Bannister Center for Rehabilitation and Health Car
For profit - Limited Liability company
161 Beds
ADVINIACARE
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
4/100
#49 of 72 in RI
Photo by AdviniaCare Providence
Photo by AdviniaCare Providence
Photo by Vivaan
1 / 5 photos
Last Inspection: August 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Bannister Center for Rehabilitation and Health Care currently holds a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #49 out of 72 facilities in Rhode Island places it in the bottom half, and #26 out of 41 in Providence County suggests there are only a few local options that are better. Unfortunately, the facility appears to be worsening, with issues increasing from 6 in 2024 to 8 in 2025. Staffing is a relative strength with a turnover rate of 28%, which is below the state average, but RN coverage is concerning as it is lower than 85% of state facilities, meaning less oversight for patient care. Notably, there were critical findings, including a resident not receiving adequate supervision to prevent wandering and another not receiving proper respiratory care, highlighting serious lapses in safety and health protocols.
- Trust Score
- F
- In Rhode Island
- #49/72
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ✓ Good
- 28% annual turnover. Excellent stability, 20 points below Rhode Island's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- $67,874 in fines. Lower than most Rhode Island facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 24 minutes of Registered Nurse (RN) attention daily — below average for Rhode Island. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
4/100
Bottom 32%
Review needed
6 → 8 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 6 issues
2025: 8 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (28%) · Staff stability means consistent care
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Full Sprinkler Coverage · Fire safety systems throughout facility
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No fines on record
-
Staff turnover is low (28%)
20 points below Rhode Island average of 48%
Facility shows strength in quality measures, staff retention, fire safety.
The Bad
2-Star Overall Rating
Below Rhode Island average (3.1)
Below average - review inspection findings carefully
Federal Fines: $67,874
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: ADVINIACARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 33 deficiencies on record
2 life-threatening 3 actual harm
Aug 2025
5 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Respiratory Care
(Tag F0695)
A resident was harmed · 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 4 residents reviewed for oxygen therapy, Resident ID #105.Findings are as follows:Review of the policy titled, OXYGEN - CYLINDERS dated 1/2023, states in part, .Oxygen is administered by Licensed Nurses with a Physician's Order in order to provide a resident with sufficient oxygen to their blood and tissues.PROCEDURE: .Look at the pressure gauge to determine how much oxygen is in the cylinder. A full cylinder will register around 2200 PSI [Pounds per Square Inch].Record review revealed Resident ID #105 was readmitted to the facility in March 2025 with diagnoses including, but not limited to, non-ST elevation myocardial infarction (a type of heart attack) and chronic obstructive pulmonary disease (a progressive lung disease that causes airway inflammation and damage, making breathing difficult and reducing oxygen intake. As COPD advances, many patients experience hypoxia, low oxygen levels in body tissues, often requiring supplemental oxygen).Record review revealed a physician order dated 7/7/2025 for oxygen at 2 liters/minute (LPM) via nasal cannula as needed.During a surveyor observation on 8/5/2025 at 1:57 PM, the resident did not appear to be in distress, but his/her portable oxygen cylinder was observed to be empty.Record review of the medication and treatment administration records for August of 2025 failed to reveal evidence that the resident's portable oxygen was being monitored to ensure that s/he receives the oxygen that s/he needs.During a surveyor observation of the resident, accompanied by a simultaneous interview on 8/5/2025 at 3:07 PM in the presence of the Nursing Unit Manager, Staff G, she acknowledged that the resident's oxygen cylinder was empty. Staff G then assessed the resident's oxygen saturation level using a pulse oximeter, which registered 78% (normal range: 95-100%; levels below 95% increase the risk of tissue and organ damage, and levels below 88% constitute a medical emergency requiring immediate intervention). Staff G subsequently replaced the resident's oxygen cylinder.During a follow up observation of the resident on 8/5/2025 at 3:27 PM, in the presence of Staff G, his/her oxygen saturation level was between 96% to 97% on 2 LPM.During a surveyor observation of the resident on 8/6/2025 at 9:03 AM, his/her oxygen cylinder was observed to be empty. Staff G was notified and obtained the resident's oxygen saturation level, which was noted to fluctuate between 85% to 86%.During a surveyor interview with Staff G immediately following the above observation, she indicated that there were no functional oxygen concentrators (a medical device that provides a continuous flow of oxygen to individuals who require supplemental oxygen) available on the unit, so the resident has been utilizing the oxygen cylinders since 8/4/2025. Additionally, she indicated that she was unsure how long an oxygen cylinder lasts.Record review of the facility document titled E CYLINDER TIME CHART, revealed that the facility's oxygen cylinder is a 2000 PSIG lasts for approximately 4.5 hours if utilized for a resident with a physician's order of oxygen at 2 LPM.Surveyor observation revealed that functional oxygen concentrators were available in the facility, and the resident was provided with one on 8/6/2025.During a surveyor interview on 8/6/2025 at 9:34 AM with the Director of Nursing Services (DNS), she indicated that Resident ID #105 should have been utilizing an oxygen concentrator when s/he is in his/her room and a portable oxygen cylinder when s/he is out of his/her room. Additionally, she revealed that she would expect the staff to monitor the resident frequently if s/he has been placed on a portable oxygen cylinder.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
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 implement and revise the comprehe...
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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 implement and revise the comprehensive care plan for 1 of 3 residents reviewed for weight loss, Resident ID #119 and 1 of 1 resident reviewed for fluid restriction, Resident ID #7.Findings are as follows: Record review of a facility policy titled Care Plan - Comprehensive last revised 10/22/2025, states in part .The comprehensive, person centered care plan will.describe that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.should be developed within seven (7) days of the completion of the required comprehensive assessment.when there has been a significant change in the resident's condition.1. Record review revealed Resident #119 was admitted to the facility in August of 2021, with diagnoses including, but not limited to, dementia without behavioral disturbance and adult failure to thrive.During a surveyor interview on 8/4/2025 at 1:21 PM with a member of the resident's family, s/he revealed that the family will come to feed the resident often. S/he further revealed that the resident will not eat if not fed.Record review of the residents Significant Change MDS dated [DATE], indicated that indicated the resident requires substantial/maximum assistance with eating. Substantial/maximum assistance is defined as the helper providing more than half the effort to complete the task.Review of a care plan revised on 7/28/2025 revealed, that the resident has a self-care performance deficit related to activity intolerance and confusion. The care plan contained a staff intervention dated 7/17/2025 that the resident required partial assistance of one staff member with eating. This care plan failed to be updated to reflect the resident's current needs for substantial/maximal assistance with eating.Record review of a Task titled Eating where staff document the level of assistance the resident was provided with meals for the period of 7/25/2025 through 8/5/2025 revealed that for 29 of 36 entries were documented as the resident eating independently.Surveyor observations during the breakfast meal on 8/7/2025 revealed the following:-8:42 AM the resident's breakfast tray was dropped off. The resident was in bed still sleeping.-8:48 AM a staff member entered the room helped the resident to sit in the bedside chair and told the resident that it was time to eat. Then the staff member left the room.-8:50 AM another staff member entered the resident's room and set up his/her tray, opening items on the tray for the resident, but did not assist the resident with eating. Then the staff member left the room.-8:53 AM a staff member went into the room to turn on the resident's light. This staff member then left the room without assisting the resident to eat.-8:55 AM- a staff member entered the room to speak with the resident's roommate, but did not interact with Resident ID #119.-9:03 AM- a staff member entered the room to administer the resident's medication, but did not assist the resident to eat.-9:07 AM- the resident stood up and turned off the light, then s/he laid down in his/her bed.During a surveyor observation and interview on 8/7/2025 at 9:09 AM, Registered Nurse (RN), Staff D, removed the resident's breakfast tray from the room. Staff D revealed that the resident is not a big eater, but s/he can eat independently. Staff D further acknowledged that the resident only drank the milk carton that was supplied on the tray.During a surveyor interview on 8/7/2025 at 10:31 AM with Licensed Practical Nurse (LPN) Staff F, she revealed that someone should sit with the resident to encourage and assist with eating. She further revealed that the resident eats better that way.During a surveyor interview on 8/7/2025 at 11:38 AM with the MDS Coordinator, she revealed that it was decided that the resident needed substantial/maximal assistance with meals when they met to discuss the resident's care needs. She further stated she would expect that a staff member would sit with the resident for meals and provide assistance with eating.During a surveyor interview on 8/7/2025 at 11:44 AM with the MDS Coordinator, she acknowledged that the residents comprehensive care plan failed to be revised to include his/her change in functional status related to his/her assistance needs with meals.2. Record review revealed Resident ID #7 was admitted to the facility in April of 2025 with diagnoses including, but not limited to, chronic kidney disease and dependence on renal dialysis (a treatment that filters waste and excess fluid from the blood when the kidneys are unable to do so).Record review revealed a physician's order dated 5/13/2025 for a fluid restriction of 1000 milliliters (ml) per day. Further review revealed that the order had been discontinued on 7/14/2025.Record review of a care plan last revised on 7/16/2025 indicated that the fluid restriction was still in place.During a surveyor interview on 8/7/2025 at 11:49 AM with the MDS Coordinator, she acknowledged that the fluid restriction was not removed from the care plan when the physician's order was discontinued and should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident receives t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice relative to the facility's failure to schedule appointments for physician specialists, for 1 of 6 residents reviewed, Resident ID #1, and for wound care for 1 of 3 residents reviewed, Resident ID #57.Findings are as follows:A. Record review revealed Resident ID #1 was admitted to the facility in May of 2023 and readmitted in July of 2025, with diagnoses including, but not limited to, benign prostatic hyperplasia (BPH - an enlarged prostate), urinary retention, malignant pleural effusion (occurs when cancer cells spread to the lining of the lungs), and multiple myeloma not having achieved remission (a cancer that does not respond to treatment).Record review of a Significant Change Minimum Data Set Assessment (MDS) dated [DATE], revealed an active diagnosis of cancer, and that the resident is frequently incontinent of urine.Record review revealed the following:- 10/24/2024 - a nursing progress note indicating that a request for a neurological assessment was made.- 10/24/2024 - a physician's order was entered for a neurology consult to be made to rule out dementia.- 11/6/2024 - a nursing progress note revealed that a request from the resident's oncologist (a physician who specialized in treating patients diagnosed with cancer) was made for the resident to see a urologist.- 11/7/2024 - a nursing progress note revealed that the resident requested to see a urologist due to urinary frequency.- 3/26/2025 - a nursing progress note revealed that the resident returned from an oncology appointment and a new order for a urology consult was provided related to his/her BPH.- 5/17/2025- a physician's order was provided for the resident to have a neurology consult to rule out a diagnosis of dementia.- 5/21/2025- a nursing progress note indicated the neurology appointment request was submitted to the scheduler.- 6/18/2025 - a urology appointment was requested due to the resident complaining of severe frequent urination during the night.Record review failed to reveal evidence that a neurology appointment was scheduled for the resident after it was requested by a provider on two occasions, 10/24/2024 and 5/17/2025.Record review failed to reveal evidence that a urology appointment was scheduled for the resident after it was requested by a provider on three occasions, on 11/6/2024, 3/26/2025 and 6/18/2025.During a surveyor interview on 8/6/2025 at 8:33 AM with Nurse Practitioner (NP), Staff A, she indicated that she would have expected the resident to have had the consults with neurology and urology scheduled when as they were requested.During a surveyor interview on 8/6/2025 at 12:52 PM with the Assistant Director of Nursing Services, in the presence of the Director of Nursing Services, she acknowledged that there were multiple requests for both neurology and urology appointments since October of 2024. Additionally, she revealed that she would have expected these appointments to have been scheduled when the requests were submitted. Furthermore, she acknowledged that none of these appointments were scheduled prior to this concern being brought to the facility's attention by the surveyor.B. Record review revealed Resident ID #57 was readmitted to the facility in April of 2024 with diagnoses including, but not limited to, malignant neoplasm (cancer) of the brain and colon (a part of the large intestine). Additionally, it revealed that s/he receives chemotherapy every three weeks.Review of a psychosocial evaluation dated 7/17/2025, revealed a Brief Interview for Mental Status score of 15 out of 15, indicating the resident is cognitively intact.Record review revealed a physician note dated 8/1/2025 that indicates the resident was assessed due to a complaint of extremity pain and presented with a toenail that was lifted and appeared to be loose. Additionally, the note reveals concern for a possible infection in the affected toenail, describing the resident's condition as guarded. The resident was medicated with Tylenol (a medication commonly used as a pain reliever) for the symptoms. A wound nurse evaluation and a podiatry consult (a physician who specializes in the treatment of the feet) were recommended.Record review of the Medication Administration Record revealed an order initiated on 8/1/2025 to cleanse the left great toe with normal saline, followed by bacitracin (an antibiotic ointment), and to cover with a dry clean dressing, once a day until resolved. The order was discontinued on 8/4/2025.During a surveyor interview with the resident on 8/6/2025 at 12:42 PM, s/he revealed that his/her toe continues to be painful and has not healed.During a surveyor interview on 8/6/2025 at 1:08 PM with Licensed Practical Nurse, Staff B, she stated that she was unsure if the resident was receiving treatment for his/her left great toe. After reviewing the electronic medical record, she was unable to find an order for a treatment for the toe and stated that she would assess the resident.During a surveyor observation of the resident on 8/6/2025 at 1:24 PM, in the presence of Staff B and the Infection Preventionist (IP) Nurse, revealed the resident's left great toenail was partially detached and the skin surrounding the nail bed was inflamed. The resident lifted the nail up and the nail bed was noted to be inflamed and yellow in color.During a surveyor interview with the IP Nurse immediately following the above observation, she acknowledged that the wound was not resolved and revealed that the treatment order should not have been discontinued.Further review of the progress notes revealed an entry authored by the Assistant Director of Nurses dated 8/6/2025 revealed that NP, Staff A, re-evaluated the wound to the great left toe and provided a new order to reinstate the daily treatment.Record review of a Skin & Wound Evaluation dated 8/6/2025, completed by NP, Staff A, revealed the resident's left dorsum 1st metatarsal joint (the joint on the tip of the toe) nail bed (the soft tissue underneath the toenail) had in house acquired trauma. The wound measurements were noted to be an area of 0.5 centimeters (cm) by 1.5 cm in length and 0.6 cm in width, with redness and inflammation.During a surveyor interview with the Director of Nursing Services on 8/6/2025 at 2:31 PM, she revealed that her expectation would have been that the treatment order for the left great toe would have remained active until the wound was resolved.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from any significant medication errors for 1 of 1 resident reviewed relati...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from any significant medication errors for 1 of 1 resident reviewed relative to insulin order changes, Resident ID #6.Findings are as follows:Record review revealed Resident ID #6 was admitted to the facility in February of 2020 with diagnosis including, but not limited to, diabetes mellitus (a disease characterized by high blood sugar levels) due to underlying conditions with diabetic neuropathy (nerve damage caused by diabetes), acquired absence of the right leg above the knee, and acquired absence of the left leg below the knee.Record review of a progress note dated 8/5/2025 at 2:35 PM, revealed the resident's labs were reviewed by the Nurse Practitioner (NP), Staff A, new orders were provided to increase the resident's Admelog (a fast-acting insulin used to control blood sugar levels) the evening dose from 14 units to 18 units.Record review revealed a physician's order dated 7/17/2025 for Admelog Injection Solution, 14 units subcutaneously in the evening. Further record review failed to reveal a physician's order relative to the changes made by NP, Staff A on 8/5/2025. This indicates that the order was not updated on 8/5/2025 from 14 to18 units of Admelog for the evening dose.Record review of the resident's Medication Administration Record (MAR) revealed the was administered 14 units of Admelog on 8/5/2025 and 8/6/2025 with his/her evening meal, and not the 18 units as ordered by Staff A.Record review of the resident's blood sugars revealed the following:- On 8/5 at 4:29 PM 420.0 (mg/dL; a normal blood sugar level for diabetics is 80 to 130 mg/dL)- On 8/5 at 7:57 PM 400.0 mg/dLDuring a surveyor interview on 8/7/2025 at 8:33 AM with NP, Staff A, she revealed it was her expectation that the resident would have received the increase dose of Admelog on both 8/5/2025 and 8/6/2025, prior to his/her evening meal, as ordered.During a surveyor interview on 8/7/2025 at 9:32 AM with the Director of Nursing Services (DNS), she acknowledged that the Admelog order failed to be updated until it was brought to her attention by the surveyor. She further acknowledged that the resident missed two doses of the correct insulin dosage.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed in accordance with professional standards for food serv...
