Bayview Rehabilitation and Healthcare Center
For profit - Limited Liability company
120 Beds
MARQUIS HEALTH SERVICES
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
18/100
#34 of 72 in RI
Photo by Bayview Rehabilitation at Scalabrini
Photo by Bayview Rehabilitation at Scalabrini
Photo by Bayview Rehabilitation at Scalabrini
1 / 5 photos
Last Inspection: August 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Bayview Rehabilitation and Healthcare Center has received an F trust grade, indicating significant concerns about the quality of care provided. Ranked #34 out of 72 facilities in Rhode Island, they are in the top half, but still have a lot of room for improvement. The facility's condition is worsening, as issues increased from 8 in 2023 to 14 in 2024. Staffing is a concern, with a 52% turnover rate which is higher than the state average, and less RN coverage than 81% of Rhode Island facilities, meaning residents may not receive the attentive care they need. There have been serious incidents, including a failure to protect a resident from abuse and not ensuring proper infection control measures, which raises red flags for families considering this facility. On the positive side, their quality measures received a 5 out of 5, suggesting some aspects of care are being delivered effectively. However, the high number of deficiencies and critical issues means families should proceed with caution.
- Trust Score
- F
- In Rhode Island
- #34/72
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 52% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $27,940 in fines. Lower than most Rhode Island facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 30 minutes of Registered Nurse (RN) attention daily — about average for Rhode Island. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 29 deficiencies on record. Higher than average. Multiple issues found across inspections.
18/100
Top 47%
Review needed
8 → 14 violations
★★★☆☆
3.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 8 issues
2024: 14 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Rhode Island average (3.1)
Meets federal standards, typical of most facilities
Staff Turnover: 52%
Near Rhode Island avg (46%)
Higher turnover may affect care consistency
Federal Fines: $27,940
Below median ($33,413)
Moderate penalties - review what triggered them
Chain: MARQUIS HEALTH SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 29 deficiencies on record
1 life-threatening 2 actual harm
Oct 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
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 a resident the right to participate in the development and implementation of his or her person-cen...
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Based on record review and staff interview it has been determined that the facility failed to provide a resident the right to participate in the development and implementation of his or her person-centered plan of care and facilitate the inclusion of the resident and/or resident representative for 1 of 3 residents reviewed for care planning meetings, Resident ID #1.
Findings are as follows:
Record review of a community reported complaint submitted to the Rhode Island Department of Health on 10/17/2024 alleges in part, I have several concerns on the care [Resident ID #1] is receiving .
During a surveyor interview on 10/22/2024 at 1:32 PM with the complainant, a family member of the resident, s/he revealed that s/he is very concerned that the facility has not had a care plan meeting for the resident since admission. Additionally, s/he indicated that the concerns in the complaint could have been discussed if the resident and family members were provided the opportunity to have a care plan meeting.
Record review of the facility's policy titled, Care Planning-Interdisciplinary Team revised in March of 2022, states in part, Comprehensive, person- centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT) .The IDT includes but is not limited to .
The resident's attending physician .a registered nurse .nursing assistant .a member of food and nutrition services .to the extent practicable, the resident and/or the resident's representative .other staff as appropriate or necessary to meet the needs of the resident .The resident, the resident's family and/or the resident's legal representative .are encouraged to participate in the development of and revisions to the resident's care plan .Care plan meetings are scheduled at the best time of the day for the resident and family when possible .
Record review revealed the resident was admitted to the facility in May of 2024 with diagnoses including, but not limited to, Parkinson's Disease (a disorder that affects the nervous system), muscle wasting and atrophy (the loss of muscle mass).
Record review of a facility document titled Care Plan Meeting Review revealed in part, .To be completed on admission .Quarterly, Annually and with Significant change in Condition . It further revealed that one care planning meeting was completed on 5/31/2024.
Further record review failed to reveal evidence that a quarterly care plan meeting took place.
During a surveyor interview on 10/22/2024 at approximately 3:00 PM with Social Worker, Staff A, she acknowledged that a quarterly care planning meeting was not conducted for the resident.
During a surveyor interview on 10/22/2024 at approximately 3:30 PM with the Director of Nursing Services, she revealed that she would expect care plan meetings to be conducted quarterly.
Sept 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 3 residents reviewed for constipation, Resident ID #2.
Findings are as follows:
Review of a community reported complaint received by the Rhode Island Department of Health on 8/30/2024 alleged that a resident had recently been admitted to the hospital from the facility with a diagnosis of, but not limited to, fecal impaction (a large, hard mass of stool that is stuck in the rectum that can cause serious illness or death).
Record review revealed Resident ID #2 was admitted to the facility in July of 2024 with diagnoses including, but not limited to, dehydration, urinary tract infection, and Parkinson's disease.
Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 2 out of 15, indicating severely impaired cognition. Further review revealed the resident was incontinent of bowel and was dependent on staff for toileting.
Review of a care plan dated 7/29/2024 revealed the resident has constipation related to decreased mobility, diminished appetite, and medication side effects with a goal to have a normal bowel movement at least every 3 days. Further review revealed the resident has Parkinson's Disease with interventions to monitor for constipation, implement the bowel regimen, monitor, and document effectiveness and to report ineffectiveness to a physician or designee.
Record review of the bowel movement (BM) report revealed documentation that the resident did not have a bowel movement from 8/15/2024 until 8/22/2024, indicating that the resident did not have a bowel movement for 7 days.
Record review revealed the following physician's orders for constipation dated 7/26/2024:
- Milk of Magnesia (MOM) Suspension 400 milligrams(mg)/5 milliliters- administer 30 ml by mouth as needed
- Dulcolax Suppository 10 mg- administer 1 suppository rectally as needed
- Fleet Enema 7-19 gm/118 ml- insert 1 application rectally as needed
Record review of the August 2024 Medication Administration Record revealed MOM was administered on 8/19/2024, on the 5th day without a bowel movement, and on 8/20/2024, which were both documented as being ineffective. Further review revealed a Dulcolax Suppository was administered on 8/19/2024 and on 8/21/2024, which both were documented as being ineffective. Additional review revealed a Fleet Enema was administered on 8/22/2024, which was documented as ineffective.
Record review of a progress note, dated 8/20/2024, authored by Advanced Practice Registered Nurse (APRN), Staff A, revealed .Nursing states patient having difficult BMs. [S/he] is on standing senna [a medication for occasional constipation], will add daily miralax .
During a surveyor interview on 9/3/2024 at approximately 10:50 AM with Registered Nurse, Staff B, she indicated that the nurse on 2nd shift generates a BM report and creates a bowel list of residents who have not had a BM in 72 hours. She further indicated that the bowel protocol is to start with administering MOM, then a suppository if no BM and finally, an enema if still no BM. Additionally, she indicated that the physician should be notified if the resident has not had results from the bowel protocol and has not had a bowel movement for 3 days.
Record review failed to reveal evidence that a provider was notified that the resident had not had a bowel movement for 7 days.
During a surveyor interview on 9/3/2024 at 11:33 AM with Licensed Practical Nurse, Staff C, she indicated that a resident would be on a bowel list after 3 days without a bowel movement and the bowel protocol would be initiated. She further indicated that the physician should be notified if the resident has not had a bowel movement following the bowel protocol. Additionally, she acknowledged that the resident had not had a bowel movement for 7 days, from 8/15/2024 until 8/22/2024.
The surveyor requested a copy of the facility's Bowel Protocol that Staff B and C were referring to during their interviews from the Director of Nursing Services (DNS) on 9/3/2024 at approximately 12:00 PM, and she indicated that the facility does not have a bowel protocol.
During a surveyor interview on 9/3/2024 at 1:41 PM with Staff A, she indicated that she had assessed the resident on 8/20/2024 and was informed by the nursing staff that the resident was having difficulty with bowel movements, which she assumed meant that the resident was having small or hard BMs. She further indicated that she had not been made aware that the resident had not had any bowel movements for 6 days. She further stated that if she had been made aware that the resident had not had a bowel movement for 6 days, she would not have ordered Miralax daily but would have provided a different treatment or medication.
During a surveyor interview on 9/3/2024 at 12:52 PM and again at 2:04 PM with the DNS, she indicated that she would expect as needed medications for constipation to be administered to the resident if they has not had a bowel movement in 3 days. She further indicated that she would expect the physician to be notified if the resident has not had a bowel movement in 4 to 5 days. Additionally, she could not provide evidence that a provider was notified that the resident did not have a bowel movement for 7 days.
Aug 2024
12 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmiss...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to Covid-19, for 1 of 2 units observed, the Country Unit, affecting Resident ID #s 2, 6, 11, 14, 15, 19, 26, 28, 30, 38, 42, 44, 46, 47, 49, 54, 55, 58, 64, 65, 67, 80, 82, 84, 87, 88, 92, 97, 104, and 109, as the facility failed to have cleaning and disinfecting wipes effective at killing Covid-19 readily accessible to staff and was using Micro-Kill+ Disinfecting, Deodorizing Cleaning Wipes with Alcohol, which are ineffective at killing Covid-19, to clean and disinfect multi-use resident equipment. Further, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to Enhanced Barrier Precautions (EBP), for failing to place a resident on enhanced barrier precautions (EBP) and staff who failed to don the required Personal Protective Equipment (PPE) prior to entering resident rooms that required such, for 1 of 3 residents reviewed, Resident ID #102, and 1 of 1 resident on contact precautions observed during the medication administration task in which staff failed to don the required PPE prior to entering his/her room, Resident ID #22.
Findings are as follows:
1. Record review of a facility policy titled, Isolation-Categories of Transmission-Based Precautions states in part, When transmission-based precautions are in effect, non-critical resident-care equipment items such as a stethoscope, sphygmomanometer [blood pressure cuff], or digital thermometer will be dedicated to a single resident (or cohort of residents) when possible .If re-use of items is necessary, then the items will be cleaned and disinfected according to current guidelines before use with other residents .
During a surveyor observation on 8/19/2024 at approximately at 8:00 AM, upon entering the building, signage was posted notifying staff and visitors of the required use of N95 masks due to a Covid-19 outbreak.
Record review revealed that the facility's Covid-19 outbreak started on 7/30/2024 for staff and 8/2/2024 for residents.
During surveyor observations on 8/19/2024 of the Country unit revealed that Resident ID #s 2, 11, 14, 15, 19, 26, 30, 38, 42, 44, 46, 47, 49, 54, 55, 58, 64, 65, 67, 80, 82, 84, 87, 88, 92, 97, 104, and 109 were on isolation precautions relative to Covid-19 with isolation bins and signage posted outside the rooms. Further observation of the Country Unit and the above resident's isolation bins failed to reveal evidence of dedicated care equipment or disinfecting wipes available for use.
During a surveyor observation on 8/20/2024 at 9:09 AM revealed one container of Micro-Kill+ Disinfecting, Deodorizing Cleaning Wipes with Alcohol, located on one isolation cart on the Country Unit. Further observation of the Micro-Kill+ Disinfecting, Deodorizing Cleaning Wipes with Alcohol revealed the wipes kill 13 different infectious micro-organisms, but it failed to list Covid-19 as an infectious micro-organism that it kills.
During a surveyor observation on 8/20/2024 at 9:15 AM, revealed Nursing Assistant, Staff M, entering a Covid-19 positive room, Resident IDs #46 and 64, to obtain the resident's blood pressure. Medication Technician, Staff N, entered the room and exited the room at 9:25 AM with a blood pressure cuff and stethoscope. Staff N then placed the blood pressure cuff and stethoscope on top of two open glove containers. Staff N then proceeded to pick up the equipment and clean the blood pressure cuff and the stethoscope with the Micro-Kill+ Disinfecting, Deodorizing Cleaning Wipes with Alcohol, and placed them back on the medication cart for reuse.
