], the PCV15 [a type of pneumococcal conjugate vaccine] or PCV20 [a type of pneumococcal conjugate vaccine] dose should be administered at least one year after the most recent PPSV23 vaccination. For adults 19 through [AGE] years old who have certain chronic medical indications who have only received PCV13 [a type of pneumococcal conjugate vaccine], give 1 dose of the PCV20 at least 1 year after PCV13 or give 1 dose of PPSV23 at least 8 weeks after PCV13. For adults 65 years or older who have only received PCV13, give PPSV23 or PCV20 as previously recommended. Together, with the patient, vaccine providers may choose to administer PCV20 or PCV21 to adults greater than or equal to [AGE] years old who have already received PCV13 (but not PCV15, PCV20, or PCV21) at any age and PPSV23 at or after the age of [AGE] years old.
1a. Record review for Resident ID #2 revealed the resident was readmitted to the facility in April of 2023. Record review of the resident's immunization records revealed that the resident received his/her PCV13 vaccine in February of 2019. Record review failed to reveal evidence that the resident was offered, received, or declined the PPSV23, PCV20, or PCV21 vaccine.
1b. Record review for Resident ID #7 revealed the resident was readmitted to the facility in March of 2023. Record review of the resident's immunization records revealed that the resident received his/her PCV13 vaccine in January of 2014. Record review failed to reveal evidence that the resident was offered, received, or declined the PPSV23, PCV20, or PCV21 vaccine.
1c. Record review for Resident ID #8 revealed the resident was readmitted to the facility in May of 2022. Record review of the resident's immunization records revealed that the resident received his/her PCV13 vaccine in April of 2022. Record review failed to reveal evidence that the resident was offered, received, or declined the PPSV23, PCV20, or PCV21 vaccine.
1d. Record review for Resident ID #11 revealed that the resident was admitted to the facility in February of 2017. Record review of the resident's immunization records revealed that the resident received his/her initial series included PCV13 and PPSV23. Record review failed to reveal evidence that the resident was offered, received, or declined the PCV20 or PCV21 vaccine.
During a surveyor interview on 5/21/2025 at 10:35 AM, with the Director of Nursing Services (DNS), she was unable to provide evidence that Resident ID #s 2, 7, 8 and 11's medical records included documentation that indicates, at a minimum, if the residents either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
2. Review of a facility policy titled, Resident Vaccination (Flu and pneumonia) dated 3/2020 states in part, .Vaccinations are to be provided in accordance with the most recent ACIP (Advisory Council on Immunization Practices) guidelines for these vaccinations. As of 2019, ACIP has recommended the following pneumonia vaccination schedule (Also follow CDC Vaccination for Elders guidelines): ACIP recommends a routine single dose of PPSV23 for adults aged greater than or equal to 65 years who do not have an immunocompromising condition, cerebrospinal fluid leak or cochlear implant and who have not previously received PCV13. If a decision to administer PCV13 is made, PCV13 should be administered first followed by PPSV23 at least 1 year later .
During a surveyor interview on 5/21/2025 at 10:37 AM with the DNS, she acknowledged that the policy that the facility is currently using is out of date and does not include the current guidelines for pneumococcal vaccinations. Additionally, the DNS revealed that the above immunization policy was not reviewed annually as required.
Cross reference F-882
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0940
(Tag F0940)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to implement and maintain an effective training program for all employees, consistent with their expected ro...
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Based on record review and staff interview, it has been determined that the facility failed to implement and maintain an effective training program for all employees, consistent with their expected roles, as outlined in the Facility Assessment, for 5 of 5 staff reviewed, Staff A, B, E, F, and J.
Findings are as follows:
Review of the Facility Assessment, last updated 4/30/2025, states in part, .Staff training/education and competencies .Consider the following training topics .Resident's rights .Abuse, neglect, and exploitation .Consider the following competencies .Specialized care - catheterization insertion/care .
Record review revealed Certified Medication Technician (CMT), Staff A, was hired on 2/1/2021. Review of her training records failed to reveal evidence that she received or completed resident rights or abuse, neglect, and exploitation education. Further review failed to reveal evidence that she received or completed a competency relative to catheter care.
Record review revealed CMT, Staff B, was hired on 10/6/2021. Review of her training records failed to reveal evidence that she received or completed resident rights or abuse, neglect, and exploitation education. Further review failed to reveal evidence that she received or completed a competency relative to catheter care.
Record review revealed Nursing Assistant, Staff E, was hired on 2/1/2021. Review of her training records failed to reveal evidence that she received or completed a competency relative to catheter care.
Record review revealed Registered Nurse (RN), Staff E, was hired on 5/28/2019. Review of her training records failed to reveal evidence that she received or completed resident rights or abuse, neglect, and exploitation education. Further review failed to reveal evidence that she received or completed a competency relative to catheter care.
Record review revealed RN, Staff J, was hired on 6/10/2020. Review of her training records failed to reveal evidence that she received or completed resident rights or abuse, neglect, and exploitation education. Further review failed to reveal evidence that she received or completed a competency relative to catheter care.
During a surveyor interview on 5/22/2025 at 9:04 AM, with the Director of Nursing Services, she acknowledged the missing education for Staff A, B, E, F, and J. Further, she was unable to provide evidence that the above-mentioned in-services were completed for Staff A, B, E, F, and J, as per the Facility Assessment and the regulations.
Cross reference F-656
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
Deficiency F0760
(Tag F0760)
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 residents are free of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed for medication administration, Resident ID #1.
Findings are as follows:
Record review of a community reported complaint submitted to the Rhode Island Department on Health on 1/28/2025 alleged in part, that Resident ID #1 received Ativan (also known as Lorazepam; a medication prescribed to treat anxiety disorders) in the morning along with and as needed (prn) dose of Oxycodone (a medication prescribed to treat pain). Additionally the complaint alleges that the resident received Oxycodone after it had been discontinued.
