Heatherwood Rehabilitation and Health Care Center
For profit - Limited Liability company
114 Beds
ATHENA HEALTHCARE SYSTEMS
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
16/100
#52 of 72 in RI
Photo by Heatherwood Rehabilitation & Health Care Center
Photo by Heatherwood Rehabilitation & Health Care Center
Photo by Heatherwood Rehabilitation & Health Care Center
1 / 5 photos
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Heatherwood Rehabilitation and Health Care Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided-this is below average and reflects poorly on the facility. It ranks #52 out of 72 nursing homes in Rhode Island, placing it in the bottom half of all facilities in the state, and is the lowest-rated option in Newport County. However, the facility is showing signs of improvement, with issues decreasing from 16 in 2024 to just 1 in 2025. Staffing is a strength here, boasting a 5/5 star rating with only 15% turnover, which is well below the state average, meaning staff are experienced and familiar with the residents. That said, there have been serious incidents, including a failure to ensure proper treatment for a resident with a pressure ulcer and insufficient food safety practices, highlighting areas that still need significant attention and improvement.
- Trust Score
- F
- In Rhode Island
- #52/72
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ✓ Good
- 15% annual turnover. Excellent stability, 33 points below Rhode Island's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- $16,801 in fines. Lower than most Rhode Island facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 47 minutes of Registered Nurse (RN) attention daily — more than average for Rhode Island. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 35 deficiencies on record. Higher than average. Multiple issues found across inspections.
16/100
Bottom 28%
Review needed
16 → 1 violations
★★☆☆☆
2.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 16 issues
2025: 1 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (15%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (15%)
33 points below Rhode Island average of 48%
Facility shows strength in staffing levels, quality measures, staff retention, fire safety.
The Bad
2-Star Overall Rating
Below Rhode Island average (3.1)
Below average - review inspection findings carefully
Federal Fines: $16,801
Below median ($33,413)
Minor penalties assessed
Chain: ATHENA HEALTHCARE SYSTEMS
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 35 deficiencies on record
1 life-threatening 1 actual harm
Aug 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0555
(Tag F0555)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interview, it has been determined that the facility failed to ensure the resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interview, it has been determined that the facility failed to ensure the resident has the right to choose his or her attending physician for 3 out of 4 residents reviewed related to physician choice, Resident ID #s 2, 3, and 5.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 8/7/2025 alleges in part, .My facility has a new policy of switching providers when residents go to the hospital. They don't inform the family or resident of the change .1) Record review revealed Resident ID #2 was admitted to the facility in April of 2023 with diagnoses including, but not limited to, Parkinson's disease, anxiety disorder, and major depressive disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score (BIMS) of 15 out of 15, indicating that the resident is cognitively intact.Record review revealed that the resident was under the care of Physician, Staff A, prior to a hospital stay from 7/18/2025 through 7/25/2025. Upon the resident's return to the facility on 7/25/2025 the resident's physician was changed to Physician, Staff B.Record review failed to reveal evidence that the change of physician was discussed with the resident prior to making the change. Additionally, record review failed to reveal evidence that the resident gave the facility permission to change his/her physician.Record review of the progress notes revealed a note dated 6/17/2025 at 2:43 PM which revealed in part, .Resident expressed [s/he] would like.[Physician, Staff A] as [her/his] doctor and would not like to have [Physician, Staff B].During a surveyor interview with the resident on 8/18/2025 at 2:04 PM, s/he revealed that when s/he went out to the hospital, the facility changed his/her doctor. The resident further revealed that the facility did not talk to him/her first and stated that s/he wanted to stay with his/her previous doctor.2) Record review revealed Resident ID #3 was admitted to the facility in September of 2021 with diagnoses including, but not limited to, Parkinson's disease, anxiety disorder, and disorders of psychological development.Review of an MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15, indicating that the resident has moderate cognitive impairment.Record review of a document titled .Physician Choices which was provided to the resident to determine his/her choice of physician, revealed the resident selected Physician, Staff A. The form was signed by the resident on 4/8/2025.Record review revealed that the resident was under the care of Physician, Staff A, prior to a hospital stay from 7/13/2025 through 7/15/2025. On 7/16/2025 his/her physician was changed to Physician, Staff B.Record review failed to reveal evidence that the change of physician was discussed with the resident prior to making the change. Additionally, record review failed to reveal evidence that the resident gave the facility permission to change his/her physician.Record review of a progress note written by the Admissions Director, dated 7/16/2025 at 2:30 PM, revealed, .Per center policies upon readmission this resident was assigned to [Physician, Staff B]. On this day resident verbalized .that [s/he] would like to return to [his/her] former Provider.During a surveyor interview with the Admissions Director on 8/18/2025 at approximately 10:30 AM, she revealed that after the resident told her that s/he didn't want to change his/her provider to Physician, Staff B, she contacted Physician, Staff A. She further revealed that after consulting the physician she had changed the resident back to Physician, Staff A's assignment, but another staff member reassigned the resident back to Physician, Staff B.During a surveyor interview with the resident on 8/18/2025 at approximately 2:15 PM, s/he revealed that s/he didn't know who his/her Physician was. 3) Record review revealed Resident ID #5 was admitted to the facility in June of 2021 with diagnoses including, but not limited to, nontraumatic intracerebral hemorrhage (bleeding into the brain tissue), anxiety disorder, and adjustment disorder.Review of an MDS assessment dated [DATE] revealed a BIMS score was unable to be obtained due to severe cognitive impairment.Record review revealed that the resident was under the care of Physician, Staff A, prior to a hospital stay from 7/11/2025 through 7/17/2025. On 7/17/2025 the resident's physician was changed to Physician, Staff B.Record review failed to reveal evidence that the change of physician was discussed with the resident's representative prior to making the change. Additionally, record review failed to reveal evidence that the resident's representative gave the facility permission to change the resident's physician.Record review of a progress note written by the Admissions Director, dated 7/17/2025 at 12:42 PM, revealed, .per center policies upon re admission this resident was assigned to [ Physician, Staff B]. On this day resident's [family member] verbalized to Admissions Director that [s/he] would not like to change providers.because [the resident] is very comfortable.The resident's representative was called on 8/18/2025 at 2:30 PM, this surveyor was unable to reach the family member, or to leave a message on the answering machine.During a surveyor interview on 8/18/2025 at 10:30 AM with the Admissions Director, she revealed that she was told that any new admission or anyone sent out to the hospital would be changed over to Physician, Staff B, when they returned to the facility.During a surveyor interview on 8/18/2025 at 10:40 AM with the Social Worker Director, he revealed that after Physician, Staff A, gave notice about a week ago. The facility sent out notifications that Physician, Staff B would be gradually taking over all the patients.During a surveyor interview on 8/18/2025 at approximately 1:30 PM with Physician, Staff A, and Nurse Practitioner, Staff C, they revealed that initially any new admissions were assigned to Physician, Staff B. The facility then said that anyone re-admitted from the hospital would come back under the care of Physician, Staff B. They further revealed that it became confusing and hard to determine which Physican was responsible for which resident, so on 8/8/2025 they gave notice as of October 3, 2025, they would no longer be providing care for residents at the facility.During a surveyor interview on 8/18/2025 at 3:15 PM with Physician, Staff B, he revealed that the facility was trying to ensure any admission or re-admission would now fall under his service. He was unaware how the facility was letting the residents know. He further revealed that recently the other practice had given notice that they would no longer be providing services at the facility after October 3, 2025. During a surveyor interview on 8/18/2025 at 3:20 PM with the Director of Nursing (DNS), she could not provide evidence that the above residents were given the right to choose a physician.Upon further interview with the DNS and the Administrator, they revealed that Physician, Staff A, has now provided notice that she will no longer be providing services at the facility. They further provided evidence that the following interventions were completed prior to the date of this complaint survey: a) An email dated 8/8/2025 was received from the Clinic that employs Physician, Staff A, stating that as of October 3, 2025, the physician will no longer be providing services at the facility. b) A notice was sent out to the facility employees to notify that a planned transitioned was initiated and Physician, Staff B will gradually assume care of all the residents. c) A notice was sent out to residents and responsible parties to notify them that Physician, Staff B, will gradually assume care of all the residents.
Sept 2024
15 deficiencies
1 IJ (1 facility-wide)
CRITICAL
(L)
📢 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
Food Safety
(Tag F0812)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
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 standard...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety relative to the main kitchen and for 1 of 3 nursing unit kitchenettes.
Findings are as follows:
1a. The Rhode Island Food Code 2018 Edition 4-501.114, states in part, .a chemical sanitizer for a manual or mechanical operation at contact times .shall be used as follows:
(A) A chlorine solution shall have a minimum concentration range 50-99 .
4-501.116 Ware washing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device .
1b. According to the State Operational Manual, Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 8/8/2024, states in part, .The chemical solution must be maintained at the correct concentration, based on periodic testing, at least once per shift .
During a surveyor observation on 9/3/2024 at approximately 8:30 AM of the main kitchen, revealed the dish machine was in use.
During a surveyor interview on 9/3/2024 at approximately 8:50 AM with Dietary Aide, Staff L, she revealed that the dish machine was converted from a high temperature sanitizing dish machine to a chlorine-based sanitizing dish machine. Additionally, when asked for a test strip to test the concentration of the chlorine-based sanitizing solution, Staff L provided the surveyor with a test strip that is used to test quaternary ammonium (a chemical solution used for sanitizing) sanitizer, not a chlorine-based sanitizer test strip.
During a surveyor interview with the Food Service Director (FSD) immediately following the above observation, he revealed the dish machine was changed from a high temperature sanitizing dish machine, which used hot water to sanitize, to a chemical sanitizer, using a chlorine-based solution to sanitize. Upon further interview he was unable to reveal when the conversion took place. Additionally, he was unable to provide evidence that the dish machine was being monitored to ensure the chemical sanitizing solution was at the appropriate concentration or that the appropriate test strips were available.
During surveyor interviews on 9/3/2024 at approximately 9:30 AM and 11:30 AM with the FSD, he revealed the service company for the dish machine had not yet been contacted to obtain the appropriate test strips or to check the functionality of the machine.
During a surveyor interview on 9/3/2024 at approximately 2:00 PM with the Administrator, he revealed that the service company was just contacted and would be at the facility before the days end.
During a surveyor observation and interview on 9/3/2024 at approximately 3:00 PM, with the facility's service technician, he revealed he had the appropriate test strips with him. Additionally, when he tested the chlorine-based sanitizer in the dish machine twice. The test stripa read less than 50 PPM (parts per million), indicating the dish machine was not sanitizing (the required level is 50 - 99 PPM).
The facility's failure to ensure that dishes and utensils were properly sanitized had the potential to cause more than minimal harm or death due to the risk of foodborne illness.
2. The Rhode Island Food Code 2018 Edition 4-601.11 states in part, .Nonfood contact surfaces shall be kept free of an accumulation of dirt, dust food residue and other debris .
During a surveyor observation on 9/3/2024 at approximately 8:45 AM of the main kitchen revealed the following:
- Three utility carts with heavy staining and scoring
- [NAME] colored food spills under the steam table
- Reach in refrigerator had a moderate amount of food crumbs on the bottom surface
- Baker's rack (rack that holds pans) with a buildup of grime on the ridges along the back side of the rack
- Grease build up along the sides and the corners of the stove
- Third floor kitchenette refrigerator had a moderate number of brown spills along the back sides of the second and third shelves
- Storage area under the tilt skillet with a moderate amount of grease and grime build up
- Bottom of the plate holder had an accumulation of a black crumb-like substance
- The floor mixer had a significant accumulation of rust
During a surveyor interview on 9/4/2024 at approximately 2:30 PM with the FSD, he was unable to provide evidence of a cleaning schedule for the above mentioned observations.
3. The Rhode Island Food Code 2018 Edition 4-501.12 states in part, .Surfaces that are subject to scratching and scoring shall be .discarded if they can no longer be effectively cleaned and sanitized .
During a surveyor observation on 9/3/2024 at approximately 9:50 AM, revealed 22 red lip plates with heavy scoring and deep scratches to the surface.
During a surveyor interview on 9/4/2024 at approximately 2:30 PM with the FSD, he was unable to provide evidence of purchase orders for the replacement of the red lip plates.
4. The Rhode Island Food Code 2018 Edition 3-501.13 states in part, .Thawing .
(A) Under refrigeration that maintains food temperature at .41 degrees F [Fahrenheit] or less; or
(B) Completely submerged under running water:
(1) At a water temperature of .(70 degrees F) or below .
(C) Thawed in a microwave oven .
During a surveyor observation on 9/4/2024 at approximately 1:52 PM, 3 packages of beef stew meat were sitting in a pan, thawing at room temperature.
During a surveyor interview immediately following this observation with the FSD, he was unable to explain why the beef stew meat was thawing at room temperature.
5. The Rhode Island Food Code 2018 Edition 3.501.16 states in part, .Time/Temperature Control for Safety Food, Hot and Cold Holding .shall be maintained at .5 degrees C (41 degrees F) or less .
During a surveyor observation on 9/3/2024 at approximately 11:30 AM during the lunch meal service in the main kitchen, cole slaw, egg salad and ham salad sandwiches were observed on a tray in front of the steam table. The following temperatures were obtained:
- Cold holding temperature reading of the egg salad was 49.1 degrees F.
- Cold holding temperature reading of the ham salad was 48.9 degrees F.
Additionally, record review failed to reveal evidence of a recorded cold holding temperature for the cole slaw that was being served as a vegetable.
