Grand Islander Center
For profit - Corporation
146 Beds
GENESIS HEALTHCARE
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
21/100
#50 of 72 in RI
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Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Grand Islander Center has received a Trust Grade of F, indicating significant concerns about its operations and care quality. It ranks #50 out of 72 nursing homes in Rhode Island, placing it in the bottom half, and #5 out of 6 in Newport County, meaning there is only one local facility rated higher. Unfortunately, the facility is worsening, with the number of issues increasing from 13 in 2024 to 17 in 2025. Staffing holds an average rating of 3 out of 5 stars, with a turnover rate of 44%, which is about the state average, suggesting some staff stability. However, the facility has been cited for critical safety violations, including the presence of drug paraphernalia in resident rooms and failures in food safety standards, highlighting serious risks to resident well-being.
- Trust Score
- F
- In Rhode Island
- #50/72
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 44% turnover. Near Rhode Island's 48% average. Typical for the industry.
- Penalties ✓ Good
- $35,188 in fines. Lower than most Rhode Island facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 42 minutes of Registered Nurse (RN) attention daily — more than average for Rhode Island. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 37 deficiencies on record. Higher than average. Multiple issues found across inspections.
21/100
Bottom 31%
Review needed
13 → 17 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 13 issues
2025: 17 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (44%)
4 points below Rhode Island average of 48%
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below Rhode Island average (3.1)
Below average - review inspection findings carefully
Staff Turnover: 44%
Near Rhode Island avg (46%)
Typical for the industry
Federal Fines: $35,188
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: GENESIS HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 37 deficiencies on record
2 life-threatening
Aug 2025
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 1 resident reviewed who had actu...
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Based on record review and staff interview, it has been determined that the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 1 resident reviewed who had actual fall with injury, Resident ID #1, and for 1 of 6 residents reviewed for transfers, Resident ID #2.Findings are as follows:1. Record review revealed Resident ID #1 was re-admitted to the facility in July of 2025 with diagnoses including, but not limited to, displaced intertrochanteric fracture of left femur (a broken hip).Record review of a progress note dated 7/20/2025 revealed, Resident ID #1 had been found lying on the floor at 8:00 AM in the doorway of his/her room. The resident indicated that s/he had pain to his/her left hip with swelling noted. The resident was emergently sent out to the hospital for further evaluation.Further review of his/her progress notes revealed that the resident was admitted to the hospital with a hip fracture and would require surgery to repair prior to returning to the facility.Review of a care plan focus area for falls dated 9/12/2023, failed to reveal evidence that the resident sustained an actual fall with injury on 7/20/2025.During a surveyor interview on 8/20/2025 at 3:48 PM, with the Director of Nursing Services, she was unable to provide evidence that a comprehensive person-centered care plan was developed and implemented to accurately address the resident's fall with injury.2. Record review revealed Resident ID #2 was admitted to the facility in February of 2025 with diagnoses including, but not limited to, unspecified fracture of left patella (kneecap) pain in left hip, and dementia.Review of a care plan initiated on 2/11/2025, revealed the resident requires total assistance of 2 staff persons for transfers, using a mechanical lift (a mechanical device that is used to transfer individuals who cannot bear weight or actively assist with transfers themselves).Additional review of the resident's care plan revealed a focused area for Special Instruction which states in part Slide Board (a specialized board that acts as a bridge to allow individuals to move from one seated surface to another seated surface) for transfers.4/17/25.Review of a document titled CAA Triggers Summary dated 7/29/2025 revealed in part, that the resident was dependent (the resident does not actively assist in the transfers) for all transfers. During a surveyor interview on 8/20/2025 at 3:48 PM, with the Director of Nursing Services, she acknowledged that two different devices used for resident transfers were identified on the care plan. She was also unable to provide evidence that a comprehensive person-centered care plan was developed and implemented to accurately indicate a specific transfer device for Resident ID #2.
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 F0726
(Tag F0726)
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 nursing staff have th...
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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 nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident, as determined by resident assessments and individual plans of care related to abuse and neglect training for 1 of 3 Nursing Assistants (NA) reviewed, Staff A. Findings are as follows:Review of a facility reported incident of alleged staff to resident abuse that was reported to the Rhode Island Department of Health on 7/28/2025, revealed on 7/27/2025 Resident ID #5 alleged that s/he was abused by NA, Staff A.Record review of a facility policy titled Abuse Prohibition Policy last revised 10/24/2022 states in part, .Training and reporting obligations will be provided to all employees -through orientation, Code of Conduct training, and a minimum of annually-and will include. the Abuse Prohibition policy.Record review revealed Resident ID #5 was admitted to the facility in May of 2025 with diagnoses including, but not limited to, multiple sclerosis (a chronic, often disabling disease that affects the brain and spinal cord) and rheumatoid arthritis (a chronic autoimmune disease that primarily causes inflammation of the joints, leading to pain, swelling, stiffness, and potential joint damage).Record review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating that the resident is cognitively intact.Record review revealed Staff A was hired by the facility on 6/23/2025. Record review failed to reveal evidence that Staff A had completed education relative to Abuse Prohibition upon hire, as required. During a surveyor interview on 8/20/2025 at 3:48 PM with the Director of Nursing Services, in the presence of the Administrator, she was unable to provide evidence that Staff A had completed training in abuse. Additionally, she indicated that she would have expected Staff A to have received additional Abuse Prohibition training following the allegations made by Resident ID #5 on 7/27/2025.
May 2025
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, staff and resident interview, it has been determined that the facility failed to provide, based o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, staff and resident interview, it has been determined that the facility failed to provide, based on the comprehensive assessment, care plan and the residents' preferences's, an ongoing program to support the residents' choice of activities which reflect the residents' interests, for 3 of 3 residents reviewed that were unable to watch television in their room from 5/9/2025 through 5/13/2025, Resident ID #'s 2, 86, and 99.
Findings are as follows:
1. Record review revealed Resident ID #2 was admitted to the facility with a diagnosis including, but not limited to, chronic obstructive pulmonary disease (a chronic lung disease that causes damage to the lungs).
Record review of his/her Annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Further review of the MDS, Section F, revealed that it is very important to the resident to keep up with the news.
Record review of a care plan dated 11/21/2022 revealed a focused area for opportunity to engage in daily routines that are meaningful to his/her preferences with the following interventions in place:
- I keep up with the news by reading the newspaper, and watching TV
- I like to look out the window, lay down/rest, pray, read, think, watch TV, crossword search, adult coloring by myself
- I enjoy watching/listening TV
During a surveyor interview on 5/12/2025 at 12:57 PM with the resident, s/he indicated that the television in his/her room has not worked since Friday 5/9/2025. S/he indicated that s/he was unhappy over the weekend without a television to watch the news or any movies.
2. Record review revealed Resident ID #86 was admitted to the facility with a diagnosis including, but not limited to, wedge compression fracture of the first lumbar (type of fracture where the front part of the vertebra collapses causing a wedge shape).
Record review of his/her admission MDS assessment dated [DATE], revealed a BIMS score of 15 out of 15, indicating intact cognition. Further review of the MDS, Section F, revealed that it is somewhat important to the resident to keep up with the news.
Record review of his/her care plan dated 12/2/2024, revealed a focused area for the opportunity to engage in daily routines that are meaningful relative to the resident's preferences with the following interventions:
- I keep up with the news by watching TV
- I enjoy watching/listening TV
- I like to watch TV/movies by myself in my bedroom
During a surveyor interview on 5/12/2025 at 12:48 PM with the resident, s/he indicated that the television in his/her room has not worked for several days and s/he was left with nothing to do.
3. Record review revealed Resident ID #99 was admitted to the facility with a diagnosis including, but not limited to, metabolic encephalopathy (a brain disorder that results from a disturbance in metabolism, causing brain dysfunction).
Record review of his/her Quarterly MDS assessment dated [DATE], revealed a BIMS score of 11 out of 15, indicating moderate cognitive impairment.
Record review of his/her care plan dated 8/15/2024 revealed a focused area to engage in daily routines that are meaningful and preferred, with an intervention including, but not limited to, watching and listening to TV.
During a surveyor interview on 5/12/2025 at 12:57 PM with the resident, s/he indicated that the television does not work due to an electrical issue with the plug for the television. S/he revealed that s/he was very upset especially over the weekend when there were no activities.
During a surveyor interview on 5/13/2025 at 8:27 AM with the Maintenance Director, he revealed that he was aware of the power outage, effecting the above-mentioned residents outlets.
During a surveyor interview on 5/14/2025 at 3:07 PM with the Clinical Market Advisor, he revealed it was his expectation that the residents effected by the power outage, should have been offered and provided a tablet to watch television or movies.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff and resident interview, it has been determined that the facility failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff and resident interview, it has been determined that the facility failed to ensure that a resident receives care, consistent with professional standards of practice to prevent pressure ulcers (localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure) for 1 of 2 residents reviewed, Resident ID #43.
Findings are as follows:
Record review revealed the resident was admitted to the facility in April of 2025 with diagnoses including, but not limited to, right femur fracture and osteoarthritis.
During a surveyor interview with the resident on 5/12/2025 at 11:27 AM, s/he revealed that s/he has bed sores on his/her buttocks and the areas are red. Additionally, s/he revealed that they sometimes apply a cream to both his/her butts.
Record review revealed a care plan dated 4/28/2025 indicating that the resident is at risk for skin breakdown, with interventions that include, but are not limited, to the following:
- Provide preventative skin care as ordered
- Weekly skin check by licensed nurse
Record review of the admission Minimum Data Set assessment dated [DATE] revealed, the resident is non ambulatory and requires moderate assistance from staff for bed mobility, transferring, hygiene, and dressing.
Record review of the point of care documentation, completed by the nursing assistants revealed an Intervention/Task for preventative skin care ie. creams/lotions every shift. Further review of the document revealed that staff failed to provide preventative skin care for 32 out of 36 opportunities for the month of May.
Record review of the weekly skin assessments revealed a skin check was completed on 5/1/2025, indicating no skin impairment. Further review of the weekly skin checks failed to reveal evidence that a weekly skin check was completed after 5/1/2025.
During a surveyor interview on 5/13/2025 at 12:25 PM with Registered Nurse (RN) Staff B, she acknowledged that the last skin assessment was completed on 5/1/2025 and that a skin assessment should have been completed on 5/8/2025. Staff B was unable to provide evidence that a skin check was completed after 5/1/2025.
During a subsequent interview and simultaneous observation of the resident's skin with Staff B, on 5/13/2025 at 12:27 PM, the resident expressed that s/he has bed sores on his/her buttocks. Additional observation of the resident revealed the skin to his/her buttocks was pink, with a blanchable area noted on each buttock cheek, approximately the size of a quarter. Furthermore, Staff B acknowledged the above observations.
During a surveyor interview on 5/14/2025 at 11:13 AM with the facility Wound Nurse, she revealed that typically residents needing preventative skin care are those that have intact blanchable redness, have had a previous pressure injury, and/or impaired mobility.
During a surveyor interview with the Assistant Director of Nursing on 5/14/2025 at 5:08 PM, she was unable to provide evidence that a weekly skin assessment was completed for the resident after 5/1/2025. Additionally, she indicated that she would have expected that a skin assessment would be completed weekly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight, for 1 of 5 residents rev...
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Based on record review and staff interview, it has been determined that the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight, for 1 of 5 residents reviewed, who experienced an actual weight loss and the facility failed to follow their own policy relative to weight monitoring, Resident ID #173.
Findings are as follows:
Review of a facility policy titled Weights and Heights states in part, .Obtaining and Documenting Weight:
1.1 A licensed nurse or designee will weigh the patient.
1.1.1 Admissions and re-admissions will be weighed within 24 hours of admission .
1.1.4 If the body weight is not expected, re-weigh the patient .
2.1 Significant weight changes will be reviewed by the licensed nurse for assessment .
2.2 The licensed nurse will:
2.2.1 Notify the physician .Dietitian of significant weight changes .
Record review revealed the resident was admitted to the facility in April of 2025 with diagnoses including, but not limited to, sepsis due to Enterococcus (a bacteria that enters the bloodstream and may cause a widespread inflammatory response), and diabetes mellitus.
Record review revealed the Registered Dietitian completed a nutritional admission assessment on 5/1/2025.
Review of a care plan dated 5/1/2025 revealed the resident is at nutritional risk related to a therapeutic diet. Further review of the care plan revealed interventions to provide his/her diet as ordered, and offer him/her snacks.
Record review revealed a physician's order with a start date of 5/2/2025 for weekly weights for 4 weeks.
Record review revealed the following weights were obtained:
- 4/29/2025 (admission weight): 224.8 pounds (lbs.)
- 5/3/2025: 222.0 lbs.
- 5/4/2025: 220.0 lbs.
- 5/5/2025: 218.4 lbs.
- 5/6/2025: 216.0 lbs.
- 5/7/2025: 217.4 lbs.
- 5/9/2025: 213.0 lbs.
- 5/10/2025: 210.8 lbs.
- 5/12/2025: 208.4 lbs.
- 5/13/2025: 209.7 lbs.
Record review revealed the resident experienced a 6.7% (15.1 lbs.) significant weight loss in less than one month, from 4/29/2025 to 5/13/2025.
Record review failed to reveal evidence that a nutritional intervention was implemented.
