Does Summit Commons Rehabilitation and Health Care Cent have any serious inspection findings?

Yes, Summit Commons Rehabilitation and Health Care Cent has 6 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 51 total deficiencies from recent inspections.

What are the staffing levels at Summit Commons Rehabilitation and Health Care Cent?

Summit Commons Rehabilitation and Health Care Cent has a four-star staffing rating from CMS with 0.71 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

How many beds does Summit Commons Rehabilitation and Health Care Cent have?

Summit Commons Rehabilitation and Health Care Cent has 165 certified beds.

Who owns Summit Commons Rehabilitation and Health Care Cent?

Summit Commons Rehabilitation and Health Care Cent is a for profit - limited liability company facility and is part of the ATHENA HEALTHCARE SYSTEMS chain.

Was Summit Commons Rehabilitation and Health Care Cent ever fined?

Yes, Summit Commons Rehabilitation and Health Care Cent has been fined $111,861 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is Summit Commons Rehabilitation and Health Care Cent on any federal watch list?

Summit Commons Rehabilitation and Health Care Cent is currently an SFF Candidate, meaning CMS is monitoring it for potential placement on the Special Focus Facility list due to a history of serious quality issues.

What have inspectors found at Summit Commons Rehabilitation and Health Care Cent?

Medicare inspectors have found 51 deficiencies at Summit Commons Rehabilitation and Health Care Cent: 6 critical, 1 serious, 43 moderate, 1 minor. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting Summit Commons Rehabilitation and Health Care Cent?

Families visiting Summit Commons Rehabilitation and Health Care Cent should ask about what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does Summit Commons Rehabilitation and Health Care Cent compare to other nursing homes?

Summit Commons Rehabilitation and Health Care Cent has a 1-star overall rating, which is below average compared to other nursing homes in RI. Families should carefully review inspection findings and consider alternatives.

Summit Commons Rehabilitation and Health Care Cent | 0/100 (Grade F)

Jun 2025 6 deficiencies 1 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 F0604 (Tag F0604)

Someone could have died · 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 physical restraints that are not required to treat the resident's med...

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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 physical restraints that are not required to treat the resident's medical symptoms for 1 of 1 resident reviewed for an actual restraint, as the resident was observed in bed with a bed sheet tied across his/her abdomen, Resident ID #1. Findings are as follows: Review of a facility policy titled, Restraint Management states in part, .Physical Restraints: Is any manual, mechanical or physical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Physical restraints include, but are not limited to: Leg restraints, Arm restraints, Hand mitts, Waist ties .Also included as restraints are facility practices to meet the definition of a restraint, such as: Tucking in, or using Velcro to hold a sheet, fabric or clothing tightly so that the resident's movement is restricted . Record review of a facility reported incident submitted to the Rhode Island Department of Health on 6/24/2025 states in part, The resident was observed with a blanket secured around [his/her] waist. At this time, it is unclear whether this positioning may have restricted [his/her] movement or function as a form of restraint . Record review revealed that Resident ID #1 was admitted to the facility in September of 2024 with diagnoses including, but not limited to, cerebral infarction (stroke) and anxiety. Review of the Minimum Data Set (MDS) Assessment, dated 5/12/2025, revealed a Brief Interview for Mental Status (BIMS) score of 00 of 15, which indicates severe cognitive impairment. Additionally, the MDS revealed that the resident can reposition in bed independently and is dependent on staff for personal hygiene. Record review of a care plan last updated on 5/22/2025 revealed the resident is at risk for falls related to generalized weakness, diagnosis of a stroke, and cognitive impairment. Additionally, the resident requires the assistance of two staff members for transfers and rubber mats on the left side of the bed for safety. Further record review revealed that the resident had the following unwitnessed falls from his/her bed on the following dates: 6/4/2025 6/5/2025 6/7/2025 6/10/2025 6/16/2025 6/21/2025 During a surveyor interview on 6/25/2025 at 8:15 AM with the Speech Language Pathologist, Staff A, she indicated that she went into the resident's room on 6/23/2025 at approximately 11:00 AM, the resident's upper body was turned, and s/he appeared uncomfortable and restless. She asked the resident if s/he was uncomfortable, and the resident nodded his/her head yes. When she removed the top sheet, she noticed a sheet tied to the bottom straps of the perimeter mattress loops going from one side to the other, across his/her abdomen. During a surveyor interview on 6/25/2025 at 8:26 AM with Nursing Assistants (NA), Staff B, and C, they revealed that they provided morning care on 6/23/2025 at approximately 9:30-10:00 AM and noticed that a sheet was tied to the mattress across the resident's waist. Additionally, Staff B revealed she removed it to provide care and then placed it back on the resident once care was completed. During a surveyor interview on 6/25/2025 at 11:52 AM with NA, Staff D, he revealed that he was the resident's NA on 6/22/2025 during the 11:00 PM-7:00 AM shift. Additionally, he revealed that he did observe the sheet tied to the resident's mattress on both sides going across the resident's abdomen, removed it to provide care, and then put it back in place. He was unaware why it was being used and stated, I've never seen that done before, I do not know why I didn't take it off. I just assumed they wanted it on. Record review failed to reveal evidence of a physician's order for a restraint, an assessment for the use of a restraint, medical symptoms being treated, or interventions attempted prior to the use of a restraint. During a surveyor interview on 6/25/2025 at 11:10 AM with the Director of Nursing Services, she acknowledged that Resident ID #1 was physically restrained. She indicated the facility was actively investigating and could not identify the staff member responsible for tying the sheet to the resident's mattress. Additionally, she acknowledged the overnight staff on 6/22/2025 and the first shift staff 6/23/2025 provided written statements that they removed the bed sheet and then reapplied the bed sheet after providing care to the resident. This failure had the potential to cause more than minimal harm, placing the resident at risk for entrapment, suffocation, strangulation, serious injury, or death. Although Resident ID #1 was cognitively impaired, s/he retained the ability to move independently in bed, which further increased the risk of such adverse outcomes.

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to ensure that a person-centered comprehensive care plan was developed for 1 of 1 resident reviewed for nutr...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that a person-centered comprehensive care plan was developed for 1 of 1 resident reviewed for nutrition where significant weight loss had occurred, Resident ID #3. Findings are as follows: Record review revealed that the resident was originally admitted to the facility in April of 2025, with diagnoses including, but not limited to, end stage renal disease and dysphagia (difficulty swallowing). Record review of a physician's order dated 4/10/2025 revealed a diet order for a mechanical soft, ground texture with nectar thick liquids. Record review of a Care Area Assessment (CAA), dated 4/16/2025 revealed that the resident required a therapeutic and mechanically altered diet. The CAA further revealed that the above was triggered on the Minimum Data Set Assessment and will proceed to the care plan. Record review of the resident's comprehensive care plan failed to reveal evidence of a focused CAA for nutrition, including a person specific approach with descriptive individual resident needs that includes person centered interventions that the facility would implement to assist the resident, including the level of assistance needed. During a surveyor interview on 6/24/2025 at 12:00 PM with the Speech Pathologist, Staff A, she revealed that the resident has been receiving speech services related to his/her diagnosis of dysphagia. She further revealed that the resident was in the process of getting a Modified Barium Swallow test (MBS, a procedure that evaluates swallowing function and identifies potential swallowing disorders) scheduled because s/he does not like the ground texture or thickened liquids and often refuses it. During a surveyor interview on 6/24/2025 at approximately 1:20 PM with the Director of Nursing Services, she revealed that the facility does not currently have a Registered Dietitian (RD) but does have a Corporate Dietician who helps when needed. She further revealed that the facility has not had an RD since approximately March of 2025. During a surveyor interview on 6/25/2025 at approximately 3:00 PM with the Assistant Director of Nursing and the Administrator, they acknowledged that the resident's comprehensive care plan failed to contain a focused care area for nutrition to encompass specific approaches, the resident's individual needs, and specific interventions. Cross reference F 692, F 698

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

**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 maintain acceptable parameters of...

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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 maintain acceptable parameters of nutritional status, such as usual body weight, for 1 of 1 resident reviewed, who experienced actual weight loss, Resident ID #3. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 6/19/2025 alleges that the resident is a dialysis patient and when s/he arrived for treatment s/he had an uncovered bleeding wound to his/her elbow and that s/he had severe malnutrition per the dialysis's Registered Dietician (RD). The RD at the dialysis center noted severe wasting of the thigh and calf muscles, which worsened since the last treatment. Additionally, the report alleges that the resident stated, .[s/he] was not being cared for .[s/he] is not being given protein supplements that the RD had requested . During a surveyor interview on 6/24/2025 at 10:51 AM with the complainant and the dialysis center's RD they revealed that their team had attempted to contact the nursing facility regarding the resident's weight loss for 3 weeks. Additionally, she revealed that they did speak with the facility on 6/19/2025 to express their concerns but on 6/22/2025 the resident appeared lethargic and severely malnourished. Additionally, they revealed that the facility does not communicate weight loss, or falls and the communication sheets provided just state, routine dialysis. Record review of a facility's policy titled, WEIGHTS states in part, .Weight [sic] are documented in the resident's/patient's medical record and/or the weight book. If a significant weight loss/gain is identified (>[greater than] 5% in 30 days or >10% in 6 months), the IDT [Interdisciplinary Team], dietician, physician and family are notified. All residents with a significant weight loss are reviewed by the interdisciplinary team and the resident/responsible party and interventions implemented as appropriate and are monitored weekly . Record review revealed that Resident ID #3 was originally admitted to the facility in April of 2025, with diagnoses including, but not limited to, end stage renal disease and dysphagia (difficulty swallowing). Record review of a physician's order dated 4/10/2025 revealed a diet order for a mechanical soft, ground texture with nectar thick liquids. Further record review revealed the s/he was hospitalized from [DATE]-[DATE], related to a fall resulting in a left ankle fracture and left thumb fracture. Additionally, the resident was hospitalized on [DATE] with a diagnosis of left arm pain and mitral valve vegetation (an abnormal growth on the mitral valve, often resulting from an infection of the heart valves and the inner lining of the heart chambers) and failure to thrive. Record review revealed the following weights: -5/23/2025 155.1 pounds (lbs.) -5/25/2025 154.4 lbs -6/1/2025 144.7 lbs -6/21/2025 145.4 lbs Record review revealed the resident experienced a 6.25% (9.7 lbs.) significant weight loss in one month from 5/23/2025 to 6/1/2025. Further record review failed to reveal evidence that a reweigh was obtained or the weight loss was reported to the provider on 6/1/2025 or 6/21/2025. Record review of a nursing progress note dated 6/17/2025 states in part, Resident refused dinner, and the assigned CNA (certified nurses aid) reported that [s/he] has been refusing for some time now . Record review of a progress note dated 6/19/2025 authored by the social worker revealed that the facility received a call from the dialysis center, and they had concerns with the resident's declining health and dietary concerns. Record review of a nursing progress note dated 6/20/2025 revealed new orders to start weekly weights, labs, a gastroenterologist consult related to weight loss, decreased appetite and failure to thrive. During a surveyor interview on 6/24/2025 at 12:23 PM with the resident's Nurse Practitioner, she revealed that she was not aware of the above stated resident's weights obtained by the facility and initiated orders related to the dialysis center's concerns. She further revealed that if a resident experiences a significant weight loss, she would have expected the facility to notify her immediately after the weight was obtained on 6/1/2025 and interventions could have been implemented prior to 6/19/2025. During a surveyor interview on 6/24/2025 at approximately 1:20 PM with the Director of Nursing Services, she revealed that the facility does not currently have a Registered Dietitian (RD) but does have a Corporate Dietician who helps when needed. She further revealed that the facility has not had an RD since approximately March of 2025. During a surveyor interview on 6/25/2025 at 2:58 PM with the Assistant Director of Nursing Services, she acknowledged that there was not a reweigh obtained after the weight loss was identified and could not provide evidence that the provider was notified. Cross reference F 656 and F 698

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 F0697 (Tag F0697)

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 adequate pain managem...

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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 adequate pain management was provided to a resident who required such services, consistent with professional standards of practice, and the resident's goals and preferences for 1 of 1 resident reviewed for pain, Resident ID #4. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 6/18/2025 alleged in part that Resident ID #4 was discharged from a hospital and admitted to the facility on [DATE]. S/he returned to the hospital on 6/18/2025 because s/he did not receive his/her medications as prescribed. S/he alleges that s/he waited approximately 5.5 hours and then was informed s/he was already given them and then later told that the facility did not order them from the pharmacy. Record review revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, left knee osteomyelitis (an infection in the bone) and a sacral pressure ulcer (also known as bedsore). Review of a hospital document titled, Continuity of Care (COC) - Post-Acute Facility dated 6/16/2025 states in part, .Pain plan .Dilaudid [hydromorphone, an opioid pain medication] 4 milligrams (MG) every 4 hours for moderate to severe pain .Dilaudid 4 MG once daily as needed for break through . Review of a physician's order dated 6/16/2025 revealed to administer hydromorphone 4 MG every 24 hours as needed (PRN) for breakthrough pain. Review of an additional physician's order dated 6/16/2025 revealed to administer hydromorphone 4 MG every 4 hours PRN for pain. Further record review revealed that this order was discontinued on 6/17/2025 at 9:05 PM, indicating that this resident has one PRN hydromorphone order daily. Review of a Nurse Practitioner's note dated 6/18/2025 at 2:23 AM states in part, .the nurse called .to notify us that the patient called 911 and got transferred to the hospital for pain. The patient has an order for hydromorphone 4 MG TAB Q24H [every 24 hours], [s/he] had one at 1745 [5:45 PM] on 6/17/2025. [S/he] requested another this morning and when told it was not due, [s/he] called EMS [Emergency Medical Services] and transferred .Patient not seen .already out of building before we were contacted . Review of a nursing note dated 6/18/2025 at 5:44 AM states in part, .Resident asked this writer for PRN hydromorphone around 0030 [12:30 AM] this morning. At this time resident had only an order to give hydromorphone 4 MG 1 Tab/daily and the medication was not due when the resident was asking for it. Resident said, [s/he] should have had the medication every 4 hours as needed but this order was D/C [discontinued]. Resident was very mad and decided to call 911 . Review of the June 2025 Medication Administration Record (MAR) revealed that the resident received 4 MG of hydromorphone on the following dates and times: 6/16/2025 at 9:30 PM for complaints of 10 out of 10 pain 6/17/2025 at 2:00 AM for complaints of 8 out of 10 pain 6/17/2025 at 9:40 AM for complaints of 8 out of 10 pain 6/17/2025 at 5:30 PM for complaints of 10 out of 10 pain During a surveyor interview on 6/25/2025 at 1:11 PM with Registered Nurse, Staff E, he revealed that when reviewing the resident's orders there was only a PRN daily hydromorphone order. He was not aware of the discontinued order until after the resident had left the facility. He further revealed he did not know why the order for hydromorphone every 4 hours PRN was discontinued. During a surveyor interview on 6/25/2025 at 2:41 PM with the Nurse Practitioner, she revealed that she spoke with the resident on 6/17/2025 to address his/her concerns regarding pain management and verified that s/he had both orders in place for pain management. Additionally, she revealed that if the resident had received the 4 MG of hydromorphone initially for his/her severe pain, his/her pain may have been better controlled, and s/he may not have required transport to the hospital for pain management. Further, she revealed that it would have been her expectation for the nurse to call the on-call provider to report the resident's pain and receive an order at that time. During a surveyor interview on 6/25/2025 at 2:58 PM with the Assistant Director of Nursing Services, she revealed that the order for hydromorphone 4 MG every 4 hours PRN for pain was discontinued in error. Additionally, she was unaware if the nurse attempted to call the on-call provider prior to the resident going to the emergency room.

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 F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a treatment that removes excess fluid, waste, and toxins from...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a treatment that removes excess fluid, waste, and toxins from the blood when the kidneys are no longer functioning properly) receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident reviewed for communication with the dialysis center, Resident ID #3. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 6/19/2025 alleges that the resident is a dialysis patient and when s/he arrived for treatment s/he had an uncovered bleeding wound to his/her elbow and that s/he had severe malnutrition per the Registered Dietitian (RD). The RD a the dialysis facility noted severe wasting of the quadriceps and calf muscles, which worsened since last treatment. Additionally, the report alleges that the resident stated, .[s/he] was not being cared for .[s/he] is not being given protein supplements that the RD had requested . Review of a facility policy titled, Hemodialysis, states in part, .Communication between the facility and the hemodialysis center will occur using a communication book/sheet that consist of .Any change of condition from last hemodialysis treatment .changes in weight, medications .behaviors .falls .Documentation will be completed prior to dialysis treatment . During a surveyor interview on 6/24/2025 at 10:51 AM with the complainant and the dialysis center's RD they revealed that their team had been trying to contact the nursing facility regarding the resident's weight loss for 3 weeks. Additionally, she revealed that they did speak with the facility on 6/19/2025 to express their concerns but on 6/22/2025 the resident appeared lethargic and severely malnourished. Additionally, they revealed that the facility does not communicate weight loss, or falls and communication sheets just state, routine dialysis. Record review revealed that Resident ID #3 was originally admitted to the facility in April of 2025, with diagnoses including, but not limited to, end stage renal disease and failure to thrive. Record review revealed that the resident attends dialysis three times a week on Tuesday, Thursday, and Saturday. Record review revealed that the resident had an unwitnessed fall on 5/27/2025. Further record review revealed the resident experienced a 6.25% (9.7 pounds.) significant weight loss in one month, from 5/23/2025 to 6/1/2025. Review of the communication binder and communication sheets for May and June of 2025 and the medical record, failed to reveal evidence that the resident's significant weight loss or the fall that occurred on 5/27/2025, were communicated to the dialysis center. During a surveyor interview on 6/24/2025 at 1:48 PM, with the Director of Nursing Services, she acknowledged that the resident's communication binder, communication sheets, and the medical record failed to reveal evidence that the facility notified the dialysis center of the resident's fall or of the significant weight loss. Cross reference F 656 and F 692

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, and resident and staff interviews, it has been determined that the facility failed to maintain a ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, and resident and staff interviews, it has been determined that the facility failed to maintain a safe temperature range of 71 to 81 degrees Fahrenheit (°F) in the facility as the 5th floor of the facility reached a temperature of 88 °F and the 3rd floor reached a temperature of 85 °F. Findings are as follows: Record review of a facility policy titled, HOT WEATHER EMERGENCY FAILURE OF AIR CONDITIONER states in part, .If the ambient air temperatures in resident areas are 82 degrees or higher, all personnel within the facility will be assigned duties aimed at reducing the exposure and/or effects of excessive heat and humidity. Room changes will be made necessary to decrease danger to fragile residents . Record review of two community reported complaints received by the Rhode Island Department of Health on 6/24/2025 alleged that the facility has no air conditioning. Record review revealed that the weather in Providence, Rhode Island on 6/25/2025 was 93°F. During surveyor observations of the facility on 6/25/2025 the facility was noted to be uncomfortably warm. During a surveyor observation od Resident ID #2 on 6/25/2025 at 10:50 AM, he/she was seen exiting his/her room and appeared to be breathing heavily. S/he told a staff member that it's too hot in here and my air conditioner is broken. The surveyor observed the resident's face to be red, he/she was perspiring and his/her shirt was wet. After this observation the surveyor immediately went to notify the Administrator of her findings. During a surveyor observation on 6/25/2025 at 11:08 AM, in the presence of the Administrator of the 5th floor dining room, the temperature registered at 86 °F. The facility was not aware of the temperature until it was brought to their attention by the surveyor. During a surveyor interview on 6/25/2025 at 11:14 AM with Resident ID #2 s/he stated that s/he felt that they were going to die of heat stroke. S/he further revealed that the air conditioning in their room was not working and reported this to the facility staff multiple times. Record review of a document dated 6/22/2025 in the maintenance log located at the 5th floor nurses station revealed that Resident ID #2 reported that his/her air conditioner was not working. Ambient temperature readings of the facility on 6/25/2025 at 12:55 PM, in the presence of the acting Maintenance Director, revealed the following: - 5th floor Dining room: 88 °F - 5th floor Resident room [ROOM NUMBER]: 86 °F - 5th floor Common area: 82 °F - 3rd floor Dining room: 84 °F - 3rd floor Common Areas: 82 °-85 °F During a subsequent interview with the acting Maintenance Director, in the presence of the Administrator, he revealed that the air conditioning units were too small for the area and would require industrial fans to help circulate the cold air. Additionally, he acknowledged that the above temperatures exceeded 82 °F. This failure had the potential to cause more than minimal harm as the residents were at risk for dehydration, heat exhaustion, injury, or death.

