Morgan Health Center
For profit - Corporation
120 Beds
MARQUIS HEALTH SERVICES
Data: November 2025
Trust Grade
55/100
#26 of 72 in RI
Photo by Google Maps
Photo by Morgan Rehabilitation & Healthcare Center
Photo by Morgan Rehabilitation & Healthcare Center
Photo by Morgan Rehabilitation & Healthcare Center
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Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Morgan Health Center in Johnston, Rhode Island, has a Trust Grade of C, which means it is average and in the middle of the pack among nursing homes. It ranks #26 out of 72 facilities in the state, indicating it is in the top half, and #16 out of 41 in Providence County, meaning only 15 local options are better. The facility is improving, with issues decreasing from 9 in 2024 to 7 in 2025. Staffing is a strength, earning 4 out of 5 stars, although the turnover rate is 42%, which is about average for the state. However, the center has faced significant fines totaling $55,071, raising concerns about compliance issues. Recent inspections revealed a serious concern where two residents were not offered enough fluids, leading to dehydration and other health issues, including pressure wounds. Additionally, the facility failed to maintain a safe environment to prevent infection risks related to water management and did not meet food safety standards in its kitchens. While there are strengths in staffing and quality measures, families should weigh these alongside the reported deficiencies and fines.
- Trust Score
- C
- In Rhode Island
- #26/72
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 42% turnover. Near Rhode Island's 48% average. Typical for the industry.
- Penalties ✓ Good
- $55,071 in fines. Lower than most Rhode Island facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 41 minutes of Registered Nurse (RN) attention daily — about average for Rhode Island. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 31 deficiencies on record. Higher than average. Multiple issues found across inspections.
55/100
Top 36%
Needs review
9 → 7 violations
★★★★☆
4.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 7 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (42%)
6 points below Rhode Island average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Staff Turnover: 42%
Near Rhode Island avg (46%)
Typical for the industry
Federal Fines: $55,071
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: MARQUIS HEALTH SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 31 deficiencies on record
1 actual harm
Jul 2025
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice re...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following physician's orders for 1 of 3 residents reviewed, Resident ID #3. Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/16/2025, alleged in part that Resident ID #3's medications were not administered according to the physician's orders.According to Mosby's 4th Edition, Fundamentals of Nursing page 314, states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.Record review revealed that Resident ID #3 was admitted to the facility in April of 2025 with a diagnosis including, but not limited to, hypertension. Record review revealed the following physician's orders:-Metoprolol Succinate (a medication prescribed to treat hypertension) ER 50 milligram (mg) one time daily. Hold if Systolic Blood Pressure (SBP) is less than 100. Hold if Apical Pulse (AP) is less than 60. This order had a start date of 4/26/2025 and was discontinued on 7/7/2025.-Metoprolol Succinate ER 50 mg one time daily. Hold if SBP is less than 100. Hold if AP is less than 50. This order had a start date of 7/8/2025 and was discontinued on 7/11/2025.Record review of the Medication Administration Records (MAR) for April, May, June, and July 2025, failed to reveal documentation that the resident's blood pressure or apical pulse were checked prior to administering the medication.During a surveyor interview on 7/23/2025 at approximately 10:15 AM, with Registered Nurse, Staff A, she acknowledged the resident's MAR failed to reveal evidence that the resident's blood pressure and pulse were obtained prior to the administration of the Metoprolol.During a surveyor interview on 7/23/2025 at approximately 11:00 AM with the Director of Nursing Services, she could not provide evidence that the resident's blood pressure and pulse were obtained prior to administering the Metoprolol, per the physician's order.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the pharmacist failed to report irregularities to the attending physician, the facility's Medical Director, and the Director of ...
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Based on record review and staff interview, it has been determined that the pharmacist failed to report irregularities to the attending physician, the facility's Medical Director, and the Director of Nursing Services (DNS) for 1 of 3 residents reviewed, Resident ID #3. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/16/2025, alleged in part that Resident ID #3's medications were not administered according to the physician's orders.Record review of a facility policy titled, Medication Regimen Reviews [MRR] states in part, .A licensed pharmacist reviews the medication regimen of each resident at least monthly.The MRR includes a review of the medical record to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities, for example, the use of medication.administered without adequate monitoring or in the presence of adverse consequences. ‘Irregularities' may also include.other medication errors, including those related to documentation.Record review revealed that Resident ID #3 was admitted to the facility in April of 2025 with a diagnosis including, but not limited to, hypertension. Record review revealed the following physician's orders:-Metoprolol Succinate (a medication prescribed to treat hypertension) ER 50 milligram (mg) one time daily. Hold if Systolic Blood Pressure (SBP) is less than 100. Hold if Apical Pulse (AP) is less than 60. This order had a start date of 4/26/2025 and was discontinued on 7/7/2025.-Metoprolol Succinate ER 50 mg one time daily. Hold if SBP is less than 100. Hold if AP is less than 50. This order had a start date of 7/8/2025 and was discontinued on 7/11/2025.Record review of the Medication Administration Records for April, May, June, and July 2025 failed to reveal documentation that the resident's blood pressure or apical pulse were checked prior to administering the medication.Record review of the progress notes revealed, the pharmacy had reviewed the resident's medications on 4/27/2025, 5/30/2025, and 6/26/2025. It further revealed that the pharmacist had failed to identify that the monitoring of the resident's blood pressure and pulse were not documented to ensure adequate monitoring of the medication.During a surveyor interview on 7/23/2025 at approximately 12:15 PM with the Consultant Pharmacist, she acknowledged that she had completed the resident's medication reviews on 4/27/2025, 5/30/2025, and 6/26/2025. She further acknowledged that she failed to identify the above irregularity.During a surveyor interview on 7/23/2025 at approximately 11:00 AM with the Director of Nursing Services, she acknowledged that the Consultant Pharmacist had not identified the above irregularity.
May 2025
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0605
(Tag F0605)
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 prescribed psychotropic medications (medications prescribed to affect behav...
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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 prescribed psychotropic medications (medications prescribed to affect behavior, mood, thoughts, or perception) receive gradual dose reductions (GDR), unless clinically contraindicated, in an effort to discontinue these medications, for 1 of 2 residents reviewed with a recommendation for a GDR, Resident ID #84.
Findings are as follows:
Record review of the policy titled Psychotropic Medication Use dated 2/2025 states in part, Gradual Dose Reduction .Residents on psychotropic medication receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, to determine whether the continued use of the medication is benefitting the resident, to find an optimal dose, or in an effort to discontinue the medication .
Record review revealed the resident has a physician's order for quetiapine (a psychotropic medication) 25 milligrams (mg) two times a day.
Record review of the document titled Psychiatric Evaluation & Consultation with a service date of 5/6/2025 revealed that the resident was seen for an evaluation for a GDR. Further review revealed the quetiapine should be decreased to 25 mg once daily at bedtime.
Record review on 5/21/2025 failed to reveal evidence that this GDR recommendation was acted upon by the facility, therefore the resident continued to receive quetiapine 25 mg twice daily.
During a surveyor interview on 5/21/2025 at 11:49 AM with Registered Nurse, Staff C, she was unable to provide evidence that the above GDR recommendation had been acted upon by the facility.
During a surveyor interview on 5/21/2025 at 12:21 PM with the Nurse Practitioner, Staff D, she revealed that she was not notified of the GDR recommendation to decrease the quetiapine. Additionally, she revealed that the resident did not have any disqualifying conditions that would prevent the GDR from being implemented.
During a surveyor interview on 5/21/2025 at 12:28 PM with the Director of Nursing Services, she was unable to provide evidence that the GDR recommendation to decrease the quetiapine had been acted upon, as required.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to provide pharmaceutical services that assure the accurate acquiring, receiving, dispensing, and administer...
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Based on record review and staff interview, it has been determined that the facility failed to provide pharmaceutical services that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident related to antibiotic administration for 1 of 2 residents reviewed, Resident ID #49.
Findings are as follows:
Record review revealed the resident was admitted to the facility in May of 2025 with a diagnosis including, but not limited to, pneumonia.
Record review revealed the following physician's orders:
-Amoxicillin-Potassium Clavulanate (Augmentin-an antibiotic) 875-125 milligrams (mg) give one tablet every twelve hours for ten days. This order had a start date of 5/1/2025 and it was discontinued on 5/1/2025.
-Amoxicillin-Potassium Clavulanate (Augmentin) 875-125 mg give one tablet every twelve hours for seven days. This order had a start date of 5/1/2025.
Record review of the May 2025 Medication Administration Record revealed the Augmentin was not administered per the order, because it was not available, on the following dates and times:
-5/4/2025 at 9:00 PM
-5/5/2025 at 9:00 AM
Record review of a progress note written on 5/5/2025 at 8:01 PM by Nurse Practioner, Staff D, revealed that the resident missed two doses of the Augmentin due to the pharmacy not delivering the medication.
During an interview on 5/22/2025 at 1:07 PM with the Director of Nursing Services, she revealed that when an order is put into the electronic medical record it is sent automatically to the pharmacy to be filled. She further revealed that the expectation would be that the medication would be delivered to the facility by the next day. She further revealed that the Augmentin was unable to be administered to the resident because it was not delivered by the pharmacy and there was no Augmentin left in the facility's emergency medication supply.
Record review of the pharmacy delivery slip revealed that the resident's prescription for Augmentin was delivered on 5/5/2025 at 6:53 PM, 4 days after it was ordered from the pharmacy.
Record review of an email sent to the surveyor on 5/22/2025 at 2:09 PM from the [NAME] President of Operations of the pharmacy, revealed that an order was received on 5/1/2025 at 4:28 PM for Augmentin with the directions to administer every twelve hours for ten days. While this order was being processed, another order was received on 5/1/2025 at 5:51 PM that changed the directions to every twelve hours for seven days. When the second order for Augmentin was received, it replaced the first order. However, before the first order was discontinued, the second order was thought to be a duplicate and it was moved to the refill too soon section. This is why the medication was not filled and delivered as expected from the pharmacy. Further review of the email revealed that the facility's emergency medication supply of Augmentin ran out on 5/4/2025, and a new supply wasn't delivered by the pharmacy until 5/5/2025 at 8:35 PM.
The lack of availability of the Augmentin from the pharmacy caused the resident to miss two doses of the prescribed medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each resident's medication regimen is free from a medication error rat...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 27 opportunities for errors observed during the medication administration task, there were 2 errors resulting in an error rate of 7.41%, involving Resident ID #359.
Findings are as follows:
Review of the facility policy titled, Administering Oral Medications last revised October 2010, states in part, .Prepare the correct dose of medication .For liquid medication .Place cup on a level surface and read the poured amount at eye level to check accuracy .
Record review revealed the following physician's orders:
- Amantadine (a medication prescribed to treat stiffness or tremors) oral solution 50 milligrams (mg) per 5 milliliters (mL), administer 10 mL via G-tube (gastrostomy tube - a medical device inserted through the abdomen into the stomach to provide nutrition, fluids, and nutrients to residents) two times a day.
- Cholecalciferol (Vitamin D3) 1000 units, administer 2 tablets via G-tube daily.
During a surveyor observation of the medication administration task on 5/22/2025 at 9:22 AM with Licensed Practical Nurse, Staff E, she poured the Amantadine into the liquid measuring cup and failed to measure the amount of medication on a level surface and at eye level. Additionally, she prepared two tablets of vitamin B-12 1000 mcg (micrograms) instead of the vitamin D3 1000 units, as ordered.
Subsequently, after Staff E revealed that she was ready to administer the medication to the resident, the surveyor intervened and the incorrect dose was not administered.
During a surveyor interview with Staff E immediately following the above observation and after the surveyor intervened, she acknowledged that she failed to measure the Amantadine liquid medication dose on a level surface and at eye level. After putting the medication on a level surface and measuring at eye level, she acknowledged that the medication was over the ordered dose of 10 mL and proceeded to remove approximately 2 mL of liquid medication from the mediation cup. Additionally, Staff E discarded the 2 tablets of vitamin B-12 1000 mcg, acknowledged that she prepared the wrong vitamins, and prepared 2 tablets of vitamin D3 1000 units, per the physician's order.
During a surveyor interview on 5/22/2025 at 10:22 AM with the Director of Nursing Services, she was unable to provide evidence that the facility ensured each resident's medication regimen is free from a medication error rate of 5% or greater.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principle...
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Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 2 of 3 units observed and for 1 of 1 resident observed with medications stored in their room, Resident ID #309.
Findings are as follows:
Review of a facility policy titled Medication Labeling and Storage dated 2021 states in part, .Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received .Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents .
1a. During the medication storage and labeling task on 5/20/2025 at 5:12 PM, in the presence of Certified Medication Technician (CMT), Staff F, observations of the 3rd Floor CMT medication cart revealed 17 medication cups labeled with residents' last names. Further observation revealed the medication cups containing multiple medications in each, were stacked on top of one another in two different drawers.
During a surveyor interview at the time of the above observation with Staff F, she indicated that she pre-poured the resident's evening and night time medications. She further indicated that she does this because she struggles with passing medications to all of the residents.