During a surveyor interview on 5/14/2025 at 3:30 PM with the RD, she revealed that she was unaware of the resident's significant weight loss. Additionally, she revealed that if she had been notified of the resident's significant weight loss she would have implemented an intervention of fortified foods. Lastly, she revealed she would assess the resident more often, as s/he has had a significant weight loss.
During a surveyor interview on 5/14/2025 at 4:47 PM with the resident's physician, he revealed that he was not aware of the extent of the resident's weight loss. Additionally, he revealed that he saw the resident today and would review his/her record later that day.
During a surveyor interview on 5/14/2025 at 2:25 PM with the Assistant Director of Nursing, she revealed that the computer system will trigger when a weight loss is identified at 5%, 7.5% and 10% and further revealed that when a weight loss percentage is triggered, a reweigh should be obtained that day or the next.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of practice, in accordance with physician orders and the comprehensive person...
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Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of practice, in accordance with physician orders and the comprehensive person-centered care plan, for 1 of 1 resident reviewed who was receiving antibiotics via a peripherally inserted central catheter (PICC; a long flexible tube that is inserted into a vein in the arm and threaded through a larger vein leading to the heart, used to administer intravenous (IV) fluids and medications), Resident ID #173.
Findings are as follows:
Record review revealed the resident was admitted to the facility in April of 2025 with a diagnosis including, but not limited to, enterococcal bacteremia (a bacteria that enters the bloodstream and may cause a widespread inflammatory response).
Record review revealed the resident was receiving the following antibiotics:
-Ampicillin (an antibiotic prescribed to treat various infections) 2 grams intravenously, every 4 hours.
-Ceftriaxone (an antibiotic prescribed to treat various infections) 2 grams intravenously, every 12 hours.
Record review revealed a physician's order dated 5/6/2025 to change the PICC catheter site dressing weekly. Additional review revealed to indicate the external catheter length and the upper arm circumference (10 centimeters (cm) above the antecubital [the front of the elbow]) and to notify the practitioner if the external length of the catheter has changed since the last measurement.
Record review of the hospital continuity of care document revealed the resident had a PICC line placed on 4/26/2025. Further review of the hospital paperwork failed to reveal measurements relative to the PICC line including, external catheter length or the upper arm circumference measurements.
Record review of the May 2025 Medication Administration Record (MAR), revealed the PICC line dressing change was signed off as completed with the initials of Registered Nurse (RN) Staff C, on 5/6/2025 and 5/13/2025. Additionally, the MAR failed to reveal evidence of an external catheter length measurement or the upper arm circumference measurement.
Further record review failed to reveal evidence of measurements for the PICC line's external catheter length or the right upper arm circumference for the dates of 5/6, 5/12 or 5/13/2025.
Surveyor observations of the resident's PICC line dressing to his/her right upper arm on 5/12/2025 and on 5/14/2025 revealed the dressing that was dated 5/12 with the initials of a different nurse.
During a surveyor interview with the Clinical Market Advisor on 5/14/2025 at 12:40 PM, he was unable to provide evidence of measurements for the resident's PICC line that included the external catheter length or the right upper arm circumference.
During a surveyor interview with the Assistant Director of Nursing Services (ADNS) on 5/14/2025 at 3:14 PM, she revealed that the PICC line dressing was changed on 5/12/2025 because the dressing was lifting.
During a surveyor interview on 5/14/2025 at 3:45 PM with Staff C, she indicated that she signed off that she had completed the PICC line dressing changes in error on 5/6/2025 and again on 5/13/2025. Additionally, she revealed that she has never changed the resident's PICC line dressing.
Cross reference F 726
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident who requires dialysis (a treatment that filters blood when kidneys fail to adequat...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident who requires dialysis (a treatment that filters blood when kidneys fail to adequately remove fluids and waste) receive such services consistent with professional standards of practice and the comprehensive person-centered care plan, for 1 of 1 resident reviewed receiving dialysis, Resident ID #83.
Findings are as follows:
Record review of a facility policy titled, Dialysis: Hemodialysis External Catheter Evaluation and Maintenance last revised 5/1/2025, states in part, .The licensed nurse will ensure that the dialysis access site (e.g. AV shunt or graft [a synthetic tube used to surgically connect the artery and vein, used for dialysis access]) is checked before and after dialysis treatment and every shift for patency [free from blockage or open] by auscultating for bruit [whooshing or swishing sound heard with a stethoscope] and palpating [feeling] for a thrill [a vibration felt with the fingertips when touching the AV shunt or graft] .
Record review revealed the resident was admitted to the facility in April of 2023 with diagnoses including, but not limited to, end stage renal disease and dependence on renal dialysis.
Record review of a care plan initiated on 4/5/2023, revealed the resident is at risk for complications related to hemodialysis with an intervention in place to monitor the dialysis access site for a positive bruit and a positive thrill, every shift and as needed.
Record review failed to reveal evidence of a physician's order to monitor the dialysis access site for a positive bruit and a positive thrill every shift.
Record review of the progress notes revealed 9/21/2024 was the last time the dialysis site was assessed for a positive bruit and a positive thrill.
During a surveyor interview on 5/13/2025 at 3:57 PM with Registered Nurse, Staff D, she acknowledged that the resident did not have an order to monitor for a positive bruit and thrill, as indicated per the facility policy.
Further review of the record revealed a physician's order was obtained on 5/13/2025 to check for a positive bruit and thrill to the left arm, after the concern was brought to the facility's attention by the surveyor.
During a surveyor interview on 5/14/2025 at 3:07 PM with the Clinical Market Advisor, he indicated that he would have expected an order to be initiated to monitor the resident's dialysis access site for a positive bruit and thrill on every shift and as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that the irregularities identified by the Clinical Consultant Pharmacist during the monthly pharma...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that the irregularities identified by the Clinical Consultant Pharmacist during the monthly pharmacist Medication Regimen Review (MRR) were acted upon for 3 of 6 residents reviewed, Resident ID #s 29, 76 and 96.
Findings are as follows:
1. Record review for Resident ID #29 revealed a physician's order dated 2/21/2025 for Lantus insulin (a medication prescribed to lower blood sugar), 16 units daily at bedtime, and Sitagliptin (a medication prescribed to treat type 2 diabetes mellitus), 150 milligrams (mg) daily.
Record review of the pharmacist's MRR, dated 4/15/2025, revealed the following recommendations:
- to consider decreasing the resident's Lantus insulin 16 unit dose at bedtime, by 2 units
- to evaluate the Sitagliptin 150 mg daily dose, as it exceeds the maximum recommended manufacturer's dosing of 100 mg daily
2. Record review for Resident ID #76 revealed a physician's order dated 2/6/2025 for lorazepam (a medication prescribed to treat anxiety disorders) 0.5 mg every 6 hours as needed (PRN).
Record review of the pharmacist's MRR, dated 4/15/2025, revealed a recommendation to evaluate the resident's current diagnosis, behavior, usage pattern, and his/her continued need for the medication. Additional recommendations were made to discontinue the order or indicate the duration of the PRN order.
3. Record review for Resident ID #96 revealed the following physician's orders:
- two duplicate orders of phenazopyridine (a medication prescribed to relieve pain or irritation of the urinary tract), 200 mg every 8 hours PRN
- acetaminophen (a medication prescribed to relieve mild to moderate pain), 1000 mg every 8 hours PRN
- aspirin-acetaminophen-caffeine (a medication prescribed to relieve a headache), 250mg-250mg-65mg PRN daily
- Miralax (a medication prescribed to treat constipation) oral powder 17 grams, twice daily
Record review of the pharmacist's MRR, dated 4/15/2025, revealed the following recommendations:
- to consider discontinuing one of the duplicate PRN phenazopyridine orders
- to write an order for clarification to include parameters not to exceed a maximum total dosage of 3 grams of the medications containing acetaminophen
- to consider adding an order to mix the Miralax with 4 to 8 ounces of fluid per dose
Record review for Resident ID #s 29, 76 and 96 failed to reveal evidence that the monthly MRRs, with noted irregularities, were reviewed and acted upon by the resident's provider.
During a surveyor interview on 5/14/2025 at approximately 5:30 PM with the Clinical Market Advisor and the Assistant Director of Nurses, they were unable to provide evidence that the pharmacy consultation reports were reviewed by the provider and acted upon, as required.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from any significant medication errors, for 1 of 1 resident reviewed for W...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from any significant medication errors, for 1 of 1 resident reviewed for Warfarin/Coumadin therapy (an anticoagulant medication prescribed to reduce the blood's ability to clot, preventing or treating blood clots), Resident ID #21.
Findings are as follows:
Review of a document titled, A Guide to Taking Warfarin created by the American Heart Association, states in part, .It's important to monitor the INR [International Normalized Ratio, a standardized way to measure the prothrombin time [PT] of a blood sample. The INR is used to monitor the effectiveness of Warfarin] at least once a month and sometimes as often as twice weekly to make sure the level of Warfarin remains effective. If the INR is too low, blood clots will not be prevented, but if the INR is too high, there is an increased risk of bleeding .
Record review revealed Resident ID #21 was admitted to the facility in February of 2025 with diagnoses including, but not limited to, unspecified atrial fibrillation (an irregular heartbeat), essential hypertension (high blood pressure with no identifiable underlying cause), and the presence of a cardiac pacemaker (a device used to control an irregular heart rhythm).
Record review revealed the following physician's orders:
- 5/5/2025, Warfarin Sodium Oral Tablet 3 milligrams (mg), give 1 tablet by mouth in the evening, every Monday and Wednesday for 2 administrations. Repeat PT/INR on 5/8/2025. Report results to MD/NP (Physician or Nurse Practitioner)
- 5/2/2025 Warfarin Sodium Oral Tablet 2 mg, give 1 tablet by mouth in the evening, every Tuesday, Friday, Saturday, and Sunday for 4 administrations. Repeat PT/INR on 5/8/2025. Report results to MD/NP
Record review of a document titled Lab Results Report dated 5/8/2025, revealed a PT/INR laboratory result of 2.0 (the therapeutic range for anticoagulant therapy 2.0-3.0).
Record review of a progress note dated 5/8/2025, revealed the resident's PT/INR laboratory result of 2.0 was reported to the physician, who ordered to continue the previous Warfarin dosing orders and to have a PT/INR laboratory test on 5/15/2025.
Record review of the physician's orders failed to reveal evidence that a Warfarin order was implemented on 5/8/2025.
Record review of the May 2025 Medication Administration Record (MAR) failed to reveal evidence that the resident received his/her Warfarin Sodium on the following dates and times:
- Thursday, 5/8/2025 at 5:00 PM
- Friday, 5/9/2025 at 5:00 PM
Record review revealed a physician's order dated 5/10/2025 for a one-time dose of Warfarin sodium 2 mg.
Record review of the May 2025 MAR revealed that the Warfarin 2 mg was signed off as administered by the nurse.
Record review of a PT/INR laboratory result, dated 5/11/2025, revealed a result of 1.7, indicating a subtherapeutic (less than therapeutic) result.
During a surveyor interview on 5/14/2025 at 4:41 PM with the Assistant Director of Nurses, she acknowledged that the resident missed his/her Warfarin doses on Thursday, 5/8 and Friday, 5/9/2025.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on surveyor observation and staff interview, it has been determined that the facility failed to disposed of garbage and refuse properly relative to 1 of 1 outside dumpster and the surrounding ar...
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Based on surveyor observation and staff interview, it has been determined that the facility failed to disposed of garbage and refuse properly relative to 1 of 1 outside dumpster and the surrounding area.
Findings are as follows:
Surveyor observation of the outside dumpster area, in the presence of the Food Service Director on 5/14/2025 at 8:51 AM revealed the following:
- Various sizes of cardboard boxes, broken down, on the ground surrounding the dumpster
- Scattered used surgical and N95 masks on the ground
- A tall, thin cardboard box containing 2 white wood wall baseboard pieces and 2 additional baseboard pieces on the ground
- Used bubble wrap located on the ground
- A mattress
- 5 pieces of wood located on the ground
- A large metal bed frame
During a surveyor interview with the Maintenance Director on 5/14/2025 at 9:11 AM, he acknowledged the above-mentioned items and indicated that the area surrounding the dumpster needed to be cleaned and the items needed to be discarded.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include an antibiotic stewardship ...
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Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include an antibiotic stewardship program for antibiotic use protocols for 2 of 3 residents, Resident ID #s 100 and 172.
Findings are as follows:
According to the Centers for Disease Control and Prevention (CDC) document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes states in part, Standardize the practices which should be applied during the care of any resident suspected of an infection or started on an antibiotic. These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed in your facility. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information is available .Track the amount of antibiotic used in your nursing home to review patterns of use and determine the impact of new stewardship interventions .Interventions designed to shorten the duration of antibiotic courses, or discontinue antibiotics based on post-prescription review (i.e., antibiotic time-out), may not necessarily change the rate of antibiotic starts, but would decrease the antibiotic DOT [days of therapy] .
Review of a facility policy titled, Antibiotic Stewardship Program dated 12/18/2019, states in part, .Discuss with providers if the patient meets criteria for antibiotic use or if alternative measures for treatment are warranted (careful observation, increased hydration) .
During a surveyor interview on 5/14/2025 at 9:20 AM with the Clinical Market Advisor and the Assistant Director of Nursing, they revealed that the facility utilizes the Mcgeers Criteria (a set of standardized definitions for identifying infections) for their Antibiotic Stewardship Program.