May 2025 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure tha...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the resident's environment remained as free of accident hazards as possible for 1 of 1 resident reviewed, who sustained a fall with injury from a shower chair that broke when staff attempted to pull the shower chair into the shower stall, resulting in fractured ribs and an admission to the Trauma Intensive Care Unit (TICU), Resident ID #4. Findings are as follows: Review of a facilty reported incident submitted to the Rhode Island Department of Health on 5/8/2025 revealed the resident had a fall and was sent to the Emergency Department (ED) for an evaluation and was admitted to the hospital with fractured ribs. Review of a community reported complaint submitted to the Rhode Island Department of Health on 5/13/2025 alleged a Nursing Assistant (NA) was attempting to shower Resident ID #4 when the shower chair broke and the resident fell to the floor. Record review revealed Resident ID #4 was admitted to the facility in July of 2021 with a diagnosis including, but not limited to, a history of falls with fractures. Record review of an Annual Minimum Data Set assessment dated [DATE], revealed the resident is dependent on staff for showers, personal hygiene, and bed mobility. Record review of a care plan last updated on 3/22/2024 revealed the resident is at risk for falls related to decreased endurance and strength, impaired sense of balance and unsteady gait. Additionally, the resident requires the assistance of two staff members for transfers. Review of a progress note dated 5/8/2025 at 10:00 AM, revealed the resident had a fall and was sent to the ED for an evaluation and was admitted to the hospital with rib fractures. Record review of a hospital document titled, ED To Hospital Admission dated 5/7/2025 at 2:49 PM, indicated that a NA was attempting to help the resident shower when the chair gave way, and the resident fell to the ground. The report also revealed the resident denied hitting his/her head, but complained of right-sided chest wall tenderness. Further review of the ED documentation revealed a physician's note dated 5/7/2025 at 8:11 PM stating Panscan [a term used to describe full-body imaging] notable for rib fractures .We've consulted trauma and spine team. Anticipate TICU admit. Review of the facility's investigation revealed statements from staff indicating that the front wheels of the shower chair lifted off the ground when NA, Staff A, attempted to pull the resident into the shower stall backwards. The chair tipped backwards, and Staff A was unable to lift the resident back up, so she lowered the resident to the ground and simultaneously, the back of the chair snapped in half. Additionally, statements indicated that no visible injuries were observed but that the resident complained of pain afterwards. During a surveyor observation of the 5th floor shower room in the presence of the Director of Nursing Services (DNS), on 5/14/2025 at approximately 10:30 AM, revealed the entrance into the shower stall had a pronounced incline/ramp with an approximate four inch rise over a short distance angled at approximately 45 degrees leading into the shower stall. Review of the manufactures manual for the shower chair last revised in January 2008 revealed the following: -Never allow the user to lean outside the frame of the equipment -Never allow the user to suddenly shift weight in any way creating a tipping hazard for the user and the equipment -Do not use this equipment on an incline, always make sure all casters are in constant contact with the flooring surface -The improper use of this equipment or failure to comply with all directions and warnings may result in death or injury During a surveyor interview on 5/14/2025 at 10:46 AM with Staff A, she indicated that on 5/7/2025 at approximately 10:00 AM, she, and NA, Staff B, assisted the resident from the hoyer lift (a mechanical device designed to assist caregivers in safely transferring residents or individuals with limited mobility) to the shower chair and then Staff B left with the hoyer. Staff A indicated that she could not pull the shower chair over the pronounced incline into the shower stall and so she attempted to pull the resident into the shower stall backwards in the chair, and that's when the chair started to tip. Staff A indicated that she was unable to lift the resident back up because of his/her weight, so she lowered the resident to the ground backwards and the back of the chair snapped in half on the way down and the resident fell to the floor. During a surveyor interview on 5/14/2025 at approximately 12:20 PM with the DNS, she acknowledged that the resident experienced an accident that resulted in physical injury from the result of Staff A's attempt to pull the resident in a shower chair up an incline into the shower shall.

Mar 2025 9 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

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 residents with the right to personal privacy and confidentiality of his/he...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide residents with the right to personal privacy and confidentiality of his/her personal and medical records relative to the posting of past survey results. Findings are as follows: During a surveyor observation of the main lobby area on 3/12/2025 at 2:16 PM, revealed a Survey History Binder. Record review of the Survey History Binder revealed copies of previous surveys including the resident/staff rosters which contain identifying information of residents from the following survey dates: - Resident/Staff Roster form dated 4/12/2022 with one resident identified. - Resident/Staff Roster form dated 6/14/2022 with one resident identified. - Resident/Staff Roster form dated 7/18/2022 with four residents identified. - Resident/Staff Roster form dated 7/27/2022 with one resident identified. - Resident/Staff Roster form dated 8/11/2022 with three residents identified. - Resident/Staff Roster form dated 8/30/2022 with two residents identified. - Resident/Staff Roster form dated 10/24/2022 with three residents identified. - Resident/Staff Roster form dated 1/18/2023 with six residents identified. - Resident/Staff Roster form dated 1/25/2023 with two residents identified. - Resident/Staff Roster form dated 1/17/2025 with one resident identified. During a surveyor interview on 3/11/2025 at 3:46 PM with the Administrator, he was unable to provide evidence that the facility protected the identifying information of the 21 residents listed in the survey results binder.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure residents who are fed through a feeding tube receive the appropriate treatme...

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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure residents who are fed through a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed for a continuous feeding via a gastrostomy tube (G-tube, a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine), Resident ID #102. Findings are as follows: Review of a facility policy titled Enteral Feeding [feeding provided via an alternative method via a G-tube] states in part, .Check physician order for formula, rate and water flushes . Record review revealed that Resident ID #102 was readmitted to the facility in January of 2025, with a diagnosis including, but not limited to, gastrostomy status. Record review revealed a progress note authored by the dietitian, dated 3/10/2025 at 3:38 PM, which revealed that the resident's weight has trended down since last review. It further revealed that the resident is currently on Jevity 1.2 cal (calorically dense, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding; provides 1.2 calories per milliliter) until Jevity 1.5 cal (provides 1.5 calories per millileter) is available. Additionally, due to weight loss, the residents current tube feed is changed to Jevity 1.2 cal at 75 milliliters (mL) /per hour (hr) and to flush the G-tube with 235 mL of water every shift until the Jevity 1.5 is available. Record review revealed a physician's order dated 3/10/2025 to administer Jevity 1.2 cal via feeding pump at 75 mL/hr continuously. Record review revealed a physician's order dated 3/10/2025 to flush the G-tube with 235 mL of water every shift. During a surveyor observation on 3/11/2025 at 11:50 AM, revealed the resident was receiving Jevity 1.2 cal at 60 mL/hr dated 3/11/2025, with a water flush rate of 350 mL per shift. Additionally, the observation revealed the water flush bag was empty, the tubing door to the feeding tube pump was open, and the screen was flashing a visible alarm. During a surveyor interview and simultaneous observation on 3/11/2025 at 11:54 AM with Registered Nurse, Staff A, she acknowledged that the resident's Jevity 1.2 should be running at 75 mL/hr with a water flush rate of 235 mL and not the 60 mL/hr with a water flush rate of 350 mL that the resident was currently receiving. Furthermore, she acknowledged that the water flush bag was empty, the tubing door to the feeding tube pump was open, and the screen was flashing a visible alarm. During a surveyor interview on 3/11/2025 at 12:05 PM, with the Director of Nursing Services, she revealed that she would expect that Resident ID #102's G-tube feeding and flush to be administered at the ordered rate. During a surveyor interview on 3/13/2025 at 2:22 PM with the Nurse Practitioner, he revealed that he would expect the G-tube feeding and flush to be administered at the ordered rate.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0710 (Tag F0710)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to ensure the medical care of each resident is supervised by a physician for 1 of 1 resident reviewed for si...

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Based on record review and staff interview, it has been determined that the facility failed to ensure the medical care of each resident is supervised by a physician for 1 of 1 resident reviewed for significant weight loss, Resident ID #28. Findings are as follows: Record review of a facility's policy titled, WEIGHTS states in part, .Weight [sic] are documented in the resident's/patient's medical record and/or the weight book. If a significant weight loss/gain is identified (>[greater than] 5% in 30 days or >10% in 6 months), the IDT [interdisciplinary Team], dietician, physician and family are notified. All residents with a significant weight loss are reviewed by the interdisciplinary team and the resident/responsible party and interventions implemented as appropriate and are monitored weekly . Record review revealed that Resident ID #28 was readmitted to the facility in September of 2024, with diagnoses including, but not limited to, dementia and dysphagia (difficulty swallowing). Review of a care plan last revised on 1/30/2025 revealed, the resident is at risk for malnutrition due to dementia and a history of dysphagia. Record review for the resident revealed a weight of 166.9 pounds (lbs.) on 2/1/2025 and a weight of 152.1 lbs. on 3/1/2025, indicating that the resident had an 8.87% weight loss (-14.8 lbs.) in 30 days. Further record review revealed a weight of 175.1 lbs. on 9/3/2024 indicating that the resident had an 13.14% weight loss (-23 lbs.) in six months. Record review failed to reveal evidence that the physician or nurse practitioner (NP) was notified of the significant weight loss. During a surveyor interview on 3/13/2025 at 11:58 AM with the Director of Nursing Services, she revealed that when a resident experiences a significant weight loss her expectation would be for the dietician to notify the physician or NP. She was unable to provide evidence that the physician was notified about the above-mentioned resident's weight loss. During a telephone interview on 3/13/2025 at 12:23 PM with the resident's NP, he revealed that he was not aware of the above resident's weight loss. He further revealed that if a resident experiences a significant weight loss, he would expect the facility dietitian to notify him.

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 surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that medical records are accurately documented for 2 of 3 residents reviewed...

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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that medical records are accurately documented for 2 of 3 residents reviewed for enhanced barrier precautions (EBP - refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities), Resident ID #s 13 and 217. Findings are as follows: 1. Record review revealed Resident ID #13 was admitted to the facility in January of 2025 with a diagnosis including, but not limited to, congestive heart failure. Record review revealed a physician's order dated 2/3/2025 for EBP, related to his/her wounds. Review of the February 2025 Medication Administration Record (MAR) revealed the EBP order was signed off as completed from 2/3 - 2/28/2025. Review of the March 2025 MAR revealed the EBP order was signed off as completed from 3/1 - 3/12/2025. Record review revealed the resident had a wound which was resolved on 2/13/2025. Surveyor observations on 3/10, 3/11 and 3/12/2025, failed to reveal signage posted outside of the resident's room indicating that s/he was on EBP. During a surveyor interview on 3/12/2025 at 12:32 PM with the Director of Nursing Services (DNS), she revealed that she would have expected the EBP order to have been discontinued when his/her wound was resolved, or that staff would document not applicable, as the resident was no longer on EBP. 2. Record review revealed Resident ID #217 was admitted to the facility in February of 2025 with a diagnosis including, but not limited to, personal history of Methicillin Resistant Staphylococcus Aureus (MRSA - a multi drug resistant organism). Record review revealed two physician's orders with a start dates of 2/26/2025 and 2/27/2025, for EBP, related to his/her history of MRSA. Review of the March 2025 MAR revealed the EBP orders were signed off as completed from 3/1 - 3/12/2025. Surveyor observations on 3/10, 3/11 and 3/12/2025, failed to reveal signage posted outside of the resident's room indicating that s/he was on EBP. During a surveyor interview on 3/12/2025 at 11:07 AM with Registered Nurse, Staff A, she acknowledged that the resident was not on EBP. She further acknowledged that there was a physician's order for EBP, and it was not being followed. During a surveyor interview on 3/12/2025 at 12:30 PM, with the DNS, she revealed that she would expect for there to be EBP signage and a bin containing personal protective equipment (PPE) located outside of the resident's room. She further revealed that she would expect nurses to verify that there is EBP signage, and a PPE bin, located outside of the resident's room before signing off the order in the MAR.

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 maintain an infection prevention and control program to help prevent the transmiss...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to enhanced barrier precautions (EBP- refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and glove use during high contact resident care activities), for 1 of 3 residents reviewed with a history of Methicillin-Resistant Staphylococcus Aureus (MRSA), Resident ID #217. Findings are as follows: Review of a facility policy titled, Enhanced Barrier Precautions Policy states in part, .It is the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms .important MDROs may include, but are not limited to: Methicillin-resistant Staphylococcus aureus (MRSA) .Enhanced barrier precautions require the use of a gown and gloves for certain residents during specific high-contact resident care activities in which there is an increased risk of transmission for multidrug-resistant organisms. High-contact resident care activities include bathing/showering, providing hygiene, dressing, transferring, linen changes, toileting .Signage will be posted on the door or the wall outside of the resident's room indicating the need for enhanced barrier precautions, the required personal protective equipment (PPE) .Carts with appropriate PPE will be placed outside the resident's room . Record review revealed Resident ID #217 was admitted to the facility in February of 2025 with a diagnosis including, but not limited to, personal history of MRSA. Record review of a hospital document titled, Continuity of Care- Post-Acute Facility, dated 2/26/2025, revealed that the resident tested positive for MRSA with an onset date of 10/15/2022. Record review of a physician's order dated 2/27/2025, revealed an order for EBP related to a history of MRSA. Record review of the March 2025 Medication Administration Record revealed the above order was signed off as completed from 3/1 - 3/12/2025, during all three shifts. Surveyor observations on 3/10, 3/11 and 3/12/2025, failed to reveal signage posted outside of the resident's room indicating that s/he was on EBP. During a surveyor interview on 3/12/2025 at 11:07 AM with Registered Nurse, Staff A, she acknowledged that the resident was not on EBP. She further acknowledged that there was a physician's order for EBP, and it was not being followed. During a surveyor observation and interview on 3/12/2025 at 12:13 PM, with the Infection Preventionist, she acknowledged that there was no signage posted for EBP on the resident's door or a bin containing PPE outside of the resident's room. She further revealed that the resident should be on EBP related to a history of MRSA, as ordered.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected multiple residents

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a treatment that removes excess fluid, waste, and toxins from...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a treatment that removes excess fluid, waste, and toxins from the blood when the kidneys are no longer functioning properly) receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 2 residents reviewed for fluid management, Resident ID #s 42 and 51, and for 2 of 3 residents reviewed for communication with the dialysis center, for Resident ID #s 42 and 79. Findings are as follows: 1. Review of a facility policy titled Hemodialysis, states in part, .Fluid Balance .If resident/patient is placed on fluid restriction, monitor intake . 1a. Record review revealed that Resident ID #42 was admitted to the facility in January of 2025, with a diagnosis including, but not limited to, end stage renal disease (ESRD). Record review for Resident ID #42 revealed that s/he receives dialysis three times a week. Record review revealed a physician's order with a start date of 2/11/2025 for a 1200 milliliter (mL) fluid restriction per day. Review of Resident ID #42's care plan dated 1/6/2025, revealed that the resident has a potential for impaired nutrition status due to a diagnosis of ESRD, with an intervention which includes, but is not limited to, document percent of fluids consumed. Record review for Resident ID #42, failed to reveal evidence of the amount of fluids the resident consumes in a day or the percent of fluids consumed per the physicians order and care plan. During a surveyor interview on 3/13/2025 at 9:05 AM, with Registered Nurse (RN), Staff B, she acknowledged that the resident has an order for a fluid restriction. Additionally, she revealed that the Nursing Assistants (NAs) would document that. She revealed that she was unable to find evidence under the NA's documentation and that the facility does not have a paper tracker for fluid intake. 1b. Record review revealed that Resident ID #51 was admitted to the facility in March of 2021, with a diagnosis including, but not limited to, dependence on renal dialysis. Record review revealed that Resident ID #51, receives dialysis three times a week. Record review revealed a physician's order with a start date of 12/23/2024, for a 1500 mL fluid restriction per day and to document the resident's intake on the intake and output sheet. Review of Resident ID #51's care plan dated 9/1/2023, revealed that the resident has a potential for impaired nutrition status due to a diagnosis of chronic kidney disease, with an intervention that includes, but is not limited to, document the percent of fluids consumed. Record review for Resident ID #51 failed to reveal evidence of the amount of fluids the resident consumes in a day or the percent of fluids consumed per the physicians order and care plan. During a surveyor interview on 3/12/2025 at 11:34 AM, with Licensed Practical Nurse, Staff C, she acknowledged that Resident ID #51 has a physician's order for a 1500 mL fluid restriction per day and to document the resident's intake on the intake and output sheet. Additionally, she revealed that there is no paper documentation for intake and output for fluids. During a surveyor interview on 3/13/2025 at 9:11 AM, with the Assistant Director of Nursing (ADNS), she revealed that she is responsible for the over site of the dialysis residents. She revealed that there is no paper tracker for fluid documentation. Additionally, she revealed that the documentation completed by the NAs does not include fluid documentation. Furthermore, she revealed that the facility was not tracking the amount of fluid each resident consumes, and that the facility needs to put something in place. During surveyor interviews on 3/13/2025 at 9:37 AM and 10:41 AM, with the Director of Nursing Services (DNS), she acknowledged that Resident ID #42 and 51's records failed to reveal the amount of fluid or the percentage of fluid the residents are consuming in a day, per the facility policy or resident care plan. Furthermore, she was unable to provide evidence the facility is ensuring that Resident ID #'s 42 and 51's fluid restrictions are being followed as ordered. 2. Review of a facility policy titled Hemodialysis, states in part, .Communication between the facility and the hemodialysis center will occur using a communication book/sheet that consist of .Any change of condition from last hemodialysis treatment .changes in weight, medications .behaviors .falls .Documentation will be completed prior to dialysis treatment . 2a. Record review revealed that Resident ID #42 was admitted to the facility in January of 2025, with a diagnosis including, but not limited to, ESRD. Record review revealed that Resident ID #42, attends dialysis three times a week on Monday, Wednesday, and Friday. Review of the February 2025 Medication Administration Record (MAR), revealed that the resident refused his/her medications on the following dates: - 2/1 - 2/13 - 2/14 - 2/15 - 2/16 - 2/17 - 2/18 - 2/20 - 2/22 - 2/23 - 2/25 - 2/27 Review of the March 2025 MAR, revealed that the resident refused his/her medications on the following dates: - 3/1 - 3/2 - 3/3 - 3/4 - 3/6 - 3/7 - 3/8 - 3/9 - 3/10 - 3/11 Review of the communication binder and communication sheets, for February and March of 2025, and record, failed to reveal evidence that the resident's refusal of medication was communicated to the dialysis center for the above-mentioned dates. Further record review revealed that Resident ID #42 had an unwitnessed fall on 1/23/2025. Review of the communication binder, communication sheets, and record failed to reveal evidence that the facility notified the dialysis center of the resident's fall. During a surveyor interview on 3/13/2025 at 8:59 AM, with RN, Staff B, she revealed that Resident ID #42 refuses his/her medication frequently and sustained a fall on 1/23/2025. Additionally, she revealed that it is the facility's practice to notify the physicians, the nurse practitioner and the resident's family. Furthermore, she was unaware that the facility policy states to notify the dialysis center with changes such as behaviors, medications, or falls. 2b. Record review revealed that Resident ID #79 was admitted to the facility in December of 2024, with a diagnosis including, but not limited to, dependence on renal dialysis. Record review revealed that Resident ID #79 attends dialysis on Tuesday, Thursday, and Saturday. Record review revealed that Resident ID #79 had a fall on 2/27/2025. Review of the communication binder, communication sheets, and record failed to reveal evidence that the facility notified the dialysis center of the resident's fall. During a surveyor interview on 3/13/2025 at 10:26 AM, with RN, Staff D, she acknowledged that Resident ID #79 had a fall on 2/27/2025. Additionally, she revealed that it was not the facility's practice to notify outside providers of a resident fall. Furthermore, she acknowledged that the dialysis center was not notified that Resident ID #79 fell. During a surveyor interview on 3/13/2025 at 9:11 AM, with the ADNS, she revealed that the facility does not notify the dialysis center when a resident falls. Furthermore, she revealed that she was unaware if the staff notified the dialysis center of medication refusals for Resident ID #42. During surveyor interviews on 3/13/2025 at 9:37 AM and 10:41 AM, with the DNS, she acknowledged that Resident ID #42 and 51's, communication binder, communication sheets, and records failed to reveal evidence that the facility notified the dialysis center of the resident's fall. Additionally, she acknowledged that the communication binder, communication sheets, and medical record failed to reveal evidence that the facility notified the dialysis center of Resident ID #42's medication refusals. Furthermore, she revealed that she was unaware that the facility had to notify the dialysis center of a fall, although the facility policy states to do so.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected multiple residents

Based on record review and staff interview, it has been determined that the facility failed to complete an annual performance review for every nurse aide (NA), at least once every 12 months, for 6 of ...

