Pawtucket Falls Healthcare Center
For profit - Limited Liability company
154 Beds
THE MAYER FAMILY
Data: November 2025
4 Immediate Jeopardy citations
Trust Grade
0/100
#67 of 72 in RI
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Pawtucket Falls Healthcare Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided. It ranks #67 out of 72 nursing homes in Rhode Island, placing it in the bottom half of facilities statewide, and #38 out of 41 in Providence County, meaning there are very few local options that perform better. While the facility is showing improvement, with issues decreasing from 48 in 2023 to 14 in 2024, there are serious weaknesses, including $295,995 in fines, which is higher than 91% of Rhode Island facilities. Staffing is relatively good with a 4 out of 5 star rating and a turnover rate of 32%, which is below the state average. However, there have been critical incidents, including a staff member with COVID-19 working in the kitchen and a failure to screen new residents for sex offender status, which led to a vulnerable resident being harmed.
- Trust Score
- F
- In Rhode Island
- #67/72
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 32% turnover. Near Rhode Island's 48% average. Typical for the industry.
- Penalties ○ Average
- $295,995 in fines. Higher than 51% of Rhode Island facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 28 minutes of Registered Nurse (RN) attention daily — below average for Rhode Island. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 65 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 7%
Review needed
48 → 14 violations
★☆☆☆☆
1.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 48 issues
2024: 14 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (32%)
16 points below Rhode Island average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
1-Star Overall Rating
Below Rhode Island average (3.0)
Significant quality concerns identified by CMS
Staff Turnover: 32%
14pts below Rhode Island avg (46%)
Typical for the industry
Federal Fines: $295,995
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: THE MAYER FAMILY
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 65 deficiencies on record
4 life-threatening 3 actual harm
Dec 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 F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
Based on record review, staff, and resident interview, it has been determined that the facility failed to provide medically-related social services to attain or maintain the highest practicable physic...
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Based on record review, staff, and resident interview, it has been determined that the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 2 residents reviewed who alleged staff to resident abuse, Resident ID #2.
Findings are as follows:
Review of a facility reported incident submitted to the Rhode Island Department of Health on 12/14/2024 revealed a verbal altercation occurred between Resident ID #2 and a staff member regarding his/her roommate's care. Further review revealed the staff member was suspended pending the facility's investigation and removed from the resident's roommate's assignment.
Record review revealed Resident ID #2 was admitted to the facility in December of 2019 with diagnoses including, but not limited to, anxiety disorder and major depressive disorder.
Review of a Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status score of 15 out of 15, indicating the resident's cognition was intact.
During a surveyor interview on 12/23/2024 at 10:02 AM with Nursing Assistant (NA), Staff A, she indicated that while she was in the resident's room assisting his/her roommate, she and Resident #2 began arguing related to oral care. She further indicated that Resident ID #2 told her to shut up and she responded with make me! Additionally, she indicated that Resident #2 frequently yells at her and she lost her cool at that time. Furthermore, she indicated that the nurse removed her from the resident's room.
During a surveyor interview on 12/23/2024 at 10:33 AM with Licensed Practical Nurse, Staff B, she indicated that she was the unit nursing during the time of the altercation and heard the staff member and resident yelling at each other. She further indicated that she told Staff A to leave the room, notified the nursing supervisor and returned to passing medications.
During a surveyor interview on 12/23/2024 at approximately 12:15 PM with Resident ID #2, s/he indicated that a NA had began yelling at him/her while she was in the room caring for his/her roommate. The resident further indicated that s/he told the NA to shut up and the NA responded with make me! Additionally, the resident indicated that s/he felt physically threatened by the NA, as she was walking towards him/her.
During a surveyor interview on 12/23/2024 at approximately 12:30 PM with the Social Worker (SW), Staff C, she indicated that she was aware of the incident that had recently occurred between Staff A and Resident ID #2. She further indicated that she spoke with the resident following the incident however, did not document the conversation. Additionally, she indicated that she did not follow up with the resident following the altercation.
During a surveyor interview on 12/23/2024 at 12:55 PM and 1:20 PM with the Director of Nursing Services, she indicated that the alleged staff to resident altercation had been substantiated by the facility and that Staff A had been re-educated and disciplined. Additionally, she indicated that she would expect the SW to update the resident's care plan and document that she followed up with the resident.
Dec 2024
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure that assessments accurately reflect the residents' status for 1 of 1 resident reviewed relative to a fall with injury, Resident ID #75.
Findings are as follows:
Record review revealed Resident ID #75 was readmitted to the facility in September of 2024 with a diagnosis including, but not limited to, unspecified fracture of the lower end of the left radius (a long bone in the forearm that helps you move your arm and wrist).
Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has a Brief Interview for Mental Status score of 14 out of 15 indicating intact cognitive function.
Record review of Residents ID #75's progress notes revealed the following:
- 9/18/2024 at 5:22 AM revealed the resident was found in a sitting position on the floor in his/her room and was complaining of pain to his/her left wrist with swelling noted.
- 9/18/2024 at 6:55 PM x-rays were completed at the facility and showed possible left wrist fracture.
- 9/19/2024 at 7:24 PM the resident presented with increased confusion, irregular cardiac rhythm and was sent out to the hospital.
- 9/24/2024 at 5:34 AM the resident was transported to the hospital on 9/19/2024 with a change in mental status and a left wrist fracture secondary to a fall. The resident returned to the facility on 9/23/2024 with a soft cast and instructions for non-weight bearing to his/her left upper extremity.
Record review of the residents's Quarterly MDS assessment dated 9/272024, section J, failed to reveal documentation of the above mentioned falls, as required.
During a surveyor interview on 12/10/2024 at 1:30 PM with Registered Nurse, Staff A, he revealed the MDS Assessment should have reflected the resident's fall sustained on 9/18/2024 and it did not.
Subsequent record review following the above interview with Staff A revealed, the resident's Quarterly MDS dated [DATE] had been revised on 12/10/2024 to include the resident's fall on 9/18/2024. However, the revision did not include that the resident sustained an injury from the fall.
During a surveyor interview on 12/12/2024 at 10:08 AM with the resident, s/he revealed that the fracture to his/her left wrist was not an old injury as s/he had no issues with his/her wrist until after s/he fell on 9/18/2024.
During a surveyor interview on 12/11/2024 at 12:11 PM with the Director of Nursing Services she acknowledged that the MDS assessment was coded inaccurately, and she would have expected the MDS to accurately represent the resident status during the observation period.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice re...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following physician's order for obtaining orthostatic blood pressure (a form of low blood pressure that happens when standing up from a sitting or lying down position) for 1 of 1 resident reviewed, Resident ID #76.
Findings are as follows:
According to Mosby's 4th Edition, Fundamentals of Nursing, page 314, states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients.
According to Jensen's 4th Edition, Nursing Health Assessment, A Clinical Judgement Approach page 118 states in part, Orthostatic vital signs are measured in patients to assess for a drop in blood pressure and heart rate with position changes .Assess BP [blood pressure] with patient supine [lying position] sitting, and then standing. The patient should rest supine for at least 2 minutes before the assessment of the baseline reading. Repeat measurements with the patient sitting and standing, wait 1-2 minutes after each position change to assess the readings .
Record review revealed the resident was admitted to the facility in October of 2024 with diagnoses including, but not limited to, dementia and repeated falls.
Record review of a physician's order dated 10/12/2024 through 11/12/2024 and a new start date of 11/13/2024 through 11/19/2024, revealed an order to check the resident's orthostatic blood pressure two times a day, on the morning and evening shifts.
Record review of the November 2024 Medication Administration Record (MAR) failed to reveal evidence that orthostatic vital signs had been completed.
During a surveyor interview with the Director of Nursing Services (DNS) on 12/12/2024 at 10:05 AM, she indicated that the orthostatic blood pressures were ordered due to the amount of recurrent falls that the resident had sustained. The DNS indicated that she would expect the staff to check and document the resident's orthostatic blood pressure, as ordered.
During a surveyor interview with Nurse Practitioner, Staff B, on 12/12/2024 at 11:24 AM, she indicated that she had ordered the orthostatic blood pressures to be obtained because the resident has complained of severe vertigo (a sudden internal or external spinning sensation, often triggered by moving your head too quickly) and it has resulted in the resident having multiple falls. Staff B indicated that she would expect the resident's orthostatic blood pressure to be obtained, as ordered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure a resident with limited range of motion (ROM) receives appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM for 1 of 2 residents reviewed with contractures, Resident ID #13.
Findings are as follows:
Review of the facility's policy titled Splints/Orthotics/Prosthetics [medical devices used to assist when physical impairments or limitations are present] states in part, Residents will receive splint/orthotics/prosthetics as deemed appropriate by the physician and rehabilitation services .Nursing staff will apply/remove the designated splint/orthotics/prosthetic device during scheduled wearing times .
Record review revealed the resident was readmitted to the facility in November of 2024 with diagnosis including, but not limited to, Parkinson disease (a progressive neurological disorder that causes nerve cells in the brain to die which affects movement including stiffness, and loss of balance).
Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 10 out of 15 indicating a moderate cognitive impairment.
Record review of a Quarterly MDS assessment dated [DATE] revealed the resident has upper extremities impairments on both sides. Further review of this assessment revealed the resident is totally dependent on staff for all activities of daily living, including transfers, eating, dressing, toileting, and bed mobility.
Record review of a care plan with revision dates of 3/5/2024 and 6/12/2024 revealed the resident is at risk for a decline in physical function. Staff interventions include, but are not limited to, provide carrot (a device used to prevent contractures) to left hand and bilateral palm guards (devices that are used as a barrier between the fingers and the palm to prevent injury to the palm from severe finger contractures).
Record review revealed a physician's order initiated on 8/7/2023 to place the carrot in the resident's left hand every shift, as tolerated.
During surveyor observations of the resident on 12/10/2024 at 9:08 AM, 10:46 AM, 11:37 AM, and 2:01 PM, s/he was observed in bed with bilateral hands contracted and the carrot was not applied to his/her left hand, as ordered.
Further record review of the Treatment Administration Record for December 2024 revealed the order for the carrot was signed off by Licensed Practical Nurse (LPN), Staff C as being completed on 12/10/2024, although the carrot was not observed to be in his/her left hand. Additionally, the record failed to reveal evidence the resident had refused the carrot.
Additional surveyor observations on the following dates and times revealed that the bilateral palm guards were not applied as indicated in his/her care plan:
- 12/09/2024 9:48 AM
- 12/10/2024 9:08 AM
- 12/10/2024 10:46 AM
- 12/10/2024 11:20 AM
- 12/10/2024 11:37 AM
- 12/10/2024 02:01 PM
- 12/10/2024 03:01 PM
- 12/11/2024 08:15 AM
- 12/11/2024 09:59 AM
During a surveyor interview with the resident on 12/10/2024 at 2:05 PM, s/he indicated that s/he was not utilizing the carrot or bilateral palm guards and stated that s/he had not been offered these devices by the staff on this date.
During a surveyor interview with LPN, Staff C, on 12/11/2024 at 9:16 AM, she indicated that she is responsible for applying the carrot to the resident's left hand as ordered. She indicated that she was not aware that the resident should have been wearing bilateral palm guards. Additionally, Staff C could not provide evidence the resident was using the carrot as ordered though she had signed off the carrot was in place on 12/10/2024.
During a surveyor interview with the Director of Nursing Services (DNS) on 12/11/2024 at 11:47 AM, she could not provide evidence as to why the resident's bilateral contractures were not being addressed. The DNS indicated that she would expect the staff to apply the carrot to the resident's left hand as ordered and the bilateral palm guards as indicated in the care plan. Additionally, the DNS indicated that if the resident refuses either of these devices, the staff should document the refusals in the resident's record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, and staff interview, it has been determined that the facility failed to ensure that residents ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a treatment that removes excess fluid, waste, and toxins from the blood when the kidneys are no longer functioning properly) receive such services, consistent with professional standards of practice for 1 of 2 residents reviewed for fluid restrictions, Resident ID #30.
Findings are as follows:
Record review of a facility policy titled Fluid Restrictions states in part, .The fluid restriction breakdown should be documented in the Medication Administration Record (MAR), as well as dietary or tray card .
Record review revealed the resident was admitted to the facility in July of 2024 with diagnoses including, but not limited to, end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) and cerebral infarction (a condition when blood flow to the brain is blocked, causing brain cells to die).
Further record review revealed the resident receives outpatient dialysis three times a week on Monday, Wednesday, and Fridays.
Review of a Quarterly Minimum Data Set assessment dated [DATE], revealed the resident has a Brief Interview for Mental Status score of 13 out of 15 indicating intact cognitive function.
Record review of a care plan revised on 12/8/2024 included an intervention for fluid restrictions per the physician's order.
Record review revealed the resident has a physician's order that was initiated on 10/25/2024 for a fluid restriction of 1000 milliliters (mL) daily.
Record review of the Medication Administration Records (MAR) for November 2024 and December 2024 failed to reveal evidence that the resident's 1000 mL daily fluid restriction was documented per the facility's policy.
During a surveyor observation of the resident on 12/9/2024 at approximately 10:00 AM, revealed s/he was waiting to be picked up for dialysis and had received a 240 mL cup of coffee provided to him/her by Activities Aide, Staff D.
During a surveyor interview on 12/9/2024, following the above observation with Staff D, she indicated that she was unaware of Resident ID #30's fluid restriction order.
During a surveyor interview with the resident on 12/10/2024 at 2:36 PM, s/he indicated that s/he was unaware of the physician's order for a fluid restriction. Additionally, s/he was observed to be drinking from a 480 mL travel mug.
During a surveyor interview on 12/11/2024 at 9:23 AM with Nursing Assistant, Staff E, she revealed that she was unaware that Resident ID #30 had an order for a fluid restriction.
During a surveyor interview on 12/11/2024 at 9:48 AM with Unit Manager, Staff F, she acknowledged that Resident ID #30 has a physician's order for a 1000 ml daily fluid restriction. Staff F was unable to provide evidence that the resident's daily fluid intake was being monitored.
During a surveyor interview on 12/11/2024 at 11:59 AM with the Director of Nursing Services she indicated it was her expectation that the staff would be aware of all residents with orders for a daily fluid restriction, that the resident's daily total fluid intake would be monitored, documented in the MAR.
Record review failed to reveal evidence that the facility was monitoring Resident ID #30's total daily fluid intake from 10/25/2024 per the physician's order, until after it was brought to the facility's attention by the surveyor, on 12/11/2024.
Aug 2024
6 deficiencies
2 IJ (2 facility-wide)
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Based on record review and staff interview, it has been determined that the facility was not being administered in a manner that enabled it to utilize resources effectively and efficiently to maintain...
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Based on record review and staff interview, it has been determined that the facility was not being administered in a manner that enabled it to utilize resources effectively and efficiently to maintain the highest practicable physical, mental and psychosocial well-being of each resident related to infection control. This failure resulted in immediate jeopardy for F 880. Additionally, the Administrator directed an employee, who did not have a Food Safety Manager Certification, to work as the only cook in the main kitchen for all of the facility's residents.
Findings are as follows:
As a result of the survey investigation, it was determined that the Director of Housekeeping, Staff A, who tested positive for COVID-19 on 7/31/2024, was directed by the Administrator to report to the facility and work as the [NAME] on 8/3/2024 and 8/4/2024. Additionally, Staff A does not have a Food Safety Manager Certification to work as a cook.
During a surveyor interview on 8/7/2024 at 10:24 AM with Staff A, she indicated that she was directed by the Administrator on 8/3/2024 to come into work on 8/3/2024 and 8/4/2024 as the Cook, due to no other certified dietary staff members being available during those shifts. Staff A revealed that she did work on those dates, while COVID-19 positive.
Record review failed to reveal evidence that Staff A has a Food Safety Manager Certification.
Record review revealed there were 13 residents who tested positive for COVID-19 on 8/6/2024 and another 13 residents tested positive on 8/8/2024, indicating a total of 26 residents were now positive for COVID-19. Of note, there were no COVID-19 positive residents prior to this COVID-19 positive staff member working.
Record review of the text messages exchanged between Staff A and the Administrator dated 8/3/2024 revealed the Administrator was aware that Staff A had tested positive for COVID-19 and ordered her to cover the open shifts in the kitchen as the cook for 8/3 and 8/42024.
During a surveyor interview on 8/7/2024 at 11:40 AM with the Administrator, she acknowledged that Staff A was COVID-19 positive and worked on 8/3/2024 and 8/4/2024. The Administrator further acknowledged that it is not the expectation for staff, who are COVID-19 positive, to report to work during their COVID-19 quarantine period.
Cross reference F 812 and F 880
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Based on record review and staff interview, it has been determined that the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment an...
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Based on record review and staff interview, it has been determined that the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by allowing a staff member who tested positive for COVID-19 on 7/31/2024, to work as the cook in the kitchen during the evening shift on 8/3/2024 and during the morning and evening shifts on 8/4/2024.
Findings are as follows:
Record review of the current guidance from the Center for Disease Control (CDC) titled, Interim Guidance for Managing Healthcare Personnel [HCP] with SARS-CoV-2 [COVID-19] Infection or Exposure to SARS-COV-2 states in part, Return to Work Criteria for HCP with SARS-CoV-2 Infection .HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met:
- At least 7 days have passed since symptoms first appeared if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and
- At least 24 hours have passed since last fever without the use of fever-reducing medications, and
- Symptoms (e.g., cough, shortness of breath) have improved.
*Either a NAAT (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later .
Record review of a community reported complaint submitted to the Rhode Island Department of Health on 8/5/2024 alleges in part, that the Housekeeping Director, Staff A, is positive for COVID-19; and the Administrator forced Staff A to come to the building and cook for the residents because there are no cooks, for two days while positive for COVID-19.
Record review of a laboratory report dated 7/31/2024, revealed that Staff A tested positive for COVID-19 via an antigen-based test.
Record review of Staff A's employee time sheets revealed that she was working in the facility on the following dates:
- Saturday, 8/3/2024, 3:20 PM through 6:00 PM
- Sunday, 8/4/2024, 5:23 AM through 5:49 PM
During surveyor interviews with Staff A on 8/6/2024 at 2:01 PM and on 8/7/2024 at 10:25 AM, she revealed that she started to become symptomatic for COVID-19 on Tuesday, 7/30/2024 with body aches and congestion, but tested negative for COVID-19 on a home antigen-based test. She further revealed she had taken another test at the facility, on 7/31/2024, which revealed a positive result for COVID-19. She indicated she informed the facility's Infection Preventionist, who instructed her to leave the facility and that she would be able to return to work on Wednesday, 8/7/2024 if she tested negative for COVID-19 on Sunday, 8/4/2024. Additionally, Staff A revealed she had been helping oversee the kitchen with scheduling and ordering food since 7/16/2024 and was responsible for ensuring that there was coverage of at least one cook for the preparation of all meals. On 8/1/2024, she made the Administrator aware that there was not a cook scheduled to work in the kitchen for the evening of 8/3 and both the morning and evening of 8/4. Additionally, Staff A indicated that she was directed by the Administrator on Saturday, 8/3/2024 to report to work and cover the kitchen as it was her responsibility. She further revealed that she was worked in the kitchen the evening of 8/3/2024 and on 8/4/2024 for 12 hours, while she was positive for COVID-19.
Staff A further revealed that while she was preparing dinner on 8/3 and all three of the meals on 8/4, she did not wear a surgical or a N95 (respirator) mask.
During a surveyor interview with the Infection Preventionist (IP) on 8/6/2024 at 1:41 PM, she revealed that she follows the CDC guidance regarding staff returning to work after testing positive for COVID-19. She acknowledged that Staff A tested positive for COVID-19 on 7/31/2024 and left the facility immediately after receiving the positive result. She revealed she had instructed Staff A to take a test on Sunday, 8/4/2024 (Day 5) and she would be able to return to work on Wednesday, 8/7/2024 if her test on 8/4 was negative. The IP revealed she was unaware that Staff A was in the facility, working in the kitchen, on 8/3/2024 and 8/4/2024, during her 7-day isolation period.
During a surveyor interview with the Administrator on 8/7/2024 at 11:40 AM, she revealed that she was aware that Staff A had tested positive for COVID-19, and was working in the kitchen on Saturday, 8/3/2024 and on Sunday, 8/4/2024. She further revealed that she would not expect staff to return to work in the facility while still in their 7-day isolation period for COVID-19.
Record review of surveillance testing for residents on 8/6/2024 revealed 13 residents tested positive for COVID-19 and another 13 residents tested positive on 8/8/2024, indicating a total of 26 residents were now positive for COVID-19. Of note, there were no COVID-19 positive residents in the facility prior to this staff member working while COVID-19 positive.
Cross reference F 812 and F 835.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed for medi...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed for medication administration, Resident ID #5.
Findings are as follows:
Record review revealed the resident was admitted to the facility in July of 2024 with diagnoses including, but not limited to, acute respiratory failure with hypoxia (the impairment of gas exchange between the lungs and the blood causing a lack of oxygen), atrial fibrillation (afib; a condition in which the heart pumps irregularly), alcohol dependence, urinary retention and hypertension (high blood pressure).
Record review of a hospital Continuity of Care - Post-Acute Facility document dated 7/15/2024 indicated the resident was diagnosed with urinary retention and failed voiding trials on various occasions. During his/her hospital stay, s/he had a urology consult and a urinary catheter was placed and ordered to remain in place until the resident was seen by urology for an evaluation.
Additional review of the document revealed that the resident is to continue Flomax (a medication to treat symptoms of an enlarged prostate and helps to relaxes the muscles of the bladder). Further review of the hospital Continuity of Care - Post-Acute Facility document revealed the following medication orders:
START taking these medications.
-Vitamin B-12 (a supplement for vitamin B deficiency) 500 mcg (micrograms) by mouth once daily.
-Folic acid (a supplement that helps with forming red blood cells) 1 mg (milligram) by mouth once daily.
-Lasix 40 (a medication to treat fluid retention) mg by mouth once daily.
-Flomax 0.4 mg by mouth at bedtime.
CHANGE how you take these medications.
-Metoprolol tartrate (a medication to treat high blood pressure and to assist with heart rate control) 50 mg by mouth two times a day
CONTINUE taking these medications.
-Aspirin (a medication that helps to lower the risk of a heart attack or stroke) 81 mg enteric coated by mouth once daily
STOP taking these medications.
-Heparin (an anticoagulant medication often used to prevent blood clots from forming or an obstruction in an artery) 5000 units/mL (milliLiter) injection
Record review of the physician's orders failed to reveal evidence that the Aspirin, Vitamin B-12, Folic acid or Lasix were implemented upon admission as ordered, indicating the resident had not received these medications for 24 days. Additionally, the Flomax was not initiated as ordered until 7/25/2024, after s/he was seen by the urologist, indicating the resident missed 9 doses of the medication.
Record review revealed an order with a start date of 7/16/2024 for Metoprolol tartrate 50 mg, give 3 tablets (150 mg total dose) by mouth one time a day in the morning. Further review revealed an additional order was implemented for Metoprolol 50 mg by mouth at bedtime with a start date of 7/17/2024, indicating the resident received an extra 50 mg of the medication on 7/16/2024 and an extra 100 mg of the medication for 22 days.
Record review revealed an order dated 7/16/2024 for Heparin 5000 units/ml, inject 1.5 ml subcutaneous (under the skin) every eight hours, indicating the resident has been receiving this medication for 23 days and it was not discontinued as ordered.
Record review of the provider's progress note dated 7/18/2024 states in part, .Assessment and Plan .History of afib .Continue aspirin. Patient off Metoprolol due to bradycardia [when the heart beats more slowly than usual]. Not on anticoagulation .
During a surveyor interview on 8/8/2024 at 3:28 PM with the Director of Nursing Services (DNS), after the above multiple medication errors were brought to her attention, she was unable to explain why the hospital Continuity of Care - Post-Acute Facility medication orders were not followed.
During a surveyor interview on 8/8/2024 at 4:00 PM with the resident's physician, after he was made aware of the surveyor's findings by the DNS, he revealed that he was unaware of the medication discrepancies and he would review the resident's medications in detail.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0940
(Tag F0940)
Could have caused harm · This affected multiple residents
Based on record review and staff interview it has been determined that the facility failed to develop, implement, and maintain an effective training program for all newly hired employees and annual tr...
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Based on record review and staff interview it has been determined that the facility failed to develop, implement, and maintain an effective training program for all newly hired employees and annual training for existing employees consistent with their expected roles, relative to education involving abuse, infection control, dementia behavioral health management, trauma informed care and QAPI (Quality Assurance and Performance Improvement) per the facility assessment, for 9 of 9 newly hired or existing employees, Staff A, B, C, D, F, G, H, I and J.
