Grandview Center
For profit - Corporation
72 Beds
GENESIS HEALTHCARE
Data: November 2025
Trust Grade
53/100
#39 of 72 in RI
Photo by Grandview Center
Photo by Grandview Center
Photo by Grandview Center
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Last Inspection: August 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Grandview Center in Cumberland, Rhode Island, has a Trust Grade of C, indicating it's average-neither great nor terrible. It ranks #39 out of 72 nursing homes in the state, placing it in the bottom half, and #21 out of 41 in Providence County, meaning there are only a few local options that are better. The facility is improving, having reduced issues from 10 in 2024 to just 2 in 2025. Staffing is a strength, with a 4 out of 5 rating and a turnover rate of 35%, which is lower than the state average, suggesting staff are stable and familiar with residents. However, there are some concerns: they received $17,651 in fines, indicating compliance issues, and there were serious incidents, such as a diabetic resident receiving insulin when their blood sugar was critically low, and issues with food safety standards, including improperly stored food and meals served at unsafe temperatures. Overall, while there are positives in staffing and improvement trends, potential residents and their families should be aware of these serious concerns.
- Trust Score
- C
- In Rhode Island
- #39/72
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 35% turnover. Near Rhode Island's 48% average. Typical for the industry.
- Penalties ✓ Good
- $17,651 in fines. Lower than most Rhode Island facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 67 minutes of Registered Nurse (RN) attention daily — more than 97% of Rhode Island nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 30 deficiencies on record. Higher than average. Multiple issues found across inspections.
53/100
Bottom 46%
Needs review
10 → 2 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 10 issues
2025: 2 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 (35%)
13 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: 35%
11pts below Rhode Island avg (46%)
Typical for the industry
Federal Fines: $17,651
Below median ($33,413)
Minor penalties assessed
Chain: GENESIS HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 30 deficiencies on record
1 actual harm
Sept 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0627
(Tag F0627)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who are app...
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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 who are appealing a discharge from the facility remain or return to the facility pending their appeal for 1 of 1 resident reviewed, Resident ID #2.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 8/4/2025, alleged that Resident ID #2 was admitted to the hospital, but Grandview would not accept the resident back. The complainant stated, I have no ramp here and no one to help me. Furthermore, the complaint alleges that an appeal was filed for an eviction notice issued on July 18th to The Executive Office of Health and Human Services, and the family was under the impression that the facility could not discharge the resident while in an active appeal. The complainant alleged that the family did not have the appropriate time to resolve the resident's Medicaid issues because it had only just been cancelled on July 9th. The resident and family were seeking legal counsel as well as trying to manage the resident's extensive medical issues.Record review revealed that Resident ID #2 was readmitted to the facility in July of 2025 with diagnoses including, but not limited to, end stage renal disease and dependence on renal dialysis (a process where a machine filters waste from the blood three times a week).Further record review revealed the resident required routine dressing changes to a right transmetatarsal amputation (removal of all or part of the forefoot) site and other diabetic ulcers.Record review revealed a recertification form dated 7/15/2025, for Resident ID #2, which states, I certify that post-hospital SNF [skilled nursing facility] care is required on behalf of the above named patient that, as a practical matter can only be provided in a SNF. The SNF care is needed on a daily basis for Skilled Rehab.Skilled Nursing.Teaching and Training.Observation & Assessment.Management & Evaluation.I estimate the additional period of SNF care will be 30 days. signed by the provider on 7/15/2025. Record review revealed a document titled [NAME] ISLAND DEPARTMENT OF HUMAN SERVICES PRE-TRANSFER OR PRE-DISCHARGE 30 DAY NOTICE dated 7/18/2025, revealed the resident was notified that s/he would be discharged from the facility in 30 days due to not having an active payer. Additionally, the document stated the resident had the right to appeal this discharge.Review of a document titled [NAME] ISLAND DEPARTMENT OF HUMAN SERVICES REQUEST FOR A HEARING revealed that on 7/28/2025 the resident was requesting an appeal of the discharge.Record review revealed the resident was discharged and admitted to an acute care hospital on 7/29/2025.Review of the hospital documentation dated 8/2/2025, revealed that the family wanted to be contacted as the family felt they could not care for Resident ID #2 at home and is requesting long term placement. The family voiced the inability to care for the resident at home as the resident needs more care than the family can provide. The family stated there are stairs to enter the home and the resident requires wheelchair at this time, and needs time for ramps to be installed. Further review of the hospital documentation revealed the resident was sent home from the hospital with his/her family on 8/6/2025.Review of the facility census on 9/9/2025 failed to reveal evidence that Resident ID #2 returned to the facility while appealing his/her discharge.During a surveyor interview with the Administrator on 9/9/2025 at 10:11 AM, she revealed that the resident was presented with a 30-day notice of discharge on [DATE] due to not having an active payor. Additionally, she acknowledged that the resident submitted an appeal of the discharge. Furthermore, she acknowledged that the resident was sent to the hospital on 7/29/2025 and did not return to the facility despite being in an active appeal of the resident's discharge. She was unable to provide evidence that the resident's right to return to the facility pending an appeal of the discharge was provided.
May 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on 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 ...
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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 the use of borrowed medications and inaccurately documenting in the narcotic count book for 2 of 2 residents reviewed, Resident ID #s 2 and 3.
Findings are as follows:
Review of a facility reported incident submitted to the Rhode Island Department of Health on 2/10/2025, revealed, Resident ID #3 was on hospice and received an order for Lorazepam Intensol 2 milligram (mg)/milliliter (ml) 0.25 ml every four hours and 0.25 ml every hour as needed. Resident ID #3 was presenting with symptoms, and the pharmacy was unable to deliver the Lorazepam Intensol, due to the medication being on back order. Resident ID #2 had an unused bottle of Lorazepam Intensol that was borrowed by the nurses to administer to Resident ID #3.
a. Record review revealed Resident ID #3 was admitted to the facility in January of 2025 with diagnoses including but not limited to, a malignant neoplasm (a cancerous tumor) of the bronchus and a secondary malignant neoplasm of the digestive organs.
Record review of a hospice visit dated 2/2/2025 for Resident ID #3 revealed a recommendation for Lorazepam 2mg/ml give 0.5mg (0.25ml) sublingually (under the tongue) every 4 hours, as needed for restlessness.
Record review of a progress note dated 2/3/2025 at 1:22 PM, revealed that the hospice recommendations were reviewed with and approved by the physician.
Record review revealed the following physician's orders dated 2/3/2025 for Resident ID #3:
-Lorazepam 2mg/ml inject 0.5 mg (0.25 ml) every 4 hours subcutaneously (under the skin) for restless/anxiety, not sublingually as recommended by the hospice provider and approved by the physician
-Lorazepam 2mg/ml inject 0.25 ml subcutaneously every hour as needed for restless/anxiety, not sublingually as recommended by the hospice provider and approved by the physician.
Record review of the Narcotic book documentation revealed the following:
Resident ID #2 had 30 ml of Lorazepam Intensol 2mg/ml delivered by the pharmacy on 9/20/2024. On the bottom of the page, it was written that the medication was transferred to the North team 2 Narcotic book on 2/3/2025.
Resident ID #3 had 15 mls of Lorazepam Intensol entered into the book on 2/3/2025 for administration. Additional review failed to reveal evidence that 30 mls Lorazepam Intensol was transferred to Resident ID #3 from Resident ID #2 or if it was received from the pharmacy.
During a surveyor interview on 5/7/2025 at approximately 1:15 PM, with Registered Nurse, Staff A, she revealed that she transcribed 15 mls in error for the Lorazepam, as it was 30 mls of medication that was received from Resident ID #2.
b. Record review of a facility policy titled, Medication Administration dated 1/2025, reveals in part, .Medications supplied for one resident are never administered to another resident .
Record review of Resident ID #3's February 2025 Medication Administration Record revealed s/he received Resident ID #2's Lorazepam Intensol on the following dates and times:
2/3/2025 at 10:45 AM
2/3/2025 at 5:00 PM
2/3/2025 at 7:50 PM
2/3/2025 at 9:18 PM
2/4/2025 at 1:00 AM
2/4/2025 at 5:00 AM
During a surveyor interview on 5/7/2025 at approximately 1:15 PM, with Staff A, she revealed that hospice had recommended that Resident ID #3 start on Lorazepam due to increased anxiety. Staff A, acknowledged that the physician's order should have been entered as sublingual. She further stated that the pharmacy was unable to fill the order, so she borrowed Resident ID #2's bottle of Lorazepam, that was unopened and not being used, for administration to Resident ID #3. She revealed that the Lorazepam was transferred from Resident ID #2 to Resident ID #3 in the Narcotic book, and it was being administered to Resident ID #3 sublingually.
During a surveyor interview on 5/7/2025 at 3:15 PM with the Staff Educator, Staff B, she acknowledged that Resident ID #2's medication should not have been borrowed for Resident ID #3, and that the Narcotic book documentation was inaccurate and incomplete. Additionally, she acknowledged that the Lorazepam order was entered as subcutaneous and should have been entered as sublingual.
Aug 2024
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
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 provide an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide an ongoing program to support a resident in their choice of activities designed to meet the interests of and support the well-being of each resident, based on the comprehensive assessment, care plan and preferences for 1 of 1 resident reviewed for activities who is non English speaking, Resident ID #27.
Findings are as follows:
Record review revealed the resident was re-admitted to the facility in October of 2020 with diagnoses including, but not limited to, major depressive disorder, adjustment disorder, and dementia with agitation.