Review of the List N tool: Covid -19 Disinfectants List, last updated on July 1, 2024, failed to identify Micro-Kill+ Disinfecting, Deodorizing Cleaning Wipes with Alcohol as a product that meets EPA's [Environmental Protection Agency] criteria for use against Covid-19.
During a surveyor interview on 8/20/2024 at 9:27 AM with Medication Technician, Staff N, she acknowledged that the facility uses multiuse equipment and that Resident ID #s 46 and 64 were on precautions for Covid-19. Additionally, she acknowledged the multiuse equipment was cleaned with the Micro-Kill+ Disinfecting, Deodorizing Cleaning Wipes with Alcohol.
During a surveyor interview on 8/20/2024 at 10:31 AM with the Infection Preventionist, she revealed that staff should use the bleach wipes for Covid-19 and not the Micro-Kill+ Disinfecting, Deodorizing Cleaning Wipes with Alcohol.
Further record review revealed an additional 2 residents had tested positive for Covid-19 on 8/20/2024, Resident ID #s 6 and 28.
2. Review of signage posted for Resident ID #s 14, 19, 26, 38, 46, 65, and 97 revealed Isolation Droplet/Contact .clean hands .gowns .N95 Respirator .Eye protection (goggles or face shield) .Gloves .
According to the Center for Disease Control and Prevention (CDC) titled, Infection Control Guidance: SARS-CoV-2 last revised on 6/24/2024, states in part, .use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).
Record review revealed a facility provided document titled, Summer '24 COVID Outbreak a line list for residents with a start date of the initial outbreak for residents of 8/2/2024.
During surveyor observations on 8/19/2024 revealed Nursing Assistant, Staff O, entering the following Covid-19 positive rooms without donning eye protection and wearing a KN95 mask (not an N95):
- 11:00 AM Resident ID #38's room
- 12:07 PM Resident ID #s 19 and 97 room
- 12:09 PM Resident ID #s 19 and 97 room
Further observation revealed the room had an isolation cart outside of the room and droplet/contact precaution signage posted.
During a surveyor observation on 8/19/2024 at 12:24 PM revealed the Social Worker entered Resident ID #65's room, a Covid-19 positive room, wearing a KN95 mask, gown, gloves, and eye protection. She failed to don an N95 mask. Further observation revealed the room had an isolation cart outside of the room and droplet/contact precaution signage posted.
During a surveyor observation on 8/20/2024 at 8:44 AM, Medication Technician, Staff N, entered Resident ID#s 14 and 26's room, a Covid-19 positive room, wearing a KN95 mask, gown, and gloves. She failed to don an N95 mask or eye protection. Further observation revealed the room had an isolation cart outside of the room and a droplet/contact precaution signage posted.
During a surveyor interview on 8/20/2024 at 8:47 AM with Staff N, she acknowledged that the resident was positive for Covid-19 and acknowledged the signage indicating the use of an N95 mask and eye protection and that she failed to don both an N95 mask and eye protection.
During a surveyor observation on 8/20/2024 at 9:15 AM, Nursing Assistant, Staff M, entered a Covid-19 positive room, Resident ID #s 46 and 64, wearing a KN95 mask, gown, gloves, and eye protection. She failed to don an N95 mask. Further observation revealed the room had an isolation cart outside of the room and droplet/contact precaution signage posted.
During a surveyor interview on 8/20/2024 at 10:31 AM with the Infection Preventionist, she revealed that staff should be wearing an N95 mask, not a KN95 mask, and indicated that they should wear eye protection in Covid-19 positive rooms.
3. Review of a facility policy titled, Enhanced Barrier Precautions states in part, Enhanced barrier precautions (EBP) are utilized to prevent the spread of multi-drug resistant organisms (MDRO) to residents .EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices [indwelling foley catheter, a flexible tube inserted into the bladder to drain urine] regardless of MDRO colonization .signs are posted indicating the type of precautions and PPE [personal protective equipment] required .PPE is readily available .
Record review revealed that Resident ID #102 was admitted to the facility in July of 2024 with diagnoses including but not limited to, urinary tract infection and cerebral infarction (stroke).
Record review revealed that the resident has an indwelling foley catheter.
Record review revealed an order for EBP for an indwelling foley catheter dated 8/1/2024.
During surveyor observations from 8/19/2024 through 8/22/2024 failed to reveal evidence of an isolation cart or signage posted indicating that the resident was on EBP indicating the type of PPE that is required for this resident.
During a surveyor observation and subsequent interview on 8/22/2024 at 11:39 AM with the Unit Manager, Registered Nurse (RN), Staff P, she acknowledged that the resident was not on EBP and indicated that she should have been. Further, she acknowledged that the resident did not have signage posted indicating that s/he was on EBP or that an isolation cart was outside of the resident's room. She further revealed that the resident was in a different room and was transferred to a new room on 8/13/2024 and that the precautions signage and isolation cart did not follow the resident to his/her new room.
4. Record review of a facility provided policy titled, Isolation-Categories of Transmission-Based Precautions revealed for contact precautions, staff and visitors are to wear gloves when entering the room. Additionally, staff and visitors are to wear a disposable gown upon entering the room and remove before leaving the room and to avoid touching potentially contaminated surfaces with clothing after the gown has been removed.
Record review revealed that Resident ID #22 was admitted to the facility in July of 2024 with diagnoses including, but not limited to, Methicillin Resistant Staphylococcus Aureus Infection (MRSA; a multi-drug resistant organism or MDRO) and Chronic Obstructive Pulmonary Disease (COPD; a chronic inflammatory lung disease that causes obstructed airflow from the lungs).
Record review revealed a physician's order dated 7/18/2024 for Contact Precaution for MRSA of nares, blood and right shoulder.
Review of a care plan initiated on 7/2/2024 revealed that Resident ID #22 has an active/colonized MDRO, MRSA with interventions which include, but are not limited to, isolation precautions per policy, and recommendation from the CDC and local Department of Health.
During a surveyor observation on 8/21/2024 at 8:36 AM during the medication administration task with RN, Staff K, Resident ID #22's room revealed signage posted on the doorway indicating contact precautions were required. The signage revealed that providers and staff must also don gloves and gown before entering the resident's room. Further observation revealed Staff K entered Resident ID #22's room wearing gloves. She failed to don a gown as listed in the policy and the signage. Staff K then administered the resident's intravenous antibiotic via a peripherally inserted central catheter (PICC; a long, thin tube that's inserted through a vein in your arm and is used to deliver medications and other treatments directly to the large central veins near your heart). She then touched the resident's pillows, arrange his/her bed linens, and touched the bedside table without wearing a gown.
During a surveyor interview immediately following the above-mentioned observation, she acknowledged that she did not wear a gown prior to entering the resident's room. She further acknowledged that she accessed the resident's PICC line and touched multiple potentially contaminated surfaces without wearing a gown per the facility policy and posted signage.
During a surveyor interview on 8/21/2024 at 1:22 PM with the DNS, she was unable to provide evidence that the staff followed the resident's isolation precautions as ordered.
During a surveyor interview on 8/22/2024 at approximately 2:00 PM with the DNS, she was unable to provide evidence the facility provided effective infection control practices to prevent the spread of Covid-19 and MDRO infections. These failures could have the potential to increase the transmission of Covid-19 and MDROs to multiple residents within the facility.
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
Free from Abuse/Neglect
(Tag F0600)
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 protect th...
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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 protect the residents' right to be free from abuse for 1 of 1 resident reviewed for abuse, Resident ID #46.
Findings are as follows:
Review of a facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated October of 2022 states in part, .Residents have the right to be free from abuse .This includes but is not limited to .physical abuse .Protect residents from abuse .by anyone including .other residents .
Review of a facility reported incident submitted to the Rhode Island Department of Health on 5/8/2024 alleges that Resident ID #42 approached Resident ID #46, began yelling at him/her and hit his/her left arm several times which resulted in a skin tear.
Record review revealed that the victim, Resident ID #46, was admitted to the facility in November of 2023 with a diagnoses including, but not limited to, dementia.
Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment.
Record review revealed that the perpetrator, Resident ID #42, was admitted to the facility in June of 2023 with diagnoses including, but not limited to, cerebral infarction (stroke), dysarthria (difficulty speaking,) and cognitive social or emotional deficits following a stroke.
Record review of a progress note dated 5/8/2024 at 10:38 PM, revealed that Resident ID #46 hit Resident ID #42. The note further indicates that Resident ID #46 was sitting quietly in his/her wheelchair when Resident ID #42 suddenly began to yell at Resident ID #46 and proceeded to hit him/her, striking Resident ID #46 on his/her left arm. Resident ID #46 sustained 2 skin tears which measured 1.0 centimeter (cm) by 0.5 cm and 0.5 cm by 0.5 cm.
Review of the facility's 5-Day investigation report titled, Conclusion dated 5/14/2024, revealed that Resident ID #42 had a BIMS score of 15 out of 15, indicating intact cognition. Additionally, it indicated that Resident ID #42 has impulse control issues following his/her stroke and became frustrated when Resident ID #46 did not move his/her feet.
During a surveyor interview on 8/21/2024 at 10:22 AM with Nursing Assistant, Staff L, she revealed that she witnessed the incident between Resident ID #s 42 and 46. She indicated that Resident ID #42 is alert and oriented and can be verbally aggressive towards others. She further indicated that Resident ID #46 was sitting in front of the Nurse's station when Resident ID #42 began yelling at Resident ID #46 and then struck Resident ID #46 approximately 3 times in his/her arm, resulting in skin tears. Lastly, she indicated that the incident was unprovoked.
During a surveyor interview on 8/21/2024 at 1:36 PM with the Director of Nursing Services, she revealed that Resident ID #42 can be verbally aggressive at times due to his/her speech impairment. Additionally, she acknowledged that Resident ID #46 was not kept free from physical abuse.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0740
(Tag F0740)
A resident was harmed · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident receives and is provided the necessary behavioral health care and services to a...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident receives and is provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being, for 1 of 3 residents reviewed for behaviors, Resident ID #66.
Findings are as follows:
Record review revealed the resident was readmitted to the facility in April of 2024 with diagnoses including, but not limited to, bipolar disorder and schizophrenia.
Review of the resident's care plan revealed a focus area initiated on 2/24/2024, for the use of anti-psychotic medications related to his/her diagnosis of schizophrenia. Interventions include, but are not limited to, administer anti-psychotic medication as ordered.
Record review revealed a physicians order dated 7/11/2024 for Risperdal (Risperidone, an antipsychotic medication), 50 milligrams (mg), with instructions to inject intramuscularly (IM), one time a day, every 14 days.
Review of the August 2024 Medication Administration Record (MAR) revealed the resident's IM Risperdal was documented with a 22, which indicates Drug / Treatment Not Administered, on 8/8/2024. Additionally, the order was discontinued on 8/8/2024.
Review of a progress note dated 8/8/2024 which states in part, [Pharmacy] notified of Risperdal .expected late this evening .RNP [Registered Nurse Practitioner] notified, order to change date to 8/9/24 as resident received medication every 2 weeks.
Further review of the August 2024 MAR failed to reveal evidence that a new IM Risperdal order was transcribed or administered to the resident on 8/9/2024, as ordered by the Nurse Practitioner (NP).
