Heritage Hills Nursing & Rehabilitation Center
For profit - Limited Liability company
100 Beds
MARQUIS HEALTH SERVICES
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
33/100
#40 of 72 in RI
Photo by Heritage Hills Rehabilitation & Healthcare Center
Photo by Heritage Hills Rehabilitation & Healthcare Center
Photo by Heritage Hills Rehabilitation & Healthcare Center
1 / 5 photos
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Heritage Hills Nursing & Rehabilitation Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided. They rank #40 out of 72 facilities in Rhode Island, placing them in the bottom half, and #22 out of 41 in Providence County, meaning only one facility nearby is ranked lower. The facility is reportedly improving, having reduced the number of issues from 21 to 6 over the past year. However, staffing is a concern with a below-average rating of 2 out of 5 stars, and a turnover rate of 50%, which is higher than the state average. Additionally, there have been serious incidents, including a resident successfully eloping from the facility and another resident not receiving essential medication, which raises alarm about their supervision and medication management practices.
- Trust Score
- F
- In Rhode Island
- #40/72
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 50% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $25,376 in fines. Lower than most Rhode Island facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 36 minutes of Registered Nurse (RN) attention daily — about average for Rhode Island. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 69 deficiencies on record. Higher than average. Multiple issues found across inspections.
33/100
Bottom 45%
Review needed
21 → 6 violations
★★★☆☆
3.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 21 issues
2025: 6 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Rhode Island average (3.1)
Meets federal standards, typical of most facilities
Staff Turnover: 50%
Near Rhode Island avg (46%)
Higher turnover may affect care consistency
Federal Fines: $25,376
Below median ($33,413)
Moderate penalties - review what triggered them
Chain: MARQUIS HEALTH SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 69 deficiencies on record
1 life-threatening 2 actual harm
Aug 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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on record review, staff and resident interviews, it has been determined that the facility failed to ensure that each resident receives adequate supervision and care to prevent an accident for 2 ...
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Based on record review, staff and resident interviews, it has been determined that the facility failed to ensure that each resident receives adequate supervision and care to prevent an accident for 2 of 3 residents reviewed who are at risk for falls, Resident ID #s 5 and 6. Findings are as follows:Record review of a United States Food and Drug Administration document titled A Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts states in part, to keep the bed in the lowest position with the wheels locked.1. Review of a community reported complaint submitted to the Rhode Island Department of Health on 7/30/2025 alleges that Resident ID #5 told a social worker at a local hospital that s/he was left unattended at the bedside while receiving care, sustained a fall and was sent to the hospital for an evaluation. Record review revealed Resident ID #5 was admitted to the facility in July of 2025 with a diagnosis that includes, but is not limited to, paraplegia (a type of paralysis that affects the lower half of the body, typically resulting in the loss of movement and/or sensation in both legs and sometimes parts of the lower abdomen).Record review of a Brief Interview for Mental Status (BIMS) completed on 7/31/2025 revealed a score of 13 out of 15, which indicates his/her cognition is intact. Record review of a document titled, Safe Patient Handling Evaluation, dated 7/15/2025 revealed that for bed mobility, the resident is dependent on two staff members using a sheet for turning and repositioning. Record review of the resident's Kardex (a documentation system that enables nurses to write, organize, and easily reference key resident information that shapes their nursing care plan) states in part, monitor for safety and the potential increased risk for fallsDuring a surveyor interview conducted on 7/31/2025 at 1:45 PM, Nursing Assistant Staff A stated that on 7/29/2025, she was the only staff member present in the resident's room while providing care. She reported elevating the bed to approximately waist height to facilitate care and did not return it to the lowest position afterward. Staff A indicated that the resident was positioned on his/her side in preparation for his/her wound treatment when she stepped to the doorway to call for the nurse. While she was at the door, the resident fell from the bed to the floor.Record review revealed that on 7/29/2025 the resident was sent to the emergency room for evaluation and was admitted .During a surveyor interview on 8/1/2025 at 2:15 PM with the Director of Rehabilitation Services, he revealed the resident is a fall risk, has impulsive behaviors, and needs supervision for safety if his/her bed is raised to waist level.During a surveyor interview on 8/1/2025 at 2:45 PM, the Director of Nursing Services (DNS) was unable to provide evidence that the Safe Patient Handling Evaluation dated 7/15/2025 was followed for Resident ID #5. Specifically, the resident was not assisted by two staff members or with the use of a turning/repositioning sheet, as outlined in the evaluation. 2. Record review revealed Resident ID #6 was re-admitted to the facility in March of 2024 with a diagnosis that includes, but is not limited to, spastic quadriplegic (partial or complete paralysis of all four limbs including the torso). Record review revealed a BIMS assessment was dated 4/30/2025 and a score was not able to be obtained due to his/her cognition.Record review of physician's order dated of 7/15/2025 reads in part, .floor mats to bilateral sides of the bed when resident in bed.Record review of a document titled Visual/Bedside Kardex Report states in part, .safety.bed in low position and floor mats.Record review of a care plan last revised on 6/23/2025 revealed that the resident is at risk for falls with an intervention that was implemented on 4/4/2025 to have the bed in a low position and floor mats.During a surveyor observation on 8/1/2025 at 1:40 PM, the resident was in his/her bed and only had one floor mat on the right side of the bed.During a surveyor interview on 8/1/2025 at 1:45 PM, immediately following the above-mentioned observation with a Licensed Practical Nurse, Staff B, she acknowledged a floor mat was not present on the left side of the bed and indicted one should have been.During a surveyor interview on 8/1/2025 at 2:45 PM with the Director of Nursing Services, she was unable to provide evidence that Resident #6 had floor mats to the bilateral sides of his/her bed on 8/1/2025.
Apr 2025
1 deficiency
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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure residents with pressure ulcers/injury (localized damage to the skin and/or underlying soft tissue,...
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Based on record review and staff interview, it has been determined that the facility failed to ensure residents with pressure ulcers/injury (localized damage to the skin and/or underlying soft tissue, usually over a bony prominence) receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 of 3 residents reviewed, Resident ID #s 1, 4 and 6.
Findings are as follows:
Record review of two community reported complaints dated 4/1/2025 and 4/2/2025 allege that Resident ID #4 arrived to the facility with a wound that worsened significantly, due to lack of adequate wound care while the resident was at the facility.
According to the State Operations Manual, Appendix PP Guidance to Surveyors for Long Term Care Facilities, revised 8/8/2024, states in part, A pressure ulcer/injury (PU/PI) can occur wherever pressure has impaired circulation to the tissue. A facility must .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 .
When assessing the PU/PI itself, it is important that documentation addresses:
- The type of injury (pressure-related versus non-pressure-related) because interventions may vary depending on the specific type of injury;
- The PU/PI's stage;
- A description of the PU/PI's characteristics;
- The progress toward healing and identification of potential complications;
- If infection is present;
- The presence of pain, what was done to address it, and the effectiveness of the intervention; and
- A description of dressings and treatments .
1. Record review of Resident ID #4's admission progress note dated 3/8/2025 revealed the resident was admitted to the facility in the afternoon and has a pressure injury to his/her coccyx (tailbone).
Record review of the weekly skin check dated 3/8/2025 revealed the resident has a pressure injury to his/her coccyx, measuring 4 centimeters (cm) in width x 3.5 cm in length.
Record review failed to reveal documentation of the pressure injury stage, description or characteristics.
Further record review revealed a care plan initiated on 3/8/2025, indicating the resident has a pressure ulcer related to immobility. Interventions include, but are not limited to, administer treatments as ordered.
Record review failed to reveal evidence that a treatment order was implemented for the pressure injury, until 3/10/2025, indicating the resident's pressure injury was without a treatment for 2 days.
Record review of a wound evaluation and management summary report dated 3/13/2025, revealed the resident has an unstageable coccyx pressure injury (full thickness tissue loss where the depth of the ulcer is completely obscured by dead tissue), measuring 4.1 cm in length x 4.6 cm in width x 0.1 cm in depth, with a moderate amount of serous (clear and pale yellow in color) drainage and the wound bed included 100% thick necrosis tissue (dead tissue).
Furthermore, record review of the wound evaluation and management summary reports dated 3/13/2025, 3/20/2025 and 3/27/2025, revealed recommendations for the coccyx peri wound (skin around the wound) treatment to apply skin prep (a fast-drying sterile liquid that forms a skin-protectant film and a protective layer) once daily.
Record review failed to reveal evidence of an order for the skin prep or evidence that the skin prep was applied to the peri wound of the coccyx, after it was recommended by the wound physician.
During a surveyor interview on 4/1/2025 at 3:59 PM with the Director of Nursing Services (DNS), she was unable to provide documentation of the pressure injury stage, description or characteristics until 3/13/2025. Additionally, she acknowledged that the resident did not have a treatment order for his/her wound, until 3/10/2025.
During a surveyor interview in the presence of the DNS on 4/2/2025 at approximately 9:00 AM, with the wound nurse, Staff A, she revealed she conducted wound rounds with the wound physician on 3/13/2025, 3/20/2025 and 3/27/2025 and then communicated the recommendations to the resident's provider, Nurse Practitioner, Staff B.
During the above mentioned interview, Staff A revealed Staff B has always agreed with all the recommendations made by the wound physician. Additionally, Staff A revealed she failed to transcribe the treatment order to the medical record, resulting in the skin prep not being applied. Staff A revealed the skin prep should have been applied to the coccyx peri wound as ordered.
2. Record review revealed Resident ID #1 was admitted to the facility with multiple wounds including a deep tissue injury (damage that occurs beneath the skin's surface, affecting muscles, bones, or connective tissues) to his/her left heel.
Record review revealed a care plan initiated on 1/21/2025 and revised on 2/6/2025, indicated that the left and right heel wounds are currently a stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough (dead tissue) may be present but does not obscure the depth of tissue loss) pressure injury. The care plan interventions include, but are not limited to, administer treatments as ordered.
Record review of a wound evaluation and management summary report dated 3/13/2025, revealed the resident has the following wounds:
-Left heel stage III, measuring 1.3 cm in width x 1.6 cm in length x 0.1 cm in depth, with no drainage, 50% slough, 40% other viable tissue and 10% granulation tissue (new tissue, part of wound healing).
-Right heel stage III, measuring 0.8 cm in width x 0.5 cm in length x 0.1 cm in depth, with no drainage, 10 % slough, 60% other viable tissue and 30% granulation tissue.
-Right lateral foot non-pressure wound, measuring 1.3 cm in width x 1.6 cm in length x not measurable depth, scabbed with no drainage.
-Left anterior great toe non-pressure wound, measuring 0.8 cm in width x 0.8 cm in length x 0.2 cm in depth, with no drainage, 50% granulation tissue and 50% other viable tissue.
Further record review of the wound evaluation and management summary reports dated 3/13/2025, 3/20/2025, and 3/27/2025 revealed recommendations including, but not limited to, apply skin prep once daily to the peri wounds for the following wounds:
-left heel
-right heel
-right lateral foot
-left anterior, great toe
Record review failed to reveal evidence of an order for the skin prep or evidence that the skin prep was applied to the above-mentioned wounds.
During a surveyor interview on 4/2/2025 at 9:45 AM with Staff A, she revealed that she conducted wound rounds with the wound physician on 3/13/2025, 3/20/2025 and 3/27/2025 and then communicated the recommendations to resident's provider, Staff B. Staff A revealed she failed to transcribe the treatment order to the medical record, resulting in the skin prep not being applied. Staff A revealed the skin prep should have been applied to the above-mentioned wounds as ordered.
3. Record review revealed Resident ID #6 has a care plan initiated on 11/13/2024, indicating that the resident has a stage IV pressure ulcer (deep wound that may impact muscle, tendons, ligaments, and bone) of the right lateral ankle. Interventions include, but are not limited to, administer treatments as ordered.
Record review of a wound evaluation and management summary report dated 3/13/2025 revealed the resident has a wound to his/her right knee, measuring 1.9 cm in width x 1.5 in cm length x 2.6 cm in depth.
Record review of the wound evaluation and management summary reports dated 3/13/2025, 3/20/2025, and 3/27/2025 revealed recommendations including, but not limited to, apply skin prep once daily to the right knee peri wound.
Record review failed to reveal evidence of an order for the skin prep or evidence that the skin prep was applied to the above-mentioned wounds.
During a surveyor interview with Staff A in the presence of the DNS on 4/2/2025 at approximately 11:00 AM, she revealed that she conducted rounds with the wound doctor for the resident on the above mentioned dates. Staff A revealed that after the wound rounds, she communicated the recommendations to the resident's provider, Staff B. Staff A also revealed she failed to transcribe the treatment order to the medical record, resulting in the skin prep not being applied. Staff A revealed the skin prep should have been applied to the the right knee peri wound as ordered.
During a surveyor interview on 4/2/2025 at 12:19 PM with Staff B, she revealed that she is the provider for Resident ID #s 1, 4 and 6. Staff B revealed that she approves all recommendations provided by the wound physician. Additionally, she revealed that she was unaware that the residents did not receive the skin prep as ordered.
During a surveyor interview on 4/2/2025 at approximately 1:00 PM, with Staff A, the DNS and the Regional Director of Clinical Services, they were unable to provide evidence that Resident ID #s 1, 4 and 6 received the wound treatments as ordered.
Jan 2025
1 deficiency
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 F0658
(Tag F0658)
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 receive treatment and care in accordance with professional standards of practice, r...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following a physician's order for obtaining a urology consult for 1 of 1 resident reviewed, Resident ID #1.
Findings are as follows:
According to Mosby's 4th Edition, Fundamentals of Nursing page 314, states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
Review of a community reported complaint submitted to the Rhode Island Department of Health on 1/21/2025 alleged in part, .[Resident ID #1] was taken to [hospital name] .last night as [s/he] had a fever and an infection .they found [his/her] catheter extremely dirty, which in all probability, caused [him/her] to have a UTI .
Record review revealed the resident was admitted to the facility in November of 2024 with a diagnosis including, but not limited to, retention of urine.
Record review revealed the following physician's orders:
12/9/2024 - Obtain a urologist consult if a trial void (measures the ability of the bladder to empty) failed every shift.
12/21/2024 - Obtain a urologist consult if a trial void failed as needed.
During a surveyor interview on 1/22/2025 at approximately 3:15 PM with the Administrator, she revealed that a nurse changed the urology consult order to an as needed order on 12/21/2024, therefore it wouldn't show up on the Treatment Administration Record for staff to sign off on daily.
Record review of the progress notes revealed the following:
-12/9/2024 at 10:21 PM - Nurse practitioner (NP) ordered to discontinue indwelling catheter and start a trial void. If the resident doesn't void in 8-10 hours, straight catheterize. If there is less than 250 cubic centimeters (CC) reinsert foley and obtain a urologist consult.
-12/10/2024 at 5:50 AM - Resident attempted to void 2 times without results. Urine was obtained by straight catheterization.
-12/10/2024 at 4:30 PM - Resident was straight catheterized and 400 cc of urine was obtained. Per the NP leave the foley catheter in and have the resident seen for a urology consult.
Further record review failed to reveal evidence that a urology consult was scheduled by the facility, as ordered.
A surveyor interview was unable to be conducted with Resident ID #1 during the survey as s/he had been discharged to the hospital.
During a surveyor interview on 1/22/2025 at 1:57 PM with Nurse Practitioner, Staff A, she revealed that she did order a urology consult for the resident if s/he failed a trial void. She further revealed that the resident did fail the trial void, so she wants the resident to have the urology consult.
During a surveyor interview on 1/22/2025 at approximately 3:15 PM with the Administrator, she acknowledged that the urology consult appointment failed to be scheduled.
Jan 2025
1 deficiency
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and resident interview, it has been determined that the facility failed to ensure that a resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and resident interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed who missed 2 of 3 appointments, Resident ID #1.
Findings are as follows:
Review of a community reported complaint submitted to the Rhode Island Department of Health on 1/8/2025, alleges a resident had missed appointments including, but not limited to, neurology and dental. The complaint further alleges that the family member called the facility to confirm a neurology appointment for 1/7/2025 and spoke with a nurse about the appointment.
1a. Record review revealed Resident ID #1 was admitted to the facility in July of 2024 with a diagnosis including, but not limited to, Parkinson's disease (a neurodegenerative disease).
Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 10 out of 15, indicating the resident's cognition was moderately impaired.
During a surveyor interview with the resident on 1/9/2024 at 12:07 PM with the assistance of an interpreter, s/he indicated that s/he was unsure if s/he had missed any appointments however would like to be seen by a dentist.
Record review of a nursing progress note dated 8/5/2024, revealed the resident had a neurology appointment at 11:00 AM and transportation would be provided. Additionally, the progress note failed to reveal evidence of a date for the neurology appointment.
Record review failed to reveal evidence of a Continuity of Care document or any other follow-up documents from the neurology appointment.
During a surveyor interview on 1/9/2025 at approximately 2:00 PM with the secretary of the neurology practice, she indicated that the resident had attended a neurology appointment on 8/6/2024 and a follow up was scheduled for 1/7/2025. She further indicated that the resident did not show up to the appointment on 1/7/2025, and that there had not been any communication from the facility regarding the missed appointment. Additionally, the surveyor requested the visit note regarding the resident's appointment on 8/6/2024.
Record review of the visit note from 8/6/2024 obtained by the surveyor on 1/10/2025 revealed the neurologist wanted to follow-up with the resident in four months.
1b. Record review of a Continuity of Care document dated 10/15/2024 revealed the resident had been seen by the dentist with a follow up appointment scheduled for 11/21/2024.
Record review failed to reveal evidence that the resident attended the dental appointment on 11/21/2024.
Record review of the electronic resident schedule for medical appointments revealed a dental appointment was scheduled for 12/16/2024.
Record review failed to reveal evidence that the resident attended the dental appointment on 12/16/2024.
During a surveyor interview on 1/9/2025 at approximately 11:30 AM with Registered Nurse, Staff A, she recalled Resident ID #1's family member calling the unit regarding an upcoming appointment, however she indicated that another nurse spoke with the family member, and she could not recall the date of the phone call nor the nurse who spoke with the family member. Additionally, she indicated that the facility was unaware of a neurology appointment scheduled for 1/7/2025 and that the resident had not been transported to the appointment. Furthermore, she acknowledged that the resident did not attend his/her scheduled dental appointment on 12/16/2024.
During a surveyor interview on 1/9/2025 at 12:23 PM with the Assistant Director of Nursing Services (ADNS), she indicated that many employees of the facility schedule resident appointments including, but not limited to, the Administrator, the Director of Nursing Services, nursing staff, and herself. Additionally, she indicated that she was unaware if the facility kept a record of past scheduled appointments.
During a surveyor interview on 1/9/2024 at 3:28 PM with the Regional Director of Clinical Services and the ADNS, they indicated that they would expect continuity of care documents regarding specialist appointments to be kept in each resident's medical record. They further acknowledged that Resident ID #1 did not attend his/her scheduled neurology or dental appointments.
Jan 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0574
(Tag F0574)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, resident, and resident representative interviews, 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, staff, resident, and resident representative interviews, it has been determined that the facility failed to ensure that a resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, for 1 of 1 resident reviewed who's primary language is Spanish, Resident ID #1.
Findings are as follows:
Record review of a community reported complaint submitted to the Rhode Island Department of Health on 1/2/2025 alleged that a staff member had Resident ID #1 sign financial and admission documents, which s/he was not able to read, because the documents were not written in Spanish.
Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident ID #1's preferred language is not English.
Record review revealed a notice of health insurance non-coverage document, which was written in English, that outlines the resident's last day facility services would be covered by his/her insurance and information regarding his/her rights to appeal this decision, was signed by the resident on 7/30/2024.
Further record review failed to reveal evidence that s/he received the same document in his/her preferred language, Spanish.
Further record review revealed that a 63 page document titled, admission Packet dated 8/30/2024, which was written in English, was signed by the resident.
During a surveyor telephone interview with the resident and his/her representative on 1/2/2025 at 4:57 PM, the representative translated for Resident ID #1, that a staff member told him/her to sign papers or else s/he would have to leave the facility. Additionally, the representative indicated that the person spoke to him/her in Portuguese, not the resident's dominant language of Spanish. Additionally, s/he indicated that was all s/he was told.
During a surveyor interview on 1/3/2025 at 10:47 AM, with the Admissions Coordinator, she acknowledged that Resident ID #1's admission documents were signed by the resident despite the documents being written in English and not Spanish, the language s/he understands.
During a surveyor interview on 1/3/2025 at 2:59 PM, with the Administrator, she was unable to provide evidence that the resident was provided with the above-mentioned documents in Spanish.
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, staff, resident, and resident representative interviews, it has been determined that the facility failed to ensure that residents receive treatment and ca...
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Based on surveyor observation, record review, staff, resident, and resident representative interviews, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following physician's orders for obtaining a urine sample for 1 of 1 resident reviewed, Resident ID #1 and for 1 of 1 resident reviewed relative to obtaining weights, Resident ID #2.
Findings are as follows:
According to Mosby's 4th Edition, Fundamentals of Nursing page 314, states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
1. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 12/31/2024, alleged in part, that Resident ID #1 had a urine sample collected via a catheter (a flexible tube that is passed into the bladder to remove urine) when s/he could have urinated in a test cup for a urinalysis (when urine is collected and sent to a laboratory where it is tested for abnormalities such as, a urinary tract infection). Additionally, the complaint alleges that the resident does not speak English, and that if it was explained to him/her in the language s/he speaks, Spanish, s/he could have urinated in a test cup.
Record review of a progress note dated 11/19/2024 at 5:09 PM, authored by Registered Nurse (RN), Staff A revealed that Staff A received an order from Nurse Practitioner (NP), Staff B, to obtain the resident's urine via a straight catheter.
Further record review revealed a physician's order dated 11/19/2024 indicating to obtain a urinalysis for monitoring until 11/19/2024 at 11:59 PM. Further review of the order failed to reveal instructions that the urine sample was to be obtained via a straight catheter.
During a surveyor telephone interview with the resident and his/her representative on 1/2/2025 at 4:57 PM, the representative translated for resident that some time ago a staff member, who spoke Spanish, told Resident ID #1 that s/he had to do a urine test exam and that was all that was explained to him/her. S/he then stated a staff member proceeded to hold his/her arms down and another held his/her legs down and s/he was afraid and did not know what they were going to do to him/her, as nothing else was explained to him/her. The representative revealed that after this incident occurred, the resident called several family members, a friend, and his/her representative and was crying because s/he was so upset about what had just happened to him/her.
During a surveyor interview on 1/3/2025 at 12:41 PM, with Staff A, she was unable to provide evidence that there was an order for the resident's urine to be collected via a straight catheter on 11/19/2024.
During surveyor interviews on 1/2/2025 at approximately 12:50 PM and 1/3/2025 at 12:39 PM, with NP, Staff B, she stated that she did not give an order for the resident's urine to be collected via a straight catheter on 11/19/2024 and that the resident's dominant language is not English, which would be even more reason not to use a straight catheter with him/her. Additionally, she revealed there was a book that is kept at the nurse's station that contains handwritten physician orders and documented communications between nurses and providers.
Record review of the physician's order book in the presence of Staff B, failed to reveal an order for Resident ID #1's urine to be collected via straight catheter on 11/19/2024.
During a surveyor interview on 1/6/2025 at 10:01 AM, with the physician, he indicated that a urine analysis is usually obtained by a clean urine catch. Additionally, he indicated that if a straight catheter method is ordered to obtain a urine sample, then it should be reflected in the order.
2. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 12/30/2024, alleged in part, that Resident ID #2 had a greater than 20 pound weight loss since his/her admission to the facility.
Record review revealed Resident ID #2 was admitted to the facility in October of 2024 with diagnoses including, but not limited to, bacterial infection and chronic pain.
Record review revealed physician orders with start dates of 10/25/2024 and 11/1/2024, indicating that Resident ID #2's weight should be obtained on admission, then weekly x 4, then monthly thereafter.
Record review of the October, November, and December 2024 Medication Administration Records revealed that the resident's weight was scheduled to be obtained on the following dates:
- 11/1/2024
- 11/8/2024
- 11/15/2024
- 11/22/2024
- 12/6/2024
Additional record review failed to reveal evidence that the resident's weight was obtained, as ordered on the above-mentioned dates. Furthermore, the record failed to reveal evidence that the physician or provider were notified that the resident's weights were not obtained as ordered on 11/1, 11/8, 11/15, 11/22 or 12/6/2024.
During a surveyor interview on 1/6/2025 at 10:01 AM, with the physician, he stated that anything ordered should be obtained and if not, then this should be communicated to the provider.
During a surveyor interview on 1/3/2025 at 1:24 PM, with the Director of Nursing Services, she was unable to provide evidence that Resident ID #2's weights were obtained, as ordered. Additionally, she was unable to provide evidence that the physician or provider were notified the resident's weights were not obtained, as ordered.
A surveyor interview was unable to be conducted with Resident ID #2 during the survey as s/he had been discharged to the hospital.
Sept 2024
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0675
(Tag F0675)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, and staff interview, it has been determined that the facility failed to provide services to at...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, and staff interview, it has been determined that the facility failed to provide services to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing for 1 of 1 resident reviewed for use of an external catheter (a flexible tube that collects urine and leads to a drainage bag), Resident ID #8.
Findings are as follows:
Record review revealed the resident was admitted to the facility in June of 2024 with diagnoses including, but not limited to, type II diabetes mellitus and heart failure.