.
Findings are as follows:
Review of the Facility Assessment, dated 11/15/2023, reveals in part, .[The facility] provides the following training topics .that include, but are not limited to:
In-Service
Resident's Rights .
Abuse, neglect, and exploitation .
Care/management for persons with dementia .
QAPI .
Infection Control (PPE-personal protective equipment), Hand Hygiene) .
Behavioral Health .
Record review revealed the Director of Housekeeping, Staff A, was hired on 5/21/2021. Additionally, her personnel file failed to reveal evidence that she received education or training relative to resident's rights, abuse, dementia and behavioral health management, trauma informed care, infection control and QAPI since 2021.
Record review revealed Registered Nurse (RN), Staff C, was hired on 7/7/2022. Additionally, her personnel file failed to reveal evidence that she received education or training relative to resident's right's, abuse, dementia and behavioral health, trauma informed care, infection control, and QAPI since 2022.
Record review revealed Licensed Practical Nurse (LPN), Staff D, was hired on 3/29/2024. Additionally her personnel file failed to reveal evidence that she received education or training relative to trauma informed care and QAPI.
Record review revealed LPN, Staff B, was hired on 6/5/2024. Additionally her personnel file failed to reveal evidence that she received education or training upon hire relative to trauma informed care and QAPI.
Record review revealed Housekeeper, Staff F, was hired on 9/18/2023. Additionally her personnel file failed to reveal evidence that she received education or training relative to trauma informed care and QAPI.
Record review revealed Cook, Staff G, was hired on 9/17/2019. Additionally her personnel file failed to reveal evidence that she received education or training relative to trauma informed care and QAPI.
Record review revealed Nursing Assistant (NA), Staff H, was hired on 7/28/1998. Additionally her personnel file failed to reveal evidence that she received education or training relative to resident's rights, abuse, dementia and behavioral health management, trauma informed care, infection control and QAPI since 2022.
Record review revealed NA, Staff I, was hired on 6/19/2024. Additionally her personnel file failed to reveal evidence that she received education or training upon hire relative to resident's rights, abuse, dementia and behavioral health management, trauma informed care, infection control and QAPI since 2022.
Record review revealed NA, Staff J, was hired on 7/3/2024. Additionally his personnel file failed to reveal evidence that he received education or training upon hire relative to trauma informed care.
During a surveyor interview on 8/8/2024 at 1:56 PM with the facility's Staff Development Coordinator, she was unable to provide evidence that the above-mentioned staff members were provided education for the above mentioned in-services annually or upon hire, as per the facility assessment.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure licensed nurses have speci...
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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 licensed nurses have specific competencies and skill sets necessary to care for residents' needs, relative to indwelling urinary catheters (a thin hollow tube that is inserted through the urethra into the bladder to drain urine, which is held in place by a water filled balloon), Staff B, C and D.
Findings are as follows:
Record review of a community reported complaint submitted to the Rhode Island Department of Health on 8/7/2024, alleges in part that Resident ID #4's indwelling urinary catheter was placed incorrectly at the facility.
According to a [NAME], [NAME], and [NAME] article found in Nursing 2024, titled, Inserting an indwelling urinary catheter in a [gender redacted] patient, states in part, .grasp the catheter two to three inches from the tip and gently insert it into the urethral opening .Continue inserting until urine flows, then advance one to two more inches .
Record review revealed Resident ID #4 was admitted to the facility in July of 2024 with diagnoses including, but not limited to, urinary retention, chronic kidney disease and encephalopathy (a condition in which the brain functioning is altered).
Record review of the progress notes revealed initially, the resident's indwelling urinary catheter was discontinued on 8/1/2024 after s/he reported pain and swelling. Further record review revealed the resident was experiencing abdominal discomfort, abdominal distention and urinary retention on 8/2/2024. The provider was contacted and ordered for an indwelling urinary catheter to be placed, the catheter was placed on the evening of 8/2/2024. On the morning of 8/3/2024 the resident was experiencing pain and blood in his/her urine. The provider was contacted and the resident was transferred to the hospital for an evaluation.
Record review of the hospital emergency room documentation dated 8/3/2024 revealed the resident's urinary catheter had been placed incorrectly by facility staff in the urethra instead of the bladder. The catheter balloon was then deflated and then the catheter was advanced to the bladder.
During a surveyor interview on 8/7/2024 at 2:00 PM with Licensed Practical Nurse (LPN), Staff B, she revealed that on 8/2/2024, during the day shift the resident was retaining urine and experiencing abdominal pain, which was reported to the provider. Staff B further revealed she received an order from the provider to place an indwelling urinary catheter. Staff B further revealed when she was advancing the catheter, she observed urine flow, and at that point she inflated the catheter balloon to keep it in place and did not further advance the catheter. Staff B revealed the resident eliminated 800 milliliters of urine from the catheter being placed. Additionally, Staff B revealed she was a new nurse and had recently been hired at the facility approximately 2 months ago. When asked if Staff B ever received training or completed a competency on placing an indwelling catheter, she revealed that she had not.
According to the Facility Assessment, dated 11/15/2023, states in part, .The list below includes, but is not limited to the types of care that our resident population requires, and [the facility] provides for our residents .Specific Care or Practices .intermittent or indwelling or other urinary catheter .
Record review revealed Registered Nurse (RN), Staff C, was hired on 7/7/2022. Additionally, her personnel file failed to reveal evidence of a competency training relative to the insertion of a urinary catheter.
Record review of LPN, Staff D, was hired on 3/29/2024. Additionally, her personnel file failed to reveal evidence of a competency training relative to the insertion of a urinary catheter.
Record review of LPN, Staff B, was hired on 6/5/2024. Additionally, her personnel file failed to reveal evidence of a competency training relative to the insertion of a urinary catheter.
During a surveyor interview on 8/7/2024 at 2:33 PM with the facility Staff Development Coordinator, she was unable to provide evidence that a training or competency relative to the insertion of a urinary catheters was completed for the above-mentioned staff members.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on record review and staff interview, it has been determined that the facility failed to prepare, serve and distribute food in accordance with professional standards for food service safety as t...
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Based on record review and staff interview, it has been determined that the facility failed to prepare, serve and distribute food in accordance with professional standards for food service safety as the facility failed to have any certified food protection managers available during the preparation of evening meals on 7/1, 7/7, 7/15, 7/20 and 8/3/2024 or during the preparation of all the meals on 8/4/2024.
Findings are as follows:
Review of the Rhode Island Food Code, 2018 Edition, section 2-102.12, Certified Food Protection Manager states in part, (A) At least one employee that has supervisory and management responsibility and the authority to direct and control food preparation and service shall be a certified food protection manager who has shown proficiency of required information through passing a test that is part of an accredited program .
Additional review of the Rhode Island Food Code, 2018 Edition, section 2-102.20, Food Protection Manager Certification, states in part, (A) A person in charge who demonstrates knowledge by being a food protection manager that is certified by a food protection manager certification program that is evaluated and listed by a Conference for Food Protection-recognized accrediting agency .
Record review of a community reported complaint submitted to the Rhode Island Department of Health on 8/5/2024 alleges that the Director of Housekeeping had been cooking for the residents for the past 2 days with no food service license.
During a surveyor interview with Dietary Aide, Staff E, on 8/6/2024 at 10:30 AM, she revealed that the Director of Housekeeping, Staff A, had been acting as a Food Service Director in the kitchen for approximately one month. She further revealed that when she worked the morning shift, 6:30 AM - 2:30 PM, on Sunday, 8/4/2024, Staff A was the only cook in the kitchen.
During surveyor interviews with Staff A on 8/6/2024 at 2:01 PM and on 8/7/2024 at 10:25 AM, she revealed she had been helping oversee the kitchen with scheduling and ordering food since 7/16/2024 and was responsible for ensuring that there was coverage for at least one cook in the morning and one for the afternoon/evening. On Thursday, 8/1/2024, she made the Administrator aware that there was not a cook scheduled to work in the kitchen the evening of 8/3 and for both the morning and evening of 8/4. Staff A indicated that she called several cooks throughout the day on Saturday 8/3, all of whom could not fill in the missing shifts on 8/3 and 8/4. She indicated that she was directed by the Administrator on Saturday, 8/3 to cover the kitchen as it was her responsibility to do so. She further revealed that she worked on the kitchen the evening of 8/3/2024 and for all three meals on 8/4/2024. Additionally, Staff A indicated that she prepared mechanically altered diets per the residents' diet orders.
Record review revealed 31 of 89 residents in the facility required mechanically altered diets.
During a surveyor interview with the Director of Human Resources on 8/8/2024 at 11:25 AM, she revealed that there was an additional date where Staff A was covering the kitchen as the only cook. She further revealed Staff A covered the afternoon/evening shift on 7/20/2024.
In a subsequent interview on 8/8/2024 at 1:35 PM, Staff A revealed she covered the evening meal service in the kitchen as the only cook on 7/20/2024.
Record review of Staff A's employee time sheets revealed she was working in the kitchen on the following dates and times:
- Saturday, 7/20/2024, 3:19 PM through 5:40 PM
- Saturday, 8/3/2024, 3:20 PM through 6:00 PM
- Sunday, 8/4/2024, 5:23 AM through 5:49 PM
Record review failed to reveal evidence that Staff A was a Certified Food Protection Manager (CFPM).
Record review failed to reveal evidence that a Certified Food Protection Manager was working in the kitchen during its hours of operation on the following dates and times:
- 7/1/2024, after 2:20 PM
- 7/7/2024, after 4:06 PM
- 7/15/2024, after 2:55 PM
- 7/20/2024, after 1:30 PM
- 8/3/2024, after 1:30 PM
- 8/4/2024, both morning and evening shifts
During a surveyor interview with the Regional Director of Operations on 8/8/2024 at 1:43 PM, she acknowledged that there was not a Certified Food Protection Manager in the kitchen during all hours of operation for the above dates and times.
May 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
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 written notice of bed-hold policy to the resident or resident representative, prior to the transf...
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Based on record review and staff interview, it has been determined that the facility failed to provide written notice of bed-hold policy to the resident or resident representative, prior to the transfer of the resident to the hospital, for 1 of 5 residents reviewed, Resident ID #2.
Findings are as follows:
Record review of a community reported complaint reported to the Rhode Island Department of Health on 5/6/2024 alleges, Resident ID #2 was discharged from the facility on 5/2/2024 to the hospital. On 5/3/2024 the hospital case manager was informed by the facility that the resident did not place a bed hold and the facility had already filled his/her bed. The resident was not provided with a bed hold form prior to exiting the building.
Record review for Resident ID #2 revealed s/he was admitted to the facility in April 2024 with diagnoses including, but not limited to, acute pyelonephritis (bacterial infection causing inflammation of the kidneys) morbid obesity, type 2 diabetes mellitus, major depressive disorder, and post-traumatic stress disorder.
Record review of a progress note dated 5/2/2024 at 4:03 PM, revealed the resident had reported that s/he felt wetness on his/her pants on the right side. The nurse and the facility AGNP (Adult-Gerontology Nurse Practitioner) went into the resident's room to assess him/her, at which time it was discovered the PCN (small tube that helps drain urine from the kidney) tube on his/her right side was leaking. The resident was non emergently transferred to the hospital for further evaluation at approximately 2:00 PM.
Additional record review revealed that the resident was admitted to the hospital with a diagnosis of abdominal pain.
Record review of an email dated 5/3/2024 at 7:03 AM, authored by the resident and sent to the Admissions Director states in part .Barring disaster during my procedure this morning, I should be back this afternoon .
Record review of a progress note dated 5/3/2024 at 8:28 AM authored by the Admissions Director Bed Hold Note; Text: The wireless caller is unavailable.
Record review of an email attachment that was sent to the resident by the Admissions Director on 5/3/2024 at 9:16 AM, revealed a document enclosed titled Bed Hold Policy which state The minimum 5-day condition for the per diem rate applies (meaning, its re-starts), EACH time a resident, who is covered under Medicaid LTSS, is transferred for hospitalization or other institutional therapeutic leave. The rate, for a minimum of 5 days for the Bed Hold period, should not exceed the current Medicaid daily rate at the RUG code in effect at the time of transfer for hospitalization or other institutional therapeutic leave, for the applicable Bed Hold days.
Further review of the above-mentioned email attachment failed to provide information to the resident that explains the duration of bed-hold, how long the facility will hold the bed for, if any, and the reserve bed payment policy, as well as the daily room rate for the bed hold. Additionally, the document did not address permitting the return of resident to the next available bed provided prior to and upon transfer.
Record review failed to reveal evidence that the resident was provided in writing, information that explains the facility bed hold policy, including the duration of a bed-hold, the daily room rate, as well as information to address permitting the resident to return to the facility in the next available bed, prior to being sent to the hospital on 5/2/2024.
During a surveyor interview on 5/13/2024 at approximately 9:35 AM with the Admissions Director, she acknowledged that the facility did not present the resident with a bed hold policy in writing with the required information prior to being sent out on 5/2/2024. Additionally, she endorsed the facility did have bed availability on the morning of 5/3/2024 when contacted by the hospital case manager to make arrangements for the skilled Medicaid resident to return to the facility for long term care. She further revealed the facility declined to accept the resident back to the facility and indicated concerns with behaviors that were not previously addressed or revealed to the resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
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 develop and implement a baseline ...
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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 baseline care plan within 48 hours of the resident's admission that includes instructions needed to provide effective and person-centered care that meets professional standards of quality care, the resident's immediate health and safety needs, physician and dietary orders as well as therapy and social services for 1 of 2 residents reviewed, Resident ID # 2.
Findings are as follows:
Record review of a community reported complaint reported to the Rhode Island Department of Health on 5/6/2024, revealed that a resident was discharged from the facility on 5/2/2024 to the hospital and on 5/3/2024 the hospital case manager was informed by the facility that the resident did not place a bed hold and the facility had already filled his/her bed.
Record review revealed Resident ID #2 was admitted to the facility on [DATE] with diagnoses including, but not limited to, acute pyelonephritis (bacterial infection causing inflammation of the kidneys) morbid obesity, type 2 diabetes mellitus, major depressive disorder, and post-traumatic stress disorder.
Record review failed to reveal evidence of a baseline care plan for Resident ID #2 from 4/22/2024 through 4/29/2024.
Further record review revealed a care plan initiated 4/29/2024 indicating, Resident is independently capable of pursuing their own activities without intervention from the facility.
Record review failed to reveal evidence of a care plan that includes instructions needed to provide effective and person-centered including, but not limited to, the the following care prior to the resident's discharge on [DATE]:
- Initial goals based on admission orders.
- Physician orders.
- Dietary orders.
- Therapy services.
- Social services.
- PASARR recommendation, if applicable.
During a surveyor interview on 5/10/2024 at 3:45 PM with the Director of Nurses Services, in the presence of the Administrator, she acknowledged that Resident ID #2 did not have a baseline care plan which included instructions needed to provide effective and person-centered care, prior to his/her discharge from the facility on 5/2/2024.
Mar 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the that the facility failed to ensure that the resident...
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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 that the facility failed to ensure that the resident's Advanced Directive requesting to refuse lifesaving treatment was followed for 1 of 5 residents reviewed, Resident ID #1.
Findings are as follows:
Review of the facility policy titled Resident's Rights Regarding Treatment and Advance Directives [a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity] states in part .ensure resident's wishes are met regarding Advanced Directives .it is the resident's right to accept or refuse medical or surgical treatment .on admission the facility will determine if the resident has executed an Advanced Directive .
Closed record review for Resident ID #1 revealed diagnoses that include, but are not limited to, Gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection) and chronic obstructive pulmonary disease. Further record review revealed the resident was admitted to the facility in February of 2024.
Record review of the nursing progress notes for Resident ID #1 dated [DATE] indicated the following:
- 3:57 PM- Resident evaluated by staff/Code Blue initiated
- 3:59 PM- Cardiopulmonary resuscitation (CPR) started on the resident
- 4:00 PM- Rescue called to assist with the resident's condition
- 4:10 PM- Rescue arrived at resident and took over resident care
- 4:45 PM- Resident transported to hospital by rescue
Record review of an Emergency Medical Service run report dated [DATE] at 4:20 PM, states in part .upon arrival at facility, staff advised patient maybe DNR [do not attempt resuscitation], paperwork incomplete without medical doctor signature. CPR continued by emergency medical staff, pt moved from bed to floor .
Record review of the resident's face sheet indicated that the resident wished to be a DNR.
Record review of the resident's paper medical record revealed an undated document titled, Medical Orders for Life Sustaining Treatment (MOLST- The MOLST form is a set of medical orders for residents with advanced illness who might die within 1-2 years; require long-term care services; or wish to avoid and/or receive specific life-sustaining treatments now. In order for the MOLST to be valid it should be signed by a qualified medical professional and the resident or his/her representative). The MOLST form indicated that Resident ID #1 wished to be a DNR. The MOLST form was signed by the resident's representative, but it did not have a signature from a qualified medical professional.
Additional record review revealed a second MOLST was in the medical record. This MOLST again revealed the resident wished to be a DNR. This MOLST was signed by a Nurse Practitioner and the resident's representative.
During a surveyor interview on [DATE] with the Medical Records Supervisor, she was unable to explain why the resident had two MOLST's in his/her medical record. She was also unable to explain why one MOLST was not signed by a qualified medical professional.
During a surveyor interview with the Director of Nursing Service on [DATE] at 2:48 PM she was unable to explain why there were two different MOLST forms in the resident's record. Additionally, she was unable to explain why CPR was started when the resident was a DNR as indicated on his/her MOLST and face sheet.
Dec 2023
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards o...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing for 1 of 1 resident reviewed who has an actual pressure injury, Resident ID #4.
Findings are as follows:
Review of the policy titled, Non-Sterile Dressing Change, states in part, .Procedure .If dressings need to be cut to size, use clean or sterile scissors .remove soiled dressing .remove gloves, wash hands, apply new gloves .clean wound .Remove gloves, wash hands, apply new gloves .apply wound dressing .
Record review revealed the resident was admitted to the facility in September of 2018 with a diagnosis including, but not limited to, type 2 diabetes mellitus with skin complications.
Review of the care plan, initiated on 5/17/2022, revealed the resident has an actual impairment to his/her skin integrity relative to a stage 4 pressure wound (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed and often includes undermining and tunneling) to the ischium (forms the lower and back sides of the hip bone, one of the three bones that make up the pelvis). Further review of the care plan revealed an intervention to follow the facility protocols for treatment of injury.
Review of the physician treatment orders revealed a wound care order, dated 8/18/2023, to pack the left ischium wound with hydrofera blue (foam dressing that helps manage exudate and bioburden, or the number of bacteria living on a surface that has not been sterilized, for shallow to deep and tunneling wounds) then cover with a silicone border dressing every day.
During a surveyor observation on 12/13/2023 at 9:01 AM of Licensed Practical Nurse (LPN), Staff B performing the wound dressing change, revealed the following:
- While prepping the clean barrier field for the dressing change, Staff B was observed placing scissors in the pocket of her shirt and then transferring the scissors to the pocket of her pants before placing them on the clean barrier field.
- Prior to cutting the hydrofera blue dressing she indicated that the scissors were previously cleaned, then proceeded to pick up the scissors and the hydrofera blue foam. This surveyor intervened and stopped Staff B from proceeding with the dressing change. Staff B acknowledged that she did not clean the scissors after she placed them in the pocket of her shirt and pants. She then proceeded to clean the scissors and continued on with the dressing change.
- Staff B failed to wash her hands when changing gloves after she removed the soiled dressing, before cleaning the wound and prior to applying the new clean dressing. Additionally, she used her gloved finger to apply the hydrofera blue foam directly to the wound.
During a surveyor interview on 12/13/2023 at 9:20 AM with Staff B, she acknowledged the above-mentioned observations.
During a surveyor interview on 12/13/2023 at 11:50 AM with Unit Manager, Staff C, and the Temporary Manager, they indicated that their expectations are for the policy to be followed when performing dressing changes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 ...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 3 residents reviewed for oxygen therapy, Resident ID #19.
Findings are as follows:
According to Brunner and Sudarth's textbook, Medical and Surgical Nursing, 7th Edition, 1992, p. 524, as with other medications, oxygen is administered with care, and its effects on each patient are carefully assessed. Oxygen is a drug and except in emergency situations is prescribed by a physician.
Record review of a facility policy titled, Nasal Cannula states in part, .Procedure .verify physician orders .set flow meter per physician order .
Record review revealed the resident was readmitted to the facility in December of 2017, with a diagnosis including, but not limited to, anxiety disorder.
Surveyor observations of the resident while in his/her room on 12/11, 12/12 and 12/13/2023 revealed there was an oxygen concentrator by the resident's bedside with tubing dated 9/25 6:00 AM. Additional observation of the resident on 12/13/2023 at 8:20 AM revealed s/he was receiving oxygen therapy via the nasal cannula dated 9/25 at 2.5 liter per minute.
Record review failed to reveal evidence of a physician's order for oxygen therapy.
During a surveyor interview on 12/13/2023 at approximately 8:28 AM with Registered Nurse, Staff F, she was unable to provide evidence of an order for oxygen therapy. Additionally, Staff F revealed that the resident had an order for 1-2 liters of oxygen as needed that was discontinued on 12/7/2023. She further revealed that the resident uses the oxygen at night and was unable to explain why the order for its use was discontinued. Staff F also acknowledged the date on the oxygen tubing was 9/25 and indicated that was when it was last changed.
Record review revealed a physician's order was obtained on 12/13/2023 at 9:00 AM for oxygen at 2 liters via nasal cannula as needed, after the surveyor brought this concern to the facility's attention.
During a surveyor interview on 12/13/2023 at 10:15 AM with Unit Manager, Staff C, and the Administrator, they revealed that they would expect the resident to have an order for oxygen if s/he is using it at night and for the oxygen tubing to be changed weekly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for a b...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for a blood pressure medications with parameters, Resident ID #4.
Findings are as follows:
Record review revealed the resident was readmitted to the facility in September of 2018 with a diagnosis including, but not limited to, hypertension.
Record review revealed a physician's order, dated 10/31/2023, for Metoprolol Tartrate (medication used to treat high blood pressure) 50 mg (milligram) tablet to be administered twice daily with instructions to hold for a systolic blood pressure of less than 100. Further review revealed an additional parameter to hold this medication for the heart rate, however a heart rate parameter was not included in the order.
Review of the Medication Administration Records, from November 2023 through 12/13/2023 revealed the metoprolol medication was administered twice daily. Review of the record failed to reveal evidence that the resident's blood pressure and heart rate were monitored and documented when the medication was administered to him/her, as indicated in the order.
During a surveyor interview on 12/13/2023 at 11:23 AM with the Nurse Practitioner, she revealed that the above-mentioned order was transcribed incorrectly, and the heart rate parameter should have been to hold the medication for a heart rate less than 60 beats per minute. She further indicated that she would expect that the order would have been transcribed accurately.
During a surveyor interview on 12/13/2023 at 11:50 AM with Unit Manager, Staff C, and the Temporary Manager, it was indicated that they would expect the resident's blood pressure and heart rate to be monitored and documented per the physician's order. Additionally, they were unable to provide evidence that the resident's blood pressure and heart rate was monitored, and the medication was not administered to the resident unnecessarily.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
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 the comprehensive care plan was revised by the interdisciplinary team for 3 of 6 residents re...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that the comprehensive care plan was revised by the interdisciplinary team for 3 of 6 residents reviewed for advanced directives, Resident ID #s 2, 23, and 45.
Findings are as follows:
Review of the facility policy dated 1/2017 and titled, Advanced Directives states in part, .the resident has a right to refuse treatment and to formulate an Advanced Directive .the facility will abide by the resident's advanced directive .social services and/or medical staff must inform the Executive Director whenever a resident, family member, etc. expresses a desire to change advance directives .
Review of a facility policy titled Care Planning dated 6/2023, states in part, .the facility will develop a comprehensive, resident centered care plan for each resident .the interdisciplinary team will meet when a change in condition occurs and annually to develop the comprehensive, resident centered plan of care for each resident .the goals shall be specific and agreed upon by the resident, family, and staff .enter the date that the plan is initiated, reviewed, revised, or resolved .when the problem, goal, approach or target date is changed or resolved, it is indicated on the care plan .all resident care and interventions must be carried out per the Care Plan .