Review of a document titled, PSYCHIATRIC EVALUATION & CONSULTATION dated 8/12/2024 states in part, Chief Complaint: Pt [patient] reports + HI [homicidal ideation] and + AH [auditory hallucinations] .Pt reports 'I want to stab people' and complains [his/her] HI has returned and that [s/he] is hearing voices. Pt reports that there is no specific person [s/he] wants to hurt, 'just anyone' Pt reports [his/her] mood is worsening in response to [his/her/ psychosis .After investigation and discussion with nursing staff, pt missed [his/her] scheduled injection last week .Advised that pt be restarted on Risperidone injection ASAP [As soon as possible] along with some additional oral coverage . Further review revealed the resident was considered to be a danger to him/herself or others.
Review of a progress note dated 8/12/2024, authored by the NP, Staff B states in part, .[S/he] is seen in [follow up], has been having homicidal ideations. Per nursing, pt [patient] missed her last IM Risperidone dose. PT with plan to stab people, does not have means to do so. Able to contract for safety. Seen by psych .
Further review of the progress note dated 8/12/2024 revealed the following recommendations were made:
- Restart Risperidone Consta 50mg/2ml (milliliter) IM, every 2 weeks
- Start Risperidone 2 mg at hour of sleep, for 7 days
- 15 minute safety checks until further notice
- Plastic utensils with meals
Further review of the August 2024 MAR revealed the resident received his/her dose of IM Risperdal on 8/13/2024 and received his/her dose of 2 mg Risperdal, one time a day, from 8/12 to 8/18/2024. Further review revealed the resident was on 15-minute safety checks from 8/12 to 8/20.
During a surveyor interview on 8/22/2024 at 12:49 PM, with Psychiatric Nurse Practitioner, Staff G, she revealed that had the resident not missed his/her IM dose of Risperdal, she would not have ordered the resident to receive 2 mg of Risperdal, every evening, from 8/12 to 8/18/2024.
During a surveyor interview on 8/22/2024 at 1:18 PM, with the Director of Nursing Services, she revealed that she would have expected the nurses to transcribe the resident's IM Risperdal order on 8/9/2024 and administer it, as ordered.
Although this concern was corrected by the facility on 8/12/2024 by reinstating the resident's IM dose of Risperdal, implementing Risperdal 2 mg every evening from 8/12 to 8/19/2024, and maintaining 15-minute safety checks, the missed dose of IM Risperdal on 8/9/2024, caused the resident to experience a relapse in psychosis and was considered to be a danger to his/herself and others. During this period of psychosis, the resident was experiencing homicidal ideations and auditory hallucinations. This the facility was unable to provide any formal in-service training that was completed in regards to this incident.
Cross Reference F 658
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to provided services that meet professional standards of quality for 1 of 3 residents reviewed for behaviors...
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Based on record review and staff interview, it has been determined that the facility failed to provided services that meet professional standards of quality for 1 of 3 residents reviewed for behaviors, Resident ID #66.
Findings are as follows:
Record review revealed the resident was readmitted to the facility in April of 2024 with diagnoses including, but not limited to, bipolar disorder and schizophrenia.
a) Review of a document titled, PSYCHIATRIC EVALUATION & CONSULTATION dated 8/12/2024 states in part, Chief Complaint: Pt [patient] reports + HI [homicidal ideations] and + AH [auditory hallucinations] .Pt reports 'I want to stab people' and complains [his/her] HI has returned and that s/he is hearing voices. Pt reports that there is no specific person [s/he] wants to hurt, 'just anyone' Pt reports [his/her] mood is worsening in response to [his/her] psychosis . Additionally, the resident was documented as being a danger to him/herself or others.
Review of a progress note dated 8/12/2024, authored by Nurse Practitioner (NP), Staff B, states in part, .[S/he] is seen in [follow up], has been having homicidal ideations. Per nursing, pt missed [his/her] last IM [intramuscular] Risperidone dose. PT with plan to stab people, does not have means to do so. Able to contract for safety. Seen by psych .today . Further review revealed recommendations for 15-minute safety checks and plastic utensils with meals.
Record review failed to reveal evidence that the physician's recommendation for the use of plastic utensils with meals was implemented.
During a surveyor observation on 8/19/2024 at 12:42 PM, the resident was observed eating lunch in his/her room and was noted to be using metal utensils, including a fork, spoon, and knife. Review of his/her dietary slip did not reveal plastic utensils were to be used.
During a surveyor interview on 8/19/2024 at 1:35 PM, with the Food Service Director, she revealed that she was unaware that the resident required plastic utensils and indicated that nursing is supposed to inform her. She acknowledged that the dietary slip did not reveal plastic utensils and acknowledged that the resident received metal utensils.
During a surveyor interview on 8/20/2024 at 9:27 AM, with Staff B, she revealed that she would have expected the resident to receive plastic utensils for all meals while on 15-minute safety checks, due to his/her HI.
During a surveyor interview on 8/20/2024 at 11:55 AM with the Assistant Director of Nursing Services, she revealed that the resident should have received plastic utensils while on 15-minute safety checks as that is an intervention that they typically utilize.
b) Further review of a document titled, PSYCHIATRIC EVALUATION & CONSULTATION dated 8/12/2024 revealed a recommendation to obtain the residents orthostatic blood pressure (changes in blood pressure when a person moves from lying down to standing up), once a week, for four weeks.
Record review failed to reveal evidence that the resident's orthostatic blood pressure was obtained weekly, as ordered.
During a surveyor interview on 8/22/2024 at 11:21 AM, with Staff B, she revealed that she approved the psychiatric recommendations from 8/12/2024 and would have expected nursing to transcribe and obtain the resident's orthostatic blood pressure weekly, as ordered.
During a surveyor interview on 8/22/2024 at 12:08 PM, with Licensed Practical Nurse (LPN), Staff A, she acknowledged that there was not an order to obtain the resident's orthostatic blood pressure weekly, for four weeks. She further acknowledged that there were no documented weekly orthostatic blood pressures, as ordered by the NP.
During a surveyor interview on 8/22/2024 at 12:15 PM, with Unit Manager, LPN, Staff C, she revealed that once psychiatric services makes recommendations, nursing will notify the NP who approves the orders, and nursing will transcribe the orders. She indicated that the recommendation to obtain the resident's orthostatic blood pressure was overlooked and acknowledged that there was no order.
During a surveyor interview on 8/22/2024 at 1:18 PM, with the Director of Nursing Services, she revealed that she would have expected nursing to obtain the resident's orthostatic blood pressure, as ordered.
Cross reference F 740
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 2 residents reviewed with an indwelling foley cathete...
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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 2 residents reviewed with an indwelling foley catheter (a flexible tube that collects urine from the bladder and empties the urine into a drainage bag), Resident ID #83.
Findings are as follows:
Review of a policy titled, Catheter Care, Urinary last revised August 2022 states in part, .Changing Catheters .Change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised .
Record review revealed the resident was readmitted to the facility in March of 2022 with diagnoses including, but not limited to, obstructive (a structural or functional hindrance of normal urine flow) and reflux (a condition where there is a back-flow of urine into the kidney) uropathy and retention of urine.
Review of the resident's care plan revealed a focus area initiated on 12/1/2022, for an indwelling urinary catheter related to his/her diagnosis of obstructive uropathy. Interventions include, but are not limited to, monitor, record, and report signs and symptoms of a urinary tract infection (UTI).
Review of a physician progress note dated 8/16/2024 revealed the resident was seen by the physician due to a recurrent UTI and increased behaviors, with a recommendation to obtain a urinalysis with urine culture (UA/C&S).
Record review revealed a physicians order dated 8/16/2024 which states, Obtain urine to dipstick [a process that involves dipping a specially treated paper strip into a sample of urine], and if positive send UA C&S.
Record review revealed a medication administration note dated 8/19/2024 which revealed the resident's urine was obtained and the dipstick was positive. Further review revealed a sample of urine was obtained and was placed in a bag for the lab.
Review of a progress note dated 8/19/2024 at 7:08 PM revealed the order for the UA C&S was discontinued.
During a surveyor interview on 8/22/2024 at 9:04 AM with Licensed Practical Nurse, Staff A, she revealed that the resident's urinalysis came back contaminated, and indicated that Nurse Practitioner (NP), Staff B, was made aware of the contaminated specimen and the order was discontinued.
Record review failed to reveal evidence that the resident's indwelling catheter was changed prior to obtaining a urine sample, to prevent the contamination of the resident's urine specimen.
During a surveyor interview on 8/22/2024 at 10:00 AM with Staff B, she revealed that she was made aware of the contaminated urine specimen and indicated that she would expect staff to change the resident's catheter, prior to obtaining a urine specimen.
During a surveyor interview on 8/22/2024 at 1:16 PM, with the Director of Nursing Services in the presence of the Regional Registered Nurse, she revealed that should would have expected the resident's catheter to have been replaced prior to obtaining the urine specimen. Additionally, she was unable to provide evidence that the catheter was replaced prior to obtaining the urine specimen.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5...
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Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 29 opportunities for errors observed during the medication administration task, there were 3 errors resulting in an error rate of 10.34% relative to enteral medication administration via gastrostomy tube (g-tube; a tube that provides direct access to the stomach for supplemental feeding, hydration, or medication).
Findings are as follows:
Review of the facility's policy titled, Administering Medications through an Enteral Tube dated November 2018 states in part, .Check the label and confirm the medication name and dose with the MAR [Medication Administration Record] Medication administration .Stop feeding and flush tubing with at least 15 Milliliter (ML) warm water or prescribed amount .Administering each medication separately and flush between medications .When the last medication begins to drain from the tubing, flush the tubing with 15 ML or prescribed amount .
Record review revealed Resident ID #51 has the following physician orders:
- Senna tablet give 2 tablets two times a day for constipation.
- Lorazepam 0.5 Milligram (MG) three times a day for anxiety.
- Oxycodone 100 MG/5 ML give 0.5 ML two times a day for pain.
- Flush feeding tube with 30 ML of water before and after medication administration every shift for maintenance.
During a surveyor observation of the medication administration task on 8/21/2024 at 11:09 AM with a Licensed Practical Nurse, Staff H, revealed the following:
- Lorazepam 0.5 MG and Oxycodone 0.5 ML was dispensed in the same medication cup, dissolved together and administered to the resident via the g-tube.
- One Senna tablet was administered instead of two tablets as ordered.
- Staff H was observed flushing the g-tube with 15 ML of water before and after administering the medications instead of 30 ML, as ordered.
During a surveyor interview immediately following this observation with Staff H, he acknowledged the above-mentioned observations.
During a surveyor interview on 8/21/2024 at 1:21 PM with the Director of Nursing Services, she was unable to provide evidence the above-mentioned medications were administered as ordered and per the facility's policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
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 1 of 3 medication carts were kept locked or kept under direct observat...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that 1 of 3 medication carts were kept locked or kept under direct observation of authorized staff in an area where residents could access it. Additionally, the facility failed to store all drugs and biological's in accordance with currently acceptable professional principles for 3 of 4 medication carts observed, Country Two Meadow Road cart, Side Two Country cart, and Ocean Unit cart.
Findings are as follows:
Review of the facility's policy titled, Medication Labeling and Storage dated February 2023 states in part, The facility stores all medications and biological's in locked compartments .Only authorized personnel have access .The medication label includes, at a minimum .expiration date, when applicable .
1. During a surveyor observation of the Country Two Meadow Road medication cart on 8/21/2024 at 8:00 AM in the presence of a Certified Medication Technician (CMT), Staff I, revealed the following:
- Two bottles of Nitroglycerin 0.4 Milligram (MG, a medication used to treat and prevent chest pain) with expiration dates of June 2024 and July 2024.
