St Clare Home
Non profit - Corporation
50 Beds
Independent
Data: November 2025
Trust Grade
48/100
#45 of 72 in RI
Photo by J.B. Chandler
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
St Clare Home has a Trust Grade of D, which indicates below-average performance and some concerns about the quality of care provided. They rank #45 out of 72 facilities in Rhode Island, placing them in the bottom half, and #4 out of 6 in Newport County, meaning only two local options are considered better. The facility's performance is worsening, with issues increasing from 6 in 2024 to 10 in 2025. Staffing is a relative strength with a 4/5 star rating, though the turnover rate of 59% is concerning, significantly higher than the state average of 41%. However, they have good RN coverage, exceeding 94% of state facilities, which is important for catching potential issues. On the downside, there have been some serious concerns, such as failures in providing proper wound care for three residents, leading to an increased risk of pressure ulcers. Additionally, issues were found with food safety practices, including improper storage and preparation, which could compromise resident health. Finally, documentation errors regarding vaccinations for several residents raise further concerns about adherence to care standards. Overall, while St Clare Home has some strengths in staffing and RN coverage, there are significant areas for improvement that families should consider.
- Trust Score
- D
- In Rhode Island
- #45/72
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 59% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $10,517 in fines. Higher than 93% of Rhode Island facilities. Major compliance failures.
- Skilled Nurses ✓ Good
- Each resident gets 84 minutes of Registered Nurse (RN) attention daily — more than 97% of Rhode Island nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 29 deficiencies on record. Higher than average. Multiple issues found across inspections.
48/100
Bottom 38%
Needs review
6 → 10 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 6 issues
2025: 10 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, fire safety.
The Bad
3-Star Overall Rating
Near Rhode Island average (3.1)
Meets federal standards, typical of most facilities
Staff Turnover: 59%
13pts above Rhode Island avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $10,517
Below median ($33,413)
Minor penalties assessed
Staff turnover is elevated (59%)
11 points above Rhode Island average of 48%
The Ugly 29 deficiencies on record
1 actual harm
Jul 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to have sufficient nursing staff to assure resident safety and attain the highest practicable, physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care relative to insufficient staffing for 2 of 3 residents reviewed, Resident ID #s 2 and 3.
Findings are as follows:
Review of a community reported complaint submitted to the Rhode Island Department of Health on 6/30/2025 alleged that on 6/27 - 6/28/2025 during the 10:30 PM to 6:30 AM shift, the facility had a significant staffing issue. The complaint alleged that the nurse was left to provide nursing care for residents on two units, which were on two different floors. The complaint further alleged that during that shift, there were only two Nursing Assistants (NA) assigned to three units. Additionally, the complaint alleged that the facility was understaffed and unsafe.
Review of a policy titled, Staffing Nursing states in part, .The facility provide sufficient numbers of nursing staff .to provide nursing and related care and services for all residents .Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including .assuring resident safety .attaining or maintaining the highest practicable physical, mental, and psychosocial well-being of each resident .assessing, evaluating, planning, and implementing resident care plans .[and] responding to resident needs .
1. During a surveyor interview with Licensed Practical Nurse (LPN), Staff A, she indicated that on 6/27 - 6/28/2025 during the 10:30 PM to 6:30 AM shift, the facility did not have sufficient staff, there were only two NAs and two nurses responsible for the three units in the facility. She indicated that a resident fell at approximately 5:20 AM, Resident ID #2. Additionally, she revealed that she did not have time to complete all of the residents' morning medications due to the short staffing, in particular, Resident ID #3's medications that were due at 6:00 AM. Furthermore, Staff A indicated that the [NAME] Unit was left without any staff just after the fall, because the NA assigned to that unit had to go to the downstairs unit to relieve her, before she could go up to the [NAME] Unit to assess and assist Resident ID #2 off of the floor.
During a surveyor interview on 7/2/2025 at approximately 9:30 AM with an Ombudsman, she indicated that four families of residents residing at the facility contacted the Ombudsman's office following the weekend of 6/27/2025 with complaints of insufficient staffing. She further indicated that one of the anonymous complainants alleged that the residents were left alone, without any staff for an unknown period of time, which caused the resident to be fearful.
Review of the facility's actual working schedule for the 10:30 PM - 6:30 AM shift on 6/27 - 6/28/2025 revealed only two nurses and two NAs worked in the facility during that night shift.
Record review revealed the facility has 3 units and approximately 50 residents. The Gooseberry Unit is the short-term unit with approximately 22 residents, the [NAME] Unit has approximately 15 residents, and the [NAME] Point Unit, which is on a lower level of the facility, has approximately 12 residents.
2a. Record review revealed Resident ID #2 was admitted to the facility in October of 2024 with diagnoses including, but not limited to, Parkinson's disease and a history of falling.
Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderately impaired cognition.
Record review revealed the resident required the assistance of one staff member for transfers.
Record review revealed the following progress notes:
-6/28/2025 at 6:14 AM- Resident had an unwitnessed fall approx .0525 [5:25 AM] in [his/her] room. [Resident ID #2] stated [s/he] was getting out of the bathroom and [his/her] leg buckled and [s/he] fell .denied any pain while on the floor but while getting [him/her] off the floor and putting [his/her] legs into [his/her] bed [his/her] pain became a 4/10 .
-6/28/2025 at 7:48 AM- .reached out to [Director of Nursing Services (DNS)- Name redacted] regarding the resident fall .I also did make [DNS] aware of these unsafe staffing ratios which has played a big part in patient safety.
-7/1/2025 at 6:34 AM- .resident did not sleep well but quiet. [Complained of] pain to right leg and medicated with scheduled Tylenol .
During a surveyor interview on 7/2/2025 at approximately 10:40 AM with Resident ID #2, s/he indicated that s/he had fallen over the weekend and that .it wasn't fun, and it hurt . The resident further indicated that s/he was lying on the floor of his/her room for approximately an hour until staff found him/her.
During a surveyor interview on 7/2/2025 at 11:45 AM with NA, Staff B, she indicated that she worked on the 6/27 - 6/28/2025 10:30 PM - 6:30 AM shift and was told that she had to switch from the [NAME] Unit to the downstairs [NAME] Point Unit because the facility was short staffed. She indicated that she was the only staff member on the [NAME] Unit for most of the shift and that many of the residents require two staff members for care, bed mobility, and transfers. She further indicated that she had to leave the unit unstaffed to go downstairs so the nurse could come upstairs to administer the residents medications. Additionally, she indicated that she asked an Assisted Living staff member to come to the unit to assist with turning one of the residents, and when she exited that resident's room to obtain more hygiene supplies, she noticed Resident ID #2 lying on the floor of his/her room. Furthermore, she indicated that she feels the facility's staffing is inadequate to properly care for the acuity of the residents.
During a surveyor interview on 7/3/2025 at approximately 10:30 AM with NA, Staff C, she indicated that she was originally scheduled to work on the downstairs [NAME] Point Unit for the 10:30 PM - 6:30 AM shift on 6/27 - 6/28/2025, however, when she realized the facility was short an NA, she had to complete patient care on all of the residents residing on the [NAME] Point Unit and on the Gooseberry Unit, a total of approximately 37 residents. She indicated that being short staffed has happened in the past and it is difficult to do, however, she was able to complete two rounds of care on both units during that shift. Additionally, she revealed when the facility is short staffed, staff members from the Assisted Living Residence will come to help the units when needed.
2b. Record review revealed Resident ID #3 was readmitted to the facility in October of 2024 with diagnoses including, but not limited to, hemiplegia and hemiparesis following a cerebral infarction (weakness and loss of function on one side of the body following a stroke), repeated falls, and hypertension (high blood pressure).
Review of an MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15, indicating intact cognition. Further review revealed the resident was dependent on the assistance of staff for activities of daily living and the assistance of two staff members for transfers.
Record review revealed a care plan with a focus of hypertension and a goal for the resident's blood pressure to be within normal limits. Further review revealed an intervention to administer cardiac medications as ordered.
Record review revealed the following orders:
- Acetaminophen 1000 milligrams (mg) every 8 hours
- Hydralazine (a cardiac medication) 50 mg every 8 hours
Record review of the June 2025 Medication Administration Record revealed the 6:00 AM scheduled dose of the Acetaminophen and the Hydralazine was not administered on 6/28/2025.
During a surveyor interview on 7/2/2025 at approximately 10:55 AM with Resident ID #3, s/he indicated that s/he feels that the facility does not have enough staff. The resident further indicated that s/he waits 30 minutes for staff to answer his/her call bell at times.
During a surveyor interview on 7/2/2025 at approximately 11:00 AM with Certified Medication Technician, Staff D, she indicated that she sometimes feels like the facility could use more staff but the staff members work well as a team. She further acknowledged that Resident ID #3's Acetaminophen and Hydralazine were not documented as administered for the 6:00 AM dose on 6/28/2025.
During a surveyor interview on 7/2/2025 at 2:25 PM with the Administrator, she indicated that she was aware that Resident ID #2 had an unwitnessed fall on 6/28/2025. She further indicated that she was unaware that Resident ID #3 had not received his/her 6:00 AM scheduled Acetaminophen and Hydralazine on 6/28/2025.
May 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
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 tre...
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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 treatment and care in accordance with professional standards of practice for 3 of 5 residents reviewed with constipation, Resident ID #s 2, 3 and 4.
Findings are as follows:
Review of a facility policy titled Bowel Protocol states in part, .maintain a healthy bowel regime for each resident .After 48 hours with no [Bowel Movement] BM the resident will be placed on the laxative list by the evening [3:00 PM to 11:00 PM] shift Licensed nurse to document GI [Gastrointestinal] assessment .[For example] (BS [bowel sounds], N/V [Nausea and vomiting], abdominal pain/distention) .The resident will be given MOM [Milk of Magnesia; a laxative] on the next evening shift .If no BM by the following morning, a suppository will be given upon waking .If no BM following the suppository, a fleet [enema] is to be given .If still no BM a complete assessment is done by the nurse and MD [medical doctor] to be called if indicated .
1. Record review revealed Resident ID #2 was admitted to the facility in February of 2025 with a diagnosis including, but not limited to, right side hemiplegia (paralysis) and hemiparesis (weakness) following a stroke.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident is incontinent of bowels and is dependent on staff for toileting.
Record review of the bowel records revealed the following:
- last documented BM was on 5/3/2025, indicating that s/he did not have a BM for 4 days.
- last documented BM was on 5/10/2025, indicating that s/he did not have a BM for 4 days.
Record review of the Laxative list dated 5/4/2025 indicates the resident refused MOM on two occasions despite not needing the MOM on 5/4/2025 as s/he had a documented BM on 5/3/2025.