During a surveyor interview and observation on 5/20/2025 at 5:26 PM with Registered Nurse (RN), Staff C, she indicated that medications should never be pre-poured and that education was recently provided to staff regarding this. Additionally, she acknowledged the pre-poured medications in the CMT cart and stated that the medications needed to be disposed of.
During a surveyor interview and observation on 5/20/2025 at 5:32 PM with the Director of Nursing Services (DNS), she acknowledged the pre-poured medications and indicated that pre-pouring medications is against the facility's policy. Additionally, she disposed of the medications.
1b. During a surveyor observation of the 2nd Floor east side CMT medication cart on 5/20/2025 at 5:49 PM, in the presence of CMT, Staff G, revealed a medication cup, labeled with a resident's room number, containing medications in a drawer of the cart.
During a surveyor interview at the time of the above observation with Staff G, she indicated that she previously poured the medication but the nurse was in the resident's room so she did not administer it, and put it in the cart to be given at a later time.
During a surveyor interview on 5/20/2025 at 5:52 PM with RN, Staff H, s/he acknowledged the medications in the medication cup and disposed of the medications.
During a surveyor interview on 5/20/2025 at 5:57 PM with the DNS, she indicated that she would've expected the CMT to dispose of the medications if she could not administer them to the resident immediately.
2. Review of a facility policy titled Medication Labeling and Storage states in part, .The facility stores all medications and biologicals in locked compartments .The nursing staff is responsible for maintaining medication storage .
Record review reveled that Resident ID #309 was readmitted to the facility in May of 2025 with a diagnosis including, but not limited to, pain of the right shoulder.
Record review revealed a physician's order initiated on 5/13/2025 to apply Diclofenac Sodium External Gel 1 % (a nonsteroidal anti-inflammatory topical gel prescribed to relieve pain and inflammation) to both shoulders every shift.
During a surveyor observation of Resident ID #309's room on 5/20/2025 at 9:44 AM and at 10:25 AM revealed a tube of Diclofenac Sodium Gel 1% on top of the bedside table.
During a surveyor interview on 5/20/2025 at 10:25 AM with Resident ID #309, in the presence of Staff I, s/he revealed that s/he brought the medication from the hospital and has kept in his/her room since readmission. The resident further indicated that the night nurse had been applying it.
During a surveyor interview on 5/20/2025 at approximately 10:30 AM with RN Staff I, she acknowledged that the Diclofenac Sodium Gel 1% was on Resident ID #309's bedside table. Additionally, Staff I acknowledged that the medication was not supposed to be left in the resident's room.
During a surveyor interview on 5/21/2025 at 4:54 PM with the DNS, she indicated that she was made aware that the medication was stored in the resident's room. Additionally, she indicated that she would expect medications to be properly stored in the medication cart.
Apr 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on record review, staff and resident interview, it has been determined that the facility failed to ensure that each resident receives the necessary care and services to attain or maintain the hi...
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Based on record review, staff and resident interview, it has been determined that the facility failed to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical well-being for 2 of 3 residents reviewed relative to follow up appointments, Resident ID #s 1 and 2.
Findings are as follows:
Review of a community reported complaint submitted to the Rhode Island Department of Health on 4/7/2025 alleges that Resident ID #s 1 and 2 have been trying to get to appointments for his/her hernia (an abnormal exit of tissue or an organ, such as the bowel, through the wall of the cavity in which it normally resides) and a neurologist. Additionally, the report alleges that the facility did not get these appointments and that the residents had to schedule the appointments themselves after waiting almost a year.
1. Record review revealed that Resident ID #1 was admitted to the facility in April of 2023 with diagnoses including, but not limited to, spinal stenosis and diabetes.
Review of the progress notes revealed the following:
- 9/20/2024: Per the Nurse Practitioner, order for an ultrasound to rule out a hernia.
- 9/22/2024: Abdominal ultrasound report sent for review, significant for small right inguinal hernia. Completed for resident's right sided pain and swelling.
-10/4/2024: NP [Nurse Practitioner] wants to assure that a GI [Gastrointestinal] surgical consult is being scheduled, we will check w/transport/scheduler.
Record review failed to reveal evidence of a GI surgical consult.
During a surveyor interview on 4/8/2025 at 10:32 AM with Resident ID #1, s/he revealed that s/he has a hernia and requires a surgical consult. S/he stated, I asked the nurse and transport person several times over the past several months and they did nothing. So, I just called and got one for myself. Additionally, s/he revealed that s/he went to this appointment in March and provided the nurse with the paperwork from the appointment.
During a surveyor interview on 4/8/2025 at 10:32 AM with the Transport Aide, she revealed that once a consultation is ordered, an appointment slip is filled out and given to her to set up the appointment. She further revealed that she had no documentation for a GI consult for Resident ID #1 and she was unaware that s/he had recently scheduled and went to the appointment in March.
During a surveyor interview on 4/8/2025 at 11:09 AM with the outpatient GI provider's receptionist, she revealed that Resident ID #1 had an appointment in March and left with orders for the facility to obtain cardiac clearance for Resident ID #1 to have surgery to repair his/her hernia.
During a surveyor interview on 4/8/2025 at 11:42 AM with Licensed Practical Nurse, Staff A, she revealed that she was aware that Resident ID #1 had scheduled their own GI appointment and provided him/her with a Continuity of Care Form. Additionally, she revealed that she was unaware if the form was returned or what the outcome of the appointment was.
During a surveyor interview on 4/8/2025 at 11:46 AM with the NP, she revealed that she recently took over his/her care and was unaware that Resident ID #1 went to a GI specialist. Additionally, she was unaware that s/he was waiting on cardiac clearance for surgery.
Record review failed to reveal evidence of the March GI appointment or information regarding the outcome of the appointment.
During a surveyor interview on 4/8/2025 at 12:15 PM with Resident ID #1's Physician, he revealed that Resident ID #1 recently changed Nurse Practitioners, and it would have been his expectation that the facility would have scheduled and followed up on the order for a GI consult.
2. Record review revealed Resident ID #2 was admitted to the facility in March of 2023 with diagnoses including, but not limited to, diabetes and chronic obstructive pulmonary disease.
Review of the progress notes revealed the following:
-1/28/2025: lab work ordered by Nurse Practitioner, required for neuro referral. A computed tomography scan (CT scan) and a magnetic resonance imaging (MRI) also required, will schedule.
-1/30/2025: Faxed Vitamin B12 result to Neurology, part of referral packet.
-1/31/2025: B12 results reviewed with Nurse Practitioner and were advised to fax to Neurology.
During a surveyor interview on 4/8/2025 at 10:32 AM with Resident ID #s 1 and 2, they revealed that Resident ID #2 was ordered to have a Neurology consult months ago and when they asked the Transport Aide and nurse, no one could give them any information about the appointment. Additionally, Resident ID #1 stated, After we waited two months, I just called one and made the appointment for April.
Record review failed to reveal evidence that Resident ID #2 was receiving care from a neurologist.
Record review failed to reveal evidence that the CT/MRI had been scheduled as required.
During a surveyor interview on 4/8/2025 at 10:32 AM with the Transport Aide, she indicated that she did receive a referral for a neurology but the nurses do not list where to contact and was unable to complete the appointment. Additionally, she revealed that she had no appointment scheduled for a CT, MRI and there was no follow-up documentation for the neurology referral from January.
During a surveyor interview on 4/8/2025 at 11:42 AM with Licensed Practical Nurse, Staff A, she revealed that the appointment was scheduled by the resident's spouse recently.
Record review of a nursing progress note dated 3/17/2025, states in part, New Neurohealth appointment 04/25/25 .Res [resident] has own ride provided .
During a surveyor interview on 4/8/2025 at 12:15 PM with Resident ID #2's Physician, he revealed that Resident ID #2 recently changed Nurse Practitioners, and it would have been his expectation that the facility would have scheduled and followed up on the order for a neurology referral.
During a surveyor interview on 4/8/2025 at approximately 1:00 PM with the Director of Nursing Services in the presence of the Administrator, she was unable to provide evidence that the facility followed up and scheduled the appointments as ordered by the provider.
Sept 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview, it has been determined that the facility failed to protect a resident's ri...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview, it has been determined that the facility failed to protect a resident's right to be free from abuse for 1 of 3 residents reviewed, Resident ID #1.
Findings are as follows:
Record review of facility reported incident submitted to the Rhode Island Department of Health on 8/28/2024 indicates that Resident ID #2 was witnessed by staff with his/her hand under the blanket of Resident ID #1 rubbing between his/her legs asking him/her do you like that? When staff approached to separate the residents, Resident ID #2 moved his/her hand away quickly.
Record review revealed that Resident ID #1, the victim, was admitted to the facility in August of 2024 with diagnoses including but not limited to dementia, difficulty in walking, weakness, and lack of coordination.
Further review revealed a Minimum Data Set (MDS) Assessment for Resident ID #1 dated 8/28/2024 revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition.
A surveyor interview with Resident ID #1 was unable to be conducted as s/he had been discharged home prior to this survey.
Record review revealed that Resident ID #2, the perpertrator, was admitted to the facility in July of 2024 with diagnoses including but not limited to muscle wasting, epilepsy, and difficulty in walking.
Further review of Resident ID #2's medical record revealed a MDS dated [DATE] that revealed a BIMS score of 13 out of 15, indicating intact cognition.
A surveyor interview with Resident ID #2 was unable to be conducted as, due to this incident, s/he had been discharged from the facility to an acute care hospital.
During a surveyor interview with the Administrator and the Director of Nursing Services (DON) on 9/9/2024 at approximately 10:05 AM, the Administrator revealed that this incident was witnessed by staff. Additionally, he revealed that Resident ID #2 had a history of using inappropriate language towards others.
Record review of a written statement authored by Activities Staff, Staff A, dated 8/31/2024 states in part, I saw [Resident ID #2's] hand under [Resident ID #1's] blanket. [Resident ID #2] was moving [his/her] hand saying 'do you like that' on [Resident ID #1's] private parts .
During a surveyor interview with the MDS Coordinator, on 9/9/2024 at approximately 11:20 AM, she revealed that she was working at the time of the incident and that she was notified by another staff member of what had occurred between Resident ID #s 1 and 2. Additionally, she indicated that, because Resident ID #2 had a BIMS score of 13 out of 15, she believed s/he was well aware of what s/he was doing. She further revealed that because Resident ID #1 had a BIMS score of 3 out of 15, s/he would not have the cognitive ability to consent.
During a surveyor interview on 9/9/2024 at approximately 2:00 PM with the Administrator and the DON, they acknowledged that Resident ID #2 was observed touching Resident ID #1 inappropriately.
Jul 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0773
(Tag F0773)
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 promptly notify the ordering phys...
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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 promptly notify the ordering physician or a provider of laboratory results that fall outside of clinical reference ranges for 1 of 3 residents reviewed, Resident ID #1.
Findings are as follows:
Review of a community reported complaint submitted to the Rhode Island Department of Health on [DATE] alleges in part, .I was called by the nurse at [facility] .told that [resident] was having a hard time breathing and there was some blood in [his/her] stool so they were going to call an ambulance and have [him/her] transported to the hospital .the attending and a surgeon informed us that [resident] had a ruptured intestine and had sepsis [a life threatening complication of an infection] .[s/he] died shortly after .
Record review revealed the resident was admitted to the facility in January of 2022 with a diagnosis including, but not limited to, alcoholic cirrhosis of liver without ascites (abnormal build up of fluid in the abdomen).
Record review revealed a physician's order with a start date of [DATE] for a basic metabolic panel (common blood test that measures kidney function, blood sugar, and electrolyte balance) and a complete blood count (common blood test that screens for disorders affecting your blood cell counts) every 6 months on the 23rd of each month for labs.
Review of a document titled, Lab Results Report dated [DATE] revealed the following abnormal lab results including, but not limited to:
- [NAME] Blood Cells (WBC, part of your immune system that protects your body from infection): 13.0 K/uL (thousands per cubic milliliter). Normal range is 4.0 - 10.0 K/uL. An elevated WBC count may be indicative of an infection.
- Monocytes (a type of WBC that fight infections): 1.35 K/uL. Normal range is 0.2 - 1.0 K/uL. An elevated monocyte count may be indicative of an infection, inflammation, and other health issues.
- Hemoglobin (a protein found in red blood cells that carries oxygen to your tissues): 11.1 g/dL (grams per deciliter). Normal range is 14.0 - 18.0 g/dL. A low hemoglobin level may occur from blood loss.
Record review failed to reveal evidence that a provider was notified of the lab results from [DATE].
Record review of a progress note dated [DATE] at 10:03 AM revealed that the resident was noted to have trouble breathing, a bloated abdomen, and rectal bleeding, and was subsequently transferred to the hospital via rescue.
During a surveyor interview on [DATE] at 9:33 AM with the Unit Manager, Registered Nurse, Staff A, she revealed that when they recieve lab results, staff will report them to the provider and document in the progress notes that the labs were reported and if there are any new orders or not.
During a surveyor interview on [DATE] at 10:39 AM with the Nurse Practitioner, Staff B, she revealed that she was away during that time, therefore she was unaware of the lab results. She further revealed that the labs should have been reported to another provider in her absence. She would have expected the labs to have been reported that same day to a provider. Additionally, she indicated that she would have ordered follow up lab work based on the lab results including, encouraging fluid intake, a chest X-Ray, possibly a urine culture, and to repeat the same labs in 2-3 days and include a procalcitonin (a blood test to help diagnose or rule out a bacterial infection or sepsis).