Review of an admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 10 out of 15, indicating moderate cognitive impairment.
Review of a progress note dated 8/27/2024 states, Resident requesting [external] cath [catheter] at night for quality of life. [Nurse Practitioner] in agreement order entered Resident pleased.
During a surveyor interview on 9/12/2024 at 11:03 AM with the resident, s/he revealed that s/he wants the external catheter overnight to stop waking up wet in the morning. Additionally, s/he revealed that s/he has only received the external catheter one night and has not received it since. The resident revealed that it would make him/her more comfortable to wear the external catheter.
Review of the September 2024 Treatment Administration Record revealed the external catheter was not utilized 5 out of 10 opportunities.
During a surveyor interview on 9/12/2024 at 11:26 AM with Licensed Practical Nurse, Staff D, she acknowledged that the external catheter was not signed off as in use for 5 out of 10 opportunities. Additionally, she was unable to explain why the resident had not recieved the external catheter, as ordered.
During a surveyor interview on 9/12/2024 at 11:36 AM with the Director of Nursing Services, she revealed that if the resident refused use of the external catheter that there should be a progress note indicating that. Additionally, she was unable to provide evidence that the facility provided the external catheter to promote the resident's highest practicable wellbeing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 ...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 residents reviewed for oxygen use, Resident ID #58.
Findings are as follows:
Review of a facility policy titled, Oxygen Administration states in part, .Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated .
Record review revealed that Resident ID #58 was admitted to the facility in November of 2023 with diagnoses including, but not limited to, Alzheimer's disease and dementia.
Record review revealed the resident was admitted to hospice care on 7/21/2024.
Record review revealed that the resident was evaluated by hospice services on 9/11/2024 and the resident was placed on oxygen therapy related to abnormal breath sounds and inability to obtain an oxygen level, with an oxygen delivery rate of 2 to 3 liters (L), per minute.
Record review revealed a physician's order dated 9/11/2024 for oxygen via nasal cannula (a lightweight plastic tube that is inserted just inside a person's nostrils to provide oxygen) at 2L per minute, for comfort.
Review of the September 2024 Medication Administration Record revealed the resident was initiated on the oxygen therapy on the night shift at 2L.
During surveyor observations on 9/12/2024 the following was observed:
- 10:29 AM The resident's oxygen tank was observed to be on empty by the surveyor.
- 10:30 AM The Minimum Data Set (MDS) Coordinator was notified by the surveyor of the oxygen tank and acknowledged that the oxygen tank was empty.
- 10:32 AM The MDS Coordinator asked the Certified Medication Technician (CMT), Staff F, to get the resident some oxygen, where Staff F responded, the nurse needs to do it I need to pass meds [medications].
- 10:32 AM CMT, Staff F looked in a room on the unit for oxygen and stated, we don't even have any.
- 10:33 AM CMT, Staff F attempted to call someone on the phone and stated, there's no answer. The MDS Coordinator indicated to Staff F that this was a priority, where Staff F stated, I know it's a priority, but it looks like I'm the only one who is going to have to do it.
- 10:34 AM The surveyor asked if the facility had oxygen concentrators, where the MDS Coordinator then asked the unit nurse if the facility had oxygen concentrators. Licensed Practical Nurse (LPN), Staff D stated, I don't think we have one.
- 10:35 AM LPN, Staff D then stated, I need to get to work.
- 10:35 AM LPN, Staff D, had a dressing change to complete on a different resident that was due on the 7:00 AM to 3:00 PM shift and was scheduled to complete this dressing change with a surveyor. Staff D continued to prioritize the dressing change with the surveyor, while Resident ID #58's oxygen tank was still empty. The surveyor had to intervene to alert the nurse that a resident's need for oxygen takes a higher priority than a dressing change.
- 10:35 AM The MDS Coordinator revealed that she was not sure where the full oxygen tanks were located.
- 10:36 AM LPN, Staff D stated, I guess I have to go downstairs myself.
- 10:36 AM MDS Coordinator revealed that she is not in and out of the residents' rooms much and indicated that she was trying to think where another oxygen tank was located
- 10:37 AM CMT, Staff F arrived on the unit and asked where the nurse is.
- 10:37 AM CMT, Staff F gave the new oxygen tank to the MDS Coordinator.
- 10:38 AM The MDS Coordinator attempted to switch over the oxygen tank, but was unsuccessful.
- 10:39 AM The Director of Nursing Services (DNS) took over for the MDS Coordinator and switched over the tank successfully.
-10:40 AM The resident was placed on 2L of oxygen.
- 10:41 AM The DNS stated that the tank on 2L per minute would only last about 2 to 4 hours.
- 10:46 AM The DNS instructed LPN, Staff D to obtain a set of vital signs because, that is more important than a piece of paper.
- 10:47 AM The resident's oxygen level read at 78% (normal oxygen level falls between 95% and 100%) on 2L of oxygen.
During a surveyor interview on 9/12/2024 at 11:57 AM with the DNS she revealed that she was aware of the situation and indicated that she will re-educate the staff on oxygen administration, importance of breathing, and storage of supplies. Additionally, she revealed there is a call out to hospice and the facility will request hospice to provide the resident with an oxygen concentrator. Furthermore, she was unable to provide evidence that the resident was provided respiratory care consistent with professional standards of practice.
CONCERN
(D)
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 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 pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 wound treatments observed, Resident ID #5.
Findings are as follows:
Record review revealed that Resident ID #5 was admitted to the facility in August of 2023 with diagnoses including, but not limited to, pressure ulcer of unspecified site and adult failure to thrive.
Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 1 out of 15, indicating severely impaired cognition.
Review of a document titled, WOUND EVALUATION & MANAGEMENT SUMMARY dated 9/4/2024 revealed the resident has the following wounds;
- Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) to his/her right heel measuring 4.7 centimeters (cm) by 3.0 cm by 0.7 cm
- Stage 4 pressure ulcer to his/her right ankle measuring 5.5 cm by 3.1 cm by 0.3 cm
- Stage 3 pressure ulcer (full thickness of the skin and may extend into the subcutaneous [fat] tissue layer) to his/her right medial foot measuring 1.4 cm by 1.0 cm by 0.3 cm
- Non-pressure wound to his/her right shin measuring 1.2 cm by 1.0 cm by 0.5 cm
Review of the resident's care plan imitated on 8/11/2023 revealed that s/he has the potential to demonstrate physical behaviors related to poor impulse control when the resident is in pain or anxious. Additionally, the care plan revealed an intervention including, but not limited to, assess and anticipate his/her needs for comfort, body positioning, and pain.
Additional review of the care plan dated 3/29/2024 revealed that the resident currently has pressure ulcers to the right heel, right medial foot, and right ankle, and a non-pressure wound to his/her right shin. Additionally, the care plan revealed an intervention including, but not limited to, monitor for pain and treat as needed.
During a surveyor observation on 9/13/2024 at approximately 10:37 AM, revealed Licensed Practical Nurse (LPN), Staff E, performing wound care of the resident's stage 4 pressure ulcer to his/her right ankle, stage 4 pressure ulcer to his/her right heel, stage 3 pressure ulcer to his/her right medial foot and non-pressure wound to his/her right shin. Throughout the duration of the wound treatment, the resident was noted to be yelling, complaining of pain, and attempting to retract his/her right leg from the LPN who was providing care. The resident was noted to have complained of pain a minimum of 7 times during the wound treatments.
During a surveyor interview on 9/13/2024 at 10:58 AM during wound care, with Staff E, the surveyor inquired if the resident received anything for pain and Staff E indicated that s/he received Tylenol around 6:00 AM and does not have anything else for pain medication available. Staff E then continued to provide wound care to the resident stating, I'm sorry hunny and I am almost done. Lastly, Staff E failed to stop the wound treatment, notify the provider of the resident's pain, or utilize any non-pharmacological interventions to manage the resident's pain such as repositioning the resident as per the care plan.
Review of the September 2024 Medication Administration Record revealed that the resident receives Tylenol 1000 milligrams three times a day for pain, with the last administration at 6:00 AM on 9/13/2024.
During a surveyor interview on 9/13/2024 at 11:38 AM, with the Director of Nursing Services, she was unable to provide evidence that Resident ID #5 was kept free from pain.
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 maintain medical records that are accurately documented in accordance with profess...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 3 residents reviewed for vascular wounds, Resident ID #8.
Findings are as follows:
Record review revealed the resident was admitted to the facility in June of 2024 with diagnoses including, but not limited to, type II diabetes mellitus and heart failure.
Record review revealed the following physician's orders to the resident's right lower extremity:
- Apply Unna Boot - 2-layer compression system (a type of compression bandage that is specifically designed to treat and manage venous leg ulcers. It consists of a layer of zinc-impregnated, semi-rigid gauze wrapped around the affected leg, followed by an outer layer of cohesive compression bandage) twice weekly on Monday and Friday, with a start date of 6/24/2024.
- Apply A+D ointment to leg along with clobetasol (a medicated cream). Cover with foam dressing. Apply tubi grip (an elastic bandage that provides continuous support for management of swelling) with a start date of 8/27/2024.
Review of a progress note dated 8/24/2024 revealed the resident was seen at a wound clinic and new recommendations were made to change the treatment from the Unna Boot to clobetasol and a tubi grip.
Review of the September 2024 Treatment Administration Record revealed the Unna Boot treatment was signed off as completed on 9/6 and 9/9/2024.
During surveyor observations on 9/12/2024 and 9/13/2024 revealed the resident did not have an Unna Boot in place.
During a surveyor interview on 9/13/2024 at 8:08 AM with Registered Nurse, Staff B, she revealed that the order was changed on 8/27/2024 and that the resident does not have an Unna Boot in place. Additionally, she revealed that the Unna Boot treatment should have been discontinued and she was unable to explain why it was still being signed off as completed.
During a surveyor interview on 9/13/2024 at 8:20 AM with the Director of Nursing Services, she acknowledged that the order for the Unna Boot was signed off as completed although the resident did not have the Unna Boot in place. Additionally, she was unable to explain why the resident's medical record was not accurate.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**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 m...
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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 meet professional standards of quality for 1 of 1 resident reviewed for the utilization of a Freestyle Libre sensor (a continuous glucose monitoring system that is designed to replace finger sticks and lessen the need for test strips for persons with diabetes), Resident ID #194, following a physicians order for daily dressing changes on a surgical site and daily weights for 1 of 1 resident reviewed, Resident ID #192 and 2 of 2 residents reviewed with non-pressure wounds, Resident ID #s 8 and 194.
Findings are as follows:
1. Review of the Freestyle Libre 2 User Manual revealed that the sensor is to be changed every 14 days.
Record review revealed that the resident was admitted to the facility in September of 2024 with diagnoses including, but not limited to, diabetes and acute kidney failure.
During a surveyor interview with the resident on 9/11/2024 at 8:54 AM, s/he revealed that s/he has a Freestyle Libre sensor. Additionally, s/he revealed that the Freestyle Libre sensor needs to be changed every 14 days.
Record review failed to reveal evidence of a physician's order for a Freestyle Libre sensor.
Record review failed to reveal evidence of documentation indicating when to change the resident's Freestyle Libre sensor or the last time it had been changed.
During a surveyor interview with Licensed Practical Nurse (LPN), Staff A, on 9/12/2024 at 7:55 AM, she revealed that there was no documentation indicating that the resident had a Freestyle Libre sensor, when to change the Freestyle Libre sensor, or the last time it was changed, and indicated that staff utilize the sensor to obtain the resident's blood glucose levels. Additionally, she revealed that there should be a physician's order for the Freestyle Libre sensor and an order to change it.
During a surveyor interview with the Director of Nursing Services (DNS) on 9/12/2024 at 8:29 AM, she was unable to provide evidence of documentation indicating that the resident had a Freestyle Libre sensor, when to change the Freestyle Libre sensor, or the last time it was changed. Additionally, she revealed that there should be a physician's order for the Freestyle Libre sensor and an order to change it.
2. 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.
a) Record review revealed that Resident ID #192 was admitted to the facility in September of 2024 with diagnoses including, but not limited to, presence of prosthetic heart valve and heart failure.
Review of the hospital Discharge summary dated [DATE] revealed an order to complete daily weights following cardiac surgery and to report an increase in weight over 2 pounds for 2 days to the cardiac team.
Record review revealed a physician's order with a start date of 9/10/2024 for daily weights, 9 days after admission to the facility.
Record review revealed the following weights were obtained:
- 9/1/2024 299.0 pounds (lbs)
- 9/5/2024 299.0 lbs
- 9/11/2024 303.6 lbs
Record review failed to reveal evidence of daily weights being obtained from 9/1/2024 until 9/12/2024, for 8 of 11 opportunities to obtain daily weights.
Record review revealed that on 9/11/2024 the resident had new 3+ pitting edema (excess fluid builds up in the body, causing swelling) to his/her bilateral lower extremities and a 4 pound weight gain since 9/1/2024.
Record review revealed the resident attended a cardiology appointment on 9/12/2024 with an order to start Lasix (a medication to help with edema) 40 milligrams (mg) twice a day for a week and then decrease to Lasix 40 mg daily.
During a surveyor interview on 9/12/2024 at 8:05 AM with the Registered Nurse, Staff B, she revealed that the resident has an order to obtain daily weights, but the weight is not reflected in the resident's record. She further revealed it should be documented somewhere.
During a surveyor interview on 9/12/2024 at 8:27 AM with the DNS, she revealed that daily weights should have been obtained per the physician's order.
b) Record review revealed an order with a start date of 9/3/2024 to cleanse the right chest wound with normal saline, pat dry, apply xeroform (sterile wound dressing) to the surgical site, followed by gauze and a tegaderm (transparent dressing) daily.
Record review revealed an order with a start date of 9/3/2024 to cleanse the surgical wound to the abdomen with wound wash, pat dry, apply xeroform to the surgical site, and cover with a clean dressing daily.
During a surveyor observation on 9/10/2024 at 11:15 AM with Staff A, she revealed that the surgical wound dressing on the right chest wall and abdomen were dated 9/8/2024.
During a follow up surveyor interview on 9/10/2024 at 11:40 AM with Staff A, she acknowledged that the wound dressing was dated 9/8/2024 and should have been changed on 9/9/2024. She further revealed that she worked on 9/9/2024 and didn't have time to change the dressing and states she passed it on.
Record review failed to reveal evidence that the dressing change was completed on 9/9/2024 to the right chest wall surgical site and abdominal surgical site.
During a surveyor interview on 9/10/2024 at 12:18 PM with the Regional Nurse and the DNS, they revealed that would investigate the dressing dated 9/8/2024 on the right chest wall and the abdomen. Additionally, they were unable to provide evidence that the dressing changes to the right chest wall and abdomen surgical sites were changed as ordered on 9/9/2024.
3. Review of a facility policy titled, Wound Care dated October 2010 states in part, The following should be recorded in the resident's medical record: .All assessment data (i.e., wound bed, color, size, drainage, etc) obtained when inspecting the wound .
According to Wound Care Education Institute, 2020, wound care documentation should be carried out weekly including type of wound, measurements, type of tissue, symptoms of infection, presence of drainage, wound edges, pain, and current treatment.
a) Record review revealed that Resident ID #8 was admitted to the facility in June of 2024 with diagnoses including, but not limited to, type II diabetes mellitus and heart failure.
Record review revealed that the resident has a vascular wound to his/her right lower extremity with a daily treatment in place.
Record review failed to reveal evidence of documentation which included wound bed characteristics, color, size, and drainage documented from 6/20/2024 until it was brought to the facility's attention on 9/12/2024, per the facility policy and the standard of practice.
Additionally, the facility was unable to obtain wound care paperwork from the outside wound care provider from 8/23/2024 when the surveyor requested the documentation.
During a surveyor interview on 9/13/2024 at 8:20 AM with the DNS, she revealed that the resident was seen by an outside wound provider but was unable to obtain the wound care consultation notes, as of yet. Additionally, she was unable to provide evidence that wound evaluations were being completed from 6/20/2024 through 9/12/2024.
b) Record review revealed that Resident ID #194 was admitted to the facility in September of 2024 with diagnoses including, but not limited to, type II diabetes mellitus and orthopedic aftercare following surgical amputation.
Record review of the resident's discharge summary from the hospital dated 9/3/2024 revealed that the resident has a wound to his/her right 2nd toe with serosanguineous (thin, clear, or pink fluid from a wound) drainage, unattached wound edges, and a pink/red wound bed with a dressing in place. Further review revealed that the resident presented to the hospital due to his/her toe becoming blueish in color and that the wound was debrided (removal of damaged tissue) in the hospital, and the resident was started on antibiotics for a right toe diabetic foot infection.
Record review revealed that the resident had an admission skin check on 9/3/2024 which documented a diabetic neuropathic ulcer (preventable ulcers associated with diabetes mellitus) to the resident's right toe(s). Further review of the skin assessment failed to identify any characteristics of the wound.
Further record review revealed a physician's order with a start date of 9/5/2024 for daily dressing changes to the resident's right second toe.
Record review failed to reveal evidence at the time of admission that the wound was documented in the medical record to include the underlying condition contributing to the wound, wound edges, and the wound bed, location, shape and the condition of surrounding tissue per the regulation, policy, and standard of practice.
During a surveyor interview on 9/13/2024 at approximately 8:24 AM with LPN, Staff C, he revealed that he was a float nurse and is unsure about the wound treatments and that he would not be completing them today as another nurse is coming to do them.
During a surveyor interview on 9/13/2024 at 8:26 AM with the DNS, she revealed that the resident does have a skin impairment to his/her right second toe and will investigate measurements and characteristics of the wound. Additionally, she was unable to provide evidence of an initial wound evaluation for this resident related to his/her right second toe wound.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice an...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive care plan relative to 3 of 4 residents reviewed for specialist appointments, Resident ID #s 74, 79, and 194.
Findings are as follows:
Review of a facility policy titled, Resident Rights dated February 2021 states in part, Federal and state laws guarantee certain basic rights to all residents of this facility. The rights include the resident's right to .access to people and services, both inside and outside the facility .
1. Record review revealed that Resident ID #74 was admitted to the facility in June of 2024 with diagnoses including, but not limited to, traumatic brain injury and subarachnoid hemorrhage (bleeding within the area between the brain and the tissue covering the brain).
Review of a hospital form titled Continuity of Care form dated 6/12/2024 revealed the resident was treated for a traumatic brain injury and started on Keppra (anticonvulsant medication) in the hospital for seizure activity. Additionally, it revealed an order to make a follow up appointment with neurology.
Record review failed to reveal evidence of the resident attending an appointment with neurology or the facility attempting to make an appointment with neurology.
Review of a progress note dated 9/12/2024 revealed the facility contacted the neurology office to make an appointment, after it was brought to their attention by the surveyor.
During a surveyor interview on 9/12/2024 at 8:10 AM with Registered Nurse (RN), Staff B, she acknowledged that the resident was supposed to follow up with neurology after admission to the facility. Additionally, she was unable to provide evidence of an appointment being made for the resident.
2. Record review revealed that Resident ID #79 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, skin cancer and hypertension.
Review of a progress note dated 8/24/2024 revealed the resident complained of mouth pain and a new order was implemented for Tylenol 650 milligrams three times a day and to follow up with a dentist the following week.
Record review failed to reveal evidence that the resident was seen by a dentist or that the facility attempted to make an appointment with the dentist to treat the resident's mouth pain.
During a surveyor interview on 9/12/2024 with Licensed Practical Nurse (LPN), Staff D, she was unable to provide evidence that the resident had an appointment with a dentist due to his/her mouth pain.
3. Record review revealed that Resident ID #194 was admitted to the facility in September of 2024 with diagnoses including, but not limited to, type II diabetes mellitus and orthopedic aftercare following surgical amputation.
Review of a hospital discharge document titled, Continuity of Care form dated 9/3/2024 revealed the resident was treated with intravenous antibiotics for a right toe diabetic foot infection. Additionally, it revealed an order to make a follow up appointment with a podiatrist within one week.
Record review failed to reveal evidence of an appointment for the resident to follow up with a podiatrist relative to his/her right foot infection.
During a surveyor interview on 9/12/2024 at 11:04 AM with LPN, Staff A, she revealed that she does not make the appointments, the scheduler does. Additionally, she was unable to provide evidence that an appointment had been made for the resident to follow up with a podiatrist relative to a right foot infection.
During a surveyor interview on 9/12/2024 at 11:53 AM with the Director of Nursing Services, she acknowledged that the appointments for the above-mentioned residents were not made.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives the necessary treatment and 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 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 2 of 2 residents reviewed for pressure ulcers, Resident ID #s 5 and 62.
Findings are as follows:
1. Review of a policy titled Wound Care states in part, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify that there is a physicians order for this procedure .
Record review revealed that Resident ID #5 was admitted to the facility in August of 2023 with diagnoses including, but not limited to, pressure ulcer of an unspecified site and adult failure to thrive.
Record review revealed that the resident has a care plan dated 3/29/2024 that revealed the resident has actual and potential for pressure ulcer and alterations in skin integrity related to a history of pressure ulcers, immobility and incontinence of urine and is followed by a wound care team. It further revealed that there are currently pressure ulcers on the right heel, right ankle, and right medial foot.
Record review revealed that the resident was seen by an in-house wound physician on 9/4/2024 with recommendations to:
Cleanse the right heel, right ankle, and right medial foot pressure wounds with ¼ strength Dakin solution (a diluted sodium hypochlorite solution, 0.125% concentration, commonly used as a topical antiseptic. It is effective in treating and preventing infections in wounds), pat dry, apply collagen powder (stimulates new tissue growth) on to the wound and cover with calcium alginate with silver (absorbent dressing with antimicrobial properties) and cover with an absorbent dressing and wrap with a gauze stretch roll daily.
Record review revealed physician's orders dated 8/3/2024 to cleanse the right medial and right heel pressure wounds with ¼ strength Dakin's solution, pat dry, sprinkle collagen powder on to the wound and cover with calcium alginate with silver and cover with an absorbent dressing and wrap with a gauze stretch roll daily to the right medial foot and right heel.
Further record review failed to reveal evidence of an order to treat the right ankle wound.
During a surveyor observation on 9/13/2024 at 10:37 AM with Licensed Practical Nurse (LPN), Staff E, she was observed to mix 30 milliliters (ml) of half strength Dakin's (hypochlorite solution, 0.25% concentration) in a wash basin obtained from the resident's drawer with 15 ml of sterile water. Additionally, she was observed to dress the right ankle wound by cleansing the wound with the above-mentioned mixed Dakin solution and sterile water, drying the wound, pressing the collagen powder directly into the wound with her gloved hand and covered the collagen with calcium alginate with silver. She then proceeded to cover the wound with an absorbent dressing and wrap with a gauze stretch roll.
During a surveyor interview immediately following the above-mentioned observation with Staff E, she acknowledged that there was not a physician's order in place to dress the resident's ankle wound. Additionally, she revealed that she was unsure how to make ¼ strength Dakin's solution and indicated that she was instructed by another nurse to mix the 1/2 strength Dakin's solution with the sterile water, in order to make ¼ strength Dakin's solution.
During a surveyor interview with the Wound Physician on 9/13/2024 at 11:24 AM, he revealed that he would have to ask a pharmacist on how to mix solutions to get a ¼ strength Dakin's from a ½ strength Dakin's solution. Additionally, he revealed he would expect there to be a treatment for the ankle pressure wound.
During a surveyor interview on 9/13/2024 at 11:40 AM with the Director of Nursing Services (DNS), she revealed that she would look in to why there was no order to dress the ankle wound since 9/10/2024. Additionally, she revealed that she was unsure on how to mix ½ strength Dakin's solution to make ¼ strength Dakin's solution.
During a surveyor interview with the Nurse Practitioner on 9/13/2024 at 12:25 PM, she revealed that she was unfamiliar with Dakin's solution and was unaware of how to mix it to make ¼ strength Dakin's. Furthermore, she revealed that she would expect there to be an order in place for the ankle pressure wound.
2. Record review revealed that Resident ID #62 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, right femur fracture and muscle wasting.
Record review revealed the resident is being followed by an in-house wound physician.
Record review revealed the following wound recommendations on 8/14/2024, 8/21/2024, 8/28/2024 and 9/11/2024:
Cleanse the left and right buttocks pressure wounds with ¼ strength Dakin solution, pat dry, and cover the wound with calcium alginate (absorbent dressing) and cover with a gentall blue (hydrofera blue; wound care product used to improve epithelialization (new skin growth) while wicking drainage and debris from the wound bed) three times a week.
Further review of the 8/14/2024 recommendation revealed to discontinue collagen powder and calcium alginate with silver.
Record review revealed a physician's order dated 9/2/2024 to cleanse the right and left buttocks wounds with ¼ strength Dakin's solution, sprinkle collagen powder into wound and on calcium alginate with silver and pack hydrofera blue into wounds and cover the wound with a dressing three times a week.
During a surveyor interview on 9/13/2024 at approximately 8:24 AM with LPN, Staff C, he revealed that he was a float nurse and was unsure about the resident's wound treatments and indicated that he would not be completing them today.
During a surveyor interview with the wound physician on 9/13/2024 at 11:28 AM, he revealed that he changed the order to discontinue the use of the calcium alginate with silver and collagen powder some time ago and is unsure why the order is still in place.
During a surveyor interview with the Nurse Practitioner on 9/13/2024 at 12:25 PM, she revealed that she would agree with the wound recommendations from the provider as he is the specialist.