- Fluticasone Propionate and Salmeterol 100/50 Micrograms (MCG, a combination of two medications that are used to treat the symptoms of asthma such as shortness of breath, coughing, and chest tightness) inhaler, opened and not dated. Manufacturer instructions indicate to discard 30 days after opening or when the counter reaches zero or whichever comes first.
- Incruse Ellipta 62.5 MCG inhaler (a medication used to treat respiratory disease), with an open date of 7/24 and discard date of 7/11/25. Manufacturer instructions indicate to discard 6 weeks after opening or when the counter reads zero or whichever comes first.
During a surveyor interview immediately following this observation with Staff I, she acknowledged the above-mentioned observations.
2. During a surveyor observation of the Side-Two Country medication cart on 8/21/2024 at 8:13 AM in the presence of a CMT, Staff J, revealed a Trelegy Ellipta 100/62.5/25 MCG inhaler, opened and not dated. Manufacturer instructions indicate to discard 6 weeks after opening or when the counter reads zero or whichever comes first.
During a surveyor interview immediately following this observation with Staff J, she acknowledged the inhaler was opened and not dated.
3. During a surveyor observation of the Ocean Unit on 8/21/2024 during the medication administration task with Registered Nurse, Staff K, who was utilizing this medication cart to administered medications, revealed the medication cart was observed in the hallway unlocked, unattended, and within proximity of residents during the following times:
- 8:36 AM - 8:40 AM
- 8:42 AM - 8:46 AM
- 8:50 AM - 8:57 AM
During a surveyor interview on 8/21/2024 at 8:58 AM with Staff K, she acknowledged the medication cart was left unlocked and unattended during the above-mentioned times.
4. During a surveyor observation of the Ocean medication cart on 8/21/2024 at 9:03 AM, in the presence of Staff K, revealed a bottle of liquid protein, opened, and not dated. Manufacturer instructions indicate a shelf life of three months after opening.
During a surveyor interview immediately following this observation, Staff K acknowledged the liquid protein was opened and not dated.
During a surveyor interview on 8/21/2024 at 1:21 PM with the Director of Nursing Services, she was unable provide evidence the above-mentioned medications were stored appropriately, as required.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to develop and implement a comprehen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 2 residents reviewed relative to Post-traumatic stress disorder (PTSD, occurs in some individuals who have encountered a shocking, scary, or dangerous situation) Resident ID #49 and 1 of 1 resident reviewed for wandering, Resident ID #65.
Findings are as follows:
1. Review of a facility provided policy titled, Wandering and Elopements states in part, .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for resident .If identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety .
Record review revealed that Resident ID #65 was readmitted to the facility in April of 2024 with diagnoses including, but not limited to, adjustment disorder and psychosis.
Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was documented as wandering 1 to 3 days during the 7 day look back period.
Record review revealed the resident resides on a secured unit.
Record review revealed the following progress notes regarding the resident wandering behavoirs from the facility:
- [DATE] which states in part, .Nursing reports patient has had a technical elopement. Patient went outside with activities and did not come back in with staff and was missing. Patient has come back in and in no acute distress .
- [DATE] which states in part, Resident self propelled outside of east doors, resident self propelled outside [approximately] 50 feet [away] from building. Resident easily redirected back into building without difficulty. No injuries noted, resident pleasant and cooperative time of redirection.
- [DATE] Resident again exited building from the east day room, but was successfully redirected back inside
Record review failed to reveal evidence of a care plan that includes strategies and interventions to maintain the resident's safety and prevent future wandering behaviors.
During a surveyor interview with Licensed Practical Nurse, Staff A, on [DATE] at 2:02 PM and [DATE] at 8:09 AM, she revealed that the resident does wander and needs frequent redirection.
During a surveyor interview on [DATE] at 1:12 PM with the Director of Nursing Services (DNS) and the Regional Registered Nurse, they acknowledged that there was not a care plan in place related to the residents wandering behaviors and indicated that there should be one in place.
2. Record review revealed that Resident ID #49 was readmitted to the facility in March of 2022 with a diagnosis including, but is not limited to, PTSD.
Review of a Comprehensive MDS assessment dated [DATE] revealed the resident is coded as having a diagnosis of PTSD, anxiety, and depression.
Record review revealed the resident was seen by psychiatric services with the following concerns:
- [DATE] The resident goes on to repeat the sad story of losing so many of [his/her] children in life and dealing with a 'vicious' aunt. The resident endorses that [s/he] has trouble falling asleep at night sometimes related to having intrusive memories. [The resident] denies formal depression or anxiety and explains that is normal for [him/her] to feel this way because of [his/her] past traumas, and thus continues to appear mildly sad and anxious .
- [DATE] The resident .reports similarly to last month and denies any major problems or concerns and again repeats [his/her] story of the loss of [his/her] children. [The resident] denies major depression or anxiety, or significant appetite or sleep concerns. [The resident] is pleasant, cooperative, mood and affect appear brighter today .
- [DATE] Provided brief supportive therapy to [the resident]. [The resident] is alert, easy to engage. Purpose of session is to evaluate mood and accompanied symptoms. Speech tends to be hyperverbal. I do not belong here but I am. Perseverates on [his/her] eight children, most of whom are now deceased . Two are currently living. Tends to focus on the same issues, being 96 now, staying in a nursing home. Prefers to stay alone vs engage with others. Responsive to support and encouragement offered; [The resident] should continue to be followed regularly to provide support .
- [DATE] revealed psychiatric services met with the resident for behavioral health services. The resident .Endorsed anxiety, depression and lack of appetite. States does not attend activities and mostly stays in room. Provided emotional support and coping skills training - effects of depression on physical and mental health. Identified activities to elevate mood and encouraged [the resident] to engage [with] others/activities. Introduced mindfulness to self soothe and increase calm/peace .
- [DATE] Current Assessment/Plan [the resident] is sitting up in [his/her] room, sleepy this morning but rousable, alert, confused/forgetful, pleasant. [The resident] presents with stable mood and affect, good eye contact Will continue to monitor .PTSD .
Record review revealed the physician saw the resident on [DATE] at 1:01 PM and noted the resident's diagnosis of PTSD, with psychiatric services involved.
Record review failed to reveal evidence of a trauma informed care plan that identifies trauma triggers and interventions to implement related to the diagnosis of PTSD.
During a surveyor interview on [DATE] at 9:18 AM with the Social Worker, she revealed that when she meets with the resident s/he talks to her about his/her children passing away. She further revealed that she was unaware that the resident had a diagnosis of PTSD. Additionally, she acknowledged that the resident did not have a care plan related to PTSD and indicated that there should be one.
During a surveyor interview on [DATE] at approximately 3:00 PM, with the DNS, she was unable to provide evidence that a comprehensive person-centered care plan was developed and implemented to address the resident's PTSD.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice ...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice for 1 of 2 residents reviewed for skin abrasions, Resident ID #83.
Findings are as follows:
Review of a facility policy titled Wound Care last revised October 2010 states in part, .The following information should be recorded in the resident's medical record .All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound .
According to Wound Care Education Institute, 2020, Wound care documentation should be carried out weekly including type of wound, measurements, type of tissue, symptoms of infection, presence of drainage, wound edges, pain, and current treatment.
Record review revealed the resident was initially admitted to the facility in February of 2022 with a diagnosis including, but not limited to, dementia.
Review of the resident's care plan revealed a focus area initiated on 8/15/2024, which indicated the resident has impaired skin integrity related to an abrasion. Interventions include, but are not limited to, evaluate and document healing process, report significant changes and declines to the provider, and monitor for new or worsening signs or symptoms of complications and infection, such as necrosis (dead tissue), erythema (abnormal redness), warmth, edema (swelling), exudate (drainage), foul odor, maceration (the softening or breaking down of skin due to moisture), pain/tenderness, fever/chills, etc.
Review of a progress note dated 4/7/2024 revealed the resident returned to the facility following a hospitalization, and was noted to have a new open area to his/her mid/upper back, measuring 0.3 centimeters (cm) by 0.4 cm. It further revealed there was no drainage or foul odor noted, wound bed was pink and the area surrounding the wound was blanchable (skin that remains white or pale for longer than normal when pressed).
Record review revealed a physicians order dated 4/7/2024 for a wound care consult.
Record review failed to reveal evidence that a wound care consult was obtained until 8/15/2024, approximately four months after it was initially ordered.
Record review revealed the following physician wound treatment orders relative to the above-mentioned wound:
- 4/7/2024 - 5/17/2024 Cleanse open area to mid upper back with wound cleanser, apply bacitracin (wound ointment) to wound bed and cover with bordered gauze once daily.
- 5/17/2024 - 5/20/2024 Cleanse open area to mid upper back with wound cleanser, apply xeroform (wound dressing) to wound bed and cover with bordered gauze once daily.
- 5/21/2024 - 7/30/2024 Cleanse open area to mid upper back with wound cleanser, apply xeroform to wound bed and cover with bordered gauze once daily.
- 7/31/2024 - 8/14/2024 Cleanse open area to mid upper back with wound cleanser, apply xeroform to wound bed and cover with bordered gauze once every other day.
- 8/15/2024 (current treatment) Cleanse open area to mid upper back with wound cleanser, apply alginate (wound dressing) to wound bed and cover with bordered gauze once every other day.
Record review revealed the following dates a full body skin assessment was completed, following his/her readmission to the facility in April of 2024:
- 4/8/2024: revealed an open lesion other than an ulcer located on his/her upper back with a treatment in place.
- 4/11/2024: revealed an open lesion other than an ulcer located on his/her mid back with a treatment in place and was documented as healing.
- 4/18/2024: revealed an open lesion other than an ulcer located on his/her mid back with a treatment in place and was documented as healing.
- 4/25/2024: revealed an open lesion other than an ulcer located on his/her mid back with a treatment in place.
- 5/2/2024: revealed an open lesion other than an ulcer located on his/her mid back with a treatment in place.
- 5/9/2024: revealed an open lesion other than an ulcer located on his/her upper-mid back with a treatment in place.
- 5/16/2024: revealed an abrasion located on his/her upper-mid back with a treatment in place.
- 5/23/2024: revealed an open lesion other than an ulcer located on his/her upper-mid back with a treatment in place, which recently changed, and was documented as healing.
- 5/30/2024: revealed an open lesion other than an ulcer located on his/her upper back with a treatment in place and was documented as improving.
- 6/6/2024: revealed an excoriation to his/her upper back, with a treatment in place.
- 6/13/2024: revealed an excoriation to his/her upper back, with a treatment in place.
- 6/20/2024: revealed no skin impairments were noted.
- 6/27/2024: revealed a new skin tear to his/her left elbow, sustained from a fall, with a treatment in place. It further revealed an open lesion other than an ulcer located on his/her upper back with a treatment in place and tolerated by the resident.
- 7/4/2024: revealed an open lesion other than an ulcer located on his/her upper back with a treatment in place.
- 7/18/2024: revealed an open lesion other than an ulcer located on his/her mid back.
- 7/25/2024: revealed an open lesion other than an ulcer located on his/her upper-mid back, open quarter size lesion, with a treatment in place.
- 8/2/2024: revealed no skin impairments.
- 8/8/2024: revealed a skin impairment was noted.
- 8/15/2024: revealed a skin impairment was noted.
Further review of the above-mentioned skin assessments failed to reveal documentation of the resident's wound including, but not limited to, wound bed color, size, and drainage, as per facility policy.
Review of a document titled Skin & Wound Evaluation dated 8/15/2024, revealed the resident has a facility acquired abrasion to his/her right scapula (shoulder blade), measuring 2.0 cm by 2.3 cm by 0.1 cm. It further revealed the wound had moderate bloody/sanguineous (discharge that is made up of both blood and serum) discharge.