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Based on record review and staff interview, it has been determined that the facility failed to complete an annual performance review for every nurse aide (NA), at least once every 12 months, for 6 of 6 NA personnel records reviewed, Staff E, F, G, H, I and J. Findings are as follows: Record review of the personnel records failed to reveal evidence that an annual performance evaluation was completed for the following NA's: -Staff E, hired in March of 2015 -Staff F, hired in November of 2011 -Staff G, hired in August of 2022 -Staff H, hired in February of 2020 -Staff I, hired in August of 2023 -Staff J, hired in October of 2023 During a surveyor interview with the Director of Nursing Services on 3/13/2025 at 12:41 PM, she was unable to provide evidence that performance evaluations were completed to their entirety for Staff E, F, G, H, I and J within the last 12 months.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected multiple residents

Based on record review and surveyor interview, it has been determined that the facility failed to ensure the QAPI/QAA (quality assurance performance improvement/quality assessment and assurance) commi...

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Based on record review and surveyor interview, it has been determined that the facility failed to ensure the QAPI/QAA (quality assurance performance improvement/quality assessment and assurance) committee includes the required committee members consisting at a minimum of, the Director of Nursing Services (DNS), the Medical Director, Infection Preventionist and at least three other members of the facility staff. Findings are as follows: Review of a policy titled Policy & Procedure Manual Quality Assessment and Assurance Committee states in part, .The Committee will be composed of staff who understand the characteristics and complexities of the care and services delivered in each unit and/or department. The QAA committee will be composed of, at a minimum .The Director of Nursing or Assistant Director of Nursing .The Infection Preventionist .The infection preventionist must be a member of the QAA committee and report to the committee on the infection prevention and control program . Record review revealed the QAPI/QAA committee met on the following dates in 2024/2025: - 4/11/2024 - 7/24/2024 - 10/16/2024 - 1/15/2025 Review of the QAPI/QAA committee sign in sheet dated 4/11/2024 failed to reveal evidence that the Infection Preventionist attended the meeting. Review of the QAPI/QAA committee sign in sheet dated 10/15/2024 failed to reveal evidence that the Infection Preventionist or the DNS attended the meeting. Review of the QAPI/QAA committee sign in sheet dated 1/15/2025 failed to reveal evidence that the Infection Preventionist or the DNS attended the meeting. During a surveyor interview on 3/13/2025 at approximately 10:00 AM, with the Administrator, he was unable to provide evidence that the Infection Preventionist and DNS were in attendance for all of the above mentioned QAPI/QAA committee meetings.

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 and distributed in accordance with professional standar...

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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 and distributed in accordance with professional standards for food service safety, relative to the main kitchen and 3 of 3 kitchenettes observed. Findings are as follows: 1. Record review of Rhode Island Food Code, 2018 Edition, Section 3-501.17 states in part, .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and 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 less for a maximum of 7 days. The day of preparation shall be counted as Day 1 . During the initial tour of the main kitchen's walk in coolers in the presence of a Cook, Staff K on 3/10/2025 at 8:15 AM, revealed the following: - eight turkey and cheese sandwiches on white bread without a label or date - three sheet pans approximately 15 inches () x 21 full of cooked sausage links without a label or date - three baking pans approximately 12 x 10, containing white cakes without a label or date - one 4 deep, stainless steel steam table pan filled with unidentified gelatinous yellow liquid without a label or date - a pack of American cheese wrapped in plastic wrap approximately 1 thick without a label or date During a surveyor interview following the above observations with Staff K, he acknowledged that the above mentioned items should have been labeled and dated per regulations. 2. Record review of facility policy titled Use & Storage of Food Brought in By Family or Visitors states in part, .the facility may refrigerate, label and date prepared items in the nourishment refrigerator .If not consumed within 3 days, food will be thrown away by facility staff . During a surveyor observation of the 2nd floor kitchenette on 3/10/2025 at approximately 8:50 AM in the presence of Certified Medication Technician, Staff L, the following was revealed: - one large round covered plastic container, approximately 2 quarts in size filled with chili, without a label or date - one large square covered plastic container, filled with an unidentified food, without a label or date - one rectangular covered plastic container, filled with an unidentified food, without a label or date - one black plastic bag without a label, dated 3/1/2025, containing a covered plastic container approximately 2 quarts in size. During a surveyor interview immediately following observations of the 2nd floor kitchenette with Staff L, she acknowledged the above-mentioned items should have been labeled, dated or discarded as indicated per the facility policy. During a surveyor observation of the 4th floor kitchenette on 3/10/2025 at approximately 9:05 AM in the presence of Nursing Assistant, Staff E, the following was revealed: - one 12-ounce (oz) container of crab salad, without a label or date - one round container approximately 32 oz containing cut watermelon, without a label or date - one square container approximately 4 oz containing cut fruit, without a label or date During a surveyor interview immediately following the observations of the 4th floor kitchenette with Staff E, she acknowledged the above-mentioned items should have been labeled, dated or discarded as indicated per the facility policy. During a surveyor observation of the 5th floor kitchenette on 3/10/2025 at approximately 9:20 AM in the presence of the Administrator, the following was revealed: - one black covered, multi compartment rectangular to go container containing taco meat, shredded cheese, and a hard taco shell, without a label or date - one small plastic bag of lettuce and diced, partially liquefied, without a label and date - one container with a yellow lid, approximately 4 oz containing sour cream, without a label and date - one round container with a red lid, approximately 32 oz with cut up cucumbers, without a label or date - one 12 oz container labeled cod fish salad, without a date - one black to-go container approximately 6 x 9 containing an unidentified food, without a label or date - one black to-go container approximately 6 x 9 containing cooked rice, without a label or date During a surveyor interview immediately following the observation of the 5th floor kitchenette with the Administrator, he acknowledged the above-mentioned items should have been labeled, dated or discarded as indicated per the facility policy. During a surveyor interview on 3/10/2025 with the Food Service Director at 2:25 PM, he acknowledged that all of the items listed above in the main kitchen, 2nd floor kitchenette, 4th floor kitchenette, and the 5th floor kitchenette, should have been labeled, dated or discarded as indicated per regulations and the facility policy.

Jan 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

Based on record review and staff interviews it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed for Levo...

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Based on record review and staff interviews it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed for Levothyroxine (a medication used to treat hypothyroidism, an underactive thyroid), Resident ID #3. Findings are as follows: Record review revealed the resident was readmitted to the facility in January of 2025 with a diagnosis including, but not limited to, cerebral infraction (stroke). Record review revealed a physician's order with a start date on 1/24/2025 for Levothyroxine Sodium oral tablet, 100 micrograms (MCG) one time a day, for thyroid disease. Record review revealed a progress note dated 1/24/2025, which revealed that the resident's laboratory work up was reviewed by the Nurse Practitioner (NP) and a new order was obtained to decrease the Levothyroxine to 87.5 and recheck his/her labs in 6 weeks. Record review revealed the following physician's orders with a start date of 1/25/2025: - Levothyroxine Sodium Oral Tablet 100 MCG one time a day for thyroid disease. - Levothyroxine Sodium Oral Tablet 87.5 MCG by mouth one time a day for hyperthyroidism. Review of the January 2025 Medication Administration Record (MAR) revealed that both the Levothyroxine 87.5 MCG and Levothyroxine 100 MCG were administered together for a total dose of 187.5 MCG, on the following dates: - 1/25/2025 - 1/26/2025 - 1/27/2025 - 1/28/2025 - 1/29/2025 During a surveyor interview on 1/29/2025 at 11:28 AM, with Registered Nurse, Staff A, she acknowledged that the resident was initially on Levothyroxine 100 MCG on 1/24/2025. Additionally, she revealed that the provider reviewed the labs on 1/24/2025 and updated the order to decrease the Levothyroxine from 100 MCG to 87.5 MCG. Furthermore, she acknowledged that both the Levothyroxine 87.5 MCG and Levothyroxine 100 MCG were administered together for a total dose of 187.5 MCG, on 1/25, 1/26, 1/27, 1/28 and 1/29/2025. During a surveyor interview with the NP on 1/29/2025 at 12:10 PM, he revealed that he ordered the Levothyroxine to be decreased from 100 MCG to 87.5 MCG on 1/24/2025. Additionally, he acknowledged that in January 2025 MAR revealed that the resident was receiving a total dose of 187.5 MCG on 1 /25, 1/26, 1/27, 1/28 and 1/29/2025 and not the 87.5 MCG, as ordered. During a surveyor interview on 1/29/2025 at 12:27 PM with the Director of Nursing Services, she acknowledged that the January 2025 MAR revealed that the resident was receiving a total dose of 187.5 MCG of Levothyroxine and not the 87.5 MCG as ordered. She further acknowledged that the facility was unaware of this medication error until it was brought to their attention by the surveyor.

Jan 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

Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from significant medication errors for 1 of 3 residents reviewed...

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Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from significant medication errors for 1 of 3 residents reviewed for medication administration, Resident ID #1. Findings are as follows: Record review revealed Resident ID #1 was admitted to the facility in December of 2024 with diagnoses including, but not limited to, nontraumatic subarachnoid hemorrhage (bleeding in the brain) and essential hypertension (high blood pressure). Record review revealed a physician's order for Nimodipine (a medication prescribed to treat high blood pressure) 30 MG (milligrams), give 2 tablets orally every 4 hours. Record review of the resident's Medication Administration Record for January 2025 revealed that s/he had not received his/her Nimodipine every 4 hours as ordered by the physician on the following dates: - 1/2/2025 s/he missed 6 doses, indicating that s/he did not receive any Nimodipine - 1/3/2025 s/he missed 5 doses - 1/4/2025 s/he missed 2 doses - 1/7/2025 s/he missed 1 dose - 1/10/2025 s/he missed 2 doses - 1/11/2025 s/he missed 2 doses - 1/12/2025 s/he missed 3 doses - 1/15/2025 s/he missed 2 doses Record review of the progress notes revealed the medication was not administered as the facility was waiting for pharmacy delivery on 19 separate occasions and the resident refused the medication on 4 occasions. Further review of the progress noted failed to reveal documentation that the provider was notified that the resident did not receive all prescribed daily doses of his/her Nimodipine. During a surveyor interview on 1/16/2025 at 2:35 PM with Director of Nursing, she revealed that upon admission the facility was unable to obtain all of Resident ID #1's prescribed medications due to pharmacy approval. She revealed that some of the resident's medications had to be brought in from home by the family for the facility to administer. Additionally, she acknowledged that the physician's order for Nimodipine was initiated while the resident was in the hospital and would not have come from home. She further indicated that it was her expectation that if a resident refused any medications or if a medication was unavailable, there would be documentation in the resident's record that the provider was notified. During a surveyor interview on 1/16/2025 at 3:10 PM with Advanced Practice Registered Nurse (APRN), Staff A, he indicated he was aware that some of the resident's medications were unavailable due to awaiting pharmacy approval. He was unable to provide evidence that he was made aware that the prescribed Nimodipine was not available for administration for Resident ID #1 on 19 occasions due to unavailability of the medication or that he was notified of the 4 opportunities that were documented as refusals. During a surveyor interview on 1/17/2025 at 10:08 AM with the facility's Medical Director, he revealed that the facility had issues procuring some medications for Resident ID #1, however he was unaware of the duration or the specific medications in question.

Jan 2025 4 deficiencies 1 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 F0760 (Tag F0760)

Someone could have died · This affected 1 resident

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents are free from significant medication errors for 1 of 5 resid...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents are free from significant medication errors for 1 of 5 residents observed who receive insulin, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 12/26/2024, alleged that numerous medication errors involving several residents were being made, including insulin. Review of the facility policy titled, MEDICATION ADMINISTRATION BY ROUTE OR DOSAGE, revised in 3/2017, revealed that licensed nurses should verify medication orders on the Medication Administration Record (MAR) and check against the physician's order. Record review of Drugs.com revealed that Insulin Lispro is the not the same as Novolog, as these insulin's have different chemical structures. Record review revealed that Resident ID #1 was admitted to the facility with a diagnosis including, but not limited to, diabetes. Further record review revealed the resident requires the administration of insulin to manage this diagnosis. During a surveyor observation on 12/30/2024 at 11:46 AM, Licensed Practical Nurse (LPN), Staff A, administered 8 units of Insulin Lispro (a fast-acting insulin that starts to work in approximately 15 minutes after injection, it peaks in approximately 1 hour, and continues to work for 2 to 4 hours), subcutaneously (under skin, tissue layer between skin and muscle) to the resident. The surveyor completed the medication reconciliation after the above observation and the record failed to reveal evidence that the resident had an active order for Insulin Lispro. Further record review revealed this resident has had orders in the past for Insulin Lispro but these orders were discontinued, most recently on 12/21/2024. During a surveyor interview on 12/30/2024 at 12:10 PM with Staff A, she acknowledged that she administered Insulin Lispro without a physician's order. Staff A further explained that she administered the Insulin Lispro because she thought it was the same insulin as Novolog. She indicated that the resident has an order for Novolog which is to be given in the afternoon. During a surveyor interview on 12/30/2024 at 12:40 PM with the Director of Nursing Services (DNS), she was unable to provide evidence that the resident had an order for Insulin Lispro to be given on 12/30/2024. During a surveyor interview on 12/31/2024 at 10:45 AM with the resident's physician, he revealed that Insulin Lispro and Novolog are fast acting insulin's but these insulin's have different chemical structures. The resident's physician further revealed that he would expect that the ordered insulin would be the insulin that is administered. During a surveyor interview on 1/8/2025 at 1:25 PM with the DNS, she revealed that the resident was previously on Insulin Lispro and when Staff A went to administer the insulin on 12/30/2024 she did not see the prescribed insulin in the medication cart, so she went to the medication refrigerator and took out a discontinued bottle of Insulin Lispro and administered it to the resident. The failure of the facility to administer the correct insulin to the resident had the potential to place the resident at risk for serious injury, impairment, harm or death.

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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional s...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following physician's orders relative to using an insulin pen injector to administer insulin, Resident ID #6. Findings are as follows: Record review of the facility's clinical competency titled, Use of Insulin Pen, undated, revealed the nurse should remove the cap from the insulin pen, wipe the top of the pen with an alcohol wipe where the insulin pen needle is to be attached. Additionally, the nurse should then remove the paper pull tab from the Insulin pen needle (BD AutoShield Duo Applicator) and screw it on to the insulin pen until tight. Record review revealed that Resident ID #6 was admitted to the facility with a diagnosis including, but not limited to, diabetes. Further record review revealed the resident requires the administration of insulin to manage this diagnosis. Additionally, record review revealed the resident has a physician's order dated 12/10/2024 for Lantus (a long acting insulin, absorbed slowly by the body, which takes approximetly 1.5 to 2 hours to start working and lasts for 24 hours, providing a steady amount of insulin during this time) SoloStar 100 units/milliliters Solution pen-injector, inject 10 units subcutaneously in the morning related to diabetes. During a surveyor observation on 1/3/2025 at 7:55 AM of LPN, Staff B, she obtained 10 units of Lantus from the Lantus pen-injector by drawing it out of the pen using an insulin syringe, instead of using the insulin pen needle applicator that is designed to be screwed on to the insulin pen. During a surveyor interview immediately following the above observation, Staff B revealed they do not have the insulin pen needle applicators on the unit. Staff B acknowledged that she obtained the insulin from the insulin pen by drawing it out with an insulin syringe. She indicated that she also obtained the insulin from the pen yesterday using an insulin syringe. During a surveyor interview with Staff B, in the presence of the unit Supervisor, Registered Nurse, Staff C, on 1/3/2025 at 8:05 AM, Staff B acknowledged that she should have used the insulin pen needle applicator with the Lantus pen-injector per the physician order. During a surveyor interview on 1/3/2025 at approximately 8:15 AM with the DNS, she indicated Staff B should have used the insulin pen needle applicator, as ordered.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

Based on record review, and staff interview, it has been determined that the facility failed to maintain medical records that are complete in accordance with professional standards and practices for 1...

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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 complete in accordance with professional standards and practices for 1 of 2 residents reviewed for blood sugar parameters for insulin administration, Resident ID #1. Findings are as follows: Record review revealed that Resident ID #1 was admitted to the facility with a diagnosis including, but not limited to, diabetes. Further record review revealed the resident requires the administration of insulin to manage this diagnosis. Record review revealed the resident has a physician order dated 12/31/2024 for NovoLog (a fast-acting insulin with an onset of effect within approximately 15 minutes, peak effect in approximately 30-90 minutes and duration of approximately 3-7 hours) Injection Solution 100 unit/milliliter (ML), inject as per blood sugar sliding scale and to contact provider if blood sugar is more than 351 milligrams per deciliter (mg/dL). Review of the resident's January 2025 Treatment Administration Record (TAR) revealed the resident's blood sugar on 1/3/2025 at 7:30 AM was 395 mg/dL. Record review failed to reveal evidence that the provider was contacted. During a surveyor interview on 1/3/2025 at 3:02 PM with Licence Practical Nurse (LPN), Staff A, she revealed that she failed to document that she contacted the provider in the resident's medical record. Additionally, review of the January 2025 TAR revealed the resident's blood sugar on 1/2/2025 at 4:30 PM was 442 mg/dL. Record review failed to reveal evidence that the resident's provider was contacted. During a surveyor interview on 1/3/2025 at 3:35 PM with LPN, Staff E, she revealed that she failed to document that she contacted the provider in the resident's medical record. During a surveyor interview on 1/3/2025 at approximately 4:00 PM with the Director of Nursing Services, she was unable to provide evidence that the resident's medical record was complete in accordance with professional standards and practices.

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 F0838 (Tag F0838)

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 document all required components of the facility-wide assessment. Findings are as follows: Review of a f...

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Based on record review and staff interview, it has been determined that the facility failed to document all required components of the facility-wide assessment. Findings are as follows: Review of a facility provided document titled, Facility Assessment, reviewed and approved on 8/7/2024, failed to reveal that the facility developed and maintained a plan to maximize recruitment and retention of direct care staff as required. During a surveyor interview on 1/3/2025 at approximately 4:00 PM with the Administrator, he acknowledged that the facility assessment failed to develop and maintain a plan to maximize recruitment and retention of direct care staff.