Record review of the Mcgeers criteria provided by the facility revealed the following:
For residents with an indwelling catheter both criteria 1 and 2 must be present:
1. At least 1 of the following sign or symptom subcriteria
a. Fever, rigors (shivering), or new-onset hypotension (low blood pressure), with no alternate site of infection
b. Either acute change in mental status or acute functional decline, with no alternate diagnosis and leukocytosis (elevated white count)
c. New-onset suprapubic (above the pubic bone) pain or costovertebral (joints connecting the ribs to vertebral column) angle pain or tenderness
d. Purulent (pus) discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis (a tube attached to each testicle), or prostate (a gland below the bladder)
2. Urinary catheter specimen culture with at least 105 cfu/mL (colony-forming units per milliliter) of any organism(s).
A. Record review for Resident ID #100 revealed s/he was admitted to the facility in September of 2024 with a diagnosis including, but not limited to, nontraumatic intracerebral hemorrhage (brain bleed).
Record review revealed a physician's order with a start date of 12/4/2024 to provide indwelling catheter care (a thin, flexible tube inserted in to the bladder to treat urinary retention) twice daily.
Record review of a nursing progress note dated 4/26/2025 at 12:45 PM revealed that the resident's urinary catheter was not draining. The catheter was changed and immediately drained 300 mLs of purulent amber urine. A nurse practitioner was notified and a new order for a STAT (immediate) urinalysis (a laboratory test that detects the presence of microscopic properties), culture (a laboratory test to check for microorganisms; a positive result indicates the presence of bacteria or yeast) and sensitivity (a laboratory test that determines which antibiotics are effective in stopping the growth of a microorganism found in a urine sample) was ordered.
Record review revealed a physician's order for Bactrim DS (an antibiotic prescribed to treat infections) 800-100 mg (milligrams) twice daily for a possible UTI [urinary tract infection] for 5 days from 4/27/2025 through 5/2/2025.
Record review failed to reveal evidence that the antibiotic was reviewed or that an antibiotic time out was completed following the Bactrim DS being initiated on 4/27/2025.
B. Record review for Resident ID #172 revealed s/he was admitted to the facility in May of 2025 with a diagnosis including, but not limited to, atrial fibrillation (irregular heartbeat).
Record review revealed the following physician's orders:
- 5/4/2025, Perform indwelling catheter care twice daily
- 5/4/2025, Re-start Eliquis (a medication prescribed to treat and prevent blood clots) in 24 hours if urine is free from hematuria (blood in the urine)
Record review of the document titled Skilled Evaluation dated 5/10/2025 at 10:44 PM, revealed that the resident had an episode of hematuria (blood in urine).
Record review of a progress note dated 5/11/2025 at 9:27 AM revealed, the resident continued experiencing hematuria and that his/her Eliquis was still on hold. Orders to obtain a urinalysis, culture, and sensitivity, start ceftriaxone 1 gram daily until the urinalysis results are obtained, replace the urinary catheter, and obtain STAT laboratory tests, CBC (complete blood count - a test that measures the heath of a person's immune system) and a CMP (comprehensive metabolic panel - a test that provides a snapshot of how a person's liver and kidneys are working with blood sugar level, electrolyte, and fluid balance).
Record review revealed a physician's order for Ceftriaxone (an antibiotic to treat an infection) 1 gram once a day for urinary tract infection until urinalysis results; adjust order and antibiotic for 5 days with a start date of 5/11/2025.
Record review failed to reveal evidence that the resident met the Mcgeers criteria prior to starting the Ceftriaxone on 5/11/2025. Additionally, the resident's urine culture and sensitivity obtained on 5/11/2025 failed to reveal evidence of any bacterial growth on 5/13/2025 at 8:48 AM.
During a surveyor interview on 5/14/2025 at 9:53 AM with the Assistant Director of Nursing and the Clinical Market Advisor, they acknowledged that the facility failed to complete an antibiotic time-out for Resident ID #100. Additionally, they were unable to provide evidence that the facility's antibiotic stewardship program was followed based on the Mcgeers criteria for Resident ID #172, per the facility policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on record review, staff and resident interview, it has been determined that the facility failed to ensure that a resident's comprehensive person-centered care plan was implemented relative to we...
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Based on record review, staff and resident interview, it has been determined that the facility failed to ensure that a resident's comprehensive person-centered care plan was implemented relative to weekly skin assessments for 3 of 7 residents reviewed, Resident ID #s 29, 32 and 172.
Findings are as follows:
1. Record review for Resident ID #29 revealed s/he was re-admitted to the facility in February of 2025 with a diagnosis including, but not limited to, stroke.
Record review revealed a care plan dated 2/27/2024 to conduct a comprehensive skin inspection weekly.
Record review of the resident's weekly skin inspection documentation failed to reveal evidence that a weekly skin inspection was completed since 5/2/2025, indicating that the skin assessment was not completed on 5/9/2025.
During a surveyor interview on 5/14/2025 at 3:06 PM with the Assistant Director of Nursing (ADON), she was unable to provide evidence that the resident's skin assessment was completed weekly, per the plan of care.
2. Record review for Resident ID #32 revealed s/he was admitted to the facility in May of 2024 with a diagnosis including, but not limited to, stroke.
Record review revealed a care plan dated 5/28/2024 to conduct a comprehensive skin inspection weekly.
Record review of the resident's weekly skin inspection documentation failed to reveal evidence that a weekly skin assessment was completed since 4/17/2025, indicating that the skin assessments were not completed on 4/24, 5/1, and 5/8/2025.
During a surveyor interview on 5/14/2025 at 1:52 PM with Registered Nurse, Staff A, she was unable to provide evidence that the resident's skin assessments were completed weekly, per the plan of care.
3. Record review for Resident ID #172 revealed s/he was admitted to the facility in May of 2025 with a diagnosis including, but not limited to, dementia.
Record review revealed a care plan dated 5/5/2024 for weekly skin checks by a licensed nurse.
Record review of the resident's weekly skin assessment documentation failed to reveal evidence that a weekly skin assessment was completed since 5/3/2025, indicating that the skin assessment was not completed on 5/10/2025.
During a surveyor interview on 5/14/2025 at 2:00 PM with the ADON, she was unable to provide evidence that the resident's skin assessment was completed weekly, per the plan of care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
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 nursing staff have the appropriate competencies and skills sets to provide nursing and relate...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skills sets to provide nursing and related services to assure resident safety, to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments, and considering the number, acuity, and diagnoses of the facility's resident population, in accordance with the facility assessment, for 4 of 4 nurses reviewed, Staff B, D, E and F. Additionally, the facility failed to have the appropriate competencies and skill sets relative to a peripherally inserted central catheter (PICC; a long flexible tube that is inserted into a vein in the arm and threaded through a larger vein leading to the heart, used to administer intravenous [IV] fluids and medications), for 3 of 3 nurses reviewed, Staff G, H, and I.
Findings are as follows:
Record review of the Facility Assessment dated 2/12/2025, states in part, .Center staff .receive initial training .staff training/competency/skill sets are sets that are necessary to provide the level and types of care needed for the patient/resident population .yearly .and as necessary .the following is a breakdown of departments and the area in which they receive competencies. Licensed Nurses .I.V. skills .PPE [personal protective equipment], infection control .catheters, G-tube [gastrostomy tube; a flexible tube inserted through the abdominal wall] .
1. Record review failed to reveal evidence that the following staff had completed annual nursing competencies since 2023:
- Registered Nurse (RN) Staff E, hired in March of 2009
- RN Staff B, hired in March of 2023
- RN Staff F, hired in August of 2023
- RN Staff G, hired in May of 2016
2. Record review of the facility assessment revealed that the facility provides services for the resident population including, but are not limited to, IV therapy. Further review of the assessment requires staff to be competent in this skill set.
Record review of the education/competency files for Staff H, I and J failed to reveal evidence that they had completed their yearly IV competency to manage and administer medications via a PICC line, per the facility assessment.
- Licensed Practical Nurse (LPN) Staff H, hired in May of 2016
- LPN Staff I, hired in October of 2006
- RN Staff J, hired in December of 2020
During a surveyor interview on 5/14/2025 at 5:07 PM with the Clinical Market Advisor, he was unable to provide evidence that any of the above-mentioned staff members had completed their yearly competencies according to the facility assessment, as required.
Cross reference F 694
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 3 of 7 medication carts observed, and for 2 of 3 medication rooms.
Findings are as follows:
According to the facility policy titled, Disposal of Medication Waste dated 7/1/2024, states in part, .All medications will be disposed of in accordance with applicable federal, state and local regulations .
Medications for disposal include:
-Medications which are not taken with the patient upon discharge;
-Discontinued, expired, or contaminated medications not returned to the pharmacy .
1a. A surveyor observation on 5/13/2025 at 4:45 PM of the Homestead Unit medication cart, revealed a medicine cup with one round white pill on top of the medication cart located in the hallway, unattended. Certified Medication Technician (CMT), Staff K, was observed exiting the restroom and walking towards the medication cart.
During a surveyor interview immediately following the above observation with CMT, Staff K, she revealed that she dispensed 3 Tylenol tablets and placed one of the tablets in a cup and left the cup on the medication cart. Staff K acknowledged that she should have discarded the pill and should not have left it unattended on the medication cart.
1b. A surveyor observation on 5/14/2025 at approximately 8:30 AM of the Avenue Unit medication cart, in the presence of Registered Nurse (RN), Staff A, revealed the following:
-1 Lantus insulin pen, opened without a date. Manufacturer's instructions state to discard 28 days after opening.
-1 Lantus insulin pen, opened with a date of 2/11. Manufacturer's instructions state to discard 28 days after opening.
-1 Breo Ellipta inhaler, opened without a date, manufacturer's instructions state to discard 6 weeks after opening.
-1 Active Liquid Protein, (with the majority of the contents consumed) opened without a date. Manufacturer's instructions state to discard 3 months after opening.
During a surveyor interview with Staff A immediately following the above observations, she acknowledged that the Lantus insulin pen had a date of 2/11 and that it was expired. Additionally, she acknowledged that the remaining above-mentioned medications were opened, without a date and should have been dated when opened.
2a. A surveyor observation on 5/14/2025 at approximately 8:30 AM of the Transitional Care Unit medication room, in the presence of Licensed Practical Nurse, Staff H, revealed the following:
-2 Kayexalate bottles in the medication cabinet, prescribed for a resident that no longer resides on the unit.
-1 box of Lovenox 30 milligram (mg) injections, 7 injections remaining, prescribed for a resident that no longer resides on the unit.
During a surveyor interview with Staff H, she indicated that they should have been placed in the discarded medication bin.
2b. A surveyor observation on 5/14/2025 at 9:00 AM of the M Nurses Station medication room refrigerator, revealed the following:
-1 Lispro insulin pen, opened without a date. Manufacturer's instructions state to discard 28 days after opening.
During a surveyor interview immediately following the above observation with RN Staff L, she acknowledged that the Lispro insulin pen was open without a date and that it should have been dated when opened and was going to be discarded.
2c. A surveyor observation on 5/14/2025 at 9:50 AM of the Homestead medication room refrigerator revealed the following:
-1 bottle of Lorazepam Intensol, with an expiration date of 5/6 written on the medication box.
During a surveyor interview with RN, Staff M, she acknowledged that the Lorazepam medication was expired and should have been discarded.
During a surveyor interview on 5/14/2025 at 2:19 PM with the Assistant Director of Nursing Services, she acknowledged the above-mentioned medications were not dated when opened, that the expired medications were still in use and the prescribed Kayexalate and Lovenox were located in the medication storage cabinet and should have been discarded.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmiss...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to Enhanced Barrier Precautions (EBP; involves using a gown and gloves during high-contact resident care activities) for 2 of 2 residents reviewed with wounds, Resident ID #s 34 and 47, and for 1 of 1 resident reviewed with a urinary catheter, Resident ID #88.
Findings are as follows:
Review of a facility policy titled, .Enhanced Barrier Precautions (EBP) In addition to Standard Precautions, (EBP) will be used when Contact Precautions do not otherwise apply .It employs targeted personal protective equipment [PPE] use during high contact patient/resident .activities is .Implementation of EBP .Patient Status .a wound or indwelling medical device without secretions or excretions that are unable to be covered or contained .
Record review of the facility procedure for EBP last revised on 5/1/2025 states in part,
1. Post the appropriate Enhanced Barrier Precautions sign on the patient's room door .
1.3 Print precaution signs in color .Follow the Centers for Disease Control and Prevention (CDC) guidance table below. 'Precautions .Enhance Barrier All patients with any of the following .Chronic wounds and /or indwelling medical devices (e.g, central line, urinary catheter, enteral feeding tube .PPE used for these situations .During high contact patient care activities: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use, central line, urinary catheter Wound care: any skin opening requiring a dressing .'
A. Record review revealed Resident ID #34 has a diagnosis including, but not limited to, a blister on the right foot.
Record review revealed a physician's order dated 5/1/2025 to cleanse the opened blister to the right heel, pat dry, apply skin prep around the wound and cover with a bordered gauze daily.
B. Record review revealed Resident ID #47 has a diagnosis including, but not limited to, an open wound to the right lower leg.
Record review revealed a physician's order dated 4/2/2025 for Fluocinonide External Cream 0.05 % (a topical medication prescribed to treat skin conditions that involve inflammation), apply to the right lower leg daily for bullous pemphigoid (an autoimmune skin disorder characterized by the formation of large, blisters that can rupture and leave open sores) for 8 Weeks.