During a surveyor interview on [DATE] at 11:56 AM with the Director of Nursing Services, she revealed that she would expect staff to have reported the labs and document in a progress note. She was unable to provide evidence that a provider reviewed or acted upon the resident's labs.
Jun 2024
1 deficiency
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 provide a safe and sanitary environment to help prevent the transmission of infect...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide a safe and sanitary environment to help prevent the transmission of infections related to implementing a water management program based upon industry standards and/or the Centers for Disease Control and Prevention (CDC) toolkit.
Findings are as follows:
Record review of the CDC document titled, Developing a Water Management Program to Reduce Legionella [a bacteria that may cause a very serious type of lung infection] Growth & Spread in Buildings, dated June 2021, version 1.1 states in part, .The key to preventing Legionnaires' disease is maintenance of the water systems in which Legionella may grow .Water stagnation: Encourages biofilm growth and reduces temperature and levels of disinfectant. Common issues that contribute to water stagnation include .reduced building occupancy .Stagnation can also occur when fixtures go unused, like a rarely used shower .
A. Record review of the facility's water management binder failed to reveal evidence that the water flow assessment identified areas where legionella could grow and spread.
B. During surveyor observations on 6/5/2024 at approximately 12:10 PM with the Maintenance Director and the Regional Plant Operations Director, the second and fourth floor tubs were observed being used as storage.
During a surveyor interview with the Maintenance Director and the Regional Plant Operations Director following the above observation, they acknowledged that both tubs were still functioning. They were unable to provide evidence that both tubs have been flushed regularly to maintain the water quality.
Further record review failed to reveal evidence that the facility was monitoring and flushing infrequently used fixtures including, but not limited to, the second and fourth floor tubs.
During a surveyor interview with the Regional Plant Operations Director and Administrator on 6/5/2024 at approximately 2:00 PM, they were unable to provide evidence that the facility had a water flow assessment that identified areas where legionella could grow and that the second and fourth floor tubs were flushed regularly to prevent the growth of legionella. Additionally, the facility was unable to provide evidence that they maintained or implemented a water management program based upon industry standards and the CDC toolkit for the prevention of Legionella, as required.
Mar 2024
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
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, record review, staff, resident and resident representative interviews, it has been determined th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, record review, staff, resident and resident representative interviews, it has been determined that the facility failed to treat each resident with respect and dignity, and is cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life relative to assistance with toileting and communication with a resident whose primary language is not the dominant language of the facility, Resident ID #2.
Findings are as follows:
Review of a facility reported incident submitted to the Rhode Island Department of Health on 3/25/2024 alleges that a Nursing Assistant (NA) punched the resident in his/her leg.
Review of an undated facility policy titled, Translation and/or Interpretation Services states in part, .This facility will ensure that individuals who are non-English speaking or have a communication disability will have access to translation and/or interpretation methods .
1. The facility will determine a means to communicate with any resident admitted who is non-English speaking .
2. The facility utilizes Interactive Voice Response (IVR) to connect to an interpreter for limited English proficient resident.
3. The facility utilizes Cue Cards (Communication Boards) to assist health professionals and residents who have English language difficulties or communication difficulties to communicate .
Record review revealed the resident was admitted to the facility in January of 2024 with diagnoses including, but not limited to, hemiplegia (paralysis on one side of the body) and fracture of the lateral malleolus of the left fibula (ankle fracture).
Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. Additionally, the MDS revealed that the resident's preferred language is not English, and s/he wants or needs an interpreter to communicate with health care staff.
Record review of a care plan dated 1/3/2024 revealed a focus area indicating that the resident requires the services of an interpreter because English is not his/her primary language. Interventions include, but are not limited to the following:
- Monitor the resident for signs of withdrawing from attempts to communicate such as symptoms of anger or feelings of frustration.
- Provide him/her with a communication board including common words in English and the resident's preferred language to aide in communication for simple daily needs.
- Use the Language Line [which includes Video Remote Interpretation Services] as needed to provide adequate communication with the resident.
During a surveyor interview on 3/28/2024 at 1:02 PM with the resident and the resident's representative via telephone, the representative translated the following. It was revealed that at some time during the 11:00 PM - 7:00 AM shift on 3/23/2024 into 3/24/2024, the NA (Staff B) assigned to the resident did not assist him/her with transferring from bed to the bathroom as s/he requested and preferred. The resident's representative indicated that the resident wanted to use the bathroom however the NA gave him/her the bedpan instead. Additionally, they indicated that physical therapy had recently cleared the resident for transferring out of bed. Prior to that s/he was not able to bear weight on his/her lower extremity. Staff B was the only staff member present in the room. The resident's representative further revealed that the resident urinated in the bedpan because s/he had no other choice. The NA did not respond to his/her requests to use the bathroom. It was further revealed that at some point the bedpan was filled with urine and the urine had spilled. The resident believes this caused the staff member to become upset and hit him/her on the right leg with a closed fist.
During a surveyor observation at the time of the above-mentioned interview, a communication board was observed pinned on the wall near the resident's bed. The communication board contained pictures of common items labeled in the resident's preferred language. Additionally, the resident's bathroom is approximately 10 feet from his/her bed.
During a surveyor telephone interview on 3/28/2024 at 3:08 PM, with Staff B, she revealed that she was the NA assigned to provide care to Resident ID #2 during the 11:00 PM - 7:00 AM shift on 3/23/2024 into 3/24/2024. Additionally, Staff B revealed that she entered the resident's room at some time during the shift to provide the resident with care. She further indicated that the resident was speaking in his/her primary language and appeared furious and began throwing things. Staff B indicated that she does not speak the resident's primary language and acknowledged that she did not utilize an interpreter or the communication board and acknowledged she should have. Furthermore, Staff B indicated that she got the nurse to assist her due to the resident's frustrations and indicated that she did not assist the resident to the bathroom.
During a surveyor telephone interview on 3/29/2024 at 1:22 PM, with Licensed Practical Nurse (LPN) Staff C, she revealed that she was Resident ID #2's assigned nurse on the 11:00 PM -7:00 AM shift on 3/23/2024 into 3/24/2024. Staff C further indicated that Staff B asked her to go into the resident's room towards the end of care because Staff B was having an issue with the him/her. Staff C indicated that the resident pointed to his/her leg and said something in his/her primary language. She further revealed that she does not speak or understand the resident's primary language. Staff C acknowledged that she did not utilize an interpreter, the communication board or the Language Line to communicate with the resident and acknowledged she should have. Staff C further revealed that Staff B does not usually work on the resident's unit and does not believe that she knew the resident goes into the bathroom instead of using the bedpan. Staff C acknowledged that she did not provide Staff B with that information in shift report and acknowledged she should have.
During a surveyor interview on 3/29/2024 at 2:43 PM with the Director of Nursing Services (DNS), she revealed that she would expect staff to utilize an interpreter, the communication board, or the Language Line when assisting Resident ID #2 with care to facilitate communication with him/her. Additionally, the DNS was unable to provide evidence that Resident ID #2 was provided with respect and dignity.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that all alleged violation...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made. If the events that cause the allegation involve abuse or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to other officials (Rhode Island Department of Health;RIDOH), in accordance with State law, for 1 of 1 resident reviewed for an allegation of abuse, Resident ID #1.
Findings are as follows:
Record review of a community reported complaint submitted to the RIDOH on 3/21/2024, alleges that the facility failed to follow up on an allegation of staff to resident sexual abuse.
Record review of a facility policy last revised in September of 2022 titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, states in part, .All reports of resident abuse .are reported to local, state and federal agencies (as required by current regulations) .
During a surveyor interview with the complainant on 3/22/2024 at 11:36 AM, s/he revealed that the resident reported an allegation that a male staff member inserted their finger in the resident's rectum during care. Additionally, s/he indicated the facility was made aware of this allegation sometime in January or February of 2024 and indicated the facility failed to follow up on this allegation.
Record review revealed the resident was admitted to the facility in December of 2023 with diagnoses including, but not limited to, diabetes, cerebrovascular accident (stroke) and depression.
Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 13 out of 15, indicating intact cognition.
Surveyor interviews with the resident and his/her family member were attempted, however, unsuccessful throughout the duration of the investigation.
During a surveyor interview on 3/22/2024 at 1:00 PM, with the Director of Nursing Services (DNS), she indicated that she was not aware of Resident ID #1's allegation of sexual abuse.
During a surveyor telephone interview on 3/22/2024 at 2:10 PM with the Social Services Director (SSD), she revealed that she participated in a telephone care conference held with the resident, the resident's family member, Staff A, and the facility's Wound Nurse in February of 2024. She was unable recall the date. Additionally, the SSD revealed that during the conference, the resident reported that a male staff member inserted their finger in his/her rectum. The SSD further indicated that she immediately reported the allegation to the Administrator.
During a surveyor interview with the Administrator on 3/22/2024 at approximately 3:00 PM, in the presence of the DNS and the Regional Director of Clinical Services, he acknowledged that he was made aware of Resident ID #1's allegation of staff to resident sexual abuse on 2/19/2024 after it was reported to staff during a care conference. Furthermore, the Administrator acknowledged that he did not report the allegation to RIDOH or other officials in accordance with State and Federal law and per the facility's policy, until the surveyor questioned him, which was approximately four weeks after he was made aware of the resident's allegation of staff to resident sexual abuse.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to provide evidence that all alleged...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to provide evidence that all alleged violations are thoroughly investigated for 1 of 1 resident reviewed for allegations of abuse, Resident ID #1.
Findings are as follows:
Record review of a community reported complaint submitted to the Rhode Island Department of Health (RIDOH) on 3/21/2024, alleges that the facility failed to follow up on an allegation of staff to resident sexual abuse.
Record review of a facility policy last revised in September of 2022 titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, states in part, .All reports of resident abuse .are .thoroughly investigated by facility management .Within five (5) business days of the incident, the administrator will provide a follow-up investigation report .
During a surveyor interview with the complainant on 3/22/2024 at 11:36 AM, s/he revealed that the resident reported an allegation that a male staff member inserted their finger in the resident's rectum during care. Additionally, s/he indicated the facility was made aware of this allegation some time in January or February of 2024 and indicated the facility failed to follow up on this allegation.
Record review revealed the resident was admitted to the facility in December of 2023 with diagnoses including, but not limited to, diabetes, cerebrovascular accident (stroke) and depression.
Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 13 out of 15, indicating intact cognition.
During a surveyor telephone interview on 3/22/2024 at 2:10 PM with the Social Services Director (SSD), she revealed that she participated in a telephone care conference held with the resident, the resident's family member, Staff A, and the facility's Wound Nurse in February of 2024. She was unable recall the specific date. Additionally, the SSD revealed that during the conference, the resident reported that a male staff member inserted their finger in his/her rectum. The SSD further indicated that she immediately reported the allegation to the Administrator.
During a surveyor interview with the Administrator on 3/22/2024 at approximately 3:00 PM, in the presence of the DNS and the Regional Director of Clinical Services, he acknowledged that he was made aware of Resident ID #1's allegation of staff to resident sexual abuse on 2/19/2024 after it was reported to staff during a care conference. Furthermore, the Administrator acknowledged that the facility did not conduct a thorough investigation as required.
Feb 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident's drug regimen is free from unnecessary drugs for 2 of 3 residents reviewed, Resid...
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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 2 of 3 residents reviewed, Resident ID #s 1 and 2.
Findings are as follows:
1. Record review revealed Resident ID #1 was admitted to the facility in May of 2023 with diagnoses including, but not limited to chronic diastolic heart failure and atherosclerotic heart disease (thickening or hardening of the arteries).
Record review of the order summary revealed the following physician orders:
- Hydralazine HCL 25 milligrams (mg) give two times daily for hypertension. Hold if Systolic Blood Pressure (SBP) is less than 110 or - Heart rate (HR) is less than 60. The order start date was 1/31/2024 and the discontinue date was 2/18/2024.
Record review of the February 2024 Medication Administration Record (MAR) revealed the Hydralazine was given outside of parameters on the following dates and times:
2/1/2024 at 9:00 AM with a documented HR of 59
2/9/2024 at 9:00 AM with a documented HR of 57
2/12/2024 at 9:00 AM with a documented HR of 54
2/13/2024 at 5:00 PM with a documented HR of 57
Additional record review revealed a physician's order for Metoprolol Succinate extended release 25 mg give 1/2 tablet once daily for hypertension. Hold for heart rate less than 60. The order start date was 12/30/2023 and the discontinue date was 1/29/2024.
Record review of the January 2024 MAR revealed the Metoprolol Succinate was given outside of parameters on the following dates and times:
1/1/2024 at 9:00 AM with a documented HR of 56
1/3/2024 at 9:00 AM with a documented HR of 56
1/4/2024 at 9:00 AM with a documented HR of 58
1/16/2024 at 9:00 AM with a documented HR of 57
1/20/2024 at 9:00 AM with a documented HR of 54
1/24/2024 at 9:00 AM with a documented HR of 55
2. Record review revealed Resident ID #2 was admitted to the facility in November of 2023 with diagnoses including, but not limited to orthostatic hypotension (dizziness when standing after sitting or lying down) and hypertension.