During a surveyor observation on 9/4/2024 at approximately 11:40 AM, revealed 12 seafood salad sandwiches on a tray in front of the steam table. When the temperature was checked, the internal cold holding temperature was 50 degrees F.
During a surveyor interview on 9/4/2024 at approximately 11:45 AM with the FSD, he acknowledged that the cold holding temperatures for the seafood, egg and ham salads were not within the acceptable temperature parameters for potentially cold hazardous foods. Additionally, he revealed the cold holding temperature for the coleslaw was not taken prior to the onset of the lunch meal.
6. The Rhode Island Food Code 2018 Edition 4-901.11 states in part, .Equipment and Utensils, Air-Drying Required .After cleaning and SANITIZING, EQUIPMENT and UTENSILS .
(B) May not be cloth dried .
During a surveyor observation on 9/3/2024 at approximately 9:30 AM and on 9/4/2024 at 9:45 AM, of the Dietary Aide, Staff Q, she was observed drying wet meal trays with a napkin.
During a surveyor interview on 9/4/2024 at approximately 2:30 PM with the FSD, he was unable to explain why Staff Q was drying the meal trays with a napkin.
7. The Rhode Island Food Code 2018 Edition 4-601.11 states in part, .food contact surfaces shall be cleaned to sight .
During a surveyor observation on 9/4/2024 at approximately 1:50 PM of the ice machine, revealed the lower portion of the ice chute had an accumulation of a black and pink substance.
During a surveyor interview on 9/4/2024 at approximately 2:30 PM with the Regional Clinical Nurse, she acknowledged the ice machine was in need of cleaning and service.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · 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 a r...
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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 a resident who is at risk for pressure ulcers receives the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 4 residents reviewed with an actual pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence), Resident ID #67.
Findings are as follows:
Record review revealed the resident was re-admitted to the facility in June of 2024 with diagnoses including, but not limited to, diabetes, Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) and a stage 3 pressure ulcer (a wound that involves full-thickness skin loss that extends into the subcutaneous tissue) of the sacral region.
Review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15 out of 15, indicating the resident is cognitively intact. Additionally, it revealed the resident requires extensive assistance of 2 staff members for bed mobility.
Record review of a document dated 7/28/2024 titled, Braden Scale for Prediction of Pressure Score Risk, revealed a score of 16, indicating the resident is at risk for developing pressure ulcers.
Record review of a care plan revised on 8/6/2024, revealed the resident is at risk for potential alterations in skin integrity related to decreased and impaired mobility, with interventions including, but not limited to, skin condition checks weekly, inspect feet daily with care, and assess skin under footwear.
Record review of a physician's order dated 6/16/2024, revealed an order for weekly body checks on Thursdays.
Review of the August 2024 Treatment Administration Record (TAR) revealed the last body check for the resident was completed on 8/22/2024. Additional review failed to reveal evidence that the weekly body check was completed on 8/29/2024, as ordered.
During a surveyor interview with the resident on 9/5/2024 at 2:54 PM, s/he revealed that s/he has pain to his/her right heel periodically and receives pain medication from the staff. Additionally, the resident indicated that s/he was told by staff that s/he has an open wound to his/her right heel and that the wound has been there since late August of this year.
During a surveyor observation on 9/5/2024 at 2:52 PM of the resident's right heel, revealed an open wound to the resident's right heel, without a treatment or covered by a dressing.
During a surveyor observation of the resident's right heel on 9/5/2024 at 3:12 PM, in the presence of a Registered Nurse, Staff B, revealed an open wound to the resident's right heel.
During a surveyor interview immediately following the above observation with Staff B, he acknowledged that the resident has an open wound to his/her right heel. Staff B could not provide evidence as to when the resident's right heel was first observed to be open, but he indicated that the resident's right heel has remained unchanged over the last few days. Staff B further indicated that he had applied skin prep (a skin protectant that should not be applied directly to an open wound) to the resident's right heel on the morning of 9/5/2024 and that he did not notify the physician of the open wound to the resident's right heel.
After the wound was brought to the facility's attention, record review revealed a progress note titled, Wound Note dated 9/5/2024 at 7:51 PM, revealing the resident had a right heel deep tissue pressure injury which was resolved on 8/26/2024 but has reopened. Additionally, the note revealed the wound to the resident's right heel was measured as 3 centimeters (cm) in width by 2 cm in length by 0.2 cm in depth.
During a surveyor observation and simultaneous interview on 9/5/2024 at 3:34 PM with the Director of Nursing Services (DNS), she acknowledged that the resident had an open wound to his/her right heel. Additionally, the DNS indicated that the wound did not have a dressing or treatment order and further indicated that the wound did not appear to have just opened as of today. The DNS acknowledged that the facility was not aware of the resident's right heel wound until it was brought to their attention by the surveyor on 9/5/2024. The DNS further indicated that she would expect the staff to notify the physician of changes to the resident's skin condition and obtain an appropriate treatment for the wound.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure residents receive and consume food in the appropriate form, for 1 of 3 resi...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure residents receive and consume food in the appropriate form, for 1 of 3 residents observed with physician orders for a mechanical soft diet, Resident ID #39.
Findings are as follows:
Record review revealed the resident was admitted to the facility in January of 2018 with a diagnosis including, but not limited to, dementia.
Record review of a physician's diet order 9/13/2023 states in part, .LCS [Low Concentrated Sweets]; Mechanical soft [proteins that are ground or cut up] .
Record review of the lunch menu for Thursday September 6, 2024 revealed the following:
-Salisbury Steak
-Mashed Potatoes
-Peas
During a surveyor observation during the lunch meal on 9/5/2024 at approximately 12:30 PM, the resident was eating his/her lunch.
Record review of the resident's diet ticket during the above observation revealed in part, .LCS/Chopped .
Further observation of the resident's meal tray revealed that the Salisbury Steak was cut in strips that were approximately 1 1/2 inch x 1 inch.
During a surveyor interview at approximately on 9/5/2024 at 12:50 PM with Nursing Assistant, Staff O, she revealed that sometimes the dietary staff will cut the resident's food before it is served to the resident and sometimes the nursing staff cut the food. Staff O further revealed that she cut the resident's Salisbury Steak today. Additionally, she acknowledged Salisbury Steak was cut in strips that were approximately 1 1/2 inch x 1 inch.
During a surveyor interview on 9/5/2024 at 1:45 PM with Speech Language Pathologist, Staff P, she revealed that a resident with a diet order of mechanical soft, would have the Salisbury Steak cut into pieces less than a 1/2 an inch in size.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of quality relativ...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of quality relative to following physician's orders for 1 of 1 resident reviewed for obtaining and documenting weights on dialysis treatment days, Resident ID # 61, 1 of 10 residents reviewed with a pressure relieving device, Resident ID #62, and 1 of 2 residents reviewed who receives TED [thrombo-embolis deterrent- a type of compression stocking designed to help prevent blood clots and swelling in the legs] stockings daily, Resident ID # 67.
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.
1. Record review revealed Resident ID #61 was initially admitted to the facility in October of 2019 with diagnoses including, but not limited to, end stage renal disease and dependence on renal dialysis.
Record review a physician's order dated 10/27/2023 to record the residen't weights in the computer system per the dialysis center recommendations every Monday, Wednesday and Friday.
Record review of the documented weights, failed to reveal evidence of the resident's weights on the following dates:
-7/5/2024
-7/8/2024
-7/17/2024
-7/19/2024
-7/24/2024
-8/2/2024
-8/7/2024
-8/12/2024
-8/14/2024
-8/16/2024
-8/26/2024
-8/28/2024
-9/4/2024
2. Record review revealed Resident ID #62 was admitted to the facility in May of 2019 with diagnoses including, but not limited to, Alzheimer's Disease and a history of a pressure injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence).
Record review revealed a physician's order dated 4/26/2023 which states, May have Air Mattress for skin integrity. Check function and settings every shift.
Surveyor observations on the following dates and times revealed the resident was lying in bed with the air mattress setting at 200/static:
-9/4/2024 at 10:02 AM
-9/5/2024 at 10:57 AM
-9/6/2024 at approximately 9:00 AM
Additionally, during surveyor observations on the above-mentioned dates and times the resident's air mattress pressure pump device revealed a white sticker affixed to the upper right portion of the air pump that indicates set to 100. Further the pump indicated a setting for alternating or static, and the mattress was set to static.
During a surveyor interview on 9/6/2024 at 11:59 AM with Licensed Practical Nurse, Staff A, she acknowledged the air mattress setting was on 200/static and that the mattress should be set to 100, but she did not think it should be set to static. Additionally, she revealed the nurses check the air mattress function and setting each shift. Further, she revealed the setting is per the resident's weight but she could not explain why the air mattress was on static.
Further record review revealed the resident's weight was 114 pounds.
3. Record review revealed Resident ID #67 was admitted to the facility in December of 2022 with diagnosis including, but not limited to, arteriosclerotic heart disease and pulmonary embolism (when a blood clot gets stuck in an artery in the lung, blocking blood flow).
During a surveyor observation on 9/4/2024 at 9:01 AM revealed swelling to the resident's right and left lower extremity, the right lower extremity was observed to be more swollen than the left.
Record review revealed a physician's orders dated 6/16/2024 for TEDs: apply in the AM and Remove at HS [hour of sleep] .
Surveyor observations on the following dates and times revealed the resident was observed with only the left TED stocking on:
-9/4/2024 at 12:03 PM and 12:21 PM
-9/5/2024 at 10:03 AM, 12:04 PM and at 12:15 PM
During a surveyor interview on 9/5/2024 at 12:18 PM with Registered Nurse, Staff B, he acknowledged that the resident did not have a TED stocking applied to his/her right lower extremity as ordered. Additionally, he was unable to explain why the TED stockings were not applied to both lower extremities as ordered.
During a surveyor interview on 9/6/2024 at approximately 1:30 PM with the Director of Nursing Services, she was unable to explain why the above-mentioned physician orders were not followed. Additionally, she was unable to to explain if the air mattress should have been on an alternating or static setting.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure residents with limited range of motion receive appropriate treatment to pre...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure residents with limited range of motion receive appropriate treatment to prevent further decline in range of motion for 3 of 4 residents reviewed, Resident ID #s 18, 61 and 70.
Findings are as follows:
1. Record review revealed Resident ID #18 was re-admitted to the facility in December of 2023 with diagnoses including, but not limited to, stroke and hemiplegia (paralysis on one side of the body).
Record review revealed a physician's orders dated 4/23/2024 for Left resting hand orthosis [splint] may be worn during day hours, as tolerated.
Surveyor observations on the following dates and times revealed the resident was without his/her left hand splint applied as ordered:
-9/3/2024 at approximately 9:45 AM and 12:00 PM
-9/4/2024 at approximately 10:00 AM
-9/6/2024 at 8:53 AM and 10:15 AM
Record review of the nursing progress notes failed to reveal evidence that the resident removed or refused to wear his/her hand splint.
During a surveyor interview on 9/6/2024 at 11:15 AM with the Assistant Director of Nursing Services (ADNS), she acknowledged that the left hand splint had not been applied. Additionally, she indicated she was the nurse assigned to Resident ID #18 on 9/4/2024 and revealed she did not apply the left hand splint as she could not locate the splint.
During a surveyor interview on 9/6/2024 at 2:03 PM with the Director of Nursing Services (DNS), she revealed that she would expect the splint to be applied as ordered.
2. Record review revealed Resident ID #61 was admitted to the facility in October of 2019 with diagnoses which include, but are not limited to, stroke and hemiplegia.
Record review of the physician's orders revealed an order dated 10/24/2023 for Right resting hand splint to be donned [to put on] during the day, as tolerated every shift.
Surveyor observations on the following dates and times revealed the resident lying in bed without his/her right-hand splint applied:
-9/5/2024 at 1:20 PM
-9/6/2024 at approximately 12:45 PM
-9/6/2024 at 1:10 PM
Further observations revealed the resident's splint was located on the window sill on 9/5/2024 and 9/6/2024 during the above observations.
Record review of the progress notes failed to reveal evidence that the resident removed or refused to wear his/her hand splint.
During a surveyor interview on 9/6/2024 at 1:10 PM in the presence of the DNS, she acknowledged the right-hand splint was not applied and noted it to be on the resident's window sill. Further, she was unable to explain why the splint was not applied as ordered.
3. Record review revealed Resident ID #70 was re-admitted to the facility in December of 2022 with diagnoses including, but not limited to, stroke and hemiplegia.
Record review of the physician's orders revealed an order dated 6/18/2023 for Right resting hand splint to be donned during the day, as tolerated every shift.
Surveyor observations on the following dates and times revealed the resident lying in bed without his/her right-hand splint applied:
-9/4/2024 at 10:37 AM
-9/6/2024 at 11:12 AM
-9/6/2024 at 1:15 PM
-9/6/2024 at 1:34 PM
Record review of the progress notes failed to reveal evidence that the resident removed or refused to wear his/her hand splint.
During a surveyor observation and simultaneous interview on 9/6/2024 at 1:15 PM with the DNS, she acknowledged the right-hand splint was not applied and was unable to explain why the splint was not applied as ordered.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure res...
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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 residents that are fed through a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed receiving nutrition via a gastrostomy tube (a feeding tube that delivers nutrition, hydration and medication to your stomach through the abdomen), Resident ID #197.