Record review failed to reveal evidence that the resident received bowel interventions on 5/6 and 5/7/2025, that a GI assessment was completed or that the MD was notified that the resident had not had a bowel movement for 4 days, per the bowel protocol.
2. Record review revealed Resident ID #3 was admitted to the facility in April 2025 with diagnoses including, but not limited to, Alzheimer's disease and urinary incontinence.
Review of an admission MDS assessment dated [DATE] revealed the resident is incontinent of bowels and requires assistance from staff for toileting.
Review of the bowel records revealed that the resident had no BM documented from 4/30/2025 until 5/5/2025, indicating that s/he did not have an BM for 5 days.
Record review failed to reveal evidence that the resident received bowel interventions per the facility's bowel protocol on 5/2/2025. On 5/2/2025 the resident should have received MOM. Additional review revealed the was offered MOM on 5/3/2025 but refused it. Further the resident received MOM and a suppository on 5/4/2025 with no result and no further interventions were completed by the facility.
Record review failed to reveal evidence of a completed GI assessment or that the MD was notified that the resident had refused MOM on 5/3/2025 and had no results from the MOM and suppository administered on 5/4/2025. Further the record failed to reveal evidence that the provider was notified that the resident had not had a bowel movement for 5 days.
3. Record review revealed Resident ID #4 was admitted to the facility in April 2025 with diagnoses including, but not limited to, mild cognitive impairment and malignant neoplasm of the urinary organ (a cancer of the urinary system).
Review of an admission MDS assessment dated [DATE] revealed that the resident is continent of bowels and requires supervision or touching assistance from staff for toileting.
Review of the bowel records revealed the resident had one small BM documented from 5/1/2025 until 5/5/2025, indicating that s/he did not have an adequate BM for 4 days.
Record review revealed a physician's order dated 4/29/2025 for Polyethylene Glycol powder (a medication used for constipation), give 17 grams by mouth every 24 hours as needed for constipation.
Record review of the May 2025 Medication Administration Record failed to reveal evidence that the Polyethylene Glycol was administered to the resident as ordered.
Record review failed to reveal evidence that the resident received bowel interventions per the facility's bowel protocol on 5/3 and 5/4/2025. The resident should have received MOM on 5/3 and a suppository on 5/4/2025.
Record review failed to reveal evidence of a completed GI assessment or that the MD was notified that the resident had not had a BM for 4 days.
During a surveyor interview on 5/16/2025 at approximately 10:10 AM with Registered Nurse, Staff A, she indicated that a small bowel movement is not adequate, and that the bowel protocol should be implemented following three days without an adequate bowel movement.
During a surveyor interview on 5/16/2025 at 2:50 PM with the Director of Nursing Services, she acknowledged that an adequate bowel movement had not been documented for Resident ID #'s 2, 3 and 4 on the above-mentioned dates. Additionally, it would be her expectation to notify the provider if there is a refusal or no result from interventions. Further, she could not provide evidence that the facility completed a GI assessment per the facility protocol for Resident ID #'s 2, 3, and 4.
Apr 2025
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure tha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents are treated with respect and dignity for 1 of 1 resident observed who was not being assisted with eating, Resident ID #39.
Record review revealed the resident was admitted to the facility in April of 2024 with diagnoses including, but not limited to, dementia and anxiety.
Review of the Minimum Data Set assessment dated [DATE] revealed the resident required physical assistance with eating.
During a surveyor observation in the unit's common dining area on 4/8/2025 at 12:04 PM, Resident ID #39 was served his/her lunch tray along with other resident's in the common area. The resident sat at the table with the food in front of him/her while two other residents were being fed. At 12:34 PM, 30 minutes after his/her meal was placed at the table, staff began to assist the resident.
During a surveyor interview on 4/8/2024 at 12:34 PM with Certified Medication Technician, Staff A, she acknowledged that there are a lot of residents who require assistance with eating and that Resident ID #39 had to wait to eat while other residents were eating at the table.
During a surveyor interview on 4/9/2024 at 1:07 PM with the Director of Nursing Services, she indicated that six residents on the unit require staff to assist them with eating and it's difficult for them to all be assisted at the same time. She further indicated that a transport aide typically assists with feeding the residents however she was on vacation. She further indicated that she would expect that the resident would not sit for 30 minutes unassisted, while other residents were having their meals.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
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 the assessment accura...
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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 the assessment accurately reflected the resident's status for 1 of 1 resident reviewed receiving hospice services, Resident ID #21.
Findings are as follows:
Record review revealed the resident was readmitted to the facility in December of 2024 with diagnosis including, but not limited to, adult failure to thrive.
Review of a hospice admission service agreement dated 1/27/2025 revealed the resident had signed a consent to receive hospice services, as of this date.
Review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE], Section O, titled Special Treatments, Procedures, and Programs revealed the resident was coded as not receiving hospice services.
During a surveyor interview on 4/8/2025 at 12:49 PM with the MDS Coordinator, she acknowledged that the resident's MDS assessment was inaccurate and did not reflect that the resident is receiving hospice services.
During a surveyor interview on 4/9/2025 at 10:08 AM with the Director of Nursing Services, she indicated that she would expect the resident's MDS to accurately reflect the resident's hospice status.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that a person-centered comprehensive care for 1 of 1 resident reviewed for Post Traumatic Stress D...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that a person-centered comprehensive care for 1 of 1 resident reviewed for Post Traumatic Stress Disorder (PTSD, a mental health condition that's caused by an extremely stressful or a terrifying event), Resident ID #41.
Findings are as follows:
Record review revealed the resident was admitted to the facility with a diagnosis including, but not limited to, PTSD.
Record review of a Social Service Trauma-Informed Care Screening Tool dated 11/27/2024 states in part, .Have you ever had an experience that was so upsetting to you that it changed you, emotionally, spiritually, physically, or behaviorally ., revealed the resident indicated yes.
Record review of the resident's comprehensive care plan failed to reveal evidence that any care plan or interventions were implemented for the resident's history of trauma until it was brought to the facility's attention by the surveyor.
During a surveyor interview on 4/9/2025 at 1:00 PM with the Director of Operations, she indicated she would have expected that a care plan would be implemented for the resident related to his/her diagnosis of PTSD.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to review and revise the resident's comprehensive care plan for 1 of 2 residents reviewed with a deep tissue...
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Based on record review and staff interview, it has been determined that the facility failed to review and revise the resident's comprehensive care plan for 1 of 2 residents reviewed with a deep tissue injury (DTI; a type of pressure injury where damage occurs to the underlying soft tissue) and a Foley catheter (a device that drains urine from the bladder into a collection bag), Resident ID #35.
Findings are as follows:
Record review revealed the resident was readmitted to the facility in March of 2025 with diagnoses including, but not limited to, urinary retention and diabetes.
Review of a progress note dated 3/21/2025 revealed the resident returned to the facility from the hospital with a DTI to his/her left heel and had a Foley catheter in place.
Record review revealed the resident's comprehensive care plan was last revised on 3/8/2025, indicating it had not been updated to include that the resident now had a DTI to his/her left heel or had a Foley catheter in place.
During a surveyor interview on 4/10/2025 at 10:57 AM with the Minimum Data Set (MDS) Assessment Coordinator, she was unable to provide evidence that the resident's comprehensive care plan had been reviewed and revised to reflect that the resident has a DTI to his/her left heel and has a Foley catheter in place. Additionally she indicated that the care plan should have been updated to reflect the current status.
During a surveyor interview on 4/10/2025 at 11:30 AM with the Director of Nursing Services, she indicated that she would expect the resident's comprehensive care plan to have been reviewed and revised to reflect that the resident has a Foley catheter and a DTI to the left heel.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional s...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following physician's orders for 1 of 1 resident reviewed, with an order for a nutritional consult, Resident ID #41.
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 physicians' orders unless they believe the orders are in error or would harm the clients.
Record review revealed Resident ID #41 was admitted to the facility with diagnoses including, but not limited to, high blood pressure and high cholesterol.
Record review revealed a physician's order dated 3/17/2025 for a nutritional consult related to weight gain.
Record review failed to reveal evidence that the nutritional consult was completed per the above physician's order.
During a surveyor interview on 4/9/2025 at 8:57 AM with Registered Nurse, Staff B, she acknowledged that the nutritional consult was not completed.
During a surveyor interview on 4/9/2025 at 11:44 AM with the Director of Nursing Services, she revealed that she would have expected the physician's order to have been completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**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 tre...
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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 treatment and care in accordance with professional standards of practice for 2 of 2 residents reviewed with constipation, Resident ID #s 29 and 148.
Findings are as follows:
Review of a facility policy titled Bowel Protocol states in part, .maintain a healthy bowel regime for each resident .After 48 hours with no [Bowel Movement] BM the resident will be placed on the laxative list by the evening [3:00 PM to 11:00 PM] shift .The resident will be given MOM [Milk of Magnesia; a laxative] on the next evening shift .If no BM by the following morning, a suppository will be given upon waking .If no BM following the suppository, a fleet [enema] is to be given .If still no BM a complete assessment is done by the nurse and MD [medical doctor] to be called if indicated .
1. Record review revealed Resident ID #29 was admitted to the facility in January of 2025 with diagnoses including, but not limited to, dementia and muscle weakness.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident is incontinent of bowels and is dependent on staff for toileting.
Review of the bowel records revealed the resident had only one small BM documented from 3/30/2025 until 4/8/2025, indicating that s/he did not have an adequate BM for 8 days.
Record review of the April 2025 Medication Administration Record (MAR) revealed the resident was not administered any of the medications outlined in the Bowel Protocol until 4/8/2025.
Record review failed to reveal evidence of a completed assessment or that the MD was notified that the resident had not had a bowel movement for 8 days.
During a surveyor interview on 4/9/2025 at approximately 9:45 AM with Registered Nurse, Staff C, she acknowledged that an adequate bowel movement had not been documented for the resident from 3/30/2025 until 4/8/2025. She further indicated that a small bowel movement is not an adequate bowel movement, and that the bowel protocol should have been implemented following three days without an adequate bowel movement.
During a surveyor interview on 4/9/2025 at 9:59 AM with the Director of Nursing Services (DNS), she acknowledged that an adequate bowel movement had not been documented for the resident from 3/30/2025 until 4/8/2025 and that the bowel protocol should have been implemented.
2. Record review revealed Resident ID #148 was admitted to the facility in February 2025 with diagnoses including, but not limited to, Alzheimer disease and gastro-esophageal reflux disease with esophagitis and bleeding (inflammation of the esophagus [the tube connecting the mouth to the stomach] due to frequent severe stomach acid backflow).