Review of a Minimum Data Set (MDS) assessment dated [DATE], revealed the resident is dependent on staff for all care needs.
Review of a care plan dated 4/27/2023, revealed the resident expresses interest in leisure activities with interventions including, but not limited to, providing the resident with magazines, books, materials related to Europe/[NAME]/Spain, Portuguese recipes, spirituality, and to highlight opportunities to participate in music. Further review revealed a care plan dated 11/15/2023, which states in part, the resident .will have opportunities to make decisions/choices .for self-directed involvement in meaningful activities .Encourage and facilitate .activity preferences by offering the chronicle in Spanish/Portuguese, pet visits and spirituality .
During surveyor observations on multiple occasions of group activities being conducted from 7/29/2024 through 8/1/2024, this resident was not in attendance.
During the following surveyor observations, the resident was awake in his/her room, without a T.V., radio, reading material, or any other activitt:
-7/29/2024 at 10:05 AM
-7/30/2024 at 11:38 AM
-7/31/2024 at 9:03 AM
- 8/1/2024 at 8:45 AM
During a surveyor interview on 8/1/2024 at 8:45 AM with Licensed Practical Nurse, Staff A, she acknowledged that the resident did not have any activities provided at that time and that there was not a T.V., radio, or reading material in his/her room. Additionally, she was unaware of the resident's activity preferences or if any activities were regularly provided to the resident.
During a surveyor interview on 8/1/2024 at 9:17 AM with the Recreational Director she indicated that the resident enjoys singing and praying. Additionally, she acknowledged that activities had not been provided to the resident in accordance with the plan of care.
During a surveyor interview on 8/1/2024 at 10:34 AM with the Director of Nursing Services, she indicated that she was unaware that the resident did not have a T.V., radio, or reading materials in his/her room. Additionally, she indicated that she would expect activities to be provided to the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, resident and staff interviews, it has been determined that the facility failed to provide adequate supervision to prevent an accident hazard for 1 of 1 re...
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Based on surveyor observation, record review, resident and staff interviews, it has been determined that the facility failed to provide adequate supervision to prevent an accident hazard for 1 of 1 resident reviewed who requires the assistance of two staff for transfers with a gait belt, Resident ID #9.
Findings are as follows:
Record review revealed the resident was originally admitted to the facility in April of 2019, with diagnoses including, but not limited to, hemiplegia and hemiparesis following a cerebral infarction (paralysis and weakness to one side of the body following a stroke), unsteadiness on the feet, and abnormality of gait (walking) and mobility.
Record review of the Minimum Data Set (MDS), Optional State Assessment, dated 6/23/2024, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident is cognitively intact. Additionally, the MDS revealed that the resident required extensive assistance of 2 people with transfers.
Review of a care plan dated 8/15/2019 revealed the resident is at risk for the decreased ability to perform activities of daily living (ADLs) including transfers. Further review revealed an intervention dated 10/23/2023 that the resident required 2 people for all transfers with a gait belt every shift to prevent falls due to weakness.
Record review revealed a physician's order dated 10/29/2023 that the resident requires two staff members to transfer with a gait belt every shift to prevent falls due to weakness.
During a surveyor interview on 7/29/2024 at 11:02 AM with the resident, s/he indicated that s/he requires the assistance of 2 staff members to transfer out of bed, however, s/he often feels unsafe because they frequently transfer him/her with only 1 staff member.
During a surveyor observation on 8/1/2024 at 10:06 AM, a Nursing Assistant (NA), Staff D, transferred the resident out of bed and into a wheelchair without the assistance of a second staff member.
During a surveyor interview on 8/1/2024 at 10:15 AM with NA, Staff D, she acknowledged that she transferred the resident by herself. Additionally, she indicated that the resident only requires the assistance of 2 staff members sometimes if s/he is weak and that she frequently transfers the resident by herself, including the day before.
During a surveyor interview on 8/1/2024 at 10:19 AM with Licensed Practical Nurse, Staff A, she indicated that the resident is transferred with the assistance of only 1 staff member at times. Additionally, she acknowledged that the resident has an active care plan and physician's order in place for the assistance of 2 staff members for transfers.
During a surveyor interview on 8/1/2024 at 10:32 AM with the Director of Nursing Services, she indicated that the resident should be transferred with the assistance of 2 staff members as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
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 are trauma survivors receive trauma informed care in accordance with profession...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors receive trauma informed care in accordance with professional standards of practice and accounting for the resident's experiences and preferences for 1 of 1 resident reviewed with post-traumatic stress disorder (PTSD, a health condition triggered by a terrifying event causing flashbacks and nightmares), Resident ID #54.
Findings are as follows:
Record review revealed the resident was admitted to the facility in February of 2024, with diagnoses including, but not limited to, PTSD and anxiety disorder.
Review of the care plan dated 4/9/2024, revealed the resident has a diagnosis of a mood disorder related to PTSD. Further review revealed the resident .will be appropriately evaluated and re-evaluated for specialized services as needed and per state requirements .will receive appropriate specialized services to attain or maintain [his/her] highest practicable psychological, physical, functional, and psychosocial well-being . Additional review revealed the resident exhibits, or is at risk for, distressed or fluctuating mood symptoms related to a psychiatric mood disorder.
Record review failed to reveal evidence that a Trauma Informed Care evaluation was completed to identify triggers related to PTSD.
During a surveyor interview on 8/1/2024 at 10:42 AM with the Director of Nursing Services and the Lead Clinical Specialist, they were unable to provide evidence that a trauma informed care assessment had been completed since the resident was admitted to the facility. Additionally, they acknowledged that an assessment needs to be completed to identify triggers for PTSD.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide special adaptive eating equipment and utensils for a resident who requires...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide special adaptive eating equipment and utensils for a resident who requires a divided lip plate, Resident ID #9.
Findings are as follows:
Record review revealed the resident was admitted to the facility in April of 2019 with diagnoses including, but are not limited to, hemiplegia (paralysis of partial or total body function), hemiparesis (one sided weakness following a stroke), and muscle weakness.
Record review revealed a care plan dated 8/15/2019 indicating the resident has a self-care performance deficit related to having a one sided weakness with interventions including, but not limited to, maintaining the highest capable level of his/her self-care and the use of a divided lip plate and built-up utensils for self-feeding.
Record review of the diet slip revealed the resident was to be provided with a divided lip plate for all meals.
During surveyor observations on the following dates and times, the resident was observed without a divided lip plate at meals:
-7/30/2024 at 8:31 AM
-7/31/2024 at 8:42 AM
-7/31/2024 at 12:05 PM
During a surveyor interview on 7/31/2024 at 12:11 PM with Nursing Assistant, Staff E, she indicated that she was unaware that the resident should be provided with a divided lip plate and that she had not observed the resident's meals served on a divided lip plate in the past.
During a surveyor interview on 7/31/2024 at 12:13 PM with Licensed Practical Nurse, Staff A, she acknowledged that the resident should be provided with a divided lip plate as indicated on the diet slip.
During a surveyor interview on 7/31/2024 at 12:19 PM with the Director of Nursing Services, she indicated that she would expect that the resident would be provided with a divided lip plate for all meals.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, staff and resident interviews, it has been determined that the facility failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, staff and resident interviews, it has been determined that the facility failed to treat each resident with respect and dignity and relative to providing assistance to residents who require supervision and/or one-to-one assistance with eating for 3 of 4 residents reviewed, Residents ID #s 16, 54 and 60.
Findings are as follows:
1. Record review revealed that Resident ID #16 was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, osteoarthritis, anemia, and generalized muscle weakness.
Record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident's cognition is intact.
Record review of a progress note dated 7/16/2024 revealed a hospice recommendation for one-to-one feeding assistance for all meals related to bilateral hand contractures.
Review of a physician's order dated 7/30/2024 revealed one-to-one feeding assistance for all meals.
During a surveyor observation on 7/30/2024 at 8:40 AM, the resident was observed with his/her breakfast tray in front of him/her without receiving one-to-one feeding assistance. Further, s/he was observed palpating around the plate with his/her right hand attempting to find the food on the plate. Additionally, at 8:55 AM, s/he was observed picking up scrambled eggs with his/her hand. A staff member entered the resident's room to provide assistance with eating at 9:03 AM, 23 minutes after the resident had his/her meal tray in front of him/her.
During a surveyor observation on 7/31/2024 at approximately 8:40 AM, Resident ID #16 was observed to be eating his/her breakfast without assistance. Additionally, s/he was observed to be palpating around the plate multiple times with his/her right hand before picking up the food. A staff member entered the resident's room to provide assistance with eating at 9:02 AM, 22 minutes after the resident had his/her meal tray in front of him/her.
During a surveyor observation on 7/31/2024 at 12:20 PM, the resident was observed feeding him/herself lunch and palpating around the plate before finding a piece of pizza. A staff member entered the resident's room to provide assistance with eating at 12:38 PM, 18 minutes after the resident had his/her meal tray in front of him/her.
During a surveyor interview on 7/31/2024 at 12:53 AM with Physical Therapy Assistant, Staff H, she indicated that the resident requires one-to-one staff assistance because s/he can't see.
During a surveyor interview on 7/31/2024 at approximately 1:35 PM with the resident, s/he revealed that s/he can't see what is on the meal tray and needs staff to help him/her.
2. Record review revealed that Resident ID #54 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, anxiety disorder and mood disorder.
Record review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 out of 15, indicating the resident's cognition is intact. Further review revealed the resident requires assistance with eating.
Review of a physician's order dated 7/2/2024 revealed the resident requires one-to-one assistance with eating for all meals related to weight loss.