During a surveyor interview on 9/13/2024 at 11:38 AM with the DNS, she revealed that she would investigate why the wound treatment did not match the wound recommendations. Additionally, she was unable to provide evidence that Resident ID #s 5 and 62 received pressure ulcer care to promote healing, prevent infection, and prevent new ulcers for developing.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to have sufficient nursing staff to provide nursing and related services to...
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Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care affecting 2 of 3 units including, 1 of 3 residents observed to be saturated in urine prior to a wound dressing change, Resident ID #5 (on the South Unit), 1 of 1 observation made for timeliness of staff response to a call light triggered for Resident ID #291 (on the [NAME] Unit), and complaints of long response times to call lights and untimely assistance for morning care identified during the Resident Council task affecting residents on the East, West, and South Units on various shifts, including Resident ID #s 18, 27, and 196.
Findings are as follows:
Review of the Facility Assessment states in part, .in the event of staffing challenges, our facility may utilize contracted staff to ensure that the needs of the residents are met .
1a) During the entrance conference with the facility on 9/10/2024 at approximately 9:00 AM with the Administrator and Director of Nursing Services (DNS), they revealed that they do not utilize contracted nursing staff.
During multiple surveyor interviews on 9/11/2024 at 3:01 PM with various residents in attendance during the Resident Council task, the following concerns were mentioned:
- Resident ID #196 indicated long wait times for staff response to call lights on the 11:00 PM - 7:00 AM shift on the East Unit
- Resident ID #18 indicated long wait times for staff response to call lights on the 3:00 PM - 11:00 PM shift on the South Unit
- Resident ID #27 indicated that s/he did not receive the necessary assistance from staff to get out of bed until approximately 2:00 PM that afternoon, 9/11/2024, on the South Unit
During a surveyor interview on 9/10/2024 at 12:27 PM with Nursing Assistant (NA), Staff G, working on the [NAME] Unit, she revealed that she still has 4 residents that have yet to receive morning care and will finish when she can. Additionally, she indicated that they are short-staffed and revealed they only have 3 NAs working the unit and should have 5 NAs.
During a surveyor interview on 9/13/2024 at 11:28 AM with NA, Staff H, she revealed that at times she is still assisting residents with morning care around 2:30 PM - 3:00 PM. Additionally, she indicated that resident's often complain to her about long wait times before staff respond to their call lights.
During a surveyor interview on 9/13/2024 at 12:17 PM with NA, Staff I, working on the [NAME] Unit, she revealed that she just completed morning care and has 14 residents on her assignment. She indicated that some days she may have up to 20 residents on her assignment.
During a surveyor interview on 9/13/2024 at 12:21 PM with the DNS in the presence of the Regional Nurse, she revealed that the [NAME] Unit should be staffed with 4 NAs on the 7:00 AM - 3:00 PM shift and was unable to explain why only 3 NAs were working the 7:00 AM - 3:00 PM shift on 9/13/2024.
1b) Record review revealed Resident ID #291 was admitted to the facility in September of 2024 with a diagnosis including, but not limited to, difficulty in walking.
Review of a progress noted dated 9/13/2024 at 4:26 PM, revealed that the resident was admitted to the facility for a decline in activities of daily living, function, and mobility and required therapy services.
During a surveyor observation and simultaneous interview on 9/13/2024 at approximately 9:47 AM of Resident ID #291, s/he was observed to have his/her call light triggered and the resident was observed to be self-toileting him/herself. S/he indicated to the surveyor that s/he had to bring him/herself to the bathroom because nobody was available to help him/her. Additionally, 3 staff members were observed to walk by the resident's room and/or interact with the resident from the doorway, however, did not provide him/her assistance and indicated that another staff member would be in shortly to help him/her. Further, at approximatley 10:00 AM a staff member entered his/her room and turned off the resident's call light.
During a surveyor interview on 9/13/2024 at 12:21 PM with the Regional Nurse in the presence of the DNS, she revealed that she would expect residents to be provided assistance with morning care and be up out of bed prior to 12:00 PM. Additionally, she indicated that she expects staff to respond to resident call lights within 2 to 5 minutes.
1c) Record review revealed that Resident ID #5 was admitted to the facility in August of 2023 with diagnoses including, but not limited to, pressure ulcer of an unspecified site and adult failure to thrive.
Review of a care plan focus area dated 8/15/2023 revealed that the resident has skin breakdown related to urinary incontinence and limited mobility with an intervention to keep the resident clean and dry, and to provide incontinence care every 2-3 hours and as needed.
Record review revealed that the resident has orders to provide daily wound care to his/her right heel and right medial foot wound.
During a surveyor observation on 9/13/2024 at 10:37 AM of the resident, as the surveyor was waiting to observe staff conduct the above-mentioned wound dressing changes, the resident's brief, clothes, and bed linens were all observed to be saturated with urine. Additionally, Staff E proceeded to complete wound care without having provided incontinence care. Staff E completed wound care at 11:09 AM indicating that the resident remained soiled during wound care with Staff E aware for approximately 33 minutes. Additionally, she was unsure when the resident was last provided incontinence care.
During a surveyor interview on 9/13/2024 at 11:11 AM with NA, Staff J, she acknowledged that the resident's clothes and bed linens were saturated with urine and revealed that she had yet to change the resident since she began her shift at 7:00 AM. Additionally, she was unsure when the resident was last provided incontinence care.
During a surveyor interview on 9/13/2024 at 11:40 AM with the DNS, she was unable to explain why the resident was found to be saturated in his/her urine and had not been provided incontinence care that morning, or prior to the dressing change, at the time of the surveyor's observation. She was unable to provide evidence that the facility has sufficient nursing staff to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individual plans of care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to ...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident relative to the administration of hypodermoclysis (a method of infusing fluids into the fatty tissue below the skin by means of gravity and a dial flow meter to approximate the infusion rate) for Resident ID #191 for 3 of 3 staff reviewed, Staff A, B, E, and 2 of 3 staff reviewed for wound dressing changes observed for Resident ID #s 5 and 192, Staff A and E.
Findings are as follows:
Review of the Facility Assessment revealed that the facility provides services including hypodermoclysis and wound care. Additionally, it indicates that department specific training and competencies are completed with staff throughout employment to ensure that they can safely and competently provide the level and types of care required by the resident population.
1a) Review of a policy titled, Wound Care states in part, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify that there is a physicians order for this procedure .
Record review revealed that Resident ID #5 was admitted to the facility in August of 2023 with diagnoses including, but not limited to, pressure ulcer of an unspecified site and adult failure to thrive.
Review of a care plan focus area dated 3/29/2024 revealed that the resident currently has pressure ulcers on his/her right heel, right ankle, and right medial foot.
Further record review failed to reveal evidence of a physician's order to treat the resident's right ankle wound.
During a surveyor observation on 9/13/2024 at 10:37 AM with Licensed Practical Nurse (LPN), Staff E, was observed to be providing wound care to the resident's right ankle wound, although there was no physician's order in place. Additionally, Staff E was observed removing a wash basin from the resident's drawer and proceeded to mix a wound solution in the wash basin, without cleaning the basin prior to use, and proceeded to complete the resident's wound care using the solution mixed in the wash basin.
During a surveyor interview immediately following the above-mentioned observation with Staff E, she acknowledged that there was not a physician's order to dress the ankle wound. Additionally, she acknowledged that she removed the basin from the resident's drawer and then mixed wound care solution in it and proceeded to cleanse the wound.
Review of a completed Wound Care Competency Assessment for Staff E dated 7/25/2024 and signed by Staff E and the observer/trainer which states in part, .B) Preparation 1. Verify that there is a physician's order for this procedure .8. Pour liquid solutions directly on gauze sponges on their papers .
1b) Record review revealed that Resident ID #192 was admitted to the facility in September of 2024 with diagnoses including, but not limited to, presence of prosthetic heart valve and heart failure.
Record review revealed the following physician's orders:
- 9/3/2024: Cleanse the right chest wound with normal saline, pat dry, apply xeroform (sterile wound dressing) to the surgical site, followed by gauze and a tegaderm (transparent dressing) daily.
- 9/3/2024: Cleanse the surgical wound to the abdomen with wound wash, pat dry, apply xeroform to the surgical site, and cover with a clean dressing daily.
During a surveyor observation on 9/10/2024 at 11:15 AM, revealed LPN, Staff A, removed scissors and other wound care supplies from the treatment cart and entered Resident ID #192's room to provide wound care. Staff A was then observed using the scissors to cut the xeroform, where she failed to clean the scissors prior to cutting the xeroform.
During a surveyor interview immediately following the above observation, Staff A acknowledged that she did not clean the scissors, prior to cutting the xeroform.
Review of an undated Wound Care Competency Assessment for Staff A revealed that 2 of 4 pages were missing and lacked signatures from Staff A and the observer/trainer.
2a) Review of a facility policy titled, Hypodermoclysis - Subcutaneous Infusion states in part, .Infusion .Connect solution administration set to catheter connector. Start fluid and adjust flow to ordered rate of infusion .
Record review revealed Resident ID #191 was admitted to the facility in August of 2024 with a diagnosis including, but not limited to, Alzheimer's disease.
Record review revealed Resident ID #191 has a physician's order for Dextrose Solution 5% (D5 solution) to be administered via hypodermoclysis at 50 milliliters (ml) per hour (ml/hr).
Review of the hypodermoclysis tubing packaging states in part, .DIRECTIONS .Check maintenance of proper flow rate at regular intervals .
During a surveyor observation and simultaneous interview during the medication administration task on 9/10/2024 at 12:45 PM with Registered Nurse, Staff B, she set up hypodermoclysis with the 1 liter of D5 solution and attached it to the resident, then set the dial flow to 50ml/hr (for the D5 solution to infuse for a duration of 20 hours and finish at approximately 8:45 AM on 9/11/2024). She indicated that she checks the infusion site once a shift and failed to indicate that she assesses the drip rate (drops per minute in the fluid chamber of the tubing) and dial flow meter to ensure that the resident is receiving his/her fluids at 50ml/hr, as ordered (the drip rate to equal 50ml/hr should be approximately 17 drops per minute). Staff B failed to assess the drip rate and exited the resident's room. The drip rate was noted by surveyor at approximately 12 drops per minute.
During multiple surveyor observations revealed the D5 solution was infusing at approximately 12 drops per minute instead of 17 drops per minute on the following dates and times:
- 9/10/2024 at 2:44 PM
- 9/11/2024 at 9:27 AM
- 9/11/2024 at 2:27 PM
During a surveyor observation and simultaneous interview on 9/11/2024 at 2:35 PM of the resident with Staff A, she acknowledged that the D5 solution was still infusing. She revealed that she does not calculate the drip rate when using hypodermoclysis and would need to look up how to calculate it.
During a surveyor interview on 9/11/2024 at 2:43 PM with Staff B, she revealed that she began working for the facility 8 months prior and has not received any competencies or education relative to hypodermoclysis.
Record review for nursing competencies for Staff A, B, and E relative to hypodermoclysis revealed the following:
- Staff A: An undated competency
- Staff B: A completed competency dated 7/25/2024
- Staff E: A competency dated 7/25/2024 unsigned by Staff E
During a surveyor interview on 9/13/2024 at 12:17 PM with the Nurse Practitioner, she revealed that she would expect that staff would calculate the drip rate when utilizing hypodermoclysis for a resident to ensure that s/he is receiving the proper flow rate, as ordered.
During a surveyor interview on 9/13/2024 at 12:21 PM with the Regional Nurse in the presence of the Director of Nursing Services, she revealed that she would expect staff to calculate the drip rate relative to hypodermoclysis and wound dressings to be completed only if there is a physician's order. She was unable to provide evidence that nursing staff are competent and have skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Cross reference F 686, 759, 880
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to address pharmacy recommendations in a timely manner for 3 of 6 residents reviewed, Resident ID #s 15, 58,...
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Based on record review and staff interview, it has been determined that the facility failed to address pharmacy recommendations in a timely manner for 3 of 6 residents reviewed, Resident ID #s 15, 58, and 63.
Findings are as follows:
Review of a facility policy titled, Consultant Pharmacist Reports dated November 2021 states in part, .Recommendations are acted upon and documented by the facility staff and/or the prescriber. Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing .The Director of Nursing or designated licensed nurse address and document recommendations that do not require a physician intervention, e.g., monitor blood pressure .
1. Record review revealed that Resident ID #15 was readmitted to the facility in June of 2024 with diagnoses including, but not limited to, bipolar disorder, anxiety, and depression.
Review of a document titled, Consultant Pharmacist Recommendations to Nursing dated 6/26/2024 revealed to complete the diagnoses for use on orders lacking reason entered into the Electronic Medical Record (EMAR).
Review of a document titled, Consultant Pharmacist Recommendations to Nursing dated 7/28/2024 revealed to complete the diagnoses for use on orders lacking reason entered into the EMAR.
Review of a document titled, Consultant Pharmacist Recommendations to Nursing dated 8/28/2024 revealed to complete the diagnoses for use on orders lacking reason entered into the EMAR.
Record review revealed the following physician medication orders without diagnoses or reasons for use:
- Divalproex Sodium 500 milligrams (MG) give 1 tablet two times a day for.
- Risperidone Oral Tablet 0.5 MG give two times a day for.
- Atorvastatin Calcium 10 MG give at bedtime for.
- Flomax Oral Capsule 0.4 MG give 1 capsule in the evening for.
- Levothyroxine Sodium Oral Tablet 25 Micrograms (MCG) give one time a day for.
- Vitamin B1 Oral Tablet give one time a day for.
- Trazodone Oral Tablet 50 MG give at bedtime for.
During a surveyor interview on 9/13/2024 at 11:03 AM with the Director of Nursing Services (DNS), she acknowledged that the pharmacy recommendations for Resident ID #15 had not been addressed for June, July, or August of 2024.
2. Record review revealed that Resident ID #58 was readmitted to the facility in November of 2023 with diagnoses including, but not limited to, Alzheimer's disease, anxiety, and depression.
Review of a document titled, Consultant Pharmacist Recommendations to Nursing dated 7/28/2024 revealed that liquid concentrate orders should include instructions for both the dose in milligrams (MG) as well as milliliters (ML), to help avoid medication errors. Additionally, it instructs to adjust orders accordingly.
Review of a document titled, Consultant Pharmacist Recommendations to Nursing dated 8/28/2024 revealed that liquid concentrate orders should include instructions both the dose in MGs as well as MLs, to help avoid medication errors. Additionally, it instructs to adjust orders accordingly.
Record review revealed the following physician's orders that lack the MGs that should be administered:
- Lorazepam Intensol Oral Concentrate 2 MG/ML give 0.25 ml sublingually every 4 hours for restlessness
- Morphine Sulfate Concentrate Oral Solution 20 MG/ML give 0.25 ml sublingually every 2 hours as needed for pain/discomfort
During a surveyor interview on 9/13/2024 at approximately 12:00 PM with the DNS, she acknowledged that the pharmacy recommendations to add the milligrams to the order had not been completed.
3. Record review revealed that Resident ID #63 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, atrial fibrillation (an irregular and often very rapid heart rhythm) and myopathy (diseases that attack your skeletal muscles and make your muscles weak).
Review of a document titled, Consultant Pharmacist Recommendations to Nursing dated 8/28/2024 revealed that the resident is receiving an anticoagulant, Eliquis, and to ensure documentation of regular monitoring for signs and symptoms of bleeding.
Review of a second document titled, Consultant Pharmacist Recommendations to Nursing dated 8/28/2024 revealed to adjust Eliquis order to be given every 12 hours instead of 9:00 AM and 5:00 PM.
Record review revealed the following physician order for Eliquis:
- Eliquis 2.5 MG twice daily, administer at 9:00 AM and 5:00 PM with a start date of 8/15/2024
Record review failed to reveal evidence of monitoring for signs and symptoms of bleeding per the pharmacy recommendation and failed to adjust the order to every 12 hours as recommended by the pharmacist.
During a surveyor interview on 9/13/2024 at 12:06 PM with the DNS and the Regional Nurse, they acknowledged that the pharmacy recommendations for Resident ID #s 15, 58, and 63 were not completed for June, July, and August 2024.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5...
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Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 25 opportunities for error observed during the medication administration task, there were 14 errors resulting in a medication error rate of 56%, involving Resident ID #s: 74, 83, 191, and 241.
Findings are as follows:
Review of a facility policy titled, Administering Medications states in part, .Medications are administered in a safe and timely manner, and as prescribed .3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with prescriber orders, including any required time frame .7. Medications are administered within one (1) hour of their prescribed time .
1a) Record review revealed Resident ID #241 has physician's orders for the following medications:
- Guaifenison 600 milligrams (mg) give 2 tablets for congestion at 8:00 AM and 8:00 PM
- Acetaminophen 325mg give 2 tablets for pain at 9:00 AM and 5:00 PM
- Aspirin 81mg give 1 tablet for congestive heart failure at 9:00 AM
- Vitamin D 25 micrograms give 1 capsule for bone health at 9:00 AM
- Potassium Chloride 20 millequivalents give 1 packet twice daily for low potassium at 9:00 AM and 5:00 PM
- Midodrine 5mg give one tablet for low blood pressure at 8:00 AM, 1:00 PM, and 6:00 PM
- Finasteride 5mg give one tablet at 9:00 AM
During a surveyor observation during the medication administration task on 9/10/2024 at 11:32 AM with Licensed Practical Nurse (LPN), Staff K, she administered the above-mentioned medications to the resident at 11:47 AM, approximately 3 to 4 hours after the scheduled time.
During a surveyor interview immediately following the above observation with Staff K, she acknowledged that some of the resident's medications were administered late. She revealed that medications are often administered late.
1b) Record review revealed Resident ID #83 has physician's orders for the following medications:
- Zoloft 25mg give 3 tablets for depression at 8:00 AM
- Sennosides 8.6mg give 2 tablets for constipation at 9:00 AM and 5:00 PM
- Calcium Carbonate (Tums) give 1 tablet for upset stomach at 9:00 AM and 5:00 PM before meals
- Acetaminophen 325mg give 3 tablets for pain at 8:00 AM, 2:00 PM, and 10:00 PM
During a surveyor observation during the medication administration task on 9/10/2024 at 11:52 AM with Staff K, she administered the above-mentioned medications to the resident at 11:57 AM, approximately 3 to 4 hours after the scheduled time. Additionally, she administered the resident his/her Tums although the medication is ordered to be administered before meals.
1c) Record review revealed Resident ID #191 has a physician's order for Dextrose Solution 5% (D5 solution) to be administered via hypodermoclysis (a method of infusing fluids into the fatty tissue below the skin by means of gravity and a dial flow meter to approximate the infusion rate) at 50 milliliters (ml) per hour (ml/hr).
During a surveyor observation and simultaneous interview during the medication administration task on 9/10/2024 at 12:45 PM with Registered Nurse, Staff B, she set up hypodermoclysis with the D5 solution and attached it to the resident, then set the dial flow to 50ml/hr. She indicated that she checks the infusion site once a shift and failed to indicate that she assesses the drip rate (drops per minute in the fluid chamber of the tubing) and dial flow meter to ensure that the resident is receiving his/her fluids at 50ml/hr, as ordered (the drip rate to equal 50ml/hr should be approximately 17 drops per minute). Staff B failed to assess the drip rate and exited the resident's room. The drip rate was noted by surveyor at approximately 12 drops per minute.
During a surveyor observation on 9/10/2024 at 2:44 PM revealed the drip rate remained at approximately 12 drops per minute.
1d) Record review revealed Resident ID #74 has physician's orders for the following medications:
- Metoprolol Tartrate 50mg give 1 tablet twice daily for high blood pressure with parameters to hold the medication if the resident's apical pulse (a pulse point on your chest that is obtained by using a stethoscope) is less than 60 beats per minute
- Prevacid (treats heartburn) 30mg give 1 tablet twice daily. Additionally, the instructions on the medication packaging indicated to not crush or chew the medication
During a surveyor observation during the medication administration task on 9/11/2024 at approximately 9:45 AM with LPN, Staff A, she failed to obtain the resident's apical pulse prior to the administration of his/her Metroprolol Tartrate. Additionally, Staff A crushed his/her Prevacid and then administered it to the resident.
During a surveyor interview on 9/11/2024 at approximately 10:20 AM and again at 2:52 PM with Staff A, she revealed that she should have obtained the resident's apical pulse and acknowledged that she did not. She further acknowledged that she crushed his/her Prevacid and indicated that she should not have crushed the medication prior to administering it.
During a surveyor interview on 9/11/2024 at approximately 3:00 PM with the Regional Nurse in the presence of the Director of Nursing Services, she revealed that she would expect the residents to receive their medications as ordered and within the scheduled time frame. Additionally, she was unable to provide evidence that the facility ensured each resident's medication regimen is free from a medication error rate of 5% or greater.
Cross reference F 726
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
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 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 scabies (an itchy skin rash caused by a tiny burrowing mite that can spread through close contact) management for 2 of 2 residents reviewed, Resident ID #s 42 and 45, and relative to Enhanced Barrier Precautions (EBP; involves using gown and gloves during high-contact resident care activities), Resident ID #s 78 and 192. Additionally, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to 2 of 3 wound care observations, Resident ID #s 5 and 192. Furthermore, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to the handling of soiled linen in the laundry room.
Findings are as follows:
1. Review of a facility policy titled, Scabies, Identification, Treatment, and Environmental Cleaning last revised August 2016, states in part, .Environmental Control: Typical Scabies .Place bed linens, towels and clothing used by an affected person during the 4 days prior to the initiation of treatment in plastic bags inside the resident's room, handled by gloved and gowned staff without sorting, and washed in hot water for at [least] 10-20 minutes .Use the hot cycle of the dryer for at [least] 10-20 minutes .Place non-washable blankets and articles in a plastic bag for at least 72 hours .Change all bed linens, towels and clothes daily .Vacuum mattresses, upholstered furniture and carpeting .For non-fabric items, routine disinfection procedures are adequate .
a) Record review revealed Resident ID #45 was admitted to the facility in May of 2022 with a diagnosis that includes, but not limited to, dementia.
Review of a provider note dated 9/10/2024 which states in part, Member is seen today for rash. Member has small, raised, red bumps in tracks across arms, trunk and legs. Member has been observed to be scratching rash frequently. Rash is consistent with scabies .
Record review revealed a physician's order dated 9/10/2024, to ensure that all the residents belongings are bagged and removed from his/her room and given to housekeeping prior to treatment.
Surveyor observations on the following dates and times, failed to reveal evidence that the resident's belongings were bagged or removed from his/her room, per facility policy and physician's order:
- 9/10/2024 at 9:54 AM and 12:16 PM
- 9/11/2024 at 11:13 AM
- 9/12/2024 at 1:23 PM
b) Record review revealed Resident ID #42 was readmitted to the facility in June of 2024 with a diagnosis that includes, but not limited to, dementia.
Record review revealed a physician's order dated 9/10/2024, to ensure that all the resident's belongings are bagged and removed from his/her room and given to housekeeping prior to treatment.
Surveyor observations on the following dates and times, failed to reveal evidence that the resident's belongings were bagged or removed from his/her room, per facility policy and physician's order:
- 9/10/2024 at 9:54 AM and 12:16 PM
- 9/11/2024 at 11:13 AM
- 9/12/2024 at 1:23 PM
During surveyor interviews on 9/12/2024 at 1:24 PM and 1:54 PM, with Nursing Assistant, Staff H, she revealed that she was not instructed to bag the resident's belongings and indicated that she has been placing the resident's dirty linens in the unit laundry basket.
During a surveyor interview on 9/12/2024 at 1:32 PM, with Registered Nurse, Staff B, she revealed that any resident with suspected scabies should have all belongings placed in black bags, removed from their rooms, and kept separate from other resident's laundry, for at least 72 hours. She further revealed that she was informed of the resident's potential scabies on 9/9/2024 and indicated that she informed all floor staff about the scabies and expected process.
During a surveyor interview on 9/12/2024 at 1:46 PM, with the Director of Housekeeping, in the presence of the Regional Maintenance Director, he revealed that he was informed of the resident's potential scabies and indicated that he gave Staff B the black bags to use for the resident's belongings. He further revealed that he was unsure if the resident's belongings were bagged, indicating that no one called him to remove the bags from the resident's room, nor did he delegate the task to another staff member. Further, he revealed that after the black bags are collected from the resident's rooms, they are stored in an outside storage pod for at least 72 hours.
During a surveyor observation on 9/12/2024 at 1:52 PM of the outside storage pod, no black bags were observed in the pod.
During a surveyor interview on 9/12/2024 at 2:28 PM, with the Director of Nursing Services (DNS), she revealed that she would expect staff to follow the facility's scabies policy and physician's order.
2. Review of a facility policy titled, Enhanced Barrier Precautions last revised August 2022, states in part, .Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control intervention .EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include .device care or use ( .feeding tube .) .wound care (any skin opening requiring a dressing) .
a) Record review revealed Resident ID #74 was readmitted to the facility in August of 2024 with a diagnosis that includes, but not limited to, respiratory failure.
Record review revealed the resident has a gastrointestinal tube (G-tube [feeding tube]; inserted through the abdomen and into the stomach, which allows liquid nutrition to be given directly into the stomach).
Review of the resident's care plan revealed a focus area initiated on 9/10/2024 which revealed the resident requires EBP related to his/her feeding tube. An intervention includes, but is not limited to, gloves and a gown must be worn during high-contact care activities.