1. Record review revealed Resident ID #2 was readmitted to the facility in September of 2023 with diagnoses including, but not limited to, type 2 diabetes mellitus, and hypertensive heart disease.
Review of a signed MOLST (Medical Orders for Life Sustaining Treatment) document dated 12/7/2019, revealed the resident's advanced directive wishes are to be DNR (do not resuscitate-not to have cardiopulmonary resuscitation should the heart or breathing stop).
Review of a care plan initiated on 12/29/2020, and revised on 12/12/2023, revealed the resident has established advanced directives and his/her MOLST reflects wishes for DNR/CMO (comfort measures only where the natural dying process is permitted to occur while assuring maximum comfort). Review of the comprehensive care plan's interventions state in part, .effectively communicate FULL Code status [all resuscitation procedures will be provided] when resident must be transferred outside of the facility .call 911 immediately .
During a surveyor interview with the Director of Nurses (DNS) on 12/12/2023 at 12:35 PM she indicated that she would expect the information in the resident's care plan to match their current advanced directive.
2. Record review revealed Resident ID #23 was admitted to the facility in September of 2022, with diagnoses including, but not limited to, left bundle branch block (a delay or blockage of electrical impulses to the left side of the heart), stroke and atrial fibrillation (irregular heart rate that causes poor blood flow).
Review of a signed MOLST document dated 11/27/2023, revealed the resident's advanced directive wishes are to be DNR/CMO.
Review of a physician order dated 11/28/2023 revealed the resident is on Hospice services and is a DNR/CMO.
Review of a care plan initiated on 12/8/2023 states in part, .[resident name redacted] is at risk for alteration in code status, the resident is a Full Code. Review of the comprehensive care plan's interventions state in part, .effectively communicate Full Code status wishes when the resident must be transferred outside of the facility .intercede rapidly and begin immediate resuscitative efforts utilizing all life-sustaining measures available if the resident's heart stops beating .
3. Record review revealed Resident ID #45 was admitted to the facility in July of 2020 with diagnoses including, but not limited to, dementia, and chronic obstructive pulmonary disease (a lung disease that restricts air flow).
Review of a signed MOLST document dated 5/14/2021, revealed the resident's advanced directive wishes are to be DNR.
Review of a care plan dated 12/2/2021 and revised on 4/11/2023, states in part, .[resident name redacted] is at risk for alteration in code status, the resident is a Full Code. Review of the comprehensive care plan's interventions state in part, .intercede rapidly and begin immediate resuscitative efforts utilizing all life-sustaining measures available if the residents heart stops beating, or the resident stops breathing .effectively communicate Full Code status wishes when resident must be transferred outside of the facility .
During a surveyor interview on 12/12/2023 at approximately 10:50 AM, with Licensed Practical Nurse, Agency Staff A, she was unable to explain the discrepancy between the resident's code status and the interventions in his/her care plan.
During a surveyor interview on 12/12/2023 at approximately 11:07 AM, with the DNS she revealed, her expectation is for a resident's care plan to reflect accurate information related to their desired code status. Additionally, she acknowledged that the residents' comprehensive care plans should have been revised to ensure they reflect accuracy related to the residents' code status.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for care of a resident for 4 of 4 resid...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for care of a resident for 4 of 4 residents reviewed with catheters, Resident ID #s 2, 4, 35 and 54.
Findings are as follows:
According to The Center for Disease Control and Prevention (CDC) document titled, Guideline for Prevention of Catheter Associated Urinary Tract Infections [UTI] 2009, states in part, .Proper techniques for Urinary Catheter Maintenance .Do not rest the bag on the floor .
Record review of a facility policy titled Catheter-Foley states in part, .empty the Foley bag every 8 hours, or when the drainage bag is 2/3 full to avoid traction on the catheter from the weight of the drainage bag to prevent infection .
1. Record review for Resident ID #2 revealed that s/he was readmitted to the facility in September of 2022 with diagnoses including, but not limited to, neuromuscular dysfunction of the bladder and urinary tract infections.
Additional record review revealed the resident has a suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow that drains into a urinary collection bag).
Surveyor observations of the resident on 12/12/2023 at 11:30 AM revealed s/he was laying in his/her bed and his/her urinary collection bag was resting directly on the floor, out of the privacy bag, with a discarded empty plastic bag next to it.
During an additional surveyor observation of the resident on 12/12/2023 at 3:39 PM revealed the resident's urinary collection bag was full of urine, still on the floor, out of the privacy bag, with a discarded empty plastic bag next to it. Further observation revealed the tubing of the urinary collection bag was full of urine all the way up the tube leading to the resident in the bed.
During a surveyor interview and simultaneous observation of the resident with the Registered Nurse, Staff D, on 12/12/2023 at 3:49 PM, she acknowledged that the urinary bag was resting directly on the floor and was full of urine that backed up into the tubing that lead all the way to the resident on the bed.
Record review of a Nursing Assistant (NA) task folder titled urinary function found in the resident's electronic medical record (EMAR), indicated that 750 milliliters (ml) of urine was drained from his/her urinary collection bag at 1:20 PM on 12/12/2023. Further review of the record revealed that NA, Staff E, had signed off that she completed this task.
During a surveyor interview with Staff E on 12/13/2023 at 9:58 AM, she revealed that she had emptied the resident's urinary drainage bag of 750 ml at 1:20 PM on 12/12/2023 and had returned to his/her room at 3:00 PM and removed another 120 ml of urine from the bag. Additionally, Staff E was unable to explain why the urinary collection bag remained on the floor in the same position when it was observed by the surveyor on 12/12/2023 at 11:30 AM and at 3:39 PM, if she had been in the room twice that day to empty it. She further indicated that it would have been impossible for the resident's urinary drainage bag and its tubing to be found full of urine at 3:39 PM if she had emptied it at 3:00 PM.
During a surveyor interview with the Director of Nursing Services (DNS) on 12/12/2023 at 4:00 PM, she indicated that it was her expectation that the urinary drainage bag would be hung on the resident's bed and not to be placed directly on the floor. Additionally, she was unable to explain how Resident ID #2's urinary drainage bag and tubing were found to be full of urine at 3:39 PM if 750 ml of urine had been removed from it at 1:20 PM, as documented in the resident's EMAR.
2A. Further review of the facility policy titled, Catheter-Foley, states in part, .Patient care and considerations .Document the following .record urine output as ordered .
Record review revealed that Resident ID #4 was readmitted to the facility in September of 2018 with diagnoses including, but not limited to, UTI, infection, and inflammatory reaction due to indwelling urethral catheter and presence of urogenital implants.
During a surveyor observation of the resident on 12/13/2023 at 9:01 AM it was revealed that s/he had a urinary drainage bag.
Review of the physician's orders failed to reveal evidence of an order to record urine output.
Record review of the resident's care plan, dated 5/17/2022 and last revised on 4/13/2023, revealed the resident has an indwelling foley catheter with interventions to monitor, record, and report to the physician if s/he has no urine output.
Record review failed to reveal evidence that resident's urine output was being monitored or recorded as indicated in the plan of care and the facility policy.
2B. Record review revealed Resident ID #35 was readmitted to the facility in May of 2018 with diagnoses including, but not limited to, surgical aftercare following surgery on the genitourinary system (the organs of the genital (reproductive) and urinary systems) and chronic kidney disease.
Record review of the resident's care plan, dated 5/11/2023, revealed that the resident had a suprapubic catheter with interventions to provide suprapubic tube care every shift.
Record review failed to reveal evidence that resident's urine output was monitored or recorded as indicated in the facility policy.
During a surveyor interview on 12/13/2023 at 11:50 AM with Unit Manager, Staff C, and the Temporary Manager, they indicated that they would expect the urine output for Resident ID #s 4 and 35 to be monitored and documented as indicated in the plan of care and the facility policy.
2C. Record review revealed Resident ID #54 was admitted to the facility in July of 2023 with diagnoses including, but not limited to, benign prostatic hyperplasia (BPH) and obstructive and reflux uropathy (blockage of urinary flow).
Record review revealed a physician's order dated 8/7/2023 for a Foley catheter to drainage bag for diagnosis of BPH with obstruction - catheter size 14 [French] coude with 10 [milliliter] balloon.
Record review of the resident's plan of care initiated on 7/14/2023 revealed an intervention to Monitor and document intake and output per facility policy.
Record review for the resident failed to reveal evidence that his/her urinary output was being monitored and documented per his/her plan of care and the facility policy.
During a surveyor interview with the Administrator, Director of Nursing, and Unit Manager, Staff C, on 12/13/2023 at 11:10 AM, they were unable to provide evidence that the resident's urinary output was being monitored and documented as indicated in his/her plan of care or according to the facility policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors, receive culturally competent, trauma-informed care in acc...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors, receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents experiences, and preferences, in order to eliminate, or mitigate triggers that may cause re-traumatization of the resident for 10 of 15 residents reviewed for Trauma Informed Care, Resident ID #s 2, 9, 23, 24, 35, 45, 49, 54, 58, and 59.
Findings are as follows:
Review of a facility policy titled, Trauma Informed Care, states in part, .on admission, upon significant change in condition that includes changes in mood state and behavior, evaluate for any history of a traumatic experience they may have experienced .when a resident is unable to complete the screening tool the representative will be interviewed and the Trauma Informed Questionnaire will be completed by the Representative .the Social Worker will document the findings of the Trauma Informed Questionnaire in the initial Psychosocial history .
Review of the Centers for Medicare and Medicaid Services (CMS) State Operations Manual, Appendix PP states in part, .'Trauma' results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being .'Trauma-Informed Care' is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma .a trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization .
1. Record review revealed Resident ID #2 was readmitted to the facility in September of 2023, with diagnoses including, but not limited to, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and hypertensive heart disease.
Further record review failed to reveal evidence of a trauma informed care assessment.
2. Record review revealed Resident ID #9 was readmitted to the facility in November of 2023, with diagnoses including, but not limited to, depression, anxiety, and antisocial personality disorder (a mental health disorder characterized by disregard for other people).
Further record review failed to reveal evidence of a trauma informed care assessment.
3. Record review revealed Resident ID #23 was admitted to the facility in September of 2022, with diagnoses including, but not limited to, dementia, and agitation (a state of anxiety or nervous excitement).
Further record review failed to reveal evidence of a trauma informed care assessment.
4. Record review revealed Resident ID #24 was readmitted to the facility in August of 2021, with diagnoses including, but not limited to, heart disease and chronic kidney disease.
Further record review failed to reveal evidence of a trauma informed care assessment.
5. Record review revealed Resident ID #35 was admitted to the facility in November of 2022, with diagnoses including, but not limited to, dementia, psychotic and mood disturbance (mental disorder characterized by a disconnection from reality) and anxiety.
Further record review failed to reveal evidence of a trauma informed care assessment.
6. Record review revealed Resident ID #45 was admitted to the facility in July of 2020, with diagnoses including, but not limited to, dementia, and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).
Further record review failed to reveal evidence of a trauma informed care assessment.
7. Record review revealed Resident ID #49 was readmitted to the facility in August of 2023, with diagnoses including, but not limited to, depression and heart failure.
Further record review failed to reveal evidence of a trauma informed care assessment.
8. Record review revealed Resident ID #54 was readmitted to the facility in July of 2023, with diagnoses including, but not limited to, adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions, and changes in behavior).
Further record review failed to reveal evidence of a trauma informed care assessment.
9. Record review revealed Resident ID #58 was admitted to the facility in May of 2022, with diagnoses including, but not limited to, dementia, and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors).
Further record review failed to reveal evidence of a trauma informed care assessment.
10. Record review revealed Resident ID #59 was readmitted to the facility in January of 2023, with diagnoses including, but not limited to, depression and anxiety.
Further record review failed to reveal evidence of a trauma informed care assessment.
During a surveyor interview on 12/12/2023 at 2:46 PM with the Social Worker, she revealed that she has been at the facility since June of 2023, and acknowledged that she has not completed any trauma informed care assessments during that time.
During a surveyor interview with the Administrator, Director of Nursing Services and the Social Worker immediately following the above interview they acknowledged that trauma informed care assessments for the above-mentioned residents were not completed as required per the facility policy and the regulation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted profes...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 2 of 2 medication storage rooms and 2 of 2 medication carts observed.
Findings are as follows:
Review of the facility policy titled, Storage of Medications, revised 8/2020, states in part, .Expiration Dating .Certain medications or package types, such as .multiple dose injectable vials .require an expiration date shorter than the manufacturer's expiration date once opened .When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated .all expired medications will be removed from the active supply .
1. During a surveyor observation of the School Street Unit medication cart on 12/12/2023 at 12:07 PM, in the presence of Licensed Practical Nurse (LPN), Staff A, the following was revealed:
- 2 boxes (each containing three tubes) of Microdot Glucose Gel fast acting glucose gel 40% (used to treat low blood sugar levels) with an expiration date of 1/2023
- 3 boxes of Ipratropium Bromide and Albuterol Sulfate inhalation solution (used to help control the symptoms of lung diseases) 0.5 mg (milligram)/3 mL (milliliter) with an expiration date of 9/2023
During a surveyor observation of the School Street Unit fridge in the medication storage room, on 12/12/2023 at approximately 1:00 PM in the presence of Staff A, revealed 1 multidose vial of purified protein derivative (PPD, a skin test reagent used for the diagnosis of tuberculosis), approximately half full, opened and not dated. The manufacturer's instructions indicate to discard the opened product after 30 days.
During a surveyor interview immediately following the above-mentioned observations, Staff A acknowledged that the glucose gel and inhalation solution medications were expired and should have been removed from the active supply. Additionally, she acknowledged that the PPD solution was not dated when the vial was originally opened and should have been.
2. During a surveyor observation of the Division Street Unit medication cart on 12/12/2023 at 1:10 PM, in the presence of Registered Nurse (RN), Staff G, the following was revealed:
- 4 tubes of Microdot Glucose Gel fast acting glucose gel 40% with an expiration date of 1/2023
- 1 multidose vial of Lidocaine 1%, approximately half full, opened and not dated
During a surveyor observation of the Division Street Unit fridge in the medication storage room, on 12/12/2023 at approximately 1:30 PM in the presence of Staff G, revealed 2 multidose vials of PPD solution, one approximately ½ full and the other approximately ¼ full, both opened and not dated. The manufacturer's instructions indicate to discard the opened product after 30 days.
During a surveyor interview immediately following the above-mentioned observations, Staff G acknowledged that the glucose gel medications were expired and should have been removed from the active supply. Additionally, she acknowledged that the PPD solution and the multidose vial of lidocaine were not dated when the vials were originally opened and should have been.
During a surveyor interview on 12/12/2023 at 3:36 PM with the Director of Nursing Services (DNS) and Unit Manager, Staff C, they indicated that they would expect the policy to be followed, medication vials to be dated when opened and that medications are discarded when they are expired.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to protect identifying information for 13 residents listed in the facility's survey results binder, Resident...
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Based on record review and staff interview, it has been determined that the facility failed to protect identifying information for 13 residents listed in the facility's survey results binder, Resident ID #s 4, 6, 26, 27, 30, 31, 43, 49, 52, 463, 464, 465, and 466.
Findings are as follows:
During a surveyor observation on 12/12/2023 at approximately 2:30 PM, the survey results binder for 2023 was observed to be in a bin outside of the Administrator's office, in a common area of the facility.
Record review of the survey results binder revealed the following:
- Survey results for exit date 3/10/2023 with a staff/resident roster attached, identifying Resident ID #43
- Survey results for exit date 4/5/2023 with a staff/resident roster attached, identifying Resident ID #463
- Survey results for exit date 11/6/2023 with a staff/resident roster attached, identifying Resident ID #s 464, 27, 31, 30, 26, 6, 52, 465, 466, 4, and 49
Further record review of the above surveys with the attached rosters contained information including, but not limited to, physician's orders and medical diagnoses.
During a surveyor interview with the Administrator following the above observation, she was unable to provide evidence that the facility protected the identifying information of the 13 residents listed in the survey results binder.
Nov 2023
3 deficiencies
2 IJ (1 affecting multiple)
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 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 each resident receives...
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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 each resident receives adequate supervision based on the risks and current professional standards of practice relative to preventing an incident by a known sex offender, Resident #1.
Findings are as follows:
Record review of a facility reported incident submitted to the Rhode Island Department of Health on 10/30/2023 indicates that Resident ID #1 was observed grabbing Resident ID #2's chest in the hallway.
Review of a facility policy titled, Abuse Prevention, dated October 2022, states in part, .Protocol 5. Implementation and ongoing monitoring consist of the following: Screening, Training, prevention, identification, protection, investigation, and reporting .
Record review of the facility assessment dated [DATE] revealed that known sex offenders would be denied admission to the facility.
Record review revealed Resident ID #1, the alleged perpetrator, was admitted to the facility in September of 2023 with diagnoses including, but not limited to, altered mental status and cognitive communication deficit.
Record review for Resident ID #1 revealed a quarterly MDS assessment dated [DATE], with a BIMS score of 12 out of 15 indicating moderately impaired cognition.
During a surveyor interview on 11/2/2023 at 8:38 AM with the Administrator, she revealed that on 9/8/2023 the facility received a telephone call from a person who identified herself as the Probation Officer for Resident ID #1. The Probation Officer communicated to the facility that Resident ID #1 was a Level III Sex Offender.
Record review revealed that the facility conducted a search for Resident ID #1 on 9/8/2023 at 9:52 AM in the National Sex Offender Public Website and found that s/he was a Level III Sex Offender (a high risk of repeatable behavior and a threat to public safety).
Record review for Resident ID #1 revealed a care plan dated 9/18/2023, developed 10 days after they became aware of his/her criminal history, indicating the resident is registered as a level three sex offender and s/he has a probation officer. Further review of the care plan revealed interventions including to alert his/her parole officer and assigned detective to be informed of all resident whereabouts, resident may not reside within 300 feet of a daycare establishment or public or private school property. Further review of the care plan failed to reveal evidence of interventions to reduce the risks to other residents such as, supervision to mitigate the risk of his/her behaviors to other residents in the facility or interventions for staff to implement/utilize to provide supervision to ensure the safety of the other residents residing in the facility after they were informed of his/her history on 9/8/2023.
Record review of a progress note dated 10/1/2023 authored by Licensed Practical Nurse, Staff B, revealed that Resident ID #1 touched her inappropriately on the buttock on 10/1/2023.
During a surveyor interview on 11/2/2023 at 9:13 AM, with Staff B, she indicated that on 10/1/2023 Resident ID #1 smacked her buttocks inappropriately and stated, oh and it's nice and soft. Staff B further revealed that she told the Social Worker, Staff D, about the above incident and she was told to keep her distance and not turn around in front of him/her. She also indicated that she was unaware of Resident ID #1's criminal history until she spoke to Staff D.
Record review failed to reveal evidence of any interventions that were put into place related to the supervision of Resident #1 after s/he touched Staff B inappropriately and knowing that Resident ID # 1 was a Level III Sex Offender.
Record review of a progress note authored by Staff B, dated 10/28/2023 states in part [Resident ID #2] was touched inappropriately by another resident [Resident ID #1] .[Resident ID #2's] daughter notified and was very upset over the phone .was very concerned for [Resident ID #2 's] safety .
Record review of the police report dated 10/28/2023 indicated that the Officer met with Staff B who stated she witnessed an assault occur between Resident ID #1 and 2. Resident ID #1 touched Resident ID #2 on the inside of both of his/her thighs and then grabbed his/her breasts.
Record review revealed Resident ID #2 was admitted to the facility in September of 2022 with a diagnosis that includes, but is not limited to, dementia.
Record review for Resident ID #2 revealed a comprehensive Minimum Data Set (MDS) assessment dated [DATE] with a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating severely impaired cognition.
During a surveyor interview on 10/31/2023 at 11:15 AM, with Nursing Assistant, Staff A, she revealed that on 10/28/2023, she witnessed Resident ID #1 touch Resident ID #2's upper thighs and breasts with both of his/her hands. Additionally, she revealed that she was not provided education from anyone in the facility regarding interventions that were in place for the supervision of Resident ID #1. She further revealed that she was made aware of Resident ID #1's criminal history by Staff B, only after Staff B was inappropriately touched on her buttocks by Resident ID #1.
During a surveyor interview on 10/31/2023 at 11:25 AM, with Staff B, she revealed that on 10/28/2023 she witnessed Resident ID #1 touch Resident ID #2's thighs and breasts in an inappropriate manner. She immediately separated both residents and stated to Resident ID #1 you can't touch [him/her] like that. Additionally, Staff B revealed that she had communicated her concerns to the facility's Social Worker, Staff D, regarding Resident ID #1 going into a cognitively impaired resident's room, Resident ID #3. She indicated that Resident ID #3 believed Resident ID #1 was his/her spouse.
Record review revealed Resident ID #3 was admitted to the facility in November of 2020 with a diagnosis that includes, but is not limited to, Alzheimer's disease.
Record review for Resident ID #3 revealed a Quarterly MDS assessment dated [DATE] with a BIMS score of 4 out of 15 indicating severely impaired cognition.
During a surveyor interview on 11/2/2023 at 9:13 AM, with Staff B, she acknowledged that Resident ID #1 would enter Resident ID #3's room unsupervised, and that Resident ID #3 would state oh that's my husband. Staff B indicated that she was told to keep an eye on him/her and that no-one ever told me that [s/he] shouldn't go into the room additionally, they didn't want [him\her] to think [s/he] was a predator. Staff B also revealed that there are gaps in the staff's ability to supervise the resident, such as when they are passing medications or providing care to other residents. Staff B was unable to provide evidence that Resident ID #1 was under adequate supervision.
During a surveyor interview on 10/31/2023 at 11:51 AM, with Staff D, she revealed that Staff A, made her aware that Resident ID #1 would also sit outside of another cognitively impaired resident's room, Resident ID #4.
Record review for Resident ID #4 revealed a Quarterly MDS assessment dated [DATE] with a BIMS score of 6 out of 15 indicating severely impaired cognition.
During a surveyor interview on 11/2/2023 at 8:48 AM with Staff D, she revealed that her expectation is that the staff would monitor Resident ID #1 to ensure that s/he is never in another resident's room alone and that another resident is not alone with him/her in his/her room.
During a surveyor interview on 11/2/2023 at approximately 8:45 AM with the Administrator and the Social Worker, they were unable to provide evidence that the facility provided appropriate supervision to prevent an incident by a known registered sex offender.
After the facility was made aware of Resident ID #1's history on 9/8/2023 they failed to ensure that Resident ID #1 received adequate supervision to prevent an incident from occurring as evidenced by him/her touching Resident ID #2 inappropriately on the breasts and thighs. The facility had multiple opportunities to implement safety measures to protect the other vulnerable residents that reside in the facility, such as Resident ID #3 and 4. This continued failure to implement interventions to supervise Resident ID #1 to prevent incidents had the potential to place all residents in the facility at risk for serious harm.
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · 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 keep a resident free from sexual a...
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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 keep a resident free from sexual abuse for 1 of 6 residents reviewed, Resident ID #2. The facility also failed to screen newly admitted residents upon admission for their sex offender status (as required by the facility assessment) for 2 of 2 newly admitted residents from June 2023 through September of 2023, Resident ID #s 1 and 7, resulting in Resident ID #1 touching a vulnerable resident in a sexual manner, Resident ID #2.
Findings are as follows:
1. The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023, states in part, .sexual contact is nonconsensual if the resident .lacks the cognitive ability to consent .
Review of a facility policy titled, Abuse Prevention, dated October 2022, states in part, .The facility prohibits the .abuse of residents/patients .by anyone including staff, family, friends, etc .
Record review of the facility assessment dated [DATE] revealed known sex offenders would be denied admission to the facility.
Record review of a facility reported incident submitted to the Rhode Island Department of Health on 10/30/2023 indicates that Resident ID #1 was observed grabbing Resident ID #2's chest in the hallway.
Record review revealed Resident ID #2, the alleged victim, was admitted to the facility in September of 2022 with a diagnosis that includes, but is not limited to, dementia.
Record review of a Comprehensive Minimum Data Set (MDS) Assessment for Resident ID #2 dated 7/20/2023 revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating severely impaired cognition.
Record review revealed Resident ID #1, the alleged perpetrator, was admitted to the facility on [DATE]th, 2023, with diagnoses including, but not limited to, altered mental status, and cognitive communication deficit.
Record review of a Quarterly MDS Assessment for Resident ID #1 dated 9/13/2023, revealed a BIMS score of 12 out of 15, indicating moderately impaired cognition.