Review of an admission MDS assessment dated [DATE] revealed the resident is occasionally incontinent of bowels and requires moderate assistance from staff for toileting.
Record review of a document titled Task revealed Resident ID #148 had no bowel movements on the following dates:
- 3/1, 3/2, 3/3, 3/4 and 3/5/2025, for 5 consecutive days
- 3/13, 3/14, 3/15, 3/16, and 3/17/2025, for 5 consecutive days
- 3/21, 3/22, and 3/23/2025, for 3 consecutive days
- 3/25, 3/26, 3/27, and 3/28/2025, for 3 consecutive days
-4/6, 4/7, and 4/8/2025, for 3 consecutive days
Record review failed to reveal evidence that the resident received bowel interventions per the facility's bowel protocol on the above-mentioned dates.
During a surveyor interview on 4/9/2025 at 12:53 PM with the DNS, she indicated that the resident should have had orders for bowel medication as indicated in the facility's bowel protocol.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on surveyor observation and staff interview, it has been determined that the facility failed to store food in accordance with professional standards of food service safety, relative to the main ...
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Based on surveyor observation and staff interview, it has been determined that the facility failed to store food in accordance with professional standards of food service safety, relative to the main kitchen.
Findings are as follows:
During the initial tour of the main kitchen on 4/7/2025 at approximately 8:50 AM, in the presence of the Food Service Director (FSD), the following observations were made:
- Seven -24-ounce (oz) containers of grits with a Best by date of 1/3/2025.
- Two -1-gallon containers of relish with a Best by date of 2/20/2025.
- Six -20 oz French's mustard with a Best by date of January 2025.
- Four - 97 oz cans of evaporated milk with a Best by date of 2/23/2025.
During a surveyor interview immediately following the above observations with the FSD, he acknowledged that the items were expired and should have been discarded.
MINOR
(B)
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected multiple residents
1. Record review revealed Resident ID #2 was transferred to the hospital on 2/6/2025, 2/14/2025 and 2/17/2025.
Record review failed to reveal evidence that the Office of the State Long-Term Care Ombud...
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1. Record review revealed Resident ID #2 was transferred to the hospital on 2/6/2025, 2/14/2025 and 2/17/2025.
Record review failed to reveal evidence that the Office of the State Long-Term Care Ombudsman was notified of the hospital transfers for Resident ID #2.
2. Record review revealed Resident ID #20 was transferred to the hospital on 3/5/2025.
Record review failed to reveal evidence that the Office of the State Long-Term Care Ombudsman was notified of the hospital transfer for Resident ID #20.
During a surveyor interview with the Director of Operations on 4/9/2025 at 9:33 AM, she acknowledged that the Ombudsman was not notified of the transfers for Resident ID #s 2 and 20.
Nov 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to review and revise the resident's care plan relative to 2 of 3 residents reviewed for falls, Resident ID #...
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Based on record review and staff interview, it has been determined that the facility failed to review and revise the resident's care plan relative to 2 of 3 residents reviewed for falls, Resident ID #s 1 and 2.
Findings are as follows:
1. Record review revealed Resident ID #1 was admitted to the facility in June of 2018 and re admitted in August of 2024 with a diagnosis that includes, but is not limited to, a displaced fracture of the base of neck of left femur (thighbone).
Record review of a document titled Monthly Falls Tracking revealed s/he had sustained falls on 9/27/2024 and on 10/16/2024.
Record review of a care plan that was initiated on 6/10/2024 and revised on 11/13/2024, after it was brought to the Director of Nursing Sevices attention had a focus of the resident having falls on 6/9/2024, 9/27/2024, and 10/16/2024. The care plan interventions failed to be reviewed and revised for the falls that occurred on 6/9/2024 and 9/27/2024.
2. Record review revealed Resident ID #2 was admitted to the facility in April of 2024 with a diagnosis that includes, but is not limited to, orthopedic aftercare following a surgical amputation.
Record review of a care plan dated 5/20/2024 had a focus of the resident being at risk for falls and sustaining falls on 5/23/2024, 7/27/2024, 9/29/2024, 10/22/2024, and 10/25/2024.
Further record review of the care plan failed to reveal evidence that the care plan interventions were reviewed and revised for the above-mentioned falls.
During a surveyor interview on 11/13/2024 at approximately 3:00 PM with the Director of Nursing Services, she was unable to provide evidence that the care plans were reviewed and revised for Resident ID #s 1 and 2.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency 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 error for 1 of 3 residents reviewed, Resident...
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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 error for 1 of 3 residents reviewed, Resident ID #6.
Findings are as follows:
1. Resident ID #6 was admitted to the facility in April of 2022 with a diagnosis including, but is not limited to, multiple sclerosis (a disease in which the immune system eats away the protective covering of the nerves).
Record review of the November Medication Administration Record (MAR) revealed s/he is to receive Methylphenidate HCL (Ritalin, type of medication that is a stimulant that improves focus and impulsive behaviors) oral tablet 30 Milligrams(mg) three times daily.
Record review of the MAR revealed a missed dose of Ritalin on 11/7/2024, 11/8/2024, and 11/9/2024.
During a surveyor interview on 11/13/2024 at approximately 2:00 PM with a Registered Nurse, Staff A, she revealed the resident did receive a 10:00 AM dose of the medication at approximately 12:00 PM and the 2:00 PM dose at approximately 2:20 PM. Additionally, she revealed the medication was not available for a period of time, as the keys to the medication cart were locked in the cart.
Record review of progress notes failed to reveal evidence that the medical provider was notified that the prescribed medication was not administered as ordered on 11/7/2024, 11/8/2024, and 11/9/2024.
During a surveyor interview on 11/13/2024 at approximately 2:00 PM with Staff A, she was unable to provide evidence that the medical provider was contacted.
During a surveyor interview with the Director of Nursing Services on 11/13/2024 at approximately 3:00 PM, she was unable to provide evidence that the resident did receive the medication at the scheduled times. Additionally, she could not provide evidence the medical provider was made aware of the missed doses of medication.
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 F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store and ...
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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 store and label drugs and biologicals in accordance with currently accepted professional principles, for 2 of 3 residents reviewed for medication storage, Resident ID #s 4 and 5.
Findings are as follows:
Record review revealed the facility policy titled, Medication Labeling and Storage, states in part, .If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items .
1. Resident ID #4 was admitted to the facility in September of 2024 with a diagnosis that includes, but is not limited to, pneumonia.
Record review of a progress note dated revealed that the resident had expired on [DATE].
During a surveyor observation of the nursing medication cart on [DATE] at approximately 2:15 PM with Registered Nurse, Staff A, and in the presence of the Director of Nursing Services (DNS), revealed a blister medication card with 10 tablets of Methylphenidate HCL (Ritalin, a medication that is a stimulant that improves focus and impulsive behaviors) 5 mg (milligrams) with Resident ID #4's name on it.
2. Resident ID #5 was admitted to the facility in November of 2024 with a diagnosis that includes, but is not limited to, Alzheimer's disease.
Record review of a document titled, 'Medication Error, reads in part, Resident ID #5 was administered 1 tab of Alprazolam (Xanax, an anxiety medication) instead of 1 tab of Lorazepam (also an anxiety medication) on [DATE].
Record review revealed there was not a physichian's order for Alprazolam for Resident ID #5 at any time during the resident's admission to the facility.
During a surveyor observation on [DATE] at approximately 2:00 PM of the nursing medication cart on the [NAME] nursing unit, with Registered Nurse, Staff A, in the presence of the Director of Nursing Services (DNS), a blister medication card with 26 tablets of 0.25mg. Alprazolam with Resident #5 name on it was identified.
Surveyor observations revealed medications were not removed from the medication carts per the facility policy.
During a surveyor interview on [DATE] at approximately 2:30 PM with the DNS, she acknowledged that the medications for Resident ID #s 4 and 5 should have been destroyed, per facility policy.
Apr 2024
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to meet professional standards of quality relative to following physician's ...
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Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to meet professional standards of quality relative to following physician's orders for 1 of 1 resident reviewed for glucose gel and the utilization a Freestyle Libre (a continuous glucose monitoring system that's designed to replace fingersticks and lessen the need for test strips in people with diabetes) for 1 of 1 resident reviewed for implementing orders related to the use of an insulin pump, Resident ID #146.
Findings are as follows:
1. Review of the Omnipod Insulin Management System User Guide states in part, .Your Pod should be changed at least once every 48 to 72 hours (2 to 3 days) or after delivering 200 units of insulin .When using the extended bolus function, check your blood glucose levels more frequently to avoid hypoglycemia [low blood sugar] or hyperglycemia .Check with your healthcare provider before adjusting your Bolus Calculator settings .Warnings: Rapid-acting U-100 insulin: The Omnipod DASH® System is designed to use rapid-acting U-100 insulin. The following U-100 rapid-acting insulin analogs have been tested and found to be safe for use in the Pod: NovoLog® (insulin aspart), Fiasp® (insulin aspart), Humalog® (insulin lispro), Admelog® (insulin lispro), Lyumjev® (insulin lispro-aabc), and Apidra® (insulin glulisine). NovoLog, Fiasp, Humalog, Lyumjev, and Admelog are compatible with the Omnipod DASH® System for use up to 72 hours (3 days). Apidra is compatible with the Omnipod DASH® System for use up to 48 hours (2 days) .
Review of the facility provided document titled Diabetes Skills Checklist Insulin Administration: Insulin Pump states in part, .1. Follows medical orders for blood glucose testing, insulin dosing if/when needed 2. Document any special circumstances 3. Monitor functionality of pump every shift .
Record review revealed that Resident ID #146 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, long term current use of insulin and influenza.
Record review revealed a physician's order dated 4/12/2024 for Omnipod DASH Pods (Insulin Infusion Disposable Pump) for diabetes and to change the pod every 2 days.
During a surveyor interview with the resident on 4/15/2024 at 12:35 PM s/he revealed that s/he has an insulin pump. S/he revealed that s/he manages his/her own insulin pump including replacing the pump, refilling the insulin pump with Novolog and changing his/her bolus dose of insulin with his/her meals based on what s/he eats. S/he revealed that his/her pump is set to deliver a basal rate of 2 units of insulin per hour. S/he revealed that the pump does have alarms in place to alert him/her of any issues.
Additional record review failed to identify the type of insulin in the resident's pump, the basal rate of insulin administration, and the amount of insulin delivered via a bolus if needed. This indicates that there is no documentation in the resident's record in regards to the amount of insulin the resident receives.
Further review failed to reveal evidence of a physician's order to monitor the functionality of the pump every shift per the facility policy.