During a surveyor interview on 8/21/2024 at 11:01 AM with the Wound Physician, she revealed that she comes to the facility every Wednesday and acknowledged that the resident had his/her initial wound consult for the above-mentioned wound on 8/14/2024. She further revealed that she would expect the facility to be measuring the resident's wound weekly in her absence.
During a surveyor interview on 8/21/2024 at 11:26 AM with the Unit Manager, Licensed Practical Nurse, Staff C, she revealed that she was unaware of the order for a wound consult back in April. Additionally, she revealed that she obtained a wound consult for the resident's wound because the nursing staff indicated to her that the wound was worsening. Furthermore, she revealed that she does not obtain wound measurements for abrasions unless it is non-healing or worsening.
During a surveyor interview on 8/21/2024 at 1:27 PM with the Director of Nursing Services, she revealed that she would expect wound measurements and wound descriptions to be documented upon conducting weekly skin assessments. Further, she revealed that she would have expected a wound consult to have been obtained when it was initially recommended in April of 2024.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to complete an annual performance review for every Nursing Assistant (NA), at least once every 12 months, fo...
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Based on record review and staff interview, it has been determined that the facility failed to complete an annual performance review for every Nursing Assistant (NA), at least once every 12 months, for 3 of 3 NA personnel records reviewed, Staff D, E, and F.
Findings are as follows:
Record review of the personnel files failed to reveal evidence that an annual performance evaluation was completed for the following NA's:
-Staff D, hired in February of 2023
-Staff E, hired in July of 2022
-Staff F, hired in July of 2023
During a surveyor interview with the Administrator on 8/21/2024 at 2:20 PM, he acknowledged that the above-mentioned NA's have not had a yearly performance evaluation and indicated it will be added to Quality Assurance and Performance Improvement (QAPI) as of 8/29/2024. Further, he was unable to provide evidence that performance evaluations were completed within the last 12 months for the above-mentioned NA's.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed, in accordance with professional standards for food ser...
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Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed, in accordance with professional standards for food service safety, relative to the main kitchen and 2 of 2 kitchenettes.
Findings are as follows:
Record review of Rhode Island Food Code, 2018 Edition, Section 3-501.17 states in part, .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and help in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees Celsius or 41 degrees Fahrenheit or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 .
1. During the initial tour of the main kitchen in the presence of the Food Service Director (FSD), on 8/19/2024 at 8:10 AM, the following was observed in the walk-in refrigerator:
- A half size hotel pan approximately ½ full of uncooked chicken with a use by date of 8/17/2024.
- A quarter size hotel pan approximately ¾ full and labeled puree chicken with a use by date of 8/18/2024.
- A package of 20 frozen prepared egg rolls, unlabeled and undated.
During a surveyor interview with the FSD immediately following the above observations, she acknowledged the above items should have been labeled, dated, and discarded according to the dates.
During a surveyor observation of the Ocean Unit Kitchenette on 8/21/2024 at 10:35 AM, revealed the following:
- A blue soup bowl, covered, containing cooked oatmeal without a label or use by date.
- A 1-quart container of vanilla ice cream with a manufacturer's use by date of 8/14/2024.
During a surveyor observation of the Country Unit Kitchenette on 8/21/2024 at 10:50 AM, revealed an undated individual packaged dessert with a manufacturer's label of strawberry cream pie without a use by date.
During a surveyor interview with the FSD immediately following the above observations, she revealed the above items should have been labeled, dated, and discarded according to the dates.
2. During a surveyor observation of lunch service in the main kitchen, in the presence of the FSD on 8/21/2024 at 11:35 AM, revealed a large hotel sheet pan placed on a preparation area beside the gas stove located behind the hot food service line. The tray contained several plated alternative meal options, which included cold salad plates and sandwiches. The following observations were made:
- A salad plate containing two scoops of chicken salad on top of a tossed salad with a holding temperature of 51 degrees Fahrenheit (F).
- A plate containing a chicken salad sandwich on wheat bread with a holding temperature of 48 degrees F.
- A plate containing a tossed salad with cut up fresh fruit and a large scoop of cottage cheese with a holding temperature of 51 degrees F.
During a surveyor interview with the FSD immediately following the above-mentioned observations, she acknowledged the holding temperatures of the food items were not safe to serve. Additionally, she acknowledged that cold food temperatures should not have been greater than 41 degrees F and should have been refrigerated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records on each resident that are complete and accurately documen...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records on each resident that are complete and accurately documented, relative to hearing aids for 1 of 1 resident reviewed for hearing impairment, Resident ID #46.
Findings are as follows:
Record review revealed the resident was admitted to the facility in November of 2023 with a diagnosis including, but not limited to, dementia.
Review of the resident's care plan revealed a focus area initiated on 11/14/2023 which revealed the resident is hard of hearing and wears hearing aids. Interventions include, but are not limited to, provide the resident with appropriate hearing aids, as required.
Review of a Sensory and Communication Status note dated 8/14/2024 revealed the resident has bilateral hearing limitations that affects his/her ability to function.
Record review revealed a physician's order dated 2/3/2024 to insert bilateral hearing aids every morning and remove at bedtime.
Review of the Medication Administration Records (MAR) for July and August 2024 revealed the above-mentioned order was documented as completed from July 1st through July 31st and August 1st through August 21st.
During a surveyor observation on 8/21/2024 at approximately 10:08 AM, the resident was observed without his/her hearing aids in place.
During a surveyor interview immediately following the above observation with Certified Medication Technician, Staff I, she acknowledged that the resident's hearing aids were not in place. Additionally, she revealed that the resident's right hearing aid had been broken for a few weeks. Further, she acknowledged that the order was inaccurately documented as being completed.
During a surveyor interview on 8/21/2024 at 11:34 AM with the Unit Manager, Licensed Practical Nurse, Staff C, she revealed that the resident's hearing aid has been broken for approximately 6 weeks.
During a surveyor interview on 8/21/2024 at 1:39 PM with the Director of Nursing Services, she indicated that she would expect the staff to accurately document when the resident is wearing his/her hearing aids, as ordered.
Dec 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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to protect a resident's right to be ...
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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 protect a resident's right to be free from sexual abuse for 1 of 5 residents reviewed, Resident ID #1.
Findings are as follows:
On 12/16/2023, the Rhode Island Department of Health (RIDOH) received a facility reported incident of staff to resident sexual abuse on behalf of Resident ID #1 and Registered Nurse, Staff A. The report further alleged on the evening of 12/16/2023, between the hours of 12:02 AM and 6:00 AM, the resident was administered medication from Staff A for a reported headache which left the resident feeling groggy and out of it. Staff A was reported to have returned to the resident's room and sexually molested him/her.
Record review of a facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating states in part, .all reports of resident abuse are thoroughly investigated by facility management .upon receiving any allegations of abuse .the Administrator is responsible for determining what actions are needed to protect the residents .Corrective Actions .if the investigation reveals that the allegation(s) of abuse are founded, the employee(s) is terminated .any allegations of abuse are filed in the accused employee's personnel record along with any statement by the employee .if the investigation reveals that the allegation(s) of abuse are unfounded, the employee(s) may be reinstated .records concerning allegations that are determined to be unfounded are archived.
Record review revealed Resident ID #1 was admitted to the facility in December of 2023, with diagnoses including, but not limited to, Guillain-Barre Syndrome (a medical condition in which the immune system attacks the nerves), high blood pressure and insomnia (sleep disorder).
Record review of a Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status Assessment score of 15 out of 15 indicating the resident's cognition is intact. Further review of the MDS revealed the resident is dependent on staff for all activities of daily living.
Record review of a care plan dated 12/18/2023 states in part, .I have a psychosocial well-being problem r/t [related to] traumatic event of inappropriate touching.
During a surveyor interview on 12/18/2023 at 2:46 PM with the resident, in the presence of his/her family, s/he revealed that on 12/16/2023 at approximately 8:00 PM, s/he was assisted with care, received his/her evening medications and at approximately 9:30/10:00 PM s/he indicated s/he went to bed for the night. The resident revealed s/he was woken from sleep approximately 3 hours later with a headache for which s/he asked for some Tylenol. The resident revealed the male nurse, Staff A, came into his/her room and administered the Tylenol in applesauce which s/he revealed had a sour taste. The resident further revealed that later s/he was sleeping and was awakened by Staff A, who came into his/her room and sexually abused him/her with use of his hands and mouth to the resident's genitalia. The resident revealed that s/he was unable to move or speak and revealed during the time this was happening, a Nursing Assistant (NA), Staff D, came to the door, and asked the nurse if he needed any help with the resident. The resident revealed the nurse stopped what he was doing when the NA came to the door and stated that he was just cleaning the resident up. The resident revealed that the NA left the doorway and the nurse continued to sexually abuse him/her.
During a surveyor interview on 12/19/2023 at 9:54 AM with NA, Staff D, she revealed that she took care of the resident during the overnight shift on 12/16/2023. She further revealed that she is familiar with the resident and described him/her as very alert and oriented. Staff D revealed when she saw the resident's call light on, she went to his/her room and the door was closed so she knocked and opened the door. Staff D revealed that Registered Nurse, Staff A had his back to the doorway however, she indicated that he was changing the resident. In a written statement authored by Staff D, she revealed the time Staff A was in the resident's room was approximately 30 minutes.
During a surveyor interview on 12/19/2023 at approximately 12:45 PM with Staff A, he revealed that he worked on 12/16/2023 for the 11-7 overnight shift and during that time he was informed that the resident had requested Tylenol. Staff A revealed that he brought two Tylenol to the resident however the resident requested the medication be given in applesauce. Staff A indicated that he left the residents room to put the Tylenol in applesauce and in doing so, was asked to assist another resident. Staff A revealed after he assisted the other resident and then retrieved the Tylenol which had been sitting in applesauce for a few minutes, he gave it to Resident ID #1. Staff A revealed that he went back to the resident's room to respond to his/her call light, the resident complained of feeling itchy. Staff A revealed that he checked the resident's brief and found the resident was incontinent and proceeded to wash and change the resident. When asked how long he was in the room with the resident, Staff A indicated no more than 10 minutes.
During a surveyor interview on 12/19/2023 at approximately 1:11 PM with Unit Manager, Staff E, she revealed that she was the on-call supervisor on 12/16/2023. Staff E revealed that she received a call from the 7:00 AM to 3:00 PM Licensed Practical Nurse, Staff C, informing her of Resident ID #1's allegation that s/he was drugged and molested by Staff A. Staff E revealed that she spoke with the Director of Nursing Services (DNS) and was given instructions to report the abuse allegation to the police and the on-call provider.
Record review revealed a progress note dated 12/16/2023 at 11:59 AM and authored by telehealth Advanced Practice Registered Nurse (APRN), Staff B, which states in part, .primary chief complaint: allegation of abuse .contacted by the nurse as the resident reported sexual abuse occurred last night .says s/he received Tylenol at 0200 [2:00 AM] and started feeling funny and was then assaulted .orders .Stat (should occur immediately) urine and serum tox screen.
Record review revealed a progress note dated 12/16/2023 at 8:08 PM, which states in part .at 0815 [8:15 AM] CNA [certified nursing assistant] notified this writer that resident wanted to speak with nurse .upon entering resident's room and inquiring what s/he wanted to talk about resident stated, I was molested last night .writer immediately notified on call supervisor .police .person resident made allegation against removed from unit.
Further record review revealed a progress note dated 12/18/2023 at 12:06 PM, authored by the Social Worker which states in part, .met with resident, spouse and stepdaughter regarding alleged events from 11-7 shift on 12/15/2023 .resident and family show signs of distress .will have supportive care follow up and social service to continue support.