Findings are as follows:
Review of a facility policy titled, Enteral Feeding states in part, Enteral feeding provides an alternative method of nutritional support via a gastrostomy .tube and is used to enhance and maintain nutritional status when there is an inability to take adequate nutrients orally .PROCEDURE Check physician order for formula, rate and water flushes .Check feeding tube placement with stethoscope .Aspirate [a process to use a syringe to check for contents remaining] stomach contents to check for residual [quantity of tube feed remaining in the stomach] .Hold feeding for residual amount designated by physician order .Flush tube with 30 cc of water .Record intake, flush and free water volume administered .
Record review revealed that the resident was readmitted to the facility in August of 2024 with a diagnoses including, but not limited to, dysphagia (difficulty swallowing) and gastrostomy.
Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed s/he has a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment.
Record review of the medical record revealed that the resident had a gastrostomy tube placed on 7/17/2024.
Record review of a care plan last updated on 8/20/2024 revealed that the resident requires enteral feeding for nutrition and hydration related to dysphagia due to an osteophyte (abnormal bony outgrowth or projection). The approaches listed include, but are not limited to, check placement and residuals of tube prior to feeding every shift and administer enteral nutrition and flushes per physician order.
Record review revealed the following physician's orders:
- 8/15/2024, Check tube placement by aspirating stomach contents before meals.
- 8/15/2024, Check tube placement by auscultating (listening to) air passage before meals.
- 8/20/2024, 75 milliliters water before and after bolus (administering a large amount of tube feeding in a short period of time) feeding four times a day at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM.
- 8/20/2024, Glucerna (type of feeding) 1.2 CAL give a 360-ounce carton bolus four times daily at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM.
Record review of the resident's progress notes revealed several notes since admission indicating that the resident was administering his/her own bolus feedings.
During a surveyor interview on 9/6/2024 at 11:07 AM with the resident, s/he revealed that s/he administers his/her own bolus feedings. When asked by the surveyor if the nurses check the tube placement before the administration of the tube feeding, s/he stated that they do not. The resident also indicated that s/he does not check the tube placement before the administration of the tube feeding.
During a surveyor interview on 9/5/2024 at 12:54 PM with Licensed Practical Nurse, Staff C, she revealed that she frequently has the resident on her assignment, and the resident self-administers his/her bolus feedings and flushes. When asked if she checks for tube placement prior to the resident administering the bolus feeding, she acknowledged that sometimes she does not.
During a surveyor interview on 9/5/2024 at 1:01 PM with the Director of Nursing Services, she acknowledged that the resident does self-administer the bolus. She was unable to provide evidence of a completed assessment indicating that the resident was competent to safely self-administer the bolus feeding.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 ...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 residents reviewed for respiratory care, Resident ID #49.
Findings are as follows:
Record review of a facility policy, with a revision date of November 2020, titled, Oxygen Administration Nasal Cannula states in part, .Replace and date cannula [tubing that delivers oxygen through the nose] and tubing weekly or when visibly soiled or damaged .
Record review revealed the resident was admitted to the facility in May of 2023 with a diagnosis including, but not limited to, chronic obstructive pulmonary disease (a condition caused by damage to the airways or other parts of the lungs that blocks airflow and makes it difficult to breathe).
Review of a physician's order dated 6/24/2024 revealed an order for the resident to receive supplemental oxygen at 1-2 liters/minute via nasal cannula as needed every shift.
During surveyor observations on the following dates and times, the resident was observed receiving oxygen via nasal cannula which was discolored throughout and the tubing was dated 7/18:
-9/3/2024 at 9:08 AM
-9/4/2024 at 9:22 AM and 9:59 AM
During a surveyor interview with the resident on 9/5/2024 at 8:55 AM, s/he indicated that s/he uses oxygen nightly as well as during the day when needed.
During a surveyor interview with the Director of Nursing Services (DNS) on 9/5/2024 at 9:02 AM, she indicated that she would expect the oxygen tubing to be changed weekly, per the facility's policy. Additionally, she was unable to provide evidence as to why the tubing was not changed.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the pharmacist failed to report irregularities to the attending physician, the facility's Medical Director, and the Director of ...
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Based on record review and staff interview, it has been determined that the pharmacist failed to report irregularities to the attending physician, the facility's Medical Director, and the Director of Nursing Services (DNS) for 1 of 8 residents reviewed for monthly drug regimen reviews, Resident ID #59.
Findings are as follows:
Record review of a facility policy titled Drug Regimen Review- Monthly revealed in part, .the consultant Pharmacist shall review the medical record of each resident and perform a Drug Regimen Review at least once each calendar month. The Consultant Pharmacist shall identify, document and report possible medication irregularities for review and action by the attending Physician, where appropriate .Consultant Pharmacist .Shall perform Medication Regimen Review for each resident at least monthly. This review shall be performed by evaluating the medical record of each resident, which contains the current Medication Regimen as documented on the most recent Physician's Order Sheets or electronic record of current orders .
Record review revealed Resident ID #59 was admitted to the facility in April of 2023 with a diagnosis including, but not limited to, type 2 diabetes mellitus (a condition that causes high blood sugar levels).
Record review revealed a physician's order dated 6/7/2024 for Fiasp (a type of insulin) 100 unit/milliliter (ml) sliding scale.
Special instructions: Per sliding scale if blood sugar is less than 70, call MD [medical doctor]
If blood sugar is 150 to 199, give 1 units
If blood sugar is 200 to 249, give 2 units
If blood sugar is 250 to 300, give 3 units
If blood sugar is 301 to 349, give 4 units
If blood sugar is 350 to 399, give 6 units
If blood sugar is 400 to 449, give 8 units
If blood sugar is 450 to 500, give 10 units.
If blood sugar is greater than 500, call MD .
Record review of the August 2024 Medication Administration Record (MAR) from 8/3/2024 through 8/14/2024 revealed the Fiasp was administered outside of the ordered parameters on the following dates and times:
8/3/2024 at 7:30 AM and 11:30 AM
8/4/2024 at 7:30 AM
8/6/2024 at 4:30 PM
8/8/2024 at 7:30 AM and 11:30 AM
8/9/2024 at 7:30 AM
8/10/2024 at 11:30 AM
8/13/2024 at 7:30 AM and 11:30 AM
Review of the Pharmacist Consultation Recommendation Report dated 8/15/2024, failed to reveal evidence that the pharmacist identified that the Fiasp insulin was administered outside of the ordered parameters on the above-mentioned dates and times.
During a surveyor interview on 9/6/2024 at 1:15 PM with the Regional Clinical Nurse, she revealed that she would expect the pharmacist to have identified that the Fiasp was administered outside of parameters on the August medication regimen review. She was unable to provide evidence that the above irregularities were identified by the pharmacy, or reported to the attending physician, the facility's Medical Director, and the Director of Nursing Services as required.
Cross reference F760
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 4 residents reviewed receivi...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 4 residents reviewed receiving insulin, Resident ID #59 and 1 of 4 residents reviewed receiving an Antipsychotic medication (medications that mainly treat psychosis and, related conditions and symptoms), Resident ID #74.
Findings are as follows:
1. Record review revealed Resident ID #59 was admitted to the facility in April of 2023 with a diagnosis including, but not limited to, type 2 diabetes mellitus.
Record review revealed a physician's order dated 6/7/2024 for Fiasp (insulin) 100 unit/milliliter (ml) sliding scale.
Special instructions: Per sliding scale if blood sugar is less than 70, call MD [medical doctor]
If blood sugar is 150 to 199, give 1 units.
If blood sugar is 200 to 249, give 2 units
If blood sugar is 250 to 300, give 3 units
If blood sugar is 301 to 349, give 4 units
If blood sugar is 350 to 399, give 6 units
If blood sugar is 400 to 449, give 8 units
If blood sugar is 450 to 500, give 10 units.
If blood sugar is greater than 500, call MD .
Review of the August 2024 Medication Administration Record (MAR) revealed that the Fiasp was given outside of parameters on the following dates and times:
8/3/2024 at 7:30 AM- blood sugar (BS) 211 (1 unit administered) and 11:30-BS 210 (1 unit administered)
8/4/2024 at 7:30 AM- BS 205 (1 unit administered)
8/6/2024 at 4:30 PM- BS 200 (1 unit administered)
8/8/2024 at 7:30 AM- BS 280 (2 units administered) and 11:30 AM-BS 225 (1 unit administered)
8/9/2024 at 7:30 AM- BS 252 (2 units administered)
8/10/2024 at 11:30 AM- BS 228 (3 units administered)
8/13/2024 at 7:30 AM- BS 236 (1 unit administered) and 11:30 AM- BS 200 (1 unit administered)
8/15/2024 at 7:30 AM- BS 272 (2 units administered) and 11:30 AM- BS 196 (0 units administered)
8/16/2024 at 7:30 AM- BS 244 (1 unit administered) and 11:30 AM- BS 225 (1 unit administered)
8/17/2024 at 11:30 AM- BS 216 (1 unit administered)
8/19/2024 at 7:30 AM- BS 190 (0 units administered)
8/23/2024 at 7:30 AM- BS 209 (1 unit administered) and 11:30 AM- BS 238 (1 unit administered)
8/25/2024 at 11:30 AM- BS 354 (4 units administered)
8/26/2024 at 7:30 AM- BS 253 (2 units administered)
8/27/2024 at 7:30 AM- BS 250 (2 units administered) and 11:30 AM- BS 221(1 unit administered)
Review of the September 2024 MAR revealed that the Fiasp was given outside of parameters on the following dates and times:
9/3/2024 at 7:30 AM- BS 357 (4 units administered)
2. Record review revealed Resident ID #74 was admitted to the facility in February of 2022 with a diagnosis including, but not limited to, paranoid schizophrenia ( is a term used for a subtype of schizophrenia with delusions and auditory hallucinations).
Record review revealed a physician's order dated 7/26/2024 for Quetiapine extended release tablet (antipsychotic medication) 50 milligrams by mouth at bedtime.
Review of the September 2024 MAR revealed that the Quetiapine 50 milligrams was not administered as ordered on the following dates and times, due to the medication being unavailable:
9/1/2024 at 8:00 PM
9/3/2024 at 8:00 PM
9/4/2024 at 8:00 PM
9/5/2024 at 8:00 PM
During a surveyor interview on 9/6/2024 at 10:21 AM and at 2:05 PM with the Director of Nursing Services, she acknowledged that the above medications were not administered as ordered on the above dates and times. Additionally, she revealed her expectation is that the physician would be notified if an ordered medication was unavailable and not administered.
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 drugs and biological's in accordance with currently accepted professional principles relativ...
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Based on surveyor observation and staff interview, it has been determined that the facility failed to store drugs and biological's in accordance with currently accepted professional principles relative to 1 of 2 medication rooms observed, 2 of 2 medication carts observed on unit 2, and 2 residents observed with medications at the bedside, Resident ID #s 22 and 63.
Findings are as follows:
1. Surveyor observation on 9/5/2024 at 9:39 AM in the presence of Medication Aide, Staff I, of the basement medication storage room revealed the following:
-Six medication bottles of Calcium 600 mg (milligram) with Vitamin D 10 mcg (microgram) with an expiration date of 8/2024.
-Two medication bottles of Acetaminophen 160 mg/5 ml (milliliter), one with an expiration date of 1/2024 and the other with an expiration date of 2/2024.
During a surveyor interview at time of observation with Staff I, she acknowledged the medications were expired and indicated they should be discarded.
2. During a surveyor observation on 9/4/2024 from 12:25 PM to 12:55 PM of the second floor revealed the following:
-Medication Cart A was observed unlocked, unattended with the second drawer of the cart left half ajar.
-Medication Cart B was observed unlocked and unattended.
Multiple staff and residents were observed ambulating by both medication carts while unattended by staff and left unlocked.
During a surveyor interview on 9/4/2024 at 12:56 PM with Medication Aide, Staff J, he acknowledged that medication carts A and B were left unattended and unlocked and that the second drawer to medication cart A was left half ajar.
During an interview on 9/5/2024 at 9:00 AM with the Director of Nursing Services (DNS), she indicated that her expectation is that medication carts are to be kept locked when unattended.
3a. During a surveyor observation on 9/3/2024 at 9:41 AM of Resident ID #63's bedside table, revealed a plastic medication cup containing 5 medications that were unattended and left on the resident's bedside table while the resident was asleep.
During a surveyor interview immediately following the observation with the Nursing Assistant, Staff K, she acknowledged the medications at the bedside.
During a surveyor interview on 9/3/2024 at 9:51 AM with Licensed Practical Nurse, Staff C, she acknowledged that medications were left on the resident's bedside table. Additionally, Staff C was unable to explain which medications were left at the resident's bedside, as she indicated that she had not yet administered the resident's morning medications.
3b. Surveyor observation on 9/4/2024 at 8:49 AM during Resident ID #22's medication pass revealed Staff J, was unable to locate the resident's Spiriva (a daily medication that assists with symptoms due to chronic breathing conditions) inhaler in the medication cart to administer with the rest of the resident's medications. Upon entering the resident's room, the Spiriva inhaler was observed on the resident's bedside table by the surveyor. After Staff J administered the resident's medications to him/her, Staff J and the surveyor walked back into the hallway to the medication cart. The surveyor alerted Staff J that the Spiriva inhaler was observed on the resident's bedside table. Staff J and the surveyor re-entered the resident's room to retrieve the inhaler.
During a surveyor interview on 9/5/2024 at 8:58 AM with Staff J, he revealed that he administered the Spiriva inhaler to Resident ID #22 yesterday and that he may have left the inhaler on his/her bedside table.