Oct 2024 1 deficiency 1 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

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, staff, and resident interview, it has been determined that the facility failed to ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, staff, and resident interview, it has been determined that the facility failed to ensure that a cognitively impaired resident received adequate supervision to prevent accidents for 1 of 4 residents reviewed for elopement, Resident ID #1. Findings are as follows: Review of an anonymous community reported complaint submitted to the Rhode Island Department of Health on 10/8/2024 alleges that Resident ID #1 eloped from the facility on 10/7/2024 during the early afternoon. The complaint indicates that management does not disclose when these things happen, and management wanted him/her to wait before filing a complaint. Review of the facility policy titled Leave of Absence (LOA) states in part, Nursing staff will obtain an order for LOA with Responsible Party for a resident/patient on admission .If a resident is their own responsible party they may go on LOA unattended .When the resident is leaving the facility, an attempt will be made to complete the LOA log acknowledging that the resident or person taking the resident on LOA accepts responsibility for his/her well-being . Review of the facility policy titled ELOPEMENT states in part, .The licensed Nurse will conduct an Elopement Risk Assessment on admission, readmission, annually, quarterly, and upon change of condition .When it is determined that a resident may be missing .The senior nursing person on duty at the time will direct a systematic search procedure .The police should be notified as soon as the resident is not located within the facility or on the immediate grounds .Document relevant information in the Resident's medical record, Incident report, and DPH [Department of Public Health] report, as warranted . Review of the elopement binder reveals that the facility is equipped with a wander guard system (a system with three components: bracelets that residents wear, sensors that monitor doors, and a technology platform that sends safety alerts in real time when a resident wearing a sensor approaches an exit door) on the fourth floor. Record review revealed the resident was readmitted to the facility in October of 2023 with diagnoses including, but not limited to, mild neurocognitive disorder due to known physiological condition, malignant neoplasm of the stomach (stomach cancer), nicotine dependence, chronic pain syndrome, abnormalities of gait and mobility, adult failure to thrive, opioid use disorder, epilepsy (a brain disorder that causes recurring, unprovoked seizures), viral hepatitis C, and acute embolism and thrombosis (blood clot) of the left lower extremity. Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) a score of 9 out of 15 indicating the resident has moderate cognitive impairment. Record review of a care plan dated 10/19/2023 revealed the resident has impaired cognition related to short term memory loss. Additional review of a care plan with a revision date of 5/3/2024 revealed the resident is at risk for falls related to decrease endurance/strength, generalized weakness, and poor safety awareness due periods of forgetfulness. Record review of a nursing progress note dated 10/7/2024, written at 11:20 PM revealed that when staff went to administer the resident his/her evening medications on 10/7/2024, the resident was not in his/her room and the nursing supervisor was immediately notified. Record review of a progress note dated 10/8/2024 at 12:30 AM states in part, This writer was informed at 2045 [8:45 PM] that this resident was unable to be located since 3:00 PM at the beginning of the shift .Every inch of the facility, including the outer parameters were searched and the resident was still not located .ADNS [Assistant Director of Nursing Services] called police department at 23:05 [11:05 PM] . Record review of a progress note dated 10/8/2024 at 5:48 AM revealed the facility received a phone call from Landmark Hospital (Landmark Hospital is approximately 13.4 miles from the facility) indicating that Resident #1 received an evaluation at 4:10 AM in the emergency room and the physician was requesting the facility to fax Resident ID #1's demographics and medication list. The progress notes also indicates that the family was informed of the resident's location. Record review of a progress note dated 10/8/2024 at 11:50 AM revealed the resident returned from the hospital after having been medically cleared after leaving the facility against medical advice. Record review of an Emergency Department (ED) note dated 10/8/2024 at 4:25 AM revealed the resident arrived at the hospital at 4:22 AM by the Woonsocket police. The resident was noted to be confused and admitted to smoking marijuana that night. The ED spoke to the resident's family member and the family member indicated that the resident has poor memory at his/her baseline. Additional review of an ED note dated 10/8/2024 at 5:18 AM from Landmark Hospital revealed that the resident was brought to the ED by the police after s/he reported that s/he was lost. Additionally, this progress note revealed the resident was found by the Woonsocket police at a coffee shop on [NAME] Avenue in Woonsocket. This location is approximately 13.2 miles from the facility. The resident was discharged back to the facility without being treated for any acute medical issues. Surveyor review of the facility's video surveillance footage on 10/10/2024 at 1:59 PM revealed the resident exited the facility with his/her walker on 10/7/2024 at 2:41 PM. Record review failed to reveal evidence that the facility implemented safety measures to ensure the resident's well-being upon his/her return to the facility after his/her successful elopement on 10/8/2024 until it was brought to the facility's attention by the surveyor on 10/9/2024. Additionally, the facility failed to conduct an elopement assessment upon the resident's return following a change in condition as indicated in the facility's policy. During a surveyor interview with the Administrator and the Regional Director of Nursing on 10/9/2024 at 10:30 AM, they both indicated that this was not an elopement, that the resident was his/her own responsible party/decision maker and that s/he was out on an LOA. The Administrator revealed that the resident walks down the street daily for a coffee or cigarettes and that s/he has always returned. When questioned by the surveyor as to why the facility initiated their elopement policy/procedure on 10/7/2024, including calling the police department, if they felt this was an LOA, they were unable to answer. Record review failed to reveal evidence that an order was obtained for Resident ID #1's LOA that the facility indicated that s/he took on 10/7/2024. Additional record review of the LOA log for 10/7/2024 failed to reveal evidence that this resident had left the facility. During a surveyor interview with Licensed Practical Nurse, Staff A (who was on duty from 3:00 PM to 11:00 PM on 10/7/2024 when the resident was identified as missing), on 10/8/2024 at 3:00 PM she revealed that she had seen the resident at the beginning of the shift and that it was a very busy night. Staff A indicated that she was not aware the resident was missing until 8:45 PM when the Medication Technician went to administer the resident's medications and s/he was not in the room. Staff A indicated that she notified the nursing supervisor immediately and that the supervisor initiated their elopement policy/procedure. The Providence Police were notified of the missing resident on 10/7/2024 at 11:05 PM by the ADNS. During a surveyor interview with the ADNS on 10/9/2024 at approximately 9:30 AM, she revealed that she was notified at 9:00 PM on 10/7/2024 that Resident ID #1 was missing. She notified the Administrator, and she then went to the facility to assist. The ADNS indicated that the resident was unable to be located and therefore she called the Providence Police Department at 11:05 PM. During a surveyor interview with the resident's family member on 10/10/2024 at 10:06 AM, s/he revealed that the facility contacted him/her on 10/7/2024 at approximately 9:00 PM to let him/her know that the resident was missing. S/he also revealed that the Woonsocket police called him/her notifying him/her that the resident was found in Woonsocket at coffee shop and flagged down the police because the s/he was lost. During a surveyor interview with the resident on 10/10/2024 at 9:40 AM s/he indicated that s/he had gone for a long walk to downtown Providence and got lost, so s/he flagged down the police who took him/her to the hospital. S/he had no idea that s/he was found in Woonsocket and had no recollection of how s/he had gone from Providence to Woonsocket. This resident left the faciity on [DATE] at 2:41 PM with his/her walker. The facility did not know the resident was missing until approximately 8:45 PM on 10/7/2024, which was 6 hours after s/he had left the facility. The facility initiated their elopement policy/procedure at approximately 8:45 PM but the police were not called until 11:05 PM. The whereabouts of the resident was unknown from 2:41 PM until the resident flagged down a Woonsocket police offer at a coffee shop as s/he indicated s/he was lost (time unknown). The facility was unaware of how the resident traveled approximately 13.2 miles from his/her facility in Providence to Woonsocket during the evening, night, and early morning hours of 10/7/2024 into 10/8/2024. The resident was treated at Landmark Hospital at approximately 4:10 AM and was discharged back to the facility without being treated for any acute medical issues. When the resident returned on 10/8/2024 to the facility approximately 14 hours after s/he went missing the facility failed to implement any safety measures to ensure his/her well-being in the facility including safety checks, providing a wander guard, or putting him/her on the secured unit. Additionally, the facility did not follow their elopement policy/procedure relative to conducting an elopement assessment after the resident had successfully eloped. The facility's failure to recognize this incident as an elopement placed him/her at risk for more than minimal harm, impairment, or death as they did not implement any interventions to keep him/her safe. Due to the facility's failure to investigate this incident, they had no pertinent information available to share with the surveyors during the investigation of this complaint. The information found in this statement of deficiencies was gathered by the surveyors.

Sept 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on surveyor observation, record review and staff interview it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional sta...

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Based on surveyor observation, record review and staff interview it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to wound care for 1 of 2 residents reviewed for burns, Resident ID #2. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 9/20/2024 alleges that Resident ID #1 had reported that the facility was not adhering to the medical treatment plan related to his/her bilateral lower extremity wounds. Review of a policy titled Skin Care Non-Pressure Wound Assessment which states in part, .Residents with non-pressure injuries .are assessed, documented and provided appropriate treatment to promote healing .ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. Post op surgical site incisions are evaluated and documented on a least weekly .until it is resolved .documentation of non-pressure ulcers include Location, measurement .type of wound .partial thickness [damage of the first two layers of skin], full thickness [extends beyond the first layers of skin], draining amount, drainage color, odor .appearance of the wound bed, appearance of wound edges, appearance of peri wound, pain, effectiveness of treatment. Review of a policy titled Weekly Body Audit which states in part, All residents will have a body audit to address any skin issues on a weekly basis. If an alteration in skin integrity .is discovered, it will be documented on the Weekly Skin Audit form as soon as the nurse observes the area. Monitoring of any area will continue until the area is resolved . Record review revealed that Resident ID #2 was admitted to the facility in September of 2024 with diagnoses including, but not limited to, dementia, muscle wasting and surgical aftercare following surgery. 1. Record review of a hospital continuity of care form revealed that the resident was discharged from the hospital on 9/6/2024 after receiving a surgical procedure for his/her burns with wound debridement (removal of dead tissue) of left hand and left thigh with an allograft procedure (a transplant of tissue from one person to another) to his/her left thigh. Record review of an admission document titled Weekly Skin Audit dated 9/6/2024, failed to indicate that the resident had a burn with an allograft to his/her left thigh. Record review of a document titled non-pressure wound evaluation dated 9/11/2024 failed to indicate that the resident had a burn with allograft to his/her left thigh, per the facility's policy. Record review of a burn clinic document titled Continuity of Care Consultation and Referral Form dated 9/16/2024 revealed the resident was evaluated at a burn clinic with a recommendation for daily treatment to the left hip. The recommendations included to apply a wet to dry dressing (a dressing applied wet and removed when dry). Further record review failed to reveal evidence that the burn clinic's recommendations on 9/16/2024 were reviewed with the provider and acted upon until it was brought to the facility's attention on 9/24/2024 by the surveyor, indicating the left hip wet to dry dressing treatment was not completed for 8 days. During a surveyor observation and simultaneous interview on 9/24/2024 at 1:35 PM with Licensed Practical Nurse (LPN), Staff A, she revealed that she was the nurse on shift caring for the resident and was not aware of the burn clinic's treatment recommendation to the left hip. Staff A, assessed the resident's skin in the surveyor's presence and indicated the resident's right foot had four areas that were uncovered with no treatment in place. Staff A was unsure of the type of wounds that were present on his/her right foot. 2. Record review of an admission Weekly Skin Audit dated 9/6/2024, revealed the resident had four blistered areas to his/her right foot with different stages of healing, pink in color with no fluid which were not covered. Record review of a weekly skin audit dated 9/13/2024 failed to reveal evidence of the above mentioned blisters to his/her right foot. During a surveyor interview on 9/24/2024 at 2:42 PM with the facility's Wound Nurse, she was unable to explain why the burn clinic's recommendation for treatment to the resident's left hip had not been reviewed with the provider or acted upon. Additionally, she indicated she was not aware of the blisters on the resident's right foot and acknowledged she had not yet assessed them. During a surveyor interview with the Nurse Practitioner on 9/24/2024 at 3:31 PM, he revealed that he would have agreed with the wound recommendations made by the burn clinic as they are the specialists. He indicated the recommendations from the burn clinic should have been reviewed with the provider and acted upon. Additionally, he would have expected the resident to have a treatment in place for his/her blisters to the right foot. During a surveyor interview on 9/24/2024 at approximately 3:50 PM with the Director of Nursing Services, she revealed it would be her expectation for the wound nurse to follow up with all new admissions to ensure treatment orders are in place for residents with wounds. Additionally, she revealed she would investigate why the burn clinic recommendations were not reviewed with the provider and put into place for 9/20/2024. Further, she acknowledged the skin assessments completed on 9/6/2024, 9/11/2024 and 9/13/2024 did not accurately reflect the status of the resident's skin.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives the necessary treat...

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Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 2 residents reviewed for pressure ulcers, Resident ID #2. Findings are as follows: According to the State Operations Manual, Appendix PP Guidance to Surveyors for Long Term Care Facilities, revised 8/8/2024 which states in part, A pressure ulcer/injury (PU/PI) can occur wherever pressure has impaired circulation to the tissue. A facility must .Identify whether the resident is at risk for developing or has a PU/PI upon admission and thereafter .Implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors .If a PU/PI is present, provide treatment and services to heal it and to prevent .It is important that each existing PU/PI be identified, whether present on admission or developed after admission .Any new PU/PI suggests a need to reevaluate the adequacy of prevention measures in the resident's care plan. Record review of a community reported complaint received by the Rhode Island Department of Health on 9/20/2024 alleges that Resident ID #1 had reported that the facility was not adhering to the medical treatment plan related to his/her bilateral lower extremity wounds. Review of a policy titled Prevention & Management of Pressure Injuries which states in part, .Residents with pressure injuries .are identified, assessed and provided appropriate treatment to encourage healing and/or maintenance of skin integrity. Care plans are developed .ongoing monitoring and evaluation are provided to ensure optimal resident outcomes .on admission .pressure injuries are assessed and documented on at least weekly .until it is resolved .pressure injury assessment includes Location, measurement .stage .draining amount, drainage color, odor .appearance of the wound bed, appearance of wound edges, appearance of peri wound, pain, effectiveness of treatment .Stage 3 [full thickness tissue loss, subcutaneous fat may be visible] .pressure injuries should be covered . Review of a policy titled Weekly Body Audit which states in part, All residents will have a body audit to address any skin issues on a weekly basis. If an alteration in skin integrity .is discovered, it will be documented on the Weekly Skin Audit form as soon as the nurse observes the area. Monitoring of any area will continue until the area is resolved .All resident with skin integrity issues will have this addressed on their plan of care. Record review revealed that Resident ID #2 was admitted to the facility in September of 2024 with diagnoses including, but not limited to, dementia, muscle wasting, surgical aftercare following a surgery. Record review of an admission Weekly Skin Audit dated 9/6/2024, revealed the resident had a pressure injury to his/her right knee which was red and pink in color and uncovered. Additional review of the skin audit failed to reveal evidence that the assessment included the measurement, stage, appearance of the wound bed, appearance of the wound edges, appearance of peri wound, pain, indicated if there was or was not presence of drainage or odor, per the facility policy. Record review of a Pressure injury evaluation form dated 9/11/2024, revealed an initial skin evaluation was completed of the resident's pressure injury measuring, 3.4 centimeters (cm) in length by 2.6 cm in width by 0.3 cm in depth, 50% Eschar (black, brown, or dead tissue), 50% (slough-yellow/white/tan or necrotic tissue), moderate drainage. Additional review of this document indicates that the current treatment was effective, although there was no evidence that a treatment was in place for this pressure injury. Further record review of the September Treatment 2024 Administration Record failed to reveal evidence of a wound treatment order for the resident's right knee pressure injury. Record review of a subsequent weekly skin audit dated 9/13/2024 failed to reveal evidence that the resident had a pressure injury to his/her right knee. Record review of the facility's contracted Wound Physician's progress note dated 9/20/2024 indicated, an evaluation was completed of the resident's right knee, which revealed a stage 3 pressure ulcer measuring 3.2 cm in length by 1.9 cm in width by 0 cm in depth. The wound base was observed with 25-49% slough (dead tissue). Additional review revealed a recommendation for a daily treatment to cleanse the right knee with wound cleanser, apply honey alginate (highly absorbent wound dressing with medical honey) to the base of the wound and secure with bordered foam dressing (a foam dressing with adherent edges). Record review of the physician's orders failed to reveal evidence that the wound physician's recommendations were acted upon from 9/20/2024 until it was brought to the facility's attention on 9/24/2024 by the surveyor. This indicates that the resident's right knee pressure wound was without a treatment in place for 18 days. During a surveyor observation and simultaneous interview on 9/24/2024 at 1:35 PM with Licensed Practical Nurse (LPN), Staff A, she revealed that she was the nurse caring for the resident and was not aware of the pressure area to the resident's right knee or the above-mentioned wound physician's treatment recommendations. She also acknowledged that there was not a physician's treatment order for the right knee pressure injury. Upon observing the right knee pressure injury in the surveyor's presence, she indicated the resident's right knee had an open area that was currently open to air. Additionally, she was observed palpating (pressing) the residents wound and the resident verbalized s/he was experiencing pain to the area. Staff A, also acknowledged that this resident did not have a current treatment in place for the right knee pressure injury. During a surveyor interview on 9/24/2024 at 2:42 PM with the facility Wound Nurse, she was unable to explain why there was not a treatment order in place for the right knee pressure injury after the recommendation was made by the wound physician on 9/20/2024. Additionally, she was unable to provide evidence that a treatment was in place for the pressure injury to the right knee, until brought to her attention by the surveyor on 9/24/2024. During a surveyor interview with the Nurse Practitioner on 9/24/2024 at 3:31 PM, he revealed that he would agree with the recommendations from the facility's contracted Wound Physician, as she is the specialist. Additionally, he indicated he would have expected a treatment to have been in place for the pressure injury to the right knee. During a surveyor interview on 9/24/2024 at approximately 3:50 PM with the Director of Nursing Services, she revealed it would be her expectation for the wound nurse to follow up with all new admissions to ensure treatment orders are in place for residents with pressure ulcers. Additionally, she was unable to provide evidence that Resident ID #2 had a treatment in place for the pressure injury to his/her right knee from 9/6/2024 until brought to the facility's attention by the surveyor on 9/24/2024. Additionally, she indicated she would be going to assess the wound and put a treatment in place.

May 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency 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 keep residents free from significant medication errors for 1 of 3 residents reviewed, Resident ID #1. Find...

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Based on record review and staff interview it has been determined that the facility failed to keep residents free from significant medication errors for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint received at the Rhode Island Department of Health on 5/15/2024 alleges that Resident ID #1 received Suboxone (a medication that is used to treat pain) in error. Record review of the facility policy titled, MEDICATION ADMINISTRATION BY ROUTE OR DOSAGE, revealed in part, .Sublingual Medications .Procedure Verify medication order on MAR [Medication Administration Record]. Check against physician order. Ask resident his/her name. Record review revealed that Resident ID #1 was admitted to the facility in May of 2024 with diagnoses including, but not limited to, multiple myeloma (a cancer that forms in a type of white blood cell), atrial fibrillation (irregular heartbeat) and chronic obstructive pulmonary disease. Record review of a telehealth evaluation authored by Advanced Practice Nurse, Staff C, dated 5/14/2024 revealed that a nurse from the facility paged her to report that Resident ID #1 received an accidental dose of Suboxone, which s/he does not have an order for. Record review of the 2nd Floor Unit Controlled Substance Log Book revealed that on 5/15/2024 Suboxone was removed from the medication cart by License Practical Nurse, Staff A. During a surveyor interview on 5/16/2024 at 11:29 AM with the Unit Manager, Staff B, she revealed that Staff A, accidentally administered Suboxone to Resident ID #1. Additionally, she revealed that the medication was prescribed for another resident. During a surveyor interview with the Director of Nursing Services on 5/16/2024 at 1:00 PM, she acknowledged that the Resident ID #1 received Suboxone in error. She indicated that during her investigation Staff A failed to properly identify Resident ID #1 before administering the medication.

Apr 2024 3 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to obtain laboratory services to meet the needs of its residents for 1 of 1 resident reviewed for a valproic...

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Based on record review and staff interview, it has been determined that the facility failed to obtain laboratory services to meet the needs of its residents for 1 of 1 resident reviewed for a valproic acid level (a laboratory test that is monitored when a patient is receiving Depakote) Resident ID #83. Findings are as follows: Record review revealed the resident was admitted to the facility in April of 2023 with diagnoses including, but not limited to, bipolar disorder and violent behaviors. Record review revealed that the resident is prescribed Depakote (a drug used for those with bipolar disease or a seizure order. A person receiving this medication must have labs drawn to ensure appropriate therapeutic levels. Record review revealed a new order dated 3/5/2024 to check the resident's valproic acid level in 2 weeks, indicating that the lab should be drawn on 3/18/2024. Record review failed to reveal evidence that the lab was obtained as ordered. During a surveyor interview with Licensed Practical Nurse, Staff A, on 4/3/2024 at 10:38 AM, she acknowledged that the lab had not been obtained as ordered. During a surveyor interview with the Physician on 4/3/2024 at 11:44 AM, he revealed that he would have expected a valproic acid to have been obtained in 2 weeks as ordered. During a surveyor interview with the Director of Nursing Services on 4/3/2024 at 10:56 AM, she acknowledged the valproic acid level was not obtained per the physician's orders.