During a surveyor interview with the Director of Nursing Services (DNS) on 4/16/2024 at 1:44 PM, she was unable to provide evidence that the facility maintained documentation of the type of insulin in the resident's pump, the basal rate of insulin administration, and the amount of insulin delivered via a bolus if needed. She was unable to explain how the facility would communicate the above information to another provider (hospital, primary care doctor, endocrinologist) as it is not documented in the record.
2. Review of the Freestyle Libre Resources revealed to change the sensor every 14 days.
During a surveyor interview with the resident on 4/16/2024 at 9:10 AM, s/he revealed that s/he has a Freestyle Libre. Additionally, s/he revealed that the Freestyle Libre needs to be changed every 14 days.
Review of the record failed to reveal evidence of documentation indicating when to change the resident's Freestyle Libre sensor or the last time it had been changed.
During a surveyor interview with the DNS on 4/16/2024 at 1:44 PM, she was unable to provide evidence of documentation indicating when to change the Freestyle Libre or when the last time was it had been changed.
3. Record review of the physician's orders revealed an order dated 4/12/2024 for Glucose Oral Gel 40 % (Dextrose used for low blood sugar) Give 1 packet by mouth as needed for hypoglycemic event.
Further record review of the resident's physicians order for glucose oral gel failed to reveal parameters for the resident's blood sugar related to when to administer the glucose gel.
During a surveyor interview with the DNS on 4/16/2024 at 1:44 PM, she acknowledged that there were no parameters provided in the physician's order to indicate when the glucose oral gel should be administered to the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed with a suprapubic catheter (SP tu...
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Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed with a suprapubic catheter (SP tube, a flexible tube inserted into your bladder via a surgical opening in the abdomen), Resident ID #1.
Findings are as follows:
Record review revealed the resident was admitted to the facility in May of 2019 with diagnoses including, but not limited to, multiple sclerosis (a chronic, disabling neurological disease that can affect any part of the body including the bladder) and neuromuscular dysfunction of the bladder.
Review of a care plan focus area dated 4/11/2022 revealed that the resident has an SP tube and is at risk for complications with an intervention to follow up with urology as indicated.
Record review revealed the following physician orders relative to the SP tube:
- 2/27/2024 Renacidin irrigation solution (prevents clogging in catheters) instill 30 milliliters (mL) daily every Tuesday, Thursday, and Saturday for maintenance.
- 2/28/2024 Irrigate SP tube with 30 mL of normal saline (NS) every evening shift on Monday, Wednesday, Friday, and Sunday for occlusion prevention.
Review of a progress note dated 4/11/2024 at 1:16 PM revealed that the resident went to a urology appointment.
Review of a document titled, Continuity of Care [COC] Consultation and Referral Form dated 4/11/2024 signed by the Urologist, revealed in part that the resident has recurrent leakage around the SP tube. It further revealed that the SP tube was exchanged and the preexisting SP tube was noted to have an encrusted tip. Additionally, the new SP tube was irrigated for mucus-like debris, and it was recommended to continue irrigating the SP tube every evening, but to use 60 mL of NS and irrigate and aspirate (flush and draw back with a syringe) on Monday, Wednesday, and Friday.
Record review failed to reveal evidence that the above-mentioned recommendations were addressed by the facility or provider.
During a surveyor interview on 4/16/2024 at 10:47 AM, with Licensed Practical Nurse, Staff A, she revealed that the resident has recurrent blockages and drainage problems with his/her SP tube. She revealed that the resident recently had a urology follow up and staff are continuing to flush his/her SP tube every Monday, Wednesday, and Friday with 30 mL of NS. Additionally, she revealed that staff only flush the SP tube and do not aspirate. Furthermore, she acknowledged that the resident's current orders to irrigate the SP tube do not reflect the recommendations from the recent urology appointment and indicated that the facility had yet to address the recommendations with the provider.
During a surveyor interview on 4/16/2024 at 2:07 PM with the Director of Nursing Services, she revealed that she would have expected the staff to have addressed the Urologist's recommendations with the provider on the day s/he returned from his/her appointment. She was unable to explain why the recommendations were not addressed by the facility prior to being brought to the facility's attention by the surveyor.
Further record review revealed a progress note dated 4/16/2024 at 11:17 AM states in part, .Follow up from 4/11 .Suggested to increase NS flush from 30 mL nightly to 60 mL nightly and to aspirate after .NP [Nurse Practitioner] approved order and order changed .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
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 the resident's medical record includes documentation that the resident either received the influen...
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Based on record review and staff interview, it has been determined that the facility failed to ensure the resident's medical record includes documentation that the resident either received the influenza or pneumococcal vaccination or did not receive the vaccination due to medical contraindications or refusal, for 4 of 6 residents reviewed for pneumococcal vaccination, Residents ID #s 1, 6, 23, and 26 and for 3 of 6 residents reviewed for the influenza vaccination, Resident ID #s 23, 26, and 29.
Findings are follows:
1a. Record review for Resident ID #1 revealed the resident was admitted to the facility in May of 2019. Record review of the resident's immunization record failed to reveal evidence that the PPSV23 or PCV20 was offered, received, or declined.
1b. Record review for Resident ID #6 revealed the resident was admitted to the facility in July of 2023. Record review of the resident's immunization record failed to reveal evidence that the PPSV23 or PCV20 was offered, received, or declined.
1c. Record review for Resident ID #23 revealed the resident was admitted to the facility in January of 2024. Record review of the resident's immunization record failed to reveal evidence that the PVC13, PCV15, or PCV20 was offered, received, or declined.
1d. Record review for Resident ID #26 revealed the resident was admitted to the facility in October of 2022. Record review of the resident's immunization record failed to reveal evidence that the PVC13, PCV15, PPSV23 or PCV20 was offered, received, or declined.
2a. Record review for Resident ID #23 revealed the resident was admitted to the facility in January of 2024. Record review of the resident's immunization record failed to reveal evidence that the influenza vaccine was offered, received, or declined.
2b. Record review for Resident ID #26 revealed the resident was admitted to the facility in October of 2022. Record review of the resident's immunization record failed to reveal evidence that the influenza vaccine was offered, received, or declined.
2c. Record review for Resident ID #29 revealed the resident was admitted to the facility in May of 2022. Record review of the resident's immunization record failed to reveal evidence that the influenza vaccine was offered, received, or declined.
During an interview on 4/17/2024 at 10:57 AM , with the Infection Preventionist, she acknowledged there there were no consent or declination forms for the above-mentioned residents, relative to the pneumococcal vaccine or influenza vaccine. Additionally, she was unable to provide evidence that the above-mentioned resident's medical records included documentation that indicates, at a minimum, if the residents either received the pneumococcal immunization or influenza vaccine or did not receive the pneumococcal immunization or influenza vaccine due to medical contraindication or refusal, until brought to the attention of the facility by the surveyor.
Feb 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from significant medication errors, relative to medication omiss...
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Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from significant medication errors, relative to medication omissions for 1 of 3 residents reviewed for medication administration, Resident ID #1.
Findings are as follows:
According to the 2023 article published by the National Center for Health Research, titled, FDA Updates Black Box Warning for Benzodiazepines states in part, .Benzodiazepines, often called benzos, are a type of anti-anxiety medication. The most commonly prescribed benzodiazepines are .clonazepam (Klonopin) .Withdrawal from benzodiazepines includes symptoms such as anxiety, restlessness, delirium, and seizures, and can happen after taking the drug each day for as little as 3 weeks .
Record review of a community reported complaint that was received by the Rhode Island Department of Health on 2/19/2023, alleges that on, .Sunday, February 19, 2023, I became aware that [the resident] had not received .anti-anxiety medication KlonoPIN, for 2 days because 'they ran out' .
Record review revealed the resident was re-admitted to the facility in March of 2021 with diagnoses including, but not limited to, bipolar disorder and anxiety disorder.
Record review revealed the following physician's orders:
- 1/19/2023 - KlonoPIN Oral Tablet 1 MG (milligram) (Clonazepam) Give 1 mg by mouth every day shift for Anxiety
- 1/28/2023 - KlonoPIN Oral Tablet 1 MG (Clonazepam) Give 1 mg by mouth every 24 hours for Anxiety, Give at 9 pm
Record review of the February Medication Administration Record failed to reveal evidence that the resident received his/her Klonopin as ordered on the following dates and times:
- 2/18/2023 at 6:30 AM
- 2/18/2023 at 9:00 PM
- 2/19/2023 at 6:30 AM
Record review of progress notes revealed the following:
- 2/18/2023 at 10:17 AM - Medication not available
- 2/18/2023 at 2:59 PM - Need Refill
- 2/18/2023 at 10:32 PM - KlonoPIN has not arrived yet
- 2/19/2023 at 2:30 PM - medication was not available. Awaiting refill.
- 2/19/2023 at 9:41 PM - Stat order for clonazepam 0.5 mg 2 tabs
Additional record review of the progress notes on 2/18/2023 at 3:58 PM revealed, the resident was very anxious and was awaiting delivery of his/her medication.
Record review of the resident's Electronic Transmission Report (the system used by the facility to request medication refills from the pharmacy), failed to reveal evidence that a request to refill his/her KlonoPIN was placed prior to 2/19/2023 at 8:35 AM, and that a request for a new order to pull the medication from the Emergency Medication Supply was not placed until 2/19/2023 at 9:40 PM, indicating that the facility failed to place a request until after the resident had missed three doses of his/her medication.
During a surveyor interview on 2/21/2023 at 9:15 AM with the Interim Director of Nursing in the presence of the Administrator, she acknowledged that the resident had missed three doses of his/her KlonoPIN and was unable to provide evidence that the facility requested a refill prior to 2/19/2023.
Feb 2023
12 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
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 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 pressure ulcers from developing for 3 of 6 residents reviewed, Resident ID #'s 20, 31 and 38.
Findings are as follows:
Review of the facility policy titled, Skin and Wound Management, dated February 2022, states in part, .The facility will ensure that .A resident .does not develop pressure ulcers .Interventions will be implemented in the resident's care plan to prevent pressure ulcer development .prevent deterioration and promote healing of the pressure ulcer .The facility may utilize an outside wound care specialist, to assist with wound management and treatment, if deemed necessary .
1. Review of the record for Resident ID #38 revealed that s/he was admitted to the facility in August of 2020 with diagnoses including, but not limited to, Alzheimer's disease and dementia.
Review of the order summary report, revealed the following physician's orders:
- 12/15/2021, to .off load bilateral heels while bed resting/heel boots .for protection .
-9/1/2021, for .skin prep [forms a protective film or barrier] bilateral heels 2 [times] day .