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Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed in accordance with professional standards for food service safety, relative to the main kitchen and two of three kitchenettes.Findings are as follows:1. Record review of Rhode Island Food Code, 2022 Edition, Section 3-501.17 states in part, .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees Celsius or 41 degrees Fahrenheit or below for a maximum of 7 days. The day of preparation shall be counted as Day 1 .a. During the initial tour of the kitchen on 8/4/2025 at 8:20 AM in the presence of the Food Service Director (FSD), the following was observed without a label or a date:In the walk-in refrigerator:- opened butter with visible food matter on it- 9 bowls of pudding- 6 plates and 8 bowls of lemon merengue pie- an opened block of cheese- a hotel pan of sliced tomatoes- a hotel pan of cut up lettuce- an opened 15-ounce container of ricotta cheeseDuring a surveyor interview with the FSD following the above observation, she acknowledged that the above-mentioned items failed to be labeled and dated appropriately, per the food code.b. Record review of the policy titled FOOD FROM OUTSIDE dated 1/2023 states in part: .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.All refrigerated foods should be discarded within 48 [hours].During a surveyor observation of the second-floor kitchenette's refrigerator on 8/5/2025 at 7:44 AM, the following items failed to be dated:- two food containers labeled for two different residents- an opened and uncovered Styrofoam cup with red liquid insideAdditionally, an opened butter was noted to be placed inside a biohazard bag.During a surveyor interview with the FSD following the above observation, she acknowledged that the items in the kitchenette's refrigerator failed to be labeled and dated appropriately, per the facility policy.c. During a surveyor observation of the third-floor kitchenette's refrigerator on 8/5/2025 at 8:06 AM, the following items failed to be dated:- a resident's food with a room number- a resident's food inside a black bag- a resident's food in a bagDuring a surveyor interview with the FSD following the above observation, she acknowledged that the items failed to be labeled and dated appropriately, per the facility policy.2. Record review of The Rhode Island Food Code 2022 Edition 4.601.11 reads in part, .(A) equipment food contact surfaces .shall be clean to sight .During a surveyor observation of the main kitchen on 8/4/2025 at 11:44 AM, a kitchen fan with an accumulation of dust was noted to be blowing towards food that was being prepared.During a surveyor interview with the FSD immediately following the above observation, she acknowledged the presence of dust accumulation on the fan.3. Record review of the Rhode Island Food Code 2022 Edition 2-402.11 reads in part, .FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair .to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS .During a surveyor observation on 8/4/2025 at 12:12 PM Dietary Aide, Staff J, failed to have his hair fully covered by a hair net.During a surveyor interview on 8/5/2025 at 8:11 AM with the Dietitian, she acknowledged that Staff J should've been wearing a hair net that covers all of his hair.
May 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interviews, it has been determined that the facility failed to ensure residents ar...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interviews, it has been determined that the facility failed to ensure residents are free from any significant medication errors for 1 of 3 residents reviewed for psychotropic medications, Resident ID #1.
Findings are as follows:
Record review of a facility reported incident submitted to the Rhode Island Department of Health on 5/21/2025 indicated a suspected misappropriation of two 0.5 milligram (mg) clonazepam pills for Resident ID #1 from the 11:00 PM - 7:00 AM shift on 5/19/2025 into the 7:00 AM to 3:00 PM shift on 5/20/2025.
Review of the Federal Drug Administration's labeling/packet insert for Klonopin (clonazepam, a medication used to treat certain types of seizures and control panic attacks) states in part, .The continued use of benzodiazepines, including Klonopin, may lead to clinically significant physical dependence. The risks of dependence and withdrawal increase with longer treatment duration and higher daily dose. Abrupt discontinuation or rapid dosage reduction of Klonopin after continued use may precipitate acute withdrawal reactions, which can be life-threatening .
Review of Resident ID #1's record revealed s/he was admitted to the facility in May of 2024 with diagnoses including, but not limited to, bipolar disorder and major depressive disorder.
Record review of a Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 13, indicating the resident is cognitively intact.
Record review of physician's orders revealed the resident has been receiving clonazepam tablet 1 milligram (mg) twice a day for anxiety since October of 2024.
Additional record review revealed a psychiatric evaluation and consultation follow up document dated 4/23/2025, which stated in part, .Discontinue Clonazapam 1 mg BID [twice daily] for anxiety. Give Clonazapam 0.5 mg BID x 14 days and reassess .
Record review revealed two physician's orders, dated 5/2/2025 and 5/13/2025, for clonazepam 0.5 mg oral tablet twice daily for anxiety and to reassess the resident after 5/16/2025.
Additional review revealed these orders were discontinued on 5/13/2025 and 5/16/2025.
Further review revealed a physician's order dated 5/19/2025 for clonazepam 0.25 mg twice daily.
Record review of a progress note dated 5/16/2025 at 8:37 PM states in part, Resident inquired regarding dose of Clonazepam .educated resident the dose being D/C'd (discontinued) due to [him/her] needing to be re-evaluated .
During a surveyor interview with Resident ID #1 on 5/28/2025 at 1:15 PM, s/he indicated that the week before s/he did not receive his/her clonazepam for a few days. Additionally, the resident revealed that s/he was feeling more anxious and the shaking of his/her hands had gotten worse.
Record review of the May 2025 Medication Administration Record revealed that the resident did not receive any clonazepam from the evening of 5/16/2025 through 5/19/2025.
During a surveyor interview with Advanced Practice Registered Nurse (APRN), Staff B, on 5/28/2025 at 3:35 PM she revealed that she was the resident's current psychiatric provider. Additionally, she revealed that the facility staff requested her to meet with Resident ID #1 on 5/20/2025, as s/he was very anxious.
Record review revealed a psychiatric evaluation and consultation follow up document dated 5/20/2025, authored by, APRN, Staff B, which states in part, .Physical exam .Nursing reports that this is day two that [s/he] has not had any Klonopin and overall [s/he] is doing OK .
During a surveyor interview with the Medical Director on 5/28/2025 at 2:21 PM, she revealed that she was not notified by the facility until 5/19/2025 that the resident had not had any clonazepam since 5/16/2025 and needed an order for it. She indicated that she provided the order for the resident to receive clonazepam 0.25 mg twice daily, as the staff had informed her that the resident was experiencing withdrawal symptoms. Additionally, she revealed that she was aware that the resident was on clonazepam long term and was undergoing a gradual dose reduction (GDR; is the tapering of a dose of medication to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) that was initiated by APRN, Staff C's recommendation on 5/2/2025. However, she was unclear of what Staff C's plan was for the GDR after 5/16/2025 and would have to refer to psychiatry for recommendations.
During a surveyor interview with the APRN, Staff C, on 5/29/2025 at 10:29 AM, she revealed that she was previously the psych provider for Resident ID #1 and last saw him/her on 5/7/2025. She indicated that she had recommended a GDR on 4/23/2025 for the resident's clonazepam to be tapered down from 1 mg twice daily to 0.5 mg twice daily for 14 days. Additionally, she revealed she did not follow up with the resident after 5/7/2025 as she was no longer assigned to the resident's facility. Furthermore, she indicated that if she had been able to reassess the resident following the reduction of the resident's clonazepam, her plan was for the resident to remain on 0.5 mg of clonazepam twice a day. Furthermore, she revealed that the clonazepam should not be abruptly stopped because of the potential of dangerous withdrawal symptoms of that medication.
During a surveyor interview with the Director of Nursing in the presence of the Administrator on 5/29/2025 at 12:33 PM, she was unable to provide evidence that the resident remained free of any significant medication errors due to the significant medication being abruptly discontinued without an appropriate GDR.
Jan 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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, r...
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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 orders for 1 of 1 resident reviewed with parameters for weights, Resident ID #2.
Findings are as follows:
According to Mosby's 4th Edition, Fundamentals of Nursing page 314, states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
Record review revealed Resident ID #2 was readmitted to the facility in July of 2024 with a diagnosis including, but not limited to, congestive heart failure (a condition where the heart is unable to pump blood effectively).
Record review revealed a physician's order dated 12/12/2024 to notify the provider for a weight greater than 200 pounds.
Record review of the January 2025 vital signs report revealed that the resident's weight was greater than 200 pounds on the following dates:
- 1/8/2025
- 1/19/2025
Additional record review failed to reveal evidence that the provider was notified that the resident's weights were greater than 200 pounds, as ordered, on 1/8/2025 and 1/19/2025.
During a surveyor interview on 1/22/2025 at 2:46 PM, with the Nurse Practitioner, she revealed that she was not made aware of the resident's weights on 1/8/2025 and 1/19/2025.
During a surveyor interview on 1/22/2025 at approximately 3:00 PM, with the Director of Nursing Services, she was unable to provide evidence that the physician's order was followed.
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 accurately document in the resident's medical record for 3 of 4 residents reviewed for weekly skin checks...
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Based on record review and staff interview, it has been determined that the facility failed to accurately document in the resident's medical record for 3 of 4 residents reviewed for weekly skin checks, Resident ID #s 2, 3 and 4.
Findings are as follows:
Review of a facility policy titled Risk and Skin Assessments states in part, Prevention of pressure ulcers requires early identification of at-risk residents and implementation of prevention strategies .weekly skin checks [skin assessment] should be done by a licensed nurse weekly .
1. Record review revealed Resident ID #2 was readmitted to the facility in July of 2024 with a diagnosis including, but not limited to, chronic obstructive pulmonary disease (COPD- a lung disease characterized by airflow limitation).
Record review revealed a physician's order dated 11/18/2024, indicating a weekly skin assessment should be completed using a user-defined assessment (UDA, a monitoring tool the facility uses for skin assessments).