During a surveyor interview at 9/5/2024 at 1:12 PM and on 9/6/2024 at 1:17 PM with the Director of Nursing Services, she indicated that she would not expect medications to be left at the bedside unattended and that staff administering the medications are to remain with the resident until all medications are administered. Additionally, she would expect expired medications to be discarded.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with profess...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 2 of 4 residents reviewed with a splint (a device used to prevent decreased range of motion), Resident ID #s 61 and 70, and 1 of 2 residents reviewed who has an order for TED stockings (thrombo-embolis deterrent- a type of compression stocking designed to help prevent blood clots and swelling in the legs) daily, Resident ID #67.
Findings are as follows:
1. Record review revealed Resident ID #61 was admitted to the facility in October of 2019 with diagnoses which include, but are not limited to, stroke and hemiplegia (paralysis on one side of the body).
Record review of the physician's orders revealed an order dated 10/24/2023 for Right resting hand splint to be donned [to put on] during the day, as tolerated every shift.
Surveyor observation on 9/5/2024 at 1:20 PM revealed the resident lying in the bed, without his/her right-hand splint applied as ordered. Further observation revealed the resident's splint was observed on the window sill.
Record review of the September 2024 Treatment Administration Record (TAR) revealed the right-hand splint was inaccurately signed off as applied during the day shift on 9/5/2024.
During a surveyor interview and observation of the resident on 9/6/2024 at 1:10 PM with the Director of Nursing Services (DNS), she acknowledged that the resident was not wearing the splint and she was unable to explain why the splint was signed off on the TAR as being applied when it was not.
2. Record review revealed Resident ID #67 was admitted to the facility in December of 2022 with diagnoses including, but not limited to, arteriosclerotic heart disease and pulmonary embolism (when a blood clot gets stuck in an artery in the lung, blocking blood flow).
During a surveyor observation on 9/4/2024 at 9:01 AM, revealed swelling to the resident's right and left lower extremity, the right lower extremity was observed to be more swollen than the left.
Record review of the physician's orders revealed an order dated 6/16/2024 for TEDs: apply in the AM and Remove at HS [hour of sleep] .
Surveyor observations on the following dates and times revealed the resident was observed with only the left TED stocking on:
-9/4/2024 at 12:03 PM and 12:21 PM
-9/5/2024 at 10:03 AM, 12:04 PM and at 12:15 PM
Record review of the September 2024 TAR revealed the above-mentioned physician's order was inaccurately signed off as being completed during the day shifts on 9/4/2024 and on 9/5/2024.
During a surveyor interview and observation of the resident on 9/5/2024 at 12:18 PM with Registered Nurse, Staff B, he acknowledged that the resident did not have a TED stocking applied to his/her right lower extremity as ordered. Additionally, he was unable to explain why the TED stockings were not applied to both lower extremities as ordered. He was unable to explain why he had documented that both TED stockings were applied when they were not.
During a surveyor interview on 9/6/2024 at approximately 1:30 PM with the DNS, she was unable to explain why both TED stockings were signed off on the TAR as being applied when they were not.
3. Record review revealed Resident ID #70 was re-admitted to the facility in December of 2022 with diagnoses including, but not limited to, stroke and hemiplegia.
Record review of the physician's orders revealed an order dated 6/18/2023 for Right resting hand splint to be donned during the day, as tolerated every shift.
Surveyor observation on 9/4/2024 at 10:07 AM revealed the resident lying in the bed without his/her right hand splint applied, as ordered.
Record review of the September 2024 TAR revealed the right-hand splint was inaccurately signed off as applied on 9/4/2024.
During a surveyor interview and observation of the resident on 9/6/2024 at 1:15 PM with the DNS, she acknowledged that the resident was not wearing the splint and she was unable to explain why the splint was signed off on the TAR as being applied when it was not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on surveyor observation and staff interview, it has been determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents, staff and the public related ...
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Based on surveyor observation and staff interview, it has been determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents, staff and the public related to the basement conference room.
Findings are as follows:
Surveyor observation in the basement conference room on 9/5/2024 at 12:07 PM, revealed a large amount of water pouring down from the ceiling light onto a table below, spraying liquid droplets in an approximate four foot radius, saturating a surveyor's computer, resident records and personnel training records.
During a surveyor interview on 9/5/2024 at 12:09 PM with the Assistant Director of Maintenance, Staff R, he revealed the cause of the water coming from the ceiling was due to a toilet on the second floor that was clogged by a large bowel movement and was overflowing. Additionally, he revealed this happened on two previous occasions last week. Staff R further revealed that he did not inform anyone of issue with the toilet overflowing because he felt that he had fixed the issue by plunging the toilet.
During a surveyor interview on 9/5/2024 at 12:26 PM with the Administrator, he acknowledged that the water was caused by an overflowing toilet on the second floor. Additionally, he revealed that he was not made aware of this issue by staff previously, and would have expected that maintenance would have informed him that the toilet had previously overflowed.
During a surveyor interview on 9/5/2024 at 1:28 PM with the Director of Nursing Services, she revealed that she was not aware that the toilet had overflowed previously causing unsanitary water to enter the basement conference room through the light. She was unable to explain how the room was sanitized after the previous occasions.
During a subsequent surveyor interview on 9/5/2024 at 1:35 PM with Staff R, he revealed that the facility just purchased a new toilet for the resident's bathroom, where the toilet overflowed.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected most or all residents
Based on record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skill sets to provide nursing and related...
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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 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 for 2 of 2 Registered Nurses (RNs) reviewed, Staff B and Staff D and 4 of 6 Nursing Assistants (NAs) reviewed, Staff E, F, G and H.
Findings are as follows:
Record review failed to reveal evidence of any competencies that were completed for the following nursing staff :
-RN, Staff B
-RN, Staff D
-NA, Staff E
-NA, Staff F
-NA, Staff G
-NA, Staff H
During a surveyor interview on 9/5/2024 at 3:45 PM with the Infection Preventionist, during the Staffing Task, she was unable to provide evidence of any completed nursing competencies for the above-mentioned staff.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the menus meet the nutritional needs of the residents in accordance wi...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the menus meet the nutritional needs of the residents in accordance with established national guidelines, that are reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy.
Findings are as follows:
Record review of the facility's diet manual titled, US Foods Menu Solutions 2015, failed to meet the current established national guidelines (the United States Department of Agriculture established and reviewed national guidelines every 5 years, to promote health, meet nutrient needs and provide guidance for healthy dietary patterns by life stages). The diet manual provided to the surveyor from the facility was from 2010 to 2015, indicating the guidelines were outdated as the current national guidelines were revised in 2020 with new recommendations.
Record review of the facility's menu, failed to reveal evidence of the therapeutic exchanges (in the exchange system, foods with a similar nutritional content per serving size are grouped together. The foods within each list can be exchanged for one another during meal planning) to ensure the nutritional adequacy for residents requiring the following physician diet orders, Low Concentrated Sweets (LSC), 50-gram fat (low fat diet), Cardiac, No Added Salt (NAS), Renal, Mechanical Soft and Puree.
Record review of the menu for 9/3/2024 revealed the following:
-Swedish Meatballs
-Egg Noodles
-Broccoli
Surveyor observation of the lunch meal service on 9/3/2024 at approximately 11:30 AM revealed Swedish meatballs in gravy were being served.
Record review of the packaging label for the Swedish meatballs revealed a serving size consisted of 1 cup of the meatballs, without gravy.
Record review of the recipe provided by the Food Service Director (FSD) was obtained from All Recipes (a recipe retrieved from the internet). The recipe did not provide a nutritional analysis and listed the serving size to be 1 cup.
Further surveyor observation of the lunch meal service revealed that a 4 oz. ladle was being used to portion the Swedish meatballs and gravy, which did not equal the 1 cup serving size as indicated on the packaging label for the Swedish meatballs or the recipe that the FSD provided.
During a surveyor interview on 9/3/2024 at approximately 1:30 PM with the FSD he was unable to provide evidence that a standardized recipe (recipes that include ingredients, portion size, cooking temperatures, and nutritional analysis), are used for meal preparation. Additionally, he was unable to provide evidence of the nutrient content of the lunch meal that was served.
During a surveyor observation of the lunch meal service and interview with Dietary staff member, Staff M on 9/4/2024 at approximately 11:50 AM, he revealed he has been trained on what to serve resident who require Renal diet, LCS diet, 50 GM Fat, NAS diet.
During a surveyor interview with the FSD on 9/4/2024 at approximately 12:00 PM, he was unable to provide evidence that, although Staff M stated that he was trained on therapeutic diets, there is no evidence to support that training.
Surveyor observation of the lunch meal service on 9/5/2024 revealed the pureed peas had a very light green color.
During a surveyor interview with Cook, Staff N, immediately following the above observation, he revealed that he does not use a recipe when preparing pureed foods. He further revealed that he was trained on how to prepare pureed foods.
During a surveyor interview with the FSD on 9/4/2024 at approximately 2:30 PM, he was unable to provide evidence that, although Staff N stated that he was trained on therapeutic diets, there is no evidence to support that training. Additionally, he was unable to provide evidence that the facility utilized standardized recipes for meal preparation, to ensure the nutritional adequacy of the foods being served.
During a surveyor interview on 9/4/2024 at approximately 2:45 PM with the Registered Dietitian, she revealed she is not involved in the facility's menu planning. Additionally, she revealed she has not reviewed or signed the facility's menu to ensure its nutritional adequacy, or the appropriateness of therapeutic diets served.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0940
(Tag F0940)
Could have caused harm · This affected most or all residents
Based on record review and staff interview it has been determined that the facility failed to develop, implement, and maintain an effective training program for annual training for existing employees ...
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Based on record review and staff interview it has been determined that the facility failed to develop, implement, and maintain an effective training program for annual training for existing employees consistent with their expected roles, relative to education involving abuse, resident rights, infection control, dementia, behavioral health management, trauma informed care, communication and QAPI (Quality Assurance and Performance Improvement), per the facility assessment, for 8 of 8 employees, Staff B, D, E, F, G, H, S and T.
.
Findings are as follows:
Review of the Facility Assessment, dated 7/19/2024, revealed in part, training and competencies are completed upon hire, annually and on an as needed basis. Additional review of the assessment indicated the following training are required for direct care staff:
Abuse
Resident Rights
Infection Control
Dementia & Alzheimer's Disease
Behavioral Health
Communication
QAPI program
Record review revealed Registered Nurse (RN), Staff B was hired on 3/12/2015. Review of his training records failed to reveal evidence that he received education or training relative to communication and the QAPI program.
Record review revealed RN, Staff D was hired on 5/29/2019. Review of her training record failed to reveal evidence that she received education or training relative to communication, abuse, the QAPI program, behavioral health and dementia & Alzheimer's disease.
Record review revealed Nursing Assistant (NA), Staff E was hired on 10/5/2016. Review of her training records failed to reveal evidence that she received education or training relative to communication, abuse, the QAPI program, behavioral health, infection control, dementia & Alzheimer's disease, and resident rights.
Record review revealed NA, Staff F was hired on 3/1/2022. Review of her training records failed to reveal evidence that she received education or training relative to the QAPI program.
Record review revealed NA, Staff G was hired on 2/5/2020. Review of his training records failed to reveal evidence that he received education or training relative to communication, abuse, the QAPI program, infection control and resident rights.
Record review revealed NA, Staff H was hired on 8/29/2013. Review of her facility training record failed to reveal evidence that she received education or training relative to communication, abuse, the QAPI program, behavioral health, infection control, dementia & Alzheimer's disease, and resident rights.
Record review revealed NA, Staff S, was hired on 4/16/2014. Review of his training record failed to reveal evidence that he received education or training relative to communication and the QAPI program.
Record review revealed NA, Staff T was hired on 10/10/2010. Review of his training record failed to reveal evidence that he received education or training relative to communication, abuse, the QAPI program, behavioral health, infection control, dementia & Alzheimer's disease, and resident rights.
During a surveyor interview on 9/5/2024 at 4:25 PM and 9/6/2024 at 8:44 AM, with the Director of Nursing Services, she was unable to provide evidence that the above-mentioned in-services were completed for Staff B, D, E, F, G, H, S and T, as per the facility assessment.
Jun 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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to ensure that residents receive adeq...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to ensure that residents receive adequate supervision to prevent an accident for 1 of 3 residents reviewed for elopement, Resident ID #1.
Findings are as follows:
Record review of a facility policy titled elopement dated July 2015 states in part, .elopement is defined as the ability for a resident who is not capable of protecting himself or herself from harm to successfully leave the facility unsupervised .
Record review of a facility reported incident submitted to the Rhode Island Department of Health on 6/11/2024 indicated, that Resident ID #1 was found outside of the facility on 6/10/2024.
Record review revealed that the resident was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, dementia, delusional disorder (psychotic disorder), and paranoid personality disorder.
Review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 7 out of 15, indicating s/he has severe cognitive impairment.
Review of a care plan dated 4/18/2024 indicated the resident has impaired cognitive skills that is evidenced by poor decision making skills, poor short and long-term memory. Interventions include, but are not limited to, reporting unanticipated changes in cognitive status to the physician and to escort the resident to activities.
Record review revealed the resident resides on a secured unit. On 6/10/2024 the resident attended an activity in a non-secured area of the facility and was able to elope from the facility without staff present.
Review of video surveillance footage with the Administrator on 6/12/2024 at approximately 10:20 AM, revealed the resident was observed to exit the facility through the front door and was outside of the facility without staff supervision on 6/10/2024.
During a subsequent interview with the Administrator on 6/12/2024 at 10:20 AM, he revealed the facility activities schedule on 6/10/2024 was music from 2:00 PM to 3:00 PM and bingo from 3:00 PM to 4:00 PM.