During a surveyor observation on 8/1/2024 at 8:51 AM, Resident ID #54 was observed with his/her meal tray in front of him/her with the covers still on the food and drinks. A staff member entered the resident's room to provide assistance with eating at 9:05 AM, 14 minutes after the resident had his/her meal tray in front of him/her.
During a surveyor interview on 8/1/2024 at 9:11 AM with Licensed Practical Nurse (LPN), Staff A, she indicated that staff usually deliver the meal trays to the residents who require assistance with eating, leave them in the room and go back sometime later when the staff have time to assist the residents.
3. Record review revealed that Resident ID #60 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, abnormal weight loss, dementia, and generalized muscle weakness.
Record review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 0 out of 15, indicating severe cognitive impairment. Further review revealed the resident requires extensive assistance for eating.
Review of a physician's order dated 5/10/2024 indicates that the resident requires supervision for all meals.
During a surveyor observation on 7/30/2024 at 8:24 AM, Resident ID #60 was observed with his/her breakfast tray in front of him/her untouched. Additional observations revealed the resident was staring at the tray and falling asleep on and off until approximately 8:40 AM.
During a surveyor observation on 7/31/2024 at 8:27 AM, the resident was observed with his/her breakfast tray in front of him/her. Further observation revealed that the plate was opened and untouched with no staff members around.
During a surveyor observation on 8/1/2024 at 8:33 AM, the resident's breakfast tray was observed in front of him/her, opened but untouched with no staff members around to supervise him/her as ordered. Further observations revealed the resident was looking at the plate but was not eating. At 8:59 AM, approximately 25 minutes after the resident was observed with his/her tray unattended, a staff member was observed entering the room.
During a surveyor interview on 8/1/2024 at 11:20 AM with the Director of Nursing Services, she indicated that she was unaware that residents were not receiving assistance with meals as ordered in a timely manner. She further stated that the food should be kept in the warmer until they are ready to assist the resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to monitor and assess as outlined by the comprehensive care plan to meet professional...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to monitor and assess as outlined by the comprehensive care plan to meet professional standards of quality related to anticoagulant therapy (blood thinner) for 4 of 6 residents reviewed, Resident ID #s 9, 10, 41, and 373.
Findings are as follows:
1. Record review revealed Resident ID #9 was readmitted to the facility in August of 2023 with a diagnosis including, but not limited to, atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to a stroke or other serious complications).
Record review revealed a physician's order dated 8/7/2023 for Eliquis (a blood thinner that prevents or reduces the coagulation of blood, prolonging the clotting time) 5 milligrams (mg) by mouth two times a day.
Review of the care plan last revised on 7/8/2024, states in part, .at risk for injury or complications related to the use of anticoagulation therapy . interventions include, but are not limited to, monitor for signs and symptoms of bleeding.
Record review failed to reveal evidence that the resident was being monitored for signs and symptoms of bleeding related to the use of anticoagulation therapy as outlined by the comprehensive care plan.
2. Record review revealed Resident ID #10 was admitted to the facility in May of 2023 with a diagnosis including, but not limited to, atrial fibrillation.
Record review revealed a physician's order dated 7/29/2024 for Coumadin (blood thinner) 4.5 mg by mouth in the evening for atrial fibrillation.
Review of the resident's care plan last revised on 6/3/2024, states in part, .is at risk for injury or complications related to the use of anticoagulation therapy . Interventions include, but are not limited to, monitor for signs and symptoms of bleeding.
Record review failed to reveal evidence that the resident was being monitored for signs and symptoms of bleeding related to the use of anticoagulation therapy as outlined by the comprehensive care plan.
During an interview with Licensed Practical Nurse (LPN), Staff A, on 7/31/2024 at 8:53 AM, she revealed that the nurse should monitor for bleeding and bruising for residents that are on anticoagulation therapy. Additionally, she indicated that she would expect a physician's order to be in place to monitor residents for signs and symptoms of bleeding. Furthermore, she acknowledged that there was not an order in place to monitor for signs and symptoms of bleeding for Resident ID #s 9 and 10.
3. Record review revealed Resident ID #41 was readmitted to the facility in June of 2024 with a diagnosis including, but not limited to, atrial fibrillation.
Record review revealed a physician's order dated 5/23/2024 for Eliquis 5 mg by mouth two times a day for atrial fibrillation.
Review of the resident's care plan last revised on 6/19/2024, states in part, .is at risk for injury or complications related to the use of anticoagulation therapy . Interventions include, but are not limited to, monitor for signs and symptoms of bleeding.
Record review failed to reveal evidence that the resident was being monitored for signs and symptoms of bleeding related to the use of anticoagulation therapy as outlined by the comprehensive care plan.
4. Record review revealed Resident ID #373 was admitted to the facility in July of 2024 with a diagnosis including, but not limited to, history of venous thrombosis and embolism (a blood clot that blocks the flow of blood through your veins or that can travel through the veins to the lungs).
Record review revealed a physician's order dated 7/20/2024 for Xarelto (blood thinner) 20 mg by mouth in the evening.
Review of the resident's care plan initiated on 7/21/2024, states in part, .is at risk for injury or complications related to the use of anticoagulation therapy . Interventions include, but are not limited to, monitor for signs and symptoms of bleeding.
Record review failed to reveal evidence that the resident was being monitored for signs and symptoms of bleeding related to the use of anticoagulation therapy as outlined by the comprehensive care plan.
During a surveyor interview with LPN, Staff B on 7/31/2024 at 10:19 AM, she was unable to provide evidence that Resident ID's 41 and 373 were being monitored related to the use of anticoagulation therapy.
During a surveyor interview with the Lead Clinical Specialist, and in the presence of the Director of Nursing Services (DNS) on 7/31/2024 at 11:35 AM, he revealed that for residents receiving anticoagulant therapy the expectation would be that the nurse would monitor for signs and symptoms of bleeding. He further explained that the order would be generated to the treatment administration record (TAR) from the care plan and nurses would sign as completed. He further acknowledged that there was no order in place to monitor residents for signs and symptoms of bruising and bleeding.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, staff and resident representative interviews, it has been determined that the facility failed to ensure that a resident receives proper treatment to maint...
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Based on surveyor observation, record review, staff and resident representative interviews, it has been determined that the facility failed to ensure that a resident receives proper treatment to maintain hearing abilities for 1 of 1 resident reviewed for hearing concerns, Resident ID #10.
Findings are as follows:
Record review revealed the resident was admitted to the facility in May of 2023 with diagnoses including, but not limited to, diabetes mellitus type 2 and chronic obstructive pulmonary disease.
Record review of a care plan dated 6/1/2023 revealed the resident has impaired communication as evidenced by being hard of hearing. Further record review revealed an intervention for an ears, nose, and throat (ENT) specialist or audiologist (a health-care professional who evaluates, diagnoses, treats, and manages hearing loss) consult to evaluate new hearing loss or progression of deteriorating hearing loss.
During a surveyor interview on 7/30/2024 at 1:32 PM with the resident's family member, s/he indicated that the resident has difficulty hearing and increased hearing loss which causes the resident frustration. S/he further indicated that the resident had an appointment for ear wax removal in November of 2023, however, the appointment was cancelled and the facility had not followed up.
Record review of the progress notes revealed the resident's family member was concerned with the resident's difficulty hearing in September of 2023. Further review revealed an appointment was scheduled for ear wax removal on 11/16/2023. Additional review revealed that appointment was cancelled and had not been rescheduled.
During the following surveyor observations, the resident had difficulty hearing the surveyor as evidenced by the resident pointing and cupping his/her ears:
-7/29/2024 at 10:50 AM
-7/30/2024 at 1:32 PM
-7/31/2024 at 9:36 AM
During a surveyor interview on 7/31/2024 at 9:40 AM with Licensed Practical Nurse, Staff A, she acknowledged that the resident has difficulty hearing and indicated that an appointment was made for ear wax removal and cancelled in November of 2023. She could not provide evidence that any follow up or additional interventions were put into place after the appointment had been cancelled.
During a surveyor interview on 7/31/2024 at 9:43 AM with the Director of Nursing Services, she indicated that she would expect the facility to follow up with the resident's hearing loss. Additionally, she could not provide evidence that any interventions had been put into place since the appointment had been cancelled in November of 2023.
During a surveyor interview on 7/31/2024 at 10:06 AM with Nurse Practitioner, Staff C, he indicated that he would expect the resident's hearing difficulty to be addressed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 2 ...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 3 residents reviewed for oxygen use, Resident ID #s 5 and 10.
Findings are as follows:
1. Record review revealed that Resident ID #5 was admitted to the facility in November of 2022 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and chronic respiratory failure with acute exacerbation.
Record review revealed a physician's order dated 5/25/2024 for oxygen at 2 liters/minute (L/M) via nasal cannula. Change oxygen tubing weekly and label each component with date and initials.
During surveyor observations on the following dates and times failed to reveal evidence that the resident's oxygen tubing was labeled with a date:
- 7/29/2024 10:29 AM
- 7/31/2024 1:48 PM
During a surveyor interview with Licensed Practical Nurse (LPN), Staff A, on 7/31/2024 at 1:50 PM, she acknowledged that the above resident's oxygen tubing was not dated per the facility policy.
2. Record review revealed that Resident ID #10 was admitted to the facility in May of 2023 with a diagnosis including, but not limited to, chronic obstructive pulmonary disease.
Record review revealed a physician's order dated 5/11/2023 for oxygen at 2 L/M via nasal cannula at bedtime for comfort and remove per schedule. Change oxygen tubing weekly and label each component with date and initials.