Record review revealed the resident was admitted to the facility in September of 2024 with diagnoses including, but not limited to, anxiety disorder and a right hip fracture.
Record review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 99 out of 15 indicating that the resident was unable to complete the assessment due to a diminished level of cognition.
Record review revealed the following physician orders:
- Lorazepam, Give 0.5 milligrams (mg) at bed time with a start date of 1/10/2025.
- Oxycodone, Give 2.5 mg every 8 hours as needed for pain with a start date of 1/24/2025.
- Oxycodone, Give 5 mg every 8 hours as needed for pain with a start date of 1/11/2025 and a discontinue date of 1/14/2025.
Record review of the resident's progress notes revealed entries dated 1/13/2025 and 1/27/2025 which revealed the following:
- 1/13/2025 at 2:28 PM- Medication error on 11:00 PM to 7:00 AM shift, as resident was given 0.5 milligrams (mg) of Ativan at 6:45 AM instead of 5 mg of Oxycodone. The provider and family were notified. An assessment was completed with no adverse effect. The resident was medicated with PRN (as needed) Oxycodone at 8:00 AM with good effect.
- 1/27/2025 at 8:54 AM- Resident noted to have received Oxycodone 5 mg by mouth instead of Oxycodone 2.5 mg by mouth. A medication error report was completed. The provider, family and Director of Nursing Services was notified.
During a surveyor interview with Registered Nurse, Staff A, on 1/30/2025 at approximately 9:50 AM, she acknowledged that she gave the resident 0.5 mg of Ativan on the morning of 1/13/2025 in error and not the 5 mg of Oxycodone per the physician's order. Additionally, she revealed that the error was discovered after completing the medication count and she received education. She further acknowledged that she made secondary medication error for this resident on 1/27/2025 when she gave the resident 5 mg of Oxycodone in error rather than the 2.5 mg that was ordered.
During a surveyor interview with the Director of Nursing Services, on 1/29/2025 at 1:20 PM, she acknowledged that Staff A administered the above-mentioned medications to Resident ID #1 in error.
May 2024
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
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 revise each...
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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 revise each resident's care plan, by the interdisciplinary team, after each assessment, including both the comprehensive and quarterly review assessments for 1 of 2 residents reviewed relative to falls, Resident ID #22, and 1 of 1 resident reviewed relative to oxygen therapy, Resident ID #31.
Findings are as follows:
1. Record review of a facility document titled, Policy and Procedure for Accidents and Incidents last revised 9/2019, states in part, .Fall occurring without injury .Care Plan and CNA [Certified Nurse Assistant] care card will be updated .
Record review revealed Resident ID #22 was admitted to the facility in December of 2023 with diagnoses that include, but are not limited to, spinal stenosis (a condition where spinal column narrows and compresses the spinal cord) and difficulty walking.
Record review of an admission Minimum Data Set (MDS) Assessment completed on 1/8/2024, revealed the resident had a fall in the last month prior to admission and experienced a fall resulting in a fracture within the last 6 months prior to admission.
Record review of a Quarterly MDS Assessment completed on 3/19/2024, revealed that the resident had 2 or more falls with no injury and one fall resulting in an injury since the prior assessment.
Record review of the care plan dated 1/4/2024, states in part, .the resident was at risk for falls due to weakness, balance and activity tolerance . Interventions include but are not limited to, keep his/her walker within reach at all times with a start date of 1/4/2024 and to offer additional toileting at set times with a start date of 4/26/2024.
Review of the resident's progress notes, dated 1/29/2024 through 4/24/2024, revealed that the resident had experienced 8 unwitnessed falls on the following dates:
-1/29/2024
-2/6/2024
-3/8/2024
-3/21/2024
-3/28/2024
-4/16/2024
-4/23/2024
-4/24/2024
Record review failed to reveal evidence that the resident's care plan was updated with interventions related to the 8 unwitnessed falls from 1/29/2024 through 4/24/2024.
Record review failed to reveal evidence that the resident's care plan was revised by the interdisciplinary team after the March 2024 Quarterly MDS Assessment to include interventions for the unwitnessed falls.
During a surveyor interview on 5/23/2024 at 8:41 AM with Registered Nurse, Staff A, she revealed that if a resident has a fall the staff would follow the facility policy which includes adding an intervention to prevent another fall. She further revealed that the intervention would be added to the care plan by the nurse, or an email would be sent to the MDS Coordinator to add it to the care plan.
During a surveyor interview with the Director of Nursing Services on 5/23/2024 at approximately 8:55 AM, she acknowledged that the care plan had not been updated for Resident ID #22 after s/he had several unwitnessed falls. Additionally, at this time, she was unable to provide evidence that the care plan was updated with interventions after the resident experienced several unwitnessed falls from 1/29/2024-4/24/2024.
2. Record review revealed Resident ID #31 was admitted to the facility in May of 2022 with diagnoses that include, but are not limited to, chronic respiratory failure with hypoxia (a below-normal level of oxygen in your blood) and chronic obstructive pulmonary disease.
Record review revealed a Quarterly MDS assessment dated [DATE], which revealed the resident requires oxygen.
Record review of a physician's order dated 4/1/2024 states Oxygen via nasal canula at 2-4 liters as needed for shortness of breath, POX [pulse oximetry, needle-free test that measures the amount of oxygen in your blood] less than 88%.
Record review failed to reveal evidence that the resident's care plan was updated to include the oxygen therapy.