Record review of the November, December 2024 and January 2025 Medication Administration Records (MAR) revealed that the skin evaluation and UDA was documented as completed on the following dates:
- 11/15/2024
- 12/2/2024
- 12/9/2024
- 12/16/2024
- 12/23/2024
- 12/30/2024
- 1/6/2025
- 1/13/2025
- 1/20/2025
Additional record review failed to reveal evidence that the UDAs were completed on the dates listed above.
2. Record review revealed Resident ID #3 was admitted to the facility in January of 2025, with a diagnosis including, but not limited to, obesity.
Record review revealed a physician's order dated 11/14/2024, indicating a weekly skin evaluation should be completed using a UDA.
Record review of the January 2025 MAR revealed that the skin assessment and UDA were documented as completed on 1/21/2025.
Additional record review failed to reveal evidence that the UDA was completed on 1/21/2025.
3. Record review revealed Resident ID #4 was admitted to the facility in October of 2024, with a diagnosis including, but not limited to, diabetes.
Record review revealed a physician's order with a start date of 7/3/2024, indicating a weekly skin assessment should be completed using a UDA.
Record review of the January 2025 MAR revealed that the skin assessment and UDA were documented as completed on 1/10/2025.
Additional record review failed to reveal evidence that the UDA was completed on 1/10/2025.
During a surveyor interview on 1/22/2025 at approximately 10:00 AM with the Director of Nursing Services she was unable to provide evidence that the above-mentioned residents' UDAs were accurately documented in the medical records.
Oct 2024
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
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to protect the residents' right to b...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to protect the residents' right to be free from abuse for 2 of 2 residents reviewed who sustained injuries as a result of a resident-to-resident altercation, Resident ID #s 1 and 3.
Findings are as follows:
Review of a facility policy titled, Abuse, last revised October of 2022 states in part, .The facility prohibits the .abuse of residents .by anyone .Definitions Abuse: The willful infliction of injury .or punishment resulting physical harm, pain or mental anguish .to residents .Physical abuse Includes hitting, slapping .
1. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 9/25/2024 indicates that Resident ID #1 (the victim) alleged that the Skilled Nursing Facility was aware that s/he had been threatened by Resident ID #2 (the perpetrator), resulting in Resident ID #1 being assaulted by Resident ID #2.
Record review revealed that Resident ID #1 was admitted to the facility in September of 2024 with a diagnosis including, but not limited to, chronic multifocal osteomyelitis (bone infection) of the right ankle and foot, anxiety disorder and chronic post-traumatic stress disorder (PTSD).
Review of Resident ID #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact condition.
Record review of Resident ID #1's care plan revealed a focus area initiated on 9/26/2024 indicating the resident was a victim of a recent traumatic event related to his/her diagnosis of PTSD, with interventions including but not limited to maintaining a safe environment for his/her safety.
Record review of a progress note dated 10/14/2024 at 8:15 PM revealed a skin check was authored by Registered Nurse (RN), Staff A, which indicated that Resident ID #1 did not have any bruises or redness to his/her face or neck.
Further review of the progress notes dated 10/14/2024 at 8:59 PM authored by RN, Staff B, revealed that Resident ID #1 accused Resident ID #2 of hitting him/her with a commode cover on the head and face and requested to be seen at the hospital.
Record review of an Emergency Department (ED) provider note dated 10/14/2024 at 9:50 PM revealed that Resident ID #1 presented to the hospital after reportedly being a victim of an assault. S/he reports that s/he was in his/her room and was assaulted by another resident who previously verbally abused her/him.
Further review of the ED provider note revealed that the resident had a Computed Tomography (CT; a test that uses special x-ray equipment to help assess injuries) of the brain, face, and cervical spine that resulted positive for a nondisplaced right maxillary bone (right upper jaw) fracture involving lateral wall of right maxillary sinus (area near the side of the nose).
Record review revealed that, Resident ID #2, was admitted to the facility in April of 2024 with diagnoses including, but not limited to, dementia with behavioral disturbance with behavioral disturbance.
Record review of a psychiatric evaluation and consultation note dated 10/7/2024 revealed that nursing staff requested this consultation because of Resident ID #2's behavior. In addition, it revealed a current assessment/plan that indicated, in part, to monitor his/her mood for behavior changes or concerns, give medications as ordered and to continue with the plan of care.
Record review of Resident ID #2's care plan initiated on 5/2/2024 revealed a focus area for behavioral problems related to agitation that includes in part, yelling, wandering into other resident's rooms, taking their belongings, history of homicidal ideation and striking out against staff and residents. Interventions include in part, to provide one on one care when needed for periods of agitation, and restlessness.
During a surveyor interview on 10/18/2024 at 12:15 PM with Nursing Assistant (NA), Staff D, revealed that Resident ID #2 walks around the unit aimlessly and enters other residents' rooms taking their belongings. She then described Resident ID #2 as being out of control. In addition, Staff D states that Resident ID #2 requires two staff for care and that s/he is sometimes physically aggressive toward staff and would slap or scratch when while they are providing care. She further revealed that Resident ID #2 will take other residents' belongings when she/he wanders into other residents room and then attempts to slap other residents when they try to get their belongings back.
Record review of a progress notes dated 10/15/2024 revealed the following:
- 12:28 AM: Resident ID #2 was accused by another resident of hitting him/her on the head with a commode cover. Resident ID #2 was interviewed by two police officers but was unable to tell the story due to his/her dementia.
- 9:42 PM: Resident ID #2 was sent out to the hospital for evaluation secondary to having a physical altercation with another resident in addition to having increased wandering behaviors including going into other residents' rooms.
During a surveyor interview on 10/21/2024 at 1:30 PM with the Director of Nursing Services (DNS), she revealed that Resident ID #2 is not an appropriate candidate for this facility and that s/he should be in a memory care unit. Additionally, she acknowledged that that Resident ID #1 was not kept free from physical abuse.
During a surveyor interview on 10/21/2024 at approximately 2:30 PM with the Administrator she acknowledged that Resident ID #1 was not kept free from physical abuse.
2. Record review of a facility reported incident submitted to the Rhode Island Department of Health on 9/20/2024 alleges that (the perpetrator) Resident ID #4 entered (the victim's) Resident ID #3's room. Resident ID #3 attempted to redirect Resident ID #4 out of his/her room and Resident ID #4 refused to leave. Staff E, NA, heard the altercation and went to the room and separated the residents. Resident ID #3 was assessed, and a skin tear was noted on his/her lower lip.
Record review revealed that Resident ID #3 was admitted to the facility in October of 2019 with a diagnosis including, but not limited to, multiple sclerosis (a chronic autoimmune disease that damages the central nervous system) and anxiety disorder.
Review of Resident ID #3 's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact condition.
Record review of a progress note dated 9/20/2024 at 11:37 PM authored by Licensed Practical Nurse (LPN), Staff F, revealed that at around 9:30 PM, Resident ID #s 3 and 4 were involved in an altercation, which resulted in Resident ID #3 sustaining a bloody lip.
Record review revealed that Resident ID #4 was admitted to the facility in September of 2024 with diagnoses including, but not limited to, dementia and delusional disorder.
Review of Resident ID #4's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15, indicating moderately impaired cognition.
Record review of a care plan revised on 9/23/2024 revealed a focus area for behavior problem related to impulsive behavior that includes in part, difficult to redirect, increased aggression, taking food from other's trays, wandering behavior, displayed aggressive behaviors towards others related striking another resident. The interventions include but are not limited to providing a program of activities.
Record review of a progress notes dated 9/20/2024 at 11:41 PM authored by Staff F, revealed that Resident ID #4 had an altercation with another resident and was removed from his/her room and was transferred to the hospital for a psychiatric evaluation.
Record review of a hospital Discharge summary dated [DATE] revealed that the resident was sent out to the hospital after punching another resident. Additionally, it revealed that the resident had been intermittently aggressive towards residents and staff in the facility.
During a surveyor interview on 10/21/2024 at approximately 1:30 PM with the DNS, she acknowledged that that Resident ID #3 was not kept free from physical abuse and sustained an injury to his/her lip as a result of the altercation.
Aug 2024
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiot...
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Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 2 of 2 residents reviewed for antibiotic use, Resident ID #s 17 and 54.
Findings are as follows:
According to the Centers for Disease Control and Prevention (CDC) document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes states in part, Standardize the practices which should be applied during the care of any resident suspected of an infection or started on an antibiotic. These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed in your facility. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information is available .Track the amount of antibiotic used in your nursing home to review patterns of use and determine the impact of new stewardship interventions .Interventions designed to shorten the duration of antibiotic courses, or discontinue antibiotics based on post-prescription review (i.e., antibiotic time-out), may not necessarily change the rate of antibiotic starts, but would decrease the antibiotic DOT [days of therapy] .
Review of the facility's Quality Assurance and Performance Improvement (QAPI) plan revealed the data collection for infection control and antibiotic stewardship information is collected on a weekly basis.
1. Record review revealed that Resident ID #17 was re-admitted to the facility in January of 2020 with diagnoses including, but not limited to, Chronic Obstructive Pulmonary Disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and bipolar disorder.
Record review revealed a physician's order for Amoxicillin (an antibiotic) 500 milligram (mg) capsule every eight hours for a tooth extraction for 21 days with a start date of 7/11/2024 and an end date of 8/1/2024.
Record review failed to reveal evidence that the facility implemented an antibiotic review process to determine if the antibiotic is still indicated or adjustments should be made.
Review of the facility provided infection control and antibiotic stewardship program tracking tool failed to reveal evidence of tracking antibiotic use for the month of July 2024 including, but not limited to, Resident ID #17.
2. Record review revealed that Resident ID #54 was admitted to the facility in June of 2024 with diagnoses including, but not limited to, hematuria (blood in urine) and anxiety disorder.
Record review revealed a physician's order for Cipro oral tablet 250 mg by mouth two times a day for a urinary tract infection for 5 Days with a start date of 7/29/2024.
Record review failed to reveal evidence that the facility implemented an antibiotic review process, to determine if the antibiotic is still indicated or adjustments should be made.
Review of the facility provided infection control and antibiotic stewardship program tracking tool failed to reveal evidence of tracking antibiotic use for the month of July 2024 including, but not limited to, Resident Id #54.
During a surveyor interview on 7/31/2024 at 11:20 AM with the Director of Nursing Services (DNS), she revealed that the facility utilizes an infection control and antibiotic stewardship program tracking tool to review antibiotics. During this interview and subsequent record review, revealed that the month of July's antibiotic tracker was empty. The DNS further revealed that the tracker is filled out at the end of the month. Additionally, she was unable to provide evidence of antibiotic reviews for the month of July or that tracking and trending were being completed.
During a surveyor interview with the DNS and the Administrator on 8/1/2024 at 9:29 AM, they revealed that they completed the tracker for the month of July after it was brought to their attention by the surveyor. Additionally, they were unable to provide evidence that the antibiotic stewardship tracking system was completed to its entirety, per regulation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practi...
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Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 1 resident reviewed for tracheostomy (trach; an opening that surgeons make through the front of the neck and into the windpipe. A tube is placed into the opening for breathing) suctioning, Resident ID #114.
Findings are as follows:
Review of a facility policy titled, Tracheostomy Care revealed in part, .Tracheostomy care has identical goals: to ensure airway patency by keeping the tube free of mucus buildup, to maintain mucous membrane and skin integrity, to prevent infection .Check physician order .
Record review revealed Resident ID #114 was readmitted to the facility in October of 2023 with diagnoses including, but not limited to, acute respiratory failure with hypoxia (low level of oxygen), history of malignant Neoplasm of the larynx (cancer of an organ in the neck that forms an air passage to the lungs). Further record review revealed the resident has a tracheostomy.
Review of the physician's orders revealed the following:
10/13/2023- Suction trach using a single-use suction catheter and suction kit as needed for excessive secretions and airway maintenance.
Record review failed to reveal evidence of when to change, clean, or replace the suction equipment. It further failed to reveal evidence of a current order for the resident to perform the suctioning themselves.
Further record review failed to reveal evidence that the resident was assessed as being safe to self suction following readmission to the facility in October of 2023.
During a surveyor observation and interview on 7/31/2024 at 10:51 AM with the resident in his/her room revealed a suction machine with the canister filled to 350 cc (cubic centimeter) of secretions with floating sediment. The canister and the attached tubing were undated. The resident stated that s/he suctions his/her own trach.
During a surveyor interview with Registered Nurse, Staff A, on 7/31/2024 at 10:55 AM, she revealed that the resident does suction the trach him/herself. She acknowledged that there was no date on the suction machine tubing or canister. Additionally, she was unable to provide evidence of when the canister was emptied last or changed.
During a surveyor interview with the Registered Nurse, Unit Manager, Staff B, on 7/31/2024 at 11:04 AM, she acknowledged that the tubing and canister on the suction machine should be dated and was unable to provide evidence of when the canister was last emptied or changed. Additionally, she could not provide a current order for the resident to self-suction his/her trach, although she revealed that the resident has been doing it for months.
During a surveyor interview with the Director of Nursing Services, on 7/31/2024 at 11:32 AM, she was unable to provide evidence of a current physician order allowing the resident to self-suction, an assessment for safety following readmission, or an order of when to change, clean, or replace the suction equipment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for b...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for blood pressure medications with parameters, Resident ID #80.