During surveyor observations on the following dates and times failed to reveal evidence that the resident's oxygen tubing was labeled with a date:
- 7/29/2024 at 10:50 AM
- 7/30/2024 at 8:38 AM
- 7/31/2024 at 9:02 AM
- 7/31/2024 at 1:40 PM
During a surveyor observation on 7/31/2024 at 1:40 PM, the resident's prongs on the nasal cannula were observed to be discolored and yellow. Further observation revealed the oxygen tubing bag was dated 5/28 and 6/30.
During a surveyor interview on 7/31/2024 at 1:41 PM with Staff A, she acknowledged that the Resident ID #10's oxygen tubing was not dated, that the prongs on the nasal cannula were discolored, and the tubing bag was dated 5/28 and 6/30.
During a surveyor interview on 7/31/2024 at 2:00 PM with the Director of Nursing Services, she revealed that the oxygen tubing should be changed every Thursday and should be dated.
Cross reference F 867
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed relativ...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed relative to medication administration with parameters, Resident ID #20.
Findings are as follows:
Record review revealed the resident was readmitted to the facility in November of 2023 with diagnoses including, but not limited to, hypertension (high blood pressure), heart murmur (abnormal heart sound), and dementia.
Record review revealed a physician's order dated 11/27/2019 for Losartan potassium 25 milligrams (mg) by mouth daily for hypertension. Hold for systolic blood pressure (the pressure in the arteries when the heart beats and pumps blood out, the top number of a standard blood pressure reading) less than 110.
Record review revealed a pharmacy consultation report dated 3/18/2024 through 4/1/2024, which indicated the importance of holding the medication within the parameters ordered. Additionally, the document revealed that staff were educated related to the medication parameters as of 4/2/2024.
Record review of the resident's May, June, and July 2024 Medication Administration Records revealed that the medication was administered when the systolic blood pressure was less than 110:
- 5 of 31 opportunities in May of 2024
- 6 of 30 opportunities in June of 2024
- 9 of 30 opportunities in July of 2024
During a surveyor interview on 7/31/2024 at approximately 11:30 AM with the Director of Nursing Services, she acknowledged that the medication had been administered outside of the ordered parameters.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review and staff interview, it has been determined that the facility has failed to measure success and track performance of Quality Assurance and Performance Impr...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility has failed to measure success and track performance of Quality Assurance and Performance Improvement (QAPI) actions to ensure that improvements are realized and sustained relative to changing and dating oxygen tubing.
Findings are as follows:
Record review of the QAPI plan and meeting minutes from January 2024 to July 2024 revealed changing and dating oxygen tubing per facility policy was a problem area that required improvement.
Record review of a facility document titled, Oxygen Audit with a start date of 1/18/2024, states in part, .oxygen tubing and filters changed on Thursdays per policy .
During surveyor observations from 7/29/2024 through 7/31/2024, it was revealed that 2 of 3 residents reviewed for oxygen therapy had oxygen tubing that had not been dated as ordered and were not identified by the QA process or ongoing audits.
During a surveyor interview on 8/1/2024 at 10:45 AM with Lead Clinical Specialist he could not provide evidence that the facility successfully implemented a program for monitoring and evaluating oxygen orders.
Cross reference F 695
Aug 2023
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to develop and implement a baseline ...
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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 develop and implement a baseline care plan within 48 hours of admission, for identified communication concerns and instructions needed to provide effective and person-centered care, for 1 of 1 residents reviewed for baseline care plans, Resident ID #62.
Findings are as follows:
Record review revealed the resident was admitted to the facility in July of 2023 following a hospitalization related to a pathological (caused by a physical disease) fracture of the left femur (thigh).
Record review of the Minimum Data Set (MDS) dated [DATE] revealed, s/he was assessed as needing or wanting an interpreter to communicate with a doctor or healthcare staff member. His/her preferred language is Creole.
Record review of the baseline care plan initiated on July 21, 2023 failed to reveal evidence that a care plan was developed to assist the resident with communication to a doctor or a healthcare staff member.
During a surveyor observation and interview with the resident on 8/1/2023 at approximately 12:55 PM, s/he was speaking Creole when interviewed. The interview was being interpreted by the resident's family member.
During a surveyor interview on 8/4/2023 at approximately 8:45 AM with Licensed Practical Nurse, Staff A, she revealed the resident only speaks Creole.
During a surveyor interview on 8/4/2023 at approximately 9:55 AM with the Director of Nursing Services, he acknowledged the resident speaks Creole and was unable to provide evidence that a baseline care plan was developed for communication.
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 p...
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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 physician's orders for 1 of 4 residents reviewed for supplemental oxygen use, Resident ID #12.
Findings are as follows:
Mosby's 4th Edition, Fundamentals of Nursing, page 314 states: The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
Record review revealed the resident was readmitted to the facility in October of 2022 with diagnoses including, but not limited to, asthma and dependence on supplemental oxygen.
Record review revealed a physician's order dated 10/24/2022 for oxygen at 2 liters per minute via nasal cannula (medical device to provide supplemental oxygen therapy) to be used continuously.
Review of the care plan revealed the resident is at risk for respiratory complications related to congestive heart failure with an intervention including, but not limited to, oxygen as ordered.
During surveyor observations the resident was observed without oxygen being used on the following dates and times:
- 8/1/2023 at 10:24 AM
- 8/1/2023 at 11:59 AM
- 8/2/2023 at 9:49 AM
- 8/2/2023 at 2:27 PM
During a surveyor interview on 8/2/2023 at approximately 2:30 PM with Registered Nurse, Staff B, she acknowledged that the resident was not using oxygen continuously, as ordered.
During a surveyor interview on 8/2/2023 at approximately 2:40 PM with the Director of Nursing Services and the Administrator, they were unable to provide evidence that the oxygen order was followed.
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 ensure that residents receive treatment and care in accordance with professional standards of practice, f...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, for 1 of 1 residents reviewed for an orthopedic follow up, Resident ID #62.
Findings are as follows:
Review of a facility provided policy titled, Transportation and Escort: Patient dated 9/1/2022 states in part, Centers will arrange for ambulance and other appropriate transportation services to provide transportation of patients/residents .for scheduled appointments as well as emergencies .
Record review revealed the resident was admitted to the facility in July of 2023 following a hospitalization related to a pathological (caused by a physical disease) fracture of the left femur (thigh).
Record review of the resident's After Visit Summary dated 7/20/2023 revealed the resident was scheduled to have a post operative follow-up visit on 8/1/2023 at 11:45 AM for his/her left femur fracture.
Record review of the progress notes dated 7/20/2023 through 8/1/2023 revealed documentation of the facility's awareness of the resident's scheduled appointment on 8/1/2023.
Record review failed to reveal evidence that the resident attended his/her post operative appointment on 8/1/2023 or that transportation was set up for the resident to attend the post operative appointment.
During a surveyor interview on 8/2/2023 at 12:48 PM with Registered Nurse, Staff C, she acknowledged that the resident had an appointment for 8/1/2023. Additionally, she was unable to provide evidence the resident attended the appointment.
During a surveyor interview on 8/4/2023 at 10:30 AM with the Director of Nursing Services, he acknowledged that the resident had a follow-up appointment with orthopedics following a femur fracture. Additionally, he was unable to provide evidence that the resident was scheduled with transportation to his/her follow-up appointment on 8/1/2023. Furthermore, he was unable to provide evidence that the facility was aware that the resident missed his/her scheduled orthopedic appointment until it was brought to their attention by the surveyor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents with pressure ulcers receive necessary treatment and service...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 7 residents reviewed relative to pressure ulcers, Resident ID #59.
Findings are as follows:
Record review revealed that the resident was admitted to the facility in July 2023 with a diagnosis including, but is not limited to, osteoporosis (condition that weakens your bones) with current pathological fracture, right femur (thigh).
Review of the care plan revealed the resident is at risk for skin breakdown with an intervention that includes, but is not limited to, pressure redistribution surface to bed- PROmatt plus [air mattress, positioning device].
Record review of a physician's order dated 7/18/2023 states, Pressure redistribution surface to bed- Promatt Plus.
Review of a document titled Wound Management on 7/24/2023 and 7/31/2023 for an unstageable wound (pressure ulcer which the base of the wound is covered by slough: debris that appears tan, yellow, green, or brown in color or eschar: hard plaque that's tan, brown, or black in color) on his/her sacrum (coccyx) with a recommendation for a specialty mattress for pressure relief. Further record review revealed on 7/31/2023 the wound status is not improved.
A surveyor observation on 8/3/2023 at 10:33 AM revealed the resident was lying in bed with the air mattress set to standby mode, indicating the mattress was not providing appropriate pressure redistribution.
A surveyor observation on 8/4/2023 at 8:43 AM, revealed the resident was lying in bed on his/her back with the air mattress set to standby mode, indicating the mattress was not providing appropriate pressure redistribution.
During a surveyor interview with the resident immediately following the observation on 8/4/2023, s/he stated that his/her bottom in causing pain due to his/her wound on his/her sacrum.
During a surveyor interview on 8/4/2023 at 8:52 AM with Licensed Practical Nurse, Staff A, she acknowledged that the mattress was on standby mode and she was unsure of what the air mattress setting should be.
During a surveyor interview on 8/4/2023 at 9:57 AM with the Director of Nursing Services, he acknowledged that the air mattress should not be on standby mode. Additionally, he was unable to provide evidence that the facility provided interventions to promote healing for the resident as indicated by the physician's order and care plan.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on record review, surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is served, in accordance with professional standards for food serv...