Record review of the order summary revealed the following physician orders:
Amlodipine besylate 2.5mg give once daily for hypertension. Hold if SBP is less than 110 and if HR is less than 60. Order start date of 11/21/2023.
Losartan Potassium 50 mg once daily for hypertension. Hold if SBP is less than 110 and if HR is less than 60. Order start date is 11/21/2023.
Record review of the February 2024 MAR revealed the Amlodipine Besylate, and the Losartan Potassium were given outside of parameters on the following dates and times:
2/12/2024 at 9:00 AM with a documented HR of 55
2/19/2024 at 9:00 AM with a documented HR of 58
Record review of the January 2024 MAR revealed the Amlodipine Besylate, and the Losartan Potassium were given outside of parameters on the following dates and times:
1/6/2024 at 9:00 AM with a documented HR of 50
1/24/2024 at 9:00 AM with a documented HR of 59
During a surveyor interview on 2/20/2024 at 12:59 PM with the Director of Nursing Services, she acknowledged the above medications were administered outside of the ordered parameters.
Feb 2024
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
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a resident received incontinence care as per the resident's plan of care for 1 of 1 resident observed, Resident ID #1.
Findings are as follows:
Record review of the community reported complaint sent to the Department of Health (DOH) on 2/5/2024 alleged that .someone from DOH needs to pay attention to these poor, vulnerable residents, They sit all day in 1 position at table .
Record review revealed the resident was admitted to the facility in November of 2022 with diagnoses including but not limited to; Alzheimer's disease, impaired visual function and lack of coordination.
A review of an Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 6 out of 15, indicating severe cognitive loss. Additionally, the MDS indicates the resident required extensive assistance from staff for transfers, hygiene and toileting.
Record review of the resident's current plan of care revealed the resident has self care performance deficits related to cognitive impairment and decreased mobility. This care plan also indicates the resident has a communication deficit related to Alzheimer's disease.
Record review revealed a care plan dated 5/28/2023 for .I have urinary incontinent r/t [related to] cognitive impairment . with interventions including but not limited to .Establish voiding pattern .Check resident at regular intervals and provide incontinence care as needed .
Surveyor observation of the resident on 2/7/2024 from 9:00 AM through 1:55 PM (approximately 5 hours) revealed the resident sitting in his/her wheelchair in the dining room. During this observation period, incontinence care was not provided to this resident.
During a surveyor interview with a nursing assistant, Staff A on 2/7/2024 at 11:02 AM, she revealed that she is a primary nursing assistant for the resident and she has been caring for the resident for approximately 8 months.
During an additional surveyor interview with Staff A on 2/7/2024 at 1:50 PM, she revealed she did not take the resident to the bathroom and she only stood [him/her] up quick from the wheelchair from 9:00 AM through 1:55 PM while the resident was in the dining room.
During a surveyor observation in the presence of Staff A, of the resident on 2/7/2024 at 1:55 PM revealed the resident's incontinence pad was wet with urine and soiled with brown matter.
During a surveyor interview with the Director of Nursing Services (DNS) on 2/8/2024 at 8:50 AM, she revealed they do not have policy and procedure relative to incontinence care. The DNS revealed staff should provide incontinence care to the resident at regular intervals, between breakfast and lunch and then after lunch. The DNS further revealed standing the resident up is not adequate way to check for incontinence. Additionally, the DNS further revealed her expectation is that Resident ID #1 would be taken to bathroom for toileting and checking for incontinence.
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
Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmis...
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Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases for 1 of 3 residents reviewed who tested positive for Influenza A, Resident ID #1.
Findings are as follows:
Record review of an undated facility's policy and procedure for Influenza Outbreak, states in part
.2. Contact and droplet precautions are implemented during care of a resident with suspected or confirmed influenza, in addition to standard precautions used with all residents regardless of symptoms.
3. Contact and droplet precautions are continued for seven (7) days after illness onset or until after 24 hours the resolution of fever and respiratory symptoms, whichever is longer. Precaution may continue for longer periods based on clinical judgement .
During a surveyor interview with the Infection Control Nurse on 2/7/2024 at 11:20 AM, she revealed they have 40 residents on the third floor unit and 16 residents had tested positive for Influenza A since 1/28/2024.
Record review revealed Resident ID #1 was admitted to the facility in November of 2022 with diagnoses including but not limited to Alzheimer's disease. Further record review revealed the resident tested positive for Influenza A on 2/1/2024.
Surveyor observation on 2/6/2024 at 12:05 PM revealed signs posted on the wall near the resident's room door. One sign was for Droplet Precautions which indicates .Clean their hands including before entering and when leaving the room. Make sure their eyes nose and mouth are fully covered before room entry . Another sign was for Contact Precautions which indicates EVERYONE MUST: Clean their hands including before entering and when leaving the room. PROVIDER AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit .
Surveyor observation on 2/7/2024 at 8:55 AM revealed two nursing assistants, Staff A and B assisting the resident with transferring him/her to the wheelchair. The surveyor noted that both Staff A and B were wearing only surgical masks. Both staff members failed to wear eye protection, gowns and gloves as per the signs posted near the door.
During an additional observation on 2/7/2024 at 1:55 PM, revealed Staff A and B taking the resident back into his/her room for toileting. Upon entering the room, the two staff were observed wearing only a surgical mask. Staff A and B failed to apply eye protection, gowns and gloves. When questioned by the surveyor as to why they did not don eye protection, gowns and gloves before entering the room, Staff A revealed the resident has the Flu and staff only need to wear a mask. The surveyor then asked her to read the signs posted near the door. After reading the signs, Staff A revealed she was not aware that she needed to wear the eye protection, gown and gloves upon entering the room.
Additionally, surveyor observation on 2/8/2024 at 9:05 AM revealed an Activity Staff, Staff C standing next to the resident's bed, wearing only a surgical mask. The surveyor noted that Staff C's clothing was touching the resident's blanket and bed while talking to the resident.
Furthermore, the surveyor noted that Staff C walked towards the resident's roommate (Resident ID #3) and moved his/her bedside table and spoke with Resident ID #3. Staff C then exited the room and failed to performed hand hygiene.
During a surveyor interview after the observation with Staff C on 2/8/2024 at 9:10 AM, Staff C acknowledged that she failed to apply eye protection, gown, and gloves before entering the room and perform hand hygiene upon leaving the room.
During a surveyor interview with the Infection Control Nurse on 2/8/2024 at 9:45 AM, she revealed residents who test positive for Influenza A will be placed on isolation for at least a 7 full days.
The Infection Control Nurse further revealed that Resident ID #1 tested positive for Influenza on 2/1/024. Additionally, she stated that her expectation is for staff to wear the appropriate PPE (personal protective equipment) and perform hand hygiene as indicated.
During a surveyor interview with the Director of Nursing Services on 2/8/2024 at approximately 11:00 AM, she was unable to provide evidence that the facility maintained an infection prevention and control program to help prevent the transmission of Influenza A.
Oct 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the ...
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Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to staff entering a COVID-19 (SARS-CoV-2) positive room without wearing personal protective equipment (PPE) for 1 of 3 residents reviewed for COVID-19, Resident ID #4.
Findings are as follows:
According to the Centers for Disease Control and Prevention guidance, last updated on May 8, 2023, the recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection include the following:
.Personal Protective Equipment- Health Care Personnel who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) .
Review of a facility provided document titled Covid-19 Infection Control Facility Management Interventions states in part, .source control will be instituted to ONLY the areas affected (resident room, unit) based on the facility review, under the following situation .a. If staff or resident have suspected or confirmed SARS-CoV-2 infection .b. If staff or residents had close contact or higher risk exposure with someone with SARS-CoV-2 infection, for 10 days after their exposure; or c. if residents reside or staff work on a unit/area of the facility experiencing a SARS-CoV-2 outbreak .the facility will implement universal use of personal protective equipment (PPE). Including the implementation of NIOSH-approved N 95 or equivalent, eye protection for HC [health care worker] during such resident encounter .
Record review of a community reported complaint sent to the Rhode Island Department of Health on 10/13/2023 alleges that Resident ID #3 is concerned that staff are not wearing PPE when they are caring for his/her roommate, Resident ID #4, who is positive for COVID-19.
Review of Resident ID #4's record revealed s/he was admitted to the facility in October of 2023 with diagnoses including, but are not limited to, generalized anxiety disorder, depression, and muscle weakness.
Additional record review revealed a physician's order dated 10/13/2023 which indicated that the resident is on droplet precautions (prevention of the spread of pathogens that are passed through respiratory secretions) for COVID-19 through 10/23/2023.
During a surveyor observation on 10/17/2023 at 9:55 AM, Registered Nurse, Staff A was observed entering the room of Resident ID #s 3 and 4 without wearing a gown, face shield or goggles.
During a surveyor interview following the above observation with Staff A, she acknowledged that she was not wearing a gown or eye protection when she entered a COVID-19 positive room. She further revealed that she only went in the room to answer the resident's call light and didn't physically care for the resident. Additionally, she indicated that she was not aware that she needed to wear a gown and eye protection when entering a COVID-19 positive room.
During a surveyor interview on 10/17/2023 at 10:00 AM with Resident ID #3 s/he revealed that most staff do not wear PPE when entering his/her room even though his/her roommate tested positive for COVID-19.
During a surveyor interview on 10/17/2023 at 1:36 PM with the Infection Control Nurse, she revealed that everyone should don an N 95 mask, gown, gloves, and eye protection before entering a COVID-19 positive room. She acknowledged that Staff A should have been wearing a gown and eye protection prior to entering Resident ID # 3 and 4's room.
Oct 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with prof...
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Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to 1 of 1 resident reviewed for a non-pressure related skin conditions, Resident ID #1.
Findings are as follows:
Record review of a facility policy titled, Skin tears - abrasions and minor breaks, care of, states in part, .The purpose of this procedure is to guide the prevention and treatment of abrasions, skin tears, and minor breaks in the skin .1. Obtain a physician's order as needed. Document physician notification in medical record .
Record review revealed the resident was admitted to the facility in April of 2022 with diagnoses including, but not limited to, non-infective disorder of the lymphatic vessels (small tubes that carry fluid) and lymph nodes (small bean shaped organs that fight infection) and seborrheic dermatitis (skin condition).
Record review revealed a physician order dated 6/9/2023 to conduct weekly skin checks on Thursday's during the 3:00 PM-11:00 PM shift. Further review of the order revealed directions to complete under the evaluations tab.
Record review of the evaluations tab revealed skin check documentation on the following dates and times:
-8/31/2023 7:26 PM: Skin impairment noted (yes), Is this a new skin impairment (No), Rash, Description: Right thigh, left arm, left knee, top of head
-9/7/2023 2:23 PM: Skin impairment noted (yes), Is this a new skin impairment (No), Rash, Description: Skin itchy rashes on both upper limbs and both lower limbs
-9/14/2023 5:31 PM: Skin impairment noted (yes), Is this a new skin impairment (No), Rash, Description: Rashes on face, neck, lower and upper limbs
-9/21/2023 5:31 PM: Skin impairment noted (yes), Is this a new skin impairment (No), Rash, Description: on back, neck, Bilateral lower and Bilateral upper extremities
-9/28/2023 5:47 PM: Skin impairment noted (yes), Is this a new skin impairment (No), Rash, Description: Red, itchy, raised rash on face, bilateral upper and lower extremities
-10/3/2023 12:34 PM: Skin impairment noted (yes), Is this a new skin impairment (No), Description: Rash, self-induced scratches
During a surveyor observation on 10/4/2023 at 10:52 AM with the Social Worker, Staff A, the resident was observed with two open areas to his/her right upper extremity, round in appearance, approximately two centimeter (cm) wide, with redness extending out and surrounding the areas approximately one and a half inches wide. The left forearm had three scabbed areas, round in appearance approximately two and a half cm wide with redness surrounding the area extending approximately one inch beyond the opening. The left thigh had three open areas approximately two cm wide, round in appearance with approximately one inch of redness surrounding each area.
During a surveyor observation and interview on 10/4/2023 at 11:15 AM with Licensed Practical Nurse, Staff B, she acknowledged the open areas to the resident's bilateral upper extremities and right lower leg.
Further review of the resident's physician orders failed to reveal evidence of a treatment order for the above-mentioned skin areas.
During a surveyor interview on 10/4/2023 at 11:45 AM with the Wound Nurse, she revealed she was not aware of the resident's skin areas.
During a subsequent interview on 10/4/2023 at 2:27 PM with Staff B, she further revealed she had been applying skin prep to the resident's rash and it had been there for a week. She was unable to provide evidence of a skin prep order for the resident's skin.
During a surveyor interview on 10/4/2023 at 2:40 PM with the Nurse Practitioner, she revealed that she was not notified by the facility of the skin condition present in the above-mentioned skin checks. She further revealed she would expect the facility to notify her of the skin condition for her to initiate a treatment order.