Record review of the initial psychosocial care plan for Resident ID #1 dated 9/8/2023, revealed s/he was admitted for short term rehabilitation and medical monitoring and was to return to the community shelter when appropriate for discharge from the facility.
Record review of a nursing note authored by Licensed Practical Nurse (LPN) Staff B, dated 10/28/2023 states in part .was touched inappropriately by another resident [Resident ID #1] .daughter notified and was very upset over the phone .was very concerned for [Resident ID #2 's] safety .
Record review of the police report dated 10/28/2023 indicated that the Officer met with Staff B who stated she witnessed the assault occur and Resident ID #1 touched Resident ID #2 on the inside of both of his/her thighs and then grabbed his/her breasts.
During a surveyor interview on 11/2/2023 at 8:38 AM with the Administrator she revealed that on 9/8/2023 the facility received a call from a person who identified herself as the Probation Officer for Resident ID #1. The Probation Officer communicated to the facility that Resident ID #1 was a Level III Sex Offender.
Record review revealed that the facility conducted a search for Resident ID #1 on 9/8/2023 at 9:52 AM in the National Sex Offender Public Website and found that s/he was a Level III Sex Offender (a high risk of repeatable behavior and a threat to public safety).
Additional record review failed to reveal interventions to mitigate the risk of his/her behaviors to other residents in the facility or interventions for staff to implement/utilize to ensure the safety of the other residents residing in the facility after they were informed of his/her criminal history on 9/8/2023. The care plan was updated on 9/18/2023, 10 days after the facility learned that Resident ID # 1 was a Level III Sex Offender and has a Probation Officer. Interventions only included; is not allowed to be within 300 feet of a daycare or school, to be provided with psych services as needed and to place weekly counseling sessions on hold while the resident resides in the facility. The care plan failed to implement any interventions for the vulnerable residents that currently reside in the facility who were placed at risk for serious harm by Resident ID #1.
Record review of a progress note dated 10/1/2023 authored by Licensed Practical Nurse, Staff B, revealed that Resident ID #1 touched her inappropriately on the buttock on 10/1/2023.
During a surveyor interview on 11/2/2023 at 9:13 AM, with Staff B, she indicated that on 10/1/2023 Resident ID #1 smacked her buttocks inappropriately and stated, oh and it's nice and soft. Staff B further revealed that she told the Social Worker, Staff D, about the above incident and she was told to keep her distance and not turn around in front of him/her. She also indicated that she was unaware of Resident ID #1's criminal history until she spoke to Staff D.
During a surveyor interview on 10/31/2023 at 11:15 AM, with Nursing Assistant (NA), Staff A, she revealed that on 10/28/2023, she witnessed Resident ID #s 1 and 2 in the dining room together. She indicated that she saw Resident ID #1 touch Resident ID #2's upper thighs and breasts with both hands in an inappropriate manner.
During a surveyor interview on 10/31/2023 at 11:25 AM, with Staff B, she revealed that on 10/28/2023 she witnessed Resident ID #s 1 and 2 sitting together in the dining room. She indicated that she saw Resident ID #1 touch Resident ID #2's thighs and breasts in an inappropriate manner. She immediately separated both residents and stated to Resident ID #1 you can't touch [him/her] like that. Additionally, Staff B revealed that she had communicated her concerns to the facility's Social Worker, Staff D, regarding Resident ID #1 going into a cognitively impaired resident's room, Resident ID #3. She indicated that Resident ID #3 believed Resident ID #1 was his/her spouse. Further, Staff B, indicated that on 10/1/2023 Resident ID #1 touched her buttocks inappropriately. Staff A further revealed that she was unaware of Resident ID #1's criminal history until after she was inappropriately touched on her buttocks on 10/1/2023, 3 weeks following his/her admission.
During a surveyor interview on 10/31/2023 at approximately 12:26 PM, with the Unit Manager, LPN, Staff C, she acknowledged that the facility has denial criteria for sex offenders on the facility assessment. She further revealed that Resident ID #1 was not identified as a Level III Sex Offender prior to his/her admission. Staff C was unable to provide evidence that the staff had been educated regarding Resident ID #1 being a Level III Sex Offender or on interventions to mitigate the risk s/he placed for other residents. Additionally, when the surveyor asked what the facility plan should have been once they knew of his/her history, she indicated that staff should have been constantly watching this resident.
Record review failed to reveal evidence that Resident ID #1 was constantly watched.
During a surveyor interview on 11/2/2023 at 8:48 AM, with the Social Worker, Staff D, she acknowledged that the facility had been made aware of Resident ID #1 being a Level III Sex Offender by his/her Probation Officer. Additionally, she revealed that Staff A, had made her aware that Resident ID #1 would sit outside of other resident rooms, and she indicated to Staff A, we had to have eyes on [him/her]. When questioned by the surveyor as to what have eyes on a resident is, Staff D was unable to explain her expectations and stated, just general like anyone else.
Record review failed to reveal evidence that staff were educated to have eyes on Resident ID #1.
During a surveyor interview on 11/2/2023 at 4:00 PM with the Facility Manager, Registered Nurse, Staff E, she acknowledged that the facility should not have admitted Resident ID #1 as s/he was a Level III Sex Offender which is contrary to the Facility Assessment. Additionally, she was unable to provide evidence that Resident ID #2 was kept free from abuse.
2. Record review of the Facility assessment dated [DATE] revealed known sex offenders would be denied admission to the facility.
Record review revealed that Resident ID #1 was admitted to the facility in September of 2023. Further record review failed to reveal evidence that the National Sex Offender Public Website was checked prior to his/her admission. Additional record review revealed that Resident ID #1 was a Level III Sex Offender.
Record review revealed Resident ID #7 was admitted to the facility in August of 2023 and was discharged in September of 2023. Further record review failed to reveal evidence that the National Sex Offender Public Website was checked prior to his/her admission or at any time while s/he was a resident.
During a surveyor interview on 11/2/2023 at 10:20 AM with Staff E, she acknowledged that the facility had not checked the National Sex Offender Public Website for all admissions since June of 2023. Additionally, she was unable to provide evidence that the facility kept all residents free from abuse by admitting a Level III Sex Offender, Resident ID #1.
After the facility was made aware of Resident ID #1's history on 9/8/2023 they failed to implement any safety measures to protect the vulnerable residents that were residing in the facility. On 10/1/2023 Resident ID #1 inappropriately touched a staff member on the buttocks. Although the facility had Resident ID #1 seen by psych services, they again failed to implement any safety measures to protect the vulnerable residing in the facility. Then on 10/28/2023 Resident ID #1 touched a severely cognitively impaired resident inappropriately on the breasts and thighs. This continued failure had the potential to place all resident in the facility at risk for serious harm.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all 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 be administered in a manner that e...
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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 be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 2 out of 2 residents related to determining if a resident was a registered sex offender prior to admission from June of 2023 until September of 2023, Resident ID #s 1 and 7.
Findings are as follows:
Record review of the facility assessment dated [DATE] revealed known sex offenders would be denied admission to the facility.
Record review revealed Resident ID #1, was admitted to the facility in September of 2023 with diagnoses including, but not limited to, altered mental status, and cognitive communication deficit.
Record review failed to reveal evidence that the National Sex Offender Public Website was checked prior to the facility admitting Resident ID #1. Additional record review revealed that Resident ID #1 was a Level III Sex Offender.
Record review revealed that Resident ID #1 inappropriately touched Licensed Practical Nurse, Staff B and Resident ID #2. See F Tag F 600 and F 689.
Record review revealed Resident ID #7 was admitted to the facility in August of 2023 and was discharged in September of 2023. Further record review failed to reveal evidence that the National Sex Offender Public Website was checked prior to his/her admission or at any time while s/he was a resident.
During a surveyor interview on 11/2/2023 at approximately 10:50 AM with the Administrator she reveled that she became aware that Resident ID #1 was a Level III Sex Offender after she received a call from his/her Probation Officer on 9/8/2023. She acknowledged that the above-mentioned residents were not screened on the National Sex Offender Public Website prior to their admissions.
Jun 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 ensure residents are free from ve...
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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 residents are free from verbal abuse for 1 of 3 residents reviewed, Resident ID #1.
Findings are as follows:
Record review of a facility reported incident received by the Rhode Island Department of Health on 5/30/2023 states in part, Activity director reported an allegation of verbal abuse between a resident and CNA [certified nursing assistant] .
Record review revealed Resident ID #1 was admitted to the facility in May of 2022 with diagnosis including, but not limited to, multiple sclerosis (a potentially disabling disease of the brain and spinal cord).
Record review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12 out of 15 indicating the resident has moderately impaired cognition.
Record review of the statement written on 5/29/2023 authored by the Activity Director states in part, .I witnessed [Resident ID #1] say to [Staff A] 'F*** you N****.' I then heard [Staff A] respond 'It takes two to f***. I'll f*** your mother and your sister .'
Record review of a statement written on 5/29/2023 by the Licensed Practical Nurse, Staff B states in part, .I asked [Resident ID #1] 'What happened yesterday? .were there any issues with you and [Staff A] yesterday?' [Resident ID #1] then responded with, 'yes, I told him f*** you n*****, and he told me that he would f*** my mother and my sister .
Further record review of the above statement revealed that the resident was able to repeat the sequence of the story during his/her interview to a police officer.
During a surveyor interview with the resident on 6/1/2023 at approximately 2:45 PM, s/he confirmed that the above interaction reported by the Activity Director happened and that Staff A told him/her that .he would f*** my mother and my sister .
During a surveyor interview with the Compliance Monitor, Staff C on 6/1/2023 at approximately 4:00 PM, she was unable to provide evidence that the resident was kept free from verbal abuse.
Apr 2023
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on surveyor observation 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 stan...
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Based on surveyor observation 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 safety relative to the main kitchen.
Findings are as follows:
During a tour of the main kitchen on 4/10/2023 at approximately 12:45 PM in the dry food storage area the following was revealed:
- 2 opened bags of long grain rice
- 1 opened five pound bag of spaghetti
- 1 opened five pound bag of rotini
During a surveyor interview with the Regional Food Service Director (FSD), on 4/10/2023 at approximately 2:00 PM he acknowledged that once the bags of rice, spaghetti, and rotini were opened, they should have been placed in a closed container to prevent contamination.
Record review of the Rhode Island Food Code 2018 edition, section 4-602.11 states in part, .(C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris .
During a surveyor observation of the freezer at approximately 3:00 PM on 4/10/2023 revealed the following:
- the strip curtains contained a heavy accumulation of frost
- the entrance floor contained two mounds of ice
- the floor along the walls had an accumulation of debris
During a surveyor interview with the Regional FSD following the above observations, he revealed the freezer floor needed to be cleaned and that he would find a solution to the frost/ice accumulation.
During a subsequent visit to the main kitchen on 4/10/2023 at 4:37 PM, the following was observed:
- 7 vanilla puddings sitting out by the trayline
- 4 large salads containing pieces of chicken and 2 large salads containing a hardboiled egg sitting out by the trayline
- 1 large container of chicken salad sitting out by the trayline
- 15 ready to use coffee mugs with a scrapeable brown film accumulation on the inside of the mugs
Following the above observations, the Regional FSD acknowledged that the potentially hazardous foods should not be sitting out during meal service and should be put on ice.
During a surveyor interview with the Regional Manager on 4/10/2023 at approximately 5:00 PM, he acknowledged the brown film in the coffee mugs and further acknowledged that the mugs were clean for service.
Apr 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
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 have a discharge interagency that...
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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 have a discharge interagency that was completed in its entirety. The interagency failed to include the necessary care for the resident's wounds, treatments, medications, and referrals to outside agencies for provision of care were provided to 1 of 1 residents reviewed, Resident ID #1.
Findings are as follows:
Record review of a community reported complaint received by the Rhode Island Department of Health (RIDOH) on March 26, 2023, alleges that this resident was not provided with a safe discharge relative to suitable housing and necessary wound care. This complaint also reveals that the resident was re-hospitalized on [DATE] for a right foot wound with new right lower extremity pain. The resident was diagnosed with cellulitis and was being treated with broad spectrum IV antibiotics. Additionally, wound cultures were being obtained.
Record review revealed the resident was admitted to the facility in April of 2022 with diagnoses including, but not limited to: necrotizing fasciitis (a rare bacterial infection that spreads quickly in the body and can cause death), gangrene (a serious condition where a loss of blood supply causes body tissue to die), non-pressure chronic ulcer of right heel and midfoot with fat layer exposed, and type two diabetes.
Additional record review revealed the resident had a physician's order dated 10/27/2022 for treatment to his/her right foot plantar wound, that included to cleanse the wound with normal saline, apply skin prep (a liquid film-forming dressing that forms a protective film) and sodium Hypochlorite gel (an antibiotic used to treat or prevent infections) and cover with a gauze island border three times a week for nine days. Further review of this order revealed the wound is to be off-loaded and repositioned.
Additional record review revealed a physician's order dated 10/27/2022 that indicates to apply skin prep daily to right plantar and left distal foot.
Record review of the Continuity of Care (COC) form dated 11/3/2022, failed to reveal evidence that there was any coordination of a transition of care or that the COC form was completed in its entirety including the necessary care for the resident's wounds, treatments, medications, and referrals to outside agencies for provision of care.
Further review of the COC form revealed that the resident was discharged to a motel on 11/3/2022.
Additional record review of the progress notes revealed the following:
- 11/2/2022 at 5:38 PM- Social Worker met with resident today and discussed his/her discharge to the motel.
- 11/3/2022 at 7:19 AM- Alert and responsiveness, all teaching provided, as ordered by the unit manager, the resident returned demonstration and said as long [s/he] got writing instructions, [s/he] will be able to self administered medications.
- 11/3/2022 at 11:03 AM- Move out/Discharge Note- Resident D/C [discharge] will all medications a/o [as ordered] this morning. Resident took all belongings, refused to sign discharge paperwork. Advised to follow with MD [medical doctor] in community in the next few days.
During a surveyor interview with the Director of Nursing Services and the Administrator on 3/31/2023 at approximately 2:30 PM, they were unable to provide evidence that the COC was completed in its entirety and that a safe discharge, including the necessary care for the resident's wounds, treatments, medications, and referrals to outside agencies for provision of care were provided to the resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0836
(Tag F0836)
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 the facility failed to operate and provide services in compli...
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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 the facility failed to operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility, relative to the Licensed Administrator and Resident ID #1's discharge documentation.
Findings are as follows:
According to the Rhode Island Criminal and Traffic Law Manual, 2004 Edition, .Giving false document to agent, employee, or public official.- (a) No person shall knowingly give to any agent, employee, [NAME] in public or private employ, or public official any receipt, account, or other document .which contains any statement which is false or erroneous, or defective .and which, to his or her knowledge is intended to mislead the principal, master employer, or state, city, or town of which he or she is an official .
Record review of a community reported complaint received by the Rhode Island Department of Health (RIDOH) on March 26, 2023, alleges that this resident was not provided with a safe discharge relative to suitable housing and necessary wound care. This complaint also reveals that the resident was re-hospitalized on [DATE] for a right foot wound with new right lower extremity pain. The resident was diagnosed with cellulitis and was being treated with broad spectrum IV antibiotics. Additionally, wound cultures were being obtained.
Record review revealed the resident was admitted to the facility in April of 2022 with diagnoses including, but not limited to: necrotizing fasciitis (a rare bacterial infection that spreads quickly in the body and can cause death), gangrene (a serious condition where a loss of blood supply causes body tissue to die), non-pressure chronic ulcer of right heel and midfoot with fat layer exposed, and type two diabetes.
Record review of the Continuity of Care (COC) form dated 11/3/2023, failed to reveal evidence that there was any coordination of a transition of care or that the COC form was completed in its entirety including the necessary care for the resident's wounds, treatments, medications, and referrals to outside agencies for provision of care.
Additional record review of the progress notes revealed the following:
- 11/2/2022 at 5:38 PM- Social Worker met with resident today and discussed his/her discharge to the motel.
- 11/3/2022 at 7:19 AM- Alert and responsiveness, all teaching provided, as ordered by the unit manager, the resident returned demonstration and said as long [s/he] got writing instructions, [s/he] will be able to self administered medications.
- 11/3/2022 at 11:03 AM- Move out/Discharge Note- Resident D/C [discharge] will all medications a/o [as ordered] this morning. Resident took all belongings, refused to sign discharge paperwork. Advised to follow with MD [medical doctor] in community in the next few days.
During a surveyor interview with the Director of Nursing Services and the Administrator on 3/31/2023 at approximately 2:30 PM, they were unable to provide evidence that the COC was completed in its entirety for this discharge.
Record review of a document provided to the state agency via e-mail, on 4/3/2023, revealed a document titled Leaving Against Medical Advice [AMA] indicating the resident left the facility AMA and s/he refused to sign the form. This form was signed by the former Director of Nursing Services along with an illegible signature.
Additional record review failed to reveal evidence that the resident requested to be discharged AMA or that there was a physician's order or entry in the record acknowledging the resident was discharged AMA.
Record review of a statement that was provided to the state agency by the facility's third-party monitor, who was put into place per the facility's compliance order dated 2/8/2023, to oversee the quality of care and staffing at the facility, indicated that the Administrator and other facility staff had discussed fabricating an AMA document to send to the state agency.
During a surveyor interview with the resident's primary care physician on 4/4/2023 at 12:52 PM, he indicated after reviewing the record the resident's discharge appeared to be routine, not AMA.
During an interview with the former Director of Nursing Services on 4/5/2023 at approximately 11:00 AM, she indicated that this resident was not discharged AMA. S/he was discharged to a motel. She also revealed (after seeing the AMA document) that it was not her signature on the form.
Mar 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, record review, staff and resident interview, it has been determined that the facility failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, record review, staff and resident interview, it has been determined that the facility failed to ensure that a resident's environment remains as free from accident hazards as possible for 1 of 3 residents reviewed, resulting in a burn, Resident ID #1.
Findings are as follows:
Review of a facility reported incident submitted to the Department of Health on 3/8/2023 revealed the resident was seen by rehab on 3/4/2023, .was treated with a hydrocollator pack and sustained a burn as a result .
Review of the Hydrocollator Heating Units Service/User Manual revealed The hydrocollator Heating Unit is equipped with an immersion type heating element and a hydraulic capillary-type thermostat which evenly maintains the HotPac temperature in the water and provides a ready supply of heated packs. Further review revealed the recommended operating temperature is 160 -165 degrees Fahrenheit (a temperature hot enough to cause skin injury).
Review of the policy last updated 10/28/2022 titled Policy: 8.25 - Physical Agent Modalities revealed .Hot Packs Procedure Screen for precautions or contraindications to hot pack use. Ensure skin is clean and dry. Remove topical analgesics, if applicable, prior to applying hot packs. Fold 4 towels in half, width-wise .forming 8 layers of toweling .If using a terry cloth hot pack cover, the terry cloth acts as two layers .When using a hot pack, clinicians must document .a pre/post skin assessment .
Record review revealed that the resident was admitted to the facility in August of 2022 with diagnoses including, but not limited to, diabetes mellitus type 2, muscle weakness and pain in left shoulder.
Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed s/he has a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired cognition.
Review of the March 2023 Medication Administration Record (MAR) revealed a physician's order dated 2/18/2023 for Voltaren External Gel 1% (a topical analgesic) .Apply to shoulders topically four times a day for pain. Further review revealed this medication was applied to the resident's shoulders on 3/4/2023 at 8 AM, prior to receiving therapy at approximately 10 AM.
Review of an Occupational Therapy Treatment Encounter Note(s) with the date of service of 3/4/2023 states in part, .placement of hot pack on L [left] shoulder for 15 minutes prior to deep tissue massage to L shoulder deltoid area . Further review failed to reveal documentation of a skin assessment before or after the application of the hot pack, per the facility policy.
Additional review of the March 2023 MAR revealed the resident reported a pain level of 10 on 3/4/2023 at 4:00 PM following the application of the hot pack.
Review of a progress note dated 3/4/2023 at 9:39 PM revealed a new skin alteration was discovered to the resident's left shoulder. Further review revealed .First degree burn .7.5cm [centimeter] x[by] 4cm. Resident states burn happened during therapy with warm compress. Area cleansed with normal saline, then covered with xeroform [a sterile petroleum gauze] and bordered foam dressing.
Review of an initial wound evaluation and management summary from VOHRA Wound Physicians (an outpatient wound specialty group) dated 3/8/2023 revealed the resident had a focused wound exam to a burn wound of the left, posterior shoulder. Further review revealed the wound was described as partial thickness (a second degree burn that affects the top two layers of skin and can continue to evolve to a full thickness burn, even after initial treatment), with light serous exudate (draining of liquid from an open wound) measuring 7.2 cm in length, 3.6 cm in width and an unmeasurable depth. Additional review revealed a dressing treatment plan including Silver sulfadiazine [a treatment for significant second and third degree burns].
Record review of the OT [Occupational Therapy] Evaluation & Plan of Treatment for the resident's OT certification period of 2/22/2023-4/22/2023 does not specify the use of a physical modality such as a hot pack.
During a surveyor interview on 3/9/2023 at 12:04 PM with the Certified Occupational Therapist Assistant (COTA), Staff A, she revealed she did not cleanse the resident's skin or remove the topical analgesic prior to administering the hot pack for approximately 15 minutes. She further revealed the temperature of the hydrocollator that she obtained prior to use was approximately 165 degrees Fahrenheit. She revealed that she used 2 towels folded to make 4 layers and the hot pack cover totaling only 6 layers between the resident's skin and the hot pack. Additionally, she could not provide evidence that a pre/post skin assessment was completed.
During a surveyor observation on 3/9/2023 at 1:18 PM in the presence of Licensed Practical Nurse (LPN) Staff B, the resident's left shoulder wound was observed to have an open area with a red and yellow wound bed. The resident was observed to wince when the wound dressing was removed by the LPN at that time.
During a surveyor interview on 3/9/2023 at 2:25 PM with a telephone interpreter and the resident, s/he revealed the burn was sustained on 3/4/2023 during therapy after a staff member applied wet hot cloths on my shoulder.
During a surveyor interview on 3/9/2023 at approximately 1:30 PM with the Occupational Therapist, Staff C, he indicated that a hot pack is considered a physical modality. Additionally, he acknowledged that the use of a hydrocollator hot pack was not part of the resident's plan of treatment.
Mar 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to store all drugs and biologicals in locked compartments for 1 of 1 resident reviewed relative to medicatio...
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Based on record review and staff interview, it has been determined that the facility failed to store all drugs and biologicals in locked compartments for 1 of 1 resident reviewed relative to medication storage, Resident ID #1.
Findings are as follows:
Record review of a facility reported incident received by the Rhode Island Department of Health on 2/27/2023, states in part, Resident had 6 tablets of Xanax 1mg (milligram; used to treat anxiety and panic disorders) when last counted at 730am this morning. [S/he] was moved to another unit this afternoon @ (at) 330pm. At @ 419pm agency nurse [Staff A] was found searching the med cart. When asked she stated she was searching for Xanax for resident. She stated that she tucked the narcotic in the narcotic book and left it on the cart while she was waiting for the residents to all be moved off of the unit. All units, med carts, trash, resident rooms and belongings were searched with no result .Police were notified. Attorney General's office made aware .
Review of a facility policy titled, Storage of Medications revised in April of 2019, states in part, .1. Drugs and biologicals used in the facility are stored in locked compartments .Only persons authorized to prepare and administer medications have access to locked medications .
Record review of the facility's internal investigation revealed a statement dated 2/27/2023 authored by Registered Nurse, Staff A, which states in part, .this writer pull [pulled] the Xanax out to go give report to another nurse .at that time this nurse left the med on the top of the cart to pick up my bags. When I come [sic] back the med was missing.
During a surveyor interview on 3/6/2023 at 2:20 PM with the Director of Nursing Services, she revealed the resident was relocating to another unit and Staff A had been instructed to take the resident's Xanax to the new unit and give report to the unit Nurse. Additionally, she revealed a search of the facility failed to produce the missing medication. Furthermore, her expectation would have been that the medication would be locked back up if there was a delay in delivery.
Feb 2023
7 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
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 residents maintain acceptable parameters of nutritional status, such a usual body weight or desir...
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Based on record review, and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such a usual body weight or desirable body weight and failed to follow their policy relative to weight loss, for 1 of 12 residents reviewed, Resident ID #4.
Findings are as follows:
Review of the facility policy titled, Weight Assessment and Intervention, state in part, .The nursing staff will measure resident weights on admission and weekly for four weeks thereafter .Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .1 month - [minus] 5% weight loss is significant; greater than [>] 5% is severe .