Record review of a progress note dated 6/10/2024 at 5:01 PM indicated the resident was exit seeking around 3:00 PM stating, [spouse] was picking [him/her] up and wanted to go downtown. Further review revealed the resident was able to get out the front door unattended.
Record review of a staff witness statement authored by the Dementia Coordinator, revealed in part, on 6/10/2024 at approximately 1:50 PM, she was bringing residents downstairs from the secure unit for a music performance on the first floor. The resident indicated s/he wanted to go outside and was walking toward the exit doors and the resident required redirection.
Record review of staff witness statement authored by the Activity Director, revealed in part, on 6/10/2024 at approximately 3:00 PM, the resident stated something about wanting to leave and began exiting the dining room, walking toward the side porch door, and was again redirected from exit seeking.
During a surveyor interview on 6/12/2024 at 2:06 PM with the Activities Assistant, she revealed that after bingo ended at approximately 4:00 PM, the resident was located outside the building unsupervised. She further revealed the resident stated, I was looking for the entrance, I haven't been here in years.
During surveyor interviews on 6/12/2024 at 10:20 AM and 6/13/2024 at 12:01 PM with the Administrator, he acknowledged that the above-mentioned exit seeking behavior was a change in condition for this resident. Additionally, he revealed he would expect the activity staff to communicate the residents change in condition, when it occurred to the interdisciplinary team. Further, he could not provide evidence that the facility ensured that the resident received adequate supervision to prevent an elopement.
Sept 2023
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that all alleged violation...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that all alleged violations are thoroughly investigated for 1 of 1 residents reviewed who was noted to have bruising to his/her genital area, Resident ID #85.
Findings are as follows:
According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023 states in part, .Possible indicators of physical abuse include an injury that is suspicious because the source of the injury is not observed, the extent or location of the injury is unusual .Examples of injuries that could indicate abuse include, but are not limited to .Bruises, including those found in unusual locations .The location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) .Examples of Injuries of Unknown Source .Unobserved/Unexplained bruising or other injuries in the genital area .
Record review of the facility policy dated September 2020, titled, ABUSE PROHIBITION POLICY, states in part, .each resident has the right to be free from abuse .Any allegation of abuse will be thoroughly investigated .All alleged violations involving abuse .including injuries of unknown source .The Administrator, Director of Nursing or their designee assumes responsibility for .Ensuring that there is documentation in the resident's medical record of the incident, any interventions, physician and family notification at the time of the incident. Having evidence that all alleged violations are thoroughly investigated .
Record review revealed the resident was admitted to the facility in November of 2022 with a diagnosis including, but not limited to, Alzheimer's disease.
Record review of a quarterly Minimum Data Set assessment dated [DATE] revealed the resident's cognition was documented as severely impaired with short-and long-term memory problems.
Further record review revealed a progress note dated 9/9/2023 at 7:28 PM, which indicates that a purple discoloration, bruise, was noted to the resident's genital area.
During a surveyor interview on 9/11/2023 at 4:27 PM, with the Director of Nursing Services (DNS), when the surveyor asked if she was aware that the resident was noted with a bruise to his/her genital area on 9/9/2023, she stated, sounds familiar. The DNS further indicated she would look for an incident report.
Record review of documents provided by the DNS on 9/12/2023, the day after the surveyor inquired about the resident's bruise, revealed a document titled SKIN TEAR/BRUISE INCIDENT REPORT & INVESTIGATION, which was signed by the DNS on 9/11/2023 and the Administrator on 9/12/2023. The investigation report included an undated document authored by the Supervisor, Licensed Practical Nurse, Staff A, which states in part, .bruise of unknown origin found on 9/9/2023 Based on the presentation and coloring of area, it matches up with the time frame of the resident's fall on 9/3/2023.
Record review of a progress note dated 9/3/2023 at 2:11 PM, revealed that the resident was found on the floor in another resident's room. The note states in part, .Upon assessment there is no bruising or swelling, or gross abnormality present .
Record review of the facility document dated 9/3/2023 titled, FALL INVESTIGATION, revealed that the resident was in another resident's room when s/he was found on the floor. The document also indicates that the other resident, Resident ID #62, reported that Resident ID #85 was on the floor and indicated s/he tripped.
Additional record review of the facility's fall event document dated 9/3/2023 at 7:41 PM, indicates that the fall was unwitnessed.
During a surveyor interview on 9/13/2023 at 9:11 AM with Nursing Assistant (NA) Staff B, she indicated that she worked on the unit on 9/3/2023 during the 7:00 AM - 3:00 PM shift. She further indicated the resident was found on the floor in another resident's room and she and another NA assisted the resident from the floor. Additionally, she indicated the resident was lying on the floor on his/her right side, fully clothed.
Further record review of the facility's investigation file revealed that the NA who found the bruise to the resident's genital area on 9/9/2023 was not interviewed by the DNS until 9/11/2023 at 5:47 PM, after it was brought to the attention of the facility by the surveyor.
Record review of a weekly skin audit completed on 9/6/2023 failed to reveal evidence that the resident had a bruise to his/her genital area.
Record review failed to reveal evidence that any additional staff who provided care to the resident between 9/3/2023 through 9/9/2023 were interviewed or provided a statement for the investigation.
During a surveyor observation on 9/12/2023 at 3:42 PM, in the presence of NA Staff C, revealed an area approximately greater than 5 centimeters with purple and yellow discoloration to the resident's genital area.
During a surveyor interview on 9/13/2023 at 5:04 PM with the DNS, she indicated that she is attributing the resident's bruise to the fall s/he sustained on 9/3/2023, which was 6 days prior to the bruise being identified. Additionally, she revealed that she had not begun her investigation into the origin of the resident's bruise until the surveyor brought it to her attention on 9/11/2023. Furthermore, she was unable to provide evidence that the incident was thoroughly investigated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each resident receives necessary respiratory care and services that ar...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each resident receives necessary respiratory care and services that are in accordance with professional standards of practice for 1 of 5 residents reviewed for respiratory care, Resident ID #49.
Findings are as follows:
Record review revealed the resident was admitted to the facility in May of 2023 with a diagnosis including, but not limited to, stage four chronic obstructive pulmonary disease (a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation).
Surveyor observations of the resident on the following dates and times revealed s/he was receiving oxygen therapy via nasal cannula at 2 liters per minute:
-9/11/2023 at 9:17 AM
-9/12/2023 at 8:26 AM
-9/12/2023 at 10:12 AM
During a surveyor interview with the resident on 9/12/2023 at 10:12 AM s/he revealed that s/he has not been receiving oxygen therapy for very long, but that s/he does get out of breath sometimes.
Record review failed to reveal evidence of a physician's order for oxygen therapy.
During a surveyor interview on 9/12/2023 at 3:10 PM with Licensed Practical Nurse, Staff G, she was unable to provide evidence of an order for oxygen therapy.
Record review of the physician orders on 9/13/2023, revealed an order was obtained on 9/12/2023 for Supplemental oxygen at 1-2 liters/minute via nasal, cannula continuously, to maintain O2 sats [saturation] > [greater than] 90% .
Further record review failed to reveal evidence that the resident's oxygen saturation levels were monitored as ordered on 9/12/2023 and 9/13/2023.
During a surveyor interview on 9/13/2023 at 1:50 PM with the resident's provider, she revealed she would expect the resident to have an order for oxygen therapy. Additionally, she would expect that the O2 saturation levels are documented at least daily to ensure the resident requires the oxygen.
During a surveyor interview with the Director of Nursing Services on 9/13/2023 at 8:23 AM and again at 5:14 PM, she revealed she would expect that the resident would have an order for oxygen if s/he is receiving oxygen therapy. Additionally, she was unable to provide evidence of the oxygen saturation levels for 9/12/2023 and 9/13/2023.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality for 2 of 7 residents reviewed relati...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality for 2 of 7 residents reviewed relative to physician orders, Resident ID #s 49 and 85.
Findings are as follows:
Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients.
1. Record review for Resident ID #49 revealed s/he was admitted to the facility in October of 2022 with diagnoses including, but not limited to, pain, history of venous thrombus (blood clot in the vein), spinal stenosis, and vertebral compression fractures.
Record review revealed a physician's order dated 6/7/2023, which states May have Palliative care consult for pain management.
Record review revealed the palliative care consult was completed on 8/2/2023, indicating the consult was completed almost 2 months from the order date. Further review of the palliative care consult note indicated recommendations in part, which were reviewed and verified with the facility Physician Assistant (PA) on 8/3/2023:
-Patient would like to have an evaluation by Physical Therapy (PT) and Occupational Therapy (OT) for strengthening.
-Venous ultrasound of the bilateral lower extremities as the resident has a history of extensive deep vein thrombosis to the lower extremity.
Record review revealed physician's orders for the following:
-8/3/2023 for bilateral lower extremity venous ultrasound.
-6/6/2023 to provide physical therapy/occupational therapy/speech evaluation when indicated.
Further record review failed to reveal evidence that the above-mentioned orders were completed following the palliative care consult.
During a surveyor interview on 9/13/2023 at 1:50 PM and again at 4:17 PM with the PA, she indicated that she would expect the palliative consult would have been completed within a month of the referral and that the ultrasound and the therapy evaluations would be completed as ordered.
During a surveyor interview on 9/13/2023 at 2:34 PM and again at 4:03 PM with the Director of Nursing Services (DNS), she revealed that she would expect that the resident would have had the therapy evaluations and the ultrasound completed as ordered.
2 A. According to the facility policy, dated March 2016, titled, Bowel Evacuation Protocol states in part,
.Procedure
-If the resident has had no bowel movement [BM] for 9 consecutive shifts [ 3 days], begin the bowel protocol on the 3:00 p.m. - 11:00 p.m. shift.
-The bowel protocol is to give Milk of Magnesia (MOM) on the 3:00 p.m. shift. If the MOM is ineffective, then the resident is to receive a Bisacodyl suppository on the 11:00 p.m. to 7:00 a.m. shift. If the Bisacodyl suppository is ineffective, then the resident is to receive a fleets enema on the 7:00 a.m. to 3:00 p.m. shift.
-Record the results of the Bowel Protocol .
-Notify the physician if the Bowel Protocol is ineffective .
Record review for Resident ID #85 revealed s/he was admitted to the facility in November of 2022 with diagnoses including, but not limited to, Alzheimer's Disease and constipation.
Record review revealed the following physician orders relative to the bowel protocol:
-9/11/2023 for Milk of Magnesia (MOM) Suspension 400 Mg (milligrams)/5 ml (milliliters), 30 ml by mouth as needed (PRN) if no BM for 3 days.
-11/11/2022 for Bisacodyl (Dulcolax) tablet, delayed release 5 mg by mouth once a day PRN for constipation.
-11/11/2022 for Bisacodyl suppository 10 mg, rectally once a day PRN for constipation.
-9/11/2023 for Fleet Enema 19-7 gram/118 ml, administer 1 rectally PRN. If no results from Dulcolax suppository give fleet enema on the 4th day.
Record review of the resident's bowel record completed on 9/11/2023, revealed the resident had a bowel movement last documented on 9/3/2023, which indicated the resident did not have a BM in 7 days.
Record review of the September 2023 Medication Administration Record (MAR), completed on 9/11/2023, failed to reveal evidence that the bowel protocol was initiated.
Additionally, record review of the resident's bowel record on 9/13/2023 revealed the resident had a BM on 9/13/2023 after s/he received the Dulcolax suppository.
Subsequent record review completed on 9/13/2023, of the September 2023 MAR, revealed MOM was initiated on 9/11/2023 at 9:00 PM. Additionally, the record revealed the Dulcolax suppository was not administered until the following evening, at 8:55 PM. Lastly, the Fleet enema was never administered.
Record review of the progress notes failed to reveal evidence that the provider was informed that the resident had not had a bowel movement since 9/3/2023.
2 B. Additional record review for Resident ID #85 revealed s/he was seen and assessed by psychiatric services on 8/17/2023 and 8/31/2023 with recommendations to increase his/her morning Risperdal to 1 mg and to obtain orthostatic blood pressures (a way to obtain blood pressures to determine if there is a drop in blood pressure during a change in the body's position from laying/sitting to standing) weekly for 4 weeks and discontinue if they are stable.
Record review of the physician orders revealed an order with a start date of 8/17/2023 to obtain orthostatic blood pressures weekly for 4 weeks once a day on Mondays and to discontinue if they are stable.
Record review of the August and September 2023 MARs failed to reveal evidence that the orthostatic blood pressures were obtained on 8/21/2023, 8/28/2023, 9/4/2023 and 9/11/2023 as ordered.
During a surveyor interview on 9/13/2023 at 1:25 PM with the DNS, she revealed that she would expect the bowel protocol to be followed and that the medications be administered if the resident did not have a bowel movement in 3 days. Additionally, the DNS revealed she would expect that the orthostatic blood pressures be obtained as ordered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide ne...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 2 of 5 residents reviewed with pressure ulcers (a localized injury to the skin and/or underlying skin usually over a boney prominence), Resident ID #s 37 and 73.
Findings are as follows:
Record review of the facility policy dated 7/2017 and titled, Prevention & Management of Pressure Injuries states in part, Standard .The necessary treatment and services will be provided to promote healing, prevent infection, and prevent new pressure injuries from developing. POLICY: Residents with pressure injuries and those at risk for skin breakdown are identified, assessed, and provided appropriate treatment to encourage healing and/or maintenance of skin integrity. Ongoing monitoring and evaluation are provided . PROTOCOL: Assessment: Ulcer/Risk Factors .3. The resident's skin is observed daily with care. 4. Residents will have a weekly body audit completed by licensed staff. 5. Pressure injuries are assessed and documented on at least weekly and with a significant change in wound until it is resolved. Pressure injury assessment includes: Location, measurement .Stage, Presence of tunneling or undermining, Drainage Amount, Drainage Color, Odor .Appearance of wound bed, Appearance of wound edges, Appearance of peri wound .Wound Treatments are done per MD order.