During a subsequent surveyor observation and interview on 10/4/2023 at 3:00 PM in the presence of the Director of Nursing. She acknowledged the open areas to the resident's bilateral upper extremities and right lower extremity. Further she was overheard stating to the resident, I think it is getting a little infected.
During a surveyor interview with Registered Nurse, Staff C, who authored the skin check documented 9/28/2023, he revealed in part, the rash has been there for a while .opening just started recently . Additionally, Staff C revealed, he did not notify the resident's provider of the resident's skin condition.
During a surveyor interview on 10/4/2023 at 3:30 PM with the Director of Nursing, she was unable to provide evidence of a treatment order for the resident related to the identified skin condition. Further, she was unable to provide evidence that the Nurse Practitioner was notified of the above-mentioned skin condition.
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
Deficiency F0692
(Tag F0692)
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 address the needs of every resident, including but not limited to, the resident at ...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to address the needs of every resident, including but not limited to, the resident at risk, or already experiencing impaired nutrition for 1 of 1 resident experiencing severe weight loss, Resident ID #4.
Findings are as follows:
Review of the facility's policy titled, Weight Assessment and Intervention states in part, .Any weigh change of 5% or more since the last weight assessment is retaken by the next day for confirmation .The threshold for significant unplanned and undesirable weight loss will be based on the following criteria .1 month-5% weight loss is significant; greater than 5% is severe .
Record review revealed Resident ID #4 was admitted to the facility in April of 2023 with diagnoses including but not limited to, type 2 diabetes and end stage renal disease. In addition, it revealed that the resident receives dialysis 3 times per week.
Record review of the initial nutritional review completed on 4/12/2023 revealed that the resident's weight was 228 pounds (Lbs) at the time of his/her admission.
Additional record review revealed a care plan initiated on 6/14/2023 indicating that s/he has nutritional problems or potential nutritional problems.
Further record review revealed the following documented weights:
-6/12/2023 214 Lbs had a line across with a note dated 6/28/2023 documented by Registered Dietitian (RD), Staff A, revealing it was an incorrect weight
-6/15/2023 220 Lbs
-7/3/2023 204 Lbs
Record review reveals that a severe weight loss of 16 Lbs or 7% weight loss occurred in a period of 18 days.
Record review of the dialysis center weight report revealed the following documented weights:
Pre Weight:
-7/3/2023 207
-6/30/2023 205
-6/28/2023 208
-6/26/2023 207
-6/23/2023 209
-6/21/2023 210
-6/19/2023 213
-6/16/2023 215
-6/14/2023 213
-6/12/2023 220
Post Weight:
-7/3/2023 205
-6/30/2023 205.7
-6/28/2023 204
-6/26/2023 205
-6/23/2023 207
-6/21/2023 208
-6/19/2023 209
-6/16/2023 209
-6/14/2023 211
-6/12/2023 216
Record review of the dialysis Dietician Monthly Review dated 6/27/2023 revealed Pt [patient] with significant weight loss and extreme low albumin. Spoke to RD at SNF [Skilled Nursing Facility] and recommended a liberalized diet. Pt encouraged to request any foods that are appealing .
Record review of a facility progress notes revealed a nursing note dated 6/30/2023 revealing that the resident returned from dialysis and his/her post treatment weight was 205.7 Lbs.
Further record review failed to reveal evidence that the Nurse Practioner (NP) or the physician were notified of the severe weight loss or that any interventions were put in place for Resident ID #4's severe weight loss that occurred from 6/12/2023 to 7/3/2023 until it was brought to the facility's attention by the surveyor.
During a surveyor interview on 7/3/2023 at approximately 12:00 PM with the resident s/he revealed that s/he does not like the food at the facility and that they do not offer any choices that s/he likes. In addition the resident acknowledged that s/he has lost weight since his/her admission to the facility.
During a surveyor interview on 7/6/2023 at approximately 9:30 AM with NP, Staff C, she revealed that she was not notified of Resident ID #4's significant weight loss until 7/3/2023 after the surveyor had brought the severe weight loss to the attention of the facility.
During a surveyor interview on 7/6/2023 at 12:52 PM with Staff A, she revealed that she was not notified of the severe weight loss until 7/5/2023. She could not explain why she documented on 6/28/2023 that the weight obtained on 6/12/2023 was incorrect.
During a surveyor interview on 7/6/2023 at approximately 3:40 PM with the Director of Nursing Services in the presence of the Regional Nurse she was unable to provide evidence that the NP or the physician were notified of the severe weight loss or that any interventions were put in place for Resident ID #4's severe weight loss that occurred from 6/12/2023 to 7/3/2023 until it was brought to the facility's attention by the surveyor.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, disp...
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Based on record review and staff interview, it has been determined that the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) to meet the needs of each resident for 2 of 4 residents reviewed, Resident ID #s 2 and 3.
Record review of a community reported complaint submitted to the Rhode Island Department of Health on 6/30/2023 alleges, .I was advised that two of my medications were unavailable as 'someone forgot to reorder/refill them' .
1. Record review revealed Resident ID #2 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, type 2 diabetes mellitus with ketoacidosis (serious complication of diabetes is characterized by uncontrolled hyperglycemia, metabolic acidosis, and increased body ketone concentration) with coma, type 2 diabetes mellitus with diabetic nephropathy (deterioration of kidney function) and hypoglycemia.
Record review revealed the following physician orders:
-Insulin isophane (NPH) (increase insulin levels in your body) 10 units; subcutaneously twice a day
-Fesoterodine (treat overactive bladder symptoms such as loss of bladder control or frequent need to urinate). 8 milligram (mg) oral tablet extended release, by mouth, once a day
-Myrbetriq (medicine used to treat overactive bladder) 50 mg oral tablet, extended release, by mouth, once a day.
Record review of the April 2023 Medication Administration Record (MAR) failed to reveal evidence that Resident ID #2 received the following medications on dates and times listed below:
-5/26 -Insulin isophane (NPH) 10 units evening dose
-5/27 -Insulin isophane (NPH) 10 units morning dose
- 5/27, 5/28, 5/29 and 5/30/2023 -Fesoterodine and Myrbetriq
Record review of the June 2023 MAR failed to reveal evidence that Resident ID #2 received the following medications on the dates and times below:
-6/1- Fesoterodine
-6/1, 6/2, 6/4, 6/5, 6/6, 6/7, 6/8, 6/9, 6/10, 6/11, 6/12/2023- Myrbetriq
Record review failed to reveal evidence that the physician or the Nurse Practitioner (NP) were notified that the resident did not receive his/her insulin on 5/26 (one dose) and 5/27 (one dose) for a total of 2 doses not administered.
Further review failed to reveal evidence that the physician or the NP were notified that the resident did not receive the Fesoterodine on 5/27, 5/28, 5/29, 5/30 and 6/1 for a total of 5 doses not administered.
Additional review of the records failed to reveal evidence that the physician or the NP were notified that the resident did not receive the Fesoterodine on 5/27, 5/28, 5/29, 5/30 and 6/1/2023 for a total of 5 doses not administered.
Record review of a progress noted dated 6/2/2023 revealed that the NP, Staff C, was notified on 6/2/2023 that Resident ID #2 had not received the Myrbetriq or the Fesoterodine since his/her admission.
During a surveyor interview on 7/6/2023 at 9:33 AM with Staff C she revealed that she was unaware that Resident ID #2 did not receive the above medications as ordered.
During a surveyor interview on 7/6/2023 at 9:07 AM with contracted pharmacist, she revealed that the Myrbetriq and Fesoterodine were never released to the facility for Resident ID #2.
2. Record review revealed Resident ID #3 was admitted to the facility in June of 2023 with diagnoses including, but not limited to, Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and schizoaffective disorder.
Record review revealed the following medication orders:
-Sinemet 25-100 mg (prescribed treatments for Parkinson's disease) tablet . Take 2 and a half tablets by mouth 3 times per day.
-Sinemet 25-100mg tablet. Take 1 tablet at bedtime.
-Depakote 125 mg (anticonvulsant) capsule delayed release sprinkle . Take 2 capsules by mouth 2 times daily (morning and bedtime)
-Clozapine 50 mg (antipsychotic) 3 tablets at bedtime
Record review of the June 2023 MAR revealed the resident did not receive the following medications on the dates and times below:
-Sinemet 25-100 mg. 1 tablet at bedtime on 6/8
-Sinemet 25-100 mg. 2 and a half tablets- morning dose on 6/9
-Depakote 125 mg 2 capsules- morning dose on 6/9
-Clozapine 50 mg 3 tablets at bedtime on 6/8/2023
During a surveyor interview on 7/3/2023 at approximately 3:30 PM with the Director of Nursing and the Regional Nurse they were unable to explain the reason why Resident ID #s 2 and 3 did not receive the above medications as prescribed.
During a surveyor interview on 7/6/2023 at 12:34 PM with Physician Assistant (PA), Staff D, she revealed that she does not remember being notified that Resident ID #3 missed the above medications. In addition, she revealed that the general expectation is that the provider should be notified and would expect that if the nurses notified her, a note would have been added.
During an additional interview on 7/6/2023 at approximately 3:40 PM with the Director of Nursing Services in the presence of the Regional Nurse, they were unable to provide evidence that Resident ID #'s 2 and 3 did not receive their medications as ordered.
Apr 2023
4 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a resident who requires catheterization receives appropriate treatment ...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a resident who requires catheterization receives appropriate treatment and services for 1 of 1 residents reviewed relative to an indwelling catheter, Resident ID #47.
Findings are as follows:
Review of the facility policy titled, Catheter Care, Urinary revealed General Guidelines .Ensure that the catheter remains secured with a securement device to reduce friction and movement at the insertion site .
Record review revealed the resident was initially admitted to the facility in March of 2020 with diagnoses including, but not limited to, neuromuscular dysfunction of the bladder (when either the nerves or the brain cannot communicate effectively with the muscles in the bladder), presence of urogenital implants (artificial material in your urinary organs or genitals), and dementia.
Record review of the resident's care plan last revised on 3/25/2023 revealed the resident required an indwelling catheter related to a neurogenic bladder (when the relationship between the nervous system and bladder function is disrupted by injury or disease). Further review revealed an approach to provide a foley (catheter) securement device.
Record review revealed a physician's order dated 2/8/2023 for Foley Catheter to be secured to the leg with anchor device as tolerated .every shift .document refusals.
Further review revealed a physician's order dated 2/15/2023 for foley leg bag is only placed on LOWER LEG with an extension tube and stat lock (a stabilization device)! .done every time leg bag is being used.
Record review of a Continuity of Care Form dated 2/15/2023 from the urology clinic revealed consultation notes including, .Please ensure leg bag is ONLY placed on lower leg with extension tubing and Stat lock is ALWAYS used. [Resident's] meatal breakdown is worsening from lack of using stat lock and extension tubing.
Record review of the Treatment Administration Record (TAR) revealed both orders mentioned above were initialed as completed on 4/18/2023 for the 7 AM-3 PM shift by Licensed Practical Nurse (LPN), Staff A.
During a surveyor observation on 4/18/2023 at 11:29 AM, in the presence of two Nursing Assistants (NA) Staff B and Staff C, the resident's catheter leg bag was loosely hanging around his/her ankle, not secured to the lower leg. Additionally, a stat lock and extension tube was not in place, causing tension on the catheter tubing.
During a surveyor interview with Nursing Assistants (NA), Staff B and Staff C, they acknowledged there was tension on the resident's catheter due to the tubing not being secured. Additionally, Staff B and C were unaware the resident required a stat lock.
A surveyor observation on 4/18/2023 at 2:26 PM in the presence of LPN Staff A, failed to reveal that the catheter tubing was secured or that a stat lock or extension tubing were in place. Additionally, meatal erosion (a split from the opening at the tip of the penis down the penile shaft) was observed measuring approximately 3/4 inch.
During a surveyor interview immediately following the above observations with Staff A, he acknowledged that a stat lock and extension tubing should be used to secure the catheter. Additionally, he acknowledged that he documented in the TAR that the stat lock and extension tubing were in place although they were not.
During a surveyor interview on 4/18/2023 at 3:14 PM with the Director of Nursing Services, she revealed that she would expect the physician's orders to be followed.
During a surveyor interview on 4/19/2023 at 4:59 PM with the urology clinic nurse practitioner, he revealed that the resident's meatal erosion was first noted by the clinic in November of 2022. Additionally, he revealed that the penile erosion had worsened due to the mismanagement of the resident's catheter.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principl...
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Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 1 of 2 medication storage rooms and 2 of 5 medication carts observed.
Findings are as follows:
1. Surveyor observation on 4/18/2023 at 8:10 AM of a second floor medication cart, in the presence of Certified Medication Technician (CMT), Staff D, revealed one Arnuity Ellipta 200 mcg (microgram)/actuation Inhaler in use, open and not dated. Manufacturer's instructions read to discard the inhaler 6 weeks after opening.
During a surveyor interview immediately following the observation with Staff D, she acknowledged the medication should have been dated when opened.
2. During a surveyor observation on 4/18/2023 at 8:58 AM of a third floor medication cart, in the presence of CMT, Staff E, revealed one Spiriva Respimat 1.25 mcg/actuation inhaler in use, open and not dated. Manufacturer's instructions read to discard 3 months after insertion of the cartridge.