C. Record review revealed Resident ID #88 has diagnoses including, but not limited to, obstructive and reflux uropathy (a condition where the urine flow is blocked in the urinary tract), open wound of the scalp, a history of urinary tract infections, encounter for fitting and adjustment of urinary devices and need for assistance with personal care.
Record review of the physician's orders revealed the following:
- 5/8/2025, Cleanse scalp wound with NS (normal saline; a mixture of salt and water), pat dry and cover with a bordered gauze dressing daily
- 7/21/2023, Empty the urinary catheter drainage bag at least once every eight hours when it becomes 1/2 to 2/3 full
Surveyor observations of the Homestead Unit failed to reveal evidence that the above-mentioned residents had the appropriate EBP signage on the doors to their rooms, on the following dates and times:
- 5/12/2025 at 10:14 AM, 10:20 AM, 12:00 PM, 12:30 PM, 2:18 PM, 2:28 PM, 3:05 PM and 3:26 PM
- 5/13/2025 at 8:11 AM, 8:38 AM, 10:54 AM, 11:16 AM, 12:07 PM, 1:54 PM, 4:45 PM and 5:06 PM
- 5/14/2025 at 9:11 AM, 9:31 AM, 11:16 AM, and 3:02 PM
During a surveyor interview on 5/14/2025 at 9:11 AM with Nursing Assistant (NA), Staff N, he revealed that he has been taking care of the residents on this unit who have urinary catheters and wounds. Additionally, Staff N was unaware that the residents should have been on EBP and required PPE when he provided direct care to them.
During a surveyor interview on 5/14/2025 at 1:58 PM with the Unit Manager, Registered Nurse, Staff M, she acknowledged that there are no signs indicating that the above-mentioned residents were on EBP. Furthermore, Staff M revealed that she would expect any resident with a urinary catheter and/or wounds would have been placed on EBP and signage should have been placed on their door. Additionally, she would expect that whenever staff provides direct care to residents with catheters or wounds they should wear the appropriate PPE.
During a surveyor interview on 5/14/2025 at 2:06 PM with NA, Staff O, she revealed that she has not received training on EBP and was unaware that any of the residents on the Homestead Unit required EBP.
During a surveyor interview on 5/14/2025 at 2:26 PM and at 2:35 PM with the Clinical Market Advisor, he revealed that he would expect resident's with wounds, gastrostomy tubes, and urinary catheters to be placed on EBP and that staff would utilize PPE when providing direct care.
Apr 2025
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to immediately inform the resident's representative of an accident involving the resident, which resulted in...
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Based on record review and staff interview, it has been determined that the facility failed to immediately inform the resident's representative of an accident involving the resident, which resulted in injury and the decision to transfer the resident to an acute care hospital for 1 of 1 resident reviewed, Resident ID #1.
Findings are as follows:
Record review of a community reported complaint submitted to the Rhode Island Department of Health, on 4/17/2025 alleged that the resident's representative was not informed of a fall with injury that required the resident to be transferred to an acute care hospital.
Record review of a facility policy last revised on 7/1/2024 titled Change in Condition: Notification of . states in part, .A Center must immediately inform the patient, consult with the patient's physician, and notify, consistent with their authority, the patient's representative, where there is: An accident involving the patient which results in injury and has the potential for requiring physician intervention .A decision to transfer or discharge the patient from the Center .
Record review revealed that the resident was admitted to the facility in April of 2025 with a diagnosis including, but not limited to, stroke.
Record review of a document titled Change in Condition Evaluation dated 4/12/2025 at 8:09 AM revealed, the resident sustained a fall associated with a laceration above his/her left eye, requiring sutures. Additionally, Section C of the document titled, Resident Representation Notification, under the section titled, Name of family/resident representation notified was documented as unknown at this time, on 4/12/2025 at 9:00 AM.
Record review revealed that the resident was transferred to an acute care hospital on the morning of 4/12/2025.
Additional record review failed to reveal evidence that the resident's representative was informed immediately of his/her accident which resulted in injury requiring the resident to be transfered to an acute care hospital on the morning of 4/12/2025.
During a surveyor interview with the Assistant Director Nursing Services on 4/21/2025 at 1:48 PM, she was unable to provide evidence that the resident's representative was immediately notified of the resident's fall and transfer to an acute care hospital on the morning of 4/12/2025.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of qu...
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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 meet professional standards of quality relative to evaluating a resident's neurological status after a fall for 2 of 2 residents reviewed, Resident ID #s 1 and 3.
Findings are as follows:
Record review of a community reported complaint submitted to the Rhode Island Department of Health on 4/17/2025 alleged that the facility did not complete neurological assessments (neuro check, a critical component of resident care, enabling nurses to evaluate and monitor the neurological system. This assessment helps in identifying changes in a resident's neurological status, which can be indicative of underlying conditions or responses to treatment. The assessment includes evaluating mental status, cranial nerves, motor function, sensory function, reflexes, and gait and balance) for Resident ID #1, after s/he sustained a fall with a head injury which required a transfer to an acute care hospital.
Record review of a facility policy last revised on 3/15/2024 titled, Falls Management states in part, .Post-Fall Management .Any patient who sustains an injury to the head from a fall and/or has a fall unwitnessed by staff will be observed for neurological abnormalities by performing neurological check, per policy .
1. Record review revealed Resident ID #1 was admitted to the facility in April of 2025 with a diagnosis including, but not limited to, stroke.
Record review of a document titled Change in Condition Evaluation dated 4/12/2025 at 8:09 AM revealed, the resident sustained a fall associated with a laceration above his/her left eye, requiring sutures. Review of the section titled Provider Notification and Feedback revealed that the provider was notified on 4/12/2025 at 7:45 AM with recommendations to, .Initiate facilities neuro protocol when resident returns from ER [Emergency Room] .
Further record review failed to reveal evidence that the facility's neuro protocol was initiated after the resident returned to the facility from the ER on [DATE].
During surveyor interviews with the Assistant Director of Nursing (ADNS) on 4/21/2025 at 12:35 PM and 1:48 PM, she indicated that neuro assessments are completed and documented on paper. Additionally, she was unable to provide evidence that the facility's neuro protocol was initiated for Resident ID #1 after s/he returned from the ER and per the facility's policy on 4/12/2025.
2. Record review revealed Resident ID #3 was admitted to the facility in April of 2025 with a diagnosis including, but not limited to, dementia.
Record review of a progress note dated 4/20/2025 at 9:30 PM, revealed that the resident had an unwitnessed fall at 3:00 PM.
Record review of a facility document titled, NEUROLOGICAL EVALUATION FLOW SHEET for Resident ID #3 revealed that the initial evaluation was to be completed on 4/20/2025 at 3:15 PM and every 15 minutes for the first two hours after the initial evaluation.
Further record review failed to reveal evidence that the evaluation was completed on 4/20/2025 at the following times: 3:15 PM, 3:30 PM, 3:45 PM, 4:00 PM, 4:15 PM, and 4:30 PM.
During a surveyor interview with the ADNS on 4/21/2025 at 4:35 PM, she acknowledged that the NEUROLOGICAL EVALUATION FLOW SHEET was not completed on 4/20/2025 at the above-mentioned times. Additionally, she was unable to provide evidence that Resident ID #3's neuro evaluation was completed in its entirety and indicated she would expect staff to complete the evaluation and document appropriately, per the facility policy.
Nov 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 F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight for...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight for 1 of 2 residents reviewed for significant weight loss and/or gain, Resident ID #1.
Findings are as follows:
Record review of a facility's policy titled, Procedure: Weights and Heights states in part, .Admissions and re-admissions will be weighed within 24 hours of admission .If the body weight is not as expected, reweigh the patient .Significant weight change is defined as .5% in one month .10% in 6 months .notify the physician .Dietitian of significant weight changes .
Record review of a facility policy titled, Nutrition/Hydration Care and Services states in part, .Staff will provide nutritional and hydration care and services to each patient .Observe and document oral intake of meals, supplements and snacks .
1. Record review revealed the resident was re-admitted to the facility in October of 2024, with diagnoses including, but not limited to, malignant neoplasm of the brain (brain cancer), acute subdural hemorrhage (bleeding near the brain), epilepsy (seizures), and dysphagia (difficulty swallowing).
Review of a care plan dated 10/3/2024 revealed, the resident is a nutritional risk due to being prescribed a therapeutic diet. Staff interventions include, providing fortified foods, providing the resident his/her diet as ordered, and offering snacks.
Record review of a nutritional assessment completed by the Dietitian on 11/1/2024 revealed that the most recent weight was 177.7 pounds (lbs.) obtained on 10/31/2024. It further reveals that this readmission weight represented a 9.2% loss from the resident's previous weight of 196.2 lbs. that was obtained prior to his/her hospitalization on 10/10/2024. The assessment further reveals that this weight loss was significant and unintentional.
Record review revealed the resident weighed 193.2 lbs. on 11/8/2024 which is a significant weight gain of 8.72% from his/her previous weight of 177.7 lbs on 10/31/2024.
Additional Record review revealed the resident weighed 180.8 lbs. on 11/15/2024 which is a significant weight loss of 6.42% from his/her 11/8/2024 weight of 193.2 lbs.
Record review failed to reveal evidence the resident was re-weighed on the above-mentioned dates when s/he had a documented significant weight loss or weight gain.
During a surveyor interview on 11/20/2024 at 11:49 AM with Registered Nurse, Staff C, she acknowledged that the resident should have been re-weighed after the weight discrepancies on 10/31, 11/8, and 11/15/2024.
2. Record review revealed incomplete documentation of intakes for meals and snacks from 11/1/2024 through 11/16/2024 as follows:
-11/1/2024- 1 meal documented with 100% eaten.
-11/2/2024- 1 meal documented with 50% eaten, 2 snacks documented with 0% and 100% eaten.
-11/3/2024- no documentation of meals, 2 snacks documented with 0% eaten.
-11/4/2024- 2 meals documented with 75% and 100% eaten, 3 snacks documented with 100%, 75% and 0% eaten.
-11/5/2024- no meals documented, 2 snacks documented with 100% and 0% eaten.
-11/6/2024- no meals documented, 1 snack documented with 100% eaten.
-11/7/2024- 2 meals documented with 100% and 75% eaten, 2 snacks documented with 100% and 75% eaten.
-11/8/2024- no meals documented; no snacks documented.
-11/9/2024- no meals documented, 2 snacks documented with 100% and 100% eaten.
-11/10/2024- 3 meals documented with 100%, 75% and 75% eaten, 2 snacks documented with 75% and 75% eaten.
-11/11/2024- no meals documented, 2 snacks documented with 0% eaten and 75% eaten.
-11/12/2024- no meals documented, 2 snacks documented with 100% and 100% eaten.
-11/13/2024- 2 meals documented with 100% and 100% eaten, 2 snacks with 100% and 100% eaten.
-11/14/2024- no meals documented; no snacks documented.
-11/15/2024- no meals documented, 2 snacks documented with 75% and 0% eaten.
-11/16/2024- no meals documented, 2 snack documented with 0% and refused.
The resident was unable to be interviewed because s/he was in the hospital at the time of the survey.
During a surveyor interview on 11/20/2024 at approximately 11:30 AM with Speech Therapist, Staff A, she revealed that when she works with the resident related to his/her swallowing she reports the resident's intake to the Nursing Assistant (NA) and the NA documents it in the resident's record.
During a surveyor interview on 11/20/2024 at approximately 11:40 AM with NA, Staff B, she revealed that NAs document the residents' meal and snack intakes in the electronic record.
During a surveyor interview on 11/20/2024 at 1:15 PM with the Dietitian, she acknowledged the weights documented, if accurate, were indicative of significant weight loss and weight gain. She revealed that she would have expected that the resident would have been re-weighed to ensure the accuracy of the weight. Further, she revealed that as part of her assessment process she does review the documented meal intakes and would expect meals to be documented. Additionally, she revealed that she had not been notified of the significant weight loss documented on 11/15/2024, but if she had, her usual step would have been to initiate a nutritional supplement.
During a surveyor interview on 11/20/2024 at 2:06 PM with the Director of Nursing Services (DNS) she revealed that she would have expected the staff to re-weigh the resident after his/her weights were obtained on 10/31, 11/8 and 11/15/2024. Additionally, the DNS could not provide evidence of complete meal documentation, or that the Dietitian was notified of the resident's significant weight losses or gains, as indicated in the facility's policy.
Aug 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 F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident's Advanced...
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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's Advanced Directive to refuse lifesaving treatment was followed for 1 of 4 residents reviewed, Resident ID #1.
Findings are as followings:
Review of a facility reported incident received by the Rhode Island Department of Health on [DATE], revealed that a resident passed away in the facility within 24 hours of admission.
Record review revealed the resident was readmitted to the facility in August of 2024 with diagnoses including, but not limited to, Atrial Fibrillation (a heart condition that causes irregular and often rapid heartbeat), acute osteomyelitis (an infection in the bone) of the left hand, and diabetes.
Record review revealed a document titled, Medical Orders for Life Sustaining Treatment (MOLST) dated [DATE] states in part, .Do Not Attempt Resuscitation [a person who has decided not to allow cardiopulmonary resuscitation (CPR) in an event their breathing or heart stops] .(Allow Natural Death) No defibrillator [a device that sends electric shock to the heart to restore normal rhythm heartbeat if it stopped] should be used on a person who has chosen Do not Resuscitation .