1. Record review revealed Resident ID #37 was admitted to the facility in October of 2014 with diagnoses including, but not limited to, peripheral vascular disease and history of deep vein thrombosis (blood clot).
Record review of the Pressure Ulcer Care Plan revealed a concern for actual alteration in skin integrity, which indicated a deep tissue injury (DTI - Purple or maroon area of discolored intact skin due to damage of underlying soft tissue) to the resident's right heel with a date of 8/29/2023. Interventions include, but are not limited to, skin prep to heels as ordered and an offloading boot order, already in place. Further review of the care plan did not identify any additional pressure areas.
Review of a weekly skin audit, signed and dated by Licensed Practical Nurse (LPN), Staff D on 8/26/2023 indicated the resident had a darkly pigmented stage one of right heel noted non-blanchable [stage I-discoloration of the skin that does not turn white when pressed]. R [right] side next to small toe reddened stage one. Booties in place.
Further record review of subsequent skin evaluations failed to reveal evidence of the resident's reddened, non-blanchable area next to the small toe that was initially identified on 8/26/2023.
Record review revealed the following physician's orders relative to the treatments to the resident's lower extremities:
-8/28/2023 Skin Prep to bilateral heels twice daily.
-7/5/2023 Wear offloading boots at night as tolerated to help reduce pressure to heels bilaterally twice daily.
Further record review failed to reveal evidence that a treatment order was implemented for the Stage I pressure ulcer to the side of the resident's right foot adjacent to his/her small toe, which was identified on 8/26/2023.
During a surveyor observation with Nursing Assistant, Staff B on 9/13/2023 at 9:06 AM, revealed a dark discolored area to the resident's right heel. Additionally, two darkened areas were observed, one to the lateral (outer) side of his/her right foot next to the 5th toe, which was maroon in color and another area below that, which was blackened.
During a surveyor telephone interview on 9/13/2023 at 10:42 AM with Staff D, the nurse who first identified the non-blanchable wound to the side of the resident's right foot, she revealed that she worked yesterday (9/12) and applied the skin prep to all areas of the resident's right foot, which included the heel and the other two areas near the 5th toe. Additionally, she stated, We are treating both areas.
During a surveyor observation on 9/13/2023 at 2:34 PM with the Wound Physician and the facility's Wound Nurse, revealed the existing DTI to the resident's right heel, the lateral side of his/her right foot was black in color and there was an additional area between the 4th and 5th toe that had depth.
During a subsequent interview on 9/13/2023 at 2:47 PM with the Wound Physician, she revealed that prior to today, she did not observe any additional areas opened or closed to the resident's right foot. Additionally, she revealed that she would expect the nurses to notify her or the facility Wound Nurse of new wounds.
Record review of the resident's weekly wound description and measurements documented by the Wound Physician are as follows:
-8/30/2023, .Wound Assessment(s) Wound #1 Right Heel is a Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 5cm [centimeters] length x 5cm width x 0 cm depth .no drainage noted. Wound bed has 76-100% eschar [dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color]. The periwound skin texture is normal.
-9/6/2023, .Wound Assessment(s) Wound #1 Right Heel is a Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 5cm length x 5cm width x 0 cm depth .no drainage noted. Wound bed 76-100% eschar. There is no change in the wound progression. The periwound skin texture is normal.
Additionally, the above-mentioned Wound Physician's assessments did not identify any other pressure injuries.
During a surveyor interview on 9/13/2023 at 4:27 PM with the Minimum Data Set (MDS) Coordinator, she revealed that the resident's care plan, relative to the alteration in skin integrity, is updated from the Wound Physician's Documentation.
During a surveyor interview with the Director of Nursing Services (DNS) on 9/13/2023 at 5:08 PM, she was unable to explain why a treatment order was not implemented for the pressure ulcers to the side of the resident's right foot when the wound was first identified.
2. Record review revealed Resident ID #73 was admitted to the facility in March of 2021 with diagnoses including, but not limited to, vascular dementia, stroke, and pressure ulcer of the right hip.
Record review of an Annual Minimum Data Set (MDS) assessment dated [DATE] indicated the resident has an unstageable pressure ulcer (wound bed is covered by slough - non-viable yellow, tan, gray, green or brown tissue).
Record review revealed a physician's order dated 8/17/2023, May have Air Mattress for skin integrity. Check function and settings every shift.
During a surveyor interview on 9/13/2023 at 3:30 PM with the DNS, she revealed the above-mentioned air mattress order indicates the mattress is checked to ensure that it is powered on and that the setting is per the resident's weight.
During a surveyor observation on 9/11/2023 at 12:01 PM of the resident's air mattress pressure pump device revealed a piece, of masking tape, affixed to the left of the pump dial that adjusts the weight setting, with writing that reads, set here. Further observation of the round dial revealed an arrow that pointed to the weight setting, indicating the setting was on 160-240 pounds.
Subsequent observations of the resident's air mattress on 9/12/2023 at approximately 10:15 AM and again on 9/13/2023 at approximately 4:15 PM, revealed it remained set to the weight range of 160-240 pounds.
Record review revealed the resident's most recent weight was 106.9 pounds.
During surveyor observation and simultaneous interview on 9/13/2023 at approximately 4:20 PM with the DNS, Wound Nurse, and the resident's nurse, LPN, Staff E revealed the air mattress pump was on an incorrect setting of 160-240 pounds. They indicated the dial should have been set to the next weight range down. Additionally, Staff E revealed that she just goes into the resident's room and ensures that the air mattress pump is powered on and was unable to explain why the air mattress setting was not set to the correct weight range.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure tha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the residents receive treatment relative to foot care for 2 of 8 residents observed, Resident ID #s 81 and 80.
Findings are as follows:
1. Record review for Resident ID #81 revealed s/he was admitted to the facility in September of 2022 with a diagnosis that includes, but is not limited to, Parkinson's disease.
Record review of a quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating his/her cognition is intact.
Record review revealed a physician's order dated 1/31/2023 for podiatry services as needed (PRN).
During a surveyor interview on 9/11/2023 at approximately 9:17 AM with the resident, s/he revealed that s/he would like to see a podiatrist to have his/her nails cut.
During a surveyor observation of the resident's toenails on 9/12/2023 at approximately 3:30 PM revealed long, thickened, and discolored toenails, approximately 2 centimeters in length beyond the nail bed. Additionally, s/he revealed that s/he was experiencing discomfort related to the long toenails.
Further record review failed to reveal evidence that podiatry services were received since his/her admission to the facility.
During a surveyor interview on 9/12/2023 at 4:44 PM with Registered Nurse, Staff F, she was unable to provide evidence that the resident received podiatry services.
During an additional surveyor observation of the resident on 9/13/2023 at 10:52 AM in the presence of the Director of Nursing Services (DNS), she acknowledged that the resident had long toenails as well as complaints of discomfort to his/her right great toe. She was unable to provide evidence that the resident had received podiatry services since s/he was admitted to the facility in September of 2022 .
2. Record review for Resident ID #80 revealed s/he was admitted to the facility in June 2021 with diagnoses including, but not limited to, left hemiplegia (weakness of the limbs), pressure induced deep tissue damage of the right heel and type 2 diabetes mellitus with hyperglycemia (high blood sugar).
Record review of a Significant Change MDS assessment dated [DATE] revealed a BIMS score of 0 out of 15, indicating s/he has severe cognitive impairment.
Record review revealed a physician's order dated 1/31/2023 for podiatry services as needed.
During a surveyor observation of the resident's toenails on 9/13/2023 at 4:46 PM in the presence of the DNS, she acknowledged the resident's toenails to his/her left and right feet were long and thick extending beyond the nailbed. Additionally, the DNS obtained the following approximate measurements of the resident's toenails by using a measuring application on her cellular phone:
Left foot:
- great toenail 1/2 inch () in length
- 2nd 1/4 in length
- 3rd toe 1/2 in length
- 4th 1/2 in length
- 5th toe nail was 1/4 in length
Right foot:
- 3rd toenail 3/4 in length
- 4th 1/4 in length
- 5th toenail 1/2 in length
Further record review failed to reveal evidence that the resident received podiatry services since his/her admission to the facility.
During a surveyor interview on 9/13/2023 at 5:03 PM with the DNS, she was unable to provide evidence that the resident received podiatry services since s/he was admitted to the facility in June 2021.
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, record review, and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted profe...
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Based on surveyor observation, record review, 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 2 of 3 medication carts reviewed, and 2 of 3 medication rooms reviewed.
Findings are as follows:
Record review of an undated facility policy titled Medication Storage states in part, .Medications must be stored in accordance with manufacturer's specifications .
A. Medication Carts
1. During a surveyor observation on 9/12/2023 at 8:50 AM of the 3rd floor Medication Cart B, in the presence of Licensed Practical Nurse (LPN), Staff D, revealed the following:
- One box of Budesonide 0.5 milligrams (mg)/2 milliliters (mL) ampule vial neb inhaler, containing 3 sealed foil envelopes and one single ampule in the box, not in the foil envelope and not labeled with a date. Manufacturer's guidance indicates store ampules in the foil envelope. Date once the foil envelope is opened and discard after 2 weeks.
During a surveyor interview with Staff D immediately following the above-mentioned observation, she acknowledged that the above-mentioned medication was opened and not labeled with a date.
2. During a surveyor observation on 9/12/2023 at 9:03 AM of the 3rd floor Medication Cart A, with Certified Medication Technician, Staff H, revealed the following:
- One box of Ipratropium-albuterol solution for nebulization 0.5 mg-3 mg/3 mL, containing sealed foil pouch and 5 ampules in the box, not in a foil pouch and not labeled with a date. Manufacture's guidance indicates, store unused solution in the foil pouch, may be stored outside of the pouch for up to 2 weeks.
During a surveyor interview with Staff H, immediately following the above-mentioned observation, he acknowledged that the above-mentioned medication was opened with loose ampules in the box and not labeled with a date.
B. Medication Rooms
1. During a surveyor observation on 9/12/2023 at 8:46 AM of the 3rd floor medication room in the presence of Staff D, revealed the following:
- One vial of Tuberculin solution, opened and not labeled with a date. Manufacturer's guidance indicates to date when opened then discard unused portion after 30 days.
During a surveyor interview immediately following the above-mentioned observation with Staff D, she acknowledged that the Tuberculin solution was opened and not labeled with a date.
2. During a surveyor observation on 9/12/2023 at 9:38 AM of the 1st floor medication room in the presence of LPN Staff I, revealed the following:
- One box containing approximately 5 pre-filled syringes of Lovenox 80 mg/0.8 mL, opened with an expiration date of 8/2023.
During a surveyor interview with Staff I immediately following the above-mentioned observation, she acknowledged the medication was labeled with the expiration date of 8/2023. Additionally, she indicated that the cabinet the surveyor retrieved the medication from was located in the medication over-flow cabinet, and that the resident who was prescribed the Lovenox had been discharged from the facility.
Record review revealed the resident discharged from the facility in 2022.
During a surveyor interview on 9/13/2023 at 1:42 PM, she indicated she would expect medications to be labeled with a date when opened and she would expect a discharged resident's medication to be returned to the pharmacy.
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 record review, and staff interview it has been determined that the facility failed to provide or obtain from an outside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview it has been determined that the facility failed to provide or obtain from an outside resource, emergency dental services for 1 of 1 resident reviewed for dental pain, Resident ID #49.
Findings are as follows:
Record review revealed the resident was admitted to the facility in October of 2022 with diagnoses including, but not limited to, morbid obesity, other specified nutritional deficiencies, and protein calorie malnutrition (a deficit of protein).
Record review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS; an assessment tool used to evaluate a resident's cognitive function) score of 12 out of 15, indicating the resident has a moderate cognitive impairment.
Further review of the MDS assessment revealed under section L, Oral/Dental status, that the resident was assessed to have obvious or likely cavities or broken natural teeth.
Record review revealed a physician order dated 10/6/2022 for dental services as needed.
Record review of the resident's progress notes reveal the following:
-8/30/2023 at 8:12 AM Resident with complaints of some oral discomfort related to dental status suspected decay .Resident provided information on provider enrollment and signed agreement form to be seen by dental-podiatry-optometry as necessary. Signed form faxed back to provider this am [morning] and requested. resident be seen with upcoming visit if possible.
-8/30/2023 at 2:01 PM risk management nutrition note, dental consult due to tooth pain discussed with nursing authored by the dietician
-9/6/2023 at 11:47 AM risk management nutrition note, dental consult requested due to tooth pain authored by the facility dietician
Record review failed to reveal evidence that dental services were provided to the resident after s/he complained of pain on 8/30 and 9/6/2023.
During a surveyor interview on 9/12/2023 at 4:37 PM with the resident revealed his/her teeth hurt sometimes. Additionally, s/he stated, I have some that need to be pulled.
During a surveyor interview on 9/13/2023 at 11:36 AM with the Director of Nursing Services, she was unable to provide evidence that the facility provided or obtained emergency dental services from an outside agency for Resident ID #49 after s/he began experiencing dental pain on 8/30/2023.