During a surveyor observation on 9/12/2024 at 11:00 AM, revealed Licensed Practical Nurse (LPN), Staff A, was administering Resident ID #74's medications via a feeding tube without wearing a gown. Further observation revealed signage posted at the resident's door which indicated to wear a gown during device care or with care of the feeding tube.
During a surveyor interview, immediately following the above observation, Staff A acknowledged the EBP signage posted at the resident's doorway and acknowledged that she was not wearing the appropriate Personal Protective Equipment (PPE), when she administered the resident's medication, through his/her feeding tube.
During a surveyor interview on 9/12/2024 at 2:28 PM, with the DNS, she revealed that she would expect nurses to don full PPE, including a gown, when administering medication to a resident through a feeding tube.
b) Record review revealed Resident ID #78 was readmitted to the facility in February of 2024 with a diagnosis that includes, but is not limited to, dementia.
Review of the resident's care plan revealed a focus area initiated on 9/7/2024 which revealed the resident requires EBP related to wounds. An intervention includes, but is not limited to, gloves and a gown must be worn during high-contact care activities.
During a surveyor observation on 9/10/2024 at 12:20 PM, revealed a Registered Nurse (RN) from Hospice services, was observed to be providing wound care to the resident, without donning a gown. Further observation revealed signage posted at the resident's door which indicated to wear a gown during wound care.
During a surveyor interview immediately following the above observation, the Hospice RN acknowledged the signage posted at the resident's door and acknowledged she was not wearing the appropriate PPE when providing wound care to the resident.
During a surveyor interview on 9/10/2024 at 12:23 PM, with LPN, Staff K, she revealed that the Hospice RN should have worn the appropriate PPE, as described in the EBP signage, when providing wound care to the resident.
c) Record review revealed that Resident ID #192 was admitted to the facility in September of 2024 with diagnoses including, but not limited to, presence of prosthetic heart valve and heart failure.
Record review revealed that the resident has wounds that require daily wound care.
During a surveyor observation on 9/10/2024 at 11:15 AM, revealed Staff A providing wound care to the resident, without donning a gown. Further observation failed to reveal evidence of EBP signage, or a PPE bin located at the resident's door.
During a surveyor interview immediately following the above observation, Staff A acknowledged that the resident was not on EBP and indicated s/he should have been on EBP. Additionally, she acknowledged that she did not wear a gown during the resident's wound treatment.
Review of the resident's care plan revealed a focus area initiated on 9/10/2024, after this concern was brought to the facility's attention by the surveyor, which revealed the resident requires EBP related to wounds. An intervention includes, but is not limited to, gloves and a gown must be worn during high-contact care activities.
During a surveyor interview on 9/10/2024 at 12:18 PM, with the DNS and the Regional Nurse, they acknowledged that Resident ID #192 was not on EBP and indicated that the resident should have been on EBP due to his/her wounds.
3. Review of a facility policy titled, Wound Care last revised October 2010, states in part, .Use the no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers .Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound .Wear sterile gloves when physically touching the wound or holding a moist surface over the wound .Wipe reusable supplies with alcohol as indicated (i.e., outsides of containers that were touched by unclean hands, scissor blades, etc.) .
a) During a surveyor observation on 9/10/2024 at 11:15 AM, revealed Staff A removing scissors and other wound care supplies from the treatment cart and entering Resident ID #192's room to provide wound care. Staff A was then observed using the scissors to cut xeroform (sterile wound dressing), where she failed to clean the scissors, prior to cutting the xeroform.
During a surveyor interview immediately following the above observation, Staff A acknowledged that she did not clean the scissors prior to cutting the xeroform, per policy.
b) Record review revealed Resident ID #5 was admitted to the facility in August of 2023 with a diagnosis that includes, but is not limited to, pressure ulcer of an unspecified site.
During a surveyor observation of the resident's wound care on 9/13/2024 at 10:37 AM, with LPN, Staff E, she was observed removing a wash basin from the resident's drawer and proceeded to mix a wound solution in the wash basin, without cleaning the basin prior to use. Additionally, she was observed to dress the right ankle wound by cleansing the wound with the above-mentioned mixed solution and dried the wound with the same gloves. Further, using the gloves she cleaned the dirty wound with, she then proceeded to put her fingers into a package containing collagen powder and began pressing the collagen powder directly into the wound with her gloved hand.
During a surveyor interview immediately following the above-mentioned observation with Staff E, she acknowledged that she touched the wound to press the collagen directly into the wound bed with the same gloves she used to cleanse the dirty wounds. She further acknowledged that she removed the basin from the drawer and then mixed the solution in it.
During a surveyor interview with the Wound Physician on 9/13/2024 at 11:24 AM, he revealed that he would expect the staff to put the collagen powder into a cup and pour it on the wound or on to the calcium alginate with silver.
During a surveyor interview on 9/13/2024 at 11:40 AM with the DNS, she was unable to explain why the nurse did not change her gloves or pre-clean the wash basin prior to use.
4. Review of a facility policy titled, Laundry and Bedding, Soiled last revised September 2022, states in part, .All used laundry is handled as potentially contaminated using standard precautions (e.g., gloves and gowns when sorting) .
During a surveyor observation of the soiled linen area of the laundry room on 9/13/2024 at 9:39 AM, failed to reveal evidence of gowns.
During a surveyor interview immediately following the above observation, Housekeeper, Staff L, acknowledged that there were no gowns in the laundry room and revealed that she does not wear a gown when handling soiled linens.
During a surveyor interview on 9/13/2024 at 9:44 AM, with the Director of Housekeeping, he acknowledged that the soiled linen room did not have any gowns for staff to utilize when handling soiled linens, indicating that he has not found an area to keep them. He further revealed that all laundry staff should be wearing a gown when handling soiled linens.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
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 establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiot...
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Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 2 of 2 residents reviewed for antibiotic use, Resident ID #s 78 and 194.
Findings are as follows:
Review of a facility policy titled, Antibiotic Stewardship last revised in December of 2016, states in part, .Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program .The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents .
Review of a facility policy titled, Infection Preventionist [IP] last revised in September of 2022, states in part, .Responsibilities 1. The [IP] (or designee) coordinates the development and monitoring of the [IPCP] .The [IP] collects, analyzes and provides infection and antibiotic usage data and trends to nursing staff and health care practitioners .
1. Record review revealed that Resident ID #78 was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, dementia and type II diabetes mellitus.
Record review revealed a physician's order dated 7/26/2024 for Keflex (an antibiotic) 500 milligrams (mg) give 1 capsule twice daily for a foot infection for 8 weeks.
Record review failed to reveal evidence that the facility implemented an antibiotic review process (also referred to as an antibiotic timeout) to determine if the antibiotic is still indicated or if adjustments should be made.
Record review failed to reveal evidence that the facility was formally tracking and monitoring the resident's use of antibiotics for residents, including Resident ID #78, during the months of July, August, and September of 2024.
2. Record review revealed that Resident ID #194 was readmitted to the facility in September of 2024 with a diagnosis including, but not limited to, type II diabetes mellitus.
Record review revealed a physician's order dated 9/3/2024 for Augmentin (an antibiotic) 875-125mg give 1 tablet twice daily for 7 days for a bacterial infection.
Record review failed to reveal evidence that the facility implemented an antibiotic review process to determine if the antibiotic is still indicated or if adjustments should be made.
Record review failed to reveal evidence that the facility was formally tracking and monitoring the resident's use of antibiotics for residents, including Resident ID #194, during the time the resident was receiving antibiotics in September of 2024.
During a surveyor interview on 9/12/2024 at 11:02 AM with the IP, during the infection control task in the presence of the Director of Nursing Services, Administrator, and Regional Nurse, she revealed that she recently accepted the role as the IP approximately 1 month ago and does not complete antibiotic timeouts or maintain line listings of residents currently receiving antibiotics because she has yet to be shown how to do it.
During an additional surveyor interview on 9/12/2024 at approximately 11:10 AM with the Regional Nurse during the infection control task, she revealed that the facility should complete an antibiotic timeout assessment in the electronic medical record and would expect the antibiotic timeouts to be completed 3 days after the antibiotic is initiated. Additionally, she revealed that the facility could be better at completing antibiotic timeouts. She was unable to provide evidence that the facility maintained an infection control and antibiotic stewardship system to monitor antibiotic use to ensure that residents who require an antibiotic are prescribed the appropriate antibiotic.
Aug 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide tr...
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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 treatment and care in accordance with professional standards of practice and failed to follow physician's orders relative to daily wound dressing changes for 1 of 1 resident reviewed, Resident ID #1.
Findings are as follows:
Record review of a facility document titled Dressings, Dry/Clean states in part; .The purpose of this procedure is to provide guidelines for the application of dry, clean dressing .The following information should be recorded in the resident's medical record, treatment sheet or designated wound form .The date and time the dressing was changed .The name and title (or initials) of the individual changing the dressing .
Review of a document titled Competency Assessment Skin Tears-Abrasions and Minor Breaks, Care of states in part: .The purpose of this procedure is to guide the prevention and treatment of .skin tears .Apply the ordered dressing .Label with date and initials to top of the dressing .
Record review of a community reported complaint sent to The Rhode Island Department of Health on 8/8/2024 alleges that the facility was not providing adequate care to Resident ID #1. The resident was having hygiene and care issues and that s/he endures long waits without being cleaned. Additionally, it alleged that the resident had developed a severe pressure sore on his/her backside.
Record review revealed that Resident ID #1 was admitted to the facility in February of 2024 with diagnoses to include, but not limited to, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a stroke and type 2 diabetes.
Record review of the resident's Quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition.
Record review of the resident's order summary report revealed the following physician's order: Cleanse right arm with normal saline, pat dry, apply gauze followed by dry sterile dressing one time a day with a start date of 7/22/2024.
Record review of the August 2024 Treatment Administration Record revealed that the above wound dressing treatment was last completed as ordered on 8/14/2024 by Licensed Practical Nurse (LPN), Staff D.
During a surveyor interview on 8/15/2024 at approximately 12:00 PM with the resident, s/he revealed that s/he has a wound to his/her right arm but does not remember if the dressing was changed.
During a surveyor observation immediately after the above interview, there was a bordered sterile dressing placed on his/her right arm. The dressing was labeled with the initials JS and the date 8/13/24.
During surveyor interviews on 8/15/2024 at 1:48 PM and on 8/16/2024 at 8:53 AM with LPN, Staff C, he acknowledged that the wound dressing for the resident's right arm was not changed as ordered on 8/14/2024 and would expect the treatment to be completed daily.
During a surveyor interview on 8/15/2024 at 2:10 PM with the Regional Director of Clinical Services, she revealed that she would have expected for staff to change the wound dressing per physician's orders.
During a surveyor interview on 8/16/2024 at 10:50 AM with LPN, Staff E, she revealed that she had documented the wound dressing as completed on 8/14/2024. Additionally, she acknowledged that she did not change the dressing for Resident ID #1 on 8/14/2024.
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to provide adequate supervision to p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to provide adequate supervision to prevent accidents for 1 of 1 resident reviewed for falls, Resident ID #1.
Findings are as follows:
Record review of an agreement between the facility and Rhode Island College School of Nursing revealed in part, .The School of Nursing .referred as the College and [facility name redacted] .referred as the Agency .enters in the following agreement which relates to those portions of the educational program in Nursing of the College which are conducted at the Agency .The Agency's responsibilities .The Agency is responsible for client care .The Agency shall delegate to appropriate members of its staff the responsibility of assisting with the planning and coordination of the learning experiences afforded students of the College .
Record review of a community reported complaint sent to The Rhode Island Department of Health on 8/8/2024 alleges that Resident ID #1 fell in the shower while s/he was with a nursing student that was unsupervised by a licensed Nursing Assistant (NA). Additionally, the complainant alleges that the resident sustained injuries/bruising to his/her buttocks.
Record review revealed that Resident ID #1 was admitted to the facility in February of 2024 with diagnoses to include, but not limited to, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a stroke and type 2 diabetes.
Record review of the resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. Additional review of the MDS revealed that the resident requires substantial/maximal assist (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for showers.
Record review of a baseline care plan revealed that the resident was at risk for falls related to deconditioning, weakness, hemiparesis, and poor safety awareness. Interventions include, but are not limited to, assisting or reminding the resident to change positions and to have the resident get up from sitting or laying down slowly.
Record review of a facility incident report revealed that on 4/9/2024 at 10:00 AM, the Resident had a fall in the shower room while bathing. Additionally, it revealed that injuries included a bruise to the posterior right thigh and right buttock.
Record review revealed written statements from the staff members assigned to care for Resident ID #1 on 4/9/2024; NA, Staff A, and the Licensed Practical Nurse (LPN), Staff B. The statements were collected via phone by the Assistant Director of Nursing (ADNS) on 8/15/2024, as the original statements were unable to be located.
Additional record review of the written statements from Staff A and Staff B revealed the following:
- Staff A indicated that she was working with a male student nurse providing care to the resident and stepped out to grab something from the linen cart. When she returned to the shower room, the resident was on the floor on his/her bottom. She then told the student nurse to inform the charge nurse.
- Staff B indicated that a male nursing student that was working with an NA indicated that the resident had fallen in the shower room out of his/her shower chair while care was being provided. The resident was assessed and was found to have a small cut and a few areas that were starting to bruise.
Review of a Falls Risk Assessment completed on 4/9/2024 at 11:41 AM revealed the resident had a score of 16 indicating s/he was at high risk for falls. The assessment indicates the resident is unable to attain balance while standing, sitting and during transitions without physical help.
Review of a Head-to-Toe Skin Check and Evaluation completed on 4/9/2024 at 12:02 PM revealed that the following injuries were noted on the resident after the fall:
- Bruise to his/her right buttock.
- Bruise to his/her right posterior thigh.
- A scratch on the right ankle.
During a surveyor interview on 8/15/2024 at approximately 2:30 PM with the Regional Director of Clinical Services, she indicated that after speaking with the Director of Nursing Services, she revealed that the nursing student was providing care to the resident with Staff A, but that Staff A had left the resident in the shower room alone with the nursing student. During that time, she indicated that the resident fell out of his/her shower chair. Additionally, she was unable to provide evidence that Resident ID #1 was kept free from accidents.
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 maintain appropriate infection control practices to help prevent the transmission ...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain appropriate infection control practices to help prevent the transmission of communicable diseases and infections for 1 of 1 resident reviewed for isolation precautions, Resident ID #2.
Findings are as follows:
Review of a facility document titled Isolation-Categories of Transmission-Based Precautions states in part, Policy Statement Transmission-based precautions are initiated when a resident develops signs and symptoms of an infection: or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents .Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected .When a resident is placed on transmission based precautions, appropriate notifications is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution .The signage informs the staff of the type of CDC [Center of Disease Control and Prevention] precaution(s), instructions for use of PPE [Personal Protective Equipment] .
Record review revealed that Resident ID #2 was admitted to the facility in July of 2024. The resident has diagnoses which include, but are not limited to, urinary tract infection, septicemia (infection of the bloodstream), and dementia. The resident is currently positive for COVID-19 and is on isolation precautions.
During a surveyor observation on 8/16/2024 at 12:13 PM in the presence of the Assistant Director of Nursing Services (ADNS), Resident ID #2 was heard calling out, Help. You are hurting me. The surveyor walked towards the room in which the calls were coming from and observed Nursing Assistant (NA), Staff E, inside the resident's room, holding soiled linens, wearing an N95 mask (respirator), and gloves. Additional observation revealed Physical Therapy Assistant, Staff F, was already in the room wearing a gown, gloves, and an N95 mask redirecting the resident and explaining that they were changing his/her linens because they were soiled.
Further observation of the resident's room revealed signage which indicated that it was an isolation room. The sign also indicated that prior to entering the room, staff and visitors must clean their hands, wear a gown, an N95 mask, use eye protection (goggles or face shield), and wear gloves.
During a surveyor interview immediately following the above observation on 8/16/2024 with NA, Staff E, she indicated that she did not know the resident's room required isolation precautions. Additionally, she acknowledged that she was not wearing the appropriate PPE to care for the resident.
During a surveyor interview on 8/16/2024 at 12:15 PM with Staff F, she acknowledged she was not wearing the required eye protection while in a COVID-19 positive resident's room.
During a surveyor interview on 8/16/2024 at 12:16 PM with the ADNS, she acknowledged that Resident ID #2 was COVID-19 positive and that Staff E and Staff F were not wearing the appropriate PPE while in his/her room.
During a surveyor interview on 8/16/2024 at 12:27 PM with the Regional Director of Clinical Services, she stated that she would expect for staff to follow infection control practices and wear all required PPE to enter rooms under isolation precautions.
Jul 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 F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice re...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following physician's orders for 1 of 4 residents reviewed, Resident ID #1.
Findings are as follows:
According to Mosby's 4th Edition, Fundamentals of Nursing page 314 states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/28/2024 alleged that the resident did not receive some of his/her medications and other medications were administered late on 7/26/2024.
Record review revealed the resident was admitted to the facility in July of 2024 with diagnoses including, but not limited to, urinary tract infection (UTI) and Deep Vein Thrombosis (DVT; a blood clot that forms in one or more of the deep veins in the body).
Record review of the July 2024 Medication Administration Record (MAR) revealed the following physician's orders:
- 7/26/2024 Ferrous Sulfate 325 milligram (mg) tablet daily at 9:00 AM for low iron.
- 7/26/2024 Eliquis 5 mg tablet (give 2 tablets) every twelve hours for DVT at 9:00 AM and 9:00 PM.
- 7/26/2024 Mucinex extended release 600 mg (give 2 tablets) two times a day for cough at 9:00 AM and at 5:00 PM.
- 7/26/2024 Clopidogrel Bisulfate 75 mg daily at 9:00 AM for blood clot prevention.
- 7/26/2024 Aspirin 81 mg tablet daily at 9:00 AM for prevention of a DVT.
- 7/26/2024 Atorvastatin Calcium 80 mg daily at 9:00 AM for elevated cholesterol.
-7/26/2024 Metoprolol Tratrate 25 mg tablet two times a day at 9:00 AM and 5:00 PM for high blood pressure.
- 7/26/2024 Mometasone Furoate inhaler 200 micrograms (mcg) give 2 puffs two times a day at 9:00 AM and 5:00 PM for respiratory symptoms.
- 7/26/2024 Anoro Ellipta inhaler 62.5-5-25 mcg give 1 puff daily at 9:00 AM for asthma.
-7/25/2024 Bumex 1 mg tablet two times a day at 9:00 AM and 5:00 PM for diuretic (a medication that helps reduce fluids in the body).
Record review of a document titled, Medication Admin Audit Report revealed the above-mentioned medications were administered on 7/26/2024 at 12:30 PM instead of 9:00 AM, as ordered.
Additional record review of a physician's order dated 7/26/2024 revealed Cephalexin 500 mg capsule every 6 hours at 12:00 AM, 6:00 AM, 12:00 PM and at 6:00 PM, for UTI.
Record review of the July 2024 MAR failed to reveal evidence that the resident received the above-mentioned medication on 7/26/2024 at 12:00 AM, as ordered.
During a surveyor interview with the Director of Nursing Service on 7/31/2024 at 10:58 AM and at 1:00 PM, she acknowledged that the Cephalexin was not administered to the resident on 7/26/2024, as ordered. Additionally, she acknowledged that the resident's 9:00 AM medications were administered late on 7/26/2024.
Jun 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 F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to store medications in accordance with currently accepted professional principles relative to maintaining s...
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Based on record review and staff interview, it has been determined that the facility failed to store medications in accordance with currently accepted professional principles relative to maintaining safe and secure storage of all medications, including limited access and mechanisms to minimize loss or diversion, for 1 of 4 residents reviewed, Resident ID #3.
Findings are as follows:
Record review of the facility policy titled Controlled Substances dated November 2022 states in part, .The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1975) .Controlled substances are counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals sign the designated controlled substance record .
Record review of a facility reported incident received by the Rhode Island Department of Health on 5/14/2024, alleges that the facility was unable to locate 22 pills of tramadol (a schedule IV pain medication with a potential for abuse and risk of dependence) 25 mg (milligrams).
Record review of the resident revealed that s/he was admitted to the facility in December of 2023 with diagnoses including, but not limited to, dementia, anxiety disorder, and right hip pain.
Record review revealed that the resident had a physician's order for tramadol 25 mg by mouth two times a day for pain.
Record review of a statement written by the Nursing Supervisor, Staff A, dated 5/14/2024 indicates that on 5/14/2024 at approximately 8:15 AM, Staff B, Licensed Practical Nurse (LPN), told her that she needed to call the pharmacy to obtain a refill of Resident ID #3's tramadol 25 mg tablets (tabs). The statement further indicated that at the time she was unaware that the pharmacy had already delivered 60 tabs of tramadol to the facility and the medications had been stored in the Medication Technician medication cart, mixed in with the resident's other medications.
During a surveyor interview with the Assistant Director of Nursing (ADON), in the presence of the Director of Nursing (DON), and the Regional Director of Clinical Services on 6/18/2024 at 11:28 AM, she presented the following statements from staff interviews for the surveyor to review:
1. Staff C, LPN signed that she received two medication cards of tramadol 25 mg for a total of 60 pills for Resident ID #3 on 5/13/2024 at approximately 8:00 PM, and gave it to Staff D, Registered Nurse (RN).
2. Staff D, RN, denied receiving the 60 pills of tramadol 25 mg from Staff C during their shift from 3:00 PM to 11:00 PM.
3. Staff B, LPN, took over for Staff D during the 11:00 PM to 7:00 AM shift, and stated that he was unaware that the tramadol 25 mg tabs had been delivered, as they were not entered into the narcotic log book to be counted.
4. Staff A, Nursing Supervisor, found that the 60 tablets of 25 mg tramadol for Resident ID #3 were delivered by the pharmacy the night before, as they were in the medication technician's cart mixed in with Resident ID #3's non-narcotic medication and then notified the ADON of her discovery at 8:15 AM on 5/14/2024.
Immediately following the review of the above statements, the ADON revealed that Nursing Supervisor, Staff A, and herself had figured out that 22 of the 25 mg tramadol tabs went missing, and they were not able to locate them. Additionally, the DON, ADON, and the Regional Director of Clinical Services, were unable to provide evidence that the facility limited access and maintained a mechanism to minimize loss or diversion of a Schedule IV medication, as required.
Upon further interview with the DON, she provided evidence of the interventions which were initiated after the missing tramadol tabs were discovered by the facility on 5/14/2024. The following interventions were completed prior to the date of this complaint survey:
a. A thorough investigation of identified narcotic concerns.
b. Reimbursement of the resident who had missing medication.
c. Notification of the Pharmacy Representative and the medical director/provider regarding the missing medication.
d. Conducted an audit of all the current residents medication storage, to ensure all non-narcotics are stored appropriately and narcotic medications are stored securely in a lock box with an accurate count in Narcotic Book.
e. Education was provided to all current licensed nurses on the process in receiving narcotics from pharmacy; immediate storage and narcotic book documentation upon delivery, and immediate notification to the DON if a narcotic count discrepancy is identified.
f. DON will conduct random audits of narcotic medication handling and documentation for a minimum of three months or until sufficient compliance is achieved.
g. The DON and ADON will be responsible for this process. They will evaluate the audits and report on the process to the Quality Assurance Performance Improvement Committee monthly for review and revisions will be made in process, if warranted, for a period of 3-months.
May 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 record review and resident and staff interview, it has been determined that the facility failed to ensure that resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interview, it has been determined that the facility failed to ensure that residents receive adequate supervision to prevent an elopement for 1 of 1 resident reviewed who successfully eloped from the facility, Resident ID #2.
Findings are as follows:
Review of a facility policy titled, Wandering and Elopement dated March 2019, states in part, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .If identified as at risk for wandering, elopement, or other safety issues, the residents care plan will include strategies and interventions to maintain the resident's safety .
Record review failed to reveal evidence of a facility policy relative to escorting residents to medical appointments.
Review of a community reported complaint dated 5/6/2024 alleged that the resident went to an appointment in the community on 5/3/2024 unaccompanied by facility staff and his/her whereabouts were unknown.
Record review revealed that the resident was admitted to the facility in December of 2023 with diagnoses including, but not limited to, mild cognitive impairment, schizoaffective disorder, and unsteadiness on feet.
Review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 11 out of 15, indicating moderately impaired cognition.
Review of a care plan dated 12/21/2023, revealed I am at actual/potential risk for elopement r/t [related to] attempt to leave the building without informing staff.
Record review revealed the following physician's orders:
2/27/2024 - resident may go on a leave of absence with a responsible party
3/13/2024 - Wander Bracelet (WanderGuard): Check function of wander bracelet (left ankle) every day, one time a day for elopement risk
Review of a Elopement/Wandering Risk Evaluation dated 3/16/2024 revealed s/he is at risk for elopement with an intervention for a wander bracelet.
Review of a Neuropsychological Evaluation dated 1/11/2024 revealed that the resident lacks the capacity to make decisions for his/her medical care. Additionally, that his/her cognitive difficulties with functional decline are consistent with a diagnosis of major neurocognitive disorder. Further review revealed recommendations that include, but are not limited to, a surrogate for medical decision making should be activated, s/he requires supervision that would best be achieved through a residential setting such as a nursing facility and the resident is strongly encouraged to abstain from drug use.