During multiple surveyor observations on the following dates and times the resident was receiving 3 liters of oxygen via nasal canula:
5/20/2024 at 10:01 AM
5/20/2024 at 12:00 PM
5/21/2024 at 8:40 AM
During a surveyor interview on 5/21/2024 at 12:04 PM with Registered Nurse, Staff B, she revealed that the resident requires oxygen continuously.
During a surveyor interview on 5/21/2024 at 12:47 PM with the MDS Coordinator she revealed that oxygen should be included on the care plan.
During a surveyor interview on 5/21/2024 at 1:52 PM with the DNS she revealed that she would expect the care plan to be updated to include oxygen therapy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
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 ensure tha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the resident's environment remains as free from accident hazards as possible for 1 of 1 resident reviewed related to supervision with meals, Resident ID #17.
Findings are as follows:
Record review revealed Resident ID #17 was admitted to the facility in March of 2024 with a diagnosis including, but not limited to, dysphagia (a condition with difficulty in swallowing food or liquid).
Record review of the care plan last revised on 3/21/2024 states in part, .ACTIVITIES OF DAILY LIVING: Overall I require extensive assistance .and supervision with eating.
Record review of a Minimum Data Set assessment dated [DATE], revealed the resident required supervision with meals.
Record review of a facility document titled, Assignment 3, last updated 5/22/2024, states in part, .Diet: Regular as tolerated REPORT coughing @[at] meals .
During a surveyor observation on 5/23/2024 at 11:42 AM until approximately 12:05 PM, the resident was observed sitting in his/her wheelchair, with the back in a reclined position, eating his/her meal unsupervised.
During a surveyor interview on 5/23/2024 at approximately 12:05 PM with the Registered Nurse, Staff A, following the above observation, she acknowledged that the resident was eating unsupervised and was unaware if s/he required supervision with meals.
During a surveyor interview with the Director of Therapy on 5/23/2024 at 12:35 PM, she revealed that the resident would normally eat in the dayroom for meals but due to a COVID outbreak in the facility resident's are now eating in their rooms. Additionally, she was unaware if s/he required supervision with meals and would need to review the Speech Therapy notes.
During a surveyor interview on 5/23/2024 at 12:14 PM with Director of Nursing Services, she acknowledged that the resident's care plan indicates supervision with meals.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed with a suprapubic catheter (SP tu...
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Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed with a suprapubic catheter (SP tube - a device inserted through the abdomen into the bladder to drain urine), Resident ID #9.
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, multiple sclerosis (MS - a chronic disease of the central nervous system that affects the brain and spinal cord) and neuromuscular dysfunction of the bladder.
Review of a care plan focus area dated 11/3/2021 revealed the resident requires an SP tube with an intervention to follow up with the urologist as ordered.
Review of document titled, Continuity of Care Consultation and Referral Form dated 5/9/2022 revealed that the resident was seen by his/her urologist with orders to follow up in 6 months.
Review of a progress noted dated 5/9/2022 at 11:48 AM revealed the resident returned from his/her urology appointment and s/he was to follow up in 6 months.
Record review failed to reveal evidence that the resident has had any urology appointments since his/her last appointment on 5/9/2022.
During a surveyor interview on 5/22/2024 at 12:16 PM with Registered Nurse, Staff B, she revealed that she contacted the urology office and they indicated that the resident has not returned to the office since his/her last visit on 5/9/2022.
During a surveyor interview on 5/22/2024 at 1:03 PM with the Director of Nursing Services, she revealed that the resident should have returned to his/her urologist in 6 months as ordered and was unable to explain why the follow up appointment was never scheduled.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
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 the resident's medical rec...
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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 the resident's medical record includes documentation that the resident either received the pneumococcal vaccination or did not receive the vaccination due to medical contraindications or refusal for 3 of 7 residents reviewed, Residents ID #s 2, 9, and 16.
Findings are follows:
According to the Centers for Disease Control and Prevention (CDC), pneumococcal vaccination for all adults 19 through [AGE] years old who have certain chronic medical conditions or 65 years or older who have only received PPSV23 [23 vaccination], the PCV15 [type of pneumococcal conjugate vaccine] or PCV20 [type of pneumococcal conjugate vaccine] dose should be administered at least one year after the most recent PPSV23 vaccination. For adults 19 through [AGE] years old who have certain chronic medical conditions who have only received PCV13 [type of pneumococcal conjugate vaccine], give 1 dose of the PCV20 at least 1 year after PCV13 or give 1 dose of PPSV23 at least 8 weeks after PCV13. For adults 65 years or older who have only received PCV13 [type of pneumococcal conjugate vaccine], give PPSV23 or PCV20 as previously recommended.
1) Record review revealed Resident ID #2 was admitted to the facility in October of 2021 with a diagnosis including, but not limited to, dementia.
Review of his/her immunization records revealed s/he received PCV13 in February of 2019. Additionally, the record failed to reveal evidence that the PPSV23 or the PCV20 vaccines were offered, received, or declined.
2) Record review revealed Resident ID #9 was admitted to the facility in April of 2021 with a diagnosis including, but not limited to, multiple sclerosis (MS - a chronic disease of the central nervous system that affects the brain and spinal cord).
Review of his/her immunization records revealed s/he previously received PCV13. Additionally, the record failed to reveal evidence that the PPSV23 or the PCV20 vaccines were offered, received, or declined.
3) Record review revealed Resident ID #16 was admitted to the facility in June of 2023 with a diagnosis including, but not limited to, spinal stenosis (a condition where the spinal column narrows and compresses the spinal cord).
Review of his/her immunization records failed to reveal evidence that any pneumococcal vaccines were offered, received, or declined.