Additional record review revealed the above-mentioned MOLST form was signed by a Nurse Practitioner and further indicated that the form was completed with the resident's next of kin.
Record review of a progress note dated [DATE] which states in part, .Resident noted to not be breathing, absence of pulse. CPR commenced .nurse placed defibrillator on chest .while gathering paperwork, MOLST obtained from chart and noted to be DNR .CPR was stopped .EMS [Emergency Medical Staff] noted absence of vital signs .
During a surveyor interview on [DATE] at 10:23 AM and during a subsequent interview at 11:31 AM, with the Assistant Director of Nursing Services (ADNS), she acknowledged that the resident had a MOLST form which indicated that he/she was a DNR. The ANDS further acknowledged that the staff had performed CPR on the resident when he/she was found unresponsive and should not have.
Jul 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
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice for 1 of 2 residents reviewed...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice for 1 of 2 residents reviewed relative to wound care, Resident ID #1.
Findings are as follows:
According to Mosby's Fundamentals of Nursing Concepts, Process and Practice, 4th Edition, page 809, states in part, .a Registered Nurse checks all transcribed orders against the original order for accuracy and thoroughness .
Record review revealed the resident was admitted to the facility in June of 2024 with diagnoses including, but not limited to, bacteremia (an infection in the bloodstream), methicillin susceptible staphylococcus infection (a bacterial infection) and a wound to the left ischium (the lower and back part of the hip bone).
Record review of a hospital document provided to the surveyor, titled, Wound Care Note dated 6/24/2024, indicated the resident has a Stage IV (full thickness loss of skin and tissue exposing muscle, tendon, bone) pressure injury (localized injury to the skin and underlying tissue]) to his/her left ischium. Further review of the wound note states to continue the current wound treatment to the pressure injury, .Dakins [sodium hypochlorite] 0.125%, packing with a wet to dry dressing, BID [twice daily] and PRN [as needed] .
Record review revealed a physician's order dated 6/28/2024 for Sodium Hypochlorite Solution 0.125% apply to affected area topically two times a day for wound care. Further review of the order failed to reveal instructions for the wound packing or the location of the wound.
Record review of the June and July 2024 Treatment Administration Records revealed the treatment was signed off as administered.
During a surveyor interview on 7/31/2024 at 12:49 PM with the Director of Nursing Services, she acknowledged that the wound treatment order was incomplete, as it did not include instructions for the wound packing or the area to apply the treatment. Additionally, she would expect a complete order to be transcribed for a treatment.
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 a resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed receiving in...
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Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed receiving intravenous (medication administered via the vein) antibiotics, Resident ID #1.
Findings are as follows:
Record review revealed the resident was admitted to the facility in June of 2024 with diagnoses including, but not limited to, bacteremia (an infection in the bloodstream), methicillin susceptible staphylococcus infection (a bacterial infection) and osteomyelitis (an infection of the bone).
Record review of the physician's orders revealed the following:
-6/28/2024 for Meropenem Intravenous Solution, use 1 gram intravenously every 8 hours for osteomyelitis for 49 doses.
Record review of the July 2024 Medication Administration Record revealed the Meropenem was administered beyond the ordered 49 doses, indicating the resident received 4 additional doses on the following dates and times:
-7/15/2024 at 10:00 PM
-7/16/2024 at 6:00 AM
-7/16/2024 at 2:00 PM
-7/16/2024 at 10:00 PM
During an interview on 7/31/2024 at approximately 4:00 PM with the Director of Nursing Services, she acknowledged that the resident received an additional four doses of the antibiotic Meropenem. Additionally, she revealed the resident had missed two doses of the antibiotics on 7/2/2024 and 7/5/2024, and the nurse who transcribed the missed doses to be added to the order, must have entered the end date incorrectly.
May 2024
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure tha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following physician's order for 2 of 2 residents reviewed for fortified diets, Resident ID #s 63 and 88.
Findings are as follows:
According to Mosby's 4th Edition, Fundamentals of Nursing page 314 states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
Record review of a document titled Corporate Recipe-Fortified Foods provided to the surveyor by the Food Service Director, revealed the facility offers three items as fortified food choices; Fortified Cinnamon Oatmeal, Fortified Pudding Parfait, and Fortified Mashed Potatoes.
1. Record review revealed Resident ID #63 was admitted to the facility in November of 2022 with diagnoses including, but not limited to, unspecified protein-calorie malnutrition, dysphagia (difficulty swallowing), and cognitive communication deficit.
Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed the resident requires supervision with eating.
Record review of a care plan dated 1/12/2024 revealed the resident is at nutritional risk and is underweight related to decreased PO (by mouth) intake with inventions including, but not limited to, double protein portions and fortified food as ordered.
Record review of the resident's most recent weight obtained on 5/3/2024 revealed s/he is 76.8 lbs. (pounds).
Further record review of a physician's diet order dated 12/3/2023, states in part, 2 gm [gram] Sodium Dysphagia Advance texture, Moist ground-fortified foods-double protein portions .
During surveyor observations on the following dates and times, the resident was observed not receiving the double protein portions or fortified foods as ordered:
- 5/28-lunch
- 5/29-breakfast and lunch
- 5/30-breakfast and lunch
During a surveyor interview with Cook, Staff O, on 5/30/2024 at approximately 12:30 PM, he acknowledged the resident did not recieve double protein or fortified foods.
2. Record review revealed Resident ID #88 was admitted to the facility in July of 2022 with a diagnosis including, but not limited to, dementia.
Record review of a care plan dated 3/31/2023 revealed the resident is at nutritional risk related to weight loss with staff interventions including, but not limited to, a fortified diet as ordered.
Record review of the weight log revealed that the resident had an 8.4 lb. weight loss in one month.
Record review of a physician's diet order dated 10/27/2023, states in part, .regular diet regular texture, fortified foods .
During surveyor observations on the following dates and times, the resident was observed not receiving the fortified foods as ordered:
- 5/28-breakfast
- 5/29-breakfast and lunch
- 5/30-breakfast and lunch
- 5/31-breakfast
During a surveyor interview with the Registered Dietician, Staff A on 5/30/2024 at approximately 11:20 AM and 12:39 PM, she acknowledged the above-mentioned residents have had a weight loss. She further acknowledged Resident ID #63 is on a fortified double protein diet and Resident ID #88 is on a fortified diet. Additionally, she indicated that she would expect the diets to be followed as ordered.
During surveyor interviews with the Director of Nursing Services, on 5/30/2024, at approximately 1:43 PM and on 5/31/2024 at approximately 9:16 AM, she was unable to provide evidence that Resident ID #s 63 and 88 had received their diets, as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
Based on surveyor observations, record review, staff and resident representative interview, it has been determined that the facility failed to ensure that a resident receives assistive devices to main...
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Based on surveyor observations, record review, staff and resident representative interview, it has been determined that the facility failed to ensure that a resident receives assistive devices to maintain hearing abilities for 1 of 1 resident reviewed, Resident ID #63.
Findings are as follows:
Record review revealed Resident ID #63 was re-admitted to the facility in November of 2022 with a diagnosis including, but not limited to, sensorineural hearing loss (hearing loss from damage to cells or nerve fibers in the inner ear).
Record review of a care plan dated 4/28/2023 revealed the resident .has impaired communication as evidence by .impaired hearing .assist resident/patient with proper care and maintenance of hearing aids . Further record review of the care plan revealed it is important to the resident that s/he has the opportunity to engage in daily routines that are meaningful relative to his/her preferences. Additional record review revealed the resident enjoys listening to music and keeping up with the news by listening to the radio.
Review of the May 2024 Medication Administration Record revealed a physician's order dated 1/8/2023 for nursing to apply bilateral hearing devices in the morning and remove them at bedtime every day and night. Further review revealed it was documented that the resident's hearing devices were applied only once in the month of May, on 5/1/2024. Additional review revealed NA [Not Applicable] was documented for the remaining days of the month.
During the following surveyor observations, the resident did not have his/her hearing aids in his/her ears and had difficulty hearing the surveyor:
-5/28/2024 at 10:44 AM and 1:17 PM
-5/30/2024 at 9:37 AM
-5/31/2024 at 11:05 AM
During a surveyor interview on 5/29/2024 at 12:33 PM with the resident's family member, s/he revealed that the resident is hard of hearing and wears hearing aids. S/he indicated that s/he usually has to request for staff to place the resident's hearing aids in his/her ears when s/he visits and that the resident does not have them in often. Additionally, s/he indicated that the resident would benefit from wearing his/her hearing aids during the day.
During a surveyor interview on 5/31/2024 at 11:08 AM with Nurse Manager, Staff N, she indicated that the nursing staff does not apply the resident's hearing aids unless the resident has a visitor. Additionally, she acknowledged that per the physician's order, the hearing aids should be applied every day.
During a surveyor interview on 5/31/2024 at 11:13 AM with the Director of Nursing Services, she acknowledged that the resident has difficulty hearing and wears hearing aids. She further indicated that she would expect staff to be applying the resident's hearing aids every day, as ordered.
CONCERN
(D)
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 provide a resident with limited range of motion appropriate treatment and services ...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide a resident with limited range of motion appropriate treatment and services to increase range of motion and or to prevent further decrease in range of motion for 1of 3 residents reviewed for a mobility device, Resident ID #89.
Findings are as follows:
Record review revealed the resident was re-admitted to facility in April of 2024 with diagnoses including, but not limited to, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side and weakness.
Record review of the care plan dated 4/3/2024 revealed, the resident is expected to be discharged due to his/her admission for a skilled short-term stay for rehabilitation. Further record review revealed interventions including, but not limited to, functional mobility and a need for an assistive device.
Record review of a physical therapist note dated 4/24/2024 revealed, Physical Therapist (PT) was to initiate the process of getting the resident a left ankle-foot orthosis (AFO; a custom made device to assist the position and motion of the ankle).
Record review of a PT note dated 5/20/2024 revealed, the resident was cast for a left foot AFO that day.
Record review revealed a physician order dated 5/3/2024 for an AFO to the left lower extremity related to the resident's left sided weakness.
Record review of a progress note dated 5/6/2024 revealed, the orthotic company called the facility to reschedule the visit related to the AFO brace for 5/22/2024.
Surveyor observations on the following dates and times failed to reveal evidence of the ankle-foot orthoses:
5/28/2024 - 11:00 AM, 1:20 PM and 2:40 PM
5/29/2024 - 10:40 AM, 12:30 PM and 2:00 PM
5/30/2024 - 9:44 AM, 12:18 PM and 2:28 PM
5/31/2024 - 9:28 AM
During a surveyor interview on 5/31/2024 at 9:56 AM with Registered Nurse, Staff B, she revealed that two weeks ago the orthotic company came and took the resident's measurements for the AFO. She further indicated that Physical Therapy is supposed to follow-up on it.
Record review of the Detailed Prescription, the invoice used for ordering the AFO, failed to reveal evidence that the Physician signed the form, as required.
During a surveyor interview on 5/31/2024 at 11:55 AM with the Director of Rehabilitation Services, she revealed that the resident was prescribed the device to assist him/her with ambulation because s/he is unable to lift his/her left foot without assistance, due to having a stroke. Additionally, she indicated she had received the Detailed Prescription form from the orthotic company on 5/22/2024 and another one on 5/24/2024 which required the physician's authorization and signature but, did not know what to do with it.
During a surveyor interview on 5/31/2024 at approximately 12:30 PM with the Director of Nursing Services, she indicated that the Rehabilitation Services should have followed-up on the status of the resident's AFO device. Additionally, she indicated that she would expect the Rehabilitation department to have ensured that the resident received his/her AFO, as ordered.
CONCERN
(D)
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 record review, staff and resident interviews, it has been determined that the facility failed to provide appropriate tr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interviews, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 2 residents reviewed with constipation, Resident ID #103.
Findings are as follows:
Record review revealed the resident was admitted to the facility in August 2023 with diagnoses including, but not limited to, muscle weakness and urinary incontinence.
Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 13 out of 15, indicating intact cognition. Further review revealed the resident was occasionally incontinent of bowels and was dependent on staff for toileting.
Review of a care plan dated 8/8/2023 revealed, the resident exhibits or is at risk for gastrointestinal symptoms or complications related to constipation. Further review revealed interventions including, but not limited to, monitoring, and recording of bowel movements, and to assess and report signs and symptoms of decreased bowel movements.
During a surveyor interview on 5/28/2024 at 10:22 AM with the resident, s/he indicated that s/he sometimes does not have a bowel movement for more than 4 days. S/he further indicated that staff do not offer him/her medications for constipation and s/he has had to request the medications him/herself.
Record review revealed the following physician's orders for constipation:
-Miralax Powder- 17 grams (gm) by mouth as needed for constipation in 4 to 8 ounces of fluids if the resident has not had a bowel movement (BM) in 72 hours
-Milk of Magnesia (MOM) Suspension 400 milligrams(mg)/5 milliliters- administer 30 ml by mouth as needed for constipation at bedtime if no BM in 3 days
-Dulcolax Suppository 10 mg- administer 1 suppository rectally as needed for constipation if no result from MOM by next shift
-Fleet Enema 7-19 gm/118 ml- insert 1 dose rectally as needed for constipation if no result from Dulcolax within 2 hours. If no results from Fleet enema, call MD/advanced practice provider for further orders.