Record review failed to reveal evidence that interventions were implemented relative to the facility providing a responsible party for the resident during a leave of absence.
Review of a progress note dated 2/24/2024 revealed that the resident was found outside of the facility on a main road attempting to catch the bus. Additionally, the progress note indicated the staff were unaware that the resident was not in the building at the time. The resident was then placed on 15-minute checks for 5 days.
Review of a community reported allegation dated 5/3/2024 states in part, .[Resident] has noted cognitive deficits, baseline confusion, and incapacity, as well as various other concerns. [Resident] requires walker to ambulate but frequently does not use it .on today's date 5/3/24 .upon arrival, [Resident] was sitting in the waiting area of [Facility] They indicated they had an appointment .[Resident] had attempted to abscond from [Facility] a few months ago and this [Worker] recommended to facility that [Resident] not be transported to appointments at this time .Several hours later .received a phone call that [Resident] never attended their appointment .their current whereabouts are unknown .[Resident] was reportedly spotted at their apartment complex but is not believed to be there presently. At this time, [Residents] whereabouts are unknown .
During a surveyor interview on 5/7/2024 at approximately 9:55 AM with the resident s/he revealed that s/he was transported to his/her appointment alone and when s/he arrived at the appointment s/he was informed that it was cancelled. S/he revealed that s/he took three buses to go to his/her home and then went to eat at a restaurant.
During a surveyor interview with the Assistant Director of Nursing on 5/7/2024 at 10:40 AM she revealed that prior to the resident leaving for his/her appointment in the community on 5/3/2024 his/her wanderguard was removed in case something happened and s/he was admitted to the hospital, so that the facility would have possession of the device, because wanderguards are expensive.
During a surveyor interview on 5/7/2024 at 12:10 PM with the Administrator she acknowledged that the resident was dropped off for an appointment without facility staff accompanying him/her. Additionally, she acknowledged that the resident had previously left the building without staff knowledge and was care planned as an elopement risk.
During a surveyor interview on 5/8/2024 at 10:26 AM with Social Worker, Staff A, she revealed that she drove to Resident ID #2's apartment on 5/3/2024 and s/he was not there. Additionally, she revealed that she was driving around and found the resident standing on the corner of a highly traveled main road approximately 8 miles from the facility. Staff A indicated that she located the resident at 1:24 PM.
During a surveyor interview on 5/7/2024 at 3:05 PM with the Medical Director he revealed that he was unaware that the resident had been dropped off for an appointment alone and was unaware that s/he had been missing for several hours. Additionally, he revealed that he would expect a resident who is care planned as an elopement risk be accompanied by a staff member when leaving the building.
During a surveyor interview on 5/7/2024 at approximately 2:00 PM with the Administrator she was unable to provide evidence that Resident ID #2 received appropriate supervision to prevent an elopement.
Due to the facility's failure to provide adequate supervision to a cognitively impaired resident who was assessed as an elopement risk resulted in this resident to be unsupervised in the community. The resident left an appointment and took several buses to multiple locations. This resident was found by facility staff standing on the corner of a highly traveled main road approximately 8 miles from the facility which placed the resident at risk for more than minimal harm, impairment, or death.
Apr 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
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 nursing staff have the appr...
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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 nursing staff have the appropriate competencies and skill 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, for 1 of 3 residents reviewed for medication administration, Resident ID #1.
Findings are as follows:
Review of a community reported complaint submitted to the Rhode Island Department of Health on 4/1/2024 alleges in part, On March 21st [Resident ID #1] was given the wrong medications .because there were people in training .[Resident ID #1] was given oxycodone and a blood pressure medicine .[Resident ID #1's] blood pressure is low so that was not good and also the oxycodone put [him/her] in a bad state of mind .
According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023 which states in part, .To assure that all nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being .'Competency' is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully .
The facility policy titled Administering Medications, states in part, .Medications are administered in accordance with prescriber orders .The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include .checking identification band .checking photograph attached to medical record .verifying resident identification with other facility personnel .The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication .New personnel authorized to administer medications are not permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility .
Record review revealed Resident ID #1 was re-admitted to the facility in March of 2024 with diagnoses including, but not limited to, hypertension, acute kidney failure, acute pyelonephritis(sudden and severe inflammation of kidney due to a bacterial infection), and chronic obstructive pulmonary disease.
Review of a medication incident report provided by the facility revealed that on March 21, 2024, the nurse administered the wrong medication to Resident ID #1. It revealed, .Wrong medication was given to the wrong resident. Standard protocol for medication administration was not followed .Did not follow medication administration procedures (5 rights) .rushing through [medication] pass .preceptor [Licensed Practical Nurse (LPN), Staff B] was preparing medications and handing them off to trainee [ Licensed Practical Nurse, Staff C] . Additionally, the report reveals that Staff C was instructed that the medications were for the resident in one room and she brought them to the wrong room and administered them to the wrong resident. The medications administered to Resident ID #1 in error included- Aspirin 81 milligrams (mg), Duloxetine (used to treat depression and anxiety) 30 mg, Linezolid (an antibiotic) 600 mg, Oxycontin ER (extended release-a strong narcotic pain medication) 10 mg, Flomax (used to shrink an enlarged prostate) 0.8 mg and Metoprolol Succinate ER (used to treat high blood pressure) 25 mg.
Review of a statement authored by Staff B on 3/21/2024, revealed in part, This writer training new nurse .administering medications. I instructed nurse to give [room number redacted] his/her medication I did not go to the room with her as she has been training for over 1 week and wanted her to get a sense of what it is like going in room alone .Error reported to [Nurse Practitioner (NP)] .
Review of a statement authored by Staff C on 3/21/2024, revealed while she was training with Staff B there was a medication error. Staff B handed Staff C medications that were meant to be administered to the resident in one room, Staff C misheard the room number, went to the wrong room and administered the medications to Resident ID #1 instead. The error was realized later when Staff B gave Staff C Resident ID #1's medication, and Staff C stated that she had already given Resident ID #1 his/her medications.
Multiple attempts were made to interview Staff B or Staff C by phone; however, neither staff member was able to be reached.
During a surveyor interview on 4/2/2024 at 1:20 PM with the Unit Supervisor, Staff Nurse A, she revealed that because Staff C was still training Staff B should have been with her at all times during the medication administration.
During a surveyor interview on 4/2/2024 at 3:15 PM with the Director of Nursing Services (DNS) she acknowledged that Staff B should not have been pouring medications then having Staff C administer them. Her expectation would be the nurse who pours the medication would be the nurse to administer the medication to the resident. She further acknowledged that since Staff C was still in training, Staff B should have been with her, observing during the entire medication administration. Further, she could not provide evidence that Staff C had demonstrated competency in medication administration at the time of the medication error.
Upon further interview with the DNS she provided evidence of the interventions which were initiated after the medication error was identified by the facility on 3/21/2024. The following interventions were completed prior to the date of this complaint survey:
a) The resident was assessed for any adverse consequences.
b) An audit was completed for all residents' rooms to make sure that names and room numbers are posted outside of the door.
c) Electronic records were audited to ensure that the residents pictures were present.
d) All nurses were educated on medication administration, along with the responsibility of a preceptor.
e) A Quality Assurance and Performance Improvement action plan was put in place and random audits of resident identification measures were conducted.
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 3 residents reviewed, Resid...
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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 3 residents reviewed, Resident ID #1.
Findings are as follows:
Review of a community reported complaint submitted to the Rhode Island Department of Health on 4/1/2024 alleges in part, On March 21st [Resident ID #1] was given the wrong medications .because there were people in training .[Resident ID #1] was given oxycodone and a blood pressure medicine .[Resident ID #1's] blood pressure is low so that was not good and also the oxycodone put [him/her] in a bad state of mind .
The facility policy titled Administering Medications, states in part, .Medications are administered in accordance with prescriber orders .The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include .checking identification band .checking photograph attached to medical record .verifying resident identification with other facility personnel .The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication .New personnel authorized to administer medications are not permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility .
Record review revealed Resident ID #1 was re-admitted to the facility in March of 2024 with diagnoses including, but not limited to, hypertension, acute kidney failure, acute pyelonephritis (sudden and severe inflammation of kidney due to a bacterial infection), and chronic obstructive pulmonary disease.
Review of a medication error report provided by the facility revealed that on 3/21/2024, Resident ID #1 received Aspirin 81 milligrams (mg), Duloxetine (used to treat depression and anxiety ) 30 mg, Linezolid (an antibiotic) 600 mg, Oxycontin ER (extended release-a strong narcotic pain medication) 10 mg, Flomax (used to shrink an enlarged prostate) 0.8 mg, and Metoprolol Succinate ER (used to treat high blood pressure) 25 mg.
Review of Resident ID #1's physician orders revealed s/he did not have orders for the following medications that were administered to him/her in error:
-Aspirin 81 mg
-Duloxetine 30 mg
-Linezolid 600 mg
-Oxycontin ER 10 mg
-Metoprolol Succinate ER 25 mg
Review of the physician's orders revealed the resident was prescribed Flomax; however, the dosage was 0.4 mg.
Record review revealed the following progress notes dated 3/21/2024:
- 10:40 AM- .At approximately 10 am this nurse assisted in assessing resident [s/he] was [alert and oriented] to baseline .[complaint of] dizziness with movement [blood pressure] at time was 92/62 [normal blood pressure 120/80] pulse 72 [normal pulse 60-100] .
- 12:29 PM-Medication administration reviewed by [Nurse Practitioner] new orders to obtain VS [vital signs] every hour [for] 4 hours then [every 4 hours for 24 hours]. Resident refused lunch stating [s/he] doesn't have an appetite and has abdominal discomfort .
- 10:33 PM-Resident was alert and oriented [times 3]. No respiratory distress noted. Resident was able to make .needs known. Resident was not lethargic drowsy. Vital signs were stable. Resident refused vitals after 8 pm check. [S/he] stated [s/he] was tired of having vitals checked and wanted to get some sleep .
During a surveyor interview on 4/2/2024 with the NP, she revealed that when she saw the resident s/he was alert and oriented with no signs or symptoms of concern. She stated that a nurse called her later in the day and stated that the resident was very sleepy and in and out. At this point the NP recommended that the resident get sent to the hospital for evaluation due to the narcotic, but she was told that the resident and family wanted him/her to be monitored at the facility. The NP further revealed that when she saw the resident the next day, s/he was alert and oriented.
Review of the resident's blood pressure (BP) on 3/21/2024 revealed the following:
- 9:20 AM- BP 101/76
- 10:00 AM- BP 92/62
- 11:00 AM- BP 110/76
- 12:00 PM- BP 102/70
- 1:00 PM- BP 108/74
- 4:59 PM- BP 102/72
During a surveyor interview on 4/2/2024 with the Unit Supervisor, Staff A, she revealed that the resident received the wrong medication, it was realized right away, and the NP was contacted. The NP assessed the resident and ordered vital signs every hour. She further revealed that the Nurse who administered the medications stayed with the resident for the rest of the shift as a one on one to monitor him/her.
During a surveyor interview on 4/2/2024 with the Director of Nursing Services she revealed that a nurse who was training on medication administration had administered another resident's medication to Resident ID #1. She failed to provide evidence that Resident ID #1 was free of any significant medication errors or that the Administering Medication policy was followed.
Upon further interview with the DNS she provided evidence of the interventions which were initiated after the medication error was discovered by the facility on 3/21/2024. The following interventions were completed prior to the date of this complaint survey:
a) The resident was assessed for any adverse consequences.
b) An audit was completed for all resident's rooms to make sure that names and room numbers are posted outside of the door.
c) Electronic records were audited to ensure that resident pictures were present.
d) All nurses were educated on medication administration along with the responsibility of a preceptor.
e) A Quality Assurance and Performance Improvement action plan was put in place and random audits of resident identification measures were conducted.
Nov 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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, it has been determined that the facility failed to provide treatment and c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice, for 1 of 2 residents reviewed for wound care and 1 of 1 resident reviewed for antibiotic use Resident ID #1.
Findings are as follows:
Record review of a community reported complaint submitted to the Rhode Island Department of Health on 11/1/2023 alleges that the resident does not receive adequate care and is neglected by staff.
Record review revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, cellulitis (skin infection) of the left lower limb and diabetes mellitus due to an underlying condition with a foot ulcer.
1. Review of the resident's hospital summary revealed the resident has the following wounds:
- Wound 1: Right pretibial venous ulcer (shin) that was documented as being present on 10/15/2023 during his/her hospital stay
- Wound 2: skin tear to left pretibial leg that was documented as being present on 10/15/2023 during his/her hospital stay
- Wound 3: diabetic ulcer to right toe that was documented as being present on 10/15/2023 during his/her hospital stay
- Wound 4: Two wounds on the lateral right foot below the 5th toe and one below the 4th toe that was documented as being present on 10/16/2023 during his/her hospital stay
Record review revealed that physician orders for the above wounds were not implemented until 10/26/2023, 8 days after his/her admission to the facility.
During a surveyor interview on 11/2/2023 at approximately 3:10 PM with the Director of Nursing Services and the Regional Clinical Director, they were unable to provide evidence that the resident had wound orders implemented upon his/her admission.
2. Review of the Discharge summary dated [DATE], for Resident ID #1 revealed the resident had an order to take Amoxicillin-Pot Clavulanate (Augmentin, antibiotic) for cellulitis (skin infection) for 7 days, twice a day for a total of 14 tablets.
Record review of the October 2023 Medication Administration Record revealed the resident only received the medication for a total of 9 doses and not the 14 ordered doses, indicating s/he missed 5 of the 14 doses ordered.
During a surveyor interview on 11/2/2023 at approximately 3:10 PM with the Director of Nursing Services and the Regional Director of Clinical Services, they acknowledged that the medication was not administered to the resident for the total of 14 doses as ordered.
Oct 2023
13 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 keep a resident free from physical...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to keep a resident free from physical and verbal abuse for 1 of 4 residents reviewed for staff to resident abuse, Resident ID #71.
Findings are as follows:
Record review revealed that the resident was admitted to the facility in October of 2022 with diagnoses including, but not limited to, dementia, anxiety, urinary incontinence, and major depressive disorder.
Review of a Quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 1 out of 15, indicating that the resident has severe cognitive impairment. Additional review revealed the resident requires extensive assistance of 2 staff members for bed mobility, dressing, eating, toilet use and personal hygiene. Further review revealed the resident is totally dependent on two staff with transfers and bathing.
Review of the resident's care plan dated 6/23/2023 revealed a focus area for a history of rejection of care related to his/her dementia diagnosis with interventions including, but not limited to, allow the resident to make decisions about treatment regime to provide sense of control, give clear explanation of all care activities prior to and as they occur during each contact, If the resident resists with activities of daily living, provide reassurance, leave and return 5-10 minutes later.
Further review of the resident's care plan reveals a care plan dated 10/3/2023 related to possible sexual abuse as a child with interventions including, but not limited to, be consistent, positive, honest, and nonjudgmental while working with me and avoid situations that may cause flashbacks and ask me about triggers and incorporate them into my plan of care.
During a surveyor observation on 10/11/2023 at 11:48 AM, while providing care to the resident, Nursing Assistant (NA), Staff A, was overheard by the surveyor telling the resident,quit acting like a baby, you're a baby, baby [boy/girl]. Licensed Practical Nurse (LPN), Staff B, was immediately notified by the surveyor and entered the resident's room.
During a surveyor interview on 10/11/2023 at approximately 11:50 AM, immediately following the above surveyor observation, Staff B, stated that Staff A, reported to her she was joking, and she told Staff A, she could not do that.
Review of a witness statement provided by NA, Staff C, who was in the room at the time of the incident, states in part, .I was doing care for the resident getting [him/her] washed and dressed. But as I was washing [him/her], [s/he] was trying to hit us (the other C.N.A) [Certified Nursing Assistant, Staff A] whom was helping me, she was holding down [his/her] hands and said 'are you a baby?' and that was all she had stated to [him/her] .
During a surveyor interview on 10/11/2023 at 11:58 AM with NA, Staff C, she revealed that when providing morning care to the resident s/he was combative and incontinent of urine. She further stated, when you giving [him/her] care [s/he] always try and slap you .if you call [him/her] a baby it calms [him/her] down and [s/he] will smile at you .
Record review of a facility provided document titled 5-day Investigation Report states in part, C.N.A. suspended pending investigation. Statements obtained. One statement said aide held [his/her] hands down to prevent [him/her] from hitting. Aide terminated .
During a surveyor interview on 10/12/2023 at 3:23 PM with the Regional Director of Clinical Services, she revealed that Staff A had been suspended pending investigation. Additionally, she revealed that the allegation of staff to resident abuse would be substantiated, and Staff A, would be terminated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
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 assess the need for a physical restraint, assess for the least restrictive alterna...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to assess the need for a physical restraint, assess for the least restrictive alternative, the amount of time the restraint is needed and re-evaluation of the need for restraints for 1 of 1 resident reviewed for physical restraints, Resident ID #286.
Findings are as follows:
According to the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual last updated 10/4/2023, states in part, .Limb restraints include any manual method or physical or mechanical device, material or equipment that the resident cannot easily remove, that restricts movement of any part of an upper extremity (i.e., hand, arm, wrist) or lower extremity (i.e., foot, leg) that either restricts freedom of movement or access to his or her own body. Hand mitts/mittens are included in this category .
Review of a facility policy titled, Use of Restraints dated April 2017, states in part, .6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms .9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom; b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period time for the use of restraints .
Record review revealed that the resident was admitted to the facility in October of 2023 with diagnoses including, but not limited to, compression of brain and nontraumatic intracerebral hemorrhage (a blood vessel in the brain ruptures and causes bleeding inside the brain).
During surveyor observations on the following dates and times, the resident was observed with a right-hand mitt in place:
10/10/2023 at 9:58 AM
10/11/2023 at 8:15 AM
10/11/2023 at 8:39 AM
10/11/2023 at 11:54 AM
During a surveyor interview on 10/11/2023 at 11:54 AM, with the resident's spouse, they revealed that the resident must wear the right-hand mitt when the resident is alone in his/her room and not being supervised by staff. Additionally, they revealed that the resident has had the right-hand mitt in place since admission from the hospital.
Review of an Admission/readmission Evaluation Packet dated 10/6/2023 revealed a question that states, Does resident currently have restraints? answered as No. Additionally, the required assessment was not completed.
Record review failed to reveal evidence of a physician's order for the right-hand mitt.
Record review failed to reveal evidence of a care plan to include the right-hand mitt or use of a restraint.
Further record review failed to reveal evidence of an attempt for a less restrictive intervention, re-evaluation of the restraint or the amount of time the restraint would be used for.
During a surveyor interview on 10/11/2023 at 12:02 PM with Licensed Practical Nurse (LPN), Staff D, she revealed that the resident wears the right-hand mitt at all times due to him/her touching a surgical site on his/her head.
During a surveyor interview on 10/11/2023 at 12:51 PM with the Director of Nursing Services (DNS) and the Regional Clinical Director, they acknowledged that the right-hand mitt is a restraint and that an assessment was not completed as required. Additionally, they acknowledged that there was not a physician's order or a care plan in place for the restraint. The DNS and Regional Clinical Director could not provide evidence that the facility assessed the need for a physical restraint, assessed for the least restrictive alternative, the amount of time the restraint is needed or the re-evaluation of the need for restraints per the regulation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to develop and implement a baseline care plan for each resident within 48 hours of a resident's admission, t...
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Based on record review and staff interview, it has been determined that the facility failed to develop and implement a baseline care plan for each resident within 48 hours of a resident's admission, that includes the instructions needed to provide effective and person-centered care for the resident that meets professional standards of quality care relative to urinary catheter, use of a helmet, use of a right hand restraint and a stage 4 pressure wound, for 1 of 4 residents reviewed for baseline care plans, Resident ID #286.
Findings are as follows:
Record review revealed that the resident was admitted to the facility in October of 2023 with diagnoses including, but not limited to, compression of brain and nontraumatic intracerebral hemorrhage (a blood vessel in the brain ruptures and causes bleeding inside the brain).
A. During a surveyor observation on 10/10/2023 at 9:58 AM revealed a foley catheter bag hanging on the right side of the bed.
Record review of the physician's orders failed to reveal an order for a foley catheter.
Record review of the baseline care plan initiated on 10/6/2023 failed to reveal evidence of a care plan for a foley catheter. Further review of the care plan revealed a focus stating, I have urinary incontinence although the resident has a foley catheter.
B. Record review revealed special instructions that states, Helmet use during transport or changing position in bed.
Record review failed to reveal a physician's order for a helmet.
Record review of the baseline care plan initiated on 10/6/2023 failed to reveal evidence of a care plan for use of a helmet due to safety concerns following the resident having a craniotomy (surgery to cut a bony flap from the skull to access the brain).
C. During a surveyor observation on 10/10/2023 at 9:58 AM revealed the resident had a right-hand mitt in place.
Record review failed to reveal a physician's order for a right-hand mitt.
During a surveyor interview on 10/11/2023 at 12:02 PM with Licensed Practical Nurse (LPN), Staff D revealed that the resident wears the right-hand mitt at all times due to him/her touching a surgical site on his/her head.
Record review of the baseline care plan initiated on 10/6/2023 failed to reveal evidence of a care plan including the right-hand mitt or use of a restraint.
D. Review of a Wound Evaluation & Management Summary dated 10/9/2023, revealed the resident has a Stage 4 pressure ulcer (stage 4 sores are the most serious, affecting the muscles and ligaments) to his/her sacrum (triangular bone at the base of the spine).
Record review of the baseline care plan initiated on 10/6/2023 failed to reveal evidence of a care plan for the stage 4 pressure ulcer to include treatment or interventions.
During a surveyor interview on 10/11/2023 at 12:51 PM with the Director of Nursing Services (DNS) and the Regional Director of Clinical Services, they acknowledged that the resident had a foley catheter for urinary output, a helmet for safety when being transferred or moved in bed, a right-hand mitt to stop the resident from touching a head wound, and a stage 4 pressure ulcer to his/her sacrum. Additionally, they acknowledged that none of the above-mentioned concerns were part of the resident's baseline care plan. The DNS and the Regional Director of Clinical Services failed to reveal evidence that the facility implemented a baseline care plan within 48 hours of the resident's admission, that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 3 residents reviewed for assistance with meals, Resident ID #51.
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, intellectual disability, dementia, gerd (reflux), and dysphagia (difficulty in swallowing food or liquid).
Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 9 out of 15, indicating moderately impaired cognition. Additionally, the MDS revealed the resident is totally dependent on one staff member for eating.
Record review of a care plan dated 4/14/2023 and updated 4/25/2023 revealed, the resident has a self-care performance deficit related to physical limitations due to impaired mobility. Interventions include, but are not limited to, assistance with feeding all meals.
Record review of the document titled, RESIDENT CARE CARD, dated 10/12/2023 indicates the resident needs assistance with meals.
Record review of a document titled, Speech Therapy treatment encounter notes, dated 8/29/2023 revealed that the resident received speech therapy services from 7/25/2023 through 9/2/2023 for treatment including, but not limited to, swallowing dysfunction and/or oral function for feeding.
Record review of Speech Therapy Summary of Daily Skilled Services notes revealed the following on the below dates and times:
8/22/2023 3:37 PM- states in part, When given orange juice via straw, the patient is noted to be impulsive at times, taking extremely large consecutive sips. Cueing for smaller sips is necessary for increased safety. A cough response times 3 was noted during session.
8/25/2023 3:21 PM- states in part, The patient fed [him/herself] this meal, however when self-feeding the patient is observed to eat fast and stuff food into [his/her] mouth at times. Patient noted to groan while eating. At cessation of [his/her] meal the patient's reflux continues to be prevalent. [S/he] is encouraged to sit up at 90 degrees to reduce symptoms of reflux.
8/29/2023 5:03 PM- states in part, With supervision, the patient is able to utilize compensatory strategies while eating with verbal reminders. Without supervision/reminders, the patient is very impulsive with eating which poses a choking risk.
Record review of a document titled, Speech Therapy [SLP] Discharge Summary, dated 8/29/2023 states in part, .pt [patient] noted to groan and throat clear during mealtimes, especially when self-feeding .Pt able to utilize compensatory strategies given reminders; staff educated on specific compensations to promote safety during meal times .Additionally, the document revealed discharge recommendations for the patient to use the following strategies and/or maneuvers during oral intake; alteration of liquids/solids, no straws, lingual (tongue) sweep/reswallow and rate modification, upright posture during meals and upright posture for greater than 30 minutes after meals.
Record review of a document titled, Speech Therapy SLP Evaluation and Plan of Treatment, dated 10/11/2023 revealed that the resident will receive speech therapy services from 10/11/2023 through 12/9/2023. The document states in part, .with wheezing during PO [oral] intake .(coughing via straw noted) .Pt referred by NP [Nurse Practitioner] due to observed wheezing with PO intake .The patient takes extremely large, consecutive sips via straw. Immediate cough [times] one observed .recommendations to facilitate safety .it is recommended that the patient use the following strategies and/or maneuvers during oral intake .upright posture during meals and upright posture for greater that 30 minutes after meals.
During surveyor observations of the resident on the following the dates and times the following was observed:
-10/10/2023 at approximately 9:15 AM in bed, head of bed less than 90 degrees, a sign was observed on the wall at the head of the bed that read, Keep resident head of the bed 90 degrees during the meal and 30 minutes after due to reflux.