Review of his/her care plan, revised on 9/1/2022, revealed that s/he has the potential of impairment to skin integrity related to fragile skin and a deep tissue injury [a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure] to the right heel. Further review of the care plan revealed interventions including, but not limited to, offloading his/her heels when in bed.
Record review of a skin and wound assessment dated [DATE] revealed that there were no new skin areas identified.
Surveyor observations of the resident in bed on 2/13/2023, failed to reveal evidence that the heel protector boots were worn or that his/her heels were off loaded as ordered at the following times:
- 9:45 AM
- 9:54 AM
- 10:05 AM
- 10:32 AM
- 10:57 AM
During an additional surveyor observation of this resident in bed on 2/13/2023 at 11:16 AM in the presence Nursing Assistant (NA), Staff D, she acknowledged that the resident's heels were not offloaded, and that his/her boots were not applied.
During a surveyor observation of the resident in the presence of Registered Nurse (RN), Staff C, on 2/14/2023 at 8:16 AM, she acknowledged the resident's heels were not offloaded, resting directly on the mattress. At this time a new dark, discolored, non blanchable area was found on the left heel.
During a surveyor interview at the time of the above observation Staff C indicated that the wound on the left heel was previously unidentified and described it as a stage 2 or 3 (Stage 2 pressure ulcers are characterized by partial-thickness skin loss into but no deeper than the dermis. Stage 3 pressure ulcers affect the top two layers of skin, as well as fatty tissue.).
Review of the resident's record on 2/15/2023 at approximately 8:30 AM failed to reveal evidence of measurements or a description of the non-blanchable area to the resident's left heel.
During a surveyor observation of the resident, in the presence of RN, Staff B, on 2/15/2023 at 8:40 AM, a non-blanchable (discoloration of the skin that does not turn white when pressed) area was noted to his/her left heel. This skin abnormality had been brought to the attention of Staff C by the surveyor on 2/14/2023.
During a surveyor interview with the Director of Nursing Services on 2/15/2023 at 9:00 AM, she revealed that her expectation would be that the measurements and description of the non-blanchable area, would have been documented on 2/14/2023, when it was brought to the nurse's attention by the surveyor. Furthermore, the facility procedure is to request a wound consult with the provider when a skin irregularity is identified.
Record review revealed a progress note dated 2/15/2023 at 11:21 AM, written by Staff B which states in part, .resident has an area of discoloration and callousing on bottom of L[left] heel [length] 1.5 x 0.2 cm [centimeters][width] Applied skin prep to bilateral heels. Will request orders for a wound consult .
Further record review revealed that on 2/20/2023, 5 days after the wound was identified the wound was assessed and measured by the wound physician. Review of a document titled Surgical Note indicates that the physician was asked to see the resident for a new DTI on his/her left heel. The wound measured 3.0 centimeters (cm) in length, by 1.3 cm in width and the depth is undetermined and had 50% eschar (dead tissue) and 50% epithelial tissue (signifies a healing wound).
2. Record review for Resident ID #20 revealed that s/he was admitted to the facility in December of 2017 with diagnoses including, but not limited to, Alzheimer's disease and type 2 diabetes mellitus.
Review of his/her current orders revealed the following physician's orders:
- 7/30/2021: .Off load heels every shift .for Boggy [abnormal texture of tissues characterized by sponginess, usually because of high fluid content] Heels .
- 2/7/2023: .Right heel: Apply skin prep and offload every shift for skin integrity .
Review of his/her care plan, revised on 2/11/2022, revealed that s/he has potential for pressure ulcer development related to immobility with interventions, including but not limited to, following the facility policies and protocols for prevention and treatment of skin breakdown.
Surveyor observations of the resident in bed on 2/13/2023, failed to reveal evidence that his/her heels were offloaded as ordered at the following times:
- 9:47 AM
- 10:20 AM
- 10:32 AM
During an additional surveyor observation of this resident in bed on 2/13/2023 at 10:53 AM in the presence of NA, Staff D, she acknowledged that the resident's heels were not offloaded and were resting on the bed.
During a surveyor interview on 2/15/2023 at 3:41 PM with the Director of Nursing Services, she revealed that her expectation would be that the resident's heels would be offloaded as ordered.
3. Record review for Resident ID #31, revealed that s/he was admitted to the facility in August of 2022 with diagnoses including, but not limited to, open wound to left foot and pressure ulcer of sacral [tailbone] region.
Review of the wound continuity of care documentation, dated 1/23/2023, revealed in part, .WOUND LOCATION: Left Lateral Foot .ETIOLOGY: Pressure injury/ulcer .
Review of a 12/2/2022 document titled, Braden Scale-For Predicting Pressure Sore Risk, revealed that s/he is at moderate risk for pressure sores.
Review of the order summary report, revealed in part, the following physician's orders:
- 1/23/2023: .Left lateral upper foot .apply skin prep and leave open to air every day and evening shift for skin integrity .
- 2/7/2023: .Wound care to sacrum-clean and dry with NS [normal saline], apply skin prep around wound bed, apply Santyl [prescription medicine that removes dead tissue from wounds], cover with sacrum allevyn [dressing] two times a day .
Surveyor observations on 2/15/2023 at 9:13 AM of RN, Staff C, performing dressing changes for this resident, revealed that she failed to apply skin prep to his/her left lateral upper foot wound and leave it open to air. Further observations of the sacrum wound dressing revealed that she failed to apply skin prep around the wound bed.
During an interview with Staff C following these observations on 2/15/2023 at 9:36 AM, she acknowledged that she did not apply skin prep to the resident's left lateral upper foot wound and did not leave it open to air as stated in the physician's treatment order. She further acknowledged that she failed to apply skin prep to the skin around the sacrum wound bed, per the physician's treatment order.
During a surveyor interview on 2/15/2023 at 3:46 PM, with the Director of Nursing Services she stated her expectation would be that the nurse would follow the physician's treatment order.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's formulated advance directive would be followed as there were inconsistencies b...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's formulated advance directive would be followed as there were inconsistencies between the paper medical record and the electronic medical record (EMR) for 2 of 16 residents reviewed relative to advanced directives, Resident ID #s 12 and 27.
Findings are as follows:
Record review of the facility policy titled Advance Directive Policy and Procedure dated February of 2022 states in part, .All advance directive document copies will be obtained and located in the advance directives tab in the [paper] medical record and a copy may also be scanned into the EMR .
Record review of Resident ID #12's paper medical record revealed a signed advance directive belonging to another resident, Resident ID #38.
Further record review failed to reveal a copy of Resident ID #12's signed advance directive.
During surveyor interviews with the Director of Nursing Services (DNS) on 2/14/2023 at 8:41 AM and 12:50 PM, she acknowledged that Resident ID #12's paper medical record did not contain a copy of his/her own advanced directive.
2. Record review of Resident ID #27's EMR failed to reveal evidence of an advance directive.
Review of Resident ID #27's paper medical record revealed a signed advanced directive dated 1/19/2023 that indicated the resident wished to have a code status of DNR (Do Not Resuscitate).
During a surveyor interview with Licensed Practical Nurse Staff A on 2/14/2023 at 12:32 PM, she revealed that she would look in the EMR to determine the code status of a resident. Additionally, she indicated that she knew Resident ID #27 was a Full Code because she was waiting for his/her family member to come in and sign the form. When the surveyor brought Resident ID #27's signed advanced directive to Staff A's attention, she acknowledged that Resident ID #27 wished to be a DNR and his/her preference was not reflected in their EMR.
During a surveyor interview with the Director of Nursing Services on 2/15/2023 at 11:15 AM, she revealed that she would expect the resident's code status to be reflected in both their EMR and paper medical record.
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 F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to properly provide notice to residents and/or representatives informing where changes in coverage are made ...
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Based on record review and staff interview, it has been determined that the facility failed to properly provide notice to residents and/or representatives informing where changes in coverage are made to items and services covered by Medicare and/or the medical state plan related to the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) for 1 of 3 residents discharged from Medicare Part A Services, Resident ID #33.
Findings are as follows:
Review of the Center for Medicare and Medicaid Services (CMS) document (Form CMS-10055), titled, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN), states in part:
Medicare requires SNFs [Skilled Nursing Facilities] to issue the SNFABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is:
- not medically reasonable and necessary;
- or considered custodial.
The SNFABN provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must use the SNFABN when applicable for SNF Prospective Payment System services (Medicare Part A) .
Record review revealed that Resident ID #33's last covered day of Part A Services was on 8/27/2022. The facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The facility failed to provide the SNFABN form to the resident or resident representative.
During a surveyor interview on 2/14/2023 at 12:52 PM with the Minimum Data Set Nurse, she acknowledged that the SNFABN form was not provided to the above resident.
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
Assessment Accuracy
(Tag F0641)
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 assessments accurately reflect the resident's status for 2 of 2 residents r...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure assessments accurately reflect the resident's status for 2 of 2 residents reviewed relative to Braden Scale Observations [Braden Scale for Predicting Pressure Sore Risk is a screening tool that is designed to help identify residents who might develop a pressure ulcer/injury], Resident ID #s 20 and 38.
Findings are as follows:
Record review of the facility policy titled Skin and Wound Management states in part, .It is the policy of the facility to ensure it identifies and provides needed care and services .that will meet each resident's physical .needs .Upon admission and in conjunction with the Resident Assessment Instrument (RAI) [The RAI which consists of the Minimum Data Set Assessment, helps facility staff gather definitive information on a resident's strength & needs which must be addressed in an individualized care plan] and when a significant change in the resident status occurs, the resident's skin will be evaluated by licensed nurse utilizing a Braden Scale Observation .
Review of the Centers for Medicare & Medicaid Services RAI Version 3.0 Manual Chapter 3 states in part, .Determination of Pressure Ulcer/Injury .Steps for Assessment 1. Review the medical record, including .pressure ulcer/injury risk assessments .Coding Instructions .Check B if a formal assessment has been completed. An example of an established pressure ulcer risk tool is the Braden Scale for Predicting Pressure Sore Risk .
1. Record review revealed Resident ID #20 was admitted to the facility in December of 2017 with diagnoses that include but are not limited to; Alzheimer's disease, abnormal posture, and muscle weakness.
Review of the Minimum Data Set (MDS) Assessment list revealed the resident had the following MDS Assessments; an annual dated 1/4/2023, a quarterly dated 10/4/2022 and 7/4/2022. Review of the MDS Assessments revealed a, Formal Assessment Instrument/tool (e.g. [example] Braden .) was coded as completed.
Record review of the Standard Assessments revealed that a Braden Scale for Predicting Pressure Sore risk was not completed in conjunction with the above-mentioned MDS Assessments although the assessments coded that the Braden was completed.