During a surveyor interview on 5/21/2024 at 11:32 AM with the Director of Nursing Services, she was unable to provide evidence that the appropriate vaccines for the above-mentioned residents had been offered, received, or declined.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
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 an ongoing program to support a resident in their choice of activities desi...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide an ongoing program to support a resident in their choice of activities designed to meet their interests and support the well-being of each resident, based on the comprehensive assessment, care plan and preferences for 6 of 12 residents reviewed for activities, Resident ID #s 14, 16, 17, 18, 22, and 30.
Findings are as follows:
Surveyor observations during the annual recertification survey conducted on 5/20/2024 through 5/23/2024, failed to reveal an activities calendar posted with activities to meet residents interests where each resident could see it. Although a Daily Activity Schedule was provided to the survey team, continued surveyor observation failed to reveal an activities at 9:00 AM, 10:00 AM, 11:00 AM, 1:30 PM, 2:30 PM and 3:00 PM each day.
1. Record review revealed Resident ID #14 was admitted to the facility in July of 2023 with a diagnosis including, but not limited to, malignant neoplasm of the bladder (bladder cancer).
Review of an admission Minimum Data Set (MDS) Assessment, Section F, titled, Preferences for Customary Routine and Activities, dated 7/23/2023, revealed an interview for activity preference which indicated that while the resident is in the facility, it is very important for the resident to have books, newspaper, and magazines to read and to be around animals such as pets. It further revealed that it is somewhat important for the resident to do his/her favorite activities.
Review of the resident's care plan failed to reveal evidence of an activities focus area, to include the resident's preferences, as identified in the above-mentioned MDS Assessment.
2. Record review revealed Resident ID #16 was admitted to the facility in June of 2023 with a diagnosis including, but not limited to, spinal stenosis (a condition where the spinal column narrows and compresses the spinal cord).
Review of an admission MDS Assessment, Section F titled, Preferences for Customary Routine and Activities, dated 6/12/2023, revealed an interview for activity preference which indicated that while the resident is in the facility, it is somewhat important for the resident to have books, newspapers, and magazines to read, listen to music s/he likes, keep up with the news, do his/her favorite activity, go outside to get fresh air when the weather is good, and participate in religious services or practices.
Review of the resident's care plan failed to reveal evidence of an activities focus area, to include the resident's preferences, as identified in the above-mentioned MDS Assessment.
3. Record review revealed Resident ID #17 was admitted to the facility in March of 2024 with a diagnosis including, but not limited to, dementia.
Review of an admission MDS Assessment, Section F titled, Preferences for Customary Routine and Activities, dated 3/25/2024, revealed an interview for activity preference which indicated that while the resident is in the facility, it is very important for the resident to be around animals such as pets, keep up with the news, and participate in religious services or practices. It further revealed that it is somewhat important for the resident to listen to music s/he likes, do his/her favorite activity, and go outside to get fresh air when the weather is good.
Review of the resident's care plan failed to reveal evidence of an activities focus area, to include the resident's preferences as identified in the above-mentioned MDS Assessment.
4. Record review revealed Resident ID #18 was admitted to the facility in March of 2024 with a diagnosis including, but not limited to, Parkinsonism (a clinical syndrome characterized by tremors, slow movements, or stiffness or rigidity).
Review of a Significant Change MDS Assessment, Section F titled, Preferences for Customary Routine and Activities, dated 11/22/2023, revealed an interview for activity preference which indicated that while the resident is in the facility, it is very important for the resident to keep up with the news, do his/her favorite activity, and participate in religious services or practices. It further revealed it is somewhat important for the resident to have books, newspapers, and magazines to read, listen to music s/he likes, do things with groups of people, and go outside to get fresh air when the weather is good.
Review of the resident's care plan failed to reveal evidence of an activities focus area, to include the resident's preferences as identified in the above-mentioned MDS Assessment.
5. Record review revealed Resident ID #22 was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, spinal stenosis.
Review of an admission MDS Assessment, Section F titled, Preferences for Customary Routine and Activities, dated 12/19/2023, revealed an interview for activity preference which indicated that while the resident is in the facility, it is somewhat important for the resident to listen to music s/he likes, do his/her favorite activity, and participate in religious services or practices.
Review of the resident's care plan failed to reveal evidence of an activities focus area, to include the resident's preferences as identified in the above-mentioned MDS Assessment.
6. Record review revealed Resident ID #30 was admitted to the facility in March of 2024 with a diagnosis including, but not limited to, dementia.
Review of an admission MDS Assessment, Section F titled, Preferences for Customary Routine and Activities, dated 4/3/2024, revealed an interview for activity preference which indicated that while the resident is in the facility, it is very important for the resident to participate in religious services or practices. It further revealed it is somewhat important for the resident to have books, newspapers, and magazines to read, keep up with the news, to do things with groups of people, and to go outside to get fresh air when the weather is good.
Review of the resident's care plan failed to reveal evidence of an activities focus area, to include the resident's preferences as identified in the above-mentioned MDS Assessment.
During a surveyor interview on 5/23/2024 at 10:51 AM, with the Activity Director, she revealed that she previously participated in the creation of activity related care plans, but indicated that she no longer does, as the MDS Coordinator completes them now. Additionally, she acknowledged that the residents should have an activity focus area in their care plans, that is individualized and identifies the resident's preferences that are reflected in the MDS Assessments.
During a surveyor interview on 5/23/2024 at 12:12 PM, with the MDS Coordinator, she was unable to provide evidence that activity care plans were created for Resident ID #s 14, 16, 17, 18, 22, and 30.
During a surveyor interview on 5/23/2024 at 1:30 PM, with the Administrator and Director of Nursing Services, they were unable to provide evidence that an activity program was developed based on the comprehensive assessment, care plan, and the preferences of each resident.
Cross reference F 680
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards o...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards of practice for 1 of 1 resident reviewed for dialysis( a blood purifying treatment given when kidney function is not optimum), Resident ID #27.