Record review revealed a physician progress note dated 12/20/2023 at 8:43 PM, which states in part, .reason for visit, new admission .alleged sexual assault by staff over weekend .complains of abdominal cramps .social services following .continue current care.
Review of a psychiatric evaluation and consultation dated 12/21/2023, states in part, .per facility patient reported to them that [s/he] was sexually assaulted at the facility by staff last weekend .trauma, insomnia, anxiety, adjustment .reports [s/he] is coping with last weekend's incident.
Initial review of Staff A's personnel file on 12/18/2023, revealed he has been employed at the facility since October of 2019, and a Background Criminal Investigation [BCI] dated October of 2019, revealed no disqualifying information. Initially upon review of Staff A's employee file there was no evidence of any previous reports of abuse. However, additional review of his personnel file on 12/27/2023 revealed Staff A had been reported by a resident of sexually abusing the resident back in July of 2020. Additionally, upon second review of the employees file revealed reports dated 7/2020 and 8/2020 of employee education due to unprofessional conduct, inappropriate behaviors towards male and female residents.
During a surveyor interview on 12/27/2023 at 10:25 AM with the Administrator and DNS, when questioned about the additional information that is in Staff A's employee file which was not presented upon initial surveyor review on 12/18/2023, they revealed they found additional information in the Assistant Director of Nursing Service (ADNS) office when they were compiling files on behalf of Staff A. The Administrator revealed that the ADNS keeps separate folders in her office of clinical staff's educational training's. When the DNS was questioned as to why she did not disclose to the surveyor on 12/18-12/19/2023 that Staff A had a previous allegation of sexual abuse reported by another resident, the DNS revealed she forgot.
During a surveyor interview on 12/27/2023 at 1:11 PM with Licensed Practical Nurse, Staff C, she revealed that she reported the sexual abuse allegation to the on-call provider from third eye, APRN, Staff B. Additionally, Staff C revealed that a Facetime call with the APRN took place without the presence of the resident. When asked if she offered or asked if the resident wanted to go to the hospital for an examination after reporting the sexual abuse, Staff C stated she did not. When asked if she spoke with the on-call provider about having the resident go out for an examination after reporting sexual abuse, she stated she did not.
During a surveyor interview with the DNS on 12/27/2023 at approximately 10:35 AM, when questioned if the resident was asked or if it was discussed with the MD (Medical Doctor) about the resident going out to the hospital for an examination status post his/her sexual abuse allegation, she revealed that she did not even think of that.
During a surveyor interview on 12/27/2023 at approximately 1:20 PM with the resident's primary care provider APRN, Staff F, she revealed that she was made aware of the resident's report of sexual abuse via the on-call provider and indicated that she provided the resident with an assessment on 12/18/2023, however revealed I did not evaluate the resident regarding sexual abuse as this was a normal routine healthcare visit and did not include any assessment related to the abuse.
During a surveyor interview on 12/27/2023 at approximately 2:00 PM with the Administrator and DNS they were unable to provide evidence that the facility kept Resident ID #1 free from sexual abuse.
Aug 2023
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to implement ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan for 1 of 3 residents reviewed relative to requiring supervision while eating, Resident ID #50.
Findings are as follows:
Record review revealed that the resident was readmitted to the facility in September of 2019 with diagnoses including, but not limited to, cerebral infarction (stroke), and dysphagia (difficulty swallowing).
Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 3 out of 15, indicating severely impaired cognition. Additionally, the MDS revealed that s/he requires supervision (oversight, encouragement, or cueing) of one staff member for eating and drinking.
Additional record review revealed a care plan dated 5/5/2022 indicating the resident has a nutritional problem related to the diagnosis of dysphagia and requires a mechanically altered diet. Interventions include to monitor for signs and symptoms of dysphagia such as, choking or coughing during meals.
Further review revealed a care plan dated 2/15/2023, indicating the resident has a self-care deficit related to his/her diagnosis of stroke. Interventions include, .I require supervision with eating and drinking .
Surveyor observations on the following dates and times revealed:
- 8/9/2023 at approximately 8:45 AM, the resident was observed eating the breakfast meal in his/her room with no supervision from a staff member. Additionally, s/he was observed to cough while eating.
- 8/9/2023 at 11:55 AM, Nursing Assistant, Staff A, was observed delivering the resident's lunch meal tray. Staff A was observed exiting the room and did not remain to provide him/her with supervision.
- 8/9/2023 at 12:06 PM, the resident was observed eating the lunch meal in his/her room without staff supervision.
- 8/9/2023 at 12:13 PM, resident was observed eating the lunch meal in his/her room, actively coughing, and expelled a piece of food from his/her mouth, without staff supervision. A staff member was observed across the corridor in another resident's room and did not respond to Resident ID #50's room when s/he was coughing.
- 8/10/2023 at 8:23 AM, the resident was observed eating the breakfast meal in his/her room and actively coughing without staff supervision.
- 8/10/2023 at 8:27 AM, in the presence of Registered Nurse, Staff B, the resident was observed to be coughing while eating in his/her room without staff supervision.
During a surveyor interview on 8/10/2023 at 8:31 AM, with Staff B, following the above-mentioned observation, she acknowledged that the resident was coughing while eating. Additionally, she acknowledged that staff were not present to supervise the resident while s/he was eating or drinking. Furthermore, she indicated that she would expect staff to supervise the resident while eating or drinking per the care plan.
During a surveyor interview on 8/10/2023 at approximately 10:30 AM with the Director of Nursing Services, she was unable to provide evidence that staff implemented his/her care plan relative to supervision with meals.
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 services provided by the facility failed to meet professional standards of quality relative to a dressing...
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Based on surveyor observation, record review, and staff interview, it has been determined that services provided by the facility failed to meet professional standards of quality relative to a dressing observed on a resident without a physician's order for 1 of 1 resident reviewed, Resident ID #96.
Findings are as follows:
According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment .
Record review revealed the resident was re-admitted to the facility in July of 2023 following a right hip surgical wound infection.
Record review of a nursing progress note dated 7/22/2023 states in part, .open abrasions/skin tears noted to RUE [right upper extremity] .
During a surveyor observation on 8/9/2023 at 12:35 PM revealed two dressings to the resident's right forearm, which were undated.
Record review failed to reveal a physician's order for the dressings to the right forearm.
During a surveyor observation and simultaneous interview on 8/9/2023 at 1:46 PM with Registered Nurse, Staff C, she acknowledged there were two border gauze dressings observed on the resident's right forearm without a date. Furthermore, she was unable to provide evidence of a treatment order for the resident's skin.
During a surveyor interview on 8/10/2023 at 11:17 AM with the Director of Nursing Services, she was unable to explain why the resident had a dressing to his/her right forearm without a physician's order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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 a resident received adequate supervision while eating for 1 of 3 residents reviewed who require supervision during meals, Resident ID #50.
Findings are as follows:
According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023 states in part, .Supervision is an intervention and a means of mitigating accident risk. Facilities are obligated to provide adequate supervision to prevent accidents. Adequacy of supervision is defined by type and frequency, based on the individual resident's assessed needs, and identified hazards .
Record review revealed that the resident was readmitted to the facility in September of 2019 with diagnoses including, but not limited to, cerebral infarction (stroke), and dysphagia (difficulty swallowing).
Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 3 out of 15, indicating severely impaired cognition. Additionally, the MDS revealed that s/he requires supervision (oversight, encouragement, or cueing) of one staff member for eating and drinking.
Additional record review revealed a care plan dated 5/5/2022 indicating the resident has a nutritional problem related to the diagnosis of dysphagia and requires a mechanically altered diet. Interventions include to monitor for signs and symptoms of dysphagia such as, choking or coughing during meals.
Further review revealed a care plan dated 2/15/2023, indicating the resident has a self-care deficit related to his/her diagnosis of stroke. Interventions include, .I require supervision with eating and drinking .
Surveyor observations on the following dates and times revealed:
- 8/9/2023 at approximately 8:45 AM, the resident was observed eating the breakfast meal in his/her room without staff supervision. Additionally, s/he was observed to cough while eating.
- 8/9/2023 at 11:55 AM, Nursing Assistant, Staff A was observed delivering the resident's lunch meal tray. Staff A was observed exiting the room and did not remain to provide him/her with supervision.
- 8/9/2023 at 12:06 PM, the resident was observed eating the lunch meal in his/her room without staff supervision.
- 8/9/2023 at 12:13 PM, resident was observed eating the lunch meal in his/her room, actively coughing, and expelled a piece of food from his/her mouth, without staff supervision. A staff member was observed across the corridor in another resident's room and did not respond to Resident ID #50's room when s/he was coughing.
- 8/10/2023 at 8:23 AM, the resident was observed eating the breakfast meal in his/her room and actively coughing, without staff supervision.
- 8/10/2023 at 8:27 AM, in the presence of Registered Nurse, Staff B, the resident was observed to be coughing while eating in his/her room without staff supervision.
During a surveyor interview on 8/10/2023 at 8:31 AM, with Staff B, following the above-mentioned observation, she acknowledged that the resident was coughing while eating. Additionally, she acknowledged that staff were not present to supervise the resident while s/he was eating or drinking. Furthermore, she indicated that she would expect staff to supervise the resident while eating or drinking per the care plan.
Record review revealed a Speech Therapy progress note dated 8/10/2023 at 12:51 PM, which indicates that the resident was evaluated at the request of nursing due to concerns for coughing during mealtime. The note states in part, .Swallow evaluation revealed .mild-to-moderate .dysphagia .RECOMMENDATIONS .Pt [patient] recommended to receive supervision during mealtime .Nursing educated to .continue supervision during mealtime.
During a surveyor interview on 8/10/2023 at approximately 10:30 AM with the Director of Nursing Services, she was unable to provide evidence that Resident ID #50 received adequate supervision while eating as indicated in his/her care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
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 residents are free...
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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 residents are free from significant medication errors for 1 of 7 residents reviewed for medication administration, Resident ID #29.
Findings are as follows:
Record review of a facility policy titled, Administering Medications states in part, .Medications are administered in a safe and timely manner, and as prescribed .
According to the article Drugs and Supplements, published by the Mayo Clinic, last updated on August, 1 2023, states in part, Clozapine (Oral Route) .Missed Dose
If you miss a dose of this medicine, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses. If you miss 2 or more days of clozapine doses, talk to your doctor before you start taking it again. You might have to restart the medicine at a lower dose than you were taking before .
Record review revealed the resident was admitted to the facility in July of 2023 with diagnoses including, but not limited to, neurocognitive disorder with lewy bodies (a form of dementia) and Parkinson's disease.
Record review of a Minimum Data Set assessment dated [DATE] revealed that the resident's cognitive skills for daily decision making were severely impaired.
Record review revealed a physician's order dated 7/13/2023 for an antipsychotic medication, Clozapine 25 milligrams give 1 tablet daily for neurocognitive disorder with lewy bodies.
Record review of the August 2023 Medication Administration Record revealed that Clozapine was not administered to the resident on the following dates:
- 8/3
- 8/4
- 8/10
Record review of the following progress notes revealed that the resident exhibited combative behaviors towards others and was resistive to care:
- 8/8/2023 at 4:44 PM: .Pt [patient] became upset at attempt to change dressing and became combative .
- 8/9/2023 at 5:49 AM: .Attempted to give resident medication. [S/he] swung at my face and I moved out of the way .swung at me again .told me to Get the [expletive] out. Resident is extremely combative with CNAs [Nursing Assistants] and nurses.