2. Record review revealed that Resident ID #38 was admitted to the facility in August of 2020 with diagnoses that include but are not limited to; Alzheimer's disease and weakness.
Review of the MDS Assessment list revealed the resident had the following MDS Assessments; an annual dated 11/5/2022, a quarterly dated, 8/5/2022 and 5/9/2022. Review of the MDS Assessments revealed a, Formal Assessment Instrument/tool (e.g. [example] Braden .) was coded as completed.
Record review of the Standard Assessments revealed that a Braden Scale for Predicting Pressure Sore risk was not completed in conjunction with the above-mentioned MDS Assessments although the assessments coded that the Braden was completed.
During a surveyor interview with Registered Nurse, MDS Coordinator, Staff B, on 2/15/2023 at 4:37 PM, she was unable to provide evidence that the Braden Scales were completed in conjunction with the MDS Assessments for Resident ID#'s 20 and 38. Additionally, she acknowledged that the MDS assessments were coded inaccurately.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, it has been determined that the facility failed to ensure the services provided by ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, it has been determined that the facility failed to ensure the services provided by the facility meet professional standards of quality, relative to suprapubic catheters (surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow) for 1 of 1 resident reviewed, Resident ID #1, and relative to wound treatments for 1 of 6 residents reviewed, Resident ID #4.
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 a physician's order unless they believe the orders are in error or would harm the clients.
1. Review of the facility policy titled Suprapubic Catheter [SP tube] Replacement reveals in part, .The purpose of this procedure is to relieve the retention of urine in the bladder in a resident who requires a permanent or long term catheter .Verify that there is a physician's order for this procedure .maintain a daily record of resident's daily fluid intake and output, as indicated .Catheter of proper size and composition (ordered by the physician) .
Record review revealed the resident was admitted to the facility in April of 2022 with diagnoses including, but not limited to, neuromuscular dysfunction of bladder (a bladder malfunction caused by injury or disorder that leads to voiding difficulties), and calculus of Ureter (hard deposits made of minerals and salts that form inside the tubes that carry urine from the kidneys to the bladder).
Record review of the resident's Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating s/he is cognitively intact.
Record review of the physician's Orders Summary Report with active orders as of 2/13/2023 revealed the following:
-Monitor Output from Suprapubic Catheter and document every shift . This order was dated 4/20/2022.
- SP tube to be changed 6/24/22, then change every 30 days. Every 1 month(s) starting on the 24th . Review of the order failed to have the size and composition of the catheter ordered by the physician.
Further record review of the orders failed to reveal an order to change the suprapubic catheter as needed.
Record review of a progress note dated 2/8/2023 revealed in part, .Supra Pubic catheter changed this shift due to the tubing being clogged. Third shift reported flushing unsuccessful and resistance was met .Used a 16 [French] catheter [refers to the outer diameter measurement of the catheter] .
Additional record review of the progress notes on 2/8/2023 failed to reveal evidence that the resident's physician was notified, or an order was obtained to change the SP tube as needed.
Record review of the February 2023 Medication/ Treatment Administration Record (MAR/ TAR) failed to reveal documentation of the SP tube having been changed on 2/8/2023.
Record review of the nurses February 2023 TAR revealed that though the nurses were signing that they were monitoring and documenting the output from the suprapubic catheter every shift. The amount of output from the SP tube every shift failed to be documented.
Record review of the Documentation Survey Report V2 (section of the resident's electronic record where CNAs document urinary output) for February 2023 revealed the following dates and shifts where the output failed to have any documentation:
Day shift- 2/3/2023
Evening shift- 2/2, 2/6, 2/8, 2/12, and 2/13/2023
Night shift- 2/4, 2/7, 2/12, and 2/13/2023
Record review of a paper intake and output form with [DATE]- [DATE] documented on top which was also used to monitor intake/output revealed the following dates that failed to have documentation under output:
Day shift -2/3/2023
Evening shift- 2/2, 2/6, 2/8, 2/12/2023
Night shift- 2/4, 2/7, 2/12/2023
This document only contained February dates up until 2/12/2023.
Further record review of a paper titled St Clare for the date of 2/13/2023 with Resident ID #1's name printed on top failed to reveal and output documented for the evening and night shift.
During a surveyor interview on 2/15/2023 at 2:08 PM with the Medical Director he revealed that he would expect a PRN (as needed) order to be in place to change the SP tube.
During surveyor interviews on 2/15/2023 at 2:34 PM and 3:46 PM with the Director of Nursing Services she was unable to provide evidence of an order to change the resident's SP tube as needed, or the missing documentation related to the resident's output. She further acknowledged that the order to change the Suprapubic Catheter monthly did not contain a catheter size and composition ordered by the physician.
2. Record review for Resident ID #4 revealed s/he was re-admitted to the facility in January of 2023 with diagnoses including, but not limited to, atherosclerosis of native arteries of extremities with gangrene, right leg (obstruction of circulation resulting to localized death and decomposition of body tissue) and type 2 diabetes mellitus.
Record review revealed a physician's order dated 2/7/2023 for R [right] great toe- clean and dry with NS [normal saline], as tolerated. Apply betadine [antiseptic solution] and leave open to air. Be sure to apply betadine liberally to toe, entire peri-wound area, and between toes.
During a surveyor observation of Resident ID #4's treatment with Registered Nurse, Staff C, on 2/15/2023 at 10:08 AM, she failed to apply the betadine between the resident's toes as ordered until the surveyor brought it to her attention.
During a surveyor interview with the Director of Nursing Services on 2/15/2023 at 3:45 PM, she would expect that staff would follow the physician orders.
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 F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to be adequat...
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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 be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 3 residents reviewed who are at risk for falls, Resident ID #17.
Findings are as follows:
Record review revealed the resident was admitted to the facility in July of 2022 with diagnoses including, but not limited to, fracture of unspecified part of neck of right femur, muscle weakness, and other abnormalities of gait and mobility.
Record review of the resident's Minimum Data Set Assessment (MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 10 out of 15 indicating moderately impaired cognition. Additionally, s/he was coded as having two or more falls without injury since her/his admission to the facility.
Record review of the resident's care plan revealed that s/he is .High risk for falls r/t [related to] Deconditioning, recent fall at hospital with fracture, weakness.
Further record review revealed an intervention to .Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed .
The call light was observed not within reach on the following dates and times:
- 2/13/2023 at 10:55 AM the call light was on the bedside table away from the resident's reach.
- 2/14/2023 at 8:56 AM, 9:29 AM, and 4:08 PM the call light was found on the floor away from the resident's reach.
During a surveyor interview with the Registered Nurse, Staff L, on 2/14/2023 at 4:08 PM, she acknowledged that the resident failed to have his/her call light within reach.
During a surveyor interview with the Director of Nursing Services on 2/15/2023 at 11:15 AM, she acknowledged that the call light should be placed where it is easily accessible to the resident.
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 F0742
(Tag F0742)
Could have caused harm · This affected multiple residents
Based on record review and staff interview it has been determined that the facility failed to ensure that a resident who displays or is diagnosed with a mental disorder receives appropriate treatment ...
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Based on record review and staff interview it has been determined that the facility failed to ensure that a resident who displays or is diagnosed with a mental disorder receives appropriate treatment and services to attain the highest practicable mental and psychosocial well-being for 1 of 1 resident reviewed for following recommendations related to mental health services, Resident ID #4.
Findings are as follows:
Record review revealed the resident was admitted to the facility in May 2008 with diagnoses to include, but not limited to, paranoid schizophrenia (mental illness with debilitating symptoms including hallucinations and delusions), psychotic disturbance (psychosis involving seeing or hearing things that other people cannot see or hear and believing things that are not actually true), mood disturbance (feelings of distress, sadness or symptoms of depression and anxiety), bipolar disorder (disorder associated with mood swings ranging from depressive lows to manic highs), anxiety disorder, major depressive disorder and obsessive-compulsive personality disorder (mental health condition that causes an extensive preoccupation with perfectionism, organization and control).
A preadmission screening and resident review (PASSR) (a comprehensive evaluation necessary to confirm the indicated diagnosis and to determine whether placement or continued stay in a Nursing Facility is appropriate) was completed by the Rhode Island Department of Mental Health Division of Behavioral Healthcare Services on 8/27/2009. Review of this documentation revealed recommendations were made to include, but not limited to .continue to assess/complete AIMS (abnormal involuntary movement scale which is a tool used by practitioners in monitoring the effects of long-term treatment with neuroleptic medications (drug that reduces nervous tension), resident to be seen by psych, ongoing psychiatric evaluation, psychiatric consultative services, counseling by LICSW (licensed independent clinical social worker), routine monitoring of mental illness .
Review of a facility policy titled, Behavioral Health Services, states in part, . the facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychological well-being in accordance with the comprehensive assessment and plan of care .behavioral health services are provided to residents as needed .
Review of the record failed to reveal evidence that an AIMS assessment was completed.
Further record review revealed that the resident was seen for psychiatric services via telehealth on 5/24/2022 with recommendations to include, . plan to use CBT (cognitive behavioral therapy which is a form of psychological treatment that has been demonstrated to be effective for a range of problems including depression and anxiety disorders), mindfulness techniques, motivational interviewing, problem and reminiscence therapy to improve mood, aid in accepting stage of life and medical conditions and improve coping skills .
Review of the residents' medical record failed to reveal evidence that the recommendations made by behavioral health care provider were reviewed with the physician and initiated.
Record review of a care plan, initiated on 3/10/2016, indicates the resident uses psychotropic medications related to disease process depression, schizophrenia, and bipolar disorder with interventions to include, but are not limited to, review behaviors/interventions and alternate therapies attempted and their effectiveness .discuss with MD [medical doctor] .re [relative to] on going need for use of medication . Further review of the care plan failed to identify review of behaviors and interventions of alternate therapies.
During a surveyor interview on 2/15/2023 at approximately 3:23 PM with the Director of Nursing Services, she was unable to provide evidence that an AIMS assessment was completed for this resident.
During a surveyor interview on 2/15/2023 at approximately 3:30 PM with the Medical Director, he revealed that an AIMS assessment should have been completed.
During a surveyor interview on 2/15/2023 at approximately 4:00 PM with the Administrator and Social Worker, they acknowledged that the resident had not received behavioral health/psychiatric services since 5/24/2022. Additionally, they were unable to explain why the recommended interventions made by the psychiatric provider were not implemented.
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 that the facility failed to ensure a resident's drug regimen is free from unnecessary psychotropic drugs for 2 of 3 residents who hav...
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Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary psychotropic drugs for 2 of 3 residents who have as needed psychotropic medication orders extending beyond 14 days without a rationale or indication for an intended duration, Resident ID #56, and #38 and for 1 of 5 residents reviewed for Gradual Dose Reduction (GDR), Resident ID #19.