Findings are as follows:
Review of a facility policy titled, Dialysis Patients; Care Of states in part, .Care of the dialysis patient/resident will include .1. A physician order in the medical record indicating how [many] days of dialysis and location of dialysis center .
a) Record review revealed the resident was admitted to the facility in September of 2021 with diagnoses including, but not limited to, stage 4 chronic kidney disease (when your kidneys can no longer support your body's needs) and dependence on renal dialysis.
Review of a care plan problem area dated 1/5/2022 revealed the resident receives dialysis with an intervention that includes to have the resident ready for transportation to dialysis on assigned days.
Review of a physician's order dated 1/13/2022 states, Order for Dialysis. Additionally, the order failed to include the location of the dialysis center, name, contact number, and the scheduled days the resident is to receive dialysis.
During a surveyor interview on 5/21/2024 at 1:42 PM with the Director of Nursing Services (DNS), she was unable to explain why the dialysis order failed to include the above-mentioned information as indicated in the facility policy.
b) Additional review of a facility policy titled, Dialysis Patients; Care Of states in part, .2. The administrative team shall ensure there is a contractual agreement in place for services at the dialysis center treating our resident(s) .
Record review failed to reveal evidence of a contractual dialysis service agreement between the dialysis center and the facility.
During a surveyor interview on 5/21/2024 at 1:42 PM with the DNS, she revealed that the facility does not have a dialysis service agreement and was unable to explain why the facility had never prepared one.
Additionally, on 5/22/2024 the facility provided the survey team with a signed dialysis service agreement that was dated 5/21/2024 which was prepared after the concern was brought to the facility's attention.
During a subsequent surveyor interview on 5/22/2024 at 1:00 PM with the DNS, she revealed that she would expect the facility to follow their policy relative to the management and care of a dialysis resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide an infection prevention and control program designed to help prevent the d...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections relative to staff utilizing appropriate personal protective equipment (PPE) for 2 of 2 nursing units.
Findings are as follows:
Review of the Centers for Disease Control and Prevention (CDC) Appendix A, Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings revealed precautions for COVID-19 should include standard, droplet and contact precautions throughout the duration of the illness. Additional review revealed droplet precautions to include use of a mask and eye protection and contact precautions to include use of a gown, gloves and mask.
During a surveyor interview with the Director of Nursing Services (DNS) on 5/20/2024 at approximately 8:34 AM she revealed that the facility was experiencing a COVID-19 outbreak affecting a total of 5 residents, including Resident ID #s 10, 13 and 24.
1. Record review revealed Resident ID #10 was admitted to the facility in May of 2022 with a diagnosis including, but not limited to, COVID-19.
Record review of a nursing progress note dated 5/9/2024 states, Rapid Covid positive at this time and place on Quarantine. Will notify MD, family and obtain labs if ordered.
During a surveyor observation on 5/20/2024 at 12:00 PM of the resident's room revealed a sign for droplet precautions. The sign states in part, Everyone must .Make sure their eyes, nose and mouth are fully covered before entering the room .
During a surveyor observation immediately following the above observation on 5/20/2024 at 12:00 PM of Staff E, she was observed entering Resident ID# 10's room carrying the resident's meal tray wearing a gown, gloves, and a mask below her nose. She then proceeded to feed the resident without wearing eye protection.
During a surveyor interview immediately following the above observation at approximately 12:14 PM with Staff E, she acknowledged that she was in the room feeding Resident ID# 10. She further revealed that she was unaware if the resident was on precautions. Additionally, she acknowledged she was not wearing eye protection according to the signage on the door.
2. Record review revealed Resident ID #13 was admitted to the facility in April of 2023 with a diagnosis including, but not limited to, COVID-19.
Record review of a progress note dated 5/18/2024 states in part, .Remains on quarantine for covid .
During a surveyor observation on 5/20/2024 at 11:58 AM of the resident's room revealed a sign for droplet precautions. The sign states in part, Everyone must .Make sure their eyes, nose and mouth are fully covered before entering the room .
During a surveyor observation on 5/20/2024 at 11:58 AM revealed, Nursing Assistant, Staff F, entering Resident ID #13's room wearing a gown, gloves, and a mask, without wearing eye protection. Additionally, she was observed to be feeding the resident.
During a surveyor interview immediately following the above observation at approximately 12:13 PM with Staff F, she acknowledged that she did not apply eye protection prior to entering a COVID-19 positive room.
3. Record review revealed Resident ID #24 was admitted to the facility in October of 2022 with a diagnosis including, but not limited to, COVID-19.
Record review of a nursing progress dated 5/9/2024 states, All labs reported to [Providers Name] new orders for standard Paxlovid [ a medication used to treat COVID-19] PO [by mouth] .DOH [Department of Health] has been notified and resident is on Droplet and contact precautions.
During a surveyor observation on 5/20/2024 at 11:49 AM of the resident's room revealed a sign for droplet precautions. The sign states in part, Everyone must .Make sure their eyes, nose and mouth are fully covered before entering the room .
During a surveyor observation on 5/20/2024 at 11:49 AM of Nursing Assistant (NA) Staff E, she was observed entering Resident ID# 24's room carrying the resident's meal tray, wearing a gown, gloves and a mask below her nose, without any eye protection.
During a surveyor interview with the Director of Nursing Services on 5/21/2024 at 10:35 AM, she revealed that she would expect staff to follow proper infection control practices. Additionally, she was unable to explain why Staff E and F did not don (put on) appropriate PPE when they entered COVID-19 positive resident rooms.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0941
(Tag F0941)
Could have caused harm · This affected most or all residents
Based on record review and staff interview, it has been determined that the facility failed to ensure that all direct care staff completed mandatory effective communication training, for 3 of 3 staff ...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that all direct care staff completed mandatory effective communication training, for 3 of 3 staff reviewed, who have been employed by the facility greater than a year, Staff B, G, and H.