Findings are as follows:
According to Mosby's 4th Edition, Fundamentals of Nursing page 314, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
Record review revealed the resident was readmitted to the facility in August of 2023 with a diagnosis including, but not limited to, pulmonary hypertension (a condition in which high blood pressure affects arteries of the lungs and the right side of the heart).
Record review revealed a physician order with a start date of 8/6/2023, for Isosorbide Mononitrate (a medication that is used to treat high blood pressure), with instructions to administer 60 milligrams (mg) once daily and hold if the systolic blood pressure (SBP; pressure when the heart beats) is less than 110.
Record review of the Medication Administration Record and the vital sign summary report for July 2024 failed to reveal evidence that the resident's blood pressure was obtained for 30 out of 30 opportunities, prior to administering the Isosorbide Mononitrate medication, per the physician order.
Further review revealed a physician order, with a start date of 8/6/2023, for Hydralazine (a medication that is used to treat high blood pressure), with instructions to administer 25 mg, three times a day, and hold if the SBP is less than 110.
Record review of the Medication Administration Record and the vital sign summary report for July 2024 failed to reveal evidence that the resident's blood pressure was obtained for 60 out of 90 opportunities, prior to administering the Hydralazine, per the physician order.
During a surveyor interview on 7/31/2024 at 11:28 AM, with the Director of Nursing Services, she indicated that she would expect staff to obtain and document the residents blood pressure, prior to administering medication. Additionally, she was unable to provide evidence that the resident's blood pressure was monitored, and the medications were not administered to the resident unnecessarily.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmiss...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections for 1 of 3 residents reviewed relative to Multi-drug Resistant Organisms (MDRO), Resident ID #30 and 1 of 1 resident reviewed for an indwelling catheter (a flexible tube inserted into the bladder to drain urine), Resident ID #91.
Findings are as follows:
1. Review of the Center for Disease Control and Prevention (CDC) policy titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug resistant Organisms (MDROs) last updated 7/12/2022 revealed in part, .Enhanced Barrier Precautions [EBP] expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities .The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions [gown and glove upon entering the room] do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization [the bacteria is living on or in the body not causing symptoms but can the bacteria can be spread to others] as well as for residents with MDRO infection or colonization .Summary of Personal Protective Equipment (PPE) Use and Room Restriction When Caring for Residents in Nursing Homes .Enhanced Barrier Precautions .All residents with any of the following .Infection or colonization with an MDRO when Contact Precautions do not otherwise apply .
Review of a facility policy titled Enhanced Barrier Precautions states in part, .for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently targeted by CDC, the facility may consider placing residents with known MDRO colonization on EBP to control MDRO transmission, if Contact Precautions do not apply. Epidemiological important MDROs (that are not target by the CDC) may include, but are not limited to, .ESBL [Extended-spectrum beta-lactamase] .
Record review revealed Resident ID #30 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, dementia and type 2 diabetes mellitus.
Record review revealed that the resident tested positive for ESBL on 3/5/2024 at the facility.
Record review revealed a care plan dated 3/8/2024 last revised on 4/11/2024 revealed that the resident has a history of ESBL with an intervention that includes, but is not limited to, Contact Precautions.
Surveyor observations on 7/29, 7/30, 7/31 and 8/1/2024 failed to reveal evidence that the resident was on Contact or Enhanced Barrier Precautions relative to the diagnosis of a MDRO, per the facility policy, care plan, and/or the CDC.
During a surveyor interview on 8/1/2024 at 9:57 AM with the Director of Nursing Services (DNS) in the presence of the Administrator, she acknowledged that the resident was positive for ESBL in March of 2024 and that the resident was not on precautions at this time. She further revealed that the resident will now be placed on Enhanced Barrier Precautions.
2. Review of a policy titled, Catheter Guidelines states in part, .If breaks in aseptic (clean) technique, disconnection, or leakage occurs, replace the catheter and collecting system using aseptic technique and sterile equipment as ordered .Infection Control .Be sure the catheter tubing and drainage bag are kept off the floor .
Record review revealed that Resident ID #91 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, type 2 diabetes and dementia.
Record review revealed that the resident has an indwelling catheter.
Record review revealed a physicians order dated 3/2/2024 to change the residents urinary drainage bag if the bag is soiled, broken, or leaking.
Record review revealed a care plan dated 5/15/2024 last revised on 7/23/2024 which revealed that the resident has an indwelling catheter with an intervention to keep the urinary collection bag off the floor.
Surveyor observations on the following dates and times revealed that the urinary collection bag was on the floor:
-7/29/2024 at 11:39 AM
-7/31/2024 at 9:49 AM
-7/31/2024 at 9:58 AM
During a surveyor interview and subsequent observation with Registered Nurse, Unit Manager, Staff B on 7/31/2024 at 9:58 AM, she acknowledged that the urinary collection bag was on the floor leaking urine which formed a puddle. Staff B revealed that the collection bag should not be stored on the floor and it should not be not leaking.
Review of the Medication Administration Record failed to reveal evidence that the urinary drainage bag was changed after being on the floor or leaking.
During a surveyor interview with the DNS on 8/1/2024 at approximately 9:45 AM she revealed that the urinary drainage bag should be changed and should not be left on the floor per the facility policy and the care plan.
Additionally, after this concern was identified and brought to the facility's attention, the urinary drainage bag was again noted to be on the floor on 8/1/2024 at 11:46 AM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure the resident's medical rec...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure the resident's medical record includes documentation that the resident either received the pneumococcal vaccination or did not receive the vaccination due to medical contraindications or refusal, for 4 of 7 residents reviewed, Residents ID #s 17, 63, 73, and 106.
Findings are follows:
According to the Centers for Disease Control and Prevention (CDC), pneumococcal vaccination for all adults 19 through [AGE] years old who have certain chronic medical conditions or 65 years or older who have only received PPSV23 [type of pneumococcal conjugate vaccination], the PVC15 [type of pneumococcal conjugate vaccine] or PVC20 [type of pneumococcal conjugate vaccine] dose should be administered at least one year after the most recent PPSV23 vaccination. For adults 19 through [AGE] years old who have certain chronic medical indications who have only received PVC13 [type of pneumococcal conjugate vaccine], give 1 dose of the PCV20 at least 1 year after PCV13 or give 1 dose of PPSV23 at least 8 weeks after PCV13. For adults 65 years or older who have only received PVC13, give PPSV23 or PCV20 as previously recommended.
1. Record review for Resident ID #17 revealed the resident was re-admitted to the facility in January of 2020. Record review of the resident's immunization records failed to reveal evidence that the PVC15, PVC13, or PCV20 was offered, received, or declined.
2. Record review for Resident ID #63 revealed the resident was re-admitted to the facility in December of 2022. Record review of the resident's immunization records failed to reveal evidence that the PVC15, PVC13, or PCV20 was offered, received, or declined.
3. Record review for Resident ID #73 revealed the resident was re-admitted to the facility in January of 2024. Record review of the resident's immunization records failed to reveal evidence that the PVC13, PCV15, PPSV23, or PCV20 was offered, received, or declined.
4. Record review for Resident ID #106 revealed the resident was re-admitted to the facility in May of 2023. Record review of the resident's immunization records failed to reveal evidence that the PVC13, PCV15, PPSV23 or PCV20 was offered, received, or declined.
During an interview on 8/1/2024 at 10:57 AM , with the Director of Nursing Services, she was unable to provide evidence that Residents ID #s 17, 63, 73 and 106 medical records included documentation that indicates, at a minimum, if the residents either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal, until brought to the attention of the facility by the surveyor.
Nov 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
Deficiency F0760
(Tag F0760)
A resident was harmed · 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 has failed to ensure that residents are fre...
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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 has failed to ensure that residents are free of any significant medication errors for 1 of 3 residents reviewed, Resident ID #1.
Findings are as follows:
Record review of a community reported complaint sent to the Rhode Island Department of Health on 11/19/2023 alleges that Resident ID #1 was not given his/her methadone or klonopin medications for 72 hours due to the facility not having either available to administer.
Record review revealed that the resident was admitted to the facility on [DATE] with diagnoses which include, but are not limited to, opioid abuse in remission, obstructive sleep apnea (when one's breathing is interrupted during sleep), and cancer of the kidney.
Record review revealed the following physician's orders:
-11/17/2023 Klonopin 0.5 MG (milligram) give 1 tablet by mouth one time a day for anxiety
-11/17/2023 Klonopin 1 MG give 1 tablet by mouth at bedtime for anxiety
-11/17/2023 Methadone HCI oral concentrate 10 MG/ML, give 100 MG by mouth in the morning for pain
Record review of the November 2023 Medication Administration Record (MAR) failed to reveal evidence that the resident received the above-mentioned medications, as ordered, on the following dates and times:
-11/17/2023 at 6:00 AM Methadone 100 MG
-11/17/2023 at 7:00 AM to 2:00 PM Klonopin 0.5 MG
-11/17/2023 at 6:00 PM to 10:00 PM Klonopin 1 MG
-11/18/2023 at 6:00 AM Methadone 100 MG
-11/18/2023 at 7:00 AM - 2:00 PM Klonopin 0.5 MG
Record review of a progress note dated 11/17/2023 at 11:23 PM revealed in part Resident a/o [alert and oriented] x 3 [to person, place and time], behavior noted on shift screaming [s/he] wants [his/her] methadone and throwing objects from bedside table to the floor, explained that [his/her] methadone will probably be delivered tomorrow morning by [pharmacy name redacted] . Further review of the progress note revealed that the Klonopin 1 MG not delivered by pharmacy, pharmacy has not received the script .
Record review of the facility document titled SNF/NH to hospital transfer form dated 11/18/2023 at 3:00 PM revealed that the resident was transferred to a hospital.
Record review of the resident's hospital documentation revealed the following:
-11/18/2023 at 6:40 PM, Pt [patient] from [facility] with reports from facility of agitation, crying and requesting to go to ED [emergency department]. Pt is on 100 mg methadone, last dose was 11/16. Reports facial numbness for past few days .
-11/18/2023 at 7:11 PM, .presents from [facility] with concerns for methadone withdrawal. Patient was recently discharged for an acute CVA [stroke] with subsequent blindness and left upper extremity weakness as a sequalae, was hospitalized for 1 week, was discharged to [facility] Patient states since that time [s/he] has not received [his/her] methadone which is up in approximately 72 hours, [s/he] started to develop full body aches, and feeling ill .
-11/18/2023 at 7:30 PM, .[resident] presents from .[facility] with concerns for acute methadone withdrawal, inability to obtain [his/her] methadone for the last 72 hours since discharged from [hospital] .
During a surveyor interview on 11/21/2023 at 11:50 AM with Licensed Practical Nurse (LPN), Staff A, she revealed that the resident was admitted on [DATE] and was transferred to the hospital on [DATE]. She further indicated that prior to his/her admission on [DATE], she had received a telephone call from the hospital's Neuro Unit on 11/14/2023 because the resident was supposed to be transferred to the facility that day and the hospital was concerned that the methadone would not be available for the resident when s/he arrived at the facility. She further revealed that because of that telephone call the resident's admission was delayed to 11/16/2023. Additionally, Staff A revealed that on 11/17/2023 the resident's Attending Physician assigned to him/her while in the facility, provided orders for the resident for the Klonopin but s/he never received the medication.
During a surveyor interview on 11/22/2023 at 9:07 AM with LPN, Nurse Manager, Staff B, he revealed that it was not until after the resident missed two doses of his/her methadone and s/he was transferred to the hospital that the facility followed up on the delivery status of the methadone, with the methadone clinic that the order had been faxed to. Additionally, he revealed that when the facility initially faxed the order to the methadone clinic it was to the incorrect clinic, which is why the resident's methadone was never delivered to the facility. He further revealed that it was not until after the resident was transferred to the hospital when the facility realized their error and placed a follow-up telephone call to the methadone clinic to inquire about the delivery status of the medication.
During a surveyor interview on 11/21/2023 at 1:00 PM with the Director of Nursing Services, she acknowledged that the resident did not receive Methadone or Klonopin, as ordered, while in the facility. Additionally, she revealed that the Klonopin prescription was never filled by the facility's pharmacy because the pharmacy never received the prescription from the Attending Physician for the medication.
On 11/21/2023 and on 11/22/2023 the surveyor attempted to interview the Attending Physician via telephone to inquire as to the reason he ordered Klonopin for the resident and evidence the prescription was sent to the pharmacy; however, he did not answer his phone, voice mails were left for him, but the calls were not returned to the surveyor.
Nov 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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review, resident and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than...
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Based on record review, resident and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to other officials (Department of Health), in accordance with State law for 1 of 1 resident reviewed, Resident ID #1.
Findings are as follows:
Record review of the facility policy titled, Abuse states in part, .The Administrator and Director of Nursing [DON] are responsible for .reporting .notify .appropriate State Agency(s) immediately (no later than 2 hours after allegation/identification of allegation) .Upon receiving reports of physical abuse .immediately notify the physician .of a report of suspected abuse or neglect involving the resident .