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Based on record review, surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is served, in accordance with professional standards for food service safety, relative to the lunch meal service.
Findings are as follows:
Record review of the Rhode Island Food Code 2018 Edition 3-501.16 reads in part, Time/Temperature Control for Safety Food, Hot and Cold Holding indicates that cold food shall be maintained at less than or at 5 degrees Celsius/41 degrees Fahrenheit.
During a surveyor observation on 8/3/2023 at approximately 11:50 AM of the lunch meal, an egg salad sandwich had a cold holding temperature of 49.1 degrees Fahrenheit.
An additional surveyor observation of the lunch meal on the South nursing unit on 8/3/2023 at approximately 12:05 PM, the fat free milk had a cold holding temperature of 47.8 degrees Fahrenheit.
During a surveyor interview with the Food Service Director on 8/3/2023 at approximately 12:30 PM, she acknowledged the cold holding temperatures were not within the acceptable temperature range.
Jul 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 3 residents reviewed for pressure ulcers, Resident ID #1.
Findings are as follows:
1A. Review of the resident's record revealed s/he was admitted to the facility in July of 2022 with diagnoses including, but not limited to, pressure ulcer of sacral region (sacrum, base of the spine), stage 4 (a severe bed sore exposing underlying muscle, tendon, cartilage or bone), diabetes mellitus type 2, and unspecified severe protein-calorie malnutrition.
Record review of a Minimum Data Set 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 the resident's care plan dated 7/28/2022, revealed the resident has a stage 4 pressure ulcer of the sacrum with an intervention to provide wound treatment as ordered.
Record review revealed a wound assessment dated [DATE] indicating the resident's sacral pressure ulcer measured 1.6 centimeters (cm) by 2.11cm by 2.8cm.
Additional record review revealed a physician's order dated 7/11/2023 for Gentamicin Sulfate External Ointment (topical antibiotic) .Apply to .wound bed topically every day shift for wound care Stage 4 pressure ulcer .vashe (wound wash) soak to wound bed for 5 minutes. Skin prep the periwound (around the wound). Apply Gentamicin ointment to wound bed and pack with calcium alginate AG (absorbent wound dressing with silver). Cover with bordered foam dressing .
During a surveyor observation on 7/13/2023 at approximately 10:00 AM, Registered Nurse, Staff A, applied the gentamicin ointment to a cut sheet of Maxorb (calcium alginate dressing) then applied the it to the base of the resident's sacral wound then packed the wound with calcium alginate AG. This was not the intended treatment, as the above stated physician's order did not include Maxorb.
During a surveyor interview immediately following the above observation, Staff A, reviewed the current order and acknowledged that he did not follow the physician's order for the wound dressing. Additionally, he revealed that he had been off for a few days and did not review the order prior to completing the dressing change.
During a surveyor interview on 7/13/2023 at 12:28 PM with the Director of Nursing Services, he indicated that he would expect the physician's order to be followed for the resident's wound care.
1B. Record review revealed the resident had a history of a Stage 2 pressure ulcer (superficial opening of the skin due to prolonged pressure) to his/her right lateral malleolus (outside of ankle).
Record review revealed a physician's order dated 10/18/2022 to off load heels with heel offloading boots while in bed as often as patient will tolerate every shift for wound care/skin integrity.
Further record review failed to reveal evidence that the resident could not tolerate the offloading boots.
During surveyor observations on 7/13/2023 the resident's heels were not off loaded at the following times:
-9:51 AM
-10:23 AM
-11:05 AM
-1:50 PM
During a surveyor interview on 7/13/2023 at 11:05 AM with the resident, s/he indicated that s/he was uncomfortable with his/her heels laying directly on the mattress. At this time, the resident requested to be transferred out of bed into his/her wheelchair.
During a surveyor observation and interview on 7/13/2023 at 1:55 PM with Staff A, he indicated that he had just applied the residents off loading boots. He further indicated that they had not been applied previously as ordered.
During a surveyor interview on 7/13/2023 at 2:57 PM with the Director of Nursing Services, he indicated that he would expect physician's orders to be followed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to maintain acceptable parameters of nutritional status relative to weight loss for 1 of 3 residents reviewed, Resident ID #1.
Findings are as follows:
Review of the resident's record revealed s/he was admitted to the facility in July of 2022 with diagnoses including, but not limited to, pressure ulcer of sacral region (sacrum, base of the spine), stage 4 (a severe bed sore exposing underlying muscle, tendon, cartilage or bone), diabetes mellitus type 2, and unspecified severe protein-calorie malnutrition.
Record review of a Minimum Data Set Assessment (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident is cognitively intact.
Record review revealed a care plan dated 8/5/2022 indicating the resident is at nutritional risk with increased nutritional needs to support wound healing. Further review revealed an intervention to alert dietitian and physician to any significant [weight] loss .
Record review of the resident's recorded weights revealed the following:
-6/27/2023- 216.0 pounds (lbs.)
-7/1/2023- 214.7 lbs.
-7/4/2023- 209.6 lbs.
-7/11/2023- 206.0 lbs.
Further review revealed a 5.1 lb. weight loss in three days, from 7/1/2023 to 7/4/2023 and a 10 lb. weight loss in three weeks, from 6/27/2023 to 7/11/2023, indicating a significant weight loss.
Record review failed to reveal evidence that the physician or dietitian was notified of this significant weight loss. Additional review failed to reveal evidence that an intervention was put into place following the above mentioned weight loss.
During a surveyor interview on 7/13/2023 at 9:51 AM with the resident, s/he indicated that s/he had recently lost weight and would like to speak with a dietitian regarding his/her weight loss.
During a surveyor interview on 7/13/2023 at 11:32 AM with Registered Nurse, Staff A, he was unable to provide evidence that the physician or dietician were notified of the recent weight loss or that interventions had been put into place.
During a surveyor interview on 7/13/2023 at 2:57 PM with the Director of Nursing Services, he was unable to provide evidence that the resident's physician or dietitian were notified of the significant weight loss. Upon surveyor request, he was unable to provide a facility policy pertaining to obtaining weights and reweighs and indicated he had reached out to corporate regarding these policies. Additionally, he was unable to provide evidence that any interventions were put into place following the above mentioned weight loss.
May 2023
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0760
(Tag F0760)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that facility failed to ensure that residents are free from a...
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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 facility failed to ensure that residents are free from any significant medication errors for 1 of 1 diabetic resident reviewed, Resident ID #1, who received insulin when his/her blood glucose level was 45 MG/DL (milligrams/deciliter; normal blood glucose levels for diabetics are between 80 and 130 MG/DL per the Centers for Disease Control).
Findings are as follows:
Record review of a community reported complaint sent to the Rhode Island Department of Health on 4/21/2023 alleges that Resident ID #1 was hospitalized for a very low blood sugar which was in the 20's upon arrival to the hospital.
According to [NAME]: Manual of Nursing Practice, 2006, .The nurse should be knowledgeable about the type of insulin and/or diabetic agent, with regards to onset, peak and duration. Hypoglycemia- a blood glucose less than 50 MG/DL and nursing assessment includes: mental status changes, vital signs-noting, tachycardia, respiratory pattern, skin inspection-pallor [an unhealthy pale appearance], diaphoresis [excessive sweating], and tremors or fine motor loss .
Record review of the facility policy titled Hypoglycemia Protocol dated 12/1/2006 states in part,
.Perform fingerstick blood glucose measurement.
- If less than 70 or physician ordered low parameter, immediately administer rapidly absorbed simple carbohydrate such as 4 oz. [ounces] juice or 5-6 oz. regular soda pop or tube of glucose gel [product taken orally to treat hypolgycemia] .
- Remain with resident and monitor vital signs
- Repeat resident blood glucose measurement in 10-15 minutes
- If below 70, repeat juice and blood glucose measurement 10-15 minutes after juice administration.
- Hold all diabetic medications, including insulin and oral meds [medications].
- Notify physician. Obtain specific follow-up orders regarding diabetic medications and glucose monitoring .
Record review revealed the resident was admitted to the facility in April of 2023, with a diagnosis including, but not limited to, type 2 diabetes mellitus with hyperglycemia (an excess of glucose in the bloodstream).
Record review revealed a physician's order dated 4/7/2023 for Lantus (a long-acting insulin in which the effects can last up to 24 hours) Inject 20 units at bedtime for diabetes at 8:00 PM with blood glucose monitoring at the time of the insulin administration.
Record review of the Blood Sugar Summary indicated that the resident's blood glucose level on 4/16/2023 at 10:26 PM was 45 MG/DL.
Record review of the April 2023 Medication Administration Record (MAR) revealed that the Lantus was administered to the resident whose blood glucose level was 45 MG/DL on 4/16/2023 by Licensed Practical Nurse, Staff A.
Record review of a progress note dated 4/17/2023 at 12:37 AM authored by Staff A, revealed that at bedtime, the resident's blood glucose level was 49 MG/DL and the resident was drowsy, but alert. The progress note further revealed that glucose gel was given, but s/he vomited his/her medications and the glucose gel. Furthermore, Staff A proceeded to give food items to the resident, who consumed 4 cookies and 8 oz. of milk, and upon recheck, his/her blood glucose level was 59 MG/DL.
Additional review of the progress note dated 4/17/2023, states in part, that the physician was, notified of events, new order hold Lantus tonight and administer Lantus 10 units x's [times] 1. The progress note further indicated at 11:00 PM, his/her blood glucose level was 59 MG/DL.
Further record review of the April 2023 MAR failed to reveal evidence of a physician's order for Lantus 10 units or that glucose gel was administered to the resident.