During a surveyor interview immediately following this observation with Staff E, she acknowledged the medication should have been dated when opened.
3. During a surveyor observation on 4/18/2023 at 9:50 AM of the second floor medication room, in the presence of Registered Nurse, Staff F, revealed two Lorazepam Intensol liquid bottles, located in the locked refrigerator, in use, open and not dated. Additionally, manufacturer's instructions read to discard opened bottle after 90 days.
During a surveyor interview immediately following this observation with Staff F, she acknowledged the medications should have been dated when opened.
During a surveyor interview on 4/19/2023 at approximately 2:30 PM with the Director of Nursing Services, she was unable to explain why the above-mentioned medications were not dated when opened.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records in accordance with professional standards and practices f...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records in accordance with professional standards and practices for 2 of 6 residents reviewed for nutritional intake, Resident ID #'s 30 and 357 and for 1 of 1 resident reviewed relative to indwelling catheters, Resident ID #47.
Findings are as follows:
1. Review of the facility policy titled, Food and Nutrition Services, states in part, .Nursing personnel, with the assistance of the food and nutrition services staff, will evaluate and document intake .
a. Review of the record for Resident ID #30 revealed that s/he was admitted to the facility in April of 2015 with diagnoses including, but not limited to, gastritis (when the stomach lining gets red and swollen), encephalopathy (a disease in which the functioning of the brain is affected).
During a surveyor observation of the breakfast meal pass on 4/18/2023, it was revealed that the resident failed to receive his/her breakfast meal.
Further surveyor observation on 4/18/2023 at 12:02 PM and 12:21 PM failed to reveal evidence that a lunch meal tray was served to the resident.
Review of the 4/18/2023 meal intake record for this resident failed to reveal evidence of documentation for his/her meal intake, or refusal, for both breakfast and lunch.
Further review of the April 2023 meal intake documentation failed to reveal evidence of a documented intake, or refusal, on the following dates and meals:
- 4/16/2023, dinner
- 4/15/2023, all meals
- 4/14/2023, breakfast
- 4/9/2023, breakfast and dinner
- 4/8/2023, all meals
- 4/7/2023, dinner
- 4/6/2023, dinner
- 4/5/2023, breakfast and lunch
- 4/3/2023, dinner
- 4/2/2023, dinner
- 4/1/2023, dinner
Review of the March 2023 meal intake documentation failed to reveal evidence of a documented intake on the following dates and meals:
- 3/31/2023, breakfast and lunch
- 3/29/2023, all meals
- 3/25/2023, all meals
- 3/24/2023, dinner
- 3/22/2023, dinner
- 3/19/2023, dinner
- 3/18/2023, breakfast and lunch
- 3/16/2023, dinner
- 3/13/2023, dinner
- 3/11/2023, breakfast and lunch
- 3/10/2023, all meals
- 3/9/2023, breakfast and lunch
- 3/8/2023, dinner
- 3/5/2023, dinner
- 3/4/2023, breakfast and lunch
- 3/3/2023, dinner
- 3/1/2023, dinner
Further review of the record failed to reveal evidence that the resident refused the above meals.
During a surveyor interview with the Director of Nursing Services (DNS) on 4/19/2023 at approximately 2:00 PM, she was unable to provide evidence for the above-mentioned meal intakes or refusals, as indicated in the policy.
b. Record review revealed Resident ID #357 was admitted to the facility in April of 2023 with a diagnosis including but not limited to dementia.
Record review of a care plan, dated 4/10/2023, revealed that s/he is at nutritional risk related to his/her diagnoses. Interventions include but are not limited to, .Monitor and record meal intakes .
Record review of the meal intake documentation from his/her admission through 4/18/2023, failed to reveal evidence of documented intakes or refusals for meals on the following dates:
- 4/18/2023, dinner
- 4/17/2023, breakfast and lunch
- 4/15/2023, breakfast
- 4/14/2023, breakfast, lunch, and dinner
- 4/13/2023, breakfast, lunch, and dinner
- 4/12/2023, dinner
- 4/11/2023, dinner
- 4/10/2023, breakfast, lunch, and dinner
- 4/9/2023, dinner
- 4/8/2023, breakfast and lunch
During a surveyor interview on 4/19/2023 at 12:35 PM with Nursing Assistant. Staff I, she indicated that resident meal intakes and refusals are documented in the computer.
During a surveyor interview on 4/19/2023 at 2:18 PM with the Registered Dietitian, she acknowledged that the meal intake documentation was incomplete.
During a surveyor interview with the DNS on 4/19/2023 at 2:33 PM, she indicated that she would expect staff to document meal intakes or refusals for every meal.
2. Review of the facility policy titled, Catheter Care, Urinary, states in part, General Guidelines .Ensure that the catheter remains secured with a securement device to reduce friction and movement at the insertion site .
Record review revealed Resident ID #47 was initially admitted to the facility in March of 2020 with diagnoses including, but not limited to, neuromuscular dysfunction of bladder (when either the nerves or the brain cannot communicate effectively with the muscles in the bladder), presence of urogenital implants (artificial material in your urinary organs or genitals), and dementia.
Record review of the resident's care plan last revised on 3/25/2023 revealed the resident required an indwelling catheter related to a neurogenic bladder (when the relationship between the nervous system and bladder function is disrupted by injury or disease). Further review revealed an approach to provide a foley (catheter) securement device.
Record review revealed a 2/8/2023 physician's order for Foley Catheter to be secured to the leg with anchor device as tolerated .every shift .document refusals. Further review revealed a 2/15/2023 physician's order for foley leg bag is only placed on LOWER LEG with an extension tube and stat lock (a stabilization device)! .done every time leg bag is being used.
During a surveyor observation on 4/18/2023 at 11:29 AM, in the presence of two Nursing Assistants (NA) Staff B and Staff C, the resident's catheter leg bag was loosely hanging around his/her ankle, not secured to the lower leg. Additionally, a stat lock and extension tube were not in place.
A surveyor observation on 4/18/2023 at 2:26 PM in the presence of LPN Staff A, failed to reveal that the catheter tubing was secured or that a stat lock or extension tubing were in place.
Record review of the Treatment Administration Record (TAR) revealed both orders mentioned above were initialed as completed on 4/18/2023 for the 7 AM-3 PM shift by Licensed Practical Nurse (LPN) Staff A.
During a surveyor interview immediately following the above observations with Staff A, he acknowledged that a stat lock and extension tubing should be used to secure the catheter. Additionally, he acknowledged that he documented in the TAR that the stat lock and extension tubing were in place although they were not.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standar...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety relative to the main kitchen and one of three nursing unit kitchenettes on the second floor.
Findings are as follows:
Record review of the facility policy titled, Food Receiving and Storage,states in part, .All foods stored in the refrigerator .are .labeled and dated .Foods and Snacks Kept on Nursing units .All foods belonging to residents are labeled with the resident's name .and the 'use by' date .
Record review of the facility policy titled Use and Storage of Food Brought in by Visitors, indicates that all food items brought to residents from outside sources are to be stored appropriately and labeled with the resident's name and the date.
1. During a surveyor observation of the main kitchen on 4/17/2023 at 8:01 AM, the walk-in refrigerator unit revealed the following:
- five, approximately 10-pound, packages of pork loin thawing, not labeled with a date.
During a surveyor interview on 4/17/2023 immediately following the above-mentioned observation, with the Head Cook, Staff G, she acknowledged that the pork loin was not labeled with a date. Additionally, she indicated that the process is to label items with the date.
During a surveyor interview on 4/17/2023 at approximately 8:30 AM with the Food Service Director (FSD), he was unable to provide evidence that the packages of pork loin were labeled with a date.
2. During a surveyor observation of the second-floor nursing unit kitchenette on 4/17/2023 at 11:50 AM revealed the following:
- one half gallon of milk, opened and approximately half consumed with an expiration date of 4/15/2023.
- one package of Riccotta pie, opened and approximately half consumed without a label with the resident's name or use by date.
During a surveyor interview on 4/17/2023 immediately following the above-mentioned observations with Nursing Assistant, Staff H, she acknowledged the findings. Additionally, she indicated that expired food items should be discarded and that resident food items should be labeled with the resident's name and date.
During a surveyor interview on 4/18/2023 at approximately 4:20 PM with the FSD, he indicated that he would expect staff to check the refrigerator daily and discard expired items. Additionally, he indicated that he would expect all resident food items to be labeled with the resident's name and date.
Mar 2023
5 deficiencies
1 Harm
SERIOUS
(H)
📢 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 F0692
(Tag F0692)
A resident was harmed · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident is offered...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident is offered sufficient fluid intake to maintain proper hydration for 2 of 4 residents reviewed, Resident ID #s 1 and 3. Additionally, the facility failed to ensure residents maintain acceptable parameters of nutritional status, such a usual body weight or desirable body weight and failed to follow their policy relative to weights, for 2 of 4 residents reviewed, Resident ID #s 1 and 2.
Findings are as follows:
Record review of a community report complaint received at the Rhode Island Department of Health on 3/2/2023 alleges that Resident ID #1 arrived at the hospital with sunken eyes, severely dehydrated, scaly, flaky, and inflamed skin. Additionally, the report revealed the patient developed a pressure wound to his/her buttocks and had an unkempt appearance.
According to Brunner & Suddarth's Textbook, Medical and Surgical Nursing, 10th Edition, Volume 2, page 262 states signs/symptoms and laboratory findings of hypernatremia (excess amounts of sodium in the blood) include, but are not limited to lethargy, restlessness, and twitching.
According to Brunner & Suddarth's Textbook, Medical and Surgical Nursing, 10th Edition, Volume 2, page 2131 states the patient with moderate dehydration exhibit signs and symptoms including, but not limited to, sunken eyes and loss of skin turgor, and patients with severe dehydration show signs and symptoms of shock, such as lethargy and coma.
1A. Record review for Resident ID #1 revealed the resident was admitted to the facility in June of 2022 with diagnoses including, but not limited to, adult failure to thrive, chronic kidney disease, pemphigus foliaceus [autoimmune blistering of the skin] and major depressive disorder.
Record review of a quarterly Minimum Data Set assessment dated [DATE] revealed the resident scored a 15 out of 15 during a Brief Interview for Mental Status assessment, indicating s/he has intact cognition. Additionally, the assessment revealed that s/he did not have any pressure injuries. Further review of the assessment revealed under the heading Weight Gain- Gain of 5% or more in the last month or gain of 10% or more in the last 6 months, is coded as Yes, not on a physician-prescribed weight-gain regimen.
Record review of the resident's baseline admission care plan, edited on 12/13/2022 revealed a care plan which states in part, .for Dehydration Risk/ Nutrition. History of FTT [failure to thrive] and poor oral intake . with interventions including, but not limited to, Diet as ordered; Monitor for signs and symptoms of dehydration Labs per MD orders; Dietary consult as indicated .
Record review of the resident's documented daily fluid intake from 2/10/2023 through 2/27/2023 revealed the following:
-2/10/2023 720 milliliters (ml)
-2/11/2023 360 ml
-2/12/2023 720 ml
-2/13/2023 1560 ml
-2/14/2023 1080 ml
-2/15/2023 840 ml
-2/16/2023 900 ml
-2/17/2023 1560 ml
-2/18/2023 120 ml
-2/19/2023 720 ml
-2/20/2023 720 ml
-2/21/2023 1450 ml
-2/22/2023 360 ml
-2/23/2023 720 ml
-2/24/2023 1040 ml
-2/25/2023 240 ml
-2/26/2023 1080 ml
-2/27/2023 960 ml
During a surveyor interview with the Director of Nursing Services (DNS) and the Administrator on 3/2/2023 at approximately 4:00 PM, the DNS revealed the Registered Dietician (RD) and the physician review the resident's intake. Additionally, during a review of Resident ID #1's fluid intake, the Administrator acknowledged the fluid intake totals.
Record review of the nursing progress notes revealed the following:
-2/22/2023 .poor po [by mouth] intake .
-2/25/2023 2:21 AM Res [resident] with some confusion .res appears irritated and restless .shaking [his/her] legs .Drinks encouraged .
-2/27/2023 at 6:30 AM .Continues to have full body shakes .
-2/27/2023 at 4:10 PM Previous RN reported .that resident had body shakes overnight, but mild tremors present this shift .Poor PO intake this shift .Around 1500, CNA reported to this RN that resident was shaking. On assessment resident laying in bed with whole body tremors, lethargic but arousable .second shift to report to MD [medical doctor].
-2/27/2023 at 8:54 PM Res [resident] alert, verbal, continues with full body shakes .MD notified, new order obtained for Benadryl .labs .will monitor.
-2/28/2023 at 7:55 AM .Resident noted to be shaking in bed this shift .7-3 nurse notify of resident status during shift change.
-2/28/2023 at 10:16 AM .On assessment this morning resident with whole body tremors .Resident alert but lethargic .resident agreeable to hospital transfer .Reported to [resident's MD] .
-2/28/2023 at 3:14 PM Resident is being admitted at [hospital] with hypernatremia and dehydration, Na [Sodium, normal lab value range 135-145 mmo (milliequivalents)/l (liter)] 170.