Findings are as follows:
Review of a facility policy titled, Psychotropic Medication Use, states in part, .Residents on psychotropic medications receive gradual dose reductions (coupled with non- pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications .PRN [as needed] orders for psychotropic medications are limited to 14 days .For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order .For psychotropic medications that ARE antipsychotics PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication .
1. Record review for Resident ID #56 revealed s/he was admitted to the facility in January of 2023 with diagnoses including, but not limited to dementia.
Record review for Resident ID #56 revealed a physician's order dated 1/25/2023 for Quetiapine (antipsychotic medication) 50 mg [milligrams] .every 12 hours as needed for dementia with behavioral disturbance. This order has no determined end date.
Record review of the Medication Administration Record (MAR) dated January 2023, and February 2023, revealed that Resident ID #56 received the above ordered medication on 1/25, 1/26 and 2/13/2023.
During a surveyor interview on 2/14/2023 at approximately 2:30 PM with the Medical Director, he acknowledged that the above-mentioned as-needed Quetiapine order had no end date. Additionally, he was unable to provide evidence of documentation or rationale for the extended time period.
2. Record review for Resident ID #38 revealed s/he was admitted to the facility in August of 2020 with diagnoses that include but are not limited to; Alzheimer's disease, dementia, and major depressive disorder.
Additional record review revealed a physician's order with a start date of 6/22/2022 and no specified end date, which states in part, .LORazepam [antianxiety medication] .Give 0.25 ml [milliliters] by mouth every 2 hours as needed for anxiety/agitation .
Record review of a pharmacy document titled Consultation Report dated December 15, 2022, states in part, .REPEATED RECOMMENDATION from 10/13/2022 .[Resident ID #38] has a PRN order for an anxiolytic [drug used to reduce anxiety] which has been in place for greater than 14 days without a stop date .Recommendation .Please update the PRN order for Lorazepam to include a stop date that is consistent with available prescriber documentation . Additionally, the document revealed a hand written notation indicating discontinue date 1 month.
Record review of a provider progress note dated 12/16/2022 authored by the Nurse Practitioner states in part, .Patient .require use of Ativan [Lorazepam] as needed .continue on current dose .
Further record review failed to reveal evidence of documentation of the duration or stop date for the PRN order as indicated in the pharmacy recommendation.
Additional record review revealed a pharmacy document titled Consultation Report, dated 1/12/2023 which states in part, .[Resident ID #38] prescriber responded to a pharmacy recommendation regarding PRN Lorazepam order without a stop date on 12/16/22, but the order has not yet been processed. Prescriber documentation states to continue x 1 month, but a stop date was not added to the resident's PRN Lorazepam order. Recommendation .update the PRN Lorazepam order to include a stop date that is consistent with available prescriber documentation .
During a surveyor interview with the Clinical Service Director on 2/15/2023 at 2:31 PM, she was unable to provide evidence that Resident ID #38's PRN Ativan had a duration or stop date.
3.Record review for Resident ID #19 reveals s/he was admitted to the facility in November of 2023 with diagnoses including, but not limited to, Bipolar disorder (a mental health condition that causes extreme mood swings), major depressive disorder (mental health disorder having episodes of psychological depression) and anxiety disorder.
Record review for Resident ID #19 revealed a physician's order dated 6/21/2021 for Abilify (a drug used to treat mental conditions such as bipolar disorder, manic depressive disorder and schizophrenia) 5 mg [milligrams] .every day shift. This order has no determined end date.
Record review of the electronic and paper medical records failed to reveal evidence that a GDR was attempted or evidence of a physician's rationale for the contraindication of a GDR.
Record review reveals that the Minimum Data Set Assessments dated 8/19/2022, 10/4/2022 and 1/4/2023 fails to reveal evidence that a GDR was attempted.
During a surveyor interview on 2/15/2023 at 11:59 AM with the Director of Nursing Services, she was unable to provide evidence that a GDR was attempted or a rationale for why a GDR was contraindicated.
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 F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to store drugs and biological...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to store drugs and biological's in accordance with currently accepted professional principles for 2 of 3 resident care units observed during the medication tasks.
Findings are as follows:
Record review of a facility policy titled St. [NAME] operational policy and procedure manual revealed in part, .Medications will be stored in a manner that ensures maintenance of both the integrity of the medication and the safety of all residents residing in the community .All medications, including over-the-counter, are kept in locked storage at all times .All medications must be stored in accordance with label instructions .
Further record review of a facility policy titled Discarding and destroying medications revealed in part, Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances .
1. Surveyor observations and interviews on the [NAME] unit revealed the following:
Continuous surveyor observation on 2/13/2023 from 12:48 PM until 1:02 PM revealed the two [NAME] unit medication carts left unsecured and unattended with the drawers facing out into the hallway.
During a surveyor interview with Registered Nurse (RN), Staff B on 2/13/2023 at 1:02 PM she acknowledged that both carts were left unsecured and unattended.
Surveyor observation on 2/13/2023 from 1:21 PM to 1:37 PM on the [NAME] unit revealed the nurse medication cart unsecured and unattended with the drawers facing out into the hallway. Additionally, during this time period the [NAME] medication technician medication cart, was observed with the locking mechanism partially pushed in and not fully engaged. The cart was able to be opened without a key.
During a surveyor interview with Certified Medication Technician (Med Tech), Staff E, on 2/13/2023 at 1:37 PM he acknowledged that the nurse's medication cart was left unsecured and unattended. Additionally, he acknowledged that the Med. Tech. cart's locking mechanism was partially pushed in and not fully engaged, giving him the ability to open the cart without a key.
Surveyor observation on 2/14/2023 from 11:26 AM until 11:55 PM of the medication pass with RN, Staff C, on the [NAME] unit revealed the nurse medication cart was left unsecured and unattended with the drawers facing out into the hallway.
Surveyor observation on 2/14/2023 at approximately 11:40 AM of the [NAME] unit nurse medication cart in the presence of Staff C revealed a Novolog flexpen solution pen injector (insulin Apart) injection 100 units/ml [milliliter](a solution that improves blood sugar control of patients with diabetes) opened and not dated for Resident ID #49.
Manufacturer's instructions revealed that in-use (opened) insulin pens should be discarded after 28 days.
During a surveyor observation on 2/14/2023 at approximately 11:45 AM of the [NAME] unit medication room in the presence of Staff C revealed the following medications and expiration dates:
-Tucks Medicated pads 40 count for Resident ID #13, expired 11/2022.
-Two tubes Triamcinolone acetonide 1.5% cream 30 gram tube (a medication used to treat a variety of skin conditions) for Resident ID #33, expired 10/2022.
-Four boxes of Aspercreme with 4% lidocaine (a medication used for pain relief) patches, 5 count, for Resident ID #2, expired 11/2022.
During surveyor interviews on 2/14/2023 at 11:40 AM and 11:54 AM with Staff C, she acknowledged that the Novolog flex pen for Resident ID #49, was not dated when opened. Additionally, she acknowledged that the above medications in the [NAME] medication room were expired, and that her medication cart was left unlocked and unattended.
2. A surveyor observation on 2/14/2023 at 9:17 AM of the [NAME] Point unit medication cart in the presence of Registered Nurse, Staff C, revealed Refresh lubricant eye drops 0.01 fluid ounce single use containers,30 count, with an expiration date of January 2023 for Resident ID #6.
During a surveyor interview immediately following the above observation, Staff C, acknowledged that the above medication in the [NAME] Point medication cart was expired.
During a surveyor interview on 2/14/2023 at 12:30 PM with the Director of Nursing Services, she revealed that she would expect the medication carts to be locked when unattended, the Novolog Flex pen to be dated when opened, and expired medications to be disposed of.
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 F0805
(Tag F0805)
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 food prepared in a form designed to meet individual needs for 1 of 9 resid...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide food prepared in a form designed to meet individual needs for 1 of 9 residents reviewed, Resident ID #20.
Findings are as follows:
Record review revealed the resident was admitted to the facility in December of 2017 with diagnosis including, but not limited to, dysphagia (difficulty swallowing).
Record review revealed a physician's order dated 7/25/2022 for .House diet Ground [foods that are finely chopped, grated, ground, or mashed] texture, Thin consistency .
During a surveyor observation of the resident's lunch meal on 2/13/2023 at 12:12 PM, s/he was found to have been served regular textured food, beef tips.
During a surveyor interview with the Certified Medical Technician, Staff F, immediately following the above observation, she indicated that the resident's food should be chopped.
Record review of the resident's meal ticket revealed that his/her diet was listed with the wrong order of regular texture with an intervention to have his/her food chopped.
During a surveyor interview with the Speech Language Pathologist, Staff G ,on 2/13/2023 at 12:24 PM, she acknowledged that the meal ticket for the resident states the wrong diet and that she would expect it to be changed on the same day the diet order was authorized by the physician which was on 7/25/2022.
During a surveyor interview with the Registered Nurse, Staff B, on 2/13/2023 at 12:30 PM, she acknowledged that the resident received the incorrect diet. Additionally, she revealed that she would expect the resident to receive ground food 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
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide a safe and sanitary environment to help prevent the transmission of infecti...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide a safe and sanitary environment to help prevent the transmission of infections related to disinfecting blood glucose meters (a device used to monitor blood glucose) for 1 of 1 residents observed, Resident ID #29, 1 of 3 residents observed during a wound treatment, Resident ID #19 and one staff member related to improper glove usage, Nursing Assistant, Staff K.
Findings are as follows:
1. According to the facility's policy titled, Glucose Monitoring Equipment states in part, Glucometers will be cleaned with a bleach wipe and /or manufacture guidelines after each use .
Record review for Resident ID # 29 revealed s/he was admitted to the facility in October of 2017 with diagnoses including, but not limited to, Type 1 Diabetes Mellitus.
Surveyor observation on 1/4/2023 at 11:34 AM during the medication pass with Registered Nurse Staff C revealed the following:
Staff C failed to disinfect the resident's designated blood glucose meter after obtaining the resident's blood sugar. Staff C then placed the blood glucose meter in the medication cart, in a bag containing the resident's insulin's. At the time of the observation, Staff C revealed that the glucometer is designated for use only with that resident and acknowledged that she did not disinfect the glucometer after use.
During a surveyor interview on 2/14/2023 at 12:28 PM with the Director Nursing Services (DNS), she acknowledged Staff C failed to follow the policy for disinfecting blood glucose meters.
2. Record review of the facility policy dated April 2019 entitled, Dressings Change Guidelines states in part, .It is the policy of the facility to use clean technique in performing dressing changes. Sterile technique may be ordered by the physician as indicated. Universal precautions are utilized per policy .