Record review failed to reveal evidence that the physician was notified of the missed Clozapine doses on 8/3, 8/4 and 8/10/2023.
Additionally, record review failed to reveal evidence that staff contacted the pharmacy to inquire about the Clozapine for the resident when staff had documented it was Unavailable on 8/4/2023 and 8/10/2023.
During a surveyor interview on 8/10/2023 at 11:19 AM with the Unit Manager, Registered Nurse, Staff D, she revealed that the physician should be notified if a resident misses a dose of a medication. Additionally, she revealed the pharmacy should be contacted if the medication is unavailable.
During a surveyor interview on 8/10/2023 at 1:31 PM with the Director of Nursing Services, she was unable to provide evidence that the resident received his/her Clozapine as ordered on the above-mentioned dates and would expect staff to notify the physician and document if a resident misses a dose of medication.
CONCERN
(D)
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 observations, 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 observations, record review, and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 1 of 2 medication storage rooms, the Country Unit.
Findings are as follows:
Review of the manufacturer's guidance for Lorazepam solution, indicates to date the bottle when opened and discard 90 days after opening.
1. During a surveyor observation on [DATE] at 1:18 PM, of the side 1, refrigerated narcotic locked box, in the presence of Registered Nurse, Staff B, revealed one bottle of Lorazepam 2 milligrams (mg)/milliliters (mL) opened and not dated.
During a surveyor interview with Staff B immediately following the above-mentioned observation, she acknowledged the findings.
2. During a surveyor observation on [DATE] at 1:32 PM, of the side 2, refrigerated narcotic locked box, in the presence of Registered Nurse, Staff F, revealed four opened bottles of Lorazepam 2 mg/mL. Three out of the four bottles were opened and not dated. One bottle was opened and labeled with the date of [DATE], indicating that was expired.
During a surveyor interview on [DATE] immediately following the above-mentioned observations with Staff F, she acknowledged the findings and indicated that the bottles should be dated when opened. Additionally, she indicated that the bottle labeled with the open date of [DATE] should have been discarded after 90 days.
During a surveyor interview with the Director of Nursing Services on [DATE] at 10:34 AM, she indicated that she would have expected the bottles of Lorazepam to be dated when opened and discarded after 90 days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to accommodate residents' food preferences for 3 of 21 sample residents revi...
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Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to accommodate residents' food preferences for 3 of 21 sample residents reviewed, Resident ID #s 29, 81, and 513.
Findings are as follows:
1. Record review revealed Resident ID #81 was admitted to the facility in May of 2022 with diagnoses including, but not limited to, obesity and type II diabetes.
Record review of the facility's diet menu choices for the resident revealed that the resident was lactose intolerant and had crossed off the option of macaroni and cheese for lunch on Tuesday, 8/8/2023.
During a surveyor observation on 8/8/2023 at 11:26 AM of the resident's lunch meal, revealed that the resident received macaroni and cheese.
Record review of the resident's diet slips of the lunch meal on 8/8/2023 and 8/9/2023 and the breakfast meal on 8/9/2023 revealed that the resident had an allergy to lactose and disliked cheese, cream, milk, all dairy products, and was not to have butter.
During surveyor observations on the following dates and times revealed that the resident received 2 dairy creamers and 1 packet of butter on his/her tray:
- 8/8/2023 at 11:26 AM
- 8/9/2023 at 8:14 AM
- 8/9/2023 at 12:14 PM
During a surveyor interview on 8/9/2023 at 12:14 PM with the resident, s/he revealed consuming dairy products causes him/her gastrointestinal distress.
2. Record review revealed Resident ID #29 was admitted to the facility in July of 2023 with diagnoses including, but not limited to, neurocognitive disorder with lewy bodies (a form of dementia) and Parkinson's disease.
Record review of the resident's breakfast diet slip for 8/10/2023 indicated the resident dislikes cranberry juice and prefers whole milk.
During a surveyor observation on 8/10/2023 at 8:19 AM of the resident's breakfast meal revealed the resident received cranberry juice and did not receive whole milk.
During a surveyor interview following the above observation on 8/10/2023 at 8:10 AM with Nursing Assistant, Staff G, she acknowledged that the resident received cranberry juice and did not receive whole milk on his/her breakfast tray.
During a surveyor interview on 8/10/2023 at 9:12 AM with the Administrator, he revealed that he would expect the resident's food preferences to be honored.
3. Record review revealed Resident ID #513 was admitted to the facility in August of 2023 with a diagnosis including, but not limited to, dementia.
Record review of the resident's breakfast diet slip for 8/9/2023 indicated the resident dislikes cranberry juice and milk.
During a surveyor observation on 8/9/2023 at 8:30 AM of the resident's breakfast meal revealed the resident received cranberry juice and milk.
During a surveyor interview on 8/10/2023 at 11:59 AM with the Food Service Director, she acknowledged that staff should not be placing dairy products on the tray for a resident if s/he is lactose intolerant. Additionally, she revealed that staff should be honoring the residents' food preferences.
During a surveyor interview on 8/10/2023 at 1:31 PM with the Director of Nursing Services, she was unable to provide evidence that staff was honoring the residents' food preferences.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, disp...
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Based on record review and staff interview, it has been determined that the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 4 of 7 residents reviewed for medication administration, Resident ID #s 29, 54, 81 and 507.
Findings are as follows:
Review of a facility policy titled, Pharmacy Services Overview states in part, .Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency, or as needed) in a timely manner .
1. Record review revealed that Resident ID #29 was admitted to the facility in July of 2023 with diagnoses including, but not limited to, neurocognitive disorder with lewy bodies (a form of dementia) and Parkinson's disease.
Record review revealed a physician's order dated 7/13/2023 for an antipsychotic medication, Clozapine 25 milligrams (MG) give 1 tablet daily for neurocognitive disorder with lewy bodies.
Record review of the August 2023 Medication Administration Record (MAR) revealed that Clozapine was not administered to the resident on 8/4 and 8/10 due to the medication being unavailable.
Record review failed to reveal evidence that the physician was made aware of the missed doses of Clozapine.
During a surveyor interview on 8/10/2023 at 11:19 AM with the Unit Manager, Registered Nurse, Staff D, she revealed the pharmacy and the physician should be contacted if the medication is unavailable.
2. Record review revealed that Resident ID #54 was admitted to the facility in November of 2022 with diagnoses including, but not limited to, Alzheimer's disease and type II diabetes mellitus.
Record review revealed a physician's order dated 1/6/2023 for Saccharomyces boulardii capsule 250 MG to administer daily.
Record review of the June, July and August 2023 MARs revealed that the resident did not get the above mentioned medication on the following dates:
6/26, 6/27, 6/28, 6/29, 6/30, 7/1, 7/2, 7/4, 7/5, 7/6, 7/19, 7/20, 7/21, 7/22, 7/23, 7/25, 7/26, 7/27, 8/4, 8/6, 8/7, 8/8, and 8/9/2023.
Review of the progress notes revealed that the medication was not available in the facility.
Further record review failed to reveal evidence that the physician was made aware of the medication not being administered as ordered.
During a surveyor interview on 8/9/2023 at 12:46 PM with Registered Nurse (RN), Staff B, she acknowledged that the medication had not been administered as ordered due to it being unavailable.
3. Record review revealed Resident ID #81 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, type II diabetes mellitus and obesity.
Record review revealed a physician's order dated 7/12/2023 for a lactase enzyme tablet to be administered prior to meals due to being lactose intolerant.
Review of the August 2023 MAR revealed that the resident did not receive the lactase enzyme on 8/6/2023 at 8 AM and 8/7/2023 at 8 AM, 12 PM, and 5 PM.
Review of the progress notes revealed that the medication was unavailable in the facility.
Record review failed to reveal evidence that the doctor had been made aware of the missed doses of the lactase enzyme as ordered.
During a surveyor interview on 8/10/2023 at 12:40 PM with the Central Supply Coordinator, Staff E, she revealed that she orders over the counter medications but that she was unaware that the medication needed to be ordered.
4. Record review revealed that Resident ID #507 was admitted to the facility in July of 2023 with diagnoses including, but not limited to, hypothyroidism (underactive thyroid) and heart failure.
Review of a physician's order dated 7/27/2023 for Colesevelam (medication used to lower cholesterol) 625 MG tablet to administer 2 tablets once a day.
Review of the August 2023 MAR revealed that the resident did not receive the Colesevelam medication on 8/1, 8/5, 8/6, 8/7 and 8/10/2023 due to the medication being unavailable.
Further review of the physician's orders revealed an order with a start date of 7/27/2023 for Levothyroxine Sodium 125 micrograms, administer 2 capsules in the morning.
Review of the August 2023 MAR revealed that the resident did not receive the Levothyroxine Sodium on 8/1, 8/7 and 8/8/2023.
Record review failed to reveal evidence that the physician had been made aware of the missed doses of medication.
During a surveyor interview on 8/10/2023 at approximately 11:20 AM with the Unit Manager, Staff D, she acknowledged that the medication had not been administered as ordered due to the medication being unavailable.
During a surveyor interview on 8/10/2023 at approximately 1:30 PM with the Director of Nursing Services she acknowledged the missed doses of medication and was unable to provide evidence that the facility provided pharmaceutical services, including acquiring medication to meet the needs of each resident.
Jul 2022
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to assure that services being provided meet professional standards of quality relativ...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to assure that services being provided meet professional standards of quality relative to following physician's orders for 1 of 3 residents reviewed for the use of TED (thrombo-embolus deterrent) stockings, Resident ID #344.
Findings are as follows:
According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
Record review revealed the resident was admitted to the facility in June of 2022 with diagnoses including, but not limited to, nondisplaced fracture of the right lower leg, atherosclerotic heart disease (buildup of fats and other substances) and atrial fibrillation (heart disease characterized by irregular and often faster heartbeat).
Record review of the physician orders revealed an order dated 7/5/2022 for TED Stockings one time a day. Apply before getting out of bed.
Surveyor observations on the following dates and times revealed the resident without his/her TED stockings while sitting in his/her wheelchair:
-7/6/2022 at 12:02 PM
-7/7/2022 at 9:32 AM
-7/7/2022 at 1:35 PM
-7/7/2022 at 2:32 PM
Additional record review of the Treatment Administration Record revealed the TED stockings were signed off by the nurse as applied on 7/6/2022 and 7/7/2022.
During a surveyor interview on 7/7/2022 at 2:37 PM with Staff A, she acknowledged the resident did not have his/her TED stockings on. Additionally, she could not explain why she had signed off that the TED stockings were applied on the dates mentioned above, when they were not observed on the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident is offered sufficient fluid intake to maintain proper hydration for 1 of 2 residen...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident is offered sufficient fluid intake to maintain proper hydration for 1 of 2 residents reviewed with a fluid restriction, Resident ID #1.
Findings are as follows:
Record review revealed the resident was admitted to the facility in February of 2020 with diagnoses including, but not limited to, chronic diastolic congestive heart failure (inability of the heart to pump adequately), chronic kidney disease, stage 5 (damage to the kidneys which can cause waste to build up in your body) and dependence on renal dialysis.
Record review of the care plan initiated on 3/25/2020 states in part, [Resident] is S/P [status post] AV [arteriovenous] Fistula [a connection between an artery and vein that provides good blood flow for dialysis to Left Arm r/t [related to] renal failure .receives hemodialysis . indicating an intervention to .Monitor intake and output .
Record review revealed a physician's order with a start date of 9/3/2020 which states, Fluid Restrictions 1200 ml [milliliters]/Daily three times a day 120 ml am meds, 60 ML afternoon, 60ml PM, 120ml HS [hour of sleep] meds, 480ml Breakfast, 120ml Lunch 240ml Dinner.