Record review of the Hospital History & Physical documentation for Resident ID #1 states in part, .Currently residing at [facility]. Presented confused, clinically very dehydrated .Labs showed severe hypernatremia with a sodium of 176 . Acute renal failure with a BUN [Blood Urea Nitrogen] of 56 [normal lab value range 6-24 mg (milligram/dl (deciliter)] and creatinine of 2.9 [normal lab value 0.74 to 1.35 mg/dl]. Lactic acidosis of 6.0 [normal lab value 2-4 mmo/l]. Elevated troponin at 0.045 [normal lab value 0 to 0.04 nanograms per milliliter]. Leukocytosis [elevated white blood cell count] .Additional information from [residents] facility. Apparently has been declining rather rapidly over the last few weeks. Refusing medications. Not taking in a reasonable amount of fluids and daily meals .
Record review of the Hospital Discharge Summary document states in part, .Patient was admitted to [hospital] from [facility] with severe hyponatremia [sic], acute renal failure, severe sepsis in the setting of failure to thrive. [S/He] was extremely dehydrated on presentation, IVF [intravenous fluid] hydration was initiated. Broad spectrum antibiotics were given although infectious etiology was unclear; uti [urinary tract infection] vs. skin with extensive pemphigus foliaceus. Unfortunately, despite hydration, renal function worsened. Serum sodium slightly improved to 169 .[S/He] was seen by [Dr.] of [Hospice] service who discussed goals of care with niece .who wished for transition to inpatient hospice given tenuous status .
1B. Record review of the resident's nutritional care plan dated 2/8/2023 states in part, .therapeutic diet. (02/2023) Weight with recent significant gain/and loss-was on Prednisone, excellent intake, skin with tx [treatment]. Interventions include, but are not limited to, .Monitor and record meal intakes - Monitor and record weights per schedule .
Record review of a progress note authored by the RD dated 2/8/2023 at 7:50 AM states in part, Quarterly nutritional review: Most current weight (2/6) 162.5# (pounds)-history of gain/loss, now back to baseline in the 160's. Peaked at 178# in January and will trigger for a significant, yet planned loss on MDS .excellent PO intake, 75-100%. Able to take meals independently .
Record review of the resident's meal intake during the month of February revealed his/her documented meal intake was recorded as 76-100% consistently. Further review of the record revealed the resident's meal intake started to decrease on 2/24/2023. Findings below are the meals documented:
2/24/2023 no intake documented
2/24/2023 51-75% for dinner
2/25/2023 no intake documented
2/26/2023 26-50% for breakfast
2/26/2023 26-50% for lunch
2/26/2023 26-50% for dinner
2/27/2023 1-25% for breakfast
2/27/2023 26-50% for lunch
2/27/2023 None for dinner
2/28/2023 None for breakfast
Review of the physician's orders revealed the resident has an order for weekly weights and to reweigh if weight is < or > 3 pounds.
Record review of the resident's documented weights in January 2023 revealed the following:
-1/9/2023 164 pounds (lbs.)
-1/16/2023 Resident refused
-1/23/2023 178.2 lbs.
-1/30/2023 162 lbs.
Record review revealed the resident had a 14.2 lb. weight gain which was documented on 1/23/2023 from his/her previous weight of 164 lbs. Further record review failed to reveal a reweigh was obtained as ordered.
Additional record review revealed the resident had a 16.2 lb. weight loss which was documented on 1/30/2023 from his/her previous weight of 178 lbs. Further record review failed to reveal a reweigh was obtained as ordered.
Record review of the resident's documented weights in February 2023 revealed the following:
-2/6/2023 162.5 lbs.
-2/13/2023 163.5 lbs.
-2/20/2023 156.4 lbs.
Record review revealed the resident had a 7.1 lb. weight loss which was documented on 2/20/2023 from his/her previous weight of 163.5 lbs. Further record review failed to reveal a reweigh was obtained as ordered.
During a surveyor interview with the Director of Nursing Services (DNS) and the Administrator on 3/2/2023 at approximately 4:00 PM, the DNS revealed the RD and the physician review the resident's intake. Additionally, they revealed the resident's weights are obtained on a Monday and reviewed on a Wednesday, indicating a reweigh would be obtained by Wednesday. Lastly, the DNS was unable to provide evidence of a reweigh for the weights noted above as indicated.
During a surveyor interview with Resident ID #1's physician on 3/3/2023 at 12:36 PM, revealed that he was unaware of the resident's weight loss and was was not made aware of his/her tremors and decrease in po intake until 2/27/2023.
2. Record review for Resident ID #2 revealed the resident was admitted to the facility in February of 2023 with diagnoses including, but not limited to, dysphagia following cerebral infarction and dementia.
Record review of the resident's nutritional care plan dated 2/15/2023 states in part, .[Resident] has impaired swallowing with texture modified diet, weight loss prior to admission, fair intake, dependent with meals . interventions include, but are not limited to, Diet: pureed/nectar thickened liquids .Magic cup supplements .Provide additional foods/supplements if PO <50%.
Record review of a progress note dated 2/15/2023 at 9:11 AM authored by the RD states in part, Initial nutritional assessment .diet with intake 25-50% .Skin: stage 2 wound [partial thickness loss to the skin presenting as a shallow open ulcer] to coccyx and right heel .Weight (2/10): 135#-daughter reports a 10# loss prior to hospitalization. Ht [height] 67in [inches], BMI [body mass index] = 21.1/within desirable range Will rec [recommend] to add magic cup supplements 120ml 2x/day to promote wound healing, help meet needs .
Record review of a progress note dated 2/15/2023 at 9:11 AM authored by the RD states in part, Magic cup added 120ml 2x/day as previously recommended for weight loss and skin integrity .notify RD with any nutritional concerns .
Record review of the physician's orders revealed an order dated 2/16/2023 for Magic cup twice a day in the morning and evening.
Record review of the February and March 2023 Medications Administration History revealed that the resident missed 24 our of 29 opportunities to receive the Magic cup as ordered. Further review of the records revealed the Magic cup order.
During a surveyor interview with the DNS on 3/2/2023 at approximately 5:00 PM, she revealed the magic cup order for Resident ID #2 was to be provided by the kitchen during his/her meals and that the Magic cup order did not transfer to the kitchen orders for it to be delivered to the resident.
3. Record review of a community report complaint received at the Rhode Island Department of Health on 2/19/2023 alleges that Resident ID #3 had two falls and became dehydrated. Per the complaint the resident fell while attempting to get out of bed to get a drink.
Review of facility policy titled, Resident Hydration and Prevention of Dehydration, revealed in part, .If potential inadequate intake and/ or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan .the physician will be notified .Orders may be written for extra fluids to be encouraged between meals and/or with medication passes .a specific minimum amount should be included in the order .encouraging fluids is not an adequate order .nursing will monitor and document fluid intake and the dietician will be kept informed of status .the interdisciplinary team will update the care plan and document resident response to interventions until the team agrees that fluid intake and relating factors are resolved .
Record review for Resident ID #3 revealed s/he was admitted to the facility in February of 2023 with diagnoses including, but not limited to, subdural hematoma (a condition due to bleeding under the membrane covering the brain), Fahr's disease (a condition where calcium builds up in the part of the brain that controls movement), Acute encephalopathy (a term for any disease of the brain that alters brain function) and acute cystitis (infection or inflammation of the urinary bladder).
Record review of a quarterly Minimum Data Set Assessment, dated 2/19/2023, revealed under the heading Weight Loss- Loss of 5% or more in the last month or loss of 10% or more in the last 6 months, is coded as Yes, not on a physician-prescribed weight-loss regimen.
Record review of the resident's baseline admission care plan, revealed a care plan which states in part, .for Dehydration Risk/ Nutrition .resident will show no signs or symptoms of dehydration or malnutrition over the next 21 days .with interventions including, but not limited to, Diet as ordered; Monitor for signs and symptoms of dehydration Labs per MD orders; Dietary consult as indicated .
Record review of the resident's documented daily fluid intake from 2/9/2023 through 2/18/2023 revealed the following:
-2/9/2023 960 milliliters (ml)
-2/10/2023 720 ml
-2/11/2023 0 ml
-2/12/2023 720 ml
-2/13/2023 1,560 ml
-2/14/2023 1,320 ml
-2/15/2023 960 ml
-2/16/2023 2,100 ml
-2/17/2023 1,080 ml
-2/18/2023 420 ml
Record review of the nursing progress notes revealed the following:
-2/11/2023 at 2:43 AM .resident had an unwitnessed fall @ [at] 2:30 am. Was found crawling on the floor .
-2/12/2023 at 11:12 PM .Resident is confused at baseline, had unwitnessed fall at 2245 [10:45 PM]. Resident found on the floor, stated 'slid off the bed' .
-2/15/2023 at 8:22 AM .initial nutritional assessment .Estimated needs: 1200-1400ML fluids [per day] . authored by the Registered Dietician.
-2/15/2023 at 5:55 PM Lab results reported to [resident's physician's assistant] .with new orders to Encourage PO [by mouth] fluids, repeat BMP [basic metabolic panel, a type of lab] on Friday 2/17/2023 .New dietary recommendation add house supplement 120ml/2x [times] a day related to weight loss.
-2/16/2023 at 7:22 PM .res[ident] is restless and not able to stay in bed safely .will continue to monitor.
-2/19/2023 at 1:41 AM .resident was found lying next to [his/her] bed by C.N.A.[Certified nursing Assistant] .This writer was unable to get this resident VS [vital signs] because [s/he] was being behavioral and [s/he] kept crawling on the floor .This writer called [resident's MD] .Resident left the facility at approx .1:20AM to go to [acute care hospital] .
-2/20/2023 at 3:46 PM admitted to [acute care hospital] with hypernatremia diagnosis of dehydration.
Record review of the following BUN [blood urea nitrogen test used to determine how well your kidneys are working] and creatinine [a waste product that comes from the normal wear and tear on muscles of the body] laboratory results reveals the following:
-2/10/2023 The day after the resident was admitted to the facility, Bun (normal range 8-23 mg/dl), 13 and creatinine (normal range 0.60-1.30 mg/dl), 0.80
-2/13/2023 Bun 37 and creatinine 1.59
-2/14/2023 Bun 38 and creatinine 1.51
-2/15/2023 Bun 52 and creatinine 2.36
-2/17/2023 Bun 47 and creatinine 1.59
Record review revealed the resident had a physician's order dated for 2/15/2023 to encourage fluids every shift by mouth.
Record review of the Medication Administration Record from 2/15/2023 through 2/19/2023 revealed the following documentation entries for the order to encourage fluids every shift:
-2/15/2023 480 ml
-2/16/2023 1,140 ml
-2/17/2023 540 ml
-2/18/2023 360 ml
Record review of the Hospital History & Physical documentation, dated 2/19/2023 for the resident revealed in part, .past medical history of .who was brought in via EMS [emergency medical services] from NH [nursing home] after sustaining 2 mechanical fall and dehydration .initial labs showed cr [creatinine] of 2.3 mg/dl vs [versus] 0.7 mg/dl on 2/5/23 .Pt [patient] admitted for further eval[evaluation] for placement and AMS [Altered Mental Status] and AKI [acute kidney injury] .
During a surveyor interview with the Director of Nursing Services (DNS) on 3/10/2023 at approximately 12:00 PM, she acknowledged that the order to encourage fluids did not include a specific minimum amount as indicated in the policy. Additionally, the DNS could not provide evidence that the amount of fluid intake on the MAR was or was not reflected in the resident's total daily fluid intake.
During a surveyor interview with the Registered Dietician on 3/10/2023 at approximately 2:00 PM, she indicated that the minimum daily fluid intake for this resident is 1,200 ml. She further indicated she was not made aware of the above fluid intakes for this resident. Additionally, she inicated that the documented amount of fluid intake was lower than estimated daily fluid needs of this resident.
During a surveyor interview with the Medical Director on 3/10/2023 at approximately 3:50 PM, he indicated that the above-mentioned laboratory values reflected AKI and he would have expected the resident to have received IV hydration or Clysis [an infusion of fluid into a subcutaneous space] at the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to prevent ...
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Based on record review and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to prevent new pressure ulcers from developing for 1 of 2 residents reviewed, Resident ID #1.
Findings are as follows:
Record review revealed that s/he was admitted to the facility in June of 2022 with a diagnosis including, but not limited to, need for assistance with personal care.
Review of the 11/28/2022 Quarterly Minimum Data Set (MDS) Assessment revealed that s/he requires extensive physical assistance of one staff member for dressing and toileting.
Review of the physician orders revealed an order, dated 6/22/2022, for weekly body checks. Review of the record from 11/14/2022 through 2/4/2023 failed to reveal evidence that weekly body checks were completed as ordered for 5 of 12 opportunities. Additional record review revealed that the resident refused weekly body checks on 2/10, 2/17 and 2/24/2023. Further record review failed to reveal evidence that the physician was notified of the resident's refusals for these weekly body checks.
Further review of the orders revealed an order, dated 12/15/2022, to complete a Braden Scale (tool used to assess a patient's risk for developing pressure ulcers) observation quarterly. Review of the record failed to reveal evidence that the Braden Scale assessment was completed as ordered.