Record review revealed the resident was admitted to the facility in October of 2022 and was readmitted in January of 2023, with diagnoses including, but not limited to, acute posthemorrhagic anemia (a condition that develops when you lose a large amount of blood quickly) and moderate protein-calorie malnutrition.
Review of the resident's care plan revealed a focus initiated on 11/10/2022 and revised on 2/15/2023, that states in part, The resident has nutritional problem or potential nutritional problem .hx [history] of sig wt [significant weight] changes .Interventions .Monitor/record/report to MD [medical doctor] PRN [as needed] s/sx [signs and symptoms] of malnutrition .significant weight loss .>5% in 1 month .
Further record review revealed the resident was admitted to the hospital in January 2023 for 4 days with a diagnosis of anemia (deficiency of healthy red blood cells in blood). On 1/17/2023, the resident underwent a thoracentesis (procedure to remove excess fluid accumulated in the chest cavity), removing 1 L (liter) of fluid. Additionally, the resident's weight was obtained at the hospital on 1/19/2023 after the thoracentesis and was documented at 197 lbs. (pounds) and 1.5 oz (ounces).
Review of a documents titled Weights and Vitals Summary, revealed the following weights documented in 2023:
- 1/5/2023 205 lbs.
- 2/10/2023 163.6 lbs.
- 2/11/2023 158.8 lbs.
- 2/15/2023 158.2 lbs.
- 2/16/2023 160.6 lbs.
- 2/17/2023 158.8 lbs.
- 2/22/2023 155.8 lbs.
Additional review of the document titled, Weights and Vitals Summary revealed the resident's weight was documented at 200 lbs. on the day of his/her readmission to the facility but was struck out by the Registered Dietician (RD) on 2/14/2023 with a note that revealed it was a mistaken entry.
Record review failed to reveal evidence of an accurate weight documented upon the resident's readmission to the facility.
Additional record review revealed the resident lost 33.4 lbs. from 1/19/2023 to 2/10/2023, indicating a severe weight loss of 16.95%.
Review of the resident's January 2023 Medication Administration Record (MAR) revealed a physician's order with a start date of 1/21/2023 and an end date of 1/22/2023 to Obtain weight every day shift x 4 weeks then monthly every day shift every 7 day(s) for 4 Weeks, which was signed off as being completed.
Review of the resident's documented weights failed to reveal evidence that a weight was obtained on 1/21/2023, per the physician's order.
Additional review of the resident's January 2023 MAR revealed a physician's order with a start date of 1/23/2023 and an end date of 2/14/2023 to Obtain weight every day shift x 4 weeks then monthly every day shift every 7 day(s) for 4 Weeks, which was signed off as being completed on 1/23/2023 and 1/30/2023.
Review of the resident's documented weights failed to reveal evidence that the weights were obtained on 1/23/2023 and 1/30/2023, per the physician's order.
Review of the resident's February 2023 MAR revealed a physician's order with a start date of 2/3/2023 and an end date of 2/14/2023 to Obtain weight every day shift x 4 weeks then monthly every day shift every 1 month(s) starting on the 3rd for 1 day(s) for monthly weight, which was signed off as being completed on 2/3/2023.
Review of the resident's documented weights failed to reveal evidence that a weight was obtained on 2/3/2023, per the physician's order.
Additional review of the February MAR revealed a physician's order with a start date of 1/23/2023 and an end date of 2/14/2023 to Obtain weight every day shift x 4 weeks then monthly every day shift every 7 day(s) for 4 Weeks, which was signed off as being completed on 2/6/2023 and 2/13/2023.
Review of the resident's documented weights failed to reveal evidence that the weights were obtained on 2/6/2023 and 2/13/2023, per the physician's order.
During a surveyor interview on 2/24/2023 at 8:41 AM, with the RD, she acknowledged that a weight was entered into the system upon the resident readmission to the facility, but indicated she struck it out, 3 weeks later, because it was an error. She revealed the resident's weight was not obtained until 2/10/2023, and at which time, the severe weight loss was identified. She further indicated intervention were then put in place following the identification of the resident's weight loss.
Record review failed to reveal evidence of interventions put in place until 2/14/2023, four days after the severe weight loss was identified.
During a surveyor interview on 2/24/2023 at 12:45 PM, with the Director of Nursing Services, she was unable to provide evidence that the resident's weights were obtained on the above-mentioned dates, per the physician orders.
During an additional surveyor interview on 2/28/2023 at 10:45 AM, with the DNS and Administrator, they were unable to provide evidence that the RD was notified in writing, on 2/10/2023 regarding the resident's severe weight loss, per facility policy. Furthermore, they were unable to provide evidence of any interventions that were put in place on 2/10/2023 when the resident's severe weight loss was identified.
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 F0676
(Tag F0676)
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 provide 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 provide the necessary care and services in accordance with activities of daily living relative to providing necessary assistance with feeding and to provide a functional communication system to assist residents with communicating their basic needs for 1 of 1 residents reviewed, Resident ID #9.
Findings are as follows:
Record review revealed the resident was readmitted to the facility in November of 2022 with diagnoses including but not limited to; dysphagia (difficulty swallowing) and protein calorie malnutrition.
A. Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed the resident requires extensive assistance of one staff member for eating and drinking. Additionally, s/he is documented as having limitation which interferes with daily functions in both of his/her upper extremities (shoulder, elbow, wrist, hand).
Additional record review revealed a physician's order dated 2/21/2023 which indicated that the resident is to receive 1 on 1 assistance with eating.
During a surveyor observation on 2/23/2023 from approximately 11:50 AM until approximately 12:15 PM, the resident was observed in his/her room with the lunch meal tray noted to be sitting on the over-the-bed table, with the dietary cover still in place, without a staff members present in the room assisting the resident. At approximately 11:57 AM, Nursing Assistant (NA) Staff A, was observed entering the resident's room and step up his/her meal before exiting the room. From approximately 12:00 PM to 12:15 PM, the resident was observed eating some of his/her meal while in bed, without a staff member present to provider ne-on-one assistance with eating.
During a surveyor interview with Staff A on 2/23/2023 immediately following the above-mentioned observation, she acknowledged that she was the staff member that the surveyor observed entering and exiting the resident's room. Additionally, she acknowledged that she did not provide the resident with one-on-one assistance for eating and indicated that she was not aware that the resident required one-on-one assistance for eating. She stated [s/he] usually feeds [him/herself] but today [s/he] needs help so I will .
During a surveyor interview on 2/23/2023 at approximately 12:15 PM with Registered Nurse, Staff B, she indicated that she was unaware of an order in place for the resident to receive one-on-one assistance with eating. When prompted by the surveyor she reviewed the order in the electronic medical record and acknowledged that the resident has an order in place for one-on-one assistance with eating and indicated that she would expect staff to assist the resident.
Record review revealed the following Speech Language Pathologist (SLP) evaluation and notes authored by SLP, Staff C:
-1/18/2023 titled, Speech Therapy SLP Evaluation and Plan of Treatment, states in part, .Assessment Summary .Pt [patient] did report that [s/he] is not having enough assistance to be fed. SLP communicated this with staff .Risk Factors: Due to the documented physical impairments and associated functional deficits .the patient is at risk for: malnutrition, dehydration and further decline in function .
-1/20/2023 progress note states in part, .Pt requested more assistance with self-feeding. Please assist patient during meals to facilitate intake/nutritional needs.
-1/23/2023 titled, Speech Therapy Treatment Encounter Note(s), states in part, .Pt does require assist to feed and continues to ask SLP to somehow communicate this with staff. SLP put order in computer .to communicate this .
Record review of the resident's paper medical record revealed a document titled, NURSING PLACEMENT HOSPICE AND PALLIATIVE CARE LLC dated 2/21/2023 which states in part, .Pt bed bound .dependent .Recommendation .Pt 1:1 feed . Additionally, the document had notation on it that states OK with a set of initials.
During a surveyor interview with the resident's family member on 2/24/2023 at 11:30 AM, she indicated that the resident does require and ask for assistance with eating and that she and other members of the family try to visit during meal times to assist because staff do not assist the resident.
During a surveyor interview with the Director of Nursing Services (DNS) on 2/23/2023 at 2:37 PM, she indicated that she discontinued the order and stated, because the nurse was an agency nurse and it was an incorrect order. Additionally, she indicated that she would expect the resident to receive one-on-one assistance if the order was entered correctly.
During a surveyor interview with Licensed Practical Nurse (LPN), Unit Manager, Staff D on 2/24/2023 at 12:47 PM he acknowledged that the hospice recommendation indicates the resident should receive one-on-one assistance with eating. He indicated that the OK and initials on it were that of the Nurse Practitioner (NP), Staff E, and acknowledged that the signature indicated the NP approved the recommendation.
During a follow-up interview with the DNS on 2/28/2023 at 11:00 AM she acknowledged that she discontinued the one-to-one assistance order and she did not call the provider prior to doing so.
B. Review of a document titled, admission RECORD, revealed the resident's primary language is Spanish.
Review of the MDS assessment dated [DATE], revealed Section A1100, titled Language, displayed a code of 0, which indicates the resident does not need or want an interpreter.
During a surveyor observation on 2/24/2023 at approximately 11:30 AM, of the resident's room, revealed multiple documents posted on the resident's wall, located behind his/her bed, and out of visual sight of the resident. One document contained the following English to Spanish translations: Mojada-Wet, Estomago-Stomach, Pillow-Almohada, Mesa-Table, Comida-Food, Ayuda-Help, [NAME]-Drink, Apaga La [NAME], Medicina-medicine. Another document revealed information and instructions for an interpreter service.
During a surveyor interview, immediately following the above observation, with the resident's family member, she revealed the resident indicated that the translated Spanish to English words on the wall would be helpful if staff could learn them. She further revealed that the resident stated to her that the facility does not use an interpreter service to communicate with him/her.
During a surveyor interview on 2/24/2023 at approximately 11:35 AM, with Unit Manager, LPN, Staff D, he was unaware that the facility has an interpreter service to communicate with resident. He further indicated that staff would try to get a Spanish speaking staff member if available to communicate with the resident.
During a surveyor interview on 2/24/2023 at approximately 12:50 PM, with Registered Nurse, Staff B, she indicated that the staff do not have to utilize an interpreter service to communicate with the resident. She further indicated that if staff do not understand the resident, they will get a Spanish speaking staff member if available to come to the resident's room and communicate with him/her.
Review of the resident's care plan revealed a focus, initiated on 2/24/2023, after the concerns were brought to the attention of the facility by the surveyor, which revealed the resident has communication needs, relative to the resident's primary language being Spanish. Interventions included: Language line provided at bedside, and resident will have access to communication line/interpreter services 24/7, and Provide language specific basic communications cards will be provided when needed. Binder available at nurses desk.
During a surveyor interview on 2/24/2023 at approximately 2:00 PM, with the Director of Nursing Services, she indicated that she expects staff to utilize the interpreter service to communicate with any resident whose first language is not English.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional s...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 13 residents reviewed for physician's orders, Resident ID #3.
Findings are as follows:
Review of a facility document titled, Process for unavailable medications, states in part, .Prescribed medication must be administered as ordered by MD [medical doctor]/NP [nurse practitioner]. When the prescribed medication can't be administered as ordered then notification needs to be made to MD/NP at the exact time that the medication is due to be given as to avoid a med [medication] error .
Record review revealed that the resident was admitted to the facility in October of 2022. S/he has medical diagnoses that include but are not limited to; respiratory syncytial virus (a very common virus that leads to cold-like symptoms) and glaucoma (disease of the eye that can cause vision loss and blindness due to high pressure inside the eye).
Additional record review revealed the following physician orders:
1. Start date of 10/26/2023 for Brimonidine Tartrate Solution .Instill 1 drop in right eye three times a day for eye pressure .
Record review of the February 2023 Medication Administration Record (MAR) revealed that the Brimonidine eye drops were documented as not administered for two out of three of the daily doses on 2/10, 2/11, and 2/12/2023.
2. Start date of 2/3/2023 Albuterol Sulfate .Aerosol Solution .2 puff inhale orally every 4 hours for SOB [shortness of breath] until 2/11/2023 .
Record review of the February 2023 MAR revealed that the Albuterol inhaler was not administered for two doses on 2/3/2023 and one dose on 2/4/2023.
3. Start date of 2/12/2023 for guaIFENesin Oral Liquid .Give 10 ml [milliliters] by mouth every 4 hours for cough for 5 days .
Record review of the February 2023 MAR revealed that the order for guaifenesin was documented as not administered for two doses on 2/12/2023 and one dose on 2/13/2023.
Further record review revealed that the above-mentioned medications were documented as not administered because the medications were not available. Additionally, the record failed to reveal evidence that the physician was notified that the medications were not administered as ordered.
During a surveyor interview with the Director of Nursing Services on 2/24/2023 at 2:08 PM, she indicated that she would have expected that staff would follow the facility protocol for medications unavailable which she indicated she implemented six months ago. Additionally, she was unable to provide evidence that the resident's received the above-mentioned medications as ordered.
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 F0700
(Tag F0700)
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 assess the...
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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 assess the resident for risk of entrapment from bed rails for 1 of 1 residents reviewed, Resident ID #9.
Findings are as follows:
Review of a facility policy titled, Side Rail Use last revised October 2022, states in part, .Procedure .On admission, readmission, quarterly and with a significant change in condition, the resident will be assessed for the need for side rails to assist in bed mobility .The use of side rails for bed mobility will be documented in the resident' plan of care .
Record review revealed Resident ID #9 was admitted to the facility in April of 2022 and was readmitted in November of 2022 with a diagnosis including, but not limited to, myasthenia gravis (a neuromuscular disorder that leads to weakness of skeletal muscles).
Review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed section P0100 titled, Physical Restraints displayed a code of 0 for bed rail which indicates the resident does not have or utilize bed rails in bed.
Record review failed to reveal evidence of a side rail assessment completed upon the resident's readmission, quarterly, or after the resident had a significant change in condition, per the facility policy.
Additional record review revealed the resident's last side rail assessment was completed in July of 2022.
Review of the resident's care plan failed to reveal evidence of side rails documented, per facility policy.
During surveyor observations on 2/24/2023 at 11:30 AM and at 2:43 PM, revealed the resident was in bed with the side rails up.
During a surveyor interview on 2/24/2023 at approximately 2:00 PM with the Director of Nursing Services, she was unable to provide evidence of a care plan relative to bed rails, or a readmission, quarterly, or significant change side rail assessment after July 2022, per facility policy.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 6 residents reviewed for ...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 6 residents reviewed for medication administration, Resident ID #13.
Findings are as follows:
Review of the facility policy titled Medication Administration dated February 16, 2022, states in part, .It is the policy .to provide safe and effective medication management .to help eliminate any harm that could be caused at any level of the medication management process .
Record review revealed the resident was admitted to the facility in January of 2023 with diagnoses including, but not limited to, hypertensive heart disease without heart failure (heart problems that occur because of high blood pressure that is present over a long time) and myocardial infarction (heart attack).
Record review revealed the following physician orders with parameters to hold the medication for blood pressure less than 110 and for a heart rate less than 60.
1. Losartan Potassium (medication to treat high blood pressure and prevent strokes in patients with an enlarged heart) 25 milligrams (mg) by mouth at bedtime, with a start date of 1/31/2023.
Review of the February 2023 Medication Administration Record (MAR) revealed the following dates when the Losartan Potasium was administered to the resident outside of the indicated parameters.
- 2/10/2023 administered with a documented blood pressure of 102/66
-2/13/2023 administered with a documented blood pressure of 100/70
-2/18/2023 administered with a documented blood pressure of 98/60
2. Nifedipine ER [extended release] (medication to treat high blood pressure) 60 mg by mouth one time a day, with a start date of 2/1/2023.
Review of the February 2023 MAR revealed the following date when the Nifedipine ER was administered to the resident outside of the indicated parameters:
-2/11/2023 administered with a documented blood pressure of 101/68
3. Metoprolol Succinate (medication to treat high blood pressure) ER 75 mg by mouth one time a day, with a start date of 2/11/2023.
Record review of the February 2023 MAR revealed the following date when the Metoprolol Succinate was administered to the resident outside of the indicated parameters:
-2/11/2023 administered with a documented blood pressure of 101/68
-2/14/2023 administered with a documented blood pressure of 100/64
-2/20/2023 administered with a documented blood pressure of 101/62
During a surveyor interview with the Director of Nursing Services on 2/24/2023 at 2:03 PM, she acknowledged the medications were administered outside the ordered parameters. Furthermore, she indicated that she would have expected staff to hold the medication.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary psychotropic drugs for 1 of 1 residents reviewe...
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Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary psychotropic drugs for 1 of 1 residents reviewed for antipsychotic medication, Resident ID #12.
Findings are as follows:
Review of the facility policy with a revision date of December 2018, titled Antipsychotic Medication Use states in part, .Antipsychotic medications will be prescribed at the lowest possible dosage .and are subject to gradual dose reduction and re-review .
Record review revealed the resident was readmitted to the facility in November of 2022 with diagnoses including, but not limited to, major depressive disorder, anxiety, and delusional disorder.
Record review revealed a current physician's order dated 12/29/2022 for OLANZapine [antipsychotic medication used to treat certain mental/mood conditions] Tablet 2.5 MG [milligrams] .one time a day for GDR [gradual dose reduction] .RE EVAL IN 14 DAYS .
Record review failed to reveal evidence that the order was revaluated by the provider 14 days after the order was written.
Additionally, review of the December, January and February MARs revealed the resident received the OLANZapine daily.
During a surveyor interview with the Director of Nursing Services on 2/24/2023 at approximately 2:00 PM, she was unable to provide evidence that the order was reevaluated after 14 days, per the physician's order.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency 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 1 of 3 residents reviewed for...
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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 1 of 3 residents reviewed for food preferences, Resident ID #5.
Findings are as follows:
Record review revealed that the resident was admitted to the facility in October of 2021 with diagnoses including but not limited to stroke and dysphagia (difficulty swallowing).
Record review revealed a care plan revised on 9/7/2022 which states in part, The resident has a nutritional problem or potential nutritional problem r/t [related to] dysphagia .2/2 [secondary to] CVA [stroke] .poor oral intake hx [history] of sig [significant] wt [weight] loss . The interventions for this care plan include but are not limited to .honor/update dietary preference as necessary .Likes .mac and cheese, jello .Dislikes .pudding .
Additional record review revealed the following Nutrition/Dietary notes;
-3/1/2023 .Family requesting rt [resident] receive mac and cheese at meals-kitchen notified of request .
-3/8/2023 .Food Preference: likes: .mac & cheese, jello .Dislikes: .pudding .
-3/8/2023 .Resident to cont [continue] receiving meal tray/pleasure tray with jello daily and mac and cheese with lunch/dinner as resident wishes .
Review of the resident's tray ticket revealed .Dislike: .pudding .coffee .
Surveyor observations of the resident during the meals revealed the following:
-3/20/2023 and 3/21/2023 no jello, no mac and cheese were observed on the resident's lunch trays
-3/21/2023 coffee was observed on the resident's breakfast tray
-3/22/2023 pudding was observed on the resident's lunch tray
During the above observations, it was revealed that the resident did not eat the meals or the pudding that was served to him/her and did not drink the coffee.
During a surveyor interview on 3/22/2023 at 3:22 PM, the resident revealed s/he likes jello and mac and cheese. The resident further revealed s/he does not like coffee or pudding.
During a surveyor interview with a Nursing Assistant, Staff B, on 3/23/2023 at 12:45 PM, she revealed that she has been taking care of the resident and that the resident likes jello, and mac and cheese.
During a surveyor interview with the Regional Food Service Director, Staff C, on 3/22/2023 at 1:30 PM, he revealed that they will try to accommodate the resident's likes and dislikes as much as possible.
During an additional interview with Staff C on 3/23/2023 at 8:50 AM, he revealed he was unaware that the resident's family requested the resident to receive mac and cheese at meals. When questioned, why coffee and pudding were on the resident's tray when the tray ticket indicated that s/he disliked coffee and pudding, Staff C stated I will take care of it.
During a surveyor interview with the Director of Nursing on 3/23/2023 at 10:00 AM, she was unable to provide evidence that the resident received meals according to his/her preference.
During a surveyor observation and interview on 3/22/2023 at approximately 1:00 PM with the resident s/he indicated that s/he did not eat his/her lunch and the facility later served him/her mac and cheese which s/he was observed eating by the surveyor.
Jan 2023
19 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0569
(Tag F0569)
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, upon a resident's death, to convey ...
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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, upon a resident's death, to convey within 30 days the resident's funds and a final accounting of those funds to the individual or probate jurisdiction administering the resident's estate, in accordance with state law for 2 of 2 residents reviewed for personal needs funds handled by the facility, Resident ID #'s 108 and 109.
Findings are as follows:
Rhode Island State Regulation under section 2.4 (H) of the Uniform Accountability Procedures for Title XIX Resident Personal Needs Funds in Community Nursing Facilities, ICF/DD Facilities, and Assisted Living Residences' requires that the facility shall:
.(c) Upon the death of a Medicaid resident, a facility shall, within 10 days, transmit a notarized statement (see form available for downloading on the EOHHS website: www.eohhs.ri.gov) indicating the amount of personal needs money on hand after funeral expenses. Funeral expenses are designated to be the first paid. Copies of receipts obtained either from the funeral home or the relative responsible for the funeral should be included .
(e) If there is a balance in the Medicaid resident's personal needs account, after payment of the above noted disbursements, a check payable to EOHHS in that amount shall be sent along with the copy of the notarized statement and receipts to EOHHS at the address listed on it's website: www.eohhs.ri.gov .
A closed record review for Resident ID #108 revealed that the resident expired in August of 2022 with a remaining balance of $4803.88 in his/her personal needs account.
A closed record review for Resident ID #109 revealed that the resident expired in March of 2022 with a remaining balance of $5112.53 in his/her personal needs account.
The facility failed to provide evidence that the funds held by the facility for the above residents were conveyed as required upon death.
During a surveyor interview on [DATE] at approximately 9:30 AM with the Business Office Manager, she acknowledged that Resident ID #108's funds failed to be conveyed at the time of the interview and failed to provide evidence that Resident ID #109's funds had been conveyed within 30 days of the resident's death.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to communicate the appropriate information to the receiving health care institution or provider to ensure a ...
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Based on record review and staff interview, it has been determined that the facility failed to communicate the appropriate information to the receiving health care institution or provider to ensure a safe and effective transition of care for 1 of 2 residents reviewed, Resident ID #105.
Findings are as follows:
Review of the resident's record revealed that s/he was admitted to the facility in November of 2022, with diagnoses including, but not limited to, chronic atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) and old myocardial infarction (heart attack).
Further review of the record revealed that s/he was discharged from the facility on 12/31/2022.
Review of the care plan, revised on 12/12/2022, revealed that the resident is at risk for developing complications secondary to having anticoagulant therapy with an intervention to obtain and report labs as ordered. Additional record review revealed that s/he has impaired cognitive function with an intervention to communicate with his/her family members/caregivers regarding his/her needs.
Review of a document titled Order Summary Report, revealed in part, the following orders:
- 12/28/2022, an order for Warfarin Sodium tablet (an anticoagulant medication that is used to treat and prevent blood clots) 3 milligrams (MG), give 1 tablet by mouth one time a day for blood thinner until 1/1/2023.
- 12/28/2022, an order for PT/INR lab (An INR, international normalized ratio, test measures the time for the blood to clot. It is also known as prothrombin time, or PT. It is used to monitor blood-thinning medicines, which are also known as anticoagulants. The INR can also be used to check if you have a blood clotting problem) one time only for one day. Further review of this order revealed a start date of 12/30/2022 and was discontinued on 12/31/2022.
Further record review revealed a nursing note dated 12/28/2022 at 1:43 PM, that states in part, New order to repeat PT/INR on Friday [12/30/2022] instead of Monday [1/2/2023]. Order entered.
Review of the December 2022 notes revealed on 12/30/2022 at 1:19 PM, Registered Nurse, Staff A documented that the resident was discharged with his/her son and that the PT/INR labs were due that day. Further review of the note revealed that she canceled the labs because the resident was discharged , and the lab would not have been able to obtain the specimen until later in the afternoon due to scheduling difficulties.
Review of the December 2022 Treatment Administration Record failed to reveal evidence that a PT/INR lab was obtained on 12/30/2022.
Review of a lab slip for this resident, dated 12/30/2022, also failed to reveal evidence that a PT/INR lab was listed as a test to be performed.