Record review of the resident's hand written bowel record revealed either a 0 was recorded or it was left blank for the resident's bowel movements from 5/20/2024 on the 7:00 AM- 3:00 PM shift until 5/26/2024 on the 7:00 AM - 3:00 PM shift, indicating the resident did not have a bowel movement for 6 days.
Record review of the May 2024 Medication Administration Record revealed, Miralax Powder (a medication for constipation) was administered at approximately 8:00 AM on 5/24/2024. Further review failed to revealed evidence that any other medications were administered or that the facility's bowel protocol was followed for constipation prior to the resident having a bowel movement on 5/26/2024.
Record review failed to reveal evidence that a provider was notified of the resident going without a bowel movement for 6 days.
During a surveyor interview on 5/29/2024 at 2:07 PM with the Director of Nursing Services (DNS), she indicated that the facility did not have a bowel protocol policy however all residents have a bowel protocol order set in place. She further indicated that the bowel protocol should start after 3 days without a BM to include MOM on the 3:00 PM - 11:00 PM shift, if no results then a Dulcolax suppository on the 11:00 PM - 7:00 AM shift, and if no results, a Fleet enema on the 7:00 AM- 3:00 PM shift.
During a surveyor interview on 5/29/2024 at 1:48 PM with Nursing Assistant, Staff C, she revealed that bowel movements are monitored and recorded for each resident every shift and documented electronically and in the bowel book. She further indicated that she does not alert the nurse if a resident has not had a bowel movement in 3 days because she thinks the computer alerts the nurse.
During a surveyor interview on 5/30/2024 at 9:34 AM with Registered Nurse, Staff D, she acknowledged that the resident did not have a substantial bowel movement documented from 5/20/2024 until 5/26/2024. She further acknowledged that Miralax was given to the resident on 5/24/2024 at approximately 8:00 AM with no results documented on the bowel record. Additionally, she acknowledged no additional interventions were administered to the resident for constipation per the physician's orders.
During a surveyor interview on 5/30/2024 at 11:30 AM with the DNS, she indicted that she would expect the bowel protocol to begin after 3 days, 9 documented 0''s in the bowel record, or if only a small bowel movement was documented. She further indicated that a small bowel movement is not considered a substantial bowel movement and the bowel protocol should still be initiated. Additionally, she acknowledged that the resident did not have a substantial bowel movement documented for 6 days and could not provide evidence that a provider was notified of the constipation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a blood purifying treatment given when kidney function is not...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a blood purifying treatment given when kidney function is not optimum) receive such services consistent with professional standards of practice for 1 of 2 residents reviewed for dialysis, Resident ID #64.
Findings are as follows:
Review of the facility policy titled Dialysis: Hemodialysis (HD) Provided by a Certified End-Stage Renal Facility [ESRD] revealed in part, .Professional standards of practice include .Ongoing communication and collaboration with the certified ESRD facility .
Record review revealed the resident was admitted to the facility in March of 2024 with diagnoses including, but not limited to, end stage renal disease (when your kidneys can no longer support your body's needs) and hypertension.
Record review of a care plan dated 3/26/2024 revealed, the resident exhibits or is at risk for impaired renal (kidney) function and is at risk for complications related to hemodialysis. Further review of the care plan revealed, the resident is at risk for cardiovascular symptoms or complications related to the diagnosis of hypertension.
Record review revealed the resident received hemodialysis three times a week at a dialysis center.
Review of a Nurse Practitioner's (NP) note dated 5/10/2024 revealed, the resident's blood pressure (BP) is elevated .220/64 [normal range 120/70], recheck later was 173/74 after medications. Patient is on [the following blood pressure medications] hydralazine, labetalol, amlodipine, and lisinopril at max doses. Will have nursing send BP log to next [dialysis] visit and see if they have any recommendations .
Review of the Hemodialysis Communication Sheet dated 5/11/2024 revealed the following communication written by nursing staff at the facility, Please review BPs and provide recs [recommendations] ie [example] alpha beta blocker [blood pressure medication] or something else . Further review revealed the residents BP log was attached to the communication sheet for review. Additional review revealed the Dialysis center left the Communication from the Dialysis Center portion of the communication sheet blank.
Record review failed to reveal evidence that the physician was notified or that the facility followed up with the dialysis center regarding the request to review the BPs or for a medication recommendation.
During a surveyor interview on 5/31/2024 at 9:50 AM with Registered Nurse, Staff E, she indicated that if the dialysis center does not document on the communication sheet, then nursing should follow up with the dialysis center. Additionally, she could not provide evidence that the facility and the dialysis center communicated regarding the request on 5/11/2024 or that the physician was notified.
During a surveyor interview on 5/31/2024 at 10:24 AM with the dialysis center's Clinic Manager, she indicated that the facility does not always send the communication sheet with the resident to the dialysis center.
During a surveyor interview on 5/31/2024 at 10:53 AM with the Medical Director, he indicated that providers typically like to consult with the nephrologist (doctor specializing in the kidneys) for medication changes related to blood pressure for residents who receive dialysis. He further indicated that he would have expected nursing to follow up with the dialysis center and notify the physician.
During a surveyor interview on 5/31/2024 at approximately 11:15 AM with the Director of Nursing Services, she could not provide evidence that the facility effectively communicated with the dialysis center or notified the physician of the lack of communication regarding the resident's elevated blood pressure.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to provide specialized rehabilitation services such as physical therapy that were required per the resident's comprehensive plan of care for 1 of 1 resident reviewed for rehabilitation services, Resident ID #93.
Findings are as follows:
Record review revealed that the resident was admitted to the facility in January of 2023 and has diagnoses including, but not limited to, cerebral infarction (stroke), hemiplegia (paralysis of one side of the body) affecting left dominant side, and abnormalities of gait and mobility.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15 indicating intact cognition. The MDS further indicated that the resident requires total dependence for bed mobility and transfer.
During a surveyor interview on 5/28/2024 at 11:11 AM with the resident, s/he revealed that s/he would like to receive more therapy, to help with mobility.
Review of an Occupational Therapy screen dated 3/7/2024 completed by Occupational Therapist, Staff I, revealed that the resident had functional impairment with wheelchair mobility, and bed and chair positioning. The screen revealed a physical therapy (PT) evaluation was requested.
Record review failed to reveal evidence that the physical therapy evaluation was completed.
During surveyor interviews on 5/30/2024 at 11:49 AM and 2:17 PM with the Director of Rehabilitation Services, she revealed that she would expect that the PT evaluation would have been completed as requested on the screen date of 3/7/2024. She was unable provide evidence that the PT evaluation was completed.
During a surveyor interview on 5/31/2024 at 10:46 AM, with Staff I, she revealed that the resident has tightness in his/her hip and discomfort sitting in his/her wheelchair. She further revealed that she feels the resident needs PT for assistance with positioning, appropriate seating, and bed positioning.
During a surveyor interview on 5/31/2024 at 11:09 AM with the Director of Nursing Services, she revealed that she would have expected the PT evaluation to have been completed and was unable to provide evidence that it was.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to assist resi...
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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 assist residents in obtaining routine dental services for 2 of 2 residents reviewed, Resident ID #s 37 and 69.
Findings are as follows:
1. Record review revealed Resident ID #69 was admitted to the facility in July of 2020 with diagnoses including, but not limited to, cognitive communication deficit and dysphagia (difficulty swallowing food or liquid).
Review of an annual Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 5 out of 15 indicating his/her cognition is severely impaired.
A surveyor observation of the resident on 5/29/2024 at 8:32 AM revealed that the s/he had multiple missing teeth. The resident was unable to answer questions related to his/her cognition.
Record review revealed a physician's order dated 7/1/2020 for Podiatry, Dental and Ophthalmology consult, and treatment as needed for patient health and comfort.
Record review of a progress note dated 4/28/2023 at 5:25 PM revealed in part, .Pt [patient] has 4 plus decayed or broken teeth/roots Pt care plan has been initiated including obtaining a dental consult as needed .
Further record review failed to reveal evidence that the resident had received routine dental services since his/her admission in July of 2020.
During a surveyor interview on 5/31/2024 at approximately 9:45 AM with the Infection Preventionist, she was unable to provide evidence that the resident had received routine dental services.
During a surveyor interview on 5/31/2024 at 11:06 AM with the Director of Nursing Services, she was unable to provide evidence that the resident had received routine dental services since his/her admission. Additionally, she was unable to provide evidence of resident refusals prior to this surveyor bringing the lack of dental services to the facility's attention.
2. Record review revealed Resident ID #37 was admitted to the facility in March of 2023 with diagnoses including, but not limited to, dementia and dysphagia.
Review of an annual Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 11 out of 15 indicating his/her cognition is moderately impaired. It further revealed obvious or likely cavity or broken natural teeth.
A surveyor observation of the resident on 5/28/2024 at 12:42 PM revealed, that the the resident had missing and broken teeth.
Record review revealed a physician's order dated 3/18/2023 for Podiatry, Dental and Ophthalmology consult, and treatment as needed for patient health and comfort.
Record review of a progress note dated 3/5/2024 at 4:00 PM revealed in part, .Pt has 4 plus decayed or broken teeth/roots .
Further record review failed to reveal evidence that the resident had received routine dental services.
During a surveyor interview on 5/31/2024 at 11:55 AM, with Licensed Practical Nurse, Staff F, she could not provide evidence that the resident had received routine dental services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide a safe and sanitary environment to help prevent the transmission of infecti...
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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 a wound dressing change for 1 of 2 residents, Resident ID #329. Additionally, the facility failed to maintain Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) for 4 of 5 residents reviewed, Resident ID #s 75, 97, 115, and 329.
Finding are as follows:
Review of the Center for Disease Control and Prevention document titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) Last Reviewed: August 1, 2023, states in part, Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities .The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents .with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include:
-Dressing
-Bathing/showering
-Transferring
-Providing hygiene
-Changing linens
-Changing briefs or assisting with toileting
-Device care or use of a device (i.e central lines, urinary catheters, feeding tubes .
1. Record review revealed Resident ID #75 was re-admitted to the facility in December of 2023 with a diagnosis including, but not limited to, a history of bladder cancer with a urostomy tube in place (an opening in the abdomen to make new passageway for urine to leave the body).
Surveyor observation of signage posted on the resident's door revealed in part, Enhanced Barrier Precautions; Attention: Caregivers, staff and visitors .Wear Gown and Gloves prior to these activities .During high-contact resident care activities .Device care or use of a device (i.e .urinary catheters) .
During a surveyor observation on 5/28/2024 at 2:44 PM, Nursing Assistant (NA), Staff J, was observed not wearing a gown as required while in the resident's room emptying his/her urostomy catheter bag.
During a surveyor interview immediately following the above observation with Staff J, she acknowledged that she had entered the resident's room and emptied his/her urostomy catheter bag and failed to wear a gown while emptying the catheter bag.
2. Record review revealed Resident ID #97 was re-admitted to the facility in October of 2023 with diagnoses including, but not limited to, end stage renal disease, hemodialysis (process where blood is removed from the body and filtered to remove harmful substances and placed back into the body), has a perma catheter to the right upper chest wall (a flexible tube placed into a blood vessel that is used for hemodialysis treatment) and a pressure ulcer (soft tissue injury that forms as a result of prolonged pressure) to the left heel.
Record review of a care plan dated 3/28/2024 revealed, the resident is at risk for MDRO infections due to a wound. Further record review revealed interventions including, but not limited to, maintaining EBP while performing all high-contact activities.
Surveyor observation of signage posted on the resident's door revealed in part, Enhanced Barrier Precautions; Attention: Caregivers, staff and visitors .Wear Gown and Gloves prior to these activities .During high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, assisting with toileting .
During a surveyor observation on 5/29/2024 at 10:40 AM, NA, Staff K, was observed transferring the resident into a wheel chair and assisted the resident to the bathroom. Further observation failed to reveal evidence that Staff K was wearing a gown, as required.
During an interview immediately following the above-observation, Staff K indicated that she had assisted the resident with bathing and toileting while s/he was in the bathroom. Staff K, acknowledged that she was not wearing a gown when she provided care to the resident.
3. Record review revealed Resident ID #115 was admitted into the facility in February of 2024 with diagnosis including, but not limited to, unspecified abnormalities of gait and mobility, need for assistance with personal care and retention of urine.
Record review of a care plan dated 3/28/2024 revealed, the resident is at risk for MDRO infections due to having an indwelling device/foley catheter (a tube that goes into the bladder to empty out urine) with interventions including, but not limited to, maintaining EBP while performing all high-contact activities.
Surveyor observation of signage posted on the resident's door revealed in part, Enhanced Barrier Precautions; Attention: Caregivers, staff and visitors .Wear Gown and Gloves prior to these activities .During high-contact resident care activities .Device care or use of a device (i.e .urinary catheters) .
During a surveyor observation on 5/28/2024 at 2:47 PM, Staff J was observed emptying the resident's foley catheter bag and was not wearing a gown, as required.
During an interview immediately following the above-observation with Staff J, she acknowledged that she had emptied the resident's catheter bag and was not wearing a gown, as required.
During a surveyor interview on 5/29/2024 at 10:45 AM with the Infection Preventionist, she indicated that she would expect staff to wear the required PPE.