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 record review and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment and to he...

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Based on record review and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment and to help prevent the development of infections for 3 of 4 residents reviewed relative to the use of positive airway pressure devices; Continuous positive airway pressure (CPAP) and Bilevel positive airway pressure (BIPAP). These devices provide breathing support which is administered through a face mask or nasal mask, Resident ID #s 5, 21 and 38. Findings are as follows: Review of a facility policy titled CPAP/BIPAP Management dated April 2015, states in part, .Cleaning of equipment: CPAP or BIPAP system/ machine cleaning - wipe machine off twice monthly with damp cloth, replace disposable filters per manufacturer guidelines, clean non-disposable filters weekly and replace when needed, use warm soapy water and let air dry before inserting back into machine. Headgear- wash as needed .masks and nasal pillows- wash daily with mild detergent or white vinegar solution, rinse with warm water and air dry between uses .add the wearing and cleaning routine of the equipment on the TAR (treatment administration record). 1. Record review revealed that Resident ID #5 was readmitted to the facility in October of 2023 with diagnoses including, but not limited to, sleep apnea (a sleep disorder where breathing is interrupted repeatedly) and chronic obstructive pulmonary disorder (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of the Treatment Administration Record (TAR) for March and April 2024 revealed that the resident has an order to use a BIPAP machine every night at bedtime. Additional review revealed that the order was signed off as in use every night. Record review failed to reveal evidence of the BIPAP machine including the mask were cleaned or disinfected in March or April of 2024 per the facility policy. 2. Record review revealed that Resident ID #21 was readmitted to the facility in May of 2023 with diagnoses including, but not limited to, obstructive sleep apnea and COPD. Review of the TAR for April and March 2024 revealed that the resident has an order for a CPAP machine to be used every night at bedtime for sleep apnea. Additional review revealed that the order was signed off as in use every night in March and April of 2024. Record review failed to reveal evidence that the CPAP machine including the mask were cleaned or disinfected in March or April of 2024 per the facility policy. 3. Record review revealed that Resident ID #38 was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, obstructive sleep apnea and COPD. Review of the TAR for March and April 2024 revealed that the resident has an order for a BIPAP machine to be used every night at bedtime for respiratory assistance. Additional record review revealed that the BIPAP was signed off as used three times in March of 2024 and once in April of 2024. The other dates were documented as the resident refused to use the BIPAP machine. Record review failed to reveal evidence of the BIPAP machine including the mask were cleaned or disinfected in March or April of 2024. During a surveyor interview on 4/3/2024 at 8:31 AM with the Infection Preventionist (IP) in the presence of Registered Nurse, Staff E, she revealed that she would expect the staff to clean the BIPAP and CPAP equipment per the facility policy to prevent infection. During a surveyor interview on 4/3/2024 at 12:31 PM with the Director of Nursing Services (DNS) she revealed that the above-mentioned residents do not have orders to clean their machines. Additionally, she was unable to provide evidence that the machines get cleaned per the facility policy. The DNS was unable to provide evidence that the facility maintained an infection control program that provided a sanitary environment to help prevent the development of infections.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to serve and store food under...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to serve and store food under sanitary conditions relative to food storage in 2 of 3 nursing unit refrigerators, the serving temperature of potentially hazardous cold food in 2 of 3 dining locations. The facility also failed to ensure staff were wearing hair restraints and beard covering in the main kitchen. Findings are as follows: 1. The State of Rhode Island Food Code 2018 Edition 3-501.6 states in part, .Except during preparation cooking or cooling .temperature control for safety shall be maintained at 5 degrees C (Celsius) 41 degrees (Fahrenheit) or less . During a surveyor observation on 4/2/2024 of the 4th floor dining room at approximately 12:05 PM for the lunch meal, the serving temperature of the tuna salad sandwich had a cold holding temperature of 51.2 degrees F. An additional surveyor observation of the 5th floor dining room at approximately 12:15 PM for the lunch meal, the serving temperature of the ham on a Chef Salad plate had a cold holding temperature of 55.2 degrees F. 2. The Rhode Island Food Code 2018 Edition 3.602.11 states in part, .label information shall include common name of the food . During a surveyor observation on 4/2/2024 at approximately 11:46 AM on the 5th floor unit kitchenette refrigerator the following was observed: - a brown paper bag without a label of contents - 2 containers without a product label. 3. The Rhode Island Food Code 2018 Edition 3-501.17 states in part, food shall be discarded .and may not exceed a manufacturer's use by date . Based on surveyor observation on 4/2/2024 at approximately 11:40 AM of the 4th floor unit kitchenette refrigerator revealed 5 containers of Dannon Light +Fit yogurt had a manufacturer use by date of 3/11/2024. 4. Record review of a facility policy posted on refrigerators on all 3 nursing units for the storage of resident food, reads in part, .any food or drink placed in fridge or freezer must be labeled and dated. Food will be discarded after 3 days or upon expiration date . During a surveyor observation on 4/2/2024 at approximately 11:40 AM of the 4th floor unit kitchenette refrigerator the following was observed: -1 container of Panera [NAME] Squash Soup with a date of 3/30. An additional surveyor observation on 4/2/2024 at approximately at 11:46 AM on the 5th floor unit kitchenette refrigerator 2 containers of food were stored with dates of 3/27. 5. The Rhode Island Food Code 2018 Edition 2-402.11 reads in part, .food employees shall wear hair restraints, such as hair nets .beard restraint that covers body hair . During surveyor observations on all days of survey from 4/1/2024 through 4/4/2024 at the lunch meal Dietary Aide, Staff B,was serving food on the 4th floor dining room with her hair net only covering the back portion of her head, leaving the front of her hair unrestrained. During surveyor observations of the main kitchen on 4/1/2024 at 9:45 AM, 4/2/2024 at 10:00 AM and 4/4/2024 at 9:45 AM Dietary Aide, Staff C was observed without a beard net while washing dishes and performing diet aide tasks in the main kitchen. Further observation of the of the main kitchen on 4/1/2024 at 9:40 AM, 4/2/2024 at 10:00 AM and 4/3/2024 at 2:00 PM, Cook, Staff D, was observed without a beard net while preparing resident food. During a surveyor interview on 4/3/2024 at approximately 2:30 PM with the Dining Director he acknowledged beard nets were not worn by the dietary staff members and hair nets were not worn properly Additionally, he acknowledged the cold holding temperatures were not within acceptable parameters and that the food storage and labeling on the nursing unit refrigerators were not stored per facility policy.

Mar 2024 2 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 F0726 (Tag F0726)

Someone could have died · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to ensure licensed nurses had the appropriate competencies and skills sets to provide nursing and related se...

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Based on record review and staff interview, it has been determined that the facility failed to ensure licensed nurses had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 1 of 1 resident reviewed relative to the need for a Glucagon injection (a medication used to treat low blood sugar) secondary to a critically low blood sugar level, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 3/8/2024 at 5:02 PM, alleges the resident was admitted to the hospital following an unresponsive episode at the nursing facility. There was a question if the unresponsive episode and subsequent emergency room visit, and hospital admission were the results of a medication error. The skilled nursing facility denies the error. Record review of a facility reported incident submitted the Rhode Island Department of Health on 3/8/2024 at 5:15 PM, revealed that the resident was found with an alteration in mental status at approximately 5:30 PM. A code blue (an emergency response) was called as the resident's blood sugar was 31 (normal blood sugar range is between 70-125 milligrams/deciliter (mg/dl). Glucagon was administered and 911 was called. The blood sugar was retaken, and the result was 38 mg/dl. A second dose of Glucagon was administered and 911 arrived and transported the resident to the emergency room for evaluation. The resident was later admitted with a diagnosis of altered mental status. Record review of the Facility Assessment revealed that the facility has identified that they are able to provide care and nursing services for residents in the category of Metabolic disorders including but not limited to Diabetes. Record review of the facility policy titled Hypoglycemia-clinical management of revealed in part, hypoglycemia is defined as fingerstick of serum glucose (blood glucose) less than 60 mg /dl .If the resident is unresponsive, administer Intramuscular (injection in the muscle) or Subcutaneous (injection under the skin) Glucagon as ordered by the physician. Record review revealed that Resident ID #1 was admitted to the facility in March of 2024 for short-term rehab. Further record review revealed that s/he is a diabetic and requires the administration of insulin to manage this diagnosis. Record review revealed a physician's order dated 3/7/2024 for Glucagon Emergency Kit - 1 mg- Inject one syringe intramuscularly as needed for hypoglycemic reaction for blood sugar under 60. Recheck blood sugar every 15 minutes until the resident's blood sugar is greater than 70. Notify the MD for blood sugar less than 60. Record review revealed a progress note dated 3/7/2024 at 6:07 PM that the resident was found to be unresponsive with a blood sugar of 31 on 3/7/2024 and a code blue was called. S/he required the administration of Glucagon to raise his/her blood sugar level, which was administered by Registered Nurse, Staff B at 5:40 PM. Further review revealed the resident's blood sugar was taken again and the results were 34 at 5:48 PM, and a second dose of Glucagon was administered to the resident by Registered Nurse Staff, C. During a surveyor interview with Staff C, on 3/12/2024 at 1:06 PM she revealed that on 3/7/2024 she responded to the code blue for Resident ID #1. She indicated that she noticed that the Glucagon bottle that Staff B had pulled to administer to the resident still had the Glucagon powder in the vial. She indicated that the resident's blood sugar was not responding to the first dose of Glucagon because s/he did not receive it, as the medication was not reconstituted, and the resident only received the sterile water. Once she realized that the Glucagon was not administered, she decided to get another vial of Glucagon and administer another dose to the resident. During a surveyor interview with Staff B, on 3/12/2024 at 1:50 PM she revealed that she was unaware that she needed to reconstitute the Glucagon prior to administering it. She acknowledged that she had only administered an injection of the sterile water as she did not reconstitute the medication. Additionally, she revealed that she had not received any trainings or competencies for the use of Glucagon. Record review of Registered Nurse, Staff B's personnel record failed to reveal evidence of a competency related to the reconstitution and administration of Glucagon. Additional record review of the expanded sample revealed that personnel files for Registered Nurses, Staff A, Staff D, Staff E and Licensed Practical Nurse Staff F failed to reveal evidence of competencies related to the reconstitution and administration of Glucagon. During a surveyor interview on 3/12/2024 at 1:40 PM with the Director of Nursing Services, she indicated that she would have expected Staff B, to give the correct dose of Glucagon by reconstituting the medication as required. Additionally, she was unable to provide evidence that Staff A, B, D, E and F received any training and/or competencies related to the reconstitution and administration of Glucagon. Cross Reference F 760

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 F0760 (Tag F0760)

Someone could have died · 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 2 residents reviewed, who r...

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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 2 residents reviewed, who received insulin, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 3/8/2024 at 5:02 PM, alleges the resident was admitted to the hospital following an unresponsive episode at the nursing facility. There was a question if the unresponsive episode and subsequent emergency room visit, and hospital admission were the results of a medication error. Record review of a facility reported incident submitted the Rhode Island Department of Health on 3/8/2024 at 5:15 PM, revealed that the resident was found with an alteration in mental status at approximately 5:30 PM. A code blue (an emergency response) was called as the resident's blood sugar was 31 (normal blood sugar range is between 70-125 milligrams/deciliter (mg/dl). Glucagon (a medication used to treat a low blood sugar) was administered and 911 was called. The blood sugar was retaken, and the result was 38. A second dose of Glucagon was administered and 911 arrived and transported the resident to the emergency room for evaluation. The resident was later admitted with a diagnosis of altered mental status. Record review of the facility policy titled Hypoglycemia-clinical management of revealed in part, hypoglycemia is defined as fingerstick of serum glucose (blood glucose) less than 60 mg /dl .If the resident is unresponsive, administer Intramuscular (injection in the muscle) or Subcutaneous (injection under the skin) Glucagon as ordered by the physician. Review of the facility policy titled Medication Administration and Documentation-General revealed that licensed nurses should review physician orders and compare the order against the Medication Administration Record (MAR). 1a. Record review revealed Resident ID #1 was admitted to the facility in March of 2024 for short-term rehab. Further record review reveals that s/he is a diabetic and requires the administration of insulin to manage this diagnosis. Record review revealed the following physician's orders: Insulin Aspart injection solution (a fast-acting insulin that starts to work about 15 minutes after, injection peaks in about one hour, and keeps working for 2 to 4 hours) 100 unit/ml (milliliter) inject 40 Units subcutaneously once a day, at 11:00 AM. Hold for a blood sugar less than 200. Insulin Aspart Prot & Aspart subcutaneous Suspension Pen-Injector (70-30) (a mix of fast acting and intermediate-acting insulin that works up to 24 hours) 100 unit/ml inject 36 units subcutaneous, at bedtime. Hold for a blood sugar less than 200. Review of the March 2024 MAR revealed that the resident's blood sugar was less than 200 on the following dates and s/he received the Aspart 70-30: - 3/3/2024- Blood Sugar 198- Administered Aspart 70-30 by Registered Nurse (RN), Staff A - 3/4/2024- Blood Sugar 157- Administered Aspart 70-30 by RN, Staff D - 3/6/2024- Blood Sugar 183- Administered Aspart 70-30 by Staff D Additional record review revealed that on 3/7/2024 at 11:00 AM the resident's blood sugar was 138. Staff A proceeded to administer the resident 40 Units of Aspart, despite his/her order to hold the Aspart for a blood sugar of then less 200. Record review of the resident's progress notes revealed the following entries: - 3/7/2024 at 6:39 AM: Received resident in bed resting with eyes closed. Equal and unlabored respirations. Resident alert and oriented. Able to make needs known . - 3/7/2024 documented as late entry at 6:07 PM: Authored by RN, Staff C- This nurse responded to a code blue for Resident ID #1. She indicated that resident was diaphoretic (clammy/sweaty skin) and unresponsive to verbal and tactile stimuli. His/her oxygen saturation level was 88% (Normal range 95-100%) on 2 liters of oxygen. The resident was placed on a non-rebreather at 15 Liters. The residents blood sugar was checked with a result of 31. Glucagon was administered at 5:40 PM. The resident's blood sugar rechecked at 5:48 with result of 34. A second dose of Glucagon was administered to the resident and his/her blood sugar continued to rise slowly with result of 38. During the code blue emergency services arrived on scene. An Intravenous (IV) was placed in his/her left hand by Emergency Medical Services (EMS), with Dextrose 10 (a medication used to increase blood sugar) administered. The resident's blood sugar was rechecked and at this time his/her blood sugar 168. -3/7/2024 at 9:41 PM: Authored by RN, Staff E, - Resident found unresponsive laying down in bed at 5:30 PM. His/her oxygen saturation was 90% on 2 liters via nasal cannula (a thin tube that goes inside the nose and delivers oxygen). His/her blood sugar was 31. The resident was placed on a non-rebreather at 15 liters, oxygen improved to 96%. 1 MG (milligram) of Glucagon was administered at 5:40 PM. The blood sugar was rechecked which resulted in the blood sugar of 34. A second dose of Glucagon 1 MG was administered at 5:48 PM. The blood sugar was rechecked and resulted in a blood sugar of 38. A code blue was called during the event and rescue was also called. The resident was picked up via 911 at 5:55 PM and sent to the hospital. -3/7/2024 11:21 PM: The resident was admitted to the hospital for altered mental status. Record review of the EMS run report revealed that the primary complaint was hypoglycemia (low blood sugar level). EMS arrived and the resident was found to be unstable. His/her blood glucose was checked resulting in a value of 38 mg/dl. Intravenous access was established, and the resident was administered D 10 intravenously and his/her blood sugar was rechecked with a value of 78. Additionally, the resident required supplemental oxygen and became more responsive and alert. Review of the hospital admission record from 3/7/2024, revealed the following physician progress note, .presenting with unresponsive episode at rehab facility .Patient's blood sugar was checked, blood glucose was 30's. EMS arrived and administered IV dextrose. On arrival to ED [emergency department] patient's glucose improved to the 190's. However [s/he] is confused .thinks [s/he] is in the car . During a surveyor interview with Staff A, on 3/11/2024 at 12:02 PM, she revealed that on 3/7/2024 she obtained the resident's blood sugar of 138 and acknowledged she administered the 40 units of Aspart insulin to the resident on 3/7/2024 and 36 units of 70/30 on 3/3/2024. Additionally, she indicated that she was unable to see that the resident had parameters for administration of his/her ordered insulin, because the entire order is not visible on the screen. She further revealed that she would have to hover her mouse over the order to be able to see that there were parameters in place for the administration of this medication. During a surveyor interview with Staff B, on 3/11/2024 at 3:10 PM she revealed that she was unaware that the resident had parameters to hold his/her insulin for a blood sugar less than 200. Additionally, she revealed that she was not aware that she should hover the mouse over the order to see the order in its entirety. Further she acknowledged she administered the resident insulin outside of ordered parameters on 3/4/2024 and 3/6/2024. During a surveyor interview on 3/11/2024 at 12:53 PM with the Director of Nursing Services in the presence of the Regional Nurse, she acknowledged that the resident received his/her 70/30 insulin on 3/3/2024, 3/4/2024 and 3/6/2024 and should not have. Additionally, she acknowledged that the resident received 40 units of Aspart insulin on 3/7/2024 which required him/her to receive glucagon administration to increase his/her low blood sugar. Lastly, she was unable to provide evidence that Resident ID #1 was kept free from significant medication errors. 1b. Record review revealed a physician's order dated 3/7/2024 for Glucagon Emergency Kit - 1 mg- Inject one syringe intramuscularly as needed for hypoglycemic reaction for blood sugar under 60. Recheck blood sugar every 15 minutes until the resident's blood sugar is greater than 70. Notify the MD for blood sugar less than 60. Record review revealed a progress note dated 3/7/2024 at 6:07 PM that the resident was found to be unresponsive with a blood sugar of 31 on 3/7/2024 and a code blue was called. S/he required the administration of Glucagon to raise his/her blood sugar level, which was administered by Registered Nurse, Staff B at 5:40 PM. Further record review revealed the resident's blood sugar was taken again and the results were 34 at 5:48 PM, and a second dose of Glucagon was administered to the resident by Registered Nurse Staff, C. During a surveyor interview with Staff C, on 3/12/2024 at 1:06 PM she revealed that on 3/7/2024 she responded to the code blue for Resident ID #1. She indicated that she noticed that the Glucagon bottle that Staff B had pulled to administer to the resident still had the Glucagon powder in the vial. She indicated that the resident's blood sugar was not responding to the first dose of Glucagon because s/he did not receive it, as the medication was not reconstituted, and the resident only received the sterile water. Once she realized that the Glucagon was not administered, she decided to get another vial of Glucagon and administer another dose to the resident. During a surveyor interview with Staff B, on 3/12/2024 at 1:50 PM she revealed that she was unaware that she needed to reconstitute the Glucagon prior to administering it. She acknowledged that she had only administered an injection of sterile water and she did not reconstitute the medication. Additionally, she revealed that she had not received any training or competencies for the use of Glucagon. During a surveyor interview on 3/12/2024 at 1:40 PM with the Director of Nursing Services, she indicated that she would have expected Staff B, to give the correct dose of Glucagon by reconstituting the medication as required. Additionally, she was unable to provide evidence of training and/or competency for Staff B related to the reconstitution and administration of the Glucagon medication. Due to the facility's failure Resident ID #1 received insulin when s/he should not have resulting in the resident experiencing a critical low blood sugar, diaphoresis, and unresponsiveness. Further the failure required the resident to receive Glucagon intramuscularly, required 15 liters of oxygen via nonrebreather, due to hypoxia, Intravenous D 10 and subsequent hospital transfer and admission. Cross Reference F 726

Mar 2024 1 deficiency 1 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 F0661 (Tag F0661)