Review of the 12/31/2022 discharge form failed to reveal evidence of a documented dose or frequency for the Warfarin Sodium medication, or that a list of the resident's current medications was attached. Further review of this documentation failed to reveal evidence that Staff A communicated to the receiving healthcare institution, provider, or the resident's son that the ordered PT/INR lab was not obtained.
During a surveyor interview with Staff A on 1/12/2023 at 10:17 AM, she acknowledged that she failed to notify the in-house physician, the community provider, or the resident's son that the PT/INR labs were not obtained on 12/30/2022. Additionally, she was unable to provide evidence that the ordered dose and frequency for the Warfarin Sodium medication was communicated to the resident's son.
During a surveyor interview with the Director of Nursing Services on 1/20/2023 at approximately 12:30 PM, she revealed that she would expect the dose and frequency for the Warfarin medication would be documented or that a current medication list would be attached on the discharge form. Additionally, she would expect the nurse to first obtain a physician's order to cancel the PT/INR lab. She also indicated that both the resident's son and the provider should have been notified that the PT/INR was not obtained.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure accurate assessments reflecting the residents' status for 2 of 8 residents ...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure accurate assessments reflecting the residents' status for 2 of 8 residents reviewed relative to weekly skin assessments, Residents ID #s 62 and 155.
Findings are as follows:
1. Record review revealed Resident ID #62 was admitted to the facility in September of 2021 with diagnoses including, but not limited to, stroke and status post Gastrostomy (G-tube; A tube inserted through the wall of the abdomen directly into the stomach. It allows air and fluid to leave the stomach and can be used to give drugs and liquids, including liquid food, to the patient).
Record review revealed a physician's order dated 11/14/2022 for Weekly Skin Checks Every Saturday on Day .
Record review of the SKIN OBSERVATION TOOL revealed the following:
-1/7/2023 .Skin CDI [clean, dry, intact] .
-1/14/2023 .Skin CDI .
During a surveyor observation on 1/19/2023 at 2:05 PM of the resident in the presence of the Registered Nurse, Staff B, revealed the resident has a G-tube surgical site on his/her abdomen.
During a surveyor interview on 1/19/2022 at approximately 3:30 PM with the Director of Nursing Services (DNS), she acknowledged that the above skin assessments were inaccurate. The DON further revealed that she would expected staff to document that the resident has a G-tube incision on his/her abdomen on the skin assessments mentioned above.
2. Record review revealed Resident ID #155 was admitted to the facility in June of 2021 with diagnoses including, but not limited to, diabetes mellitus (high blood sugar) and chronic kidney disease.
Record review revealed the following physician orders:
- 11/14/2022 for Weekly Skin Checks Every Thursday on Day .
- 12/29/2022 for Santyl ointment [medication used to help with wound healing] .Apply to left medial foot topically every day shift for wound care .
Review of the WOUND EVALUATION & MANAGEMENT SUMMARY dated 1/4/2023 and 1/11/2023 revealed the resident has an unstageable wound on his/her left, medial foot.
Record review of the SKIN OBSERVATION TOOL dated 1/7/2023 and 1/14/2023 failed to reveal evidence that the skin assessments were accurate. These skin assessments failed to reveal evidence of the resident's wound on his/her left medial foot.
During a surveyor interview with the Wound Nurse, Staff U on 1/19/2023 at 12:37 PM, she acknowledged the resident has a wound on his/her left medial foot and that she would have expected staff to document that the resident has the wound.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined the facility failed to provide the necessary services to a resident who is unable to carry out activities of d...
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Based on surveyor observation, record review, and staff interview, it has been determined the facility failed to provide the necessary services to a resident who is unable to carry out activities of daily living (ADLs) relative to personal hygiene for 3 of 6 sample residents observed, Resident ID #'s 8, 57, and 106.
Findings are as follows:
1. Record review for Resident ID #8 revealed the resident was admitted to the facility in October of 2017 with diagnoses to include, but are not limited to, muscle weakness and chronic kidney disease.
Record review of a care plan dated 12/9/2020 and revised on 2/18/2021 revealed, The resident has an ADL self-care performance deficit r/t [related to] Activity Intolerance and Disease process .Resident requires staff assist to complete ADL tasks daily. Fluctuations are expected r/t Diagnosis . This care plan has interventions including, but not limited to, .HYGIENE/GROOMING: LIMITED ASSIST X 1 .PERSONAL HYGIENE: The resident requires limited assistance by 1 staff with personal hygiene .
During surveyor observations of the resident's finger nails on the following dates and times revealed all of the resident's finger nails were long. They were approximately 0.25 centimeters (cm) - 0.5 cm:
-1/17/2023 at 11:54 AM
-1/19/2023 at 11:20 AM
During a surveyor observation on 1/19/2023 at 11:28 AM of the resident in the presence of the Wound Nurse, Staff U, revealed all of the resident's finger nails were long. She revealed she was unaware that the resident's finger nails were long and acknowledged they needed to be trimmed.
During a surveyor interview with the Director of Nursing Services (DNS) on 1/19/2022 at 3:17 PM, she revealed she would expect the resident's nails to be trimmed if they were long.
2. Record review for Resident ID #57 revealed the resident was admitted to the facility in July of 2020 with diagnoses including, but not limited to, Alzheimer's Disease, dementia without behavioral disturbances, and muscle weakness.
Record review of the care plan dated 12/11/2022 states in part, The resident has an ADL self-care performance deficit r/t Disease process. Resident requires staff assist to complete ADL tasks daily .interventions including, but not limited to, HYGIENE/GROOMING: TOTAL DEPENDENCE X 1, SHOWERING: Resident is TOTALLY DEPENDENT ON STAFF X 2 for SHOWERING .BATHING/SHOWERING: Provide sponge bath when a full bath or shower cannot be tolerated .check nail length and trim and clean on bath day and as necessary .
During a surveyor observation on 1/19/2022 at 1:05 PM in the presence of the Staff U, revealed the resident with debris under all fingernails to his/her left hand. She acknowledged the debris under each nail to the resident's left hand.
During a surveyor observation and simultaneous interview on 1/20/2023 at 1:59 PM with Nursing Assistant (NA), Staff D and Registered Nurse, Staff E, revealed the resident with debris under his/her fingernails to his/her thumb, 1st, 2nd, 3rd, and 4th digit of his/her left hand. Additionally, s/he was observed with debris under his/her fingernails to his/her thumb, 1st, 2nd, and 3rd digit to his/her right hand. Staff D revealed that she already provided care to the resident and indicated she would soak his/her fingernails. Both Staff D and Staff E acknowledged the debris under the resident's fingernails.
During a surveyor interview on 1/20/2023 at approximately 2:30 PM with the DNS, she could not explain why nail care was not provided to the resident.
3. Review of a community reported complaint received at the Rhode Island Department of Health on 1/9/2023 revealed in part, .There is also no one coming in to assist me in getting washed up bedside as I'm unable to do this myself .They don't even bring in towels or that for me to do it myself if I was able .
Record review for Resident ID #106 revealed that s/he was admitted to the facility in October of 2022 with diagnoses including, but not limited to, morbid obesity and need for assistance with personal care.
Review of the care plan, initiated on 1/11/2023, revealed that the resident has an ADL self-care performance deficit requiring staff assistance to complete ADL tasks daily.
Review of the Minimum Data Set Assessment, dated 1/7/2023, revealed a BIMS (Brief Interview for Mental Status) score of 15, indicating s/he is cognitively intact. Further review of the MDS revealed s/he requires extensive physical assistance of one staff for bathing.
During surveyor observations of the resident on 1/11/2023 at approximately 1:00 PM revealed s/he was laying in bed wearing pajamas. During a surveyor interview with the resident, it s/he revealed that s/he would like to take off his/her pajamas and wash up, but the staff has not yet provided him/her assistance.
During a surveyor interview with NA, Staff F on 1/11/2023 at approximately 1:30 PM, she revealed that the resident requires one staff assistance with ADL care and is to be provided a basin with water, a washcloth and towel for bathing at the bedside. She acknowledged that she did not provide him/her with the washing set-up previously mentioned and did not offer to assist him/her during the shift before it was brought to her attention by the surveyor.
During a surveyor interview with RN, Staff A on 1/11/2023 at approximately 2:00 PM, she revealed she would expect that NA's would offer ADL assistance to residents by lunch time and report to the nurse if a resident refuses care.
During a surveyor interview with the DNS on 1/20/2023 at approximately 1:00 PM, she revealed she would expect that the resident would be provided with ADL assistance as indicated in the care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to ensure that residents receive proper treatment and care to maintain good ...
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Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to ensure that residents receive proper treatment and care to maintain good foot health and assistance with making appointments with a qualified person for 1 of 1 residents reviewed relative to foot care, Resident ID #72.
Findings are as follows:
Record review for the resident revealed that s/he was re-admitted to the facility in October of 2022 with diagnoses including, but not limited to, type 2 diabetes mellitus with other circulatory complications and need for assistance with personal care.
Review of the order summary report revealed a current order, dated 10/25/2022, stating podiatry may be consulted as needed. Further review of this documentation revealed an order, dated 12/13/2022, to provide diabetic foot care every day at night including observation of feet, toes, ankles, and soles.
Review of wound consultation documentation, dated 11/30/2022, revealed in part, .Please have podiatry cut patient's toenails .
Record review failed to reveal evidence that the resident was seen by a podiatrist.
During a surveyor observation in the presence of Licensed Practical Nurse, Staff H, on 1/20/2023 at 10:54 AM revealed the hallux (big toe) on his/her left foot approximately 1/2-3/4 of an inch long extending beyond the toe. Further observations of the hallux on his/her right foot revealed it was dark yellow and greenish in color, very thick and curled upward. It extended approximately 1/4 of an inch upward and had a pointed shape.
During a surveyor interview with the resident following the above-mentioned observation, s/he stated that s/he has not been seen by the podiatrist.
During a surveyor interview with the Director of Nursing Services on 1/20/2023 at approximately 2:00 PM, she was unable to provide evidence that the resident was seen by the podiatrist before it was brought to the facility's attention by the surveyor. Furthermore, she would have expected that the resident would have been seen by the podiatrist.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 2 ...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 5 residents reviewed for respiratory care, Resident ID #s 262 and 357.
Findings are as follows:
According to Brunner and Sudarth's textbook, Medical and Surgical Nursing, 7th Edition, 1992, p. 524, as with other medications, oxygen is administered with care, and its effects on each patient are carefully assessed. Oxygen is a drug and except in emergency situations is prescribed by a physician.
Record review of the facility policy titled, Oxygen Administration revealed in part, .verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen [O2] administration .Documentation .The date and time that the procedure was performed .The name and title of the individual who performed the procedure .the rate of oxygen flow, route, and rationale .The frequency and duration of the treatment .reason for p.r.n. [as needed] administration .The signature and title of the person recording the data .
1) Record review revealed that Resident ID #262 was admitted to the facility in January of 2023 with diagnoses including, but not limited to, mild persistent asthma with acute exacerbation, chronic combined systolic and diastolic heart failure, and history of Covid 19.
Surveyor observations of the resident revealed s/he was receiving oxygen therapy via nasal cannula on the following dates and times:
1/18/2023 at 9:19 AM- observed on oxygen at 2.5 liters via nasal cannula.
1/19/2023 at 8:20 AM- observed resident on oxygen at 2 liters via nasal cannula.
Record review of the electronic record under the pulse oximetry section of vital signs revealed the following:
1/18/2023 at 10:34 AM- .97.0 % Oxygen via Nasal Cannula .
1/17/2023 at 8:43 AM- .96.0 % Oxygen via Nasal Cannula .
1/16/2023 at 9:15 AM- .95.0 % Oxygen via Nasal Cannula .
1/16/2023 at 5:15 AM- .94.0 % Oxygen via Nasal Cannula .
1/15/2023 at 10:14 AM- .95.0 %
Oxygen via Nasal Cannula .
1/15/2023 at 6:10 AM- .96.0 % Oxygen via Nasal Cannula .
1/14/2023 at 8:20 PM- .98.0 % Oxygen via Nasal Cannula .
1/14/2023 at 6:20 AM- .94.0 % Oxygen via Nasal Cannula .
1/13/2023 at 4:12 PM- .97.0 % Oxygen via Nasal Cannula .
1/13/2023 at 2:22 PM- .97.0 % Oxygen via Nasal Cannula .
Record review on 1/18/2023 failed to reveal a physician's order for oxygen.
During a surveyor interview on 1/19/2023 at 11:42 AM with Licensed Practical Nurse (LPN), Staff K she acknowledged that the resident has been on oxygen but failed to have a physician's order for oxygen.
2) Record review revealed that Resident ID #357 was re-admitted to the facility in November of 2022 with diagnoses including, but not limited to, dyspnea.
Surveyor observations of the resident revealed s/he was receiving oxygen therapy via nasal cannula on the following dates and times:
1/17/2023 at 10:00 AM - observed on oxygen at 2 liters via nasal cannula with the tubing undated.
1/17/2023 at approximately 12:30 PM - observed on oxygen at 2 liters via nasal cannula with tubing undated.
1/18/2023 at 8:26 AM - observed on Oxygen at 2 liters via nasal cannula, with tubing undated.
Record review of the electronic record under the pulse oximetry section of vital signs revealed the resident was receiving oxygen via nasal cannula on the following dates and times:
1/18/2023 at 9:06 AM and 5:35 AM
1/17/2023 at 8:52 AM
1/15/2023 at 8:47 AM
1/14/2023 at 9:05 AM
1/13/2023 at 11:51 AM
1/11/2023 at 6:24 PM and 8:55 AM
1/10/2023 at 9:06 AM
1/9/2023 at 9:22 AM
1/7/2023 at 1:21 PM
1/6/2023 at 9:52 AM
1/4/2023 at 7:37 PM
Record review of the resident's Treatment Administration Record (TAR) for January revealed an order with a start date of 12/3/2022 to Change PRN [as needed] oxygen tubing if in use every week on Sunday. Label each component with date and initials . Further review of the TAR failed to reveal initials indicating that the tubing was every changed as ordered.
Record review of the resident's TAR for January revealed an order with a start date of 12/3/2022 for Oxygen 2l [2 liters] per NC [Nasal Cannula] as needed .for s.o.b. [Shortness of breath]/ wheezing . Further review of the TAR failed to reveal initials indicating the oxygen was in use.
During a surveyor interview on 1/19/2023 at 11:26 AM with LPN, Staff L, he acknowledged that there was no date on the oxygen tubing to indicate when it was last changed. He further acknowledged that there was no documentation in the TAR that the tubing was changed and that oxygen was in use for the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0710
(Tag F0710)
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 physician, physician assistant, nurse practitioner, or clinical nurse specialist provide or...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that a physician, physician assistant, nurse practitioner, or clinical nurse specialist provide orders for the resident's immediate care needs and that the medical care of each resident is supervised by a physician for 1 of 7 residents reviewed for medication orders, Resident ID #69.
Findings are as follows:
Record review for the resident revealed a physician's order dated 1/4/2023 for olanzapine (antipsychotic used to treat mental disorders) 2.5 milligrams (mg) by mouth one time a day for anxiety for 14 days then re-evaluate.
Further record review revealed a progress note dated 1/16/2023, authored by the Registered Nurse Practitioner, Staff J, that states in part, .Assessment and Plan .Restlessness/agitation/anxiety - c/w [continue with] .olanzapine, monitor for behavioral disturbances .
Record review of the January 2023 Medication Administration Record revealed that the olanzapine order failed to be continued after 1/17/2023.
During a surveyor interview on 1/20/2023 at 1:46 PM with Staff J, she revealed she assessed the resident on 1/16/2023 and indicated that her plan was to continue the resident's olanzapine order. Staff J acknowledged that she failed to place a continuation order for the olanzapine.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
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 as needed (PRN) orders for psychotropic drugs are limited to 14 days for 1 of 6 residents re...
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Based on record review, and staff interview, it has been determined that the facility failed to ensure that as needed (PRN) orders for psychotropic drugs are limited to 14 days for 1 of 6 residents reviewed relative to unnecessary medications, Resident ID #62.
Findings are as follows:
Record review revealed the resident was admitted to the facility in September of 2021 with diagnoses including, but not limited to, stroke and muscle weakness.
Record review revealed a physician's order dated 12/20/2022 for, LORazepam Intensol Concentrate 2 MG [milligram]/ML [milliliter] .Give 0.5 mg via G-tube [feeding tube] every 6 hours as needed for Anxiety .
Further record review failed to reveal evidence that the above PRN order was limited to 14 days. Additionally, there was no documentation relative to the rationale or duration of the PRN order by the physician or prescribing practitioner in the resident's medical record.
Additional record review revealed the resident received 3 doses of Lorazepam (after 14 days) on the following dates and times:
- 1/4/2023 at 3:02 AM
- 1/14/2023 at 6:00 AM
- 1/18/2023 at 4:18 PM
During a surveyor interview on 1/19/2023 at 3:19 PM with the Director of Nursing Services, she acknowledged that the above PRN order was not limited to 14 days as required.
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 store and label drugs and biological's in accordance with currently accepted profes...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 1 of 1 nursing stations observed.
Findings are as follows:
Review of a policy titled, Storage of Medications revised in November of 2020, states in part, .Drugs and biological's used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications .
A continuous surveyor observation on 1/19/2023 from 8:34 AM until 9:21 AM of the first-floor Central unit revealed the following medication cards left unsecured and unattended on the nurses' desk:
-A medication blister pack of Mirtazapine 15 Milligram (mg) (antidepressant) for Resident ID #69 containing 14 tablets.
-A medication blister pack of Atorvastatin 10 mg (medication to treat high cholesterol) for Resident ID #65 containing 14 tablets.
-A medication blister pack of Mycophenolat 500 mg (an immunosuppressive) for Resident ID #69 containing 28 tablets.
-2 medication blister packs of Pyridostigm 60 mg (used to improve muscle strength) one containing 30 tablets and the other containing 12 tablets for a total of 42 tablets.
During the time of the above observation, two residents were present in the room that is used for meals, directly across from the nurses' desk. Additionally, at least 7 people, who were not authorized to administer medications, walked by the nurses' station while the medications were accessible and unsecured on the nurse's desk.
During a surveyor observation on 1/19/2023 at 9:21 AM revealed Nursing Assistant (NA), Staff M pick up the 5 medication blister packs and begin to walk away with them. When asked her title by a surveyor, she revealed that she was a NA and was picking up the medications for the Nurse.
During a surveyor interview on 1/19/2023 at 9:22 AM with Licensed Practical Nurse, Staff N, she acknowledged that the above medications were not stored in a locked compartment.
During a surveyor interview on 1/19/2023 at 9:33 AM with the Director of Nursing Services, she revealed that her expectation would be that the medications would be locked in the Medication storage room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0773
(Tag F0773)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specia...
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Based on record review and staff interview, it has been determined that the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 of 2 residents reviewed, Resident ID #105.
Findings are as follows:
Review of the resident's record revealed that s/he was admitted to the facility in November of 2022, with diagnoses including, but not limited to, heart failure, chronic atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), old myocardial infarction (heart attack), and hypertension.
Review of the care plan, revised on 12/12/2022, revealed an intervention to obtain and report labs as ordered.
Review a document titled Order Summary Report, revealed in part, the following orders:
- 12/28/2022 order for PT/INR lab (Used to measure the time it takes for blood to clot. It is used to measure anticoagulant use, blood thinning medications) to be obtained on 12/30/2022.
Review of the resident's record failed to reveal evidence that the PT/INR lab was obtained as ordered.
Further review of the Order Summary Report, revealed the following orders:
- 12/27/2022 order for BMP (Basic metabolic panel, a group of blood tests. These tests show how well your kidneys work. They also show the levels of glucose [sugar] and electrolytes in your blood).
- 12/30/2022 order for Pro BMP (SIC pro BNP, a blood test used to diagnose or rule out heart failure) one time only.
During a surveyor interview with Licensed Practical Nurse (LPN), Staff O on 1/19/2023 at approximately 3:00 PM, she clarified that the order on 12/28/2022 was for a pro BNP lab to be obtained not a Pro BMP.
Review of a lab slip, dated 12/30/2022, revealed BMP and Pro-BNP lab tests were performed. Further review of the lab slip failed to reveal evidence that a PT/INR lab was obtained.
Review of the 12/30/2022 labs revealed a critically high result for the pro-BNP of 8547.00 (reference range 0-300.00 PG/ML [picograms per milliliter], the measure of the amount of a particular substance in a sample).
During a surveyor interview with Registered Nurse, Staff A on 1/12/2023 at 10:17 AM, she revealed that she did not report the 12/30/2022 lab results to the ordering physician, physician assistant, or nurse practitioner. Additionally, she failed to notify the provider that the PT/INR labs were not obtained on 12/30/2022.
During a surveyor interview with the Director of Nursing Services on 1/20/2023 at approximately 12:30 PM, she revealed she would have expected the order for the PT/INR lab to be obtained as ordered. Additionally, she was unable to provide evidence that the critically high pro BNP lab results were reported to the provider.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
Based on record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote...
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Based on record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 3 of 8 residents reviewed for pressure ulcers (a localized injury to the skin or underlying tissue due to pressure), Resident ID #s 4, 72, and 155.
Findings are as follows:
1. Record review for Resident ID #4 revealed s/he was admitted to the facility in October of 2022 with diagnoses including, but not limited to, diabetes mellitus (high blood sugar) and muscle weakness.
Review of the WOUND EVALUATION & MANAGEMENT SUMMARY revealed the resident has a stage 4 pressure ulcer (the most serious wound, that extends into the deep tissues, including muscle, tendons, and ligaments) to the resident's left ischium (lower and back of hip bone) and a skin tear to the left lower buttock.
Further record review of the above wound evaluation revealed the following recommendations by the wound physician:
-12/7/2022 .ISCHIUM .Peri wound Treatment Skin prep apply once daily for 25 days .Zinc 220mg [milligrams] once daily po [by mouth] for 14 days .LOWER BUTTOCK .Peri wound Treatment Skin prep apply once daily for 25 days .
-12/14/2022 .ISCHIUM .Peri wound Treatment Skin prep apply once daily for 18 days .LOWER BUTTOCK .Peri wound Treatment Skin prep apply once daily for 18 days .
-12/28/2022 .ISCHIUM .Peri wound Treatment Skin prep apply once daily for 30 days .LOWER BUTTOCK .Peri wound Treatment Skin prep apply once daily for 30 days .
-1/4/2023 .ISCHIUM .Peri wound Treatment Skin prep apply once daily for 23 days .LOWER BUTTOCK .Peri wound Treatment Skin prep apply once daily for 23 days .
-1/11/2023 .ISCHIUM .Peri wound Treatment Skin prep apply once daily for 16 days .LOWER BUTTOCK .Peri wound Treatment Skin prep apply once daily for 16 days .
Record review failed to reveal evidence that the physician's orders were obtained to include the above recommendations by the wound physician.
Record review revealed the most recent wound measurements dated 1/11/2023 included the following:
-Stage 4 pressure wound to the left ischium: 1.5 centimeters (cm) L (length) x 1.2 cm W (width) x 2.7 cm D (depth) with surface area 1.8 cm (squared), and 3.2 cm undermining with moderate serous (thin clear or yellow drainage).
-Skin tear wound to the left, lower buttock 4.8 cm x 2.5 cm x not measurable cm with surface area 12 cm squared with light serous drainage.
During a surveyor interview on 1/20/2023 at 11:34 AM with the Director of Nursing Services (DNS), she revealed that the resident's primary care physician usually agrees with the wound specialist's recommendations. She further revealed that she would expect staff to obtain orders to include all recommendations by the wound specialist.
2. Review of the record for Resident ID #72 revealed that s/he was re-admitted to the facility in October of 2022 with diagnoses including, but not limited to, type 2 diabetes mellitus with other circulatory complications.
Review of the resident's orders revealed that s/he has Stage 3 pressure ulcers (full thickness skin loss extending under the skin layer) to the left and right heels. Further review revealed an order, dated 11/30/2022, to offload heels at all times using prevalon boots [used to alleviate pressure to the heels] or pillows every shift.
Surveyor observations on the following dates and times failed to reveal evidence of any prevalon boots or pillows in place or that the resident's bilateral heels were offloaded:
- 1/17/2023 at approximately 10:00 AM
- 1/17/2023 at approximately noon
- 1/18/2023 at 9:01 AM
- 1/18/2023 at 10:06 AM
- 1/18/2023 at 12:20 PM
- 1/18/2023 at 4:17 PM
- 1/19/2023 at 10:58 AM
- 1/19/2023 at 12:19 PM
During a surveyor interview with Nursing Assistant, Staff G and Licensed Practical Nurse, Staff H following the above observation on 1/19/2023 at 12:19 PM, they were unable to locate the resident's Prevalon boots or provide evidence that his/her heels were offloaded at all times per the order.