Findings are as follows:
Record review failed to reveal evidence that the following staff completed the mandatory effective communication training or education for 2023:
- Registered Nurse, Staff B, hired on 5/28/2019
- Nursing Assistant, Staff G, hired on 5/25/2022
- Certified Medication Technician, Staff H, hired on 10/6/2021
During a surveyor interview on 5/22/2024 at 12:01 PM, with the Director of Nursing Services, she was unable to provide evidence that the effective communication was completed for the above-mentioned staff.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0944
(Tag F0944)
Could have caused harm · This affected most or all residents
Based on record review and staff interview, it has been determined that the facility failed to provide mandatory training to all their staff, that outlines and informs staff of the elements and goals ...
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Based on record review and staff interview, it has been determined that the facility failed to provide mandatory training to all their staff, that outlines and informs staff of the elements and goals of the facility's QAPI (Quality Assurance and Performance Improvement) program, for 3 of 3 staff reviewed, who have been employed by the facility greater than a year, Staff B, G, H.
Findings are as follows:
Record review failed to reveal evidence that the following staff completed QAPI training or education for 2023:
- Registered Nurse, Staff B, hired on 5/28/2019
- Nursing Assistant, Staff G, hired on 5/25/2022
- Certified Medication Technician, Staff H, hired on 10/6/2021
During a surveyor interview on 5/22/2024 at 12:01 PM, with the Director of Nursing Services, she was unable to provide evidence that the QAPI training was completed for the above-mentioned staff.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected most or all residents
Based on record review and staff interview, it has been determined that the facility failed to provide a minimum of 12 hours per year of in-service training to ensure the continuing competence of nurs...
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Based on record review and staff interview, it has been determined that the facility failed to provide a minimum of 12 hours per year of in-service training to ensure the continuing competence of nurse aides for 2 of 2 Nurse Aides (NA) reviewed, who have been employed at the facility greater than a year, Staff G and H.
Findings are as follows:
Review of Staff G's personnel record revealed she was hired on 5/25/2022.
Review of Staff H's personnel record revealed she was hired on 10/6/2021.
Record review failed to reveal evidence that Staff G and H had a minimum of 12 hours per year of in-service training.
During a surveyor interview on 5/22/2024 at 12:01 PM with the Director of Nursing Services, during the staffing task, she indicated that the facility records attendance not hours and was unable to provide evidence that Staff G and H received the minimum of 12 hours per year of in-service training.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0949
(Tag F0949)
Could have caused harm · This affected most or all residents
Based on record review and staff interview, it has been determined that the facility failed to provide all staff with behavioral health training, for 3 of 3 staff reviewed, who have been employed by t...
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Based on record review and staff interview, it has been determined that the facility failed to provide all staff with behavioral health training, for 3 of 3 staff reviewed, who have been employed by the facility greater than a year, Staff, B, G, and H.
Findings are as follows:
Record review failed to reveal evidence that the following staff completed the mandatory behavioral health training or education for 2023:
- Registered Nurse, Staff B, hired on 5/28/2019
- Nursing Assistant, Staff G, hired on 5/25/2022
- Certified Medication Technician, Staff H, hired on 10/6/2021
During a surveyor interview on 5/22/2024 at 12:01 PM, with the Director of Nursing Services, she was unable to provide evidence that the behavioral health training was completed for the above-mentioned staff.
Apr 2023
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to develop a comprehensive person-centered care plan that includes measurable objectives and timeframes to m...
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Based on record review and staff interview, it has been determined that the facility failed to develop a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical and nursing needs for 1 of 1 resident reviewed for the use of a Baclofen pump (a small device that is placed under the skin of one side of the abdomen near the hip bone. It is used to deliver baclofen, a medication used to treat muscle spasms, directly into the spinal canal), Resident ID #7.
Findings are as follows:
According to SynchrinMed II Drug Infusion Pump SELECT WARNINGS AND PRECAUTIONS, states in part, .It is mandatory that all patients, caregivers, and treating physicians receive adequate information regarding the risks of the mode of treatment. Instruction Abrupt discontinuation of intrathecal baclofen, regardless of the cause, has resulted in sequelae that include high fever, altered mental status, exaggerated rebound spasticity, and muscle rigidity, that in rare cases has advanced to rhabdomyolysis, multiple organ-system failure and death. Prevention of abrupt discontinuation of intrathecal baclofen requires careful attention to programming and monitoring of the infusion system, refill scheduling and procedures, and pump alarms. Patients and caregivers should be advised of the importance of keeping scheduled refill visits and should be educated on the early symptoms of baclofen withdrawal. Special attention should be given to patients at apparent risk (e.g. spinal cord injuries at T-6 or above, communication difficulties, history of withdrawal symptoms from oral or intrathecal baclofen) .
Record review revealed the resident was admitted to the facility in April of 2021 with diagnoses which include, but are not limited to: multiple sclerosis (a disease that affects central nervous system. The immune system attacks the myelin sheath, the protective layer around nerve fibers and causes Inflammation and lesions. This makes it difficult for the brain to send signals to rest of the body) and chronic pain.
Record review revealed a progress note dated 4/17/2023 at 12:38 PM, which revealed the resident went out to an appointment for a routine pump refill.
Record review of the resident's care plan failed to reveal evidence that the resident had an implanted baclofen pump and how to monitor or care for the pump.
Review of a Continuity of Care form dated 4/17/2023 revealed the resident has a SynchrinMed II Drug implanted Infusion Pump.