Review of a community reported complaint, received by the Rhode Island Department of Health on 10/27/2023, alleges that Resident ID #1 reported to hospital staff that while sleeping s/he felt someone hit him/her and two female nursing aides held him/her down by the arms. Further review of this document revealed the nursing facility is aware of the allegations and are investigating.
Record review revealed that the resident was admitted to the facility in September of 2023 with diagnoses including but not limited to, fracture of left clavicle and fracture to one rib on the left side.
Record review of an admission Minimum Data Set Assessment, dated 9/4/2023, revealed s/he has a Brief Interview for Mental Status score of 13 out of 15 indicating that s/he is cognitively intact.
During a surveyor interview on 11/2/2023 at 11:59 AM with the resident, s/he revealed that s/he reported to hospital staff during a recent admission that a guy .beat me up .big guy squished me . and further indicated that s/he was half asleep and one female held [him/her] down.
During a surveyor telephone interview on 11/2/2023 at 12:51 PM with the hospital Social Worker, he indicated that the resident's allegation of staff to resident abuse was reported to the facility's Director of Nursing on 10/27/2023.
During a surveyor interview on 11/2/2023 at 2:54 PM with the Director of Nursing in the presence of the Administrator, she acknowledged that she was notified of the resident's allegation of staff to resident abuse via a telephone call she received on the morning of 10/27/2023 from a hospital employee, Staff A. She indicated that Staff A had reported to her that the resident alleged that a male staff member punched him/her in the stomach, but she did not report this allegation to the Administrator, resident's physician, or to the Department of Health, as indicated in the facility policy. The Administrator revealed that she would expect that the facility policy would be followed regarding reporting resident allegations of abuse.
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
Investigate Abuse
(Tag F0610)
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 evidence that all alleged violations were thoroughly investigated for 1 of 1 resident reviewed for...
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Based on record review and staff interview it has been determined that the facility failed to provide evidence that all alleged violations were thoroughly investigated for 1 of 1 resident reviewed for an allegation of abuse, Resident ID #1.
Findings are as follows:
Record review of the facility policy titled, Abuse states in part, .Investigation .Allegations/reports of suspected abuse .shall be promptly and thoroughly investigated by facility management .The investigation should be thorough with witness statements from staff, residents, visitors, and family members who may be interview able and have information regarding the allegation .
Review of a community reported complaint, received by the Rhode Island Department of Health on 10/27/2023, alleges that Resident ID #1 reported to hospital staff that while sleeping s/he felt someone hit him/her and two female nursing aides held him/her down by the arms. Further review of this document revealed the nursing facility is aware of the allegations and are investigating.
During a surveyor telephone interview on 11/2/2023 at 12:51 PM with the hospital Social Worker, he indicated that the resident's allegation of staff to resident abuse was reported by an employee of the hospital, Staff A, to the facility's Director of Nursing (DON) on 10/27/2023.
Record review failed to reveal evidence that the above incident was investigated by the facility.
During a surveyor interview on 11/2/2023 at 2:54 PM, with the DON, in the presence of the Administrator, she acknowledged that she was notified of the resident's allegation of staff to resident abuse via a telephone call she received on the morning of 10/27/2023 from a hospital employee, Staff A. The DON was unable to provide evidence that a thorough investigation into the abuse allegation was completed.
The Administrator revealed that she would expect that the facility policy would be followed regarding investigating resident allegations of abuse.
Jul 2023
12 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 record review and staff interview, it has been determined that the facility failed to ensure that the assessment accura...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that the assessment accurately reflected the resident's status for 7 of 23 residents reviewed for a Brief Interview for Mental Status (BIMS) Assessment, Resident ID #s 2, 8, 17, 30, 85, 98, and 90.
Findings are as follows:
1. Record review revealed that Resident ID #2 was admitted to the facility in November of 2022 with diagnoses including, but not limited to, schizophrenia and cerebral infarction (stroke).
Record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the BIMS assessment was coded with dash's (-) indicating the resident was not assessed.
2. Record review revealed that Resident ID #8 was admitted to the facility in January of 2022 with diagnoses including, but not limited to, cognitive communication deficit and paranoid schizophrenia.
Record review of the Quarterly MDS assessment dated [DATE] revealed the BIMS assessment was coded with dash's (-) indicating the resident was not assessed.
3. Record review revealed that Resident ID #17 was admitted to the facility in January of 2019 with a diagnosis including, but is not limited to, schizophrenia.
Record review of the Quarterly MDS assessment dated [DATE] revealed the BIMS assessment was coded with dash's (-) indicating the resident was not assessed.
4. Record review revealed that Resident ID #30 was admitted to the facility in February of 2023 with diagnoses including, but not limited to, vascular dementia and cognitive communication deficit.
Record review of the Quarterly MDS assessment dated [DATE] revealed the BIMS assessment was coded with dash's (-) indicating the resident was not assessed.
5. Record review revealed that Resident ID #85 was readmitted to the facility in May of 2023 with diagnoses including, but not limited to, dementia and delusional disorder.
Record review of the Quarterly MDS assessment dated [DATE] revealed the BIMS assessment was coded with dash's (-) indicating the resident was not assessed.
6. Record review revealed that Resident ID #98 was readmitted to the facility in May of 2023 with diagnoses including, but not limited to, dementia and cerebral infarction.
Record review of the Comprehensive MDS assessment dated [DATE] revealed the BIMS assessment was coded with dash's (-) indicating the resident was not assessed.
7. Record review revealed that Resident ID #90 was readmitted to the facility in January of 2023 with diagnoses including, but not limited to, adjustment disorder and adult failure to thrive.
Record review of the Quarterly MDS assessment dated [DATE] revealed the BIMS assessment was coded with dash's (-) indicating the resident was not assessed.
During a surveyor interview on 7/26/2023 at 12:48 PM, with the MDS Coordinator, she revealed that if the social worker did not sign the assessment by the Assessment Reference Date (ARD) then the assessment will get dashed (-) out.
During a surveyor interview on 7/27/2023 at 11:02 AM with the Administrator and Social Services Director, they acknowledged that the BIMS assessments were not completed on the above mentioned residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to assure that services being provided meet professional standards of quality related ...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to assure that services being provided meet professional standards of quality related to following physician's orders for 1 of 1 residents, Resident ID #69.
Findings are as follows:
Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
Record review revealed the resident was admitted to the facility in May of 2023 with a diagnosis including, but not limited to, heart failure.
Record review of a physician order revealed, .Apply Teds [compression socks to aid in blood flow] in the morning and remove at bedtime as tolerated .
During surveyor observations on the following dates and times the resident was observed not wearing TED stockings:
7/24/2023 at 10:30 AM
7/25/2023 at approximately 12:30 PM
7/26/2023 at approximately 11:00 AM
During a surveyor interview on 7/26/2023 at approximately 11:15 AM with the Unit Manager, she revealed the resident was not wearing TED stockings as ordered.
During a surveyor interview on 7/26/2023 at approximately 3:00 PM with the Director of Nursing Services, she was unable to provide evidence the resident was wearing TED stockings as ordered. Additionally, she indicated that she would expect the physician's orders to be followed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice ...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed for the use of geri sleeves and limb elevation, Resident ID #35, 1 of 1 resident reviewed relative to podiatry recommendations, Resident ID # 35, and 1 of 2 residents reviewed relative to surgical wounds, Resident ID #109.
Findings are as follows:
1a. Record review revealed Resident ID #35 was readmitted to the facility in December 2022 with diagnoses including, but not limited to, muscle weakness and contracture of the right hand and vascular disease.
Record review of the resident's care plan dated 3/18/2021 revealed that s/he is at risk for bleeding/bruising secondary to Aspirin and Eliquis use with the intervention dated 10/26/2021 .apply geri sleeves as protection .
Further review of the resident's care plan initiated on 8/26/2020 revealed that s/he has limited physical mobility R/T [related to] right arm weakness with the following interventions Elevate right arm on pillow at all the times .
During a surveyor observation, the resident was observed in bed without geri sleeves and his/her right arm was not observed to be elevated on the pillow on the following dates and times:
7/24/2023 at 9:30 AM, 11:07 AM, 12:30 PM, 1:45 PM, 2:14 PM, and 2:40 PM
7/25/2023 at 8:30 AM, 10:00 AM, 11:15 AM, 11:52 AM, 12:30 PM, 1:46 PM, and 2:30 PM
7/26/2023 at 8:15 AM, 9:00 AM, 9:30 AM, and 10:20 AM
During a surveyor interview on 7/26/2023 at 10:24 AM with Registered Nurse, Staff A, she acknowledged the geri sleeves were not applied and his/her right arm was not elevated on the pillow.
During a surveyor interview on 7/26/2023 at approximately 2:00 PM with the Director of Nursing Services (DNS), she indicated that the resident's care plan included the geri-sleeves and to elevate his/her right arm on the pillow. Additionally, she was unable to provide evidence that the resident received treatment and care in accordance with professional standards of practice.
1b. Review of a document titled, HealthDrive dated 6/26/2023 revealed that Resident ID #35 was seen by a podiatrist with a recommendation for a vascular consultation related to .multiple areas of concerning vascular involvement .
Record review revealed a Wound Evaluation and Management Summary indicating a .focused wound exam (site 6) unstageable due to necrosis (death of all the cells in a tissue due to failure of blood supply) of the left heel full thickness .focused wound exam (site 7) unstageable due to necrosis of the right heel full thickness .focused wound exam (site 8) unstageable due to necrosis of the left lateral (to the side of the foot) foot full thickness.
Additional record review failed to reveal evidence that the resident was seen for a vascular consultation as the podiatrist recommended on 6/26/2023.
During a surveyor interview on 7/26/2023 at approximately 10:30 AM with the Unit Manager, she revealed that she was unaware of the podiatrist recommendation until it was brought to her attention by the surveyor.
During a surveyor interview on 7/27/2023 with the Director of Nursing Services (DNS) at approximately 1:30 PM, she acknowledged that her staff failed to follow-up on the vascular consultation recommendation.
2a. Record review revealed Resident ID #109 was readmitted to the facility in July of 2023 with diagnosis including, but not limited to, right leg above the knee amputation.
Record review of the July 2023 Medication admission Record (MAR) revealed an order with a start date of 5/10/2023 for, right lower extremities, check skin integrity every shift, two times a day under right knee immobilizer. Further review of the MAR revealed this order was documented as completed daily from 7/15/2023 through 7/26/2023.
During a surveyor observation on 7/24/2023 at 8:51 AM the resident was observed with his/her right leg amputated above the knee with a wound vac (Vacuum-assisted closure of a wound is a type of therapy to help wounds heal) to right thigh stump. Further surveyor observation revealed the knee was absent and without a knee immobilizer in place.
During a surveyor interview on 7/27/2023 at 8:31 AM with Registered Nurse, Staff B, she revealed that the resident does not have a right knee and that the order should not be in place. Additionally, she acknowledged that the order was signed off as completed from 7/15/2023 to 7/26/2023.
During a surveyor interview on 7/27/2023 at 9:05 AM with the DNS, she acknowledged that the resident had an order to monitor the skin integrity under the right knee immobilizer brace and has a right above the knee amputation. Additionally, she revealed she would have expected the order to have been discontinued when the resident returned from the hospital with the above the knee amputation.
2b. According to the Wound Care Advisors, How to write effective wound care orders, Dated 12/2012 states in part, .For a comprehensive treatment order that will promote consistent care, include all of the following:
·
Wound location
·
Cleansing solution
·
Primary dressing to be applied to wound bed
·
As needed, a moisture barrier for the periwound area to prevent maceration
·
As needed, a secondary dressing to be placed over the primary one
·
As needed, secure with _____
·
Frequency of dressing change (follow manufacturer's guidelines or change more often based on exudate amount)
·
Expected duration of need
Record review of the July 2023 MAR revealed an order dated 7/15/2023 which states Wound Vac/Negative pressure at 125 mmHg [millimeters of mercury] to right above knee amputation. Change 3 [times] week. every day shift every Mon, Wed, Fri for wound care.
Record review failed to reveal evidence of how to cleanse the wound, what solution to cleanse the wound with, periwound (surrounding wound) care, the type of contact dressing such as black or white foam, and the type of cover dressing.
During a surveyor interview on 7/27/2023 at 8:31 AM with Staff B, she acknowledged that the wound care order failed to reveal the above mentioned documentation.
During a surveyor interview on 7/27/2023 at 9:00 AM with the DNS, she acknowledged that the resident had a wound vac to his/her right above the knee amputation site. She further revealed that she would expect the order to include instructions on how to care for the wound site, including how to cleanse the wound, what type of foam to utilize, periwound care and dressing type. Additionally, she was unable to provide evidence that the order included all necessary components for wound care.
2c. According to Wound Care Education Institute, 2020, Wound care documentation should be carried out weekly including type of wound, measurements, type of tissue, symptoms of infection, presence of drainage, wound edges, pain, and current treatment.
Record review revealed the resident has a right above the knee amputation. Further record review revealed that the resident has a wound vac located on the right above the knee thigh stump.
Record review of the facility policy titled Clinical Protocol- Wound Care and Wound Rounds states in part, .New Admissions .All new admissions will have a complete body check to identify all open areas .Resident will be seen for weekly wound rounds .