-10/10/2023 at 12:28 PM, the resident was observed in bed with the lunch meal. S/he was eating without any staff assisting him/her and the head of the bed was elevated less than 90 degrees.
-10/11/2023 at 12:30 PM, the resident was observed in bed with the lunch meal. S/he was eating without any staff assisting him/her and the head of the bed was elevated less than 90 degrees.
-10/12/2023 from 12:20 PM until 12:45 PM, the resident was observed in bed with the lunch meal. S/he was eating and drinking from a straw without any staff assisting him/her and the head of the bed was elevated less than 90 degrees. The resident was observed to be coughing.
During a surveyor interview on 10/12/2023 at 12:45 PM immediately following the last observation with Nursing Assistant (NA), Staff E, she acknowledged that the resident was eating without staff assistance, drinking with a straw and the head of the bed was not elevated to 90 degrees.
During a surveyor interview on 10/12/2023 at 1:40 PM with the Nurse Practitioner, Staff F, she revealed that her expectation would be that the resident would have staff assistance during meals, no straws and the head of the bed would be elevated to 90 degrees at meals and for 30 minutes after as recommended by Speech Therapy.
During a surveyor interview on 10/12/2023 at 2:46 PM with the Speech Therapist, she revealed it would be her expectation and recommendation that the resident is upright at 90 degrees during meals and for 30 minutes after due to reflux and aspiration risk. She indicated that she hung the signage in the resident's room. Additionally, she revealed that the resident should not have straws due to the resident doing quick sequential sips and bolus formation for risk of aspiration.
During a surveyor interview on 10/13/2023 at approximately 3:15 PM with the Regional Director of Clinical Services, she acknowledged the sign was present in the resident's room to keep the head of the bed elevated to 90 degrees during the meal and for 30 minutes after.
During a surveyor interview 10/13/2023 at 3:16 PM with Director of Rehab in the presence of the Regional Director of Clinical Service she revealed that she would have expected the resident to have received staff assistance with meals based on his/her care plan and that the head of the bed should be elevated to 90 degrees during meals and for 30 minutes after based on the Speech Therapy recommendations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and servi...
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Based on surveyor observation, record review, and staff 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 2 of 3 residents observed for wound care, Resident ID #s 32 and 286.
Findings are as follows:
1. Record review revealed that Resident ID #32 was admitted to the facility in August of 2023 with diagnoses including, but not limited to, type II diabetes mellitus and protein calorie malnutrition.
Review of a Wound Evaluation & Management Summary dated 10/9/2023 revealed the resident has a stage 4 pressure ulcer (stage 4 sores are the most serious, affecting the muscles and ligaments) to his/her left lateral foot and a deep tissue injury (DTI) to his/her left lateral ankle.
Record review revealed the following wound care orders with a start date of 10/3/2023:
Left Lateral Foot - apply silver sulfadiazine [topical is used to treat or prevent serious infection of a wound or burn] to wound bed house barrier cream to surrounding skin for protection. cover with foam silicone border dressing [highly absorbent bandage with adhesive gentle border].
Left Lateral Ankle - silver sulfadiazine to wound, apply house barrier cream, cover with foam silicone border dressing
During a surveyor observation of wound care on 10/11/2023 at 11:30 AM, with Licensed Practical Nurse (LPN), Staff G and LPN, Staff D, Staff G was observed to removing a soiled dressing from the left lateral foot and a dressing from the left lateral ankle. Then Staff G was observed applying silver sulfadiazine to the wound bed and applying a bordered gauze dressing to the left lateral foot. Staff G did not cleanse the wound between removing a soiled dressing and applying a clean dressing. Additionally, Staff G did not apply a dressing to the DTI of the left lateral ankle and then applied a ted stocking.
During a surveyor interview on 10/11/2023 at 11:46 AM with Staff D, she revealed that she was unaware that there was a wound care order for the left lateral ankle until being brought to her attention by the surveyor. Additionally, Staff D acknowledged that the wound was not cleansed between removing a soiled dressing and applying a clean dressing. Staff D also acknowledged that a bordered gauze was applied and not a foam dressing as ordered.
During a surveyor interview on 10/11/2023 at 12:43 PM with the Wound Care Nurse, LPN, Staff H, she revealed that she would expect all wounds to be cleansed after removing a soiled dressing and applying a clean dressing. Additionally, she revealed that the Wound Care Doctor did wound rounds with her this week and did not give an order to not clean the wound. She also revealed that she would expect the staff to follow the wound care orders for the left lateral ankle and not apply a ted stocking over an open wound.
During a surveyor interview on 10/16/2023 at 1:42 PM with the Wound Care Doctor, he revealed that he would expect the nurse to cleanse the wound with normal saline when a soiled dressing is removed and prior to applying a clean dressing. Additionally, he would expect the staff to follow the orders in place for the left lateral ankle.
2. Record review revealed that Resident ID #286 was admitted to the facility in October of 2023 with diagnoses including, but not limited to, compression of brain and nontraumatic intracerebral hemorrhage (a blood vessel in the brain ruptures and causes bleeding inside the brain).
Review of a Wound Evaluation & Management Summary dated 10/9/2023, revealed the resident has a Stage 4 pressure ulcer to his/her sacrum (triangular bone at the base of the spine).
Record review revealed a physician order for sacrum: apply 1/4 strength Dakin solution (used to prevent and treat skin and tissue infections) to rolled gauze until moist and pack wound, cover with ABD pad (used for large wounds or for wounds requiring high absorbency) and bordered gauze.
During a surveyor observation of wound care on 10/11/2023 at 12:28 PM with LPN, Staff D, and LPN, Staff G, Staff D was observed to unroll a package of rolled gauze into a ball in her hand, pour ¼ strength Dakins solution onto the gauze and then attempt to push the ball of gauze directly into the wound with her hand instead of using an applicator. As a result, the gauze was not packed properly into wound and was observed to be falling out of the wound.
During a surveyor interview on 10/11/2023 at 12:43 PM with the Wound Care Nurse, Staff H, she acknowledged that she would expect the nurse to pack a wound using an applicator to assure that the gauze was inside the wound versus sitting on top of the wound.
During a surveyor interview on 10/16/2023 at 1:42 PM with the Wound Care Doctor, he revealed that he would expect the staff to pack a wound using an applicator a small amount at a time to ensure the wound is packed and not use their hands.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight for 2 of 6 sample residen...
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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 2 of 6 sample residents reviewed, Resident ID#s 46 and 15.
Findings are as follows:
Record review of a facility policy titled, Weight Assessment and Intervention dated 2001 MED-PASS, Inc, revised March 2022 states in part: .individual care plans shall address the identified causes of weight loss .undesirable weight change is evaluated by the treatment team .the physician and multi disciplinary team identify conditions and medications that may be causing weight loss .
1. Record review revealed Resident ID #46 was re-admitted to the facility in June of 2023 with diagnoses including, but not limited to, acute kidney failure and cerebral infarction (stroke).
Review of a document titled weight summary revealed the resident had a documented weight of 149.0 lbs.(pounds) on 8/4/2023 and had a documented weight of 112.4 lbs. on 10/4/2023, which is a weight loss of 36.6 lbs., indicating a significant weight loss of 25% over an 8-week period.
Record review of a dietary note dated 10/6/2023 states in part, weight obtained at 112.4, weight loss present as suspected, 14% in 3 months, supplement in place .no feeding tube indicated, proceed with current POC [plan of care].
Additional record review failed to reveal evidence that the physician was notified of the resident's significant weight loss.
Further record review failed to reveal evidence of a care plan that addressed the significant weight loss with identified causal factors, until it was brought to the attention of the Registered Dietician (RD) by the surveyor.
During a surveyor interview on 10/16/2023 at approximately 9:57 AM, with the RD, she revealed she did not address the significant weight loss and that she did not change the interventions to the nutritional plan of care.
2. Record review revealed Resident ID #15 was admitted to the facility in July of 2014 with diagnoses including, but not limited to, esophageal stenosis (a condition characterized by an abnormal narrowing of the esophagus, which can limit or block food and liquid that's traveling from the throat to the stomach) and chronic dysphagia (difficulty in swallowing food or liquid).
Review of a document titled weight summary revealed the resident had a documented weight of 148.6 pounds (lbs.) on 9/28/2023 and had a documented weight of 140.8lbs. on 10/10/2023, which is a weight loss of 7.8 lbs., indicating a significant weight loss of 5.2% over a 12-day period.
Review of a progress note dated 10/6/2023, authored by the RD, states in part, .wt.[weight] 143.8 stable, diet upgraded .
Additional review of progress notes revealed a note dated 10/10/2023, authored by the facility RD, which states in part, .wt. 140 pounds this week, not significant .
Record review failed to reveal evidence that the physician was notified of the significant weight loss of 5% from 9/28/2023 to 10/10/2023.
Additional record review failed to reveal evidence of a care plan focus relative to the resident's significant weight loss with causal factors identified.
During a surveyor interview on 10/12/2023 at approximately 9:03 AM with the RD, she revealed she did not address the significant weight loss in her notes or in the resident's care plan. Additionally, she revealed she did not change the nutritional plan of care after the significant weight loss was identified until it was brought to her attention by the surveyor.
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 2 residents reviewed who receive nutrition via a feeding tube, Resident ID #286.
Findings are as follows:
Record review revealed the resident was admitted to the facility in October of 2023 with a diagnosis including, but not limited to, pneumonitis (inflammation of the lung tissue) due to inhalation of food and vomit.
Review of a care plan revealed a focus dated 10/10/2023 which states in part, I have a nutritional problem or potential nutritional problem [related to] requires feeding tube to meet nutrition needs. Interventions include, but are not limited to, monitor tube feeding tolerance per protocol and speech therapy consult for chewing and swallowing problems.
Review of a physician order dated 10/7/2023 revealed the resident's head of bed (HOB) should be elevated 30-45 degrees during enteral feeding, flushing, medication administration, and for 1-hour after feeding.
During a surveyor observation on 10/11/2023 from 10:55 AM until 12:02 PM, the resident was observed laying flat in his/her bed while the enteral feeding was being administered.
During a surveyor interview on 10/11/2023 at 12:02 PM with Licensed Practical Nurse (LPN), Staff D and LPN, Staff G, they acknowledged that the resident was laying flat while the enteral feed was running and acknowledged that the head of bed should have been elevated at least 30 degrees.
During an additional surveyor observation on 10/12/2023 at approximately 9:10 AM, the resident was observed to be laying flat in his/her bed while the enteral feeding was being administered.
During a surveyor interview on 10/12/2023 at 10:00 AM with Registered Nurse, Staff I, she acknowledged that the resident was laying flat in his/her bed while the enteral feeding was being administered and indicated the head of bed should be elevated during enteral feedings.
During a surveyor interview on 10/12/2023 at approximately 2:30 PM with the Director of Nursing Services and the Regional Director of Clinical Services, they both indicated that the resident's head of bed should be elevated during enteral feedings, per physician order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
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 meet professional standards of practice, in accordance with physician orders and th...
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Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to meet professional standards of practice, in accordance with physician orders and the comprehensive person-centered care plan, relative to a peripherally inserted central catheter (PICC), for 1 of 2 residents observed for intravenous (IV) antibiotic administration via a PICC line, Resident ID #17.
Findings are as follows:
Review of a facility provided policy titled Peripheral and Midline IV Dressing Changes, which states in part, .General Guidelines 1. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened or visibly soiled) .4. Change the dressing if it becomes damp, loosened or visibly soiled and .immediately if the dressing or site appears compromised .6. Assess the peripheral/midline access device with each infusion and at least daily. a. Visually inspect the entire infusion system (solution, administration set, and dressing); b. Check expiration dates of the infusion, dressing and administration set; c. Assess the patency of the vascular access device; d. Palpate and inspect the skin, dressing and securement device for signs of complications, including: (1) dislodgement; (2) redness; (3) tenderness; (4) swelling; (5) infiltration; (6) induration; (7) elevated body temperature; or (8) drainage .f. Remove any non-transparent dressing and visually inspect the insertion site if any changes or signs or symptoms of complication are present. 7. Assess the integrity of securement devices with each dressing change. 8. For midline catheters [a small tube inserted into a peripheral vein in the upper arm and used to give treatments], measure arm circumference and compare to baseline when clinically indicated to assess for edema and possible deep-vein thrombosis .
Record review revealed the resident was admitted to the facility in March of 2023 with diagnoses including, but not limited to, chronic kidney disease, stage 3 (when your kidneys have mild to moderate damage, based on lab results) and urinary tract infection.
Review of physician orders revealed the following:
- Ertapenem (antibiotic), give 1 gram intravenously, once daily for 9 days, for an infection, with a start date of 10/8/2023
- Obtain an IV midline, one time only for IV access, with a start date of 10/8/2023
Further record review revealed the resident had a midline catheter inserted into his/her right arm on 10/8/2023 at 7:45 PM.
Further review of the physician orders failed to reveal any orders relative to the care and monitoring of the resident's PICC line.
Review of the comprehensive care plan failed to reveal evidence of a focus relative to the resident's PICC line.
During a surveyor observation on 10/10/2023 at 9:14 AM, the resident was noted to have a PICC line in his/her right arm, with tegaderm (clear dressing) covering the insertion site, that was noted to be peeling from the edges.
During a surveyor observation on 10/11/2023 at 11:46 AM, the resident's tegaderm was noted to be lifting and peeling from the edges.
During an additional surveyor observation on 10/12/2023 at 9:10 AM, the tegaderm was noted to be lifting and peeling, with the insertion site exposed and visible.
During a surveyor interview on 10/12/2023 at 11:30 AM with Registered Nurse (RN), Staff J and RN, Staff K, they revealed that the evening shift oversees the administration of the Ertapenem to the resident and indicated that they do not touch the site or do anything with the PICC line during the day. They acknowledged that the tegaderm needed to be changed, as it was observed to be peeling away from the edges, leaving the insertion site exposed. Additionally, they indicated that there should be physician orders in the system to address the care and monitoring of the PICC line.
During a surveyor interview on 10/12/2023 at 11:38 AM with the Regional Director of Clinical Services, she acknowledged that the tegaderm was lifted, with the insertion site visible, and indicated that it needed to be changed and cleaned up. Additionally, she acknowledged that there were no physician orders in the resident's medical record regarding his/her PICC line and indicated she would expect orders to have been put in place upon the insertion of the PICC line.
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.
Findings are as follows:
During a surveyor observation of the medication cart on the [NAME] unit (cart 2), on 10/13/2023 at 9:38 AM revealed a bottle of medication for Resident ID #333, indicating the drug contained within the bottle was Tafamidis (a medication used to treat heart failure) 61 MG (milligrams) oral capsule. Further review of the bottle of medication revealed a label visible underneath the Tafamidis label indicating the bottle contained Carbidopa-Levodopa 25-100 MG oral tablets (a medication to treat Parkinson's Disease).
During a surveyor interview on 10/13/2023 at approximately 9:50 AM, with Registered Nurse, Staff L, she acknowledged that the medication bottle had two different medication labels, one on top of the other.
During a surveyor interview on 10/13/2023 at 10:09 AM with the Director of Nursing Services, she was unable to explain why the bottle had two labels. Additionally, she was unable to provide evidence that the facility stored and labeled drugs and biologicals in accordance with currently accepted professional principles per the regulation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
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 maintain a...
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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 for 2 of 2 resident's reviewed for Extended spectrum beta-lactamases (ESBL, an infection that is resistant to specific types of antibiotics), Resident ID #51 and foley catheter care relative to it leaking on the floor, Resident ID #286.
Findings are as follows:
1. Review of the CDC's document titled, Multidrug-resistant organisms (MDRO) management states in part, .For ill residents (e.g., those totally dependent upon healthcare personnel for healthcare and activities of daily living .) .use Contact Precautions in addition to Standard Precautions .For MDRO colonized or infected patients without draining wounds, diarrhea, or uncontrolled secretions, establish ranges of permitted ambulation, socialization, and use of common areas based on their risk to other patients and on the ability of the colonized or infected patients .
Review of a facility policy titled, Isolation, Discontinuing dated October 2018, states in part, .Precautions will be discontinued as soon as the resident is no longer at significant risk of transmitting the infection, for example: a. risk factors for transmission (i.e., uncontained excretions or secretions, cognitive deficits, non compliance, etc.) are reduced or eliminated; or b. clinical or laboratory results indicate that the infection is resolved.
Review of a facility provided form titled, Management of MDRO's Re-Culture schedule dated 5/31/2023, revealed that ESBL requires 1 negative culture taken 48 hours after the antibiotic is completed to be removed from precautions.
Record review revealed Resident ID #51 was admitted to the facility in April of 2023 with diagnoses including, but not limited to, dementia and chronic kidney disease.
Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed the resident is always incontinent and is totally dependent of staff assistance for toileting, bathing, and personal hygiene.
Record review revealed special instructions that states, Contact Precautions for ESBL.
During surveyor observations from 10/10/2023 until 10/16/2023 the resident was not on contact precautions.
Review of a Urinalysis report dated 7/27/2023 revealed the resident is positive for ESBL.
Record review failed to reveal evidence of further laboratory testing to determine the status of the ESBL.
Record review revealed a progress note dated 10/14/2023 authored by the Nurse Practitioner (NP), Staff F, revealed that the resident was being tested for ESBL due to an acute illness.
During a surveyor interview on 10/16/2023 at 9:38 AM with the Infection Control Preventionist (ICP), she acknowledged that the resident is not on contact precautions. Additionally, she revealed that she would expect the staff to put the resident on contact precautions if testing for ESBL. The ICP was unable to provide evidence that the resident had a negative culture to remove the contact precautions.
2. Review of a facility policy titled Catheter Care, Urinary dated August 2021, states in part, .Be sure the catheter tubing and drainage bag are kept off the floor .
Record review revealed that Resident ID #286 was admitted to the facility in October of 2023 with diagnoses including, but not limited to, compression of brain and nontraumatic intracerebral hemorrhage (a blood vessel in the brain ruptures and causes bleeding inside the brain).
During a surveyor observation on 10/11/2023 at 10:55 AM of the resident, revealed his/her catheter bag laying on the floor with a clear trash bag tied around it.
During a surveyor observation on 10/11/2023 at 11:56 AM of the resident revealed his/her catheter bag on the floor with a clear trash bag tied around it and a large puddle of urine on the floor under his/her bed.
During a surveyor interview on 10/11/2023 at 11:56 AM with Licensed Practical Nurse (LPN), Staff D, she revealed that the catheter bag was leaking and that is why it was inside a trash bag.
During a surveyor interview on 10/11/2023 at 12:00 PM with the ICP she acknowledged the large puddle of urine located under the bed and that the resident's catheter bag was on the floor and leaking and had been put inside a trash bag. Additionally, she revealed that she would have expected the staff to change the catheter bag if it was leaking and not place it in a trash bag. She also would expect the catheter bag to not be placed on the floor.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure the resident's medical rec...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure the resident's medical record includes documentation that the resident either received the pneumococcal vaccination or did not receive the vaccination due to medical contraindications or refusal, for 5 of 8 residents reviewed, Residents ID #'s 5, 9, 10, 19 and 42.
Findings are follows:
According to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, Revised 2/3/2023 states in part, .The resident's medical record includes documentation that indicates, at a minimum, the following::.That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal .
According to the Centers for Disease Control and Prevention (CDC), pneumococcal vaccination for all adults 19 through [AGE] years old who have certain chronic medical conditions or 65 years or older who have only received PPSV23 [23 vaccination], the PCV15 [type of pneumococcal conjugate vaccine] or PVC20 [type of pneumococcal conjugate vaccine] dose should be administered at least one year after the most recent PPSV23 vaccination. For adults 19 through [AGE] years old who have certain chronic medical conditions who have only received PCV13 [type of pneumococcal conjugate vaccine], give 1 dose of the PCV20 at least 1 year after PCV13 or give 1 dose of PPSV23 at least 8 weeks after PCV13. For adults 65 years or older who have only received PCV13 [type of pneumococcal conjugate vaccine], give PPSV23 or PCV20 as previously recommended.
1. Record review for Resident ID #5 revealed the resident was admitted to the facility in August of 2020. Record review of the resident's immunization records failed to reveal evidence that the PPSV23 or the PCV20 vaccines were offered, received, or declined.
2. Record review for Resident ID #9 revealed the resident was admitted to the facility in February of 2019. Record review of the resident's immunization records failed to reveal evidence that the PCV15 or PCV20 vaccines were offered, received, or declined.
3. Record review for Resident ID #10 revealed the resident was admitted to the facility in June of 2016. Record review of the resident's immunization records failed to reveal evidence that any pneumococcal vaccines were offered, received, or declined.
4. Record review for Resident ID #19 revealed the resident was admitted to the facility in May of 2020. Record review of the resident's immunization records failed to reveal evidence that any pneumococcal vaccines were offered, received, or declined.
5. Record review for Resident #42 revealed the resident was admitted to the facility in October of 2016. Record review of the resident's immunization records failed to reveal evidence that any pneumococcal vaccines were offered, received or declined.
During a surveyor interview on 10/16/2023 at approximately 9:38 AM with the Infection Control Preventionist she acknowledged the pneumococcal vaccines were not in place and was unable to provide evidence that they had been offered, received or declined to the above mentioned residents.
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 standa...
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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.
Findings are as follows:
1.) The Rhode Island Food Code 2018 Edition 4-601.11 states in part, .nonfood contact surfaces of equipment shall be kept free of an accumulation of dirt .and other debris .
During surveyor observations on 10/10/2023 at approximately 8:35 AM, during the initial tour of the main kitchen and on 10/12/2023 at approximately 10:30 AM, the following observations were made:
- The hood over the stove was noted to have grease accumulation along the inner rim
- Two reach in refrigerator units were noted to have a black substance on the back wall of each unit, accumulation of debris in the cover of the circulating fan within the unit, and were noted to have dust accumulation along the inner ridges of the grates covering the tops of the units.
2.) The Rhode Island Food Code 2018 Edition 3-501.16 states in part, (D) .marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises .or sold .
During a surveyor observation on 10/10/2023 at approximately 8:35 AM, during the initial walk through of the main kitchen, the following items were observed stored in the reach in refrigerator units:
- A container of peach yogurt, unopened with a use by date of 9/19/2023
- 2 containers of cottage cheese, opened with use by dates of 9/1/2023 and 10/6/2023
- 1 container of cottage cheese, unopened with a use by date of 10/6/2023
Additional surveyor observations of food stored in the walk in refrigerator revealed the following:
- Fresh mozzarella with a use by date of 10/6/2023
-1 package (pkg) of sliced turkey with a use by date of 10/8/2023
- 2 pkg of sliced ham with a use by date of 10/8/2023
- A pan of prepared sloppy joe mixture with a use by date of 10/9/2023
- Marinara sauce with a use by date of 10/7/2023
- Chicken salad with a use by date of 10/6/2023
- Beet salad with a use by date of 10/8/2023
- Tomato paste with a use by date of 9/25/2023
3.) The Rhode Island Food Code 2018 Edition 4-701.10 states in part, .equipment food-contact surfaces and utensils shall be SANITIZED .
During a surveyor observation on 10/12/2023 at approximately 10:30 AM, Dietary Aide, Staff M, was observed carrying washed and sanitized domes, bowls and trays against his body when placing them in storage.
4.) The Rhode Island Food Code 2018 Edition 3-501.16 reads in part, .except during preparation . or TIME/TEMPERATURE CONTROL FOR SAFETY shall be maintained .(2) . 41 degrees Fahrenheit.
During a surveyor observation, in the presence of the Food Service Director (FSD) on 10/12/2023 at approximately 12:10 PM, on the [NAME] unit, a 4 oz container of whole milk ready to be served to the residents had a holding temperature of 50 degrees.
During a surveyor interview on 10/12/2023 at approximately 12:15 PM, with the FSD, he acknowledged that the milk being served to the residents was not within the acceptable temperature ranges.
During a surveyor interview on 10/13/2023 at approximately 11:40 AM with the FSD, he acknowledged that the stored food items were being stored beyond the use by dates, the equipment was in need of cleaning and the dietary aide was carrying sanitized food service equipment against his body.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
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 establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiot...
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Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use, for 3 of 3 residents reviewed for antibiotic use, Resident ID #s 17, 37, and 51.
Findings are as follows:
Review of a facility provided policy titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, states in part, .1. As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist, or designee .All resident antibiotic regimens will be documented on the facility - approved antibiotic surveillance tracking form. The information gathered will include: a. resident name and medical record number; b. unit and room number; c. date symptoms appeared; d. name of antibiotic .e. start date of antibiotic; pathogen identified .g. site of infection; h. date of culture; i. stop date; j. total days of therapy; k. outcome; and l. adverse events.
1. Record review revealed Resident ID #17 was admitted to the facility in March of 2023 with a diagnosis including, but not limited to, urinary tract infection.
Record review of the physician orders revealed an order with a start date of 10/8/2023 and an end date of 10/18/2023 for an antibiotic, Ertapenem Sodium Solution, 1 gram intravenously every 24 hours.
Record review of the October 2023 Medication Administration Record (MAR) revealed the above medication was documented as being administered, per physician order.
2. Record review revealed Resident ID #37 was admitted to the facility in September of 2023 with a diagnosis including, but not limited to, acute osteomyelitis (infection in the bone) of the right ankle and foot.