Review of a care plan relative to impaired skin integrity for current wounds, revised on 11/7/2022, revealed interventions, including but not limited to, document wound for size, depth, margins, peri-wound skin, amount of drainage and circumference weekly and as necessary.
Review of the weekly wound assessments and progress notes failed to reveal evidence that either a wound assessment or that measurements were obtained as indicated in the plan of care on the following weeks:
- 12/25/2022 through 12/31/2022
- 12/11/2022 through 12/17/2022
- 12/4/2022 through 12/10/2022
- 11/27/2022 through 12/3/2022
- 11/20/2022 through 11/26/2022
- 11/13/2022 through 11/19/2022
- 11/6/2022 through 11/12/2022
During a surveyor interview with the Wound Nurse, Staff U on 1/20/2023 at 9:40 AM, she revealed that she took on the role as wound nurse and began measuring the resident's left and right heel wounds on 12/23/2022. She was unable to provide evidence of measurements for the week of 12/25/2022 through 12/31/2022.
During a surveyor interview with the Unit Manager, Licensed Practical Nurse (LPN), Staff I on 1/20/2023 at 9:49 AM, she revealed that she would expect that the wound description and measurements would be documented weekly.
During a surveyor interview with the DNS on 1/20/2023 at approximately 2:00 PM, she was unable to provide the missing documentation of the resident's wound measurements and/or descriptions for the weeks mentioned above. She revealed she would expect that wound measurements and descriptions would be documented weekly as indicated in the care plan and the resident's heels would be offloaded per the order.
3. Record review for Resident ID #155 revealed s/he was admitted to the facility in June of 2021 with diagnoses including, but not limited to, diabetes mellitus and chronic kidney disease.
Record review of the WOUND EVALUATION & MANAGEMENT SUMMARY, revealed the resident has an unstageable (due to death of tissue) pressure ulcer to the left medial foot.
Further record review of the above wound evaluation revealed the following recommendations by the wound physician:
-12/21/2022 .Peri Wound Treatment Skin prep apply once daily for 30 days .
-12/28/2022 .Peri Wound Treatment Skin prep apply once daily for 23 days .
-1/4/2023 .Peri Wound Treatment Skin prep apply once daily for 16 days .
-1/11/2023 .Peri Wound Treatment Skin prep apply once daily for 9 days .
Record review failed to reveal evidence that the physician's orders were obtained to include the above recommendations by the wound specialist.
Record review revealed the most recent wound measurements, dated 1/11/2023, included the following:
-An unstageable wound to the left medial foot was 0.8 cm (L) x 0.5 cm (W) x not measurable cm (D), surface area 0.4 cm squared with no drainage.
During a surveyor interview on 1/19/2023 at 12:37 PM with the Wound Nurse, Staff U, she revealed the resident's primary physician usually agrees with the recommendations. She acknowledged she failed to obtain a physician's order to include the skin prep to the peri wound.
During a surveyor interview on 1/19/2023 at 1:00 PM with DNS, she acknowledged the wound recommendations had not been implemented. She further indicated that she would expect staff to obtain physician orders to include all recommendations by the wound specialist and to notify the physician of any wound recommendations.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usu...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight and failed to follow their policy relative to weight loss and weight gain for 2 of 11 residents reviewed, Resident ID #s 31 and 69.
Findings are as follows:
Review of the facility policy titled, Weight Loss/Gain Protocol, states in part .
PROCEDURE .a significant weight discrepancy is defined as: 1. A weight change of 3 pounds or more in one week (if resident on weekly weights); 2. A loss/gain of 5% or greater within one month .1. WHEN A SIGNIFICANT WEIGHT LOSS/GAIN IS NOTED .THE FOLLOWING INTERVENTIONS MUST OCCUR: .All monthly weights must be done by the end of the first two (2) weeks of the month. 1. Reweigh all residents who are reported to have a significant weight discrepancy in order to assess the accuracy of the weight. The reweigh shall be done within 48 hours .2. If the re-weigh is accurate and there has been a significant weight loss/gain, nursing must notify.
Physician
Dietician [RD]
DNS [Director of Nursing Services]
3. Consider calorie count. 4. Review the resident's current diet for appropriateness. 5. Start weekly weights .6. Rule out any medical reason(s) for weight loss .
1. Record review for Resident ID #31 revealed the resident was re-admitted to the facility in November of 2022 with diagnoses including, but not limited to, metabolic encephalopathy (neurological disorder resulting from systemic illness such as diabetes), cognitive communication deficit, and type 2 diabetes mellitus (high blood sugars).
Review of the resident's weight record revealed the following weights:
- 12/12/2022
149.6 pounds (Lbs.)
- 12/19/2022
149 Lbs.
- 12/30/2022
147.6 Lbs.
- 1/9/2023
138.2 Lbs.
- 1/10/2023
139 Lbs.
Further review of the record revealed the resident lost 10.6 pounds in approximately one month, which is a significant weight loss of 7.1%.
Record review of a progress note dated 1/11/2023 documented by the RD, states in part, Resident with significant/unplanned weight change of 7.1% x 1 month .This weight loss was not desirable .Resident reports enjoying oatmeal and pudding. Resident to begin receiving 6oz [ounces] fort. [fortified] Oatmeal QD [daily] and 4oz fort. Pudding BID [twice daily] to help meet nutritional needs and support weight maintenance .
Record review revealed a physician's order dated 11/15/2022 for, Limited Carb Diet (LCD) diet Mechanical Soft* texture, Thin consistency, 6oz fortified oatmeal daily @ breakfast; 4oz fortified pudding daily @ lunch/dinner .
During surveyor observations on the following dates and times revealed the resident did not have fortified pudding on his/her meal tray:
- 1/17/2023 at 12:35 PM
- 1/18/2023 at 12:44 PM
- 1/19/2023 at 12:47 PM
During a surveyor interview with the RD on 1/20/2023 at 10:17 AM, she revealed that she implemented new interventions for the resident to have fortified oatmeal at breakfast and fortified pudding at lunch and dinner after his/her significant weight loss on 1/11/2023. She further revealed that she was unaware that the resident had not been receiving his/her fortified pudding at lunch on the above-mentioned dates.
During a surveyor interview with Registered Nurse Practitioner, Staff J, on 1/20/2023 at 10:49 AM, she revealed that she would expect the resident to receive his/her fortified pudding per the physician's order.
During a surveyor interview with the DNS on 1/20/2023 at 11:14 AM, she was unable to explain why the resident did not receive his/her fortified pudding as ordered.
2. Record review for Resident ID #69 revealed the resident was re-admitted to the facility in April of 2022 with diagnoses including, but not limited to, muscle wasting, dysphagia (difficulty swallowing), and protein-calorie malnutrition.
Record review of the physician order dated 11/10/2022 for Weigh weekly x 4 weeks every day shift every 1 month(s) starting on the 15th for 1 day(s) Re-weigh for change of 3LBS (+ or -) and notify MD .
Record review failed to reveal evidence that weekly weights were obtained on 11/17/2022 and 11/24/2022.
Review of the resident's weight record documentation revealed the following subsequent weights:
-12/20/2022 71.8 Lbs.
-1/10/2023 78 Lbs.
-1/18/2023 65.2 Lbs.
-1/19/2023 65 Lbs.
Record review revealed the weight was obtained on 1/10/2023 which revealed s/he weighed 78 pounds, indicating a significant weight gain of 6.2 pounds (8.6%) from the previous weight obtained on 12/20/2022, which was less than one month. Additionally, record review revealed the facility failed to follow their policy and reweigh the resident within 48 hours.
A subsequent weight was obtained on 1/19/2023 of 65.2 Lbs, indicating a 16.41% weight loss from the previous weight on 1/10/2023 which was 78 pounds.
During a surveyor interview on 1/20/2023 at 12:54 PM with the RD, she acknowledged the weekly weights were not obtained as ordered and a reweigh was not obtained within 48 hours when the resident had a weight change of 3 pounds or 5% from the previous weight as per the policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
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 the facility failed to ensure a resident's drug regimen is fr...
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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 the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 7 residents reviewed, Resident ID #65.
Findings are as follows:
Review of the resident's record revealed s/he was re-admitted to the facility on [DATE] with diagnoses including, but not limited to, closed hip fracture, pelvic fracture, and Alzheimer's Disease.
Record review of a document titled, Continuity of Care [COC]- Post-Acute Facility dated 11/5/2022, revealed the following medication order that was to continue upon re-admission to the facility:
- Omeprazole (medication used to treat certain stomach and esophagus problems) 20 milligrams (mg) delayed release tablet, take one tablet, 20 mg total by mouth daily.
Record review of the physician orders revealed an order dated 11/5/2022 for Omeprazole 20 mg delayed release tablet, give 20 mg by mouth before meals.
Record review of the November and December 2022 and the January 2023 Medication Administration Records revealed Omeprazole was administered three times daily and not daily as ordered, resulting in the resident receiving 2 additional doses of the medication daily from 11/5/2022 through 1/19/2023.
Further record review failed to reveal evidence of a change in the above-mentioned order from the hospital COC form after the resident was re-admitted to the facility.
During a surveyor interview on 1/20/2023 at approximately 11:00 AM with the Director of Nursing Services, she was unable to explain why the order for omeprazole was transcribed incorrectly and why the resident did not receive the medication as ordered.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected most or all residents
Based on record review and staff interview, it has been determined that the facility failed to conduct a comprehensive assessment using the resident assessment instrument (RAI), for 10 of 33 residents...
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Based on record review and staff interview, it has been determined that the facility failed to conduct a comprehensive assessment using the resident assessment instrument (RAI), for 10 of 33 residents reviewed, Resident ID #s 9, 36, 38, 56, 62, 65, 69, 208, 357, and 360.
Findings are as follows:
1. Record review for Resident ID #9 revealed that a significant change Minimum Data Set (MDS) Assessment that was due on 11/8/2022 was incomplete.
2. Record review for Resident ID #36 revealed that an admission MDS that was due on 6/28/2022 was incomplete.
3. Record review for Resident ID #38 revealed that an annual MDS that was due on 11/19/2022 was incomplete.
4. Record review for Resident ID #56 revealed that an admission MDS that was due on 5/20/2022 was incomplete.
5. Record review for Resident ID #62 revealed that an annual MDS assessment that was due on 9/21/2022 was incomplete.
6. Record review for Resident ID #65 revealed that an admission MDS that was due on 12/14/2022 was incomplete.
7. Record review for Resident ID #69 revealed that an admission MDS that was due on 6/12/2022 was incomplete.
8. Record review for Resident ID #208 revealed that an initial MDS that was due on 11/1/2022 was incomplete.
9. Record review for Resident ID #357 revealed that an admission MDS that was due on 11/28/2022 was incomplete.
10. Record review for Resident ID #360 revealed that an annual MDS that was due on 9/7/2022 was incomplete.
During a surveyor interview on 1/19/2023 at 3:17 PM with the MDS Coordinator, she was unable to provide evidence that the facility completed the above comprehensive assessments as required.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected most or all residents
Based on record review, and staff interview, it has been determined that the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not l...
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Based on record review, and staff interview, it has been determined that the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for 18 of 33 residents, Resident ID #s 8, 9, 11, 15, 24, 31, 36, 45, 50, 51, 57, 62, 78, 80, 155, 206, 216 and 360.
Findings are as follows:
1. Record review for Resident ID #8 revealed the quarterly Minimum Data Set (MDS) assessments that were due on 5/14/2022 and 11/10/2022 were incomplete.
2. Record review for Resident ID #9 revealed the quarterly MDS assessment that was due on 5/25/2022 was incomplete.
3. Record review for Resident ID #11 revealed the quarterly MDS assessments that were due on 5/27/2022 and 11/25/2022 were incomplete.
4. Record review for Resident ID #15 revealed the quarterly MDS assessment that was due on 10/9/2022 was incomplete.
5. Record review for Resident ID #24 revealed the quarterly MDS assessment that was due on 11/10/2022 was incomplete.
6. Record review for Resident ID #31 revealed the quarterly MDS assessment that was due on 6/16/2022 was incomplete.
7. Record review for Resident ID #36 revealed the quarterly MDS assessment that was due on 10/26/2022 was incomplete.
8. Record review for Resident ID #45 revealed the quarterly MDS assessments that were due on 11/15/2022 and 11/19/2022 were incomplete.
9. Record review for Resident ID #50 revealed the quarterly MDS assessment that was due on 11/20/2022 was incomplete.
10. Record review for Resident ID #51 revealed the quarterly MDS assessment that was due on 10/22/2022 was incomplete.
11. Record review for Resident ID #57 revealed the quarterly MDS assessment that was due on 10/13/2022 was incomplete.
12. Record review for Resident ID #62 revealed the quarterly MDS assessment that was due on 12/19/2022 was incomplete.
13. Record review for Resident ID #78 revealed the quarterly MDS assessment that was due on 10/11/2022 was incomplete.
14. Record review for Resident ID #80 revealed the quarterly MDS assessments that were due on 11/16/2022 and 9/23/2022 were incomplete.
15. Record review for Resident ID #155 revealed the quarterly MDS assessment that was due on 10/7/2022 was incomplete.
16. Record review for Resident ID #206 revealed the quarterly MDS assessments that were due on 10/1/2022 and 12/30/2022 were incomplete.
17. Record review for Resident ID #216 revealed the quarterly MDS assessments that were due on 5/16/2022 and 10/24/2022 were incomplete.
18. Record review for Resident ID #360 revealed the quarterly MDS assessments that were due on 6/29/2022 and 12/5/2022 were incomplete.
During a surveyor interview on 1/19/2023 at 3:17 PM with the MDS Coordinator, she was unable to provide evidence that the above MDS assessments were completed as required.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected most or all 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 electronically transmit data aft...
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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 electronically transmit data after a facility completed a resident's assessment for 14 of 33 residents, Residents ID #s 4, 9, 31, 44, 56, 67, 70, 73, 77, 78, 83, 84, and 110.
Findings are as follows:
1. Record review for Resident ID #4 revealed the quarterly Minimum Data Set (MDS) assessments, dated 5/10/2022 and 11/8/2022, were completed but not electronically transmitted as required.
2. Record review for Resident ID #9 revealed the discharge MDS, dated [DATE], was not completed or transmitted.
3. Record review for Resident ID #31 revealed the discharge MDS, dated [DATE], was not completed or transmitted.
4. Record review for Resident ID #44 revealed the discharge MDS, dated [DATE], was not completed or transmitted.
5. Record review for Resident ID #56 revealed the Comprehensive MDS, dated [DATE], and the discharge MDS, dated [DATE], was not completed or transmitted.
6. Record review for Resident ID #66 revealed the discharge MDS, dated [DATE], was not completed or transmitted.
7. Record review for Resident ID #67 revealed the discharge MDS, dated [DATE], was not completed or transmitted.
8. Record review for Resident ID # 70 revealed the quarterly MDS assessment, dated 5/7/2022 and 11/2/2022, were completed but not electronically transmitted as required.
9. Record review for Resident ID #73 revealed the discharge MDS, dated [DATE], was not completed or transmitted.
10. Record review for Resident ID #77 revealed the discharge MDS, dated [DATE], was not completed or transmitted.
11. Record review for Resident ID #78 revealed the discharge MDS, dated [DATE], was not completed or transmitted.
12. Record review for Resident ID #83 revealed the discharge MDS, dated [DATE], was not completed or transmitted.
13. Record review for Resident ID #84 revealed the discharge MDS, dated [DATE], was not completed or transmitted.
14. Record review for Resident ID #110 revealed the discharge MDS, dated [DATE], was not completed or transmitted.
During a surveyor interview on 1/20/2023 at 9:24 AM with the MDS Coordinator, she was unable to provide evidence that the above MDS assessments were electronically transmitted as required.
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 safety relative to the main kitchen and 4 of 4 unit kitchenettes.
Findings are as follows:
1. Record review of the Rhode Island Food Code 2018 edition, section 3-501.17 states in part, .(B) Except as specified paragraphs (E)-(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combination specified in paragraph (A) of this section and:
(1) The day the original container is opened and the FOOD ESTABLISHMENT shall be counted as Day 1; and
(2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturers use-by date if the manufacturer determined the use-by date based on FOOD SAFETY .
During a surveyor observation during the initial tour of the main kitchen on 1/17/2023 at 8:50 AM in the presence of the Food Service Director (FSD), the following was observed in a reach-in refrigerator in the back of the kitchen:
- One 5-pound container of 4% milkfat cottage cheese, opened. The manufacturer's use-by date on the container was 10/24/2022.
- One of one 46-ounce (oz) container of [NAME] Readycare nectar-thickened orange juice, opened and dated 12/21. The manufacturer's instructions state, .Refrigerate after opening and use within 7 days.
2. Record review of the Rhode Island Food Code 2018 edition, section 4-602.12 states in part, The FOOD-CONTACT SURFACES of cooking and baking EQUIPMENT shall be cleaned at least every 24 hours .
During a surveyor observation during the initial tour of the main kitchen on 1/17/2023 at 8:50 AM in the presence of the FSD, the stand mixer was observed to have a heavy accumulation of dried yellow and brown food debris on the base of the mixer's attachments. During a surveyor interview at the time of the observation, the FSD acknowledged the mixer was dirty and was unable to provide evidence of when the mixer was last used or cleaned.
3. Record review of the Rhode Island Food Code 2018 edition, section 4-602.11 states in part, .(C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris .
During a surveyor observation during the initial tour of the main kitchen on 1/17/2023 at 8:50 AM in the presence of the FSD, the hood over the cooking range was observed to have an accumulation of grease.
4. Record review of the Rhode Island Food Code 2018 edition, section 3-304.12 states in part, .During pauses and food preparation or dispensing, food preparation and dispensing utensils shall be stored .
(B) In FOOD that is NOT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD with their handles above the top of the food within containers or equipment that could be closed, such as bins of sugar, flour, or cinnamon .
During a surveyor observation of the initial tour of the main kitchen on 1/17/2023 at 8:50 AM in the presence of the FSD, the following was observed in the dry storage area:
- One 50-pound bag of dry quick oats, opened, with a clear scoop inside the bag with the handle touching the oats.
During a surveyor interview with the FSD immediately following the above observations, she acknowledged that the cottage cheese and thickened orange juice were beyond their use-by dates and should have been thrown out. Additionally, she acknowledged the hood above the cooking range was dirty and needed to be cleaned. Further, she acknowledged that the scoop should not have been stored directly in the oats.
5. Record review of the facility's policy titled, Foods Brought by Family/Visitors revised October 2017 states in part, .7. Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that it is clearly distinguishable from facility-prepared food .b. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use-by date .
During surveyor observations of the nourishment units on 1/18/2023 between 12:20 PM and 1:10 PM, the following was observed:
- On the Division St nourishment unit, there were 11 strawberry and 4 chocolate, 4-oz [NAME] Readycare shakes in the refrigerator, thawed and without a date. Manufacturer's instructions revealed that once thawed, the shakes need to be used within 14 days.
- On the School St nourishment unit, there were 14 strawberry, 1 vanilla, and 6 chocolate, 4-oz [NAME] Readycare shakes in the refrigerator, thawed and without a date. There were 2 glass food storage containers and one plastic quart sized food container which contained preapared food, all without a legible name and date.
- On the TCU nourishment unit, there were 7 strawberry and 6 chocolate 4-oz [NAME] Readycare shakes in the refrigerator, thawed and without a date. Additionally, there was one of one 46-oz carton of [NAME] Readycare honey thickened orange juice in the refrigerator, opened and not dated.
- On the Central St nourishment unit, there were 17 strawberry and 5 chocolate, 4-oz [NAME] Readycare shakes in the refrigerator, thawed and without a date.
During a surveyor interview with Cook, Staff P and the FSD on 1/18/2023 at 1:37 PM, they acknowledged that the [NAME] Readycare shakes should have been dated when thawed and that food brought in by visitors should be labeled with the resident's name, contents, and date.
6. During a follow up visit to the main kitchen on 1/18/2023 at 1:20 PM in the presence of Staff P, the following was observed in the reach-in refrigerator in the back of the kitchen:
- One of one 46-oz carton of nectar thickened dairy beverage, opened and not dated. Manufacturer's instructions on the label revealed to discard the beverage if not used within 4 days of opening.
- One of one 46-oz carton of honey thickened dairy beverage, opened and not dated. Manufacturer's instructions on the label revealed to discard the beverage if not used within 4 days of opening.
- One of one 46-oz carton of [NAME] Readycare nectar thickened orange juice, opened and not dated.
During a surveyor interview with Staff P following the above observation, he acknowledged that the above thickened beverages should have been dated when opened.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on record review and staff interview, it has been determined that the facility has failed to set priorities for its performance improvement activities that focus on problem-prone areas, consider...
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Based on record review and staff interview, it has been determined that the facility has failed to set priorities for its performance improvement activities that focus on problem-prone areas, consider the incidence, prevalence, and severity of problems in those areas and take actions aimed at performance improvement, measure its success, and track performance to ensure improvements are realized and sustained related to resident Minimum Data Set (MDS) assessment completion and timing.
Findings are as follows:
Record review of the MDS assessments of 33 discharged and current residents revealed MDS assessments which were not completed or submitted timely.
During a surveyor interview on 1/19/2023 at 3:17 PM with the MDS Coordinator, she acknowledged that the facility was aware that there was a problem with completing MDS assessments.
During a surveyor interview on 1/20/2023 at approximately 10:00 AM with the Administrator, she revealed that a decision is made about a concern going to QAPI when a problem spans throughout the facility and that areas are tracked until they reach a 95% correction rate for at least 3 consecutive months. She acknowledged that they had identified the MDS assessments as a concern in approximately October of 2021. Additionally, she revealed they had developed a QAPI plan related to staffing retention with a goal to get MDS staff to 80 hours per week. When that goal was reached, they discontinued the QAPI.
The Administrator further acknowledged that the facility failed to have a QAPI plan in place regarding the timely completion and transmission of MDS assessments to track performance and to ensure improvements were realized and sustained.
Clinical record review revealed a widespread pattern of incomplete MDS assessments, some dating as far back as May of 2022. Though the facility was aware of this concern, and it continued to be a concern at the time of the survey, it was not being tracked through the quality assurance process. Refer to Tags F-636, F-638 and F-640.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
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 follow the ...
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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 follow the manufacturer's instructions when COVID-19 rapid testing residents, for 14 of 14 residents observed, Resident ID #'s 11, 24, 27, 38, 45, 62, 85, 315, 316, 355, 356, 357, 359, and 362.
Findings are as follows:
The Centers for Disease Control document titled, Guidance for SARS-CoV-2 Rapid Testing Performed in Point-of-Care Settings, updated on 4/4/2022, states in part:
.During the test .When processing multiple specimens successively in batches, ensure proper timing for each specimen .as specified by the test manufacturer .After the test .Read and record results only within the amount of time specified in the manufacturer's instructions. Do not record results from tests that have not been read within the manufacturer's specified timeframe .
Review of the [NAME] BinaxNow COVID-19 Ag card (a type of test called an antigen test. Antigen tests are designed to detect proteins from the virus that causes COVID-19 in anterior nares) test procedure revealed in part, .Read result in the window 15 minutes after closing the card. In order to ensure proper test performance, it is important to read the result promptly at 15 minutes, and not before. Results should not be read after 30 minutes .False negative results can occur if test results are read before 15 minutes .
Surveyor observation of the Division Street Unit on 1/19/2023 at 8:24 AM revealed the Infection Control Nurse, Staff I, and Transport, Staff Q conducting rapid tests for COVID-19.
Further observations revealed the Infection Control Nurse collecting a specimen from each resident then returned to the cart and tested the samples utilizing the [NAME] BinaxNOW COVID-19 Ag card.
Continuous observations revealed that each Covid-19 card was left on top of the cart for less than 15 minutes before each test result was read by the Infection Control Nurse. She then disposed of the test after each negative result was read and then proceeded to prepare another card for testing. Staff Q was observed documenting each resident's test result into a computer. This method for testing continued until the surveyor questioned the Infection Control Nurse and Staff Q regarding the testing procedure.
During an interview with the Infection Control Nurse on 1/19/2023 at approximately 9:30 AM, she revealed that her practice is to read the COVID-19 test results before 15 minutes.