Someone could have died · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident representative interview, and staff interview, it has been determined that the facility failed ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident representative interview, and staff interview, it has been determined that the facility failed to reconcile all pre-discharge medications with the resident's post-discharge medications, for 1 of 3 discharged residents reviewed, Resident ID #1. The facility also failed to complete a discharge summary that includes, but is not limited to, a recapitulation of the resident's stay, a final summary of the residents status at discharge and a reconciliation of the residents medications for 1 of 3 residents reviewed Resident ID #1. Findings are as follows: According to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities last revised on 2/3/2023, states in part, .A discharge summary must include an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions, to ensure that care is coordinated and the resident transitions safely from one setting to another. The discharge summary may help reduce or eliminate confusion among the various facilities, agencies, practitioners, and caregivers involved with the resident's care .The discharge summary contains necessary medical information that the facility must furnish at the time the resident leaves the facility, to the receiving provider assuming responsibility for the resident's care after discharge .Discharge instructions and accompanying prescriptions provided to the resident and if applicable, the resident representative must accurately reflect the reconciled medication list in the discharge summary .For residents discharged to their home, the medical record should contain documentation that written discharge instructions were given to the resident and if applicable, the resident representative. These instructions must be discussed with the resident and resident representative and conveyed in a language and manner they will understand . Record review of the facility's discharge policy titled Discharge Planning states in part, This facility maintains a centralized, coordinated, organized discharge planning program to ensure that each resident has a planned program of continuing care which meets the resident's post-discharge needs . Record review of a community complaint reported to the Rhode Island Department of Health on 3/6/2024, alleges Resident ID #1 was discharged home with another resident's (Resident ID #2's) medications. Additionally, the complaint alleges that Resident ID #1 was not told how to take his/her medications and took the medications that were not his/hers for 1 week. Record review of Resident ID #1 revealed s/he was admitted to the facility in December of 2023 with diagnoses including, but not limited to, type 2 diabetes mellitus and rhabdomyolysis (a condition where the breakdown products of muscle tissue are released in the blood. These are harmful to the kidney). During an interview with Resident ID #1's primary care physician on 3/7/2024 at 10:11 AM, he revealed that the resident presented to his/her appointment with another patient's medications. During a surveyor interview with Resident ID #1's daughter on 3/7/2024 at approximately 10:15 AM she revealed that she did not receive education pertaining to the resident's medications. She indicated that during the discharge on [DATE] she was just handed a bag full of medications. She revealed that when she got home, she administered the medications to Resident ID #1 for 5 days. She revealed that since being home the resident has been confused and has fallen twice and now has pain to his/her shoulder and back. Additionally, she revealed that his/her finger is swollen and bruised and is now using medication for pain relief. She revealed that the name on the medication card was Resident ID #2. Although, Resident ID #2's name was on the medication cards, she thought it was the physician's name. It was not until she attended the primary care visit with Resident ID #1 on 3/5/2024 and the physician reviewed the medications that they realized his/her family member had been taking someone else's medications. She further revealed the following medications were sent home on 2/29/2024 at discharge: Lasix (a medication used to treat excess fluid in the body) 20 milligrams (MG), Gabapentin (a medication used to treat seizures and/or pain) 300 MG, Levofloxacin (an antibiotic) 750 MG, levothyroxine (a medication used to treat an under active thyroid) 25 Micrograms and metformin (a medication used to treat high blood sugar) 500 MG. Record review reveals Resident ID #2 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, diabetes, morbid obesity and right foot wound. Record review reveals that Resident ID # was prescribed the following medications at the time of Resident ID #1's discharge: - Lasix 20 MG - Gabapentin 300 MG - Levofloxacin 750 MG - Levothyroxine 25 MCG - Metformin 500 MG Record review revealed Resident ID #1 was not prescribed the above-mentioned medications at the time of discharge. Review of a facility document titled Continuity of Care Discharge/Transfer of Patient Form indicated that the resident's medication list was attached to this document. Further review of this document failed to reveal a discharge summary that was signed as completed by the discharging nurse or that it was signed off as reviewed by the resident or responsible party. During a surveyor interview with Registered Nurse, Staff A, on 3/7/2024 at approximately 1:21 PM, she acknowledged that she handed Resident ID #1's family a bag of medications and paperwork for discharge. She further acknowledged she did not review the medication cards with the resident or family and did not check them prior to the resident leaving the facility to ensure that they were the correct medications prescribed for this resident. Additionally, she acknowledged that she did not complete the discharge paperwork for this resident on discharge. During a surveyor interview with the Director of Nursing Services (DNS) on 3/7/2024 at approximately 11:34 AM, she acknowledged that Resident ID #1 was discharged with Resident ID #2's medications as listed above and that the Continuity of Care Discharge/Transfer of Patient Form was not completed in its entirety. Additionally, she was unable to provide evidence that all pre-discharge medications were reconciled with the resident's post-discharge medications prior to Resident ID #1 being discharged home from the facility.

Dec 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

Based on surveyor observation, record review, and staff interview it has been determined the facility failed to maintain all patient care equipment in safe operating condition for 1 of 1 wheelchairs r...

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Based on surveyor observation, record review, and staff interview it has been determined the facility failed to maintain all patient care equipment in safe operating condition for 1 of 1 wheelchairs reviewed, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/21/2023 alleges in part, A technician from [his/her] [outpatient center] confirmed [s/he] arrived to [his/her] appointment in a broken wheelchair . Record review revealed the resident was admitted to the facility in December of 2023 with diagnoses including, but not limited to, end stage renal disease (a condition where the kidney reaches advanced stage of loss of function) and polyneuropathy (damage to multiple peripheral nerves). Record review of a document from an outpatient service provider titled, Continuity of Care Consultation and Referral Form dated 12/20/2023 states in part, please do not use this wheelchair for any patient any longer because .it lacks brake which can cause a lot of injury to the patient . During a surveyor interview on 12/21/2023 at 11:49 AM with Resident ID #1 s/he revealed s/he was transported to an outpatient appointment in a broken wheelchair. During a surveyor observation on 12/21/2023 at approximately 1:30 PM of the resident's wheelchair revealed the right-side wheel lock brake failed to engage properly. Additionally, the left arm rest cushion and the lower right side of the wheelchair arm were broken off with sharp edges exposed. During a surveyor interview on 12/21/2023 at 1:35 PM with Nursing Assistant, Staff A, she acknowledged the above surveyor observation and acknowledged the wheelchair was used for the resident on 12/20/2023. Additionally, she revealed she assisted Resident ID #1 into his/her wheelchair prior to his/her appointment on 12/20/2023 and at that time the right-side wheelchair lock was not properly engaging. Further, she revealed she did not report the broken wheel lock. During a surveyor interview on 12/21/2023 at 1:43 PM with the First Shift Supervisor, Registered Nurse, Staff B, she acknowledged the broken wheel lock, the broken arm cushion and the broken right lower side of the wheelchair arm. She revealed she was not aware of any issues with the resident's wheelchair. Further, she acknowledged the wheelchair should be removed from the patient care area. During a surveyor interview on 12/21/2023 at 2:13 PM with Nursing Assistant, Staff C, she acknowledged she assisted the resident out of the broken wheelchair on 12/20/2023 when s/he returned from his/her appointment. Additionally, she revealed the resident informed her the wheelchair was broken. Further, she revealed she reviewed the continuity of care form the outpatient service provider and she then notified Registered Nurse, Staff D. During a surveyor phone interview on 12/21/2023 at 2:01 PM with Staff D, she acknowledged she was notified by Staff C that the residents wheelchair was not locking on 12/20/2023. When asked by the surveyor what was done related to the wheelchair not properly locking, she stated in part, To be honest I didn't do anything, we normally put a sign on it and put it to the side. During a surveyor interview on 12/21/2023 at 2:16 PM with the Director of Nursing Services, she acknowledged above the surveyor observation. Additionally, she revealed that her expectation would be for the wheelchair to be taken out of service. Further, she was unable to provide evidence that the facility maintained patient care equipment in safe operating condition.

Jul 2023 1 deficiency

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected most or all residents

Based on staff interview and record review, it has been determined that the facility failed to maintain an effective pest control program so that the facility is free of pests. Findings are as follows...

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Based on staff interview and record review, it has been determined that the facility failed to maintain an effective pest control program so that the facility is free of pests. Findings are as follows: Record review of an anonymous community reported complaint received by the Rhode Island Department of Health on 7/18/2023, alleges, Bedbugs and roaches in the facility. During a surveyor interview on 7/19/2023 at 1:00 PM, with the Administrator, Director of Nursing Services (DNS), Director of Dining Services and the Maintenance Director, they revealed that the facility did not have any pest control services from 4/27/2023 to 7/13/2023, due to non-payment to the vendor. This failure to maintain monthly pest control services and prevention resulted in a fruit fly and roach infestation in the kitchen and in the dishwashing floor drains, which was identified on 7/6/2023 and resolved on 7/14/2023. Additionally, there was also a bed bug problem in a resident room on the second floor, identified on 7/17/2023 and resolved on 7/17/2023. Upon further interview with the Administrator, DNS, Director of Dining Services and the Maintenance Director, they indicated that the following interventions were put into place after the pests had been identified: 7/14/2023 • The kitchen utility room along with the dishwashing area and all areas with sinks, including handwashing, were treated with EPA chemicals Nibor D (1 gallon) and Fipronil-pus-C at .0051% (1 gallon) on fan spray mode. • The dishwashing area was also treated for roaches under and behind the dishwashing equipment. • All floor drains were treated for fruit flies and larvae. 7/17/2023 • First Floor -- All offices, desks, tables and chairs were inspected for bed bugs (none found). • Second Floor -- Six resident rooms, rehab offices and rehab gym were treated with EPA chemical Clothiandin at 1.4200% (2.5 gallons) for bed bugs (only one resident room was found with bed bugs). • Third Floor -- One resident room was treated with the above EPA chemical for bed bugs (none found). • All of the above resident rooms treated included: baseboards; bed frames; bed rails; connectors; headboards; footboards; dressers; and nightstands

Jan 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Based on record review, staff, and resident interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consist...

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Based on record review, staff, and resident interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 6 residents reviewed, Resident ID #5. Findings are as follows: Record review of two community reported complaints submitted to the Rhode Island Department of Health on 1/5/2023 and 1/10/2023 alleged concerns relative to medications not being administered and wounds. Record review revealed the resident was admitted to the facility in January of 2023 with diagnoses including, but are not limited to, unspecified unstageable pressure ulcer (pressure ulcers are localized areas of tissue necrosis (tissue death) that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time. Ulcers covered with slough; nonviable tissue or eschar; dead tissue are by definition unstageable), and stageable pressure ulcer of other sites. Record review of a document titled NUR- Pressure Injury /evaluation- V2 dated 1/5/2023 indicates the resident has an unstageable pressure ulcer to his/her left elbow and a stage 3 pressure ulcer (stage 3 pressure ulcers involve full-thickness skin loss potentially extending into the subcutaneous tissue layer, slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) to his/her right lower leg rear. Record review of a progress note dated 1/6/2023 states in part, resident was admitted yesterday .[s/he] has wound on [his/her] Rt [right] lower leg measured 3x6cm [centimeter], resident has also another wound on [his/her] Right buttocks measured 3cm x 3cm, the skin is dry, peeling with multiple red and scratches area on [his/her] skin. wounds were cleaned with NS [normal saline], covered with dressings. Record review reveals that on 1/6/2023 the Wound Nurse Practitioner assessed the resident and identified the following areas and ordered the following treatments: - Wound One: Unstageable right ischial (buttocks) pressure injury- Cleanse with normal saline, apply Santyl (ointment that removes dead tissue from wounds so they can start to heal), cover with boarded foam, to be changed daily and as needed for soiling, saturation, or accidental removal. - Wound Two: Unstageable left ischial pressure injury- Cleanse with normal saline, apply Santyl, cover with boarded foam, to be changed daily and as needed for soiling, saturation, or accidental removal. - Wound Three: Left posterior thigh partial thickness moisture associated skin dermatitis- Cleanse with normal saline, apply TRIAD hydrophilic (a sterile coating that can be applied anywhere, adheres to wet skin, and keeps the wound covered) to be changed daily. - Wound Four: Stage three pressure injury to right posterior lower leg- Cleanse with normal saline, apply medihoney(used for the management of wounds and burns) with a clean dressing, to be changed daily and as needed for soiling, saturation, or accidental removal. Although wounds one through four and the wound on the left elbow were identified by the facility the record failed to reveal evidence of a treatment for these wounds on 1/5, 1/6, 1/7, 1/8 or 1/9/2023. Further record review revealed that on 1/9/2023 the Wound Nurse Practitioner assessed the resident and identified the following areas and ordered the following treatments: - Wound One: Unstageable right ischial pressure injury- Cleanse with normal saline, apply TRIAD hydrophilic wound dressing, to be changed as needed for soiling, saturation, or accidental removal. - Wound Two: Unstageable left ischial pressure injury- Cleanse with normal saline, apply Santyl, cover with boarded foam, to be changed daily and as needed for soiling, saturation or accidental removal. - Wound Three: Left posterior thigh partial thickness moisture associated skin dermatitis- Cleanse with normal saline, apply TRIAD hydrophilic to be changed daily. - Wound Four: Stage three pressure injury to right posterior lower leg- Cleanse with normal saline, apply medihoney with a clean dressing, to be changed daily and as needed for soiling, saturation, or accidental removal. - Wound Five: Unstageable left elbow pressure injury- Cleanse with normal saline, apply medihoney with a clean dressing, to be changed daily and as needed for soiling, saturation, or accidental removal. Record review of the January Treatment Administration Record (TAR) revealed the following: - Wound One: the wound treatment is- Cleanse with normal saline, apply Santyl, cover with boarded foam, to be changed daily and as needed for soiling, saturation, or accidental removal. The wound treatment for the right ischial pressure ulcer was not initiated until 1/10/2023, which was approximately 4 days after the wound was identified. However, the most current order indicates that the wound should be treated with TRIAD hydrophilic wound dressing and not Santyl. - Wound Two: Cleanse with normal saline, apply Santyl, cover with boarded foam, to be changed daily and as needed for soiling, saturation, or accidental removal. The wound treatment for the left ischial pressure ulcer was not initiated until 1/10/2023, which was approximately 4 days after the wound was identified. - Wound Three- Record review failed to reveal evidence that the treatments ordered on 1/6 and 1/9/2023 were transcribed. - Wound Four: Cleanse with normal saline, apply medihoney with a clean dressing, to be changed daily and as needed for soiling, saturation, or accidental removal. The wound treatment order for the right lower leg was not initiated until 1/10/2023, which was approximately 5 days after the wound was identified. - Wound Five: Cleanse with normal saline, apply medihoney with a clean dressing, to be changed daily and as needed for soiling, saturation, or accidental removal. The wound treatment for the left elbow was not initiated until 1/11/2023, which was approximately 6 days after the wound was identified. During a surveyor interview with the Wound Nurse Practitioner on 1/18/2023 at approximately 1:30 PM, she revealed that she saw the resident on 1/6/2023 and 1/9/2023. She was unable to explain why the orders until were not initiated until 1/10/2023 and 1/11/2023. Additionally, she indicated that she expects the facility to implement and initiate the ordered treatments when provided to the facility. During a surveyor interview on 1/18/2023 at approximately 1:00 PM with the Assistant Director of Nursing, she revealed that she oversees the facility's wound care including the Wound Nurse Practitioner's recommendations. Additionally, she acknowledged that the wounds treatment orders for Resident ID #5 were provided to her on 1/6/2023 and 1/9/2023. She further acknowledged that she failed to transcribe them into the resident's Treatment Administration Record when she received them which caused a delay in treatment. On 1/19/2023 (which was approximately 9 days after the start of the survey) the surveyor was presented with a handwritten statement, dated 1/19/2023, authored by Licensed Practical Nurse, Staff C, that indicates she worked on January 6th, 7th, and 8th. She indicates that on January 6th the Wound Nurse Practitioner was doing rounds and it was discussed to apply TRIAD to wound 1 and 2 until Santyl came in. She further indicated that over the weekend she cleansed the areas with normal saline, applied TRIAD and covered the ischium with a dry protective dressing. She also indicated the right leg did not have orders for treatments, but over the weekend she cleansed the wound with normal saline and applied a dry protective dressing. During an exit interview on 1/19/2023 at approximately 4:00 PM with the Administrator and the Assistant Director of Nursing she was unable to explain why the wound treatments ordered were not implemented until 1/10/2023 and 1/11/2023. Additionally, she was unable to explain why a treatment order was never implemented for wound number three (left posterior thigh partial thickness moisture associated skin dermatitis). Furthermore, she able to explain why the order for wound number one (unstageable right ischial pressure injury) included Santyl and not the most recent treatment order for TRIAD.

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

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 infection for 1 of 2 resident...