Review of the physician orders revealed an order with a start date of 10/7/2023 and an end date of 10/16/2023 for Vancomycin HCI (antibiotic) 1000 milligrams (mg), two times a day.
Further review of the physician orders revealed an order with a start date of 10/6/2023 for Zosyn (antibiotic), 3.375 milliequivalent, every 6 hours, for 10 days.
Record review of the October 2023 MAR revealed the above medications were documented as being administered, per physician order.
3. Record review revealed Resident ID #51 was admitted to the facility in April of 2023 with a diagnosis including, but not limited to, dementia.
Review of the physician orders revealed an order with a start date of 10/11/2023 and an end date of 10/18/2023 for Erythromycin (antibiotic) ointment, instill one inch in both eyes, two times a day.
Review of the October 2023 MAR revealed the above order was documented as being administered, per physician order.
Review of the September and October 2023 antibiotic stewardship monthly records failed to reveal documentation of completed tracking information for the above-mentioned residents, including but not limited to, type of antibiotic, antibiotic start and end date, and signs and symptoms.
Further review of the antibiotic stewardship monthly records from July 2023 through September 2023 failed to reveal documentation of completed tracking information, including but not limited to, type of antibiotic, antibiotic start and end date, and signs and symptoms.
During a surveyor interview on 10/12/2023 at 7:58 AM, with the Infection Preventionist and Regional Director of Clinical Services, they were unable to provide evidence that the antibiotic stewardship tracking system was completed to its entirety, per regulation.
Oct 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, and staff interview, it has been determined that the facility failed to provide the necessary ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, and staff interview, it has been determined that the facility failed to provide the necessary services to residents who are unable to carry out activities of daily living (ADL) relative to incontinence care for 1 of 3 residents reviewed, Resident ID #1.
Findings are as follows:
Record review of a community reported complaint submitted to the Rhode Island Department of Health on 10/2/2023 alleges that the resident does not receive incontinence care or assistance with toileting every 2 hours.
Record review revealed that the resident was readmitted to the facility in September 2022 with diagnoses including, but not limited to, diabetes and chronic kidney disease.
Record review of a quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 13 out of 15, indicating intact cognition. Additionally, the resident experiences bowel and bladder incontinence and requires the extensive assistance of one staff member for toileting needs which includes cleansing after elimination.
Record review of the care plans revealed the following:
- 5/4/2023, s/he experiences urinary incontinence. Interventions include, .Check resident approximately every 2 hours and provide incontinence care as needed.
- 5/12/2023, s/he is unable to be independent with self-care secondary to physical limitations and balance deficits.
- 8/20/2023, s/he has moisture associated skin damage (inflammation of the skin caused by prolonged exposure to various sources of moisture, including urine or stool) to his/her perineal area.
During a surveyor interview on 10/3/2023 at 9:27 AM, with the resident, s/he indicated that s/he had to sit in a soiled brief containing urine and stool for more than 2 hours on 10/2/2023 during the 7:00 AM - 3:00 PM shift.
During a surveyor observation and subsequent interview with the resident on 10/3/2023 at 10:09 AM revealed s/he was receiving incontinence care with the assistance of two staff members. The resident's incontinence brief was observed to be wet with urine. His/her abdominal skin folds and perineal area were observed to be reddened with white patches. The resident indicated that his/her perineal area caused him/her discomfort and itching because s/he had to sit in a dirty brief for more than 2 hours.
During a surveyor interview on 10/3/2023 at 10:48 AM with Licensed Practical Nurse (LPN), Staff B, she revealed that she was the nurse on duty on 10/2/2023 during the 7:00 AM - 3:00 PM shift. She further indicated that on 10/2/2023 she asked a Nursing Assistant (NA) to assist the resident with incontinence care and that 2 hours had passed before the resident received assistance. Additionally, she indicated that the resident was incontinent of urine and stool when she asked the NA to assist him/her.
During a surveyor interview on 10/3/2023 at 11:02 AM, with the Nurse Practitioner, she indicated that she would not expect staff to leave the resident in a urine and stool soiled brief for more than two hours. Additionally, she indicated that a urinary tract infection can occur when a resident remains in a brief soiled with stool.
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 F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to physician's orders, for 1 of 3 r...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to physician's orders, for 1 of 3 residents reviewed with a diagnosis of diabetes, and 1 of 1 residents reviewed with an order for a consultation with a specialist, Resident ID #1.
Findings are as follows:
Record review of two community reported complaints submitted to the Rhode Island Department of Health on 10/2/2023 alleges that the resident was left in bed for 5 hours soaked in urine which resulted in a urinary tract infection, and that the facility forgets to give the resident his/her insulin.
According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients .
Record review revealed that the resident was readmitted to the facility in September 2022 with a diagnosis including, but not limited to, diabetes.
A. Record review revealed a progress note dated 8/14/2023 at 12:52 PM which indicates the resident was noted with redness, swelling, and itching to his/her genital area. The note further indicates that the Nurse Practitioner (NP) was notified and gave an order for the resident to be seen for a consultation with an outside specialist.
Additional record review revealed a provider progress note dated 8/23/2023 at 5:01 PM indicating the resident was seen for ongoing request to see an outside specialist for ongoing white discharge from his/her genital area.
Further record review failed to reveal evidence that the resident has seen a specialist for the redness, swelling, white discharge, and itching to his/her genitalia or that an appointment had been made for him/her to see one.
During a surveyor observation and interview with the resident on 10/3/2023 at 10:09 AM revealed s/he was receiving assistance with personal care from Nursing Assistant, Staff A, and another staff member. The resident's genitalia was observed to be reddened with white patches. The resident revealed that his/her perineal area was extremely itchy and caused him/her a great deal of discomfort.
During a surveyor interview on 10/3/2023 immediately following the above-mentioned observation with Staff A, she indicated that the resident always asks her to clean his/her genital area thoroughly and extensively to relieve the itchiness.
During a surveyor interview on 10/4/2023 at 11:07 AM, with the interim Director of Nursing Services (DNS), she acknowledged that the NP did give the order for the resident to be evaluated by an outside specialist on 8/14/2023, and revealed, it was missed. She further indicated that she was scheduling the appointment today, 10/4/2023, 58 days after the order was given and the resident continues to have redness with white patches and itching to his/her perineal area.
During a subsequent surveyor interview on 10/4/2023 at 2:37 PM, with the interim DNS, she revealed that the resident's appointment with the outside specialist is scheduled for February 2024. Additionally, she was unable to provide evidence that the provider was made aware that the appointment is scheduled for 6 months after the order was obtained.
Further record review failed to reveal evidence that the provider was aware the appointment was scheduled for 6 months after it was ordered. Additionally, record review failed to reveal evidence that the facility made attempts to schedule the appointment for a sooner date.
B. Record review of the September 2023 Medication Administration Record (MAR) revealed a physician's order for Humulin insulin to be administered per sliding scale (insulin dose varies based on the blood sugar level). Additionally, the order states in part, .if Blood Sugar > [greater than] 341 give 7 units of insulin and recheck blood sugar in 2 hours .
Additional record review revealed documentation of the following blood sugars;
- On 9/1/2023 at 8:00 PM, blood sugar 377
- On 9/16/2023 at 8:00 PM, blood sugar 381
- On 9/17/2023 at 8:00 PM, blood sugar 383
Further record review failed to reveal evidence that the resident's blood sugar was rechecked 2 hours after the above-mentioned blood sugars were obtained.
During a surveyor interview on 10/3/2023 at 3:13 PM, with the Regional Registered Nurse, she indicated that she would expect nurses to follow the physician's order and document the resident's rechecked blood sugar after 2 hours.
Sept 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that the Clinical Consultant Pharmacist identified irregularities during the monthly pharmacist Me...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that the Clinical Consultant Pharmacist identified irregularities during the monthly pharmacist Medication Regimen Review (MMR) for 1 of 1 resident reviewed, Resident ID #1.
Findings are as follows:
Record review for the resident revealed that s/he was admitted to the facility in July of 2021 with diagnoses including, but not limited, to hypertension (when the pressure in your blood vessels is too high).
Review of a document titled, Order Summary Report revealed a 7/17/2023 physician's order for Metoprolol Succinate (a beta-blocker medication used to treat chest pain, heart failure, and high blood pressure) 50 mg (milligram) Extended Release 24-hour tablet. Further review of the order revealed instructions to hold if the systolic blood pressure (measures the pressure in your arteries when your heart beats) is less than 110 and if the apical pulse (a pulse point on your chest at the bottom tip of your heart) is less than 70.
Review of the 7/18/2023 through 9/13/2023 Medication Administration Records failed to reveal evidence that a blood pressure or apical pulse rate was obtained prior to administering the medication.
Further review of the record failed to reveal evidence of any blood pressure or apical pulse rate documentation.
Review of the July 2023 MMR, created between 7/28/2023 and 7/29/2023, failed to reveal evidence of any recommendations.
Review of the August 2023 MMR, created between 8/22/2023 and 8/23/2023, failed to reveal evidence of any recommendations.
During a surveyor interview with the Clinical Consultant Pharmacist on 9/13/2023 at approximately 3:30 PM, she indicated that the resident's entire record was reviewed in July and August. Additionally, she acknowledged that she was unaware that the blood pressure and apical pulse rate parameters were not followed for the Metoprolol Succinate order.
During an interview with the Director of Nursing Services on 9/13/2023 at approximately 4:00 PM, she indicated that her expectation would be that the discrepancy would have been found by the pharmacist consultant and documented on either the July or August MMR.
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 F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and resident interview, it has been determined that the facility failed to ensure that services p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and resident interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality for 1 of 2 residents reviewed relative to following a physician's order for medication parameters, Resident ID #1.
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 a community reported complaint, received by the [NAME] Department of Health on 9/11/2023, alleged quality of care concerns relative to medication errors.
Record review of the resident revealed that s/he was admitted to the facility in July of 2021 with diagnoses including, but not limited, to hypertension (when the pressure in your blood vessels is too high).
Review of a Minimum Data Set Assessment, dated 7/6/2023, revealed a Brief Interview for Mental Status score of 14 out of 15 indicating s/he was cognitively intact.
Review of a document titled, Order Summary Report revealed a 7/17/2023 physician's order for Metoprolol Succinate (a beta-blocker medication used to treat chest pain, heart failure, and high blood pressure) 50 mg (milligram) Extended Release 24-hour tablet. Further review of the order revealed instructions to hold if the systolic blood pressure (measures the pressure in your arteries when your heart beats) is less than 110 and if the apical pulse (a pulse point on your chest at the bottom tip of your heart) is less than 70.
Review of the 7/18/2023 through 9/13/2023 Medication Administration Records failed to reveal evidence that a blood pressure or apical pulse rate was obtained prior to administering the medication.
Further review of the record failed to reveal evidence of any blood pressure or apical pulse rate documentation.
During a surveyor interview with the resident on 9/13/2023 at 2:30 PM, it was revealed that the staff do not check his/her blood pressure or apical pulse rate prior to administering the Metoprolol Succinate medication. Additionally, it was indicated that s/he has felt dizzy for a while, and that it occurs frequently.
During a surveyor interview with Licensed Practical Nurse, Staff A, on 9/13/2023 at approximately 3:00 PM, she acknowledged that she failed to obtain the resident's blood pressure or apical pulse rate prior to administering the medication on 9/13/2023.
During a surveyor interview with the resident's physician on 9/13/2023 at 3:42 PM, he indicated that the instructions to obtain the blood pressure and apical pulse rate were implemented to monitor the resident due to his/her complaints of feeling dizzy. He further stated that he was unaware that the resident's blood pressure and apical pulse were not obtained and would have expected that the order would be followed.
Aug 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency 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 services provided meet professional standards of quality relative to f...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to following a physician's order for daily weights and obtaining laboratory testing for 1 of 3 residents reviewed, Residents ID #1.
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.
1a. Record review of a community reported complaint sent to The Rhode Island Department of Health on August 23, 2023 alleges that Resident ID #1 presented to the hospital with limited responsiveness and went downhill fast since arrival to [skilled nursing facility].
Record review revealed that Resident ID #1 was admitted to the facility in August of 2023 with diagnoses to include, but are not limited to, urinary tract infection and heart failure.
Review of the August 2023 Medication Administration Record (MAR) revealed a physicians' order dated 8/14/2023 to obtain the following labs:
-Comprehensive metabolic panel (CMP, is a test that measures 14 different substances in your blood. It provides important information about your body's chemical balance, metabolism, and kidney function).
-Hemoglobin A1C (a blood test that measures the average blood sugar level over the past two to three months).
-Thyroid-stimulating hormone (TSH, test measures the amount of TSH in the blood. TSH levels convey how well a person's thyroid is functioning).
Record review failed to reveal evidence the above-mentioned labs were obtained as ordered.
Record review revealed the resident was sent to the hospital on 8/23/2023 for unresponsiveness with a systolic blood pressure of 68 (normal reading is 120). The record further reveals the facility was unable to obtain any additional vital signs.
Further record review of a document titled After Visit Summary dated 8/23/2023 revealed the above-mentioned episode was related to mild kidney injury, hypotension (low blood pressure) due to hypovolemia (occurs when you don't have enough fluid volume circulating in your body).
During a surveyor interview with the Director of Nursing Services and Regional Director of Nursing Services (DNS), on 8/24/2023 at 1:58 PM, they were unable to provide evidence that the above-mentioned labs were obtained as ordered. Additionally, they indicated they would have expected the labs to have been obtained.
1b. Record review revealed a physicians' order with a start date of 8/14/2023 for Furosemide (a medication to treat fluid retention (edema) in people with congestive heart failure) 20 milligrams daily.
Record review of the MAR revealed an order dated 8/14/2023 to monitor daily weight in the morning.
Record review failed to reveal evidence that weights were obtained for 7 of 10 opportunities on the following dates:
8/15/2023
8/16/2023
8/17/2023
8/18/2023
8/20/2023
8/22/2023
8/23/2023
During a surveyor interview on 8/24/2023 at approximately 2:04 PM with the DNS and Regional DNS, they revealed that they would expect the staff to obtain and document the daily weights as ordered. Additionally, they were unable to provide evidence that the resident's weight had been obtained.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on record review and staff interview it has been determined that the facility failed to ensure that the residents are free from significant medication errors for 2 of 3 residents reviewed, Resid...
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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 2 of 3 residents reviewed, Resident ID #s 1 and 2.
Findings are as follows:
1. Record review of a community reported complaint sent to The Rhode Island Department of Health on August 23, 2023 alleges that Resident ID #1 presented to the hospital with limited responsiveness and went downhill fast since arrival to [skilled nursing facility]
Record review revealed that Resident ID #1 was admitted to the facility in August of 2023 with diagnoses to include, but is not limited to, urinary tract infection (UTI) and heart failure.
Record review of a Continuity of Care - Post-Acute Facility form dated 8/13/2023 revealed the following physicians' orders:
Cephalexin (antibiotic) 250 milligrams (MG) take one tablet by mouth every 6 hours for 5 days.
Review of the August 2023 Medication Administration Record (MAR) revealed the following physician's order:
-Cephalexin Oral Tablet 250 MG Give 250 mg by mouth every 6 hours for UTI with a start date of 8/14/2023 documented as administered at midnight and 6:00 AM and then the order was discontinued the same day.
-Cephalexin Oral Tablet 250 MG Give 250 mg by mouth one time a day for UTI with a start date of 8/14/2023 at 10:00 AM documented as administered to the resident once a day on 8/14/2023, 8/15/2023, 8/16/2023 and 8/18/2023. Additional review failed to reveal evidence the medication was administered on 8/17/2023.
Further record review failed to reveal evidence that a physician provided an order for Cephalexin every 6 hours to be discontinued or that a new order was received for Cephalexin 250 mg to be administered once a day.
During a surveyor interview with the Director of Nursing Services, on 8/24/2023 at 1:24 PM, she revealed that the nurse changed the order and that it was a transcription error. She further revealed that the resident should have received his/her antibiotics every 6 hours as initially ordered. Additionally, she was unable to provide evidence that the resident was kept free of significant medication errors.
2. Record review revealed that Resident ID #2 was admitted to the facility in April of 2023 with diagnoses including, but not limited to, anxiety disorder, diabetes, chronic systolic congestive heart failure and chronic obstructive pulmonary disease.
Record review of the resident's August 2023 MAR revealed the following medications were documented as NA (No Intervention Noted according to the MAR Chart Codes).
August 22nd and 23rd for the scheduled 8:00 AM administrations
- Aldactone Oral Tablet 25 MG for Congestive Heart Failure
- Bumex Oral Tablet 2 MG for fluid retention
- Empagliflozin Oral Tablet 10 MG for diabetes
- Glimepiride Oral Tablet 1 MG for diabetes
- Senna Oral Tablet 8.6 MG for constipation
- Sertraline HCl Oral Tablet 100 MG for anxiety disorder
- Metoprolol Tartrate Oral Tablet 25 MG for hypertension
- Gabapentin Capsule 400 MG for chronic pain
Record review failed to reveal evidence that the resident received his/her above-mentioned medication on August 22nd or 23rd for the scheduled 8:00 AM administrations. Additionally, the record failed to revealed evidence that the resident refused his/her medication or that the provider was notified of the missed medication on August 22nd and 23rd for the scheduled 8:00 AM administrations.
During a surveyor interview on 8/24/2023 at 2:01 PM with the Director of Nursing Services, she was unable to provide evidence that the resident was kept free of significant medication errors. Lastly, she revealed she would expect the record to reveal if the resident refused a medication or not.
Jul 2023
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative a physician's order for a skin treatment that was incompl...
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Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative a physician's order for a skin treatment that was incomplete, for 1 of 1 resident reviewed, Resident ID #7.
Findings are as follows:
According to Mosby's 3rd Edition, .the five guidelines to ensure safe drug administration include the right drug, the right dose, the right client, the right route and the right time .
Record review revealed Resident ID #7 was admitted to the facility in July of 2023 with diagnoses including, but not limited to stroke and hypertensive heart disease.
Record review of the resident's Wound Evaluation & Management Summary report dated 7/17/2023 indicated a resolved non-pressure wound to the resident's sacrum. Further review of the document states in part, .continue present skin care and breakdown prevention.
Record review of the physician's orders revealed the resident had an order dated 7/6/2023 that was discontinued on 7/17/2023 for Silver Sulfadiazine 1% cream [SSD] apply to butt topically every day shift for Wound. Clean open area on sacrum with wound wash f/b [followed by] a thin layer of SSD and cover with a tan dressing .
Additional review of the physician orders revealed an order dated 7/17/2023 to, apply a thin layer to butt BID [twice daily] every day and evening shift .
Further review of the above order failed to reveal what treatment or product was to be applied to the resident's buttocks twice daily.
Record review of the Treatment Administration Record TAR from 7/17/2023 through 7/26/2023 revealed that the order was signed off as being completed by staff.
During a surveyor interview on 7/27/2023 at approximately 3:00 PM with the Regional Clinical Nurse, she acknowledged that the above-mentioned order was incomplete without a treatment or product designated within the order.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide the necessary services to a resident who is unable to carry out activities of daily living (ADLs), relative to bathing and personal hygiene for 2 of 7 residents reviewed, Resident ID #s 2 and 6.
Findings are as follows:
1. Record review for Resident ID #2 revealed s/he was admitted to the facility in April of 2016 with diagnoses including, but are not limited to, diabetes mellitus and gastroesophageal reflux disease.
Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS-an assessment tool to identify a resident's cognitive function) score of 10 out of 15, indicating the resident has moderate cognitive impairment. Additionally, s/he is coded as requiring extensive assistance of one for personal hygiene.
Record review of a care plan initiated on 4/17/2023 revealed a focus area for a swallowing problem related to dysphagia (difficulty swallowing), which revealed interventions including, but not limited to .provide oral care to remove debris.
During a surveyor interview on 7/27/2023 at 1:01 PM with Resident ID #2 revealed, s/he can brush his/her teeth when staff set him/her up for the task, but s/he was not set up to brush his/her teeth today and his/her teeth have not been brushed in the last 3 days. Additionally, s/he revealed that s/he would like to have her teeth cleaned and that s/he can't remember the last time s/he saw a dentist or had his/her teeth professionally cleaned.
During a surveyor interview on 7/27/2023 at 2:05 PM with Staff D, she revealed that Resident ID #2 can brush his/her own teeth when s/he is set up by staff. Additionally, Staff D revealed she did not brush the resident's teeth during care today and she did not set the resident up to brush his/her own teeth.
2. Record review for Resident ID #6 revealed s/he was admitted to the facility in July of 2023 with diagnosis including, but not limited to, hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis) following a stroke affecting the right dominant side.
Record review of an admission MDS assessment, dated 7/26/2023 revealed a BIMS score of 15 out of 15, indicating the resident is cognitively intact. Additionally, s/he is coded as requiring assistance of one for dressing and s/he is dependent on one for bathing.
Record review of the care plan dated 7/23/2023 revealed a focus for self-care deficit with interventions including, but not limited to, .encourage me to participate in ADLs to the fullest extent possible .
During a surveyor interview and simultaneous observation with Resident ID #6 on 7/26/2023 at approximately 8:15 AM while s/he was lying in bed eating breakfast, revealed the resident was wearing an orange shirt.
During a surveyor interview and simultaneous observation on 7/26/2023 at 12:59 PM with Resident ID #6 revealed, s/he was lying in bed, wearing his/her orange shirt with his/her lunch tray infront of him/her. Resident ID #6 was visibly upset, further reporting that staff had not assisted him/her in getting washed and dressed for the day. Additionally, the resident revealed that s/he had asked every staff member that came into his/her room today to assist getting him/her ready for the day and no one has assisted him/her as of yet.
During a surveyor interview on 7/26/2023 at 1:03 PM with the nurse assigned to Resident ID #6, Licensed Practical Nurse, Staff E, she revealed she was unaware that the resident was not provided care yet and would have expected him/her to be washed and dressed for the day by now. Additionally, she was unable to state who was assigned to the resident or why the resident was not washed and ready for the day. Staff E then asked the nursing assistants (NA), in the presence of the surveyor, who was assigned to care for Resident ID #6 that day. None of the NAs indicated that Resident ID #6 was assigned to them that day.
During a subsequent interview and simultaneous observation on 7/26/2023 at 1:47 PM with Resident ID #6 revealed that s/he was washed and dressed for the day. Additionally, s/he was observed with a blue/green colored shirt now, and no longer was observed wearing his/her orange shirt.
During a surveyor interview on 7/27/2023 at 3:05 PM with NA, Staff F, she revealed Resident ID #6 rang the call bell in the morning at sometime, she could not recall when and the resident reported feeling nauseous and s/he declined to get washed. Staff F further revealed she went back to wash Resident ID #6, but could not recall the time. Additionally, she revealed that she didn't know who was assigned to the Resident and didn't know that s/he wasn't assigned to anyone.
During a subsequent surveyor interview on 7/27/2023 at 5:15 PM with Resident ID #6, s/he revealed that s/he asked to be washed at approximately 7:00 AM on 7/26/2023 and staff responded to him/her that they would be back and no one ever came back. Further, the resident revealed that prior to 7:00 AM on 7/26/2023 the physical therapist came into his/her room to work with him/her, however s/he refused to work with therapy at that time stating s/he was dizzy. Additionally, the resident indicated that it was not until after s/he was interviewed by this surveyor on 7/26/2023 at 12:59 PM, that s/he was washed and dressed for the day. Lastly, the resident revealed that at no time did s/he refuse to be washed and dressed by staff between breakfast and lunch on 7/26/2023.
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
Resident Rights
(Tag F0550)
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 treat each...
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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 treat each resident with respect and dignity in an environment that promotes maintenance of his or her quality of life for 3 of 4 residents observed who require assistance from staff for eating, Resident ID #s 1, 3 and 7.
Findings are as follows:
1. Record review revealed Resident ID #1 was admitted to the facility in November of 2017 with diagnoses including, but not limited to, vascular dementia, stroke and dysphagia (difficulty swallowing).
Record review of an Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS-an assessment tool to identify a resident's cognitive function) score of 7 out of 15, indicating the resident has severe cognitive impairment. Additionally, s/he is coded as requiring physical assistance for eating.
Record review of a care plan initiated on 6/21/2023 revealed a focus for being at risk for aspiration secondary to dysphagia. Further review revealed an intervention to feed the resident small amounts when s/he is awake and alert.
During a surveyor observation on 7/26/2023 at 9:29 AM, revealed the Speech Language Pathologist, Staff A was standing over the resident feeding him/her a cookie while the resident was lying in bed.
During a surveyor interview with Staff A on 7/27/2023 at 3:20 PM, she acknowledged that she was standing while feeding Resident #1.
2. Record review revealed Resident ID #3 was admitted to the facility in April of 2023 with diagnoses including, but not limited to, diabetes mellitus and muscle wasting atrophy.
Record review of an admission MDS assessment dated [DATE] revealed a BIMS score of 13 out of 15, indicating the resident is intact cognitively. Additionally, s/he is coded as requiring physical assistance for eating.
Record review of a care plan initiated on 6/21/2023 revealed a focus for self-care deficit with interventions including, but not limited to, .I require hands-on assistance while eating and drinking .
During a surveyor observation on 7/26/2023 at 9:26 AM, revealed Nursing Assistant (NA), Staff B was standing over the resident while feeding him/her their breakfast meal.
During a surveyor interview with Staff B on 7/27/2023 at 12:55 PM, she acknowledged standing over the resident while feeding him/her their meal.