Record review of a progress note dated 4/17/2023 at 3:25 AM authored by Registered Nurse, Staff B, states in part, Resident's Blood sugar continued to run in the 50's, [s/he] was given Glucagon [an injectable emergency medication used to treat severe low blood glucose levels] @ [at] 1am which increased [his/her] BS [blood sugar] to 67, when sugar was checked again 15minutes later, [his/her] BS had dropped back down to 59, resident was given Chocolate pudding and milk, Which [s/he] had vomited up. Residents BS was still in the 50's. [S/he] was given a second glucagon [injection] at 1:30am, Blood sugar went up to 69. Residents BS dropped back down to 55, resident was sent out via 911 per [Medical Director's] orders .
Record review failed to reveal evidence that the facility's hypoglycemic protocol policy was followed including, but not limited to, holding all diabetic medications, including insulin and monitoring vital signs.
Record review of the resident's hospital documentation dated 4/17/2023 at 4:25 AM stated in part .patient's BS 29 [MG/DL]. Given amp [ampule] of dextrose [intravenous medication to treat severely hypoglycemic residents] at this time .
During surveyor interviews on 4/26/2023 at 11:06 AM and 4/28/2023 at 12:41 PM with Staff A, she acknowledged that on 4/16/2023 the resident's blood glucose level at bedtime was 45 MG/DL. She indicated that she administered 10 units of Lantus to the resident instead of the ordered 20 units. Additionally, she was unable to explain why the MAR reflected that she administered 20 units of Lantus when she indicated she only gave 10 units of Lantus to the resident. Furthermore, Staff A acknowledged that she did not call the physician back when the resident's blood glucose continued to decrease, nor did she monitor his/her vital signs per the facility policy. Additionally, she was unable to explain why she did not follow the facility's hypoglycemic protocol policy or why she did not document the glucose gel on the MAR that she indicated was administered to the resident.
During a surveyor interview on 4/26/2023 at approximately 1:00 PM with the Medical Director, he revealed that he did not receive a phone call on 4/16/2023 from Staff A concerning the resident's low blood glucose level. Additionally, he revealed that he did not give Staff A instructions to administer 10 units of insulin with a blood glucose level of 45 MG/DL. He further revealed that he did speak to Staff B on 4/17/2023 at approximately 3:25 AM and gave her orders to send the resident to the hospital.
During a surveyor interview on 5/1/2023 at approximately 10:30 AM with the Director of Nursing Services and the Administrator, they were unable to explain why Staff A administered insulin to the resident whose blood glucose level was 45 MG/DL or why she did not follow the facility's hypoglycemic protocol policy.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and pra...
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Based on record review and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 1 resident reviewed for inaccurate documentation, Resident ID #1, relative to glucagon administration (an injectable emergency medication used to treat severe low blood glucose levels).
Findings are as follows:
Record review of a community reported complaint sent to the Rhode Island Department of Health on 4/21/2023 alleges that Resident ID #1 was hospitalized for a very low blood sugar which was in the 20's upon arrival to the hospital (normal blood glucose levels for diabetics are between 80 and 130 MG/DL [milligrams/deciliter] per the Centers for Disease Control).
Record review revealed the resident was admitted to the facility in April of 2023, with a diagnosis including, but not limited to, type 2 diabetes mellitus with hyperglycemia (an excess of glucose in the bloodstream).
Record review of the Blood Sugar Summary indicated that the resident's blood glucose level on 4/16/2023 at 10:26 PM was 45 MG/DL.
Record review of a progress note dated 4/17/2023 at 3:25 AM stated in part, .Resident's Blood sugar continued to run in the 50's .Blood sugar went up to 69. Residents BS [blood sugar] dropped back down to 55, resident was sent out via 911 per [Medical Director's] orders .
Addtional review of the progress note dated 4/17/2023 indicated that the resident received 2 glucagon injections at 1:00 AM and 1:30 AM.
Record review of a progress note dated 4/17/2023 at 9:02 AM revealed that the resident was admitted to the hospital.
Review of the April 2023 Medication Administration Record revealed that the resident was administered glucagon injections on 4/17/2023 at 3:35 PM and 3:37 PM hours after the resident was transferred to the hospital and no longer in the facility.
During a surveyor interview on 4/26/2023 at approximately 10:00 AM with Registered Nurse, Staff B, she acknowledged that she documented the glucagon injections inaccurately. She further acknowledged the resident was in the hospital and not in the facility at the time the glucagon injections were documented as administered.
During a surveyor interview on 4/26/2023 at approximately 11:00 AM with the Director of Nursing Services in the presence of the Administrator, he was unable to explain why the documentation in the resident's medical record was inaccurate.
Apr 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
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 honor the resident's right to refu...
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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 honor the resident's right to refuse medication for 1 of 3 residents reviewed for resident's rights, Resident ID #1.
Findings are as follows:
Record review for Resident ID #1 revealed s/he was initially admitted to the facility in December of 2012 with a diagnosis of, but not limited to, diabetes mellitus type two.
Review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating the resident's cognition was intact.
Record review revealed a physician's order for Levemir Subcutaneous Solution 100unit/ml (milliliter) (Insulin Determir) Inject 47 unit subcutaneously one time a day for IDDM (Insulin Dependent Diabetes Mellitus).
Record review of the April 2023 Medication Administration Record revealed the above medication was administered to the resident on 4/11/2023 at 3:31 PM.
During a surveyor interview with the resident on 4/13/2023 at 1:23 PM s/he revealed that on 4/11/2023 s/he refused his/her insulin however Staff A administered the injection against his/her will. S/he further revealed that s/he was very angry about receiving the medication after refusing it.
During a surveyor interview with Licensed Practical Nurse, Staff A, on 4/13/2023 at 1:58 PM she revealed that she attempted to administer the ordered insulin to the resident three different times during the afternoon of 4/11/2023, in which the resident refused. She further revealed that she administered the insulin to the resident while the resident was in bed at approximately 3:30 PM, despite the resident's refusal of the medication.
During a surveyor interview with the Director of Nursing Services on 4/13/2023 at 2:06 PM, he revealed that he would expect the resident's right to refuse medication be honored.
During a surveyor interview with the Medical Director on 4/14/2023 at 9:40 AM, he revealed the resident has the right to refuse medications and acknowledged Staff A should not have administered the medication to the resident after the resident refused.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to assure that services being provided meet professional standards of quality related to notifying the physi...
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Based on record review and staff interview, it has been determined that the facility failed to assure that services being provided meet professional standards of quality related to notifying the physician when a medication is refused for 1 of 3 residents reviewed for medication administration, Resident ID #1.
Findings are as follows:
Review of the facility policy titled 2.9 Refusal of Medications, Treatments, or Services with the revision date of 8/1/2016 states in part, .If the resident refuses any medication, treatment, or service staff shall .Notify the physician .All discussions with the resident, physician, and other involved persons shall be documented in the medical record .
Record review for Resident ID #1 revealed s/he was initially admitted to the facility in December of 2012 with a diagnosis of, but not limited to, diabetes mellitus type two.
Record review revealed a physician's order for Levemir Subcutaneous Solution 100unit/ml (milliliter) (Insulin Determir) Inject 47 unit subcutaneously one time a day for IDDM (Insulin Dependent Diabetes Mellitus).
Record review of the March and April 2023 Medication Administration Records revealed the above insulin was refused on the following dates:
-3/9/2023
-3/16/2023
-3/23/2023
-3/25/2023
-3/29/2023
-4/1/2023
-4/3/2023
-4/4/2023
-4/8/2023
Record review failed to reveal the physician was notified of the refused medications for the above-mentioned dates.
During a surveyor interview with Director of Nursing Services on 4/13/2023 at 2:06 PM, he revealed that he would expect the nurse to notify the physician each time a resident refuses a medication and document the physician's notification.
During a surveyor interview with the Medical Director on 4/14/2023 at 9:40 AM, he revealed he would expect to be notified when a resident's medication is refused.
Feb 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0576
(Tag F0576)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, record review, and resident, and staff interview, it has been determined that the facility faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, record review, and resident, and staff interview, it has been determined that the facility failed to ensure that a resident has the right to have reasonable access to the use of a telephone for 1 of 1 residents reviewed, Resident ID #1.
Findings are as follows:
Record review a community reported complaint submitted to the Rhode Island Department of Health on 2/6/2023 alleges in part, .[his/her] phone is placed out of reach .
Record review of the facility policy titled, RESIDENT RIGHTS UNDER FEDERAL LAW, states in part .The resident has a right to .communication with .persons .outside the facility .The resident has the right to have reasonable access to the use of a telephone .
Record review revealed that the resident was readmitted to the facility in September of 2020. S/he has medical diagnoses that include but are not limited to; major depressive disorder, muscle weakness, leukemia, and mild cognitive impairment.
Review of an annual Minimum Data Set assessment dated [DATE] revealed that the resident requires the assistance of one to two staff members for bed mobility and transfers.
During multiple surveyor observations on 2/7/2023 between approximately 10:30 AM and 2:10 PM the resident's telephone was observed to be placed on a night stand table which was positioned to the right upper side of his/her bed. Additionally, the resident's telephone was approximately 12 inches out of his/her reach. The observation also revealed a sign posted on the wall above the resident's bed which indicated that his/her phone should be placed within reach. The above-mentioned observations were made at the following times approximately:
2/7/2023 at 10:30 AM
2/7/2023 at 11:15 AM
2/7/2023 at 11:28 AM
2/7/2023 at 11:53 AM
2/7/2023 at 12:45 PM
2/7/2023 at 2:10 PM
2/7/2023 at 3:00 PM
During the surveyor observation on 2/7/2023 at approximately 11:15 AM, the resident was observed to be laying in bed and visiting with two family members. During a surveyor interview with the family members at the time of the observation, they indicated that it is difficult to reach their family member by phone because s/he cannot reach it to answer when they call him/her. They further indicated that at times it is difficult to reach staff by phone to request they help the resident access his/her phone.