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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 infection for 1 of 2 residents observed for wound care, Resident ID #4. Findings are as follows: Record review revealed the resident was admitted to the facility in June of 2016 and readmitted in October of 2022. S/he has diagnoses which include, but are not limited to, type two diabetes mellitus, and unstageable pressure ulcer [pressure ulcers are localized areas of tissue necrosis that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time. Ulcers covered with slough; nonviable tissue or eschar; dead tissue are by definition unstageable] of the sacral (the first and second sacral vertebrae) region. Further record review revealed a physician's order dated 11/20/2022 which states Cleanse coccyx wound w/ [with] normal saline. Pack w/4 x 4 gauze dampened w/ Dakin's solution [a solution used to prevent infection from pressure sores] to the depth of the wound. Cover w/ Qwick [super-absorbent dressing] wound DSG [dressing] followed by allevyn foam (absorbent foam dressing). Change twice daily. During a surveyor observation License Practical Nurse, Staff C, was observed to be changing the resident's coccyx dressing on 1/11/2023 at 12:15 PM. Staff C removed the old dressing and the surveyor observed the wound to have a moderate amount of sanguineous (bloody drainage) drainage coming from the wound. Staff C then cleansed the wound with Dakin's solution and not the Normal Saline as ordered. She was then observed to pack the wound with the same, now contaminated with sanguineous drainage, gauze that she used to clean the wound and proceeded to cover it with an Allevyn dressing. During a surveyor interview immediately following the observation with Staff C, she acknowledged that she cleansed the wound with Dakin's solution instead of Normal Saline as ordered. Additionally, she acknowledged that she used the dirty gauze that she had cleansed the wound with to pack the resident's wound. During a surveyor interview with the Administrator, the Assistant Director of Nursing, and the Regional Nurse on 1/11/2023 at approximately 3:00 PM, they indicated that Staff D did not follow proper infection control techniques when performing Resident ID #4's dressing change.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 3 of 6 residents reviewed, Reside...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 3 of 6 residents reviewed, Resident ID #s 1, 2, and 6. Findings are as follows: 1. Record review for Resident ID #1 revealed s/he was admitted to the facility in July of 2021 with diagnoses that include, but are not limited to, dementia with other behavioral disturbances and Covid-19. Record review of a progress note dated 12/26/2022 states in part, .Covid swabbed per facility protocol. Resident Covid positive . Record review of a physician's order with a start date of 12/28/2022 and an end date of 1/2/2023 states Paxlovid(antiviral medication used to treat Covid-19) (150/100) tablet therapy pack 10 x 150 MG [milligrams] give 1 tablet by mouth one time a day for Covid for 5 days. Record review of Resident ID #1's December and January's Medication Administration Records (MAR) failed to reveal evidence that the resident had received the Paxlovid as ordered. During a surveyor interview with the Administrator, the Director of Nursing Services (DNS) and the Regional Nurse, on 1/9/2023 at approximately 10:00 AM, they were unable to provide evidence that the resident received the above-mentioned medication as ordered. 2. Review of the medication insert, HIGHLIGHTS OF PRESCRIBING INFORMATION for Vimpat, states in part: .1 INDICATIONS AND USAGE 1.1 Partial-Onset Seizures VIMPAT (lacosamide) tablets are indicated as adjunctive therapy in the treatment of partial-onset seizures in patients with epilepsy .VIMPAT should be withdrawn gradually (over a minimum of 1 week) to minimize the potential of increased seizure frequency in patients with seizure disorders . Record review for Resident ID #2 revealed that s/he was admitted to the facility in July of 2022 with diagnoses to include, but are not limited to, cognitive communication deficit and seizures. Review of the resident's care plan dated 7/13/2022 revealed in part, history of seizure with the interventions of administering medications as ordered . Review of a physician's order dated 7/13/2022 states Vimpat [is classified as federally controlled substance] tablet 100 MG give 100 MG by mouth two times a day related to other seizures. Record review of the controlled substance log revealed Resident ID #2 had no available Vimpat for administration after receiving his/her Vimpat at 9:00 AM on 12/30/2022. Further review of the controlled substance log indicated that staff had administered the resident his/her Vimpat via the pyxis (the location of where the facility stores emergency and back up medications) on the following dates and times: -12/30/2022 at 7:45 PM -12/31/2022 at 8:15 AM -12/31/2022 at 8:00 PM -1/1/2023 at 8:25 AM -1/1/2023 at 8:15 PM -1/2/2023 at 9:08 AM -1/2/2023 at 9:50 PM Record review of the Med-Dispense report from the pyxis from 12/30/2022 through 1/3/2023 revealed that Lacosamide (Vimpat) was removed for administration to Resident ID #2 on the following dates and times: -12/30/2022 at 7:38 PM -12/31/2022 at 9:02 AM -1/1/2023 at 8:46 AM -1/1/2023 at 6:01 PM -1/2/2023 at 8:58 AM -1/2/2023 at 4:03 PM This indicated that Resident ID #2 missed his/her evening dose of Vimpat on 12/31/2022. Further review of the controlled substance log revealed that the pharmacy delivered 60 Vimpat tablets from the pharmacy on 1/3/2023 at 11:20 PM. Additional review of the Med-Dispense report from the pyxis for 1/3/2023 failed to reveal evidence that Vimpat had been removed for administration to Resident ID #2, indicating that s/he missed 2 doses of this medication on 1/3/2023. Record review of Resident ID #2's MAR for December 2022 and January 2023 revealed that the Vimpat was signed off as being administered for the evening dose of 12/31/2022 and for both doses on 1/3/2023 at 8:00 AM and 8:00 PM, despite it not being documented as removed from the pyxis or the controlled substance log. Record review of Resident ID #2's progress note dated 1/3/2023 at 9:00 AM, revealed Resident [anti-seizure medication] was not available. Pyxis checked and not available. Call made to P.A. [Physician Assistant; Staff A] regarding medication. Order to hold medication . During a surveyor interview with the Pharmacist on 1/9/2023 at 1:08 PM, he revealed that they received a refill request for Resident ID #2's Vimpat on Friday 12/30/2022 at 6:30 PM. He further indicated that their designated in-State pharmacy doesn't deliver on the weekends. During a surveyor interview with Staff A on 1/13/2023 at approximately 2:00 PM, she revealed that she expects residents to receive their medications as ordered. Additionally, she revealed that she was notified on 1/3/2023 about a delay in the medication delivery and did not provide an order to hold Resident ID #2's medication. She further indicated that she can't ask them to hold a medication that they don't have. The call was only a reporting that the medication wasn't available for the resident. During a surveyor interview with the Administrator, Regional Nurse, and the Assistant Director of Nursing Services (ADON) on 1/10/2023 at 3:00 PM, they were unable to provide evidence that Resident ID #2 received his/her seizure medication on the evening of 12/31/2022 or both doses on 1/3/2023. 3. Record review for Resident ID #6 revealed s/he was admitted to the facility in April of 2009 with a readmission in July of 2020 with diagnoses to include, but are not limited to, cognitive communication deficit and Covid-19. Record review revealed the following progress notes: - 1/6/2023 at 2:17 PM- Resident positive for covid. MD [physician] aware. New order for BMP [basic metabolic panel] in next 24 hours. If kidney function stable, may begin antiviral . - 1/7/2023 at 1:15 PM authored by the Infection Preventionist/ADON indicates that the resident was positive for Covid-19 as of 1/6/2023 and is complaining of cold like symptoms. The provider asked to obtain kidney function labs for resident and to follow up to see if resident's kidney function is appropriate for prescribing antiviral medication for Covid-19. Record review revealed the BMP was ordered, collected and reported to the facility on 1/7/2023. Further review of the progress notes revealed: - 1/9/2023 at 1:29 PM indicates that the labs were received and reported to the NP (Nurse Practitioner). - 1/9/2023 at 2:32 PM which indicates the NP ordered a treatment for COVID-19. Molnupiravir 800 MG PO BID X 5 days [by mouth twice a day] . Review of Resident ID #6's MAR for the month of January 2023 failed to reveal evidence that the resident received treatment for COVID-19 until 1/10/2023, which was 4 days after his/her Covid-19 diagnoses. During a surveyor interview on 1/11/2023 at approximately 3:00 PM, in the presence of the Administrator and the Regional Nurse, the ADON acknowledged that the resident did not receive treatment for Covid-19 from 1/6/2023 through 1/10/2023. During a surveyor interview with the Nurse Practitioner, Staff B on 1/12/2023 at 3:27 PM, she revealed that although there are notes indicating that she was notified of the Covid-19 positive test results on 1/6/2023, she was not aware until 1/9/2023 and provided the order for Molnupiravir. Additionally, she indicated that she would have started the resident on the antiviral medication sooner for a better outcome if she had been made aware of the positive test on 1/6/2023. During a surveyor interview on 1/18/2023 at 1:22 PM, with the ADON, she revealed that she reported the lab on Monday 1/9/2023 to the Nurse Practitioner when she came to the facility. She acknowledged that it should have been reported the same day to the on-call provider who is always available on the weekends.

Dec 2022 14 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free fr...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from abuse for 1 of 5 resident's reviewed, Resident ID #8. Findings are as follows: Review of the facility policy, titled Abuse Prohibition Policy, states in part, .Procedure .Identifying events, occurrences, patterns and trends of potential abuse for residents .Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment . Record review reveals that Resident ID #28 (perpertrator) and Resident ID #8 (victim) are roommates. Review of the record for Resident ID #28 revealed that s/he was admitted to the facility in March of 2017 with diagnoses including, but not limited to, Alzheimer's disease, vascular dementia, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) Assessment, dated 11/11/2022, revealed a Brief Interview for Mental Status (BIMS) score of 9 of 15, which indicates moderately impaired cognition. Review of the record for Resident ID #8 revealed that s/he was admitted to the facility in July of 2020 with diagnoses including, but not limited to, cognitive communication deficit and age-related cognitive decline. Review of the MDS, dated [DATE], revealed a BIMS score of 5 of 15, which indicates severely impaired cognition. Further review of the MDS revealed that s/he requires physical assistance of two or more staff to transfer out of bed and to move between locations in his/her room. Review of the record for Resident ID #28 revealed a note, dated 12/18/2022 at 8:57 PM, which states in part, .this resident went over to [his/her] roommate [Resident ID #8] and yelled for [him/her] to stop talking. Resident was then seen striking the bed only (not the patient) several times with [his/her] hand .the two are not suited as roommates together . Further review of the record revealed a note, dated 12/3/2022 at 5:48 PM, which states in part, .Resident [ID #28] agitated this AM and [s/he] reports it is R/T [related to] roommate smiling. [S/He] picked up [his/her] shoes and motioned to throw them at roommate . Additional review of the documentation for Resident ID #28 from July through October 2022 revealed the following: - 7/30/2022 at 2:15 PM: .Resident noted to be yelling over roommate while roommate was in bed. Resident not easily redirected. Resident son made aware of the situation and noted that this was not the first time this has happened . - 8/13/2022 at 1:47 PM: .Resident was found standing near [his/her] roommate's bed pointing [his/her] finger at [his /her] roommate, CNA went to remind [him/her] that [s/he] was making [his/her] roommate uncomfortable . - 10/12/2022 at 8:03 AM: Resident awake and refused to stay in bed for while with some confusion episode keep coming out without [his/her] walker to argue in [his/her] language, this nurse has cna[Certified Nursing Assistant] that speak [his/her] language to speak to resident to find out [his/her] problem, and was told that resident just confused making no sense in argument over [his/her] roommate . Review of the care plan for Resident ID #28 revealed an intervention for psychiatric consult as needed. Further review of the record failed to reveal evidence that psychiatric services were notified of the incidents on 12/3 and 12/18/2022 or that the resident was assessed by psychiatric services after 10/13/2022. During an interview with the Director of Nursing Services on 12/22/2022 at 10:34 AM and 1:18 PM, she was unable to provide evidence that Resident ID #8 was kept free from 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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Based on surveyor observation, record review and staff interview, it has been determined the facility failed to provide care to a resident who is unable to carry out activities of daily living (ADLs) ...

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Based on surveyor observation, record review and staff interview, it has been determined the facility failed to provide care to a resident who is unable to carry out activities of daily living (ADLs) and receives the necessary services to maintain personal hygiene for 1 of 6 residents reviewed, Resident ID #62. Findings are as follows: Record review for the resident revealed s/he was admitted to the facility in May of 2022 with diagnoses including, but not limited to, cognitive communication deficit and cerebrovascular accident (CVA/stroke). Record review revealed the resident has a care plan dated 5/9/2022, revised on 11/17/2022 for .has ADL deficit r/t [related to] Hemiparesis [weakness of one entire side of body] following CVA and muscle weakness . This care plan has interventions including but not limited to, .2 assist with adl's . During surveyor observations on the following dates and times, the resident was observed with all of his/her fingernails extending approximately 0.5 centimeters past the fingertips and with black matter under the middle and pointer fingernails on his/her left hand: - 12/20/2022 at 9:43 AM - 12/21/2022 at 8:26 AM - 12/22/2022 at 7:50 AM During a surveyor observation in the presence of the Unit Manager, Licensed Practical Nurse, Staff B and Licensed Practical Nurse, Staff A on 12/22/2022 at 3:25 PM revealed all of the resident's fingernails extending approximately 0.5 centimeters past the fingertips and with black matter under the middle and pointer fingernails on his/her left hand. During a surveyor interview with Staff B on 12/22/2022 at 3:35 PM, she acknowledged the resident's fingernails are long and dirty and needed to be cut and cleaned. Staff B was unable to provide evidence that the resident received the necessary services to maintain personal hygiene.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide ne...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services consistent with professional standards of practice, to promote healing and prevent new pressure ulcers from developing for 1 of 6 residents reviewed who is at risk for developing pressure ulcers or who have actual pressure ulcers, Resident ID #37. Findings are as follows: 1. Review of a facility policy titled, Pressure Injury/Non-Pressure Wound Risk Management dated 7/2017 states in part, .Maintain activity and mobility as follows for immobile patients: .When in bed, turn and reposition approximately Q2 [every two] hours or more frequently based upon resident's condition and specific needs . Record review revealed Resident ID #37 was admitted to the facility in November of 2020 with diagnoses including, but not limited to, fracture of the right femur and adult failure to thrive. Review of a Norton Plus assessment dated [DATE] revealed a score of 8 indicating that s/he is at high risk for pressure ulcers. Review of the care plan revealed a focus dated 11/17/2022 that states in part, Resident is at risk for skin breakdown r/t [related to] B+B [bowel and bladder] incontinence, decreased mobility and moisture . During constant surveyor observation on 12/21/2022 from 8:21 AM until 10:32 AM the resident was observed in bed on his/her back without staff repositioning or providing incontinent care. During a surveyor observation on 12/21/2022 at 10:32 AM with the 4th floor Unit Manager Licensed Practical Nurse (LPN), Staff E and Assistant Director of Nursing Services (ADNS) the resident was noted to have a stage I (intact skin with a localized area of non-blanchable redness) pressure injury to his/her coccyx. During constant surveyor observation on 12/22/2022 from 8:07 AM until 11:38 AM the resident was observed in bed on his/her back sitting at a 45 degree angle. During the 3 hours and 31 minutes the resident was not repositioned or provided incontinent care. During a surveyor observation on 12/22/2022 at 11:43 AM in the presence of Certified Nursing Assistant (CNA), Staff F the resident had been incontinent of bowel and bladder and had inflamed reddened skin to his/her coccyx and groin. During a surveyor interview on 12/22/2022 at 12:37 PM with the ADNS she acknowledged the resident has a stage I pressure injury to his/her coccyx. Additionally, she acknowledged that the resident is at high risk for pressure injury and should have been repositioned every two hours. 2. Review of a facility policy titled Weekly Body Audit dated 7/2017, states in part, All residents will have a body audit to address any skin issues on a weekly basis . Record review revealed that the resident had a skin assessment completed on 12/6/2022 and missed 10 weekly skin assessments between 10/18/2022 and 12/22/2022. During a surveyor interview on 12/22/2022 at 1:07 PM with the Director of Nursing Services she was unable to provide evidence of the 10 weeks of missing skin assessments. Additionally, she acknowledged the resident was at high risk for pressure injury and should have had weekly skin assessments and been repositioned every 2 hours.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to assess the...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to assess the resident for risk of entrapment from bed rails for 1 of 1 residents reviewed for use of bed rails, Resident ID #17. Findings are as follows: Record review revealed a policy titled, Bed Rails last revised August 2018, that states in part, .Evaluation is completed to identify potential benefits from utilizing side rails and minimize risks . Record review revealed Resident ID #17 was admitted to the facility in December of 2015 with diagnoses including, but not limited to, Alzheimer's disease and lack of coordination. Review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident requires extensive assistance of two or more staff with bed mobility and is totally dependent on two or more staff to transfer out of bed. Review of the care plan revealed an intervention with a revision date of 7/21/2022 that states in part, 2 quarter side rails for mobility and transferring . Review of a physician's orders with a revision date of 5/10/2022 that states, 1/4 Side rail to Both sides of bed for mobility and transfers . Further review revealed an order dated 11/17/2022 for, Air mattress; set according to weight . Further record review failed to reveal evidence of a quarterly side rail assessment being completed since 7/29/2022. During a surveyor observation on 12/21/2022 at 11:19 AM in the presence of Certified Nursing Assistant (CNA) Staff H, the resident was turned during wound care and bilateral arms were contracted and face was rolled into siderail without the resident being able to assist in the movement. Additionally, the bed was observed to have an air mattress set on the lowest setting. During a surveyor interview with Staff H directly following the above observation she revealed that the resident is unable to use the side rails to assist with bed mobility or transfers and the side rails are used to keep the resident from falling out of bed. During a surveyor interview on 12/22/2022 at 11:20 AM, with the Facility Plant Director he was unable to provide evidence of an entrapment assessment being completed with use of an air mattress for this resident. During a surveyor interview on 12/22/2022 at 1:16 PM, with the Director of Nursing Services she was unable to provide evidence that a quarterly side rail assessment or an entrapment assessment had been completed for the resident.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined the facility failed to ensure that the monthly pharmacy recommendations were acted upon for 1 of 9 residents reviewed, Resident ID #6...

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Based on record review and staff interview, it has been determined the facility failed to ensure that the monthly pharmacy recommendations were acted upon for 1 of 9 residents reviewed, Resident ID #68. Findings are as follows: Record review for the resident revealed s/he was admitted to the facility in October of 2022 with diagnoses including, but not limited to, depression and mood disorder. Record review revealed the resident has a physician order dated 10/18/2022 for Senna -Docusate Sodium [treat constipation] Tablet 8.6-50 MG [milligrams] .Give 1 tablet by mouth twice daily . Record review of the Medication Regimen Review documentation dated 11/3/2022 revealed a Consultant Pharmacist Recommendation which indicates, .Currently receiving Senna 1 tablet twice daily for constipation. Consider switching to Senna 2 tablets at bedtime for equal efficacy at greater ease of administration . Further review of the above document revealed that on 11/30/2022, the resident's physician documented that s/he was in agreement with the recommendation. Further record review failed to reveal evidence that an order was put in place for the resident to receive Senna 2 tablets at bedtime as per the recommendation by the pharmacist. During a surveyor interview with the unit manager, Licensed Practical Nurse, Staff B on 12/21/2022 at 1:52 PM, she was unable to provide evidence that the above recommendation by the pharmacist was acted upon.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principle...

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Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 1 of 3 medication carts observed. Findings are as follows: Review of a policy titled, Medication Storage Room/Medication Cart Policy dated February 2018, states in part, .Medication carts will be cleaned at least weekly and daily as needed. All spills will be cleaned immediately . During a surveyor observation on 12/21/2022 at 9:31 AM of the 4th floor med tech medication cart in the presence of Certified Medication Technician, Staff I, revealed the third drawer with brown liquid spilled in the bottom and medication bottles sticking to the substance. During a surveyor interview directly following the observation with Staff I she acknowledged the drawer was dirty and that she was unsure when the drawer had been last cleaned. During a surveyor interview on 12/21/2022 at 12:05 PM with the Director of Nursing Services she revealed that she would expect the staff to clean the medication carts whenever there is a spill.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to provide food and drinks th...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to provide food and drinks that are palatable, attractive, and at a safe and appetizing temperature relative to 1 of 18 resident reviewed, Resident ID #17. Findings are as follows: Record review revealed that Resident ID #17 was admitted to the facility in December of 2015. Review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident required extensive assistance of staff to eat. Surveyor observation of the lunch meal on 12/20/2022 at 12:30 PM revealed Resident ID #17 had his/her meal tray but staff were not assisting him/her with eating the meal. Further observation revealed the resident started to receive assistance with his/her meal at 1:18 PM, 48 minutes after the tray was delivered. Surveyor observation of the breakfast meal on 12/22/2022 at 8:38 AM revealed a breakfast meal was delivered to his/her room. At this time a test tray was requested by the surveyor. The staff member proceeded to obtain the test tray from the food truck. The surveyors placed the test tray covered at the nurses station. Further observation revealed the resident started to receive assistance with eating from Certified Nursing Assistant, Staff H, at 9:11 AM, 33 minutes after the tray was delivered. At this time the surveyor asked Staff H to observe the surveyor obtain the temperature of the test tray. Staff H took the test tray to Licensed Practical Nurse, Staff D and it was determined that the temperature of the food was 91.2 degrees. Staff D acknowledged that the food was cold and requested a new breakfast tray for the resident. During an interview with the Director of Nursing Services on 12/22/2022 at 1:14 PM, it was indicated that her expectation would be that the resident would be fed his/her food at an appetizing temperature.

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 and staff interview, it has been determined that the facility failed to assure that residents receive and consume food in the appropriate form for 1 resident observed, Re...

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Based on surveyor observation and staff interview, it has been determined that the facility failed to assure that residents receive and consume food in the appropriate form for 1 resident observed, Resident ID #17. Findings are as follows: Review of the record for the resident revealed that s/he was admitted to the facility in December of 2015 with a diagnosis including but not limited to dysphagia (difficulty or discomfort in swallowing). Further review of the record revealed a dietary order dated 12/12/2020 for .Puree Consistency-Dysphagia Level 1 texture . Review of the care plan, revised on 12/13/2022, revealed in part, .Provide puree diet . Surveyor observation on 12/22/2022 at 8:38 AM revealed a breakfast meal was delivered to the resident's room and at 9:11 AM Certified Nursing Assistant (CNA) Staff H was preparing to assist the resident with eating. Surveyor observations of the breakfast meal revealed the meal was mechanical soft consistency, not pureed consistency. During an interview with Staff H immediately following this observation it was indicated that she was unaware of the resident's current diet order. During an interview with Licensed Practical Nurse, Staff D, she acknowledged that the resident was not served his/her meal in the appropriate form per the dietary order. During an interview with the Director of Nursing Services on 12/22/2022 at 1:14 PM, it was indicated that her expectation would be that the resident would receive a pureed consistency diet as ordered.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

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 maintain medical records for each ...