During a surveyor interview on 4/26/2023 at 10:30 AM with Registered Nurse (RN), Staff A, she revealed the resident had a baclofen pump.
During a surveyor interview on 4/26/2023 at 3:55 PM with RN, Staff B, she was unaware the resident had a baclofen pump.
During a surveyor interview on 4/27/2023 at 12:14 PM with the resident's Physician Assistant, he revealed that the resident did not have a baclofen pump that he could recall.
During a surveyor interview on 4/27/2023 at 11:57 AM with the Director of Nursing Services she acknowledged there were no orders or care plan pertaining to the resident's baclofen pump, including symptoms of baclofen withdrawal, monitoring for alarms, or what to do if an alarm was to sound per the manufacturer's guidance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to a ...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to a baclofen pump (a small device that is placed under the skin of one side of the abdomen near the hip bone. It is used to deliver baclofen, a medication used to treat muscle spasms, directly into the spinal canal) use for 1 of 1 resident reviewed, Resident ID #7.
Findings are as followed:
According to SynchrinMed II Drug Infusion Pump SELECT WARNINGS AND PRECAUTIONS, states in part, .It is mandatory that all patients, caregivers, and treating physicians receive adequate information regarding the risks of the mode of treatment. Instruction Abrupt discontinuation of intrathecal baclofen, regardless of the cause, has resulted in sequelae that include high fever, altered mental status, exaggerated rebound spasticity, and muscle rigidity, that in rare cases has advanced to rhabdomyolysis, multiple organ-system failure and death. Prevention of abrupt discontinuation of intrathecal baclofen requires careful attention to programming and monitoring of the infusion system, refill scheduling and procedures, and pump alarms. Patients and caregivers should be advised of the importance of keeping scheduled refill visits and should be educated on the early symptoms of baclofen withdrawal. Special attention should be given to patients at apparent risk (e.g. spinal cord injuries at T-6 or above, communication difficulties, history of withdrawal symptoms from oral or intrathecal baclofen) .
Record review revealed the resident was admitted to the facility in April of 2021 with diagnoses which include, but are not limited to, multiple sclerosis (a disease that affects central nervous system. The immune system attacks the myelin, the protective layer around nerve fibers and causes Inflammation and lesions. This makes it difficult for the brain to send signals to rest of the body) and chronic pain.
Record review revealed a progress note dated 4/17/2023 at 12:38 PM which revealed the resident went out to an appointment for a routine pump refill.
Record review of the physician orders failed to reveal documentation of the pump or what the facility does relative to the management of the pump.
Review of a Continuity of Care form dated 4/17/2023 revealed the resident has a SynchrinMed II Drug Infusion Pump.
During a surveyor interview on 4/26/2023 at 10:30 AM with Registered Nurse (RN), Staff A, she revealed the resident has a baclofen pump.
During a surveyor interview on 4/26/2023 at 3:55 PM with RN, Staff B, she was unaware the resident had a baclofen pump.
During a surveyor interview on 4/27/2023 at 12:14 PM with the resident's Physician Assistant, he revealed that the resident did not have a baclofen pump that he could recall.
During a surveyor interview on 4/27/2023 at 11:57 AM with the Director of Nursing Services, she acknowledged there were no orders or care plan pertaining to the resident's baclofen pump, including symptoms of baclofen withdrawal, monitoring for alarms, or what to do if an alarm was to sound per the manufacturer's guidance.
CONCERN
(D)
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 residents maintain accepta...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status for 1 of 4 residents reviewed for weight loss, Resident ID #6.
Findings are as follows:
Record review of the State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities, reveals a weight loss of 5% or greater in 1 month is severe.
Record review of a facility policy titled, Resident weight program states in part, .If there is an increase or decrease in weight of 3lbs [pounds] from the previous week's weight, the resident will be re-weighed with a licensed nurse present to ensure accuracy. If the weight has been verified by the nurse as accurate, then the Dietitian shall be made aware of the change in weight. When a significant weight gain or loss, which is equivalent to 5% of the resident's body weight, is identified, the resident's physician and responsible party will be notified. Necessary interventions will be ordered and implemented as per the physician as it pertains to the individual resident.
Record review revealed the resident was admitted to the facility in March of 2023 with diagnoses including, but not limited to, Type 1 Diabetes, chronic pancreatitis, and major depressive disorder.
Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 15 out of 15, indicating the resident is cognitively intact.
Record review of a care plan focus area revealed s/he is at risk for an alteration in nutrition with interventions including, but not limited to; diet per physician orders, monitor and record intake, offer foods of preferences, and monitor weights as ordered.
Record review revealed a physician's order dated 3/8/2023 for weekly weights for 4 weeks then monthly for continued monitoring.
Record review of the resident's weekly weights from 3/6/2023 through 4/24/2023 revealed the following:
- 3/6/2023, 178 pounds
- 3/13/2023, 178.2 pounds
- 3/20/2023, 178.6 pounds
- 3/27/2023, 177.8 pounds
- 4/3/2023, 182 pounds
- 4/10/2023, 184 pounds
- 4/17/2023, 189.2 pounds
- 4/24/2023, 179.4 pounds
Further review of the weights revealed a 9.8 pound weight loss from 4/17/2023 through 4/24/2023, indicating a 5.1% weight loss in 1 week. Additionally, the resident had a weight variance of 5.2 pounds from 4/10/2023 through 4/17/2023.
Additional review of the record failed to reveal evidence that a reweigh was obtained for the above mentioned weights, per the facility policy.
Furthermore, the record failed to reveal evidence that the dietitian was notified for the 5.2 pound weight discrepancy and/or that the physician and dietitian was notified of the resident's severe weight loss of 5.1%.