4. Record review revealed Resident ID #329 was admitted to the facility in May of 2024 with diagnoses including, but not limited to, personal history of other infectious and parasitic diseases and orthopedic aftercare following a surgical amputation.
Record review of his/her care plan dated 5/14/2024 revealed, the resident has a PICC line (IV that gives your doctor access to the large central veins near the heart) relative to cellulitis, infection, and antibiotic therapy.
Surveyor observation of the signage posted on the resident's door revealed in part, Enhanced Barrier Precautions; Attention: Caregivers, staff and visitors .Wear Gown and Gloves prior to these activities .During high-contact resident care activities .Device care or use of a device (i.e .urinary catheters) .
During a surveyor observation on 5/30/2024 at approximately 10:00 AM, NA, Staff L, was observed providing care for Resident ID #329 without wearing a gown as required.
Further observation revealed that Licensed Practical Nurse (LPN), Staff M, entered the room at 10:08 to assist Staff L. Staff M proceeded to assist the resident with toileting and provided wound care to the resident without wearing a gown, as required.
During a surveyor interview immediately following the above-observations, Staff M acknowledged that the resident has an order for Enhanced Barrier Precautions and acknowledged she was not wearing the appropriate PPE.
During a surveyor interview on 5/30/2024 at approximately 11:00 AM with NA, Staff L, she revealed that she frequently provides care for Resident ID #329, without wearing a gown.
During a surveyor interview on 5/30/2024 at approximately 11:30 AM with the Infection Preventionist, she acknowledged that Resident ID #129 has a PICC line and is on EBP. Additionally, she indicated that she would expect staff to wear the appropriate PPE when caring for residents on EBP.
5. Record review revealed Resident ID #329 had a wound to his/her coccyx. Further record review revealed a physician's order dated 5/8/2024 to apply a 4x4 Optifoam to the coccyx every Monday, Thursday, and Saturday for skin integrity.
During a surveyor observation of the dressing change on 5/30/2024 at approximately 10:15 AM with Staff M, she removed the visibly soiled dressing from the resident's coccyx and placed it directly on the resident's bed. Staff M was then observed placing the soiled dressing and the soiled gauze that she used to clean the wound next to the resident's pillow. Additionally, Staff M removed her soiled gloves and placed a clean dressing on the resident's wound with ungloved hands. Staff M failed to perform hand hygiene after removing the soiled dressing, cleaning the resident's wound and prior to applying a clean dressing to the resident's wound.
During a surveyor interview immediately following the wound dressing observation with Staff M, she acknowledged that she placed the dirty soiled dressing at the head of the resident's bed and applied a clean dressing with ungloved hands.
During a surveyor interview on 5/30/2024 at approximately 1:28 PM with the DNS in presence of the Assistant Director of Nursing Services, she indicated that she would expect Staff M to perform hand hygiene, don gloves and discard the soiled dressing appropriately.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is stored...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed in accordance with professional standards for food service safety, relative to the main kitchen and 3 of 3 kitchenettes observed.
Findings are as follows:
1. Record review of the Rhode Island Food Code, 2018 Edition, Section 3-501.17 states in part, .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees Celsius or 41 degrees Fahrenheit or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 .
During the initial tour of the kitchen in the presence of the Food Service Director (FSD), on 5/28/2024 at 8:45 AM, the following was observed in the walk-in refrigerator:
- 1 large package of hot dogs, opened with approximately 6 hot dogs removed, not labeled or dated.
During the above observation with the FSD, he acknowledged the large package of hot dogs was not labeled or dated.
A surveyor observation on 5/28/2024 at approximately 9:05 AM revealed a document titled Resident Fridge located on the exterior door of the refrigerator located in the main dining area. The document states Please label all Resident Food items with their name and the date. We have provided labels and a marker for your convenience located behind this notice. All resident food items will be disposed of after three days by the Dietary Department.
During a surveyor observation of the kitchenette in the main dining room on 5/28/2024 at approximately 9:05 AM, in the presence of kitchen Staff G, the following was observed:
- 1 20 oz Styrofoam cup with a lid containing milk, not labeled or dated.
- A single serve container of Dannon yogurt with a manufacturer's use by date of 5/27/2024.
- In the freezer was a half of a bagel wrapped in clear wrap, not labeled or dated.
A surveyor interview with Staff G immediately following the observations, he acknowledged the above-mentioned items were not labeled or dated, and should have been discarded per facility policy.
During a surveyor observation in the presence of the FSD, of the kitchenette located on the transitional care unit on 5/28/2024 at approximately 9:30 AM, the following was observed:
- 2 single serve containers of Yoplait yogurt with manufacturer's use by dates of 5/6/2024.
- 1 single serve container of Siggi brand yogurt with a manufacturer's used by date of 5/21/2024.
- 1 single serve bottle of Activia Probiotic with a manufacturer's use by date of 5/27/2024.
- A one gallon zip lock bag dated 4/30 containing:
- 3 unlabeled 2 oz containers with lids containing what appeared to be tarter sauce, ketchup and an orange substance.
- 1 single serve bottle of Activia Probiotic with a manufacturer's use by date of 5/27/2024.
- 1 large black plastic container containing cooked pasta, dated 5/18.
During an interview with the FSD on 5/28/2024 at approximately 9:37 AM he acknowledged the above-mentioned items were expired and should have been discarded.
During a surveyor observation of the kitchenette located on the Homestead unit on 5/28/2024 at 9:50 AM, the following was observed:
- 1 48 oz jar of [NAME] Applesauce with a manufacturer's use by date of 5/24/2024.
- 1 48 oz jar of grape jelly with a manufacturer's use by date of 5/19/2024.
- 1 small clear reusable plastic container containing orange slices, not labeled or dated.
During a surveyor interview with Registered Nurse, Staff H on 5/28/2024 at approximately 9:55 AM, he acknowledged the above-mentioned items were expired and should have been discarded.
During a surveyor interview with the FSD on 5/28/2024 at approximately 10:30 AM, he revealed the facility dietary staff is responsible for maintaining the kitchenettes. He further acknowledged that the expired items, and the items exceeding the facility's three day policy should have been discarded. Additionally, he acknowledged that food items should be labeled and dated when opened.
Apr 2023
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**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 implement ...
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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 implement a comprehensive person-centered care plan for 1 of 2 residents reviewed, relative to wandering, Resident ID #53.
Findings are as follows:
Record review revealed the resident was initially admitted to the facility in December of 2017 with diagnoses including, but not limited to, dementia with other behavioral disturbances, restlessness and agitation, psychotic disorder with delusions, and major depressive disorder.
Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating the resident's cognition is severely impaired.
Record review of a behavioral health assessment note dated 3/28/2023 revealed the resident has a history of exit seeking behaviors.
During a surveyor observation on the following dates and times the resident was observed wandering on the unit, attempting to open the unit exit doors and entering other residents' rooms:
- 4/25/2023 at 10:04 AM, 10:36 AM, 11:09 AM, 12:06 PM
- 4/26/2023 at 1:11 PM
Record review of the resident's care plan failed to reveal a plan of care related to wandering.
During a surveyor interview with the Unit Manager on 4/27/2023 at 2:15 PM, she revealed that the resident often wanders and has wandered since his/her admission to the unit.
During a surveyor interview with the Director of Nursing Services on 4/26/2023 at 2:59 PM, she indicated that she would expect wandering to be included in the resident's current plan of care. Additionally, she was unable to provide evidence of an active plan of care relative to wandering for the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of quality related to following physician...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of quality related to following physician's orders for 1 of 4 residents relative to blood sugar monitoring, Resident ID #47.
Findings are as follows:
According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
Record review revealed the resident was re-admitted to the facility in October of 2022 with diagnoses including, but not limited to, type 2 diabetes mellitus and long term (current) use of insulin.
Record review of the April 2023 Medication Administration Record (MAR) revealed a physician order with a start date of 3/16/2023 for fingerstick monitoring (blood sugar) two times a day at 6:00 AM and 4:00 PM and notify the physician if blood sugar value is less than 70 or more than 400.
Further record review of the MAR failed to reveal evidence that the resident's blood sugar was documented for the 6:00 AM time per the physician's order on the following dates:
- 4/13/2023
- 4/19/2023
- 4/21/2023
- 4/22/2023
Record review of the resident's progress notes failed to reveal evidence of a reason why his/her blood sugar was not documented for the above-mentioned dates and times.
During a surveyor interview with Licensed Practical Nurse, Staff A and the Assistant Director of Nursing Services on 4/27/2023 at 2:20 PM, they were unable to provide evidence that the resident's blood sugar was documented on the above-mentioned dates and times.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 2 of 3 residents reviewed for cardiac...
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Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 2 of 3 residents reviewed for cardiac medications with parameters, Resident ID #s 36 and 417.
Findings are as follows:
1. Record review revealed Resident ID #36 was re-admitted to the facility in March of 2023 with diagnoses including, but not limited to, chronic diastolic congestive heart failure (abnormal heart condition characterized by an improper filling of blood in the heart causing a reduced amount of blood pumped out to the body), and hypertension (high blood pressure).
Record review of the April 2023 Medication Administration Record (MAR) revealed a physician's order with a start date of 4/4/2023, revised on dates 4/25/2023 and 4/26/2023, for metoprolol tartrate (a medication used to treat high blood pressure by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure) oral tablet 12.5 mg (milligrams) by mouth every 6 hours for hypertension, hold for heart rate (HR) less than 55 BPM (beats per minute) and systolic blood pressure (SBP) less than 100 mmHg (millimeters of mercury).
Further record review of the April 2023 MAR revealed the metoprolol 12.5 mg was administered outside of the parameters on the following dates and times:
- 4/16/ 2023 at 12:00 AM with SBP of 99 mmHg
- 4/17/2023 at 12:00 AM with HR of 54 BPM
- 4/18/2023 at 12:00 AM with SBP of 90 mmHg
- 4/23/2023 at 12:00 AM with SBP of 96 mmHg.
During a surveyor interview with the Assistant Director of Nursing Services on 4/27/2023 at 2:20 PM, she was unable to explain why the medication was administered outside the parameters set by the physician.
2. Record review for Resident ID #417 revealed s/he was admitted to the facility in April of 2023 with diagnoses including, but not limited to, atrioventricular block (a disturbance in the transmission of electric impulses between parts of the heart), hypertension, and chronic diastolic congestive heart failure.
Record review of the April 2023 MAR revealed a physician's order with a start date of 4/19/2023 for metoprolol tartrate 50 mg by mouth two times a day for hypertension, hold for a HR less than 60 BPM and SBP less than 100 mmHg.
Further record review of the April 2023 MAR revealed that metoprolol 50 mg was administered outside of the parameters on the following dates and times:
- 4/19/2023 at 4:00 PM- 10:00 PM dose with HR of 50 BPM
- 4/20/2023 at 7:00 AM- 12:00 PM dose with HR of 55 BPM
- 4/20/2023 at 4:00 PM- 10:00 PM dose with HR of 53 BPM
- 4/21/2023 at 7:00 AM- 12:00 PM dose with HR of 55 BPM
- 4/21/2023 at 4:00 PM- 10:00 PM dose with HR of 56 BPM
- 4/24/2023 at 4:00 PM- 10:00 PM dose with HR of 55 BPM
During a surveyor interview with the Director of Nursing Services on 4/27/2023 at 11:37 AM, she revealed that she would expect that the medication would be held.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff and resident interviews, it has been determined that the facility failed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff and resident interviews, it has been determined that the facility failed to ensure that a residents environment remains as free from accident hazards as possible for 2 of 4 housekeeping closets observed on the Homestead Unit and Transitional Care Units (TCU).
Findings are as follows:
Review of a facility policy titled, ENV101 Storage last revised on 7/15/2022 states in part, .Storage areas are locked when not in operation to prevent unauthorized access .
1. During surveyor observations of the secured memory care unit, Homestead Unit, on 4/25/2023 at 9:10 AM, 9:57 AM, 10:36 AM, and 11:09 AM, the housekeeping storage closet door was unlocked. Additionally, this closet contained multiple chemicals including, but not limited to, peroxide multi surface and disinfectant, toilet cleaner, and floor cleaner on low shelving.
During a surveyor observation on 4/25/2023 at 11:09 AM, Resident ID #53 began to open the unlocked housekeeping closet door where the above-mentioned chemicals were accessible. During this observation, the Assistant Director of Nursing Services (ADNS) was exiting the nearby shower room and redirected the resident away from entering the room. Prior to the ADNS exiting the shower room, no other staff members were visually supervising the resident at that time.
Record review revealed the resident was initially admitted to the facility in December of 2017 with diagnoses including, but not limited to, dementia with other behavioral disturbances, restlessness and agitation, psychotic disorder with delusions, and major depressive disorder.
Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating the resident's cognition is severely impaired. Further review revealed the resident ambulates with an assistive device and requires supervision when ambulating.
During a surveyor interview with the ADNS immediately following the above-mentioned observations at approximately 11:09 AM, she acknowledged that the resident had attempted to enter the storage closet where chemicals were kept and revealed that the closet should be locked.
During a surveyor observation in the presence of Registered Nurse, Staff B, on 4/25/2023 at 11:18 AM, she revealed that the housekeeping closet should be locked, and it is dangerous for chemicals to be unlocked on the unit.
2. During surveyor observations on the TCU, the housekeeping storage closet was observed to be unlocked on 4/25/2023 at 9:25 AM and 11:09 AM. Additionally, this closet contained a housekeeping cart and multiple bottles of chemical cleaning solutions.