The manufacturer's instructions were reviewed with the Infection Control Nurse on 1/19/2023 at approximately 10:00 AM and she acknowledged that the instructions were not followed while testing the above-mentioned residents.
During a surveyor interview with the Director of Nursing on 1/19/2023 at 12:33 PM, she revealed she would expect that the manufacturer's instructions for COVID-19 testing would be followed.
Jan 2023
5 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure tha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 2 residents reviewed for falls, Resident ID #4.
Findings are as follows:
Record review of a facility reported incident submitted to the Rhode Island Department of Health on 12/28/2022 states in part, CNA [Nursing Assistant] .reported to this writer today that on 12/25/2022 .[Resident ID #4] had a fall at the nurse's station and states that patient was not attended to by nurses that were at the nurse's station for 20 minutes.
Record review of a policy titled Falls-Clinical Protocol states in part .In addition, the nurse shall assess and document/report the following:
a. Vital signs;
b. Recent injury, especially fracture or head injury;
c. Musculoskeletal function, observing for change in normal range of motion .;
d. Change in cognition or level of consciousness;
e. Neurological status;
f. Pain .
Record review revealed the resident was admitted to the facility in May of 2021 with diagnoses including, but not limited to, cognitive communication deficit, unspecified dementia, anxiety disorder and mood disturbance.
Record review of a progress note dated 12/25/2022 at 3:28 PM authored by Registered Nurse, Staff D, revealed Resident was sitting in the w/c [wheelchair] at nurse' station, while counting narcotics, resident attempted to get up out of bed and fell to the floor at nurses' station, Resident claims [s/he] did hit [his/her] head.
Additional review of the progress notes revealed an entry authored by Staff D on 12/25/2022 at 3:49 PM which states in part, Supervisor on floor and aware. Voicemail left with [family member] and TrueCare on call [on call provider].
During a surveyor interview with Staff D on 1/6/2023 at approximately 10:00 AM she acknowledged working at the facility on 12/25/2022 on the unit in question although she could not recall a fall that occurred on 12/25/2022 at the change of shifts. The surveyor read her the progress notes she had entered into the resident's record on 12/25/2022 and she again she stated, I don't know that resident .there were no falls on Christmas day .I don't remember writing those notes or assessing anyone that fell. The surveyor then asked Staff D if she had given her username and password to the electronic medical system (EMAR) to anyone else and she replied that she had not. Additionally, she was unable to explain how those notes were entered into the system under her name.
During an interview on 12/30/2022 at approximately 10:00 AM with Licensed Practical Nurse, Staff F, she indicated that she was the supervisor on call on 12/25/2022 and did not receive any phone calls regarding Resident ID #4. She indicated if she had received the phone call concerning the resident sustaining a fall, she would have ensured that the facility spoke to the resident's physician so they could direct care for the resident.
During a surveyor interview with the Nurse Practitioner (NP) on 1/3/2023 at 10:15 AM, she indicated that she was not notified about the fall or any injuries until 12/28/2022, despite her being in the facility on 12/27/2022. Additionally, she revealed that she would expect the nurse to follow the facility's fall protocols following a resident's fall. She also revealed that if a resident was known to have hit their head, she would have ordered neurological checks on the resident.
During a surveyor interview with the Medical Director on 1/6/2023 at approximately 1:00 PM he revealed that he did not receive any phone calls or voice messages regarding the resident's fall or injury on 12/25/2022. He revealed his NP was made aware of the fall on 12/28/2022 and she ordered an x-ray of his/her clavicle. He indicated that he would expect that if a nurse had called him and left a message and no one called back that the nurse would attempt to call the physician again for orders etc.
During an interview on 12/30/2022 at approximately 9:00 AM with the Director of Nursing (DON), she revealed that the facility utilizes Point Click Care (PCC) as their EMAR. She then went into the resident's record in PCC to the Assessment tab and she was unable to find an assessment for Resident ID #4 relative to his/her fall on 12/25/2022.
Although there were nursing notes indicating the resident's vital signs were stable and that the resident was alert and responsive with no visible injuries on 12/26 and 12/27/2022, the record failed to reveal evidence that a full body assessment was completed, including musculoskeletal function, observing for a changes in range of motion and neurological status had been completed for the resident.
During a surveyor interview with NA, Staff E on 12/29/2022 at 11:23 AM he revealed he was the resident's primary NA and that he was present at the time the resident fell on [DATE]. He indicated that the resident was on the floor for 10 to 15 minutes before any of the licensed nurses responded to the resident. He indicated that he had not cared for the resident since his/her fall on 12/25/2022 until he returned to work on 12/28/2022, which is when he observed a large bruise on the resident's shoulder. He further revealed that he reported this bruise to the unit manager and at that point he questioned what had been done for this resident after s/he had fallen on 12/25/2022.
Additional record review failed to reveal evidence that any interventions, assessments including musculoskeletal function, observing for change in range of motion and neurological status, or treatments were provided to Resident ID #4, prior to Staff E's return to work on 12/28/2022.
Review of a Radiology report dated 12/28/2022 revealed Nondisplaced fracture of the clavicle (collarbone) laterally .acute fracture .
During a surveyor observation on 12/29/2022 at 1:53 PM in the presence of Registered Nurse Staff A, the resident was observed in bed with a large bruise covering his/her left shoulder.
During an additional surveyor observation on 12/30/2022 at approximately 9:30 AM the resident was observed in bed, difficult to arouse and had a large yellow, green, purple, and blue bruise covering his/her left shoulder, left chest wall, and extending down to his/her left shoulder blade. The resident was observed to be grimacing in pain when being repositioned by staff.
During a surveyor interview on 1/3/2023 with the Director of Nursing Services and the Administrator at approximately 3:00 PM, they were unable to provide evidence of a completed post fall assessment including musculoskeletal function, observing for change in range of motion and neurological status as indicated by the facility policy. Additionally, they were unable to provide evidence of any documentation of the bruise in the resident medical record.
During a surveyor interview with the DON on 12/30/2022 at approximately 9:00 AM she revealed that the resident was diagnosed with a fractured clavicle, and she indicated that the resident's family opted to place him/her on hospice services, as s/he was not a surgical candidate.
Further record review revealed the resident was admitted to hospice services on 1/1/2023 and passed away on 1/2/2023.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 3 residents reviewed for ...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 3 residents reviewed for medication administration, Resident ID #1.
Findings are as follows:
Record review revealed the resident was admitted to the facility in December of 2022 with diagnoses including, but not limited to, diastolic congestive heart failure, cardiomyopathy, venous insufficiency, and atrial fibrillation.
Record review revealed the following physician orders with parameters to hold the medication for systolic blood pressure less than 110 and for a heart rate less than 60.
1. Spironolactone (medication to treat high blood pressure and excess fluid) 50 milligrams (mg) by mouth in the morning.
2. Spironolactone 25 mg by mouth in the evening.
3. Carvedilol (medication to treat high blood pressure and heart failure) 6.25 mg by mouth two times a day.
4. Torsemide (medication to treat high blood pressure and heart failure)100 mg by mouth one time a day.
5. Torsemide 50 mg by mouth in the evening.
Record review of the December 2022 Medication Administration Record revealed the above-mentioned medications were administered on 12/18/2022 for the day time doses with a documented blood pressure of 103/59, which was outside of the ordered parameters.
Additionally, the record failed to reveal a documented blood pressure or heart rate for the evening of 12/18/2022 and the above medications were administered.
During a surveyor interview with the Director of Nurses on 12/27/2022 at approximately 4:30 PM, she acknowledged the medications were administered outside the ordered parameters and without monitoring of the blood pressure or heart rate. Additionally, she could not provide documented evidence of a blood pressure or heart rate for the evening shift on 12/18/2022.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to store all drugs and biological's in locked compartments for 1 of 1 resident reviewe...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to store all drugs and biological's in locked compartments for 1 of 1 resident reviewed relative to medications left at the bedside, Resident ID #3.
Findings are as follows:
Record review of the electronic medication administration record revealed the following medications were signed off as administered by the Licensed Practical Nurse, Staff G, on 12/28/2022 at 11:21 AM:
1. Amiodarone 200 mg, one tablet
2. Acidophilus one capsule
3. Imuran 50 mg, two tablets
4. Calcium Carbonate Chew, one tablet
5. Calcium-Vitamin D Chew, one tablet
6. Eliquis 2.5 mg, one tablet
7. Docusate Sodium 100 mg, one tablet
8. Ferrous Sulfate 325 mg, one tablet
9. Cyclosporine 100 mg, one capsule
10. Folic Acid 1 mg, one tablet
11. Multivitamin-minerals, one tablet
12. Prednisone 10 mg, one tablet
13. Vitamin B12 500 mcg one tablet
14. Vitamin D 5000 units
15. Valtrex 1 gram one tablet
16. Loratadine 10 mg one tablet
During a surveyor observation on 12/28/2022 at 11:51 AM revealed the resident was in his/her room without staff being present. Two medication cups were noted to be on his/her bedside table. One cup contained 16 pills and the other cup contained 1 pill.
During an interview on 12/28/2022 at 3:08 PM with Staff G, she acknowledged leaving the medications at the bedside and she further revealed the medications were all the resident's morning medications.
Record review failed to reveal evidence of an assessment for the resident to self-administer medications.
During a surveyor interview with the Director of Nursing Services and the Administrator on 12/29/2022 at 3:54 PM, they acknowledged that the medications should not have been left unattended at the resident's bedside. Additionally, they were unable to provide evidence that the resident's drugs and biological's were stored in a locked compartment.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and staff interview it has been determined that the facility failed to maintain medical records for each resident that are complete and accurately documented, in accordance with...
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Based on record review and staff interview it has been determined that the facility failed to maintain medical records for each resident that are complete and accurately documented, in accordance with accepted professional standards and practice for 1 of 4 residents reviewed, Resident ID #1.
Findings are as follows:
1. Record review revealed Resident ID# 1 was admitted to the facility in December of 2022 with diagnoses including, but not limited to, diastolic congestive heart failure, cardiomyopathy, venous insufficiency, and atrial fibrillation.
Record review revealed a physician's order dated 12/21/2022 which states in part, Potassium Tablet Give 20 mg [milligrams] by mouth one time a day .
According to GoodRx Health potassium supplements are ordered in milliequivalents (mEq) and not milligrams (mg).
During a surveyor interview with the Director of Nurses on 12/27/2022 at approximately 4:30 PM, she was unable to explain why the potassium order was transcribed in milligrams and further acknowledged that potassium should have been transcribed as milliequivalents and not milligrams.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from significant medication errors for 1 of 3 residents reviewed...
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Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from significant medication errors for 1 of 3 residents reviewed for medication administration, Resident ID #1.
Findings are as follows:
Record review revealed the resident was admitted to the facility in December of 2022 with diagnoses including, but not limited to, diastolic congestive heart failure, cardiomyopathy, venous insufficiency, and atrial fibrillation.
Record review of the resident's Hospital Continuity of Care document dated 12/8/2022, revealed a list of the following physician orders that were prescribed for the resident to continue at the facility:
-Enoxaparin (Lovenox) (medication to thin the blood and prevent blood clots) injection 120 milligrams (mg) /0.8 milliliter (ml) inject 115.5 mg under the skin every 12 hours for 4 days.
-Potassium chloride (medication to treat low potassium) 80 milliequivalents (mEq) twice daily.
-Spironolactone (medication to treat heart failure) 50 mg by mouth in the AM.
-Spironolactone 25 mg by mouth in the PM.
Record review of the December 2022 Medication Administration Record (MAR) revealed the following orders:
1. Lovenox Solution Prefilled Syringe 120 mg/0.8 ml .Inject 1 vial subcutaneously (under the skin) every 12 hours .for 4 days, dated 12/9/2022.
Review of the record revealed Lovenox was administered 6 times during the day shift and 5 times during the evening shift, a total of 11 times, indicating 3 additional doses were administered to the resident.
2. Potassium tablet Give 80 mEq by mouth two times a day for Hypokalemia [a lower than normal potassium level in your bloodstream] . dated 12/9/2022 and discontinued on 12/9/2022.
-A subsequent order dated 12/10/2022 for Potassium tablet Give 40 mEq by mouth two times a day for Hypokalemia .
This indicates that the order for Potassium 80 mEq twice a day was transcribed incorrectly as Potassium 40 mEq twice a day.
Additional review of the MAR failed to reveal evidence that the Potassium was administered on 12/9/2022, indicating the resident missed 2 doses of potassium.
3. Spironolactone Tablet 25 mg Give 2 tablet by mouth one time a day .scheduled for administration from 7:00 AM-12:00 PM, dated 12/9/2022.
Spironolactone Tablet 25 mg Give 25 mg by mouth in the afternoon .scheduled for administration from 1:00 PM-3:00 PM, dated 12/9/2022.
Spironolactone Tablet 25 mg Give 50 mg by mouth one time a day .scheduled for administration at 6:00 AM, dated 12/10/2022.
Further review of the record revealed the order for Spironolactone 50 mg dated 12/10/2022 was transcribed in error, resulting in the resident receiving additional doses of Spironolactone 50 mg on 12/10, 12/11, and 12/12/2022.
During an interview on 12/28/2022 at approximately 4:30 PM with the Director of Nursing Services, she could not explain why the above-mentioned medications were transcribed incorrectly. Additionally, she was unable to explain why additional doses of Lovenox and Spironolactone were administered to the resident, or why the resident missed two doses of Potassium. Furthermore, she was unable to provide evidence that the facility ensured Resident ID #1's drug regimen was free from significant medication errors.
Nov 2022
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and resident interview, it has been determined that the facility failed to ensure that services p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and resident interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to following physician's orders for 2 of 6 residents reviewed for medication administration, Resident ID #'s 3 and 4.
Findings are as follows:
According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
1. Record review revealed Resident ID #3 was admitted to the facility in October of 2022 with diagnoses including, but not limited to, infection of surgical site, bipolar disorder, and cutaneous abscess of the neck.
Review of a Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating s/he is cognitively intact.
Review of a community reported complaint submitted to the Rhode Island Department of Health on 11/7/2022, alleges in part, I am keeping tract[sic] of my meds [medications] and they were not giving me some of them for a few days.
Review of the physician's orders revealed the following:
Spiriva Respimat Aerosol Solution 2.5 MCG/ACT (microgram) 1 inhalation - inhale orally in the morning
Azelastine HCl Solution 0.1% - 2 spray in both nostrils two times a day
Propanolol HCl tablet 10 MG (milligram) - Give 1 tablet by mouth two times a day
Symbicort Aerosol 160-4.5 MCG/ACT 2 puff - inhale orally two times a day
Buspirone HCl tablet 10 MG - give one tablet by mouth three times a day
Nafcillin Sodium in dextrose solution 2 GM (gram)/100 ML (milliliter) use 2 gram intravenously every 4 hours
Fluoxetine HCl Capsule 60 MG - give one capsule by mouth one time a day
Record review of the Medication Administration Records (MAR) for October and November 2022 failed to reveal evidence that the following medications were administered as ordered.
Spiriva Respimat Aerosol Solution on 10/29 and 11/1/2022
Azelastine HCl solution 0.1% on 10/29, 10/30, 10/31, 11/2, 11/5/2022
Propranolol HCl, the morning dose on 11/5, 11/6 and 11/7/2022
Symbicort Aerosol, the morning dose on 10/30/2022
Buspirone HCl, the morning and afternoon doses on 11/5 and 11/6/2022
Nafcillin Sodium in Dextrose Solution, the 4 AM and 8 AM doses on 10/26/2022
Fluoxetine HCl, on 11/5, 11/6, 11/7 and 11/8/2022
Further record review failed to reveal evidence that the physician had been notified of the above missed medication doses.
During a surveyor interview on 11/7/2022 at 2:05 PM with Resident ID #3 s/he revealed that s/he often goes days without his/her medication due to the pharmacy being located in another state. S/he revealed s/he is upset with the situation and often feels nauseous when s/he does not get the correct medication.
During a surveyor interview on 11/9/2022 at 11:57 AM with the Nurse Practitioner, Staff A, she revealed that she was unaware that Resident ID #3 had not received the above medications. She further revealed that she would expect the staff to report to her when a resident does not receive medication for any reason.
2. Record review revealed Resident ID #4 was admitted to the facility in October of 2022 with diagnoses including, but not limited to, fracture of the upper end of the right tibia and type II diabetes mellitus.
Review of the physician's orders revealed the following:
Insulin Glargine 100unit/ ML Solution pen-injector inject 15 unit subcutaneously (beneath the skin) at bedtime
Ciprofloxacin Tablet 250 MG - give 250 MG by mouth two times a day
Glipizide Tablet 5 MG give 2 tablets by mouth two times a day
Metformin HCl tablet 1000 MG give 1 tablet by mouth two times a day
Record review of the MAR for October and November 2022 failed to reveal evidence that the following medications were administered as ordered.
Insulin Glargine 100unit/ ML Solution on 10/18, 10/19, 10/20, 10/21, 10/22, 10/23, 10/26, 10/27, 10/28, 10/29, 10/30 and 10/31/2022.
Ciprofloxacin Tablet 250 MG the evening dose on 10/25/2022
Glipizide Tablet 5 MG on 10/25 and 10/30/2022
Metformin HCl tablet 1000 MG on 11/1/2022
Further record review failed to reveal evidence that the physician had been notified of the above missed medication doses.
During a surveyor interview on 11/9/2022 at 11:57 AM with the Nurse Practitioner, Staff A, she revealed that she was unaware that Resident ID #4 had not received the above medications including his/her insulin for 10 doses. She further revealed that she would expect the staff to report to her when a resident does not receive medication for any reason including if the resident refused.
During a surveyor interview on 11/9/2022 at 10:16 AM with the Director of Nursing Services she acknowledged the medications above were not administered. Additionally, she revealed that she would expect the staff to report to the physician or nurse practitioner when any medication is not administered as ordered.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on record review, and staff interview, it has been determined that the facility failed to ensure that residents with pressure ulcers receive necessary treatment and services, consistent with pro...
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Based on record review, and staff interview, it has been determined that the facility failed to ensure that residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing for 1 of 6 residents reviewed for pressure ulcers, Resident ID #4.
Findings are as follows:
Review of a policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol last revised March 2014, states in part, .the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue .
Record review revealed Resident ID #4 was admitted to the facility in October of 2022 with diagnoses including, but not limited to, fracture of the upper end of the right tibia and type II diabetes mellitus.
Review of a care plan focus with a start date of 10/17/2022 states in part, .has actual impairment to skin integrity of the right knee/lower extremity r/t [related to] surgical incision; and Dx [diagnosis] pruritic dermatitis [itchy skin]. Right lateral foot DTI [deep tissue injury] . with an intervention to include, Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx [signs/symptoms] of infection, maceration etc. to MD [medical doctor].
Review of an Admission/ re-admission Assessment dated 10/17/2022 revealed a skin assessment indicating the resident has a blister on his/her right lateral foot.
According to The State Operations Manual, Appendix PP- Guidance to Surveyors for Long Care Term Facilities, revised 11/22/2017, states in part .stage two pressure ulcer: partial thickness skin loss with exposed dermis .may also present as an intact or open/ruptured blister .
Review of Weekly Skin Assessment dated 10/26/2022 revealed the resident has a suspected deep tissue injury to the right lateral foot.
Record review failed to reveal evidence of a description of the pressure ulcer, stage or measurements. Additionally, record review failed to reveal evidence that the physician had been notified of the pressure ulcer or a treatment order had been obtained on 10/17 or 10/26/2022 after the skin assessment identified a pressure areas.
Review of an initial wound evaluation by VOHRA Wound Physicians dated 11/2/2022 revealed the resident has an unstageable DTI of the right lateral foot measuring 1 cm [centimeter] X .8 cm X not measurable. Additionally, it indicates the etiology of the wound to be pressure and a treatment for betadine for 30 days.
During a surveyor interview on 11/9/2022 at 11:57 AM with the Nurse Practitioner, Staff A she revealed that she was unaware that Resident ID #4 was admitted with a blister to the right lateral foot. Additionally, she acknowledged that a blister and a DTI are classified as pressure ulcers and should have been reported to obtain proper treatment. She also revealed that she was made aware of the pressure injury on 11/2/2022, 17 days after the initial assessment when the resident complained of pain to the right foot.
During a surveyor interview on 11/9/2022 at 12:58 PM with the Director of Nursing Services, in the presence of the Administrator, she acknowledged that the resident has a DTI on his/her right lateral foot. Additionally, she revealed her expectation would be that staff monitor, measure, stage and report to the physician any alterations in skin including blisters and DTI's immediately upon identifying. Furthermore, she was unable to provide evidence that the facility provided necessary treatment and services to promote healing of the pressure ulcer for 17 days after a pressure injury was identified.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status for 1 of 6 residents reviewed,...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status for 1 of 6 residents reviewed, Resident ID #5.
Findings are as follows:
Record review of a facility policy titled Weight Assessment and Intervention revised March 2022, states in part,
Weight Assessment .
3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation in writing.
a. If the weight is verified, nursing will immediately notify the dietician in writing .
5. a. 1 month - 5% weight loss is significant; greater than 5% is severe .
Record review for the resident revealed s/he was admitted to the facility in December of 2021 with diagnoses including, but not limited to, dementia, stroke, heart disease-pacemaker and seizures.
Review of a physician order dated 10/3/2022 revealed Weekly weights X 4 weeks, every Monday.
Record review revealed the following dates and weights,
10/3/2022 - 143 lbs (pounds)
10/10/2022 - 142.8 lbs
10/17/2022 No weight obtained
10/25/2022 - 127.6 lbs
This constitutes a 15.4 lb weight loss in 3 weeks, or a 10.76 % loss in body weight, indicating a severe weight loss, from 10/3/2022 - 10/25/2022.
Record review failed to reveal evidence that interventions were implemented to maintain acceptable parameters of nutritional status or to prevent further weight loss. Additionally, there was no evidence that the resident was reweighted per the facility policy.
During a telephone interview with the Registered Dietician (RD), on 11/9/2022 at 10:44 AM, she revealed that she would have expected to have been notified of the severe weight loss. Additionally, the RD was unable to provide evidence that interventions were implemented to maintain acceptable parameters of nutritional status or to prevent further weight loss
During a surveyor interview with the Director of Nursing Services (DNS), in the presence of the Administrator, on 11/9/2022 at approximately 1:00 PM, she was unable to provide evidence that a weight was obtained on 10/17/2022 as ordered or a reweigh was obtained on 10/26/2022 per the facility policy. The DNS further acknowledged that she and the dietician were not notified of the severe weight loss.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 32% turnover. Below Rhode Island's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 4 life-threatening violation(s), 3 harm violation(s), $295,995 in fines, Payment denial on record. Review inspection reports carefully.
- • 65 deficiencies on record, including 4 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $295,995 in fines. Extremely high, among the most fined facilities in Rhode Island. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has 4 Immediate Jeopardy findings. Serious concerns require careful evaluation.
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About This Facility
What is Pawtucket Falls Healthcare Center's CMS Rating?
CMS assigns Pawtucket Falls Healthcare Center an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Rhode Island, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Pawtucket Falls Healthcare Center Staffed?
CMS rates Pawtucket Falls Healthcare Center's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 32%, compared to the Rhode Island average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Pawtucket Falls Healthcare Center?
State health inspectors documented 65 deficiencies at Pawtucket Falls Healthcare Center during 2022 to 2024. These included: 4 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, 57 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Pawtucket Falls Healthcare Center?
Pawtucket Falls 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 THE MAYER FAMILY, a chain that manages multiple nursing homes. With 154 certified beds and approximately 77 residents (about 50% occupancy), it is a mid-sized facility located in Pawtucket, Rhode Island.
How Does Pawtucket Falls Healthcare Center Compare to Other Rhode Island Nursing Homes?
Compared to the 100 nursing homes in Rhode Island, Pawtucket Falls Healthcare Center's overall rating (1 stars) is below the state average of 3.0, staff turnover (32%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Pawtucket Falls 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?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Pawtucket Falls Healthcare Center Safe?
Based on CMS inspection data, Pawtucket Falls Healthcare Center has documented safety concerns. Inspectors have issued 4 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-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 Pawtucket Falls Healthcare Center Stick Around?
Pawtucket Falls Healthcare Center has a staff turnover rate of 32%, which is about average for Rhode Island nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Pawtucket Falls Healthcare Center Ever Fined?
Pawtucket Falls Healthcare Center has been fined $295,995 across 5 penalty actions. This is 8.2x the Rhode Island average of $36,039. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Pawtucket Falls Healthcare Center on Any Federal Watch List?
Pawtucket Falls 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.