During a surveyor interview with the Dietitian on 4/26/2023 at 1:45 PM, she revealed that she was in the facility on 4/25/2023 and was not made aware of the resident's significant weight loss. She further revealed she would expect to be notified.
During a surveyor interview with the Director of Nursing Services on 4/26/2023 at approximately 2:00 PM, she was unable to provide evidence that a re-weight was obtained or that the physician and dietitian were notified of the residents significant weight discrepancies.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
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 require dialysis (a procedure to remove waste products and excess fluids from t...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a procedure to remove waste products and excess fluids from the blood when the kidney stops working properly) receive such services, consistent with professional standards of practice, for 1 of 1 resident reviewed for dialysis pre and post weights, Resident ID #31.
Findings are as follows:
Review of a facility policy titled Dialysis Patients; Care of states in part, Procedure .6. The resident's weight will be done at the dialysis center and monitored by the SNF [skilled nursing facility] team. Weights may be obtained per facility as well if necessary .
Record review revealed the resident was admitted to the facility in September of 2021 with diagnoses including, but not limited to: chronic kidney disease, stage 4 (damage to the kidneys which can cause waste to build up in your body) and dependence on renal dialysis.
Record review revealed the resident receives hemodialysis three times per week on Tuesday, Thursday, and Saturday.
Record review revealed the following Continuity of Care (COC) forms and documentation from the dialysis center:
4/25/2023 failed to reveal a pre-dialysis weight was documented
4/8/2023 failed to reveal a pre- and post-dialysis weight was documented
3/14/2023 failed to reveal a pre-dialysis weight was documented
3/4/2023 failed to reveal a pre-dialysis weight was documented
3/2/2023 failed to reveal a pre-dialysis weight was documented
Further record review failed to reveal the above mentioned missing weights, per their policy.
Further record review failed to reveal evidence that the facility contacted the dialysis center for documentation pertaining to the resident's weights until it was brought to their attention by the surveyor.
During a surveyor interview on 4/27/2023 at 9:28 AM with the Director of Nursing Services, she was unable to provide evidence that the resident's above-mentioned pre and post dialysis weights were obtained and monitored as required until it was brought to the facility's attention by the surveyor.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
Based on record review, resident and staff interview, it has been determined that the facility failed to update their menus periodically and have them reviewed annually by a clinically qualified profe...
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Based on record review, resident and staff interview, it has been determined that the facility failed to update their menus periodically and have them reviewed annually by a clinically qualified professional.
Findings are as follows:
Record review of the facility's four- week menu cycle revealed a date of 8/17/2017. Further review of the menus revealed the dietitian last reviewed them on 10/1/2020. Additionally, the menus posted during the week of survey were the same menus that were created on 8/17/2017.
During a surveyor interview with the resident council members on 4/25/2023 at 10:00 AM, they indicated there is a lack of variety in meal choices, and the meals served are similar each week. Additionally, they revealed concerns for the meal options, questioning if they are appropriate for all diets, such as a diabetic diet.
During a surveyor interview with the Dietitian on 4/27/2023 at approximately 11:05 AM, she acknowledged that she has not reviewed or revised the menus and that the same four week menu cycle has been repeated throughout the year.
During a surveyor interview with the Cook, Staff C, on 4/27/2023 at 11:15 AM she revealed that there are no seasonal menus.
During a surveyor interview with the Food Service Director on 4/27/2023 at 11:10 AM, he was unable to provide evidence that the menus were updated periodically.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0838
(Tag F0838)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed
to complete a facility assessment 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 complete a facility assessment that identifies the care required by the resident population considering the types of disease, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population.
Findings are as follows:
Review of the facility assessment dated [DATE], revealed the Primary Admitting Diagnosis/Conditions (including behavioral health) to be documented as ALL.
Additionally, the facility assessment revealed the overall acuity on each unit was documented as ACUITY LEVELS CHANGE.
Furthermore, the facility assessment Facility Resources revealed staffing patterns to have Typical Staffing Pattern, flexed as needed.
During a surveyor interview on 4/27/2023 at 9:28 AM with the Director of Nursing Services, she revealed that the facility does not accept all diagnoses and medical conditions as documented in the facility assessment. Additionally, she acknowledged the facility assessment did not have information pertaining to the acuity, staffing, and resident diagnoses to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Rhode Island facilities.
- • 32% turnover. Below Rhode Island's 48% average. Good staff retention means consistent care.
Concerns
- • 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Cra-Mar Meadows's CMS Rating?
CMS assigns Cra-Mar Meadows 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 Cra-Mar Meadows Staffed?
CMS rates Cra-Mar Meadows's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 32%, compared to the Rhode Island average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Cra-Mar Meadows?
State health inspectors documented 33 deficiencies at Cra-Mar Meadows during 2023 to 2025. These included: 32 with potential for harm and 1 minor or isolated issues.
Who Owns and Operates Cra-Mar Meadows?
Cra-Mar Meadows is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 41 certified beds and approximately 35 residents (about 85% occupancy), it is a smaller facility located in Cranston, Rhode Island.
How Does Cra-Mar Meadows Compare to Other Rhode Island Nursing Homes?
Compared to the 100 nursing homes in Rhode Island, Cra-Mar Meadows's overall rating (3 stars) is below the state average of 3.1, staff turnover (32%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Cra-Mar Meadows?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Cra-Mar Meadows Safe?
Based on CMS inspection data, Cra-Mar Meadows has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Rhode Island. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Cra-Mar Meadows Stick Around?
Cra-Mar Meadows has a staff turnover rate of 32%, 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 Cra-Mar Meadows Ever Fined?
Cra-Mar Meadows has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Cra-Mar Meadows on Any Federal Watch List?
Cra-Mar Meadows 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.