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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 maintain medical records for each resident that are complete and accurately documented, in accordance with accepted professional standards and practice for 2 of 4 residents reviewed for skin evaluations, Resident ID #s 1 and 4. Findings are as follows: 1. Record review revealed Resident ID #1 was admitted to the facility in December of 2015 with diagnoses including, but not limited to, Alzheimer's Disease and weakness. Record review of the physician's orders revealed a current treatment order dated 1/6/2023 which states in part, Cleanse coccyx (tailbone) wound with wound cleanser, pat dry, apply skin prep to peri (around) wound apply Medihoney (wound treatment) to wound bed . Record review of the Pressure Injury [localized injury to the skin and underlying tissue usually over a boney prominence as a result of pressure] Evaluation documents revealed the following documentation relative to the resident's pressure injury to his/her coccyx. Findings are as follows: -1/24/2023, the pressure evaluation failed to reveal evidence of the current stage of the pressure injury and inaccurately documented the current location of the wound as the left buttocks. Additionally, the document revealed the healthy tissue of the wound is 50% but failed to reveal the remaining tissue type description. -1/17/2023, the pressure evaluation failed to reveal evidence of the current stage of the pressure injury and inaccurately documented the current location of the wound as the left buttocks. Additionally, the document revealed the healthy tissue of the wound is 75% but failed to reveal the remaining tissue type description. -1/10/2023, the pressure evaluation failed to reveal evidence of the current stage of the pressure injury and inaccurately documented the current location of the wound as the left buttocks. Additionally, the document revealed the healthy tissue of the wound is 0% and failed to reveal the remaining tissue type description. Additional record review revealed a Minimum Data Set (MDS) assessment dated [DATE], under Section M-Skin Conditions coded the resident as having one Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed). Record review revealed a care plan dated 11/8/2022 states in part, .at risk for skin breakdown .Open Area to left buttock/Stage 2 pressure .Further record review of the care plan with a revision date of 11/7/2022 states in part, .skin integrity r/t [related to] sedentary lifestyle and current wounds to coccyx and BLLE [bilateral lower extremities]. During a surveyor interview on 1/25/2023 at 1:15 PM with Registered Nurse, Staff A, she acknowledged she completed the above-mentioned pressure injury evaluations and indicated the current wound is a Stage IV (Full thickness tissue loss with exposed bone, tendon, or muscle) pressure injury. Additionally, she could not explain why the pressure evaluations were inaccurate or incomplete. 2. Record review revealed Resident ID #4 was admitted to the facility in April of 2022 with diagnoses including, but not limited to, senile degeneration of the brain and type 2 diabetes mellitus. Record review of the Non-Pressure Wound Evaluation document dated 1/20/2023 revealed the resident sustained a skin tear on 1/15/2023. Further review of the document failed to reveal the location of the skin tear. During a surveyor interview with the Director of Nurses on 1/25/2023 at approximately 2:40 PM, she could not explain why the above-mentioned wound evaluations documentation was incomplete and inaccurate.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

Based on surveyor observation, record review and staff interview, it has been determined the facility failed to provide care in accordance to a resident's plan of care for 1 of 4 residents relative to...

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Based on surveyor observation, record review and staff interview, it has been determined the facility failed to provide care in accordance to a resident's plan of care for 1 of 4 residents relative to falls, Resident ID #34, and 3 of 7 residents reviewed relative to Abnormal Involuntary Movement Scale (AIMS, a tool used to assess the presence and the severity of abnormal movement of the face, limbs and body), Resident ID #s 34, 35, and 36. Findings are as follows: 1A. Record review for Resident ID #34 revealed s/he was admitted to the facility in September of 2017 with a diagnosis including, but not limited to, dementia with psychotic disturbance. Record review revealed the resident has a care plan dated 5/10/2019 and revised on 12/19/2022 which states in part, .at risk for falls secondary to Previous History of falls and weakness 12/18/22 s/p [status post] fall . This care plan has interventions including, but not limited to, .low bed .Non skid safety strips [to the floor] on door side of bed .Safety strips added to floor in front of toilet . During surveyor observations on the following dates and times, revealed the resident laying in his/her bed with the bed positioned at approximately 2.5 to 3 feet from the floor, with no safety strips to the floor on the door side of his/her bed or to the floor in front of the toilet: - 12/20/2022 at 9:15 AM - 12/20/2022 at 11:11 AM - 12/20/2022 at 12:44 PM - 12/20/2022 at 12:58 PM - 12/21/2022 at 8:13 AM - 12/21/2022 at 8:30 AM - 12/21/2022 at 9:55 AM During a surveyor observation with Licensed Practical Nurse, Staff A on 12/21/2022 at 10:01 AM, she acknowledged that the bed was not in the low position and that there were no safety strips to the floor on the door side of the bed or to the floor in front of the toilet. During a surveyor observation in the presence of Unit Manager, Licensed Practical Nurse, Staff B on 12/21/2022 at 10:42 AM, revealed the resident laying in bed. The bed was approximately 1 foot from the floor, in the low position. During a surveyor interview with the Director of Nursing Services (DNS) on 12/22/2022 at 11:00 AM, she was unable to provide evidence that the care plan for falls was followed. 1B. Further record review revealed Resident ID #34 has a care plan dated 5/10/2019, revised on 11/22/2022 for, .uses antipsychotic medication r/t [related to] Behavior management and DX [diagnoses] of Delusion [fixed belief that's false and based on an inaccurate interpretation of reality despite being presented with evidence that proves otherwise] . This care plan has interventions including but not limited to, .Perform AIMS .at baseline and then at least every six months . Further record review failed to reveal evidence that the AIMS was completed as per the plan of care. During a surveyor interview with the DNS on 12/21/2022 at 11:53 AM, she was unable to provide evidence that the above care plan was followed. 2. Record review for Resident ID #35 revealed s/he was admitted to the facility in April of 2022 with a diagnosis including, but not limited to, adjustment disorder. Record review revealed the resident has a care plan revised on 11/15/2022 for .uses psychotropic medication [treat mental illness], seroquel . This care plan has interventions including, but not limited to, .Perform AIMS .at baseline and then at least every six months . Further record review failed to reveal that the AIMS was completed as per the plan of care. 3. Record review for Resident ID #36 revealed s/he was admitted to the facility in October of 2021 with a diagnosis including, but not limited to, depression. Record review revealed the resident has a care plan revised on 11/4/2022 for, .uses ANTIPSYCHOTIC medication with risk of side effect and/or adverse reactions . This care plan has interventions including, but not limited to, .Perform AIMS .at baseline and then at least every six months . Further record review failed to reveal evidence that the AIMS was completed as per the plan of care. During a surveyor interview with the DNS on 12/22/2022 at approximately 4:30 PM, she was unable to provide evidence that the above care plans were followed for Resident ID #'s 35 and 36.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards...

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Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality relative to following physician's orders for 2 of 3 residents review related to wanderguard use, Resident ID #s 32 and 37. 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. Review of the facility policy titled, WANDERING MANAGEMENT SYSTEM dated April 2015, states in part, .Procedure .Check every shift for placement and document .Check function of on a daily basis . Record review revealed Resident ID #37 was re-admitted to the facility in October of 2022 with diagnosis including, but not limited to, dementia, and delirium. Record review revealed a physician's order with a start date of 5/11/2022 which states in part, wander guard right ankle at all times monitor for placement and function every shift . Record review of the Treatment Administration Record for December of 2022 revealed the above-mentioned order was documented as administered daily. Record review revealed Resident ID #32 was admitted to the facility in November of 2020 with diagnosis including, but not limited to, Alzheimer's disease and vascular dementia. Record review revealed a physician's order with a start date of 5/11/2022 which states, Check wanderguard function daily. every day shift. Record review of the Treatment Administration Record for December of 2022 revealed the above-mentioned order was documented as administered daily. During a surveyor interview on 12/21/2022 at 1:55 PM with Licensed Practical Nurse, Staff D, she revealed she was not sure how the wanderguard function is tested. During a surveyor interview on 12/21/2022 at 2:18 PM with Unit Manager, Staff E, she revealed she was unsure how the wandergaurds are checked for function. During a surveyor interview on 12/22/2022 at 1:28 PM with the Director of Nursing Services she revealed the wanderguard testing device was missing. Additionally, she was unable to provide evidence the staff were following physician's order relative to checking the function of the wanderguard for Resident ID #s 32 and 37, despite documenting that they were.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected multiple residents

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status for 3 of 11 residents reviewed...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status for 3 of 11 residents reviewed, Resident ID #s 37, 45, and 73. Findings are as follows: Record review of a facility policy titled Weights dated August 2015, states in part, The following residents/patients are weighed weekly X[times]4: .Newly admitted residents/patients .Residents/patients with an unanticipated, unplanned weight loss of >[less than]5% in one month .Residents with an MD [physicians] order for weekly weights .The same scale should be used for each weighing of a particular resident/patient to ensure consistency and more accurate weights .All weight loss/gain of 3 pounds or more on a resident weighing 100 pounds or less and weight loss/gain of 5 pounds or more on a resident weighing 100 pounds or more requires a reweigh for verification. A reweigh is done on the same scale, with a licensed nurse present .If a significant weight loss/gain is identified (>5% in 30 days or >10% in 6 months), the Interdisciplinary Team, dietician, physician and family are notified. 1. Record review revealed Resident ID #37 was admitted to the facility in November of 2020 with diagnoses including, but not limited to, dementia with behavioral disturbance, adult failure to thrive, and dysphagia (difficulty swallowing). Review of a Dietitian note dated 12/10/2022 at 10:27 AM reveals the resident had a 17 pound weight loss, 13% weight loss in 30 days with new recommendations for weekly weights, notify physician of weight loss and to increase Ensure supplement to four times a day. Record review revealed the following weights: 11/1/2022 136.8 LBS (pounds) 12/5/2022 119.7 Lbs 12/7/2022 119.2 Lbs Further record review failed to reveal documentation of weights from 12/12/2022 and 12/19/2022 as ordered. During an interview with the Unit Manager, Staff E on 12/21/2022 at 12:34 PM, she acknowledged that the weekly weights had not been obtained since 12/7/2022. 2. Record review for Resident ID #45 revealed s/he was originally admitted to the facility in July of 2021 with diagnoses including, but not limited to, cerebral infarction (stroke), Crohn's disease (an inflammatory bowel disease often characterized by diarrhea, abdominal pain/distension) and endocarditis (inflammation of the inner layer of the heart). Record review revealed the following weights: 12/1/2022 - 168 lbs - Hoyer lift 12/11/2022 - 158.3 lbs - Hoyer lift 12/20/2022 - 176 lbs - Hoyer Record review failed to reveal evidence that the resident was reweighed per the facility policy after weight losses or weight gain on 12/1/2022, 12/11/2022 and 12/20/2022, or that the dietician, the physician and the family were notified. During an interview with the Unit Manager, Staff G on 12/22/2022 at 10:13 AM, she acknowledged the resident was not reweighed as per the facility policy on 12/1/2022, 12/11/2022 and 12/20/2022.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain an...

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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 maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to staff wearing appropriate personal protective equipment (PPE) for 4 of 4 residents reviewed for transmission-based precautions Resident ID #s 1, 39, 51, 61 and 1 of 3 wound dressings preformed, Resident ID #11. Findings are as follows: Review of the facility policy titled, Precautions to Prevent Transmission of Infectious Agents dated 7/17 states in part, Transmission-Based Precautions are for patients who are known or suspected to be infected or colonized with infectious agents .Transmission-Based Precautions are used empirically, according to the clinical syndrome and the likely etiologic agents at the time, and then modified when the pathogen is identified or transmissible infectious etiology is ruled out .Droplet precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. In addition to standard precautions, use droplet precautions for a resident with active respiratory symptoms and known or suspected to be infected with microorganisms transmitted by droplet transmitted (coughing and sneezing) .Place Isolation Cart outside the resident's room .Provide a supply of masks, gowns, gloves, etc., needed to maintain isolation precautions. Signage will be posted on the door frame or wall outside of the resident's room indicating the type of precautions and the required personal protective equipment (PPE) . Review of a facility provided in-service education document titled, Droplet Precautions dated 12/13/2022 states in part, .Healthcare personnel wear a surgical mask .eye protection, gown and gloves .DROPLET PRECAUTIONS EVERYONE MUST: .make sure their eyes, nose and mouth are fully covered before room entry . 1A.Record review revealed Resident ID #1 was admitted to the facility in June 2022. Record review revealed a progress note dated 12/17/2022 at 7:58 AM that states in part, .RSV precautions maintained due to roommate was positive . During surveyor observations on 12/20/2022 at approximately 8:25 AM and 10:15 AM revealed Resident ID #1s room with an empty isolation cart outside of the room. During a surveyor observation on 12/20/2022 at approximately 10:19 AM of the resident's room revealed a Nurse Practitioner (NP) Staff L in the resident's room not wearing goggles or a gown. During a surveyor interview during the above-mentioned observation with the Certified Medication Technician (CMT) Staff I, she revealed that if there is no signage on the resident's door the staff should wear what's in the isolation cart.Staff I acknowledged that the isolation cart was empty, however the resident was on precautions for RSV. 1B. Record review revealed Resident ID #39 was re-admitted to the facility in June of 2018. Further record review revealed a progress note dated 12/21/2022 at 2:43 PM which states in part, Resident complained of sore throat and nasal congestion. Was seen by the provider N.O Stat [immediately] RSV, FLU and PCR Covid . During a surveyor observation on 12/22/2022 at approximately 9:45 AM revealed the resident did not have an isolation cart outside his/her room and no signage posted indicating the resident was on precautions. Additional record review revealed a positive lab result dated 12/22/2022 indicating the resident has tested positive for RSV. During a surveyor interview on 12/22/2022 at 9:48 AM with the 4th floor Unit Manger LPN, Staff E, she revealed the resident became symptomatic on 12/21/2022 with respiratory concerns and that FLU RSV and Covid-19 test was ordered. She further indicated s/he was not placed on precautions pending the results of the FLU, RSV and Covid-19 tests per the facility policy. During a surveyor interview on 12/22/2022 at 1:13 PM with the Director of Nursing Services (DNS) and Assistant Director of Nursing Services (ADNS) they acknowledged that Resident ID #39 was tested for COVID-19, FLU and RSV and was not placed on precautions when suspected to be infected with an infectious agent per the facility policy. She further revealed she would have expected the staff to have worn the proper PPE in each precaution room and signage to be posted at the doors indicating the appropriate precautions per the facility policy. 1C. Record review revealed Resident ID #51 was admitted to the facility in June 2022. Record review revealed Resident ID #51 was admitted to the hospital on [DATE] where s/he tested positive for RSV. Additional record review revealed the resident was noted to have periods of hypoxia (deficiency in the amount of oxygen reaching the tissue) when lying down. Further review revealed the resident had abnormal lung sounds bilaterally. During a surveyor observation on 12/20/2022 at 8:18 AM revealed the resident had an empty isolation cart outside of his/her room. Further observation failed to reveal signage indicating the type of precautions and the required PPE. During a surveyor observation on 12/20/2022 of the resident's room revealed the following: At 9:48 AM Licensed Practical Nurse (LPN), Staff D, entering the resident's room without wearing eye protection. At 12:36 PM Nursing Support Staff, Staff M, entered the resident's room without wearing eye protection. At 12:50 PM LPN Staff D walked into the resident's room wearing only an N95 mask, no gown, goggles, or gloves were worn. During a surveyor interview on 12/20/2022 at 8:58 AM with CNA, Staff N, she stated there should be signage posted related to the type of precaution the resident is on. Additionally, she revealed the resident was on droplet precautions. During a surveyor interview on 12/20/2022 at 12:38 PM with Staff M she revealed she was unaware that eye protection was required in Resident ID #51's room. 1D. Record review revealed Resident ID #61 was admitted to the facility in May of 2021. Record review revealed the resident tested positive for Respiratory Syncytial Virus (RSV is a contagious virus that is usually mild but can severely affect the lungs and respiratory airways in older adults) on 12/19/2022. During a surveyor observation on 12/20/2022 at 8:23 AM revealed Resident ID #61 with an isolation cart outside of his/her room. Further observation failed to reveal signage indicating the type of precautions and the required PPE to utilize when entering the room. During a surveyor interview on 12/20/2022 at 8:25 AM following the above-mentioned observation, with CNA, Staff J she revealed that if there is no signage on the door the staff wear whatever is in the bin. During a surveyor observation on 12/20/2022 at 9:57 AM of CNA, Staff K, she entered Resident ID #61's room that had an isolation cart outside of the room without eye protection on. During a surveyor observation on 12/20/2022 at 10:25 AM of the resident's room revealed LPN, Staff D in the resident's room wearing only her personal glasses, no eye protection was in use. Staff D left the room and then returned into the room with no gown or eye protection on. During a surveyor interview on 12/20/2022 at 1:18 PM with CNA, Staff K, she revealed she was unaware that she had to wear eye protection in the resident's room as there was no signage posted outside the door. During a surveyor interview on 12/22/2022 at 1:13 PM with the Director of Nursing Services (DNS) and Assistant Director of Nursing Service they revealed they would have expected the staff to have worn the proper PPE in each precaution room and signage to be posted at the doors indicating the appropriate precautions per the facility policy. 2. Record review of the facility policy titled, Clean Dressing Technique dated 7/17 states in part, .Sanitize hands and apply clean gloves .Remove old dressing and discard in plastic bag .remove gloves, sanitize hands and apply clean gloves .cleanse the wound . Record review revealed Resident ID #11 was admitted to the facility in June of 2022 with diagnoses included, but is not limited to, cellulitis (infection) of the right lower limb and cellulitis of the left lower limb. Record review revealed a physicians order dated 12/20/2022 which states in part, .Cleanse right leg with NS [normal saline], Pat dry, apply Silver antimicrobial wound gel[wound treatment] to open area, cover with 4x4[type of wound cover], then wrap with Kling[bandage] . During a surveyor observation of wound care on 12/20/2022 at 11:22 AM revealed LPN Staff D removed the old dressing dated 12/19/2022 and discarded the soiled dressing and dirty gloves on a paper towel that was placed on the floor. She then proceeded to don clean gloves pick up the trash from the floor and then place the trash into a trash bag. She then cleaned the wound with the same gloves she used to pick up the soiled dressing supplies and paper towel off the floor with. During a surveyor interview on 12/20/2022 at 11:48 AM with Staff D she acknowledged that she touched the dirty dressings and garbage on the floor and did not change her gloves prior to cleaning the wound. During a surveyor interview on 12/21/2022 at 12:05 PM with the DNS she revealed she would expect the nurse to utilize a trash bag to discard a soiled dressing. Additionally, she would expect the nurse to perform hand hygiene between glove changes and not utilize the same gloves to pick trash up off the floor and then clean the wound.

MINOR (C)

Minor Issue - procedural, no safety impact

Assessment Accuracy (Tag F0641)

Minor procedural issue · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, it has been determined that the facility assessments failed to accurately reflect 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 assessments failed to accurately reflect the resident's status for 3 of 3 residents reviewed for wanderguard use, Resident ID #s 32, 37 and 50. Findings are as follows: 1. Record review revealed Resident ID #32 was admitted to the facility in November of 2020 with diagnoses including, but not limited to, Alzheimer's disease and adult failure to thrive. Review of a physician's order dated 5/22/2022 revealed Check wanderguard function daily. every day shift . During a surveyor observation on 12/20/2022 at 9:49 AM, revealed the resident had a wanderguard device on his/her left ankle. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section P titled, Restraints and Alarms with wander/elopement alarm coded as not in use. Review of a quarterly MDS assessment dated [DATE] revealed Section P titled, Restraints and Alarms with wander/elopement alarm coded as not in use. 2. Record review revealed Resident ID #37 was admitted to the facility in November of 2020 with diagnoses including, but not limited to, dementia and psychotic disorder with delusions. Review of a physician's order dated 5/11/2022 revealed wanderguard right ankle at all times monitor for placement and function every shift . During a surveyor observation on 12/20/2022 at 12:31 PM, revealed the resident had a wanderguard device on his/her right ankle. Review of a quarterly MDS assessment dated [DATE] revealed Section P titled, Restraints and Alarms with a wander/elopement alarm coded as not in use. Review of a Significant Change MDS assessment dated [DATE] revealed Section P titled, Restraints and Alarms with a wander/elopement alarm coded as not in use. 3. Record review revealed Resident ID #50 was admitted to the facility in October of 2018 with diagnoses of, but not limited to, dementia and adult failure to thrive. Review of a physician's order dated 5/11/2022 revealed check wanderguard placement every shift . During a surveyor observation on 12/21/2022 at 1:55 PM, revealed the resident had a wanderguard device on his/her left ankle. Review of quarterly MDS assessment dated [DATE] revealed Section P titled, Restraints and Alarms with a wander/elopement alarm coded as not in use. Review of an Annual MDS assessment dated [DATE] revealed Section P titled, Restraints and Alarms with a wander/elopement alarm coded as not in use. During a surveyor interview on 12/21/2022 at 12:42 PM, with the MDS Coordinator, Staff C, she revealed that the above-mentioned residents should have been coded as using a wander/elopement alarm and it was a coding error. During a surveyor interview on 12/21/2022 at 1:46 PM with the Director of Nursing Services she revealed that she would expect the MDS to be coded accurately.

Summit Commons Rehabilitation and Health Care Cent

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