Record review for Resident ID #19 revealed s/he was admitted to the facility in November of 2021 with diagnoses including, but not limited to, flaccid hemiplegia (paralysis of one side of the body) affecting left nondominant side.
Record review of a physician's order dated 1/30/2023 for, Left ankle and left shin: cleanse with normal saline, apply skin prep to peri-wound, apply Medi-honey [antibacterial and bacterial resistant wound gel] to wound bed, cover with allevyn [dry dressing]every day shift for skin integrity.
A surveyor observation of the dressing change on 2/15/2023 at 9:37 AM with Registered Nurse, Staff B, revealed the following concerns:
-the bedside table failed to be cleaned prior to placing the clean wound dressing materials, the table already contained drinks and the tv remote.
-the soiled dressing and wipe that she used for cleansing the leg wound were placed on the bedside table with the clean dressing supplies.
-After removing the soiled dressing from the ankle and washing the wound she failed to complete hand hygiene and change gloves prior to applying the skin prep to the peri wound, Medi-honey to wound bed and covering with allevyn.
-She then removed the soiled dressing and the used normal saline cleansing wipe from the bed side table, disposed of them and failed to sanitize the resident's bed side table.
During a surveyor interview immediately following the above observation with Staff B, she could not explain why she failed to wash the table prior to placing clean supplies, or after removing the dirty dressing supplies from the table. She further could not explain why she would place the dirty dressing supplies on the bedside table instead of in a garbage can, or why she failed to perform hand hygiene and a glove change during the dressing change to the ankle.
During a surveyor interview on 2/15/2023 at 12:08 PM with the DNS, she acknowledged Staff B did not follow the proper procedure for dressing changes.
3. Surveyor continuous observation on 2/15/2023 from 8:28 AM until 8:55 AM revealed the following concerns related to glove usage by Nursing Assistant, Staff K:
- 8:28 AM Staff K was wearing gloves serving residents in the dining room
- 8:34 AM Staff K delivered a breakfast tray to Resident ID #16 in his/her room wearing the same gloves
- 8:36 AM Staff K still wearing the same gloves, delivered a tray to Resident ID #14 in his/her room and adjusted the bed
- 8:55 AM Staff K assisted Resident ID #32 to eat breakfast wearing the same gloves
During a surveyor interview on 2/15/2023 at 9:03 AM with Staff K, she acknowledged that she was wearing the same gloves during the above observations. Additionally, she acknowledged that she failed to perform hand hygiene and change gloves between residents.
During a surveyor interview on 2/15/2023 at 10:59 AM with the Infection Preventionist, she revealed she would expect Staff K to perform hand hygiene and change gloves between residents.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to properly s...
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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 properly store and prepare food in accordance with professional standards for food service safety relative to the main kitchen, and 3 of 3 units, the [NAME] Point, [NAME], and Gooseberry Units.
Findings are as follows:
Record review of the Rhode Island Food Code 2018, section 4-602.11 states in part,(A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned .(5) At any time during the operation when contamination may have occurred .
Record review of the Rhode Island Food Code 2018 edition, section 4-602.11 states in part, .(C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris .
Record review of the facility policy titled FOOD AND SUPPLY STORAGE states in part, .All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption .label and date unused portions and open packages .notify supervisor upon evidence of .water damage in any storage areas .
1. The initial tour of the main kitchen on 2/13/2023 at 8:35 AM revealed the following:
- A storage room containing the ice machine was observed to have wall molding approximately 12 feet long detached from the wall and laying on the floor. Additionally, the wall molding was observed to have areas of black matter and evidence of moisture on it.
- A walk-in refrigerator was observed to have an approximately 1 inch area of dust accumulation on the internal fan.
- A walk-in freezer was observed to have debris on the floor and an accumulation of an approximately 5 -10 inch area of frozen condensation on the ceiling above the internal fans.
During a surveyor interview with the Food Service Director (FSD) on 2/13/2023 at 8:47 AM, he acknowledged the above-mentioned findings.
2. During a surveyor observation of the [NAME] Point Unit on 2/13/2023 at 9:52 AM in the presence of Nursing Assistant (NA), Staff D, revealed the following:
- One large jar of apple sauce opened and not labeled or dated.
- One approximately 3 ounce container of ice cream, opened and partially consumed, not labeled, or dated.
During a surveyor interview with Staff D on 2/13/2023 immediately following the above observations, she acknowledged the findings.
3. A follow up observation of the main kitchen on 2/14/2023 at 7:42 AM, in the presence of Dietary Cook, Staff H, revealed the following:
- In a walk-in refrigerator the following items were observed to be opened and not labeled or dated; One large jar of apple sauce, two half gallons of milk, one can of aerosol whipped cream and one gallon of orange juice
- The walk-in refrigerator floor was observed with debris, celery stalk, celery leaves, two plastic lid caps, and pieces of torn cardboard, scattered on the floor.
- The walk-in freezer was observed to have an accumulation of frost on the perimeter of the door frame approximately 1-2 inches thick, a thick layer of ice accumulation on a cardboard box containing cake, a thick layer of ice accumulation on a cardboard box containing gluten free bread, a thick layer of ice accumulation on a cardboard box labeled Tony's Breakfast Square.
- A mound of ice accumulation approximately 3-5 inches was observed on the shelf in the walk-in freezer
- An approximately 12 inches round shaped patch of ice on the freezer floor
During a surveyor interview with Dietary Cook, Staff H, on 2/14/2023, immediately following the above-mentioned observations, she acknowledged the findings.
During a surveyor interview with the FSD, on 2/14/2023 at 9:05 AM, he acknowledged the findings and indicated that he expects all items to be labeled and dated and that the freezer and refrigerator floors are expected to be cleaned every night.
4. During a surveyor observation of the [NAME] Point Unit refrigerators on 2/14/2023 at 9:45 AM, in the presence of Registered Nurse (RN), Staff C, the following was observed:
- One refrigerator with a sign posted on the outside of the door which indicated the items in the refrigerator were for Residents Only contained one approximately 20-ounce, bottle of mango juice opened and approximately half consumed, not labeled, or dated.
- One carton of pre thickened apple juice, opened and not labeled or dated.
During a surveyor interview with Staff C, on 2/14/2023, immediately following the above-mentioned observations, she acknowledged the findings. Additionally, she indicated that all items should be labeled and dated when opened.
5. During an additional observation of the main kitchen on 2/15/2023 at 7:58 AM revealed the following:
- The walk-in freezer with an approximately ½ inch of increased accumulation of frost around the perimeter of the freezer door and an approximately 2-3 inches of frozen accumulation of ice on the shelf of the freezer.
- An approximately 1-inch layer of ice accumulation on an opened card board box that contained bags of loaves of bread.
- Frozen accumulation of condensation on the freezer ceiling above the internal fans.
During a surveyor interview with the FSD, on 2/15/2023 at 8:01 AM, he acknowledged the above-mentioned findings.
6. During a surveyor observation of the [NAME] Unit kitchenette in the presence of Dietary, Staff I, on 2/14/2023 at 11:39 AM, revealed the following:
- The unit refrigerator with a sign posted on the outside of it which indicated all products must be labeled and dated. The freezer was observed to have four, one half gallon containers of ice cream, opened and not labeled with a date.
- Dried food matter was observed on the stove. Red colored matter was observed on the exterior cabinets and food particles were observed in the drawers, and the interior of the microwave.
During a surveyor interview with Dietary, Staff I, on 2/14/2023 at the time of the above-mentioned observations, she acknowledged the findings.
7. During a subsequent surveyor observation of the [NAME] kitchenette on 2/14/2023 at 12:00 PM, Dietary, Staff I, was observed taking the holding temperatures of the lunch meal. She placed the thermometer probe into a container of pasta noodles. She then removed the thermometer from the container of pasta noodles and rinsed it under running tap water at the kitchenette sink. She then placed the thermometer probe into a pan of red sauce.
During a surveyor interview with Staff I, on 2/14/2023, immediately following the above-mentioned observations, she indicated that the red sauce contained ground meat. Additionally, she acknowledged that she did not sanitize the thermometer probe in between uses.
8. During a surveyor observation of the Gooseberry Unit dining room refrigerator on 2/14/2023 at 12:39 PM in the presence of Nursing Assistant, Staff J, revealed a gallon of ice cream, open and not labeled or dated.
During a surveyor interview with Staff J, on 2/14/2023 during the above-mentioned observation, she acknowledged the findings.
During a surveyor interview with the FSD, on 2/15/2023 at 8:05 AM, he indicated that he would have expected staff to clean the thermometer in between uses with sanitizing wipes which are located on the units. Additionally, he indicated that he expects all items in the refrigerators to be labeled and dated. Furthermore, he indicated that resident items are discarded after 48 hours. He also indicated that he expects all kitchenettes including equipment to be cleaned according to the facility cleaning schedule policy. Additionally, he was unable to provide evidence that the facility properly stored and prepared food in accordance with professional standards for food service safety relative to the main kitchen, and 3 of 3 units.
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
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • 29 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $10,517 in fines. Above average for Rhode Island. Some compliance problems on record.
- • Grade D (48/100). Below average facility with significant concerns.
- • 59% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 48/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is St Clare Home's CMS Rating?
CMS assigns St Clare Home an overall rating of 3 out of 5 stars, which is considered average nationally. Within Rhode Island, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is St Clare Home Staffed?
CMS rates St Clare Home's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 59%, which is 13 percentage points above the Rhode Island average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 65%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at St Clare Home?
State health inspectors documented 29 deficiencies at St Clare Home during 2023 to 2025. These included: 1 that caused actual resident harm, 27 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates St Clare Home?
St Clare Home is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 50 certified beds and approximately 47 residents (about 94% occupancy), it is a smaller facility located in Newport, Rhode Island.
How Does St Clare Home Compare to Other Rhode Island Nursing Homes?
Compared to the 100 nursing homes in Rhode Island, St Clare Home's overall rating (3 stars) is below the state average of 3.1, staff turnover (59%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting St Clare Home?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "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 high staff turnover rate.
Is St Clare Home Safe?
Based on CMS inspection data, St Clare Home has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Rhode Island. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at St Clare Home Stick Around?
Staff turnover at St Clare Home is high. At 59%, the facility is 13 percentage points above the Rhode Island average of 46%. Registered Nurse turnover is particularly concerning at 65%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was St Clare Home Ever Fined?
St Clare Home has been fined $10,517 across 1 penalty action. This is below the Rhode Island average of $33,184. 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 St Clare Home on Any Federal Watch List?
St Clare Home is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.