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 ensure it stores, distributes, and serves food in accordance with professional sta...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure it stores, distributes, and serves food in accordance with professional standards for food safety relative to the main kitchen and 1 of 3 unit kitchenettes.
Findings are as follows:
1. Review of Rhode Island Food Code, 2018 edition, section 3-501.17 states in part, .refrigerated 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 C [degrees Celsius] (41 F [degrees Fahrenheit]) or less for a maximum for 7 days. The date of preparation shall be counted as day 1 .
During the initial tour of the main kitchen on 9/11/2023 at 8:50 AM, there were two, 6 inch by 6 inch pans underneath the prep counter. One was filled with white, viscous food matter and the other pan contained crumbled, white food matter. Both pans were observed to be covered in plastic wrap and were not labeled or dated.
During a surveyor observation of the walk-in refrigerator during the initial tour on 9/11/2023 at approximately 9:00 AM, revealed the following:
- A pan of ham salad dated 9/12 (one day ahead)
- One small Styrofoam container containing unidentifiable food items, wrapped in plastic wrap, with no label or date
During a surveyor interview with the Food Service Director (FSD) immediately following the above observations, he revealed he expects food to be labeled and dated the day it is prepared. He further acknowledged that the small 6 inch by 6 inch pans underneath the prep table contained bacon fat and roux and were not labeled and dated. Additionally, he revealed that they were discarded.
2. Record review of a policy titled, Personal Food Policy, dated November 2016, states in part, .4. The staff person receiving the personal food shall label the container with the date it was brought into the facility (or the date of preparation, if known) and the name of the resident receiving it .8. Dietary aides are responsible for checking nourishment refrigerators daily and discarding any unused refrigerated foods after 3 days .
During a surveyor observation of the second-floor kitchenette on 9/11/2023 at 1:55 PM, revealed the following items were located in the refrigerator:
- A Styrofoam container containing unidentifiable food items, dated 8/24/23
- A small rectangular blue Tupperware containing pasta salad, no name/date
- A Cool Whip container containing unidentifiable food, dated 8/16
- A plastic takeout container with a sandwich and fries, no name/date
- A Styrofoam container containing unidentifiable food items, dated 9/5
- A small 8 ounce soup container, dated 9/5
During a surveyor interview with Licensed Practical Nurse, Staff I, immediately following the above observation, she acknowledged that the above food items should have been discarded.
During a surveyor interview with the FSD on 9/13/2023 at 11:20 AM, he revealed that he expects food brought in for the residents from outside of the facility to be labeled, dated, and discarded after 3 days per the facility's policy.
Aug 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to following a physician's ...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to following a physician's order for medication for 1 of 3 residents reviewed, Resident ID #1.
Findings are as follows:
Record review of a community reported complaint submitted to the Rhode Island Department of Health on 8/3/2023, alleges in part, that the resident complained of abdominal pain, nausea and episodes of frequent bloody vomit and had been requesting to go to the hospital for two days.
Mosby's 4th Edition, Fundamentals of Nursing, page 314 states: The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
Record review revealed the resident was readmitted to the facility in June of 2023 with diagnoses including, but not limited to, end stage renal disease (a disease where the kidneys reach an advanced state of loss of function) and hypertension.
Record review revealed a physician's order dated 6/17/2023 for hydralazine (a medication to treat high blood pressure) 50 milligram (mg) one tablet by mouth at 6:00 AM, 12:00 PM, 6:00 PM and 12:00 AM.
Record review of the June and July 2023 Medication Administration Records (MAR) revealed the 12:00 PM dose of hydralazine was not administered as ordered on the following dates:
- 6/19/2023
- 6/23/2023
- 6/26/2023
- 6/28/2023
- 6/30/2023
- 7/3/2023
- 7/5/2023
- 7/10/2023
- 7/12/2023
- 7/14/2023
- 7/17/2023
- 7/19/2023
- 7/21/2023
- 7/25/2023
- 7/26/2023
- 7/28/2023
- 7/31/2023
During a surveyor interview on 8/4/2023 at approximately 2:30 PM with the Acting Director of Nursing Services, she was unable to provide evidence that the resident's hydralazine was administered as ordered on the above- mentioned dates and times.
Apr 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined the facility failed to ensure a resident's drug regimen is free from unnecessary psychotropic drugs for 1 of 2 residents reviewed, Re...
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Based on record review and staff interview, it has been determined the facility failed to ensure a resident's drug regimen is free from unnecessary psychotropic drugs for 1 of 2 residents reviewed, Resident ID #1 who received psychotropic medications long-term without attempting a Gradual Dose Reduction (GDR). A GDR is the tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.
Findings are as follows:
Record review for Resident ID #1 revealed s/he was readmitted to the facility in August of 2018 and has diagnoses to include which are not limited to: anoxic brain damage (when your blood can't carry enough oxygen around your body to keep your organs functioning properly), unspecified dementia, and pseudobulbar affect (sudden uncontrollable and inappropriate crying or laughing).
Record review of the physicians orders revealed the following psychotropic drugs:
- 1/4/2021 Haloperidol 1mg (milligram), 1 tablet by mouth twice a day due to anxiety disorder
- 2/24/2021 Quetiapine 25 mg 1 tablet twice a day at 6:00 AM and 12:00 PM
- 2/24/2021 Seroquel (quetiapine) tablet 50 mg, once a day at 4:00 PM.
- 2/18/2022 Trazodone 50 mg, 1 tablet oral at bedtime for insomnia
- 7/10/2019 Venlafaxine 112.5 mg, twice a day at 8:00 AM and 8:00 PM
Record review failed to reveal evidence that a GDR was attempted for any of the above psychotropic drugs or that a GDR was clinically contraindicated.
During a surveyor interview with the Director of Nursing Services on 4/6/2023 at approximately 1:15 PM, she was unable to provide evidence that a GDR was attempted for any of the above listed psychotropic drugs or that a GDR was clinically contraindicated.
Nov 2022
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 meet professional standards of quality relative to physician orders for 1 of 3 residents reviewed, Reside...
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Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to physician orders for 1 of 3 residents reviewed, Resident ID #1.
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 community reported complaint submitted to the Rhode Island Department of Health, dated 11/1/2022 alleges in part .the resident had some sores on [his/her] feet .no podiatrist had ever visited [him/her] .
Record review revealed the resident was admitted to the facility in November of 2021 with diagnoses including, but not limited to, end stage renal disease, anemia, dysphagia, and pneumonitis due to inhalation of food.
Record review of podiatry orders dated 10/27/2022 revealed the following:
1) Keflex 250 Milligrams (MG) twice daily x 10 days
2) Normal Saline (NS) cleanse left 4th toe plantar aspect, pat dry, apply bacitracin and cover with dry gauze secured with tape once daily x 10 days
3) Apply betadine to eschar (dead tissue) Left great toe once daily x 10 days
4) Clotrimazole 1% cream once daily to interdigital spaces 2, 3 bilateral feet x 4 weeks
5) Wash & dry well between toes to prevent skin breakdown/infection
Record review of the October 2022 Medication Administration Record failed to reveal evidence that the resident received his/her Keflex on the following dates and times:
10/28/2022 at 8 AM and 8 PM
10/29/2022 at 8 AM and 8 PM 10/30/2022 at 8 AM and 8 PM 10/31/2022 at 8 AM and 8 PM
This indicates that the resident missed a total of 8 Keflex doses.
Record review of the October 2022 Treatments Flowsheet failed to reveal that the resident received the following treatments as ordered:
10/29/2022 and 10/30/2022 AM - betadine to eschar, left great toe.
10/29/2022 and 10/30/2022 AM - Clotrimazole Cream
10/29/2022 and 10/30/2022 AM - Normal saline cleanse Left 4TH toe plantar aspect.
During a surveyor interview on 11/2/2022 at 1:11 PM with Registered Nurse, Staff A, she was unable to provide evidence that the Keflex and the above-mentioned treatments were administered/completed on the above-mentioned dates and times.
During a surveyor interview with the Director of Nursing Services on 11/2/2022 at 2:14 PM, she acknowledged that the Keflex and the above-mentioned treatments were not administered/completed on the above-mentioned dates and times.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 3 residents reviewed, Reside...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 3 residents reviewed, Resident ID #1.
Findings are as follows:
Record review revealed the resident was admitted to the facility in November of 2021 with diagnoses including, but not limited to, end stage renal disease, anemia, dysphagia, and pneumonitis due to inhalation of food.
Record review of a podiatry order dated 10/27/2022 revealed a new order for Keflex 250 Milligrams (MG) twice daily x 10 days.
Record review of the October 2022 Medication Administration Record failed to reveal evidence that the resident received his/her Keflex on the following dates and times:
10/28/2022 at 8 AM and 8 PM 10/29/2022 at 8 AM and 8 PM 10/30/2022 at 8 AM and 8 PM 10/31/2022 at 8 AM and 8 PM
This indicates the resident missed a total of 8 Keflex doses.
During a surveyor interview on 11/2/2022 at 1:11 PM with Registered Nurse, Staff A, she was unable to provide evidence that the Keflex was administered on the above-mentioned dates and times.
During a surveyor interview with the Director of Nursing Services on 11/2/2022 at 2:14 PM, she acknowledged that the Keflex was not administered on the above-mentioned dates and times.
Jun 2022
6 deficiencies
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 ensure residents maintain acceptable parameters of nutritional status, such as usual body weight, for 1 o...
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Based on record review and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight, for 1 of 6 residents reviewed for nutrition, Resident ID# 33.
Findings are as follows:
Record review of the facility policy titled Weights states in part, .Thereafter, residents will be weighed monthly, unless clinically indicated .and all weight loss/gain of 5 pounds or more on a resident weighing 100 pounds or more requires a reweigh for verification .
Record review for the resident revealed s/he was admitted to the facility in June of 2018 with diagnoses including, but not limited to, congestive heart failure (a progressive heart disease that affects the pumping action of heart muscles) and hypothyroidism (a condition resulting from decreased production of thyroid hormones).
Record review of the resident's weights revealed the following:
- 5/2/2022- 192 lbs. (pounds)
- 4/27/2022- 187 lbs.
- 3/28/2022 - 190 lbs.
- 2/2022- No weight was obtained
- 1/14/2022- 182 lbs.
Further record failed to reveal evidence that reweights were obtained following the 5 lb. weight gain on 5/2/2022, the 8 lb. weight gain on 3/28/2022 or that a monthly weight was obtained for 2/2022.
During a surveyor interview with the Director of Nursing Services and the Regional Director of Nursing Services on 6/7/2022 at 3:03 PM, they were unable to provide evidence that the resident was weighed in February of 2022. They were also unable to provide evidence that a reweighs was completed when the 8 lb. and 5 lb. weight gain were identified as per the facility's policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on surveyor observation and staff interview it has been determined that the facility failed to ensure that facility staff utilized Personal Protective Equipment (PPE) according to professional s...
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Based on surveyor observation and staff interview it has been determined that the facility failed to ensure that facility staff utilized Personal Protective Equipment (PPE) according to professional standards to prevent the transmission of COVID-19 for 1 of 2 facility staff members observed, who had not received the COVID-19 Booster, Nurse Staff A.
Findings are as follows:
Record review of the facility's policy titled, COVID-19 Employee Exemption Policy revealed in part, .7. Health care workers who are not up to date with vaccinations must adhere to the CMS [Center for Medicare and Medicaid Services] requirements applicable to infection control and must adhere to all testing requirements as determined by CMS or their state specific Department of Health guidance .
8. Health care workers who are not vaccinated and/or up-to-date may continue to work; however, they must wear a medical grade N95 mask when the COVID-19 prevalence rate in the state is [greater to or equal to] fifty (50) cases per one hundred thousand (100,000) people per week .
Review on 6/8/2022 of the Rhode Island Covid- 19 Congregate Care Data revealed a level of 253.2 total new cases per 100,000 in the last 7 days.
Record review of the facility's document titled, COVID-Employee Vaccine Log revealed Nurse Staff A, received her primary Covid-19 vaccination series on 8/20/2021 and 9/22/2021. Further review of this document failed to reveal evidence that Staff A had received the Covid-19 booster.
During a surveyor observation on 6/8/2022 at 12:05 PM of Staff A, she was on the second floor of the facility wearing only a surgical mask.
During a surveyor interview on 6/8/2022 at 12:05 PM with Staff A, when asked about the surgical mask she was wearing, she stated we wear them all of the time unless there is an outbreak. After further questioning, she revealed that she is supposed to wear an N95 mask because she hasn't had the booster.
During a surveyor interview on 6/8/2022 at 12:47 PM with the Infection Preventionist, she acknowledged that Staff A failed to follow infection control requirements by not wearing an N95 mask because she had not received the Covid-19 booster.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to assure 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 assure that services being provided meet professional standards of quality related to following physician's orders for 2 of 7 residents reviewed for medication administration, Resident ID #s 48 and 51.
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.
1. Record review for Resident ID #48 revealed s/he was admitted to the facility in April of 2022 with diagnoses including, but not limited to, paroxysmal atrial fibrillation (a condition in which electrical impulses in the heart can cause the heart to beat rapidly and irregularly), ischemic cardiomyopathy (decreased pumping ability of the heart), and type 2 diabetes (chronic condition how the body processes blood sugar).