Review of the July 2022 Medication Administration Record (MAR) failed to reveal evidence of the resident's fluid intake. Further record review failed to reveal any evidence of the amount of fluid intake consumed by the resident.
During a surveyor interview on 7/11/2022 at 1:51 PM with the charge nurse, Staff B, she acknowledged that the resident's fluid intake was not documented and she was unable to provide evidence of the resident's fluid intake.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards ...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, for 1 of 2 residents reviewed for dialysis, Resident ID #1.
Findings are as follows:
Record review revealed the resident was admitted to the facility in February of 2020 with diagnoses including, but not limited to, chronic kidney disease, stage 5 (damage to the kidneys which can cause waste to build up in your body) and dependence on renal dialysis.
Record review revealed the resident receives hemodialysis each week on Tuesday, Thursday, and Saturday.
Record review of the physician orders relative to dialysis care revealed an order dated 8/5/2020 for L [left] A/V [arteriovenous] fistula [a connection between an artery and vein that provides good blood flow for dialysis] check for bruit [usually heard with a stethoscope] and thrill [felt on the overlying skin as a vibration] every shift three times a day.
During a surveyor interview on 7/8/2022 at 2:41 PM with Licensed Practical Nurse, Staff C, she was unable to explain how to check for a bruit and thrill for a resident with an AV fistula.
During an interview on 7/8/2022 at 2:47 PM with the Director of Nursing Services, she indicated that education would be provided to Staff Nurse C to ensure residents with an AV fistula receive care and services consistent with professional standards of practice.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen was reviewed and acted upon by the attending physician, when irregularit...
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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 was reviewed and acted upon by the attending physician, when irregularities were identified during the monthly Pharmacist Medication Regimen Review (MRR) for 1 of 6 residents reviewed, Resident ID #26.
Findings are as follows:
Record review revealed the resident was admitted to the facility in May of 2022 with diagnoses including, but not limited to, chronic pain syndrome and overactive bladder.
Record review revealed a pharmacy consult note dated 5/10/2022 which states in part, .review completed .Medications reviewed for necessary and clinical indication for use, appropriate dosing and with adequate monitoring. Performed .REC [recommendations]: see reports.
Further record review failed to reveal evidence of the MRR irregularity report or evidence that the recommendation was addressed.
During a surveyor interview on 7/8/2022 at 11:10 AM with the Unit Manager, Staff D, she was unable to locate the resident's MRR report from 5/10/2022. Additionally, she was unable to provide evidence that the report was reviewed by the physician.
During a surveyor interview on 7/8/2022 at 11:45 AM with the Director of Nursing Services (DNS), she revealed that she had to request a copy of the report from the pharmacy. Additionally, the DNS was unable to explain why the pharmacy irregularity report had not been reviewed and acted upon by the physician.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure licensed nurses have the specific competencies and skill sets necessary to care for residents' nee...
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Based on record review and staff interview, it has been determined that the facility failed to ensure licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Findings are as follows:
Record review of the facility assessment completed on January of 2022 and updated on 5/30/2022 revealed, Services required by our resident population: .Hemodialysis - Provided Through Contract or Outside Service.
Record review of the facility policy titled Hemodialysis Access Care revealed the following:
Steps in the Procedure
Care of AVFs (arterio-venous fistula) .
.4. To prevent infection and/or clotting:
.h. Check patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit of blood flow through the access.
During a surveyor interview with Staff Nurse C on 7/8/2022 at 2:41 PM, she was unable to explain how to assess a bruit and thrill for a resident receiving dialysis with an AVF.
Record review of the facility nurse competency log for Staff C, failed to reveal evidence that she completed hemodialysis training.
Further record review of the facility nurse competencies related to hemodialysis, revealed only 4 nurses out of 17 had completed competency training for hemodialysis.
During a surveyor interview with the Assistant Director of Nursing Services on 7/11/2022 at approximately 11:00 AM, she was unable to provide evidence that Staff C had completed the competency training for hemodialysis. Additionally, she was unable to provide completed competencies for hemodialysis for all licensed nurses.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident's drug regimen is free from unnecessary drugs for 1 of 6 residents reviewed rel...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident's drug regimen is free from unnecessary drugs for 1 of 6 residents reviewed relative to unnecessary medication, Resident ID #26.
Findings are as follows:
Record review of the facility policy titled, Administering Pain Medications states in part, The purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication .Steps in the Procedure .Conduct a pain assessment as indicated .Administered pain medication as ordered .
Record review revealed the resident was admitted to the facility in May of 2022 with diagnoses including, but not limited to, fracture of the right femur and chronic pain syndrome.
Record review of the physician's orders revealed the following:
-5/3/2022 to 5/27/2022 states in part, Oxycodone HCL (a narcotic medication used to help relieve moderate to severe pain) Tablet 5 MG (milligrams) Give 5 mg by mouth every 6 hours as needed for moderate to severe pain .
-5/27/2022 to 6/10/2022 states in part, Oxycodone HCL Tablet: 5 mg Give 5 mg by mouth every 6 hours as needed for moderate to severe pain .
-6/11/2022 to 6/22/2022 states, Oxycodone HCL Tablet 5 MG Give 1 tablet by mouth every 4 hours as needed for pain for 10 Days Give 5 mg by mouth every 4 hours as needed for moderate to severe pain.
-Current order dated 6/22/2022 states, Oxycodone HCL tablet: 5 MG Give 5 mg by mouth every 8 hours as needed for moderate to severe pain.
Record review of the May, June, and July 2022 Medication Administration Record (MAR) revealed oxycodone was administered for the resident on the following dates outside the ordered parameters:
Month of May:
-pain level of 0 on 5/16, and 5/23/2022
-pain level of 3 on 5/14, and 5/19/2022
-pain level of 4 on 5/9/2022
Month of June:
-pain level of 4 on 6/1, 6/6, and 6/9/2022
Month of July:
-pain level of 2 on 7/2/2022
-pain level of 4 on 7/5/2022
During a surveyor interview on 7/8/2022 at approximately 11:10 AM with Staff D, she revealed that a pain level of 5 or above indicates moderate to severe pain. Additionally, she acknowledged that staff had administered the oxycodone for a pain level less than what was indicated in the order on several occasions.
During a surveyor interview on 7/8/2022 at approximately 11:26 AM with the Assistant Director of Nurses, she revealed a pain level of 5 or above indicates moderate to severe pain. Additionally, she revealed that she would expect staff to follow the physician's order when administering the above mentioned medication.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure tha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the facility stores, distributes, and serves food in accordance with professional standards for food service safety relative to the main kitchen and 1 of 3 kitchenettes.
Findings are as follows:
The State of Rhode Island Food Code 2018 edition, titled 4-601.11 Equipment, Food-Contact Surfaces, Non-Food-Contact Surfaces, and Utensils states in part, .(B) The food-contact surfaces of cooking equipment .shall be kept free of encrusted grease deposits and other soil accumulations .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.
The State of Rhode Island Food Code 2018 edition, titled 3-305.12 Food Storage, Prohibited areas states in part, Food may not be stored: .(I) under other sources of contamination.
1. The initial tour of the main kitchen on 7/6/2022 at 8:30 AM revealed the following observations:
A. The ice machine had an orange substance on the inside.
B. 8 blue plastic ready to use coffee cups, with scrapable brown matter accumulation on the inside of the cups.
C. A fan, with an accumulation of dust (on the blades and encasement), blowing in the direction of 6 clean stainless steel pans observed at 8:30 AM. An additional observation at 8:57 AM revealed the same fan facing and blowing in the direction of 24 clean coffee cups.
D. An accumulation of dust and grease on the metal slats within the exhaust hood, located behind the stove.
E. Built up black debris found stuck to the inside of the toaster and crumbs stuck in the ridges of all 3 dials.
F. A can opener with dried matter stuck to the blade and inside the holder where the can opener is placed.
During a surveyor interview with the Food Service Director (FSD), on 7/6/2022 at approximately 9:10 AM, she acknowledged that the above-mentioned items needed to be cleaned.
G. A 5-pound bag of potatoes was found lying inside a clear plastic container resting on top of loose onions.
H. In the freezer a pound of wrapped liverwurst was found to have freezer burn.
During a surveyor interview with the FSD on 7/6/2022 at approximately 9:10 AM, she acknowledged the potential for food contamination and revealed the bag of potatoes should not be stored on top of the onions. Additionally, she acknowledged the liverwurst had freezer burn and should be discarded.
I. A subsequent surveyor observation of the main kitchen on 7/7/2022 at 11:30 AM revealed an additional 24 blue plastic ready to use coffee cups with scrapable brown matter accumulated on the inside of the cups.
During a surveyor interview with the FSD on 7/7/2022 at 11:30 AM, she acknowledged that the mugs needed to be scrapped clean and rewashed.
2. During a surveyor observation of the Country Meadow kitchenette refrigerator in the presence of the Regional FSD on 7/8/2022 at 10:50 AM revealed three 8 oz Ensure Clear and two 8 oz Glucerna nutritional supplements that were opened and not dated. Manufacturer's instructions on the cartons indicated to use within 48 hours of opening.
During a surveyor interview with the FSD on 7/8/2022 at approximately 1:30 PM, she acknowledged that the Ensure Clear and the Glucerna shake supplements should be dated [NAME] opened.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "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
- • Multiple safety concerns identified: Federal abuse finding, 1 life-threatening violation(s), 2 harm violation(s), $27,940 in fines. Review inspection reports carefully.
- • 29 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $27,940 in fines. Higher than 94% of Rhode Island facilities, suggesting repeated compliance issues.
- • Grade F (18/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Bayview Rehabilitation And Healthcare Center's CMS Rating?
CMS assigns Bayview Rehabilitation and Healthcare Center an overall rating of 3 out of 5 stars, which is considered average nationally. Within Rhode Island, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Bayview Rehabilitation And Healthcare Center Staffed?
CMS rates Bayview Rehabilitation and Healthcare Center's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 52%, compared to the Rhode Island average of 46%.
What Have Inspectors Found at Bayview Rehabilitation And Healthcare Center?
State health inspectors documented 29 deficiencies at Bayview Rehabilitation and Healthcare Center during 2022 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 26 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Bayview Rehabilitation And Healthcare Center?
Bayview Rehabilitation and Healthcare Center is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by MARQUIS HEALTH SERVICES, a chain that manages multiple nursing homes. With 120 certified beds and approximately 110 residents (about 92% occupancy), it is a mid-sized facility located in North Kingstown, Rhode Island.
How Does Bayview Rehabilitation And Healthcare Center Compare to Other Rhode Island Nursing Homes?
Compared to the 100 nursing homes in Rhode Island, Bayview Rehabilitation and Healthcare Center's overall rating (3 stars) is below the state average of 3.1, staff turnover (52%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Bayview Rehabilitation And Healthcare Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.
Is Bayview Rehabilitation And Healthcare Center Safe?
Based on CMS inspection data, Bayview Rehabilitation and Healthcare Center has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Rhode Island. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Bayview Rehabilitation And Healthcare Center Stick Around?
Bayview Rehabilitation and Healthcare Center has a staff turnover rate of 52%, which is 6 percentage points above the Rhode Island average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Bayview Rehabilitation And Healthcare Center Ever Fined?
Bayview Rehabilitation and Healthcare Center has been fined $27,940 across 1 penalty action. This is below the Rhode Island average of $33,358. 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 Bayview Rehabilitation And Healthcare Center on Any Federal Watch List?
Bayview Rehabilitation and Healthcare Center is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.