Record review of skin assessments completed on 7/17/2023, 7/21/2023, 7/22/2023, and 7/24/2023 failed to reveal evidence of measurements, type of tissue, symptoms of infection, presence of drainage, wound edges, pain, and current treatment for the right above the knee amputation site.
Record review of a Vorha Wound Management note dated 7/21/2023 failed to reveal evidence the resident's right above the knee amputation was assessed.
Record review of the nursing progress notes failed to reveal evidence of weekly wound assessments including, type of wound, measurements, type of tissue, symptoms of infection, presence of drainage, wound edges, pain, and current treatment for the right above the knee amputation site.
During a surveyor interview on 7/27/2023 at 9:11 AM with the DNS, she revealed that the resident should have an assessment completed of the resident's right amputation site by the nurses on the floor who are completing care. Additionally, she revealed that the wound nurse and outside providers do not follow this resident as s/he has a surgical wound. Furthermore, she was unable to provide evidence that the resident's wound care was being documented and monitored weekly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
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 the resident environment remains as free of accident hazards as possib...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the resident environment remains as free of accident hazards as possible relative to 1 of 4 residents who had access to smoking materials in his/her room, Resident #15. Additionally, the facility failed to ensure that the resident is provided assistive devices to prevent accidents relative to smoking for 1 of 4 residents reviewed, Resident ID #16.
Findings are as follows:
1. Review of a facility policy titled, Smoking Program states in part, .An individualized plan of care will be developed for the resident to ensure their smoking safety based on the outcome of their Smoking Assessment.
a. Safety equipment, such as but not limited to a smoking apron .
Record review revealed that Resident ID #16 was admitted to the facility in May of 2019 with diagnoses of, but not limited to, schizophrenia, bipolar disorder, and lack of coordination.
Review of the care plan dated 10/18/2019 revealed that the resident is a smoker with an intervention to provide a smoking apron during designated smoking times.
Review of a Smoking Evaluation dated 7/25/2023 revealed that the resident requires a smoking apron for safety.
During a surveyor observation on 7/25/2023 from 9:38 AM until 10:10 AM, of the smoking room revealed Resident ID #16 smoked 3 cigarettes without a smoking apron in place. Additionally, the resident was observed with his/her eyes closed while smoking.
During a surveyor interview on 7/25/2023 directly following the above observation with the Smoking Monitor, Staff C, he revealed that he was unaware that the resident required an apron until being brought to his attention by the surveyor.
Review of a facility provided Smoking List dated June 2023, and located inside the smoking material cart revealed the resident requires safety equipment including a smoking apron. Additionally, there were smoking aprons available inside the cart.
During a surveyor interview on 7/25/2023 at approximately 12:45 PM, with the Director of Nursing Services (DNS) she revealed that she would expect Resident #16 to be provided a smoking apron prior to being given a cigarette.
2. Review of a facility policy titled, Smoking Program dated 1/2022 states in part, Smoking Program .2. Residents are not permitted to hold their smoking materials (e.g. cigarettes, matches, lighters, disposable e-cigarettes, pipes, and other tobacco, and other tobacco products) a. Resident smoking materials will be stored by the facility in a locked area .
Record review revealed Resident ID #15 was re-admitted to the facility in January of 2020 with diagnoses including, but not limited to, chronic obstructive pulmonary disease, major depressive disorder, and bipolar disorder.
During a surveyor observation on 7/24/2023 at 12:18 PM of Resident ID #15's room, the resident showed the surveyor a pack of cigarettes and a lighter which were kept in the drawer of his/her bedside table.
During a surveyor observation on 7/25/2023 at 9:46 AM of Resident ID #15's room, revealed a pack of cigarettes and two lighters inside of the drawer of his/her bedside table, which was left ajar.
During a surveyor interview on 7/25/2023 at 12:08 PM with Registered Nurse, Staff A, she acknowledged that the resident had cigarettes and lighters in his/her room. Additionally, she revealed that residents are not allowed to keep smoking materials in their rooms, and she removed them.
During a surveyor interview on 7/25/2023 at approximately 12:45 PM with the DNS she acknowledged that the residents are not to keep smoking materials including cigarettes and lighters in their rooms for safety reasons.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that the residents are free from significant medication errors for 1 of 5 residents reviewed who w...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that the residents are free from significant medication errors for 1 of 5 residents reviewed who was not administered a psychotropic medication according to the physician order, Resident ID #8.
Findings are as follows:
Record review revealed that the resident was admitted to the facility in January of 2020 with diagnoses including, but not limited to, paranoid schizophrenia and homicidal ideation.
Review of a physician's order for Haloperidol Decanoate Solution (antipsychotic medication) revealed to inject 100 milligrams (mg) intramuscularly every 28 days. Review of the June 2023 Medication Administration Record (MAR) revealed that Haloperidol Deaconate was administered on 6/16/2023.
Review of the July 2023 MAR revealed that the resident was scheduled to receive the next dose of Haloperidol Deaconate on 7/30/2023, 44 days following the previous dose, not the 28 days which was ordered by the physician.
During a surveyor interview on 7/26/2023 at 8:55 AM with Registered Nurse (RN), Staff D, she acknowledged that the medication was scheduled to be given 44 days past the last dose and not the 28 days as ordered.
During a follow up interview on 7/26/2023 at 1:30 PM with Staff D, she revealed that it was a transcription error that caused the missed dose of medication. Additionally, she revealed that the provider had been notified of the missed dose after being brought to the facility's attention by the surveyor.
Review of the physician's orders revealed a new order dated 7/26/2023 to administer Haloperidol Decanoate Intramuscular Solution 100 mg/ml intramuscularly one time then continue every 28 day(s) for schizophrenia. This order was 40 days following the last dose.
During a surveyor interview on 7/27/2023 at approximately 12:45 PM with the Director of Nursing Services she revealed that the missed dose of medication was a result of a transcription error.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide food prepared in a form designed to meet individual needs for 2 of 2 resid...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide food prepared in a form designed to meet individual needs for 2 of 2 residents reviewed for puree textured diets, Resident ID #s 17 and 73.
Findings are as follows:
1. Record review revealed Resident ID #17 was admitted to the facility in January of 2019 with diagnoses including, but not limited to, dysphagia (a condition with difficulty in swallowing food or liquid) and schizophrenia.
Review of a physician's order dated 2/14/2019 states, Puree texture, Nectar Thick Liquids consistency, may have soft cookies and soft sandwiches when supervised.
Review of a care plan last revised on 7/12/2023 states in part, [Resident] has a nutritional problem r/t [related to] a h/o [history of] weight loss, chewing problems and Dysphagia. Weight is below [his/her] ideal body weight. Diet- pureed, nectar thickened liquids.
During a continuous surveyor observation on 7/24/2023 at 12:40 PM through 12:52 PM, of the 4th floor common room the resident was observed eating a mechanical soft meal including chopped chicken with gravy and sliced carrots. The resident was observed to be eating quickly and coughing while eating.
During a surveyor interview on 7/24/2023 at approximately 12:45 PM with Registered Nurse (RN), Staff D, she acknowledged that the resident received a mechanical soft texture meal and should have received a puree texture meal. Additionally, Staff D removed the incorrect meal and ordered a puree textured meal from the kitchen.
During a surveyor interview with the Speech Language Pathologist, Staff E, on 7/25/2023 at 11:40 AM she revealed that the safest diet for the resident is puree texture.
During a surveyor interview on 7/25/2023 at 12:55 PM with the Director of Nursing Services (DNS) and Staff E, they were unable to provide evidence that the resident was provided food prepared in a form designed to meet individual needs.
2. Record review revealed Resident ID #73 was readmitted to the facility in July of 2023 with diagnoses including, but not limited to, cerebral infarction (stroke) and dysphagia.
Record review revealed an order for his/her diet to be puree texture with nectar thick liquids and to have supervision with all meals.
During a surveyor observation of the lunch meal on 7/26/2023 at approximately 12:35 PM the resident was observed eating ground turkey.
During a surveyor interview on 7/26/2023 at approximately 12:30 PM, with the Unit Manager, she acknowledged the resident was not served a pureed meal as ordered. Additionally, she removed the incorrect diet and ordered a puree meal for the resident.
During a surveyor interview on 7/26/2023 at approximately 3:00 PM with the DNS she was unable to provide evidence that the resident was served food prepared in a form designed to meet individual needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected 1 resident
Based on surveyor observation and staff interview, it has been determined that the facility failed to provide eating equipment and utensils for residents as ordered by the physician for 1 of 1 residen...
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Based on surveyor observation and staff interview, it has been determined that the facility failed to provide eating equipment and utensils for residents as ordered by the physician for 1 of 1 resident reviewed for adaptive equipment, Resident ID #73.
Findings are as follows:
Record review revealed the resident was readmitted to the facility in July 2023 with diagnoses including, but not limited to, dysphagia (difficulty swallowing) following a cerebral hemorrhage (stroke), visual field defects and lack of coordination.
Record review of a physician's order revealed in part, .Kennedy cup (a cup designed with a lid, straw and one long handle for individuals with limited dexterity) at meals .
Surveyor observations of the resident revealed the following:
7/24/2023 at approximately 10:30 AM, s/he was sitting in common area with two 6 oz Styrofoam cups with cranberry juice, not a Kennedy cup.
7/25/2023 at approximately 12:50 PM and additionally on 7/26/2023 at approximately 12:50 PM, s/he was observed eating lunch in the common area with coffee not served in a Kennedy cup.
During a surveyor interview on 7/26/2023 at approximately 3:30 PM with the Food Service Director, he was unable to provide evidence that the physician's order was followed for the use of Kennedy cups.
During a surveyor interview on 7/27/2023 at approximately 10:30 AM with the Registered Dietitian, she acknowledged that a Kennedy cup is needed for all beverages.
CONCERN
(D)
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 that are accurately documented in accordance with professional standards and pra...
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Based on record review and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 2 residents reviewed for accuracy of documentation relative to the Medication Administration Record (MAR) for Resident ID #109 and 1 of 4 residents reviewed related to an accurate smoking evaluation, Resident ID #15.
Findings are as follows:
1. Record review revealed Resident ID #109 was readmitted to the facility in July of 2023 with diagnosis including, but not limited to, right leg above the knee amputation.
Record review of the July 2023 Medication admission Record (MAR) revealed an order with a start date of 5/10/2023 for right lower extremities, check skin integrity every shift, two times a day under right knee immobilizer. Further review of the MAR revealed this order was documented as completed daily from 7/15/2023 through 7/26/2023.
During a surveyor observation on 7/24/2023 at 8:51 AM the resident was observed with his/her right leg amputated above the knee and was observed with a wound vac (Vacuum-assisted closure of a wound is a type of therapy to help wounds heal) to right thigh stump. Further surveyor observation revealed the knee was absent and no knee immobilizer in place.
During a surveyor interview on 7/27/2023 at 8:31 AM with Registered Nurse, Staff B, she revealed that the resident does not have a right knee and that the order should not be in place. Additionally, she acknowledged the order was signed off as being completed from 7/15/2023 to 7/26/2023.
During a surveyor interview on 7/27/2023 at 9:05 AM with the Director of Nursing Services (DNS), she acknowledged that the resident had an order to monitor the skin integrity under the right knee immobilizer brace and has a right above the knee amputation. Additionally, she revealed she would have expected the order to have been discontinued when the resident returned from the hospital with the above the knee amputation.
2. Record review of a facility policy titled SMOKING PROGRAM last revised 1/2022 states in part, This facility shall establish and maintain a safe resident smoking program to ensure those residents who wish to smoke and are assessed to be safe to do so, will be provided with appropriate accommodations .
Record review revealed Resident ID #15 was admitted to the facility in January of 2020 with diagnoses of chronic obstructive pulmonary disease, major depressive disorder and bipolar disorder.
Record review revealed a care plan last revised on 9/13/2019 which revealed that Resident ID #15 is a smoker.
Record review of a facility provided document titled Smoking List updated 6/12/2023 revealed Resident ID #15 was listed as a smoker.
Record review of the resident's smoking evaluations completed on 3/9/2023 and 6/6/2023 revealed the resident was not a smoker.
During a surveyor observation on 7/25/2023 at 9:45 AM the resident was observed smoking in the smoking room.
During a surveyor interview on 7/25/2023 at 12:46 PM with the DNS she revealed, smoking assessments are completed on admission, with a change of condition and quarterly. Additionally, she acknowledged the above mentioned smoking evaluations are inaccurate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to follow standard precautions to prevent the spread of infections for 2 of 4 wound d...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to follow standard precautions to prevent the spread of infections for 2 of 4 wound dressings observed, Resident ID #s 39 and 102.
Findings are as follows:
Record review of a facility policy titled, Hand Hygiene revealed .Hand Hygiene is performed as a minimum at these times .after contact with objects or surfaces in the resident's room .after removing personal protective equipment (e.g., gloves .) .
Record review of the facility's Clinical Competency Assessment titled, Dressing-Aseptic/Clean revealed staff are to remove gloves and perform hand hygiene following the removal of a soiled dressing and following the completion of a wound dressing.