Record review of the resident's physician orders revealed the following:
-Donepezil (medication used to treat memory impairment) 10 mg (milligram) one tablet at bedtime
-Melatonin (medication used to treat insomnia) 3 mg, one tablet at bedtime
-Quetiapine (medication used to treat mental health conditions) 25 mg one tablet at bedtime
-Hydrochlorothiazide (medication used to treat heart failure) 12.5 mg one tablet once daily
-Lisinopril (medication to treat high blood pressure) 40 mg one tablet once daily
-Rosuvastatin (medication to teat high cholesterol) 40 mg once daily
-Vitamin D3 (medication to treat vitamin D deficiency) 1000 units one tablet once daily
-Wellbutrin (medication to treat mental health conditions) SR (sustained release) 200 mg once daily
-Metformin (medication to treat diabetes mellites) 1000 mg one tablet twice daily
-Pantoprazole (medication to treat GERD) DR (delayed release) one tablet once daily
-Creon (medication used to treat pancreatic insufficiency) DR 24,000-76,000 -120,000 unit one tablet at bedtime
Record review of the June 2022 Medication Administration Record (MAR) failed to reveal evidence that donepezil, melatonin, and quetiapine were administered as ordered on 6/1/2022.
Record review of the May 2022 MAR failed to reveal evidence that the following medications were administered as ordered on the following dates:
-5/30/2022 Hydrochlorothiazide, Lisinopril, Rosuvastatin, Wellbutrin, Metformin, and Vitamin D3
-5/29/2022 Pantoprazole, Creon, and Quetiapine
-5/27/2022 Donepezil
-5/26/2022 Metformin
-5/24/2022 Metformin
Further record review revealed the following physician order to Check blood sugar prior to Breakfast and prior to Evening dose. Notify provider if BG [blood glucose] is < [less than] 70 or > [greater than] 300.
Record review of the May 2022 MAR failed to reveal evidence that the provider was notified when the resident's blood sugar was greater than 300 at 5:00 PM on the following dates:
-5/15/2022
-5/17/2022
-5/18/2022
-5/20/2022
-5/21/2022
-5/23/2022
-5/25/2022
-5/31/2022
During a surveyor interview with the Director of Nursing Services (DNS) on 6/8/2022 at approximately 1:30 PM, she was unable to explain why the medications were not signed off as administered and she could not provide evidence that the provider was notified when the resident's blood sugar was greater than 300.
2. Record review for Resident ID #51 revealed s/he was admitted to the facility in February of 2016 with diagnoses including, but not limited to, atrial fibrillation and hypertension (high blood pressure).
Record review revealed a physician's order dated 10/10/2020 for metoprolol succinate (a medication to treat high blood pressure) 25 mg once a day, hold if pulse less than 60 beats per minute.
Further record review of the May and June 2022 MAR revealed the metoprolol was administered without evidence of obtaining the resident's pulse from May 1st through June 7th, 2022.
During a surveyor interview with the DNS on 6/8/2022 at 3:06 PM, she was unable to explain why the medication was administered without following the ordered parameters.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and resident and staff interview, it has been determined that the facility failed to ensure that each resident receives adequate supervision to prevent ac...
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Based on surveyor observation, record review, and resident and staff interview, it has been determined that the facility failed to ensure that each resident receives adequate supervision to prevent accidents relative to smoking hazards for 5 of 6 residents reviewed, Resident ID #s 23, 25, 40, 81 and 84.
Findings are as follows:
Review of the facility policy titled Smoking revised on November 2020 states in part, .Smoking will take place under the supervision of a staff member .
1. Record review for Resident ID #23 revealed s/he has a care plan revised on 4/12/2022 which indicates Resident wishes to smoke . with interventions to include but not limited to Provide protective equipment Smoking Apron .
Surveyor observation on 6/7/2022 between 10:48 and 10:58 AM revealed the resident was outside smoking under supervision by Staff B and not wearing smoking apron.
Additional observation on 6/8/2022 between 10:47 AM and 10:53 AM revealed the resident was outside smoking unsupervised and not wearing the apron.
During an interview on 6/8/2022 at 10:55 AM with Staff B, he acknowledged that the resident was not wearing an apron.
During a surveyor interview on 6/8/2022 at 11:03 AM, the resident revealed s/he wore the smoking apron once a long time ago.
2. Record review for Resident ID #25 revealed s/he has a care plan revised on 4/29/2022 which indicates that s/he was assessed as an independent smoker with supervision.
3. Record review for Resident ID #40 revealed s/he has a care plan revised on 4/26/2022 which indicates that s/he was assessed as an independent smoker with supervision.
4. Record review for Resident ID #81 revealed s/he has a care plan revised on 5/31/2022 which indicates that s/he was assessed as an independent smoker with supervision.
5. Record review for Resident ID #84 revealed s/he has a care plan revised on 3/22/2022 which indicates Resident wishes to smoke .
During a surveyor observation on 6/8/2022 from 1:17 through 1:23 PM revealed Resident ID #s 25, 40, 81, and 84 were observed smoking outside unsupervised.
During an interview on 6/8/2022 at approximately 1:30 PM, Staff C revealed he was assigned to supervise the smoking residents. Additionally, he revealed that he went to the second floor to bring another resident out to smoke.
During an interview with the Regional Director of Nursing Services on 6/8/2022 at 2:22 PM, in the presence of the Administrator, she revealed she would expect the residents to be supervised while smoking. Additionally, she was unable to explain why the facility policy was not being followed for the above-mentioned residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to test facility staff based on parameters set forth by the Secretary for conducting testing of asymptomatic...
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Based on record review and staff interview, it has been determined that the facility failed to test facility staff based on parameters set forth by the Secretary for conducting testing of asymptomatic individuals based on criteria such as the positivity rate of Covid-19 in a county for 2 of 6 staff reviewed who failed to receive the booster for Covid-19 testing, Staff M and P.
Findings are as follows:
Record review of the facility's policy titled, COVID-19 Employee Exemption Policy revealed in part, .7. Health care workers who are not up to date with vaccinations must adhere to the CMS requirements applicable to infection control and must adhere to all testing requirements as determined by CMS or their state specific Department of Health guidance .
Record review of the facility's policy titled,Covid-19 Pandemic Resident and Staff Testing states in part, .Per latest CMS guidance, .facilities will continue to test resident and facility staff based on parameters and frequency as set forth by the HHS [US Department of Health and Human Services] Secretary .Facilities may accept testing done at other locations, if documentation is provided that the required testing was completed during the timeframe that corresponds to the facility's testing frequency .Routine testing of staff who are not up-to date, should be based on the extent of the virus in the community .Facilities should use their community transmission level as the trigger for staff testing frequency .High twice a week .If the level of community transmission decreases to a lower level of activity, the facility should continue testing staff at the higher frequency, until the level of community transmission had remained at the lower activity level for at least two weeks .
Review on 6/8/2022 of the Rhode Island Covid-19 Congregate Care Data revealed a level of 253.2 total new cases per 100,000 in the last 7 days. It further revealed a high transmission level throughout May.
Record review of the facility's document titled, COVID-Employee Vaccine Log revealed the following:
Nurse Assistant, Staff M, received the primary Covid-19 vaccination series on 3/3/2022 and 3/31/2022. It further revealed that she failed to receive the Covid-19 booster.
Nurse Assistant, Staff P, received the primary Covid-19 vaccination series on 8/23/2021 and 9/14/2021. It further revealed that she failed to receive the Covid-19 booster.
Record review of the facility's Covid-19 testing failed to reveal a system of tracking Covid-19 testing for staff who are not up-to-date (do not have the Covid-19 booster) to ensure they are tested twice weekly based on the HIGH transmission level.
Record review of the facility schedule from May 1st, 2022, to June 7th, 2022, revealed the following days that Staff M worked:
- 5/1, 5/3, 5/4, 5/6, 5/9, 5/10, 5/11, 5/14, 5/15, 5/17, 5/18, 5/20, 5/23, 5/24, 5/25, 5/26, 5/28, 5/29, 5/30, 5/31, 6/1, 6/3, 6/6 and 6/7/2022.
Further record revealed that Staff M was only tested for Covid-19 on 5/17/2022 and 6/7/2022.
Record review of the facility schedule from May 1st, 2022, to May 11th, 2022, revealed the following days that Staff P worked (prior to testing positive.)
-5/9 and 5/11/2022.
Further record review revealed Staff P was only tested for Covid-19 on 5/4/2022, and then tested positive on 5/12/2022. According to The Centers for Disease Control, Test for Current Infection updated 5/16/2022, .If you have had COVID-19 in the past 90 days and recovered, you do not need to be tested .
During a surveyor interview on 6/7/2022 at 3:15 PM with the Infection Preventionist, she was unable to provide evidence of Covid-19 testing twice weekly for the above staff, as required during periods of high transmission.
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 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 serv...
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Based on surveyor observation 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 food storage and improper use of dishwashing equipment.
Findings are as follows:
1. During a surveyor observation of the 1st floor kitchenette on 6/6/2022 at 1:00 PM, 1 blue gel cold pack and 1 ice pack were noted to be in the community food freezer. Additionally, there is a sign on the freezer door that states, Please Do not put blue gel cold packs or resident ice packs in food freezer. Please place in Med [medication] Room Freezer behind Nurse's station .
During a surveyor observation with the Food Service Director (FSD) on 6/7/2022 at 11:58 AM, it was revealed that 1 blue gel cold pack and 1 ice pack were noted to be in the first-floor community food freezer. The FSD revealed that gel packs and ice packs should not be placed in the food freezer.
2. During a surveyor observation of the dishwasher on 6/8/2022 at 9:17 AM, revealed a hot water sanitizing machine with a minimum required wash temperature of 150 degrees F (Fahrenheit) and a rinse temperature of 180 degrees F.
During surveyor observation of the wash cycle (approximately 5 cycles), the temperature read 130 degrees F and the rinse cycle revealed a range of 174-178 degrees F. Subsequent interview with the FSD revealed that he let the staff use the machine because the internal temperature that he checked this morning was more than 160 degrees.
During a surveyor observation on 6/8/2022 at 9:28 AM, the surveyor asked Staff F to place the thermometer in the dishwasher and the temperature was noted to be at 142.9 degrees F. Subsequently, the FSD checked the internal temperature, which was observed to be 150.4 degrees F.
During a surveyor interview with the FSD following the above observation, he acknowledged that the wash cycle temperature should be at minimum 150 degrees F and that the rinse cycle should be at minimum 180 degrees F. Additionally, he stated that he will have the staff do the dishes in the 3 bay sinks.
3. During a surveyor observation on 6/8/2022 at 10:00 AM, of the 3 bay sink which included a washing, rinsing, and sanitizing bay. Staff F was observed to be pouring an Oasis 146 Multi Quat sanitizer directly in the sanitizing bay without measuring or checking the sanitizing solution concentration. Additionally, Staff G was observed taking the dishes and dish covers from the sanitizing bay and placing them away on the clean racks.
During a surveyor observation and interview with Staff F on 6/8/2022 at 10:15 AM, she revealed that she uses the QT-40 Hydrion test strips to check for the chemical content of the sanitizing bay. The test strips were observed to have an expiration date of May 2021. She acknowledged that she did not test the sanitizing bay after she added the sanitizing solution.
During a surveyor interview with the FSD on 6/8/2022 at 10:26 AM, he acknowledged that Staff F used an expired test strip. Additionally, he was unable to provide instructions to properly measure the water and sanitizing solution ratio.
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
- • 15% annual turnover. Excellent stability, 33 points below Rhode Island's 48% average. Staff who stay learn residents' needs.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), Special Focus Facility, 1 harm violation(s). Review inspection reports carefully.
- • 35 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $16,801 in fines. Above average for Rhode Island. Some compliance problems on record.
- • Grade F (16/100). Below average facility with significant concerns.
Bottom line: This facility is on CMS's Special Focus list for poor performance. Consider alternatives strongly.
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About This Facility
What is Heatherwood Rehabilitation And Health Care Center's CMS Rating?
CMS assigns Heatherwood Rehabilitation and Health Care 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 Heatherwood Rehabilitation And Health Care Center Staffed?
CMS rates Heatherwood Rehabilitation and Health Care Center's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 15%, compared to the Rhode Island average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Heatherwood Rehabilitation And Health Care Center?
State health inspectors documented 35 deficiencies at Heatherwood Rehabilitation and Health Care Center during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 33 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 Heatherwood Rehabilitation And Health Care Center?
Heatherwood Rehabilitation and Health Care 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 ATHENA HEALTHCARE SYSTEMS, a chain that manages multiple nursing homes. With 114 certified beds and approximately 103 residents (about 90% occupancy), it is a mid-sized facility located in Newport, Rhode Island.
How Does Heatherwood Rehabilitation And Health Care Center Compare to Other Rhode Island Nursing Homes?
Compared to the 100 nursing homes in Rhode Island, Heatherwood Rehabilitation and Health Care Center's overall rating (2 stars) is below the state average of 3.1, staff turnover (15%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Heatherwood Rehabilitation And Health Care 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 Heatherwood Rehabilitation And Health Care Center Safe?
Based on CMS inspection data, Heatherwood Rehabilitation and Health Care Center has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). 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 Heatherwood Rehabilitation And Health Care Center Stick Around?
Staff at Heatherwood Rehabilitation and Health Care Center tend to stick around. With a turnover rate of 15%, the facility is 31 percentage points below the Rhode Island average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 11%, meaning experienced RNs are available to handle complex medical needs.
Was Heatherwood Rehabilitation And Health Care Center Ever Fined?
Heatherwood Rehabilitation and Health Care Center has been fined $16,801 across 1 penalty action. This is below the Rhode Island average of $33,247. 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 Heatherwood Rehabilitation And Health Care Center on Any Federal Watch List?
Heatherwood Rehabilitation and Health Care Center is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.