During a surveyor observation on 2/7/2023 at 2:10 PM the resident's phone was observed to be placed on his/her night stand which was out of his/her reach. A surveyor interview with the resident at the time of the observation, s/he revealed that s/he could not reach or access the phone where it was located.
During a surveyor interview with Licensed Practical Nurse, Staff A, on 2/7/2023 at 3:04 PM, she acknowledged that the resident's phone was out of his/her reach and indicated that it should have been within reach. She also acknowledged that sign posted on the wall of the resident's bed indicates that the phone should be within reach.
During a surveyor interview with the Director of Nursing Services on 2/7/2023 at 1:57 PM, she was unable to provide evidence that the resiient's right to have reasonable access to a telephone was honored relative to the resident's phone being placed out of reach.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records for all residents that are accurately documented in accordance with professional standards and practices for 1 of 2 residents reviewed receiving oxygen therapy and 1 of 1 residents reviewed for meal consumption, Resident ID #1.
Findings are as follows:
1. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 2/6/2023 alleges in part, .resident needs help with eating but staff is not taking time to feed [him/her] .
Record review of the facility policy titled, Nutrition/Hydration Care and Services, states in part, .Staff will .Observe and document oral intake of meals .
Record review revealed that the resident was readmitted to the facility in September of 2020 with diagnoses that include but are not limited to; leukemia, dysphagia (difficulty swallowing), and chronic obstructive pulmonary disease (a lung disease that causes obstructed airflow from the lungs), muscle weakness, and mild cognitive impairment.
Review of an annual Minimum Data Set assessment dated [DATE] revealed s/he requires the extensive assistance of one staff member for eating and drinking.
During a surveyor observation on 2/7/2023 at approximately 12:15 PM the resident was observed to be receiving assistance with the lunch meal by his/her family member. During a surveyor interview with the family member at the time of the observation revealed that the resident's appetite was poor and that s/he only ate two bites of food that was in a small dessert or fruit cup. The entree was observed to not have been eaten. The resident was observed to sip a drink from a double handled spill proof spouted cup which the family indicated that they purchased for him/her.
During a follow up surveyor observation at approximately 1:50 PM, the resident was observed in bed with no family members present. The lunch tray was observed to still be on the resident's over the bed table with no evidence that s/he had eaten any additional food aside from the two bites in the above-mentioned surveyor interview. During a surveyor interview with the resident at the time of the observation, s/he indicated that s/he did not want anything to eat.
Record review of the meal consumption documentation dated 2/7/2023 at 2:01 PM revealed the resident's documented lunch intake as 75% eaten which is not what was observed on the meal tray.
During a surveyor interview with Licensed Practical Nurse (LPN) Staff A on 2/7/2023 at approximately 3:00 PM, she indicated that she spoke with the staff member who completed the documentation and indicated that the documentation of 75% eaten was not accurate.
During a surveyor interview with the Director of Nursing Services on 2/7/2023 at 3:25 PM, she indicated that she would have expected staff to document the meal consumption accurately.
2. Record review of the facility procedure titled, OXYGEN: NASAL CANNULA, states in part, .Nasal cannula labeled with date of initial set-up .Replace disposable set-up every seven days .Document .Date and time oxygen .administration .
Record review revealed a physician's order dated 11/6/2020 which states in part, Oxygen at 2 L/min (Liters per minute) via Nasal Cannula (medical device tubing that is used to deliver oxygen) as needed for SOB (shortness of breath).
During surveyor observations on the following dates and times revealed the resident was receiving oxygen therapy at 2 liters via a nasal cannula:
-
2/7/2023 at 10:30 AM
-
2/7/2023 at 11:15 AM
-
2/7/2023 at 11:28 AM
-
2/7/2023 at 2:10 PM
-
2/7/2023 at 3:00 PM
Additionally, the above-mentioned observations revealed the oxygen tubing was not labeled with the date and time of initial set-up.
Further record review revealed a vital report of the following documentation:
-
1/31/2023 at 10:07 AM .Oxygen via Nasal Cannula .
-
2/2/2023 at 10:29 AM .Oxygen via Nasal Cannula .
-
2/4/2023 at 6:32 AM .Oxygen via Nasal Cannula .
-
2/5/2023 at 11:11 PM .Oxygen via Nasal Cannula .
-
2/6/2023 at 11:30 PM .Oxygen via Nasal Cannula .
Review of the January and February 2023 Treatment Administration Record (TAR) revealed the order for Oxygen was not documented as administered for the above-mentioned dates and times.
During a surveyor interview with LPN Staff A, on 2/7/2023 at approximately 3:00 PM, she acknowledged that the resident was receiving oxygen therapy and that the oxygen tubing was not labeled with a date or time of initial set-up.
During a surveyor interview with the Director of Nursing Services on 2/7/2023 at approximately 2:45 PM, she indicated that she would have expected staff to document oxygen therapy use on the TAR and label and date the oxygen tubing per the facility policy.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
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 follow sta...
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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 follow standard precautions to prevent the spread of infection and to ensure a sanitary environment to help prevent the transmission of infections for 1 of 1 residents reviewed with a pressure wound, Resident ID #1.
Findings are as follows:
Record review of a community reported complaint submitted to the Rhode Island Department of Health on 2/6/2023 alleges in part, .resident had a .bedsore on [his/her] tailbone that is not getting better .
Record review revealed that the resident was readmitted to the facility in September of 2020 with diagnoses that include but are not limited to leukemia, muscle weakness, and mild cognitive impairment.
Review of an annual Minimum Data Set assessment dated [DATE] revealed that the resident requires the extensive assistance of two or more staff members for toileting needs and hygiene, experiences bowel and bladder incontinence, and has a pressure wound.
Further record review revealed a care plan dated 1/20/2023 indicating the resident has an unstageable (the wound stage is not clear because the wound bed is covered by dead tissue) pressure ulcer to the sacrum (tailbone).
During a surveyor observation on 2/7/2023 at 11:28 AM, in the presence of Nursing Assistant Staff B, revealed the resident's sacrum wound was uncovered without a dressing in place. The resident was also observed to be incontinent of bowel. Additionally, Staff B was observed performing incontinence. During the observation Staff B cleansed the resident's rectal area first and wiped in the direction of the uncovered wound. Staff B was also observed to wipe from the resident's rectal area to the front, towards his/her genital area. Staff B was also observed to place the used washcloth, which was soiled with visible fecal matter, directly on the resident's over the bed table. The table was observed to have items on it including drinking cups. Furthermore, Staff B was observed to leave the resident's room without cleaning or disinfecting the over the bed table.
Record review of a facility document titled CLINICAL COMPETENCY VALIDATION PERINEAL CARE, states in part, .CRITICAL ELEMENTS .Cleanses .wiping downward from front to back .Places soiled linen in bag for laundering .Cleanses the rectal area .using a clean washcloth, cleansing from the [genital] to the anus .Places soiled linen in bag for laundering .
According to the 1998-2023 Mayo Foundation for Medical Education and Research, prevention of urinary tract infections states in part, Prevention .Wipe from front to back .after a bowel movement .helps prevent the spread of bacteria from the anus to the [genital] and urethra [opening to bladder] .
Record review of a facility document titled, Infection Prevention and Control Program Description states in part, .Implementation of Control Measures and Precautions .includes .Standard .Based Precautions .including .cleaning/disinfecting equipment and measures to protect persons .from communicable diseases or infections .GOALS .Provide a .sanitary .environment .
During a surveyor interview with Staff B on 2/7/2023 at 11:46 AM, she acknowledged that the resident was incontinent of bowel and that she performed incontinence care by cleansing and wiping from back to front. She also acknowledge that she placed the soiled washcloth that had visible fecal matter on it directly on the resident's over the bed table. Furthermore, she acknowledged that she did not clean or disinfect the over the bed table.
During a surveyor interview with the Director of Nursing Services on 2/7/2023 at 2:48 PM, she indicated that she would expect staff to perform incontinence care per facility protocol. Additionally, she indicated that she would not expect staff to place a soiled washcloth with visible fecal matter directly on the resident's over the bed table.
Jun 2022
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to assure that services being provided meet professional standards of quality relativ...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to assure that services being provided meet professional standards of quality relative to following physician's orders for 1 of 5 residents reviewed for pressure relieving devices, Resident ID #37.
Findings are as follows:
According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
Record review revealed the resident was admitted to the facility in December of 2021 with diagnosis including, but not limited to, pressure ulcer to right buttock.
Record review of the physician orders revealed an order dated 1/31/2022 for Offloading boots to be worn at all times when in bed every shift for wound.
During surveyor observations on the following dates and times revealed the resident without his/her offloading boots, with his/her feet resting directly on the mattress:
-6/27/2022 at 2:50 PM
-6/28/2022 at approximately 9:30 AM
-6/28/2022 at approximately 10:30 AM
-6/28/2022 at 2:00 PM
-6/28/22 at 3:00 PM in the presence of Nurse Staff A
Additional record review of the Treatment Administration Record revealed the offloading boots were signed off as applied on 6/27/2022 and 6/28/2022.