1. Record review of resident ID #39 revealed that s/he was readmitted to the facility in September of 2021, with diagnoses including, but not limited to, type 2 diabetes mellitus and pain in right hip.
Review of a physician's order dated 6/2/2023 revealed a treatment to the resident's right stump Rt BKA: [right below knee amputation] NSW [normal saline wash], pat dry, skin prep peri area, apply small amount of Iodosorb gel [wound gel] to wound bed and cover w/ [with] DCD [Dry Clean Dressing] one time day for wound management.
During a surveyor observation on 7/27/2023 at 9:52 AM of the resident's dressing change to his/her right stump, Licensed Practical Nurse (LPN) Staff G was observed to remove the soiled dressing with a moderate amount of drainage then failed to remove her gloves or use hand hygiene. She was then observed taking gauze out the gauze pack and completing the clean wound dressing. Additionally, she was observed removing the wound dressing supplies, including the package of gauze, from the resident's room and placing them on the treatment cart without performing hand hygiene.
During a surveyor interview immediately following the dressing change with Staff G, she indicated that she failed to change her gloves or perform hand hygiene following the removal of the dirty dressing and before touching clean gauze from the pack. Additionally, she indicated that she didn't realize that not removing the dirty gloves and not performing hand hygiene were infection control issues.
During a surveyor interview on 7/27/2023 at approximately 2:00 PM with the Director of Nursing Services (DNS), she indicated that she would expect the nurse to remove her gloves after removing the dirty dressing. She further indicated that she would expect the nurse to perform hand hygiene after removing her gloves and before touching the clean supplies. Additionally, she indicated that the above mentioned observation was an infection control issue.
2. Record review revealed Resident ID #102 was admitted to the facility in June of 2023 with diagnoses including, but not limited to, multiple subsegmental pulmonary emboli (blood clot) and hypertension (high blood pressure) and muscle weakness.
Record review revealed a physician's order dated 7/21/2023 to apply skin prep to left lateral (outside) foot and left posterior (back) heel for skin breakdown then cover both areas with an ABD pad (absorbent dressing) and wrap with gauze roll.
During a surveyor observation on 7/26/2023 at 9:46 AM, LPN Staff H completed the resident's clean wound dressing and failed to perform hand hygiene after removing her gloves.
During a surveyor interview with Staff H immediately following the above observations, she indicated that she did not perform hand hygiene after removing her gloves and after contact with the resident.
During a surveyor interview on 7/26/2023 at 3:24 PM with the DNS, she indicated that she would expect the nurse to perform hand hygiene following wound care and after removing gloves as outlined in the facility policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected multiple residents
Based on record review, surveyor observation, resident and staff interview, it has been determined that the facility failed to ensure a resident received a therapeutic diet as ordered by the physician...
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Based on record review, surveyor observation, resident and staff interview, it has been determined that the facility failed to ensure a resident received a therapeutic diet as ordered by the physician for 8 of 8 residents reviewed for therapeutic diets, Resident ID #s 34, 62, 66, 79, 106, 109, 367 and 417.
Findings are as follows:
Record review of a facility menu dated 7/24/2023 for CCHO(Consistent Carbohydrate), a diet ordered for the management of diabetes and a Heart Healthy Diet, a diet ordered for the management of cardiovascular diseases revealed the following menu items:
Pork Chow Mein 3 ounces.
Rice, ½ cup
Mixed Oriental Vegetables, ½ cup
Blonde Brownie, ½ each
Record review of physician orders for Resident ID #s 34, 66, 79, 106, 109, 367 and 417 revealed diet orders for a CCHO diet.
Record review of a physician order for Resident ID # 62 revealed a diet order for a Heart Healthy diet.
During a surveyor observation on 7/24/2023 at approximately 9:15 AM stored in the walk in refrigerator on a bakers rack were two 1/2 inch baking pans of blonde brownies.
Further observation and interview with the Food Service Director revealed the blonde brownies was the dessert to be served at lunch for the CCHO and Heart Healthy diet orders.
During a surveyor observation of the lunch meal on 7/24/2023 at approximately 12:30 PM, Resident ID #s 34, 62, 66, 79, 106, 109, 367 and 417 received a full serving size of chocolate cake with frosting, which is not consistent with the CCHO and Heart Healthy diets.
During a surveyor interview on 7/26/2023 at approximately 3:30 PM with the Food Service Director, he was unable to provide evidence as to why the blonde brownies prepared for residents on the CCHO and Heart Healthy diets were not served on 7/24/2023 per the menu.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored, served and distributed, in accordance with professiona...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored, served and distributed, in accordance with professional standards for food service safety, relative to the main kitchen.
Findings are as follows:
The Rhode Island Food Code 2018 Edition 3-501.16 reads in part, Time/Temperature Control for Safety Food, Hot and Cold Holding .food shall be maintained .5 degrees C (41 degrees Fahrenheit) .
During a surveyor observation on 7/26/2023 at approximately 12:05 PM of the lunch meal, a tuna salad sandwich had a cold holding temperature of 53 degrees Fahrenheit.
During a surveyor interview on 7/26/2023 at approximately 12:10 PM with the Food Service Director he acknowledged that the tuna salad sandwich was not within the acceptable temperature range.
The Rhode Island Food Code 4-703.11 reads in part, Hot Water and Chemical .chemical manual .including the application of sanitizing chemicals .a contact time of at least 30 seconds .
During a surveyor observation on 7/24/2023 at approximately 9:30 AM the pot/pan sink that was filled with sanitizing solution had 5 baking pans that were not fully immersed in the solution to allow for a 30 second contact time.
An additional surveyor observation on 7/25/2023 at approximately 2:30 PM of the pot/pan sink that was filled with sanitizing solution had 4 baking pans that were not fully immersed in the solution to allow for a 30 second contact.
The Rhode Island Food Code 3-602.11 Food Labels, reads in part, .the label information .common name of the food .an adequately descriptive identity statement .
During a surveyor observation on 7/24/2023 at approximately 9:15 AM the following was observed in the walk-in refrigerator unit.
10- 2 ounce (oz) containers with an orange-colored fruit without a label descriptor
6- 2 oz. containers with a brown colored substance without a label descriptor
5- 2 oz containers with an orange-colored substance that had a pudding like appearance with the letter P without a label descriptor
During a surveyor interview on 7/27/2023 at approximately 3:30 PM with the Food Service Director he indicated that when using the pot/pan sink all items are to be fully immersed in the sanitizing solution and all food items should be proper labeled.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
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 implement and maintain an effective, comprehensive, data-driven, Quality Assurance and Performance Improv...
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Based on record review and staff interview, it has been determined that the facility failed to implement and maintain an effective, comprehensive, data-driven, Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. Additionally, the facility failed to make a good faith attempt to correct the identified concern of meal tickets matching what the resident received for a meal.
Findings are as follows:
Review of the QAPI binder for 2023 failed to reveal evidence of a good faith attempt to correct processes's for identifying and correcting quality deficiencies, including tracking and measuring performance, and establishing goals and thresholds for performance measurements related to meal tickets matching what the residents were receiving from the kitchen.
Review revealed a performance improvement plan was implemented by the facility in October of 2022 and was monitored in March of 2023 related to the meal tickets matching what residents are receiving with a total of 60% of resident receiving the correct meal, leaving 40% of the resident's meal tickets not matching what they are receiving from the kitchen.
Further record review of the July 2023 QAPI failed to reveal evidence of an ongoing QAPI plan related to meal tickets matching what residents are getting for meals.
During a surveyor observation on 7/24/2023 at 12:40 PM of Resident ID #17, s/he received the wrong consistency of meal.
Additional surveyor observation on 7/25/2023 at approximately 1:00 PM of Resident ID #73, s/he received the wrong consistency of meal.
During a surveyor interview on 7/27/2023 at 11:30 AM with the Director of Nursing Services, she was unable to provide evidence of a good faith attempt to correct the identified concern brought forth by the dietitian in October of 2022. Additionally, she was unable to provide the evidence of a comprehensive QAPI program that addressed concerns of residents receiving the meals that failed to match the tray tickets. Refer to F805.
Jun 2023
4 deficiencies
2 IJ
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
Deficiency F0675
(Tag F0675)
Someone could have died · 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 ser...
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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 services to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing for 1 of 8 sample residents reviewed, Resident ID #1.
Findings are as follows:
Review of a Continuity of Care form from an acute care hospital dated 5/24/2023, revealed that Resident ID #1 was brought to the Emergency Department (ED) by Emergency Medical Services (EMS) with reported behavior, including but not limited to, having unkempt living conditions, inability to manage daily tasks including properly self-medicating. In addition, hospital records indicate that the resident lost his/her spouse who was his/her primary caregiver and was evicted from his/her home due to non-payment and poor living conditions.
Further review of hospital records revealed Resident ID #1 had reported feeling depressed, and hopeless. In addition, the hospital records revealed the resident was admitted to the geriatric psychiatric unit for further evaluation and management of functional decline. Of note, Resident ID #1 was admitted on an involuntary legal status for worsening depression, and inability to care for his/her self in the context of psychosocial stressors, questionable substance abuse and treatment noncompliance. The hospital records state in part .the patient may benefit from an environment with 24-hour supervision to address patient's current memory and cognitive deficits, such as nursing home and provide maintenance of safe living environment for optimal function .Judgement: impaired (inability to care for self at home) .Mood: sad/depressed/anxious/worried .Affect; depressed/constricted .
Review of a preadmission screening and resident review (PASSR) (a comprehensive evaluation necessary to confirm the indicated diagnosis and to determine whether placement or continued stay in a Nursing facility is appropriate), which was completed by the Rhode Island Department of Mental Health Division of Behavioral Healthcare Services on 6/6/2023, states in part .assist with adjustment to the nursing facility .
Resident ID #1 was admitted to the facility in June of 2023 with diagnoses including, but not limited to, major neurocognitive disorder (a disorder categorized by a significant decline in at least one of the domains of cognition which include executive function, complex attention, language, learning, memory, perceptual-motor, or social cognition), major depressive disorder without psychotic features, and anxiety disorder.
Record review of the Minimum Data assessment dated [DATE], revealed a Brief Interview of Mental Status score of 4 out of 15, indicating the resident has severely impaired cognition. Additionally, the Patient Health Questionnaire (PHQ-9) which is used for screening, diagnosing, monitoring, and measuring the severity of depression and detection of anxiety symptoms revealed a score of 3 out of 27, indicating minimal depression.
Review of a policy titled,Admission-Readmission, which was last revised in September 2022, states, in part .the objectives for our admission/readmission policies are to admit residents who can be adequately cared for by the facility .assure that the facility receives appropriate medical and financial records prior to or upon the resident's admission .nursing is responsible for the clinical review and to determine, if any specialized equipment or medications are needed .the pre-admission process includes obtaining documents that include, but are not limited to, past medical history and psychological background .
Review of a [Social Service Assessment and Documentation-V3] dated, 6/8/2023, indicates that Resident ID #1 has a diagnosis of a major mental illness as evidenced by question 1a.Does the patient/resident have a diagnosis of a major mental illness, being checked off as yes.
During an interview on 6/21/2023 at approximately 11:25 AM with the Social Services Director, Staff C, she revealed that her standard of practice and expectation for social services is to refer all new admissions, regardless of diagnosis, to psych services for an evaluation secondary to being new to the facility and possibly having adjustment issues. Staff C revealed that onsite psychiatric services are provided at the facility. Staff C further indicated that a nurse practitioner and a licensed clinical social worker that provide the onsite psychiatric services are at the facility every week.
Review of a document titled, [Behavioral Health Visit Request/Follow-Up] revealed Resident ID #1 is listed on the document that is dated 6/8/2023. Reason for this Request states in part .new admission, dx (Diagnosis) MDD (Moderate Depressive Disorder) and Anxiety d/o (Disorder) .
Review of Resident ID #1's medical record revealed that the facility was aware of his/her history pertaining to a psychiatric hospitalization and the course of treatment that was provided to him/her.
Record review of a police report indicates that the police were dispatched on 6/18/2023 at approximately 9:30 PM to the resident's location, where s/he was found sitting down on the sidewalk. The resident was noted to be alert and awake but oriented to person only. The resident was noted to be hypertensive with a blood pressure reading of 142/110, (a normal blood pressure reading is 120/80), and indicated s/he had a history of dementia. Additional review of the police report revealed the resident had a bracelet on with contact information for the facility, and they called [NAME] Center who informed them that the resident eloped the day before. The resident was then transferred to an acute care hospital for a medical evaluation.
Record review failed to reveal evidence that Resident ID #1 had received psych services until 6/20/2023, after s/he successfully eloped from the facility. Of note, the psychiatric evaluation dated 6/20/2023, states in part . initial psychiatric evaluation .[s/he] recently eloped from the facility but does not remember .reports feelings of sadness, hopelessness, fatigue, and anhedonia [an inability to experience pleasure from activities usually found enjoyable] .would benefit from supportive therapy .will follow up routinely or as needed .
During an interview on 6/21/2023 at approximately 12:45 PM with Staff C, she was unable to explain why Resident ID #1 had not been seen by psych services until 6/20/2023, when s/he had been on the referral list since 6/8/2023. Additionally, Staff C was unable to provide evidence that services were provided to Resident ID #1 to attain and maintain his/her highest practicable physical, mental, and psychosocial wellbeing.