3. Record review revealed Resident ID #7 was admitted to the facility in July of 2023 with diagnoses including, but not limited to, stroke, hypertensive heart disease, and dysphagia.
Record review of an Annual MDS assessment dated [DATE] revealed a BIMS score of 2 out of 15, indicating the resident has severe cognitive impairment. Additionally, s/he is coded as requiring extensive assistance for eating.
Record review of a care plan initiated on 7/212023 revealed a focus for self-care deficit with interventions including, .encourage me to participate in ADLs to the fullest extent possible .
During a surveyor observation on 7/27/2023 at 1:30 PM, revealed NA, Staff C was standing over the resident while feeding him/her their lunch meal.
During a surveyor interview with Staff C on 7/27/2023 at 1:30 PM, she acknowledged standing over the resident while feeding him/her their lunch meal.
During a surveyor interview on 7/27/2023 at approximately 10:30 AM with the Director of Nursing Services and the Regional Clinical Director, they were unable to explain why the above-mentioned staff members were feeding residents while standing over the resident and revealed re-education will be provided to staff.
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
Dental Services
(Tag F0791)
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 assist resid...
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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 assist residents in obtaining routine dental care for 3 of 3 residents reviewed for dental services, Resident ID #s 1, 2, and 5.
Findings are as follows:
1.Record review revealed Resident ID #1 was admitted to the facility in November of 2017 with diagnoses including, but not limited to, vascular dementia, stroke, and dysphagia.
Record review of an Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS-an assessment tool to identify a resident's cognitive function) score of 7 out of 15, indicating the resident has severe cognitive impairment.
Record review failed to reveal evidence that dental services were provided to the resident.
2.Record review for Resident ID #2 revealed the resident was admitted to the facility in April of 2016 with diagnoses including, but not limited to, diabetes mellitus and gastroesophageal reflux disease.
Record review of a Quarterly MDS assessment dated [DATE] which revealed a BIMS score of 10 out of 15, indicating the resident has moderate cognitive impairment.
Record review failed to reveal evidence that dental services were provided to the resident.
3.Record review for Resident ID #5 revealed the resident was admitted to the facility in July of 2022 with diagnoses including, but not limited to, dementia, Alzheimer's Disease, and aphasia (a disorder that affects how you communicate).
Record review of a Quarterly MDS assessment dated [DATE] which revealed a BIMS score of 2 out of 15, indicating the resident has severe cognitive impairment.
Record review failed to reveal evidence that dental services were provided to the resident.
During a surveyor interview on 7/27/2023 at 1:53 PM with the Regional Clinical Director, she was unable to provide evidence that the above mentioned residents received dental services.
Jun 2023
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0760
(Tag F0760)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interview it has been determined that the facility failed to ensure that the resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interview it has been determined that the facility failed to ensure that the residents are free from significant medication errors for 1 of 4 residents reviewed, Resident ID #6.
Findings are as follows:
Review of a community reported complaint sent to the Rhode Island Department of Health on 6/28/2023 alleges that Resident ID #6 had not been receiving his/her medication as ordered.
Review of the packaging insert for Keppra, last revised in January 2023, states in part, Medication Guide .Do not stop KEPPRA without first talking to a healthcare provider. Stopping KEPPRA suddenly can cause serious problems. Stopping a seizure medicine suddenly can cause seizures .
1A. Record review revealed the resident was admitted to the facility in May of 2023 with diagnoses including, but not limited to, urinary tract infection (UTI) and Parkinson's disease.
Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident is cognitively intact.
Record review revealed that on 6/8/2023 the resident was found to have seizure activity for approximately 2 minutes and sent to the hospital for an evaluation. Further record review revealed the resident was diagnosed with a UTI and started on oral antibiotics.
Record review of a progress note authored by the Nurse Practitioner, dated 6/13/2023 revealed a new order was received from the resident's neurologist to .start Keppra 500 milligram (mg) tablet at bedtime for seven days, then 500 mg tablet twice daily for seizure management .
Record review of the June 2023 Medication Administration Record (MAR) revealed the following physician's orders:
- levetiracetam (Keppra) 500 mg by mouth at bedtime for seizure for 7 days, with a start date of 6/13/2023
- levetiracetam (Keppra) 500 mg by mouth two times a day for seizure, with a start date of 6/21/2023
Further review of the June 2023 MAR revealed the resident did not receive the above mentioned medication on 6/20/2023 or the morning of 6/21/2023.
Record review revealed that on 6/26/2023 the resident was found to have seizure activity lasting approximately 2 minutes and a fall. Further record review revealed the resident was sent to the hospital for treatment related to the seizure and fall.
Record review of the hospital documentation dated 6/26/2023 revealed the resident was evaluated and a CT scan (imaging that helps detect disease and injury) was performed. Further review revealed recommendations for the resident to follow up with his/her primary care provider in 1-2 days.
During a surveyor interview on 6/28/2023 at 4:29 PM with Registered Nurse, Staff D she indicated that she transcribed the above mentioned medication order incorrectly. She further indicated that the Keppra 500 mg twice a day order should have started on 6/20/2023 in the morning instead of 6/21/2023 in the evening. Additionally, she acknowledged that the resident missed 3 doses of the medication.
During a surveyor interview on 6/28/2023 at 3:37 PM with the Nurse Practitioner, she indicated that the Keppra 500 mg twice a day should have started on 6/20/2023 in the morning and would expect the medication to be administered as ordered. She further indicated that she was unaware that the resident missed 3 doses of the seizure medication and would have expected to be notified of the missed doses.
During a surveyor interview on 6/28/2023 at approximately 5:00 PM with the Regional Director of Nursing Services, she acknowledged the above mentioned order was transcribed incorrectly and that the resident missed 3 doses of the seizure medication.
1B. Record review of a care plan dated 6/9/2023 revealed that the resident was receiving antibiotic therapy related to a UTI with an intervention to administer medications as ordered.
Review of a physician's order dated 6/12/2023 for Imipenem-Cilastatin (antibiotic) Intravenous (IV) Solution 500 milligrams (mg) intravenously every 8 hours for ESBL (a bacteria in the urine) for 21 days.
The above order was discontinued on 6/27/2023 and a new order for Imipenem-Cilastatin was ordered on 6/27/2023 with a new end date.
Review of a physician's order dated 6/27/2023 for Imipenem-Cilastatin Intravenous Solution 500 milligrams intravenously every 8 hours for ESBL until 7/4/2023.
Review of the June 2023 MAR revealed the medication was not administered as ordered on the following dates and times:
-6/25/2023 at 2200 (10 PM)
-6/26/2023 at 1400 (2 PM)
-6/26/2023 at 2200
-6/27/2023 at 0600 (6 AM)
-6/27/2023 at 1400
-6/27/2023 at 2200
During a surveyor interview on 6/28/2023 at approximately 1:00 PM with the resident, s/he revealed that s/he recently missed several doses of his/her IV antibiotics and was concerned about his/her health related to the missed doses.
During a surveyor interview on 6/28/2023 at approximately 1:35PM with Registered Nurse, Staff D she acknowledged the resident missed several doses of the above medication as ordered. She further indicated that a physician was not notified of the missed dosed until 6/27/2023.
During a surveyor interview on 6/28/2023 at 3:37 PM with the Nurse Practitioner, she indicated that she wasn't made aware of the first 4 missed doses until the morning of 6/27/2023 and would have expected to be notified after the first missed dose. She indicated that subsequently on 6/27/2023, the order's end date was adjusted for the missed doses. Additionally, she revealed that she was contacted regarding the resident on 6/26/2023 however was not made aware that the ordered medication was unavailable and not administered.
During a surveyor interview on 6/28/2023 at 5:40 PM with the Director of Nursing Services, she could not provide evidence that the resident received the above mentioned doses of the medication as ordered or that the physician was notified of the missed doses.
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 F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview, it has been determined that the facility failed to assure that services be...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview, it has been determined that the facility failed to assure that services being provided meet professional standards of quality related to administering medications as ordered by a physician for 1 of 4 residents reviewed for medication administration, Resident ID #2.
Findings are as follows:
According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients .
1A. Record review revealed the resident was admitted to the facility in March of 2023 with diagnoses including, but not limited to, muscle wasting, A-fib (an irregular heart beat), and hypertension (high blood pressure).
Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident is cognitively intact.
Record review revealed a physician's order dated 4/19/2023 for digoxin (a medication to treat heart conditions) 0.125 milligram (mg) every other day, hold for HR (heart rate) less than 60. Normal HR is 60-100.
According to Lippincott's Nursing Drug Guide, 2006, digoxin .Warning Monitor apical pulse for 1 min [minute] before administering; hold dose if pulse < [less than] 60 .
Record review of the April 2023 Medication Administration Record (MAR) revealed the above mentioned medication was not administered on the following dates as ordered:
-4/19/2023 (with no explanation of why it wasn't administered)
-4/21/2023 (with no explanation of why it wasn't administered)
-4/23/2023 (with no explanation of why it wasn't administered)
-4/25/2023 (with no explanation of why it wasn't administered)
Further record review of the April 2023 MAR failed to reveal evidence that the resident's heart rate was obtained prior to the administration of the above mentioned medication as ordered, on the following dates:
-4/27/2023
-4/29/2023
Record review of the May and June 2023 MAR failed to reveal evidence that the resident's heart rate was obtained prior to the administration of the above mentioned medication as ordered for 27 of 27 opportunities.
During a surveyor interview on 6/23/2023 at approximately 10:40 AM with Certified Medication Technician (CMT), Staff A, she revealed CMTs administer the above mentioned medication to the resident and do not obtain the resident's heart rate prior to administration.
During a surveyor interview on 6/23/2023 at approximately 10:45 AM with the Regional Director of Nursing Services, she indicated that she would expect the resident's pulse to be obtained prior to the administration of the above medication as ordered.
During a surveyor interview on 6/23/2023 at approximately 11:40 AM with the resident s/he further indicated that staff do not obtain his/her heart rate prior to the administration of the digoxin.
1B. Record review revealed a physician's order dated 4/12/2023 for Xarelto (blood thinner) 20 mg twice a day, give with food. Further review revealed the evening dose was scheduled for 9:00 PM.
During a surveyor interview on 6/23/2023 at approximately 11:40 AM with the resident, s/he indicated that s/he is not offered food with his/her Xarelto in the evening.
During a surveyor interview on 6/23/2023 at 12:36 PM with Nursing Assistant, Staff B, she indicated that the resident only receives a snack if s/he requests it in the evening.
During a surveyor interview on 6/23/2023 at 12:40 PM with Licensed Practical Nurse, Staff C, she acknowledged that the above mentioned medication is to be administered with food. Additionally, she failed to reveal evidence that the medication is given with food as ordered.
Record review failed to reveal evidence that the above medication was administered with food at 9:00 PM from 4/12/2023 until 6/23/2023.
During surveyor interview on 6/23/2023 at 12:50 PM with the Director of Nursing Services, she indicated that she would expect that the above mentioned medication would be administered with food as ordered. Additionally, she could not provide evidence that the digoxin or the Xarelto were administered 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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview, it has been determined that the facility failed to provide pharmaceutical ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview, it has been determined that the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 4 residents reviewed, Resident ID #s 1 and 6.
Record review of a facility policy titled, Medication Ordering and Receiving from Pharmacy states in part, Medications and related products are received from the dispensing pharmacy on a timely bases .
Review of a facility policy titled, Medication Orders states in part, .F. The prescriber is contacted for direction when delivery of a medication will be delayed, or the medication is not, or will not be available .
1. Review of a community reported complaint sent to the Rhode Island Department of Health on 6/22/2023 alleged that Resident ID #1 had not been receiving his/her medication as ordered.
Record review revealed Resident ID #1 was admitted to the facility in April of 2016 with diagnoses including, but not limited to, neuromuscular dysfunction of the bladder, dementia and arthritis.
Record review revealed a physician's order dated 6/15/2023 for cyclobenzaprine (a muscle relaxant) 5 milligrams (MG) twice a day.
Review of the pharmacy delivery Packing Slip revealed the above mentioned medication was not delivered to the facility until 6/20/2023.
Record review of the June 2023 Medication Administration Record (MAR) revealed the following:
-6/15/2023 PM- documented as administered however the medication had not been delivered by pharmacy
-6/16/2023 AM- ducumented as not administered due to the medication being unavailable
-6/16/2023 PM- ducumented as not administered due to the medication being unavailable
-6/17/2023 AM- documented as administered however the medication had not been delivered by pharmacy
-6/17/2023 PM- documented as administered however the medication had not been delivered by pharmacy
-6/18/2023 AM- ducumented as not administered due to the medication being unavailable
-6/18/2023 PM- documented as administered however the medication had not been delivered by pharmacy
-6/19/2023 AM- documented as administered however the medication had not been delivered by pharmacy
-6/19/2023 PM- documented as administered however the medication had not been delivered by pharmacy
-6/20/2023 PM- documented as administered however the medication had not been delivered by pharmacy
-6/20/2023 PM- documented as administered however the medication had not been delivered by pharmacy
Record review failed to reveal evidence that the physician was notified that the above mentioned medication was unavailable for 11 doses.
During a surveyor interview on 6/23/2023 at 1:49 PM with the Assistant Director of Nursing, she revealed that the facility has a Pyxis (a machine with medications in it for emergency use) however, cyclobenzaprine is not available in the Pyxis.
During a surveyor interview on 6/23/2023 at 2:24 PM with a pharmacy technician at the pharmacy that distributed the medication to the facility, she revealed the above physician's order was received by the pharmacy on 6/15/2023. She further revealed that the medication was not delivered to the facility until 6/20/2023 at 9:55 PM.
During a surveyor interview on 6/23/2023 at approximately 3:30 PM with the Director of Nursing Services (DNS), she could not provide evidence that the above medication was given as ordered from 6/15/2023 until it was delivered on 6/20/2023. Additionally, she could not provide evidence that the physician was notified that the resident had not received 11 doses of the medication. She could not explain why staff were documenting that the medication was administered when the medication was not delevered from pharmacy.
2. Record review revealed Resident ID #6 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, urinary tract infection (UTI) and Parkinson's disease.
Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident is cognitively intact.
Record review of a care plan dated 6/9/2023 revealed that the resident is receiving antibiotic therapy related to a UTI with an intervention to administer medications as ordered.
Review of a physician's order dated 6/12/2023 for Imipenem-Cilastatin (antibiotic) Intravenous (IV) Solution 500 milligrams (mg) intravenously every 8 hours for ESBL (a bacteria in the urine) for 21 days.
Th above order was discontinued on 6/27/2023 and a new order for Imipenem-Cilastatin was ordered on 6/27/2023 with a new end date.
Review of a physician's order dated 6/27/2023 for Imipenem-Cilastatin Intravenous Solution 500 milligrams intravenously every 8 hours for ESBL until 7/4/2023.
Review of the June 2023 MAR revealed the medication was not administered as ordered on the following dates and times:
-6/25/2023 at 2200 (10 PM)
-6/26/2023 at 1400 (2 PM)
-6/26/2023 at 2200
-6/27/2023 at 0600 (6 AM)
-6/27/2023 at 1400
-6/27/2023 at 2200
During a surveyor interview on 6/28/2023 at approximately 1:00 PM with the resident, s/he revealed that s/he recently missed several doses of his/her IV antibiotics and was concerned about his/her health related to the missed doses.
During a surveyor interview on 6/28/2023 at approximately 1:35PM with Registered Nurse, Staff D, she indicated that staff is responsible for ordering medications and are expected to follow up with the pharmacy if the medication is not received timely. She further indicated that a physician was not notified of the missed doses until 6/27/2023.
During a surveyor interview on 6/28/2023 at 3:22 PM with a pharmacist at the distributing pharmacy, she revealed 3 doses of the ordered IV antibiotics were sent to the facility on 6/25/2023. She further revealed the medication was not ordered again until 6/27/2023. Additionally, she indicated that she would expect the facility staff to contact the pharmacy if they run out of an ordered medication and an emergency supply can be sent out, usually the same day.
During a surveyor interview on 6/28/2023 at 3:37 PM with the Nurse Practitioner, she indicated that she wasn't made aware of the first 4 missed doses until the morning of 6/27/2023 and would have expected to be notified after the first missed dose. She further revealed that she was contacted regarding the resident on 6/26/2023 however was not made aware that the ordered medication was unavailable and not administered. Additionally, she indicated that the distributing pharmacy has been a problem for the facility.
During surveyor interviews on 6/28/2023 at 2:48 PM and at 5:40 PM with the DNS, she indicated that she would expect medications to be ordered and received per the facility's policy. She further indicated that the facility has been having issues with receiving medications timely from the facility's distributing pharmacy. Additionally, she could not provide evidence that the resident received the above mentioned doses of the medication as ordered.
May 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
Respiratory Care
(Tag F0695)
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 re...
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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 respiratory medications and treatments as ordered consistent with professional standards of practice for 1 of 1 resident reviewed for respiratory care, Resident ID #2.
Findings are as follows:
Review of a community reported complaint received by the Rhode Island Department of Health on 5/2/2023 alleges that Resident ID #2 had contacted the complainant by phone at 7:00 AM gasping for air and saying that the facility did not have his/her nebulizer medication. In addition, the complainant indicates that the resident needed the nebulizer medication every 4 hours. The complainant further revealed that s/he contacted the facility and was informed that the facility has not received the respiratory medications or nebulizer machine (a device that turns liquids into a mist for inhaling medicine) from the pharmacy. The complainant additionally revealed that s/he raced to the facility and delivered the nebulizer machine and respiratory medications that the resident had at home.
Record review of a facility policy titled, admission Criteria states in part, .6. Residents are admitted to this facility as long as their needs can be met adequately by the facility. 7. Examples of nursing/medical needs that can be met adequately include: a. medication management .
Record review of a facility policy titled, Administering Medications states in part, .Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame .
Record review revealed the resident was admitted to the facility on [DATE] at approximately 5:30 PM, with diagnoses including, but not limited to, lung cancer, COVID-19, pneumonia, congestive heart failure, chronic obstructive pulmonary disorder (COPD), and diabetes.
Record review revealed a physician's order for Ipratropium-Albuterol solution inhale 3 milliliters every 4 hours for shortness of breath (SOB) and wheezing via nebulizer and an order for oxygen at 1 liter (L) via nasal cannula continuously.
Record review of the May 2023 Medication Administration Record (MAR) revealed that the resident did not receive the above-mentioned medication on the following dates and times:
- 5/1/2023 at 8:00 PM
- 5/2/2023 at 12:00 AM and 4:00 AM
Additional record review failed to reveal evidence that the physician was notified that the resident did not receive the above mentioned medication.
During a surveyor observation on 5/2/2023 at 11:14 AM revealed the resident in bed receiving a nebulizer treatment. Additionally, s/he had a nasal cannula in place and was receiving 3 liters of oxygen.
During a surveyor interview on 5/2/2023 at approximately 11:20 AM with Licensed Practical Nurse, Staff A, she revealed that the resident's oxygen level was 88% on 1L (normal oxygen level range is 95% - 100%) and that she increased the oxygen to 3L to help increase his/her oxygen level.
Record review of the May 2023 MAR revealed that the order for Ipratropium-Albuterol solution inhale 3 milliliters every 4 hours for shortness of breath was entered into the resident's record with a start date of 5/2/2023, indicating that it was not entered when the resident was admitted to the facility on [DATE].
During a surveyor interview on 5/2/2023 at approximately 11:30 AM with Certified Medication Technician, Staff B, she revealed that the facility did not have a nebulizer machine or the respiratory medication available until they were brought in by the resident's family member.
During a surveyor interview on 5/2/2023 at approximately 2:20 PM with the Director of Nursing Services in the presence of the Regional Nurse, she was unable to provide evidence that the resident had received the nebulizer medication as ordered. In addition, she revealed that she would expect that the nurse would have notified the physician that the resident did not receive the respiratory medication as ordered. Additionally, she would expect the nurse to notify the pharmacy and request immediate delivery of the respiratory medications.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to provide pharmaceutical services (...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 5 residents reviewed, Resident ID #s 1 and 2.
Record review of a facility policy titled, admission Criteria states in part, .6. Residents are admitted to this facility as long as their needs can be met adequately by the facility. 7. Examples of nursing/medical needs that can be met adequately include: a. medication management .
Record review of a facility policy titled, Administering Medications states in part, .Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame .
1. Record review revealed Resident ID #1 was admitted to the facility on [DATE] at approximately 7:30 PM, with diagnoses including, but not limited to, dementia with behavioral disturbance, delirium (mental state in which you are confused, disoriented, and unable to think or remember clearly), and benign prostatic hyperplasia (BPH, a condition in which the flow of urine is obstructed due to the enlargement of the prostate gland).
Record review revealed the following physician's orders:
- Flomax 0.4 milligrams (mg) give 1 capsule at bedtime for BPH.
- Seroquel 100 mg give 1 tablet at bedtime for behavioral disturbances.
- Seroquel 25 mg give 1 tablet twice daily at 8:00 AM and 2:00 PM for behavioral disturbances.
- Zyprexa 2.5 mg twice daily in the morning and evening for behavioral disturbances.
Record review of the April 2023 Medication Administration Record (MAR) revealed the resident did not receive the following medications due to the medications being unavailable to administer on the following dates and times:
- 4/23: Flomax, Seroquel 100mg, and Zyprexa bedtime doses.
- 4/24: Seroquel 25mg at 8:00 AM and 2:00 PM, and Zyprexa morning and bedtime doses.
- 4/25: Zyprexa morning dose.
Record review of a progress noted dated 4/25/2023 revealed the resident presented with increased confusion, wandering behaviors, and required one to one supervision by staff and was subsequently transferred to an acute care hospital for evaluation.
2. Record review revealed Resident ID #2 was admitted to the facility in 5/1/2023 at approximately 5:30 PM, with diagnoses including, but not limited to, lung cancer, COVID-19, pneumonia, congestive heart failure, chronic obstructive pulmonary disorder (COPD), and diabetes.
During a surveyor interview on 5/2/2023 at 11:25 AM with the resident's family member, s/he revealed that the resident was admitted to the facility on [DATE] at 5:30 PM.
Record review of the May 2023 MAR revealed that the following physician medication orders listed were not administered to the resident due to the medications not being available to be given, medication administrations omitted in the record, or incorrectly transcribed start dates causing the resident to miss several opportunities to receive his/her medication doses:
- Start date of 5/1 at 9:00 PM Lipitor 20 mg give 1 tablet at bedtime for hyperlipidemia (elevated level of fats in the blood): Medication was not administered to the resident on 5/1.
- Start date of 5/2 at 8:00 AM Synthroid 112 micrograms (mcg) give 1 tablet daily for an underactive thyroid: Medication not available on 5/2.
- Start date of 5/2 at 8:00 AM Spiriva inhaler 2.5 mcg inhale 2 puffs daily for COPD: Medication not available on 5/2.
- Start date of 5/2 at 8:00 AM Entresto 24-26 mg give 1 tablet twice daily at 8:00 AM and 5:00 PM: Medication not available on 5/2 at 8:00 AM.
- Start date of 5/2 at 12:00 AM Ipratropium-Albuterol solution inhale 3 ml via nebulizer (device that turns liquids into mist for inhaling medicine) for shortness of breath (SOB) or wheezing every 4 hours: Medication start date incorrectly transcribed missing opportunities for administration on 5/1 at 8:00 PM and medication administration omitted on 5/2 at 12:00 AM and 4:00 AM.
- Start date of 5/3 at 8:00 AM Pulmicort inhalation suspension 0.5 mg/2 ml (milliliter) inhale 1 vial daily for SOB: Medication not available on 5/2 at 8:00 AM.
During a surveyor interview on 5/2/2023 at approximately 11:20 AM with Licensed Practical Nurse, Staff A, she acknowledged that Resident ID #2's medications listed above were all not available to be given.
During a surveyor interview on 5/2/2023 at approximately 2:30 PM with the Director of Nursing Services in the presence of the Regional Nurse, she acknowledged that residents ID #s 1 and 2 did not receive their medications as ordered because they were unavailable to be given. Additionally, she revealed she would expect the nurse to notify the pharmacy to request an immediate delivery of the medications.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to ensure that residents were 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 were free from significant medication errors related to the administration of antipsychotic medications (a type of medication use to treat mental health disorders) and an antibiotic medication for 1 of 5 residents reviewed for significant medication errors, Resident ID #1.
Record review of a facility policy titled, admission Criteria states in part, .6. Residents are admitted to this facility as long as their needs can be met adequately by the facility. 7. Examples of nursing/medical needs that can be met adequately include: a. medication management .
Record review of a facility policy titled, Administering Medications states in part, .Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame .
Record review of the residents' clinical record revealed s/he was admitted to the facility on [DATE] with diagnoses that include, but are not limited to, dementia with behavioral disturbances, urinary tract infection (UTI), retention of urine, hydronephrosis (excess fluid in a kidney due to a back up of urine), benign prostatic hyperplasia (BPH, a condition in which the flow of urine is obstructed due to the enlargement of the prostate gland), and delirium (a mental state in which you are confused, disoriented, and not able to think or remember clearly).
Record review revealed the following physician medication orders:
- Seroquel (antipsychotic medication) Give 100 mg (milligram) by mouth at bedtime for behavioral disturbances.
- Seroquel Give 25 mg by mouth two times a day for behavioral disturbances.
- Zyprexa (antipsychotic medication) Give 2