During a surveyor observation of the housekeeping closet on 4/25/2023 at 9:25 AM, the housekeeping manager, Staff C, failed to lock the TCU housekeeping closet after exiting the room.
During a surveyor interview with a Social Worker on 4/25/2023 at 11:11 AM, he revealed that the housekeeping closet should be locked and acknowledged it was unlocked at that time.
During a surveyor interview with Staff C on 4/25/2023 at 11:20 AM, he indicated that the housekeeping storage closets should be locked.
During a surveyor interview with the Director of Nursing Services on 4/25/2023 at 11:26 AM, she acknowledged the housekeeping storage rooms on units contain hazardous chemicals and should remain locked.
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.
Findings are as follows:
Record review of the facility document titled, Labeling and Dating Inservice, states in part, .All foods should be dated upon receipt before being stored. Food labels must include .The date of preparation/receipt/removal from freezer .The 'use by' date .Leftovers must be labeled and dated with the date they are prepared and the 'use by' date .
During the initial tour of the main kitchen in the presence of the Food Service Director (FSD) on 4/25/2023 at 8:48 AM, revealed the following:
1. The walk-in freezer:
- one 10-pound (lbs.) bag of sliced pepperoni open and not dated
2. The walk-in refrigerator:
- two approximately ¼ lbs. packages of sliced deli meats labeled salami, dated 4/14/2023
- one container of lettuce and tomato salad labeled with the date 4/20 and use by date 4/23. Additionally, the lettuce was observed to be brown in color.
- one container of chopped lettuce, tomato, and cucumber salad, not labeled with a date or use by date
- two sandwiches containing salami labeled with the date 4/20
- one box of single sliced bacon containing 10 slices, opened and labeled with the date of 4/6
- one five lbs. container of cottage cheese, approximately half full, opened and not labeled with a date or use by date
During a surveyor interview with the Food Service Director on 4/25/2023 immediately following the above-mentioned observations, she acknowledged the findings. Additionally, she indicated that sandwiches shouldn't be kept in the refrigerator for longer than one day and food items should be labeled, dated, and discarded by the use by date. Furthermore, she was unable to provide evidence that the facility stored, prepared, distributed, and served food in accordance with professional standards for food service.
Jan 2023
2 deficiencies
2 IJ (2 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff and resident representative interview, it has been determined that the f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff and resident representative interview, it has been determined that the facility failed to ensure that the residents' environment remains as free of accident hazards as is possible for residents residing on a secured memory care unit relative to controlled substances and sharps contraband for 2 residents reviewed, Resident ID's #1 and #2.
Findings are as follows:
Review of a facility reported incident submitted to the Rhode Island Department of Health on 12/31/2022 revealed that a resident's family member went into the resident's room to visit when they observed a razor blade and a white powdery substance on a mirror on the bedside table. The report further indicated that the family member brought the paraphernalia (equipment that is used to consume illicit drugs) to the nurse at the nurse's station. The Director of Nursing Services (DNS) and the police were made aware. Additionally, the report revealed that the police questioned the aide that was assigned to care for the resident, Certified Nursing Assistant (CNA) Staff A, and she admitted to the paraphernalia being hers, she was arrested and removed from the facility.
Review of a facility policy titled Substance Abuse and Alcohol Misuse Prevention and Testing last revised on 7/01/2022 revealed in part, .This policy applies to all applicants and employees .Company policy strictly prohibits the illegal use, solicitation, sale, sharing, or possession of narcotics, drugs, paraphernalia, alcohol, or controlled substances while on the job or on Company property .Purpose .To provide and maintain a safe, drug-free environment for all employees and patients/residents and to protect the Company's assets .
Surveyor observation of the secured memory care unit at the facility on 1/04/2023 revealed ambulatory resident's walking up and down the hallway intermittently stopping at resident room doorways.
1. Record review for Resident ID #1 revealed that s/he was originally admitted to the facility in May of 2017 and has diagnoses including, but not limited to, dementia and cognitive communication deficit.
Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. The assessment further indicated that the resident is ambulatory.
Review of a progress note date 12/31/2022 at 3:38 PM revealed in part, Residents poa [power of attorney] .notified that an aide on unit today had illegal narcotic substance and paraphernalia on unit police were immediately notified arrived on unit spoke w/aide [with aide] whom admitted drugs and paraphernalia were hers .
During a surveyor phone interview with the resident representative on 1/04/2023 at 10:45 AM, s/he revealed that when s/he entered the resident's room for a daily visit, s/he observed a mirror with a razor blade and a white powdery substance on the bedside table. The family representative further indicated that s/he brought it to the nurse at the nurse's station and made them aware of where it was found. Additionally, the representative indicated that a person taking illegal narcotics is unsafe and should not be caring for the residents.
2. Record review for Resident ID #2 who is a roommate of Resident ID #1 revealed that s/he was originally admitted to the facility in December of 2018 and has diagnoses including, but not limited to, Parkinson's disease and Neurocognitive disorder with Lewy Body dementia.
Review of the resident's MDS assessment dated [DATE] revealed that the resident is rarely or never understood, has severe cognitive impairment, and displays wandering behaviors. The assessment further indicated that the resident is ambulatory.
Review of a progress note dated 12/31/2022 at 3:29 PM revealed in part, Resident's spouse notified that an aide on unit today was found w/ [with] illegal narc [narcotic] substance and paraphernalia on unit, substance was found in [residents room] on tray table, police were notified .aide admitted that drugs and paraphernalia were hers .
During a surveyor interview with Licensed Practical Nurse, Staff B, on 1/04/2023 at 11:06 AM, she revealed that she has been employed at the facility for 18 years and she indicated that some of the resident's on the memory care unit are ambulatory, that this situation was unsafe, and could have resulted in a very dangerous situation.
During a surveyor phone interview with Registered Nurse Staff C on 1/04/2023 at 12:32 PM, she revealed that while she was sitting at the nurse's station on 12/31/2022 a family representative approached her and placed a mirror with a razor blade and a white powdery substance on it in front of her stating s/he found this in resident's room on the bedside table. Staff C further indicated that the DNS was made aware, and the police arrived at the facility and interviewed Staff A who was assigned to care for the resident. Additionally, Staff C revealed that Staff A admitted to the police officers that the white powdery substance which the police identified as cocaine and the razor blade belonged to her.
Review of a police report for Staff A dated 12/31/2022 revealed in part, Staff A .admitted to bringing the cocaine to work this morning in her scrubs. She stated she was assisting [resident representative's] [parent] and she felt the razor in her pocket. She removed the items from her pocket, placed them on the small table, and forgot remove them from when she left .
During a surveyor interview with the DNS on 1/04/2023 at 8:40 AM she revealed Staff A was assigned to care for the resident on 12/31/2022. The DNS further indicated that Staff A admitted to the police that the cocaine and razor blade that was found in the resident's room on the secured memory care unit by the resident's family member belonged to her. In a subsequent interview with the DNS on 1/04/2023 at approximately 1:15 PM, she acknowledged that this situation was unsafe, and she is unsure of what may have occurred if the resident's family member had not noticed the razor blade and the white powdery substance in the resident's room and brought it to the facility's attention.
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Safe Environment
(Tag F0921)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff and resident representative interview, it has been determined that the f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff and resident representative interview, it has been determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on the secured memory care unit relative to controlled substances and sharps contraband, Resident ID's #1 and #2.
Findings are as follows:
Review of a facility reported incident submitted to the Rhode Island Department of Health on 12/31/2022 revealed that a resident's family member went into the resident's room to visit when they observed a razor blade and a white powdery substance on a mirror on the bedside table. The report further indicated that the family member brought the paraphernalia (equipment that is used to consume illicit drugs) to the nurse at the nurse's station. The Director of Nursing Services (DNS) and the police were made aware. Additionally, the report revealed that the police questioned the aide that was assigned to care for the resident, Certified Nursing Assistant (CNA) Staff A, and she admitted to the paraphernalia being hers, she was arrested and removed from the facility.
Review of a facility policy titled Substance Abuse and Alcohol Misuse Prevention and Testing last revised on 7/01/2022 revealed in part, .This policy applies to all applicants and employees .Company policy strictly prohibits the illegal use, solicitation, sale, sharing, or possession of narcotics, drugs, paraphernalia, alcohol, or controlled substances while on the job or on Company property .Purpose .To provide and maintain a safe, drug-free environment for all employees and patients/residents and to protect the Company's assets .
Surveyor observation of the secured memory care unit at the facility on 1/04/2023 revealed ambulatory resident's walking up and down the hallway intermittently stopping at resident room doorways.
1. Record review for Resident ID #1 revealed that s/he was originally admitted to the facility in May of 2017 and has diagnoses including, but not limited to, dementia and cognitive communication deficit.
Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. The assessment further indicated that the resident is ambulatory.
Review of a progress note date 12/31/2022 at 3:38 PM revealed in part, Residents poa [power of attorney] .notified that an aide on unit today had illegal narcotic substance and paraphernalia on unit police were immediately notified arrived on unit spoke w/aide [with aide] whom admitted drugs and paraphernalia were hers .
During a surveyor phone interview with the resident representative on 1/04/2023 at 10:45 AM, s/he revealed that when s/he entered the resident's room for a daily visit, s/he observed a mirror with a razor blade and a white powdery substance on the bedside table. The family representative further indicated that s/he brought it to the nurse at the nurse's station and made them aware of where it was found. Additionally, the representative indicated that a person taking illegal narcotics is unsafe and should not be caring for the residents.
2. Record review for Resident ID #2 who is a roommate of Resident ID #1 revealed that s/he was originally admitted to the facility in December of 2018 and has diagnoses including, but not limited to, Parkinson's disease and Neurocognitive disorder with Lewy Body dementia.
Review of the resident's MDS assessment dated [DATE] revealed that the resident is rarely or never understood, has severe cognitive impairment, and displays wandering behaviors. The assessment further indicated that the resident is ambulatory.
Review of a progress note dated 12/31/2022 at 3:29 PM revealed in part, Resident's spouse notified that an aide on unit today was found w/ [with] illegal narc [narcotic] substance and paraphernalia on unit, substance was found in [residents' room] on tray table, police were notified .aide admitted that drugs and paraphernalia were hers .
During a surveyor interview with Licensed Practical Nurse Staff B on 1/04/2023 at 11:06 AM, she revealed that she has been employed at the facility for 18 years and she indicated that some of the resident's on the memory care unit are ambulatory, that this situation was unsafe, and could have resulted in a very dangerous situation.
During a surveyor phone interview with Registered Nurse Staff C on 1/04/2023 at 12:32 PM, she revealed that while she was sitting at the nurse's station on 12/31/2022 a family representative approached her and placed a mirror with a razor blade and a white powdery substance on it in front of her stating s/he found this in resident's room on the bedside table. Staff C further indicated that the DNS was made aware, and the police arrived at the facility and interviewed Staff A who was assigned to care for the resident. Additionally, Staff C revealed that Staff A admitted to the police officers that the white powdery substance which the police identified as cocaine and the razor blade belonged to her.
Review of a police report for Staff A dated 12/31/2022 revealed in part, Staff A .admitted to bringing the cocaine to work this morning in her scrubs. She stated she was assisting [resident representative's] [parent] and she felt the razor in her pocket. She removed the items from her pocket, placed them on the small table, and forgot remove them from when she left .
During a surveyor interview with the DNS on 1/04/2023 at 8:40 AM she revealed Staff A was assigned to care for the resident on 12/31/2022. The DNS further indicated that Staff A admitted to the police that the cocaine and razor blade that was found in the resident's room on the secured memory care unit by the resident's family member belonged to her. In a subsequent interview with the DNS on 1/04/2023 at approximately 1:15 PM, she acknowledged that this situation was unsafe, and she is unsure of what may have occurred if the resident's family member had not noticed the razor blade and the white powdery substance in the resident's room and brought it to the facility's attention.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 44% turnover. Below Rhode Island's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), $35,188 in fines. Review inspection reports carefully.
- • 37 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $35,188 in fines. Higher than 94% of Rhode Island facilities, suggesting repeated compliance issues.
- • Grade F (21/100). Below average facility with significant concerns.
Bottom line: Trust Score of 21/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Grand Islander Center's CMS Rating?
CMS assigns Grand Islander Center an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Rhode Island, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Grand Islander Center Staffed?
CMS rates Grand Islander Center's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 44%, compared to the Rhode Island average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Grand Islander Center?
State health inspectors documented 37 deficiencies at Grand Islander Center during 2023 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 35 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Grand Islander Center?
Grand Islander Center is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 146 certified beds and approximately 115 residents (about 79% occupancy), it is a mid-sized facility located in Middletown, Rhode Island.
How Does Grand Islander Center Compare to Other Rhode Island Nursing Homes?
Compared to the 100 nursing homes in Rhode Island, Grand Islander Center's overall rating (2 stars) is below the state average of 3.1, staff turnover (44%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Grand Islander Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Grand Islander Center Safe?
Based on CMS inspection data, Grand Islander Center has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Rhode Island. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Grand Islander Center Stick Around?
Grand Islander Center has a staff turnover rate of 44%, 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 Grand Islander Center Ever Fined?
Grand Islander Center has been fined $35,188 across 1 penalty action. The Rhode Island average is $33,431. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Grand Islander Center on Any Federal Watch List?
Grand Islander 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.