During a surveyor interview immediately following the observation with Staff A, she acknowledged the resident did not have his/her offloading boots on. Additionally, she could not explain why she had signed off that the offloading boots were applied on the dates mentioned above, when they were not observed on the resident's feet.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to store medications in accor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to store medications in accordance with currently accepted professional principles, for 2 of 4 medication storage carts located on 2 of 2 units, North and South, and 1 of 2 medication storage rooms located on the South unit.
Findings are as follows:
1. During surveyor observation of the South Unit medication cart on 6/28/2022 at 9:40 AM revealed the following:
A. One Breo Ellipta Inhaler 100-25 micrograms (mcg) (used to treat chronic lung disease), in use, opened and dated 3/25/22.
Manufacturer's instructions for Breo Ellipta states, .Discard BREO ELLIPTA 6 weeks after opening the foil tray or when the counter reads '0' .
B. One Incruse Ellipta Inhaler 62.5 milligrams (mg) (used to treat chronic lung disease), in use and opened with no date.
Manufacturer's instructions for Incruse Ellipta states, .Discard INCRUSE ELLIPTA 6 weeks after opening the foil tray or when the counter reads '0' .
2. During surveyor observation of the North Unit medication cart on 6/28/2022 at 10:10 AM revealed the following:
A. One Wixela Inhaler 250/50 mcg (used to treat chronic lung disease), in use, opened and dated 4/10/22.
Manufacturer's instructions for Wixela Inhaler states, Discard Wixela Inhaler 1 month after opening the foil pouch or when the counter reads '0' .
3. An additional surveyor observation of the South Unit medication storage room on 6/28/2022 at 1:20 PM revealed the following expired medications:
3 bottles of Vitamin B6 500 units with a date of 3/22
1 bottle of Zinc 50 mg with a date of 5/22
2 bottles of [NAME] Aspirin 325 mg with a date of 05/22
3 bottles of Ferrous Gluconate 240 mg with a date of 2/22
1 bottle of Vitamin C 250 mg with a date of 05/22
1 bottle of Calcium 500 plus D3 with a date of 10/21
2 boxes of Earwax Removal Drops with a date of 05/22
During a surveyor interview on 6/28/2022 at 1:40 PM with the Director of Nursing Services, she acknowledged the expired medications and was unable to explain why the medications were still in the medication storage room after they had expired.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to properly store food under sanitary conditions relative to the main kitchen and 1 o...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to properly store food under sanitary conditions relative to the main kitchen and 1 of 2 kitchenettes, North Unit.
Findings are as follows:
1) During the initial tour of the main kitchen on 6/27/2022 at approximately 8:30 AM, the following items were observed:
- an opened package of cupcakes, with 2 remaining, dated 3/21/22 in the main freezer.
- 2 packages of frozen sliced bread located in the dry storage freezer, without a date of when they were placed in the freezer and with an expiration date of 5/20/2022.
- a clear bag of cereal without an identifying label or an expiration date.
During a surveyor interview immediately following the above observations with the Food Service Director, she acknowledged the items had expired and discarded the items mentioned above.
2) Record review of the facility's policy titled Food and Nutrition Services Policies and Procedures states in part,
PROCESS
.1.2 Food items that require refrigeration must be labeled with patient's/resident's name and date the food was brought in .
1.4 Foods unsafe for consumption or beyond the expiration date will be discarded by staff upon notification to patient/resident.
1.5 Food will be held in refrigerator for three (3) days following date on label and will be discarded by staff upon notification to patient/resident .
During a surveyor observation of the North Unit kitchenette refrigerator on 6/28/2022 at 2:45 PM revealed the following items:
- a 10.5 ounce bottle of Califia Cold Brew was observed without a resident's name, with a written date of 3/29/2022 and an expiration date of 4/1/2022.
- a bag containing leftover pancakes dated 6/19/2022
- a bottle of Italian salad dressing labeled, staff, with an expiration date of 4/21/2022.
During a surveyor interview with the Director of Nursing Services on 6/28/2022 at 2:55 PM, she acknowledged that the expired items mentioned above should have been discarded and further revealed that staff items should not be placed in the resident's refrigerator.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to implement infection control measures to provide a sanitary environment and prevent...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to implement infection control measures to provide a sanitary environment and prevent the transmission of communicable diseases and infections relative to the proper use of Personal Protective Equipment (PPE), and disinfection of non-dedicated equipment for 2 of 2 units, the North Unit (COVID-19 Unit) and the South Unit.
Findings are as follows:
1) The Center for Disease Control and Prevention (CDC) document titled Using PPE , updated on 8/19/2020, states in part, .Respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap). Perform a user seal check each time you put on the respirator .
Record review of the facility's policy titled Personal Protective Equipment (PPE) Guide for Healthcare Personnel dated 5/3/2022 and 6/23/2022 states in part, .Eye protection should be removed, cleaned, and disinfected if it becomes visible soiled or removed (e.g., when leaving the isolation area) prior to putting it back on .after task is complete in the room, staff remove PPE (gown & gloves) at the door and perform hand hygiene .Staff exiting a positive room should clean their face shield .
During a surveyor observation on 6/29/2022 at 9:16 AM of a COVID-19 positive room, nursing assistant Staff B was observed doffing (removing) her PPE prior to exiting Resident ID #9's isolation room but failed to change her N-95 mask and change or disinfect her goggles. She was then observed entering Resident ID #32's room, a COVID negative room, when she was approached by the surveyor for interview.
During a surveyor interview at the time of the observation, Staff B acknowledged that she should have changed her N-95 mask and changed or cleaned her goggles when doffing PPE.
Additional surveyor observations include the following:
1. On 6/27/2022 at 1:30 PM, nursing assistant Staff C was observed on the North Unit, exiting Resident ID # 38's COVID positive room without changing her N-95 mask. Additionally, she was observed with one strap at the base of her neck and the second strap resting on the outside front of her mask.
During a surveyor interview immediately following this observation, she revealed that she should have changed her mask.
2. On 6/27/2022 at 1:45 PM the housekeeper, Staff D, was observed on the North Unit, wearing an N-95 mask, utilizing only one strap. The lower strap was observed outside of the mask under the front fold.
3. On 6/27/2022 at 1:48 PM the housekeeping supervisor, Staff E, was observed walking down the hallway of the North Unit wearing an N-95 mask, utilizing only one strap. The lower strap was observed outside of the mask under the front fold.
During a surveyor interview immediately following the above observation with Staff E, she acknowledged that she should be using both straps while wearing the N-95 mask and the lower strap should be around the back of her neck.
4. On 6/27/2022 at 3:52 PM, the Medication Aide, Staff F, was observed standing at the medication cart on the North Unit with her N-95 mask pulled down, leaving her nose and mouth exposed.
During a surveyor interview with Staff F on 6/27/2022 at 3:56 PM, she pulled her mask up over her nose and mouth and acknowledged that her N-95 mask should be covering her nose and mouth.
During a surveyor interview with the Unit Manager, Staff G, on 6/27/2022 at 4:00 PM, she indicated that her expectation is that when staff is doffing PPE from an isolation room, they should change their N-95 mask and face shield. Additionally, Staff G revealed she would expect that staff would utilize both straps when wearing an N-95 mask, and the mask should always remain in place.
5. On 6/28/2022 at 9:12 AM, Staff F was observed on the South Unit, obtaining a blood pressure (BP) reading from using a wrist BP cuff. After obtaining the BP, she placed the BP cuff on the medication cart without disinfecting it. She then retrieved the portable vital sign (VS) machine and obtained the resident vital signs. After obtaining the resident's vital signs, Staff F brought the portable VS machine into the hallway and verbalized that she was proceeding to another resident's room. Staff F failed to perform hand hygiene or disinfect the portable VS machine.
During a surveyor interview immediately following the observation with Staff F, she revealed she was unaware that she needed to disinfect non-dedicated equipment shared by the residents on the non-Covid unit.
During a surveyor interview with the Director of Nursing Services (DNS) on 6/28/2022 at 11:00 AM, she acknowledged that Staff F should have disinfected all non-dedicated equipment after each resident use regardless of the isolation status. Additionally, she would expect an N-95 mask to be worn appropriately, utilizing both straps, and changed when doffing from an isolation room and goggles and face shields should be changed or disinfected when doffing from an isolation room as well.
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
- • 35% turnover. Below Rhode Island's 48% average. Good staff retention means consistent care.
Concerns
- • 30 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $17,651 in fines. Above average for Rhode Island. Some compliance problems on record.
- • Grade C (53/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 53/100. Visit in person and ask pointed questions.
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About This Facility
What is Grandview Center's CMS Rating?
CMS assigns Grandview Center 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 Grandview Center Staffed?
CMS rates Grandview Center's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 35%, compared to the Rhode Island average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Grandview Center?
State health inspectors documented 30 deficiencies at Grandview Center during 2022 to 2025. These included: 1 that caused actual resident harm and 29 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Grandview Center?
Grandview Center is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 72 certified beds and approximately 67 residents (about 93% occupancy), it is a smaller facility located in Cumberland, Rhode Island.
How Does Grandview Center Compare to Other Rhode Island Nursing Homes?
Compared to the 100 nursing homes in Rhode Island, Grandview Center's overall rating (3 stars) is below the state average of 3.1, staff turnover (35%) 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 Grandview Center?
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 Grandview Center Safe?
Based on CMS inspection data, Grandview Center 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 Grandview Center Stick Around?
Grandview Center has a staff turnover rate of 35%, 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 Grandview Center Ever Fined?
Grandview Center has been fined $17,651 across 2 penalty actions. This is below the Rhode Island average of $33,255. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Grandview Center on Any Federal Watch List?
Grandview Center 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.