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 surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that...
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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 resident receives adequate supervision to prevent elopements, for 1 of 8 sample residents reviewed, Resident ID #1.
Findings are as follows:
Review of the facility's policy titled, Elopement Prevention, which was last revised in February 2020, states, in part .the facility strives to promote resident safety .the facility maintains a process to assess all residents and institute measures for resident identification at the time of admission .the physical plant is secured to minimize the risk of elopement such as safety locks or key-pad entry that restrict access to dangerous areas .locking main entrance to building with designated 'unlocked' times when the door can be monitored continuously, i.e. security/receptionist .
Record review reveals that Resident ID #1 was admitted to the facility in June 2023 with diagnoses including, but not limited to, major neurocognitive disorder (a disorder characterized by a significant decline in at least one of the domains of cognition which include executive function, complex attention, language, learning, memory, perceptual-motor, or social cognition) cognitive communication deficit (difficulty with thinking and how someone uses language), anxiety disorder, CVA (stroke), major depressive disorder without psychotic features, blindness of right eye, and hypertension (high blood pressure). Additional record review revealed Resident ID #1 was admitted to the 4th floor which requires a keypad entry for elevator and stairwell access.
Record review of the Minimum Data assessment dated [DATE] revealed a Brief Interview of Mental Status score of 4 out of 15, indicating the resident has severely impaired cognition.
Review of hospital records revealed a Saint [NAME] University Mental Status Exam (SLUMS) was completed during the resident's hospitalization with a score of 6 out of 30 indicating a possible significant neurocognitive disorder. The SLUMS assessment is provided to patients with diagnoses of dementia to test attention, immediate recall, orientation, delayed recall, numeric calculation, visuospatial, executive function, and extrapolation.
Additional review of the hospital records revealed the resident was admitted to the geriatric psychiatric unit for further evaluation including management of his/her functional decline. Hospital records state in part .the patient may benefit from an environment with 24-hour supervision to address patient's current memory and cognitive deficits, such as a nursing home and provide maintenance of safe living environment for optimal function .Judgement: impaired (inability to care for self at home) .Mood: sad / depressed / anxious / worried .Affect: depressed / constricted .
During a surveyor interview on 6/19/2023 at approximately 12:30 PM with both the Administrator and Director of Nursing Services (DNS), they revealed that on 6/17/2023 Resident ID #1 had eloped from the facility via the front door. Additionally they revealed that s/he was exiting the building with other visitors. They further revealed that during the second shift, the charge nurse, Licensed Practical Nurse (LPN), Staff B, discovered the resident was not in the facility during a medication pass. A search for the resident was initiated and s/he was not found. Therefore, a code gray (alert of a missing elderly person) was initiated, and the police were notified.
During a surveyor interview on 6/20/2023 at 3:12 PM with Staff B, she revealed that she had worked a double shift on 6/17/2023 from the hours of 7:00 AM to 11:00 PM. She further revealed that when she went to change the medication administration record (MAR) in the computer from first shift to second, she saw photographs of all residents who were due for medication which included Resident ID #1. Staff B indicated that she and other staff searched the entire unit including resident rooms, all floors, stair wells and outdoor grounds and was unable to locate the resident. Therefore, a code gray was initiated, and the police were notified.
Review of the facility camera footage for 6/17/2023 revealed Resident ID #1 walked out of the front entry door at 4:36 PM alone. Additionally, the camera footage revealed that the the receptionist, who is responsible for monitoring who enters and leaves the facility, as well as unlocking the door via a buzzer, allowed the resident to exit the facility without verifying his/her identity.
Record review of the facility's policy titled, Visitation, which was last revised in December 2019, states, in part .all visitors are required to sign into Facility's visitor log upon arrival and sign out prior to leaving .
During an interview on 6/20/2023 at 12:10 PM with receptionist, Staff A, she revealed that she worked on 6/17/2023 from 4:00 PM to 12:00 AM. She further indicated that she buzzed the alarm which activated the front door to open and led to Resident ID #1 exiting the facility. Additionally, Staff A revealed that she did not know the resident as she had not seen him/her before and thought s/he was a visitor. Staff A revealed that visitors normally sign in/out of the visitor book, and she did not ask Resident ID #1 to sign out of the visitor book before she allowed him/her to exit the facility.
Record review of a police report indicates that the police were dispatched on 6/18/2023 at approximately 9:30 PM to the resident's location, where s/he was found sitting down on the sidewalk. The resident was noted to be alert and awake but oriented to person only. The resident was noted to be hypertensive with a blood pressure reading of 142/110, (a normal blood pressure reading is 120/80), and indicated s/he had a history of dementia. Additional review of the police report revealed the resident had a bracelet on with contact information for the facility, and they called [NAME] Center who informed them that the resident eloped the day before. The resident was then transferred to an acute care hospital for a medical evaluation.
During an interview on 6/21/2023 at approximately 1:40 PM with the Administrator and DNS, they revealed it is their expectation that the person sitting at the receptionist desk would verify every person's identity prior to opening the door and allowing them to leave the facility. Additionally, they were unable to provide evidence that Resident ID #1 received adequate supervision to prevent him/her from eloping from the facility on 6/17/2023.
Based on the above, the facility failed to promote safety for Resident ID #1 who successfully eloped from the facility due to a lack of supervision and monitoring which placed him/her in immediate jeopardy.
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 F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on record review and surveyor interview it has been determined that the facility failed to ensure the QAPI/QAA committee includes the required committee members consisting at a minimum of, the D...
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Based on record review and surveyor interview it has been determined that the facility failed to ensure the QAPI/QAA committee includes the required committee members consisting at a minimum of, the Director of Nursing (DNS), the Medical Director, Infection Preventionist and at least three other members of the facility staff.
Findings are as follows:
Review of the facility QAPI/QAA 2022/2023 meeting schedule and attendance sheets revealed meetings were held on the following dates:
-7/28/2022
-10/28/2022
-1/5/2023
-4/30/2023
Review of the signature attendance sheets for the above mentioned meetings failed to reveal evidence that the Infection Preventionist attended all of the QAPI meetings.
During a surveyor interview on 6/21/2023, at 3:20 PM with the Administrator and DNS, they were unable to provide evidence that the Infection Preventionist was in attendance for all of the QAPI/QAA committee meetings. Additionally, they revealed that the Infection Preventionist Nurse has had this position since November 2022 indicating there was opportunity to attend the meetings held on 1/5/2023 and 4/30/2023.
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 F0658
(Tag F0658)
Could have caused harm · This affected most or all residents
Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality for 5 of 8 sample residents which we...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality for 5 of 8 sample residents which were reviewed for physician's orders, Resident ID #s 1, 2, 3, 4, and 7.
Findings are as follows:
Mosby's 4th Edition, Fundamentals of Nursing, page 314 states: The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
1. Record review for Resident ID #1 revealed a physician's order dated 6/7/2023, and revised on 6/8/2023, for pain which states in part .evaluation every shift-use pain scale for verbal and non-verbal signs/symptoms of pain .
Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR), failed to reveal evidence of the above noted order.
Further record review failed to reveal evidence that Resident ID #1's pain was being monitored.
2. Record review for Resident ID #2 revealed a physician's order dated 6/18/2023, which states in part .check Wander guard placement to right ankle every shift and functionality daily .
Review of the MAR/TAR failed to reveal evidence that the physician's order for the wander guard was followed on 6/19/2023 and 6/25/2023 during the night shift.
Additional record review revealed a physician's order dated 10/30/2022, which states in part .monitor resident behaviors every shift and record the number of occurrences resident displayed behavior.
Review of the MAR/TAR failed to reveal evidence that Resident ID #2's behaviors were monitored on the following dates and times:
-6/2/2023 (evening shift)
-6/5/2023 (night shift)
-6/11/2023 (night shift)
-6/16/2023 (day shift)
-6/19/2023 (night shift)
-6/25/2023 (night shift)
3. Review of Resident ID #3 revealed a physician's order dated 5/19/2023, which states in part .check Wander guard placement to right ankle every shift and functionality daily .
Review of the MAR/TAR failed to reveal evidence that the above physician's order was followed on the following dates and times:
-6/2/2023 (evening shift)
-6/5/2023 (night shift)
-6/11/2023 (night shift)
-6/16/2023 (day shift)
-6/19/2023 (night shift)
Additional record review revealed a physician's order dated 10/30/2022, which states in part .monitor resident behaviors (refusal to shower, refusal to shave, agitation, anger, frustration, elopement) every shift and record the number of episodes .
Review of the MAR/TAR failed to reveal evidence that the above physician's order was followed on the following dates and times:
-6/2/2023 (evening shift)
-6/5/2023 (night shift)
-6/11/2023 (night shift)
-6/16/2023 (day shift)
-6/19/2023 (night shift)
Further record review revealed a physician's order dated 10/5/2022 which states in part, .monitor for signs and symptoms of bruising/bleeding every shift for anticoagulant use .
Review of the MAR/TAR failed to reveal evidence that the above physician's order was followed on the following dates and times:
-6/2/2023 (evening shift)
-6/5/2023 (night shift)
-6/11/2023 (night shift)
-6/16/2023 (day shift)
-6/19/2023 (night shift)
4. Review of Resident ID #4 revealed a physician's order dated 10/1/2020, which states in part .pain evaluation every shift .
Review of the MAR/TAR failed to reveal evidence that the above physician order was followed on the following dates and times:
-6/9/2023 (day shift)
-6/11/2023 (night shift)
-6/13/2023 (day shift)
-6/19/2023 (night shift)
Additional record review of a physician's order dated 3/15/2021, which states in part .monitor resident behaviors every shift and record number of episodes every shift for behavior monitoring .
Review of the MAR/TAR failed to reveal evidence that the above physician order was followed on the following dates and times:
-6/9/2023 (day shift)
-6/11/2023 (night shift)
-6/13/2023 (day shift)
-6/19/2023 (night shift)
Further record review revealed a physician's order dated, 9/20/2022, which states in part .check skin integrity of stumps twice a day .
Review of the MAR/TAR failed to reveal evidence that the above physician order was followed on the following dates and times:
-6/9/2023 (day shift)
-6/13/2023 (day shift)
5. Review of Resident ID #7 revealed a physician's order dated 4/12/2023, which states in part .check wanderguard placement to right ankle every shift and functionality daily .
Review of the MAR/TAR failed to reveal evidence that the above physician order was followed on the following dates and times:
-6/6/2023 (evening shift)
-6/7/2023 (day shift)
-6/8/2023 (day and night shifts)
During a surveyor interview on 6/21/2023 at approximately 3:40 PM with the Director of Nursing Services, she was unable to provide evidence that the above physician orders were followed. Additionally, she revealed that her expectation is for all physician orders to be followed by nurses and they will document in the MAR/TAR.
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
- • 28% annual turnover. Excellent stability, 20 points below Rhode Island's 48% average. Staff who stay learn residents' needs.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), 3 harm violation(s), $67,874 in fines. Review inspection reports carefully.
- • 33 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $67,874 in fines. Extremely high, among the most fined facilities in Rhode Island. Major compliance failures.
- • Grade F (4/100). Below average facility with significant concerns.
Bottom line: Trust Score of 4/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Bannister Center For Rehabilitation And Health Car's CMS Rating?
CMS assigns Bannister Center for Rehabilitation and Health Car an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Rhode Island, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Bannister Center For Rehabilitation And Health Car Staffed?
CMS rates Bannister Center for Rehabilitation and Health Car's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 28%, compared to the Rhode Island average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Bannister Center For Rehabilitation And Health Car?
State health inspectors documented 33 deficiencies at Bannister Center for Rehabilitation and Health Car during 2023 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, and 28 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Bannister Center For Rehabilitation And Health Car?
Bannister Center for Rehabilitation and Health Car 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 ADVINIACARE, a chain that manages multiple nursing homes. With 161 certified beds and approximately 153 residents (about 95% occupancy), it is a mid-sized facility located in Providence, Rhode Island.
How Does Bannister Center For Rehabilitation And Health Car Compare to Other Rhode Island Nursing Homes?
Compared to the 100 nursing homes in Rhode Island, Bannister Center for Rehabilitation and Health Car's overall rating (2 stars) is below the state average of 3.1, staff turnover (28%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Bannister Center For Rehabilitation And Health Car?
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 you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Bannister Center For Rehabilitation And Health Car Safe?
Based on CMS inspection data, Bannister Center for Rehabilitation and Health Car has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Rhode Island. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Bannister Center For Rehabilitation And Health Car Stick Around?
Staff at Bannister Center for Rehabilitation and Health Car tend to stick around. With a turnover rate of 28%, the facility is 18 percentage points below the Rhode Island average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.
Was Bannister Center For Rehabilitation And Health Car Ever Fined?
Bannister Center for Rehabilitation and Health Car has been fined $67,874 across 3 penalty actions. This is above the Rhode Island average of $33,758. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Bannister Center For Rehabilitation And Health Car on Any Federal Watch List?
Bannister Center for Rehabilitation and Health Car 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.