Review of the care plan, revised on 12/13/2022, revealed that s/he is dependent with self-care secondary to physical limitations related to deconditioning. Further review of the care plan revealed that s/he is at risk for pressure ulcers and skin breakdown relative to maceration, occurs when skin is in contact with moisture for too long, to his/her buttocks/coccyx (tailbone) with interventions including but not limited to weekly skin checks and Braden Scale assessments. Additional review of the care plan failed to reveal evidence that s/he was care planned for behaviors relative to refusing weekly body checks.
Review of the record revealed that the resident was transferred to an acute care hospital on 2/28/2023.
Review of the 2/28/2023 the hospital record revealed that the resident had two Stage 2 wounds (a break in the skin through the top layer of skin (epidermis) and some of the layer of skin beneath) to the coccyx with exposed dermis that were present upon arrival to the hospital.
During a surveyor interview with the Director of Nursing Services on 3/10/2023 at 12:15 PM, she was unable to provide evidence that the Braden Scale assessment and weekly skin checks were completed as ordered. She acknowledged that the resident refuses care, does not have a care plan in place to address these behaviors and that she would expect nursing to make additional attempts to assess the resident's skin. Additionally, she was unable to provide evidence that the doctor was made aware of the resident's refusals.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on record review, resident and staff interview, it has been determined that the facility has failed to ensure that a resident's drug regimen is free from significant medication errors for 1 of 1...
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Based on record review, resident and staff interview, it has been determined that the facility has failed to ensure that a resident's drug regimen is free from significant medication errors for 1 of 1 residents reviewed for medication reconciliation, Resident ID #3.
Findings are as follows:
Review of the Facility Policy, titled, Reconciliation of Medications on Admission, states in part, .The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility .gather .approved medication reconciliation form .discharge summary from referring facility .medication reconciliation is the process of comparing .medications .for the purpose of preventing unintended .omissions at transition points .using an approved medication reconciliation form .list all medications from .the discharge summary .list the dose, route and frequency for all medications .review the list carefully to determine if there are discrepancies/conflicts .if there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to dissolve the discrepancy .document findings and actions .document the medication discrepancy on the medication reconciliation form .if the discrepancy was resolved documents how the discrepancy was resolved .
Record review revealed the resident was admitted to the facility in February of 2023 with diagnoses including, but not limited to, subdural hematoma (a condition due to bleeding under the membrane covering the brain), Fahr's disease (a condition where calcium builds up in the part of the brain that controls movement), Acute encephalopathy (a term for any disease of the brain that alters brain function).
Record review of document titled, Discharge Summary, states in part, START taking these medications .Levetiracetam (Keppra) [a medication used to treat seizures] 250 mg [milligram] tablet, Take one tablet by mouth 2 (two) times a day for 1 day .Levetiracetam (Keppra) 500 mg tablet take one tablet by mouth 2 (two) times a day for 3 days .
Record review of the February 2023 Medication Administration Record (MAR) revealed that the resident received Levetiracetam (Keppra) 500 mg tablet, one tablet by mouth on the following days and times:
- 2/9/2023: 7:00 PM-11:00 PM
- 2/10/2023: 7:00 AM-11:00 AM and 7:00 PM-11:00 PM
Further review of the February 2023 MAR revealed that the resident received Levetiracetam 250 mg tablet, one tablet by mouth on the following days and times:
- 2/11/2023: 7:00 AM-11:00 AM and 7:00 PM-11:00 PM
- 2/12/2023: 7:00 AM-11:00 AM and 7:00 PM-11:00 PM
Review of a 2/11/2023 document titled, admission Medication Reconciliation Form, states in part, .Medications that are not reconciled, i.e. do not appear in all columns will be brought to the physicians attention . Review the form failed to reveal evidence of a route, frequency and/or duration documented for the Levetiracetam as well as actions taken to resolve the discrepancies.
During a surveyor interview with the Director of Nursing Services (DNS) on 3/10/2023 at approximately 12:00 PM, she was unsure of what the resident should be receiving related to the dosage of Levetiracetam. She was unable to provide evidence that the medication reconciliation process was completed per policy. Furthermore, she stated that her expectation would be that nursing would follow the policy relative to medication reconciliation.
During a surveyor interview with the Medical Director on 3/13/2023 at approximately 9:00 AM, he stated that his expectation would be that the facility would follow the medication dosage as written on the hospital discharge summary.
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
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to obtain laboratory services to meet the needs of its residents for 1 of 1 resident reviewed, Resident ID #...
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Based on record review and staff interview, it has been determined that the facility failed to obtain laboratory services to meet the needs of its residents for 1 of 1 resident reviewed, Resident ID #1.
Findings are as follows:
Record review revealed the resident was admitted to the facility in June of 2022 with diagnoses including, but not limited to, adult failure to thrive, chronic kidney disease and pemphigus foliaceus [autoimmune blistering of the skin].
Review of a progress note dated 1/21/2023 at 3:30 AM states, N.O. [new order] Repeat Labs on Monday 1/24/23, Lasix 20 mg once a day for 3 days. R/T [related to] Xray findings.
Record review of a progress note authored by the resident's physician on 2/23/2023 at 5:11 PM states in part, .3. CRI [chronic renal insufficiency] - F/U [follow up] LABS .
Record review failed to reveal evidence that the lab work was obtained on Monday 1/24/2023.
During a surveyor interview on 3/3/2023 at 12:36 PM with the resident's physician he indicated that he would have been the provider to order the lab work. He further revealed he could not recall what labs he ordered, but he would have at least ordered a Chem 7 (a blood test to show the body's electrolyte balance and/or the status of several major body organs).
During a surveyor interview with the Director of Nursing Services on 3/2/2023 at approximately 5:00 PM, she was unable to provide evidence of the ordered lab results.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on record review and staff interview, it has been determined that the facility failed to develop and implement a quality improvement program that provides criteria to monitor nursing care and se...
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Based on record review and staff interview, it has been determined that the facility failed to develop and implement a quality improvement program that provides criteria to monitor nursing care and services, including but not limited to, dehydration.
Findings are as follows:
Record review of the facility assessment revealed in part, .QAPI [Quality Assurance and Performance Improvement] PLAN .Each year the QAPI calendar shall include, but not be limited to monitoring and evaluating the following systems .Dehydration .
Record review of the facility's QAPI plan failed to reveal evidence that dehydration was being monitored as indicated in the facility assessment.
During an interview with the Administrator on 3/10/2023 at approximately 12:00 PM, he was unable to provide evidence that the facility developed and implemented a program for monitoring and evaluating dehydration.
Feb 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to provide specialized rehabilitatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to provide specialized rehabilitation services such as physical therapy and occupational therapy that were required in the resident's comprehensive plan of care for 1 of 3 residents reviewed for rehabilitation services, Resident ID #1.
Findings are as follows:
Review of a community reported complaint submitted to the Rhode Island Department of Health on 2/14/2023 alleged that a resident was admitted to the skilled nursing facility to receive rehabilitation and did not receive physical therapy.
Record review revealed that the resident was admitted to the facility in November of 2022 and has a diagnosis including, but not limited to, multiple sclerosis (a potentially disabling disease of the brain and spinal cord causing communication problems between your brain and the rest of your body).
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 indicating intact cognition. The MDS further indicated that the resident ambulated with supervision of one person with a rolling walker, was not steady, but was able to stabilize without staff assistance.
Review of a hospital Continuity of Care document dated 11/29/2022 revealed that the resident was being discharged to the facility to receive skilled nursing care, physical therapy, occupational therapy, medication management, and cardiopulmonary assessment.
Record review revealed the following physician's orders:
- 11/29/2022- Occupational therapy evaluation and treatment as indicated.
- 11/29/2022- Physical therapy evaluation and treatment as indicated.
Record review revealed a Neurology Continuity of Care Consultation form dated 1/12/2023 that revealed in part, .PT [physical therapy] evaluation for gait/balance .
Further record review failed to reveal evidence of an occupational therapy evaluation being performed. Additionally, record reviewed failed to reveal evidence of a physical therapy evaluation being performed on the resident until 2/09/2023.
During a surveyor interview with the Director of Rehabilitation on 2/15/2023 at 12:59 PM, she acknowledged that an occupational therapy evaluation was not performed and that a physical therapy evaluation was not performed until 2/9/2023 on the resident.
During a surveyor interview with the Director of Nursing Services on 2/15/2023 at 1:30 PM, she was unable to provide evidence of an occupational therapy evaluation being performed. She further was unable to provide evidence of a physical therapy evaluation being performed on the resident until 2/9/2023. Additionally, she indicated that she would have expected the evaluations to have been performed per physician's orders when the resident was admitted to the facility.
Jan 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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 a resident with limited range of motion receives appropriate treatment and ...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to prevent further decrease in range of motion relative to the use of a sling and swathe (a type of sling used to both support the arm and immobilize the shoulder) for 1 of 1 residents reviewed, Resident ID #2.
Findings are as follows:
Review of a facility reported incident submitted to the Rhode Island Department of Health on 1/7/2023, revealed in part that on 1/6/2023 the resident was noted to be restricting his/her right arm movement. The resident was subsequently diagnosed with a displaced fracture of the humerus (upper arm) on 1/6/2023, and the resident returned to the facility with a sling.
Record review revealed the resident was re-admitted to the facility in July of 2022 with diagnoses including, but not limited to, dementia and repeated falls.
Record review of a document titled After Visit Summary dated 1/6/2023 states in part, .was diagnoses with a right humeral (upper arm) fracture .Sling and Swathe as provided until cleared by ortho[orthopedic doctor] .
Further review of the hospital discharge paperwork revealed a physician's order for a sling and swathe with instructions which state in part, Physicians orders .Please dispense the equipment named above .this equipment is essential to the patients healing and rehabilitative process.
Additional record review failed to reveal a physician's order for use of a sling and swathe.
Further record review revealed a care plan dated 1/9/2023 which states in part, .had a fall with fracture of [his/her] humerus . Additional review of the plan of care failed to reveal a plan of care related the use of the sling and swathe.
During surveyor observations on 1/18/2023 at approximately 8:50 AM and 11:42 AM revealed Resident ID #2 lying in bed the swathe (wrap that goes horizontally around the outside of the sling and around the trunk of the body to secure the arm to the trunk) across the resident chest under the sling and not over the sling per the swing and swathe method (Place the elbow into the corner of the sling. Wrap the strap across the neck on the opposite side and attach to the front of the sling. Adjust the length of the strap to support the arm in order to maintain the elbow at 90 degrees. Wrap the elastic wrap horizontally around the outside of the sling and around the trunk under the unaffected arm to secure the arm to the trunk. This is the swathe).
During a surveyor interview on 1/18/2023 at approximately 8:53 AM, with Registered Nurse (RN), Staff A, he revealed that the swathe was used under the resident sling to prevent skin damage from the sling itself.
During a subsequent surveyor interview on 1/18/2023 at 1:05 PM, with Staff A, he revealed that he was unsure on how to apply the swathe and its use. Additionally, he revealed he did not receive education related to the device.
During a surveyor interview on 1/18/2023 at 2:14 PM, with Nursing Assistant, Staff B, she revealed that if the sling and swathe was dirty, she would remove them to be laundered. Additionally, she revealed she did not receive education on how to remove and reapply the sling and swathe.
During a surveyor interview on 1/18/2023 at approximately 2:30 PM with the Administrator, he was unable to provide evidence the facility obtained a physician's order per the hospital discharge paperwork, developed a care plan, or provided education to the staff for the appropriate treatment and services to prevent further decrease in range of motion related to the use and application of a sling and swathe.
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
- • 42% turnover. Below Rhode Island's 48% average. Good staff retention means consistent care.
Concerns
- • 31 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $55,071 in fines. Extremely high, among the most fined facilities in Rhode Island. Major compliance failures.
- • Grade C (55/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 55/100. Visit in person and ask pointed questions.
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About This Facility
What is Morgan Health Center's CMS Rating?
CMS assigns Morgan Health Center an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Rhode Island, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Morgan Health Center Staffed?
CMS rates Morgan Health Center's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 42%, compared to the Rhode Island average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Morgan Health Center?
State health inspectors documented 31 deficiencies at Morgan Health Center during 2023 to 2025. These included: 1 that caused actual resident harm and 30 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Morgan Health Center?
Morgan Health 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 MARQUIS HEALTH SERVICES, a chain that manages multiple nursing homes. With 120 certified beds and approximately 111 residents (about 92% occupancy), it is a mid-sized facility located in Johnston, Rhode Island.
How Does Morgan Health Center Compare to Other Rhode Island Nursing Homes?
Compared to the 100 nursing homes in Rhode Island, Morgan Health Center's overall rating (4 stars) is above the state average of 3.1, staff turnover (42%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Morgan Health 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 Morgan Health Center Safe?
Based on CMS inspection data, Morgan Health 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 4-star overall rating and ranks #1 of 100 nursing homes in Rhode Island. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Morgan Health Center Stick Around?
Morgan Health Center has a staff turnover rate of 42%, 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 Morgan Health Center Ever Fined?
Morgan Health Center has been fined $55,071 across 2 penalty actions. This is above the Rhode Island average of $33,630. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Morgan Health Center on Any Federal Watch List?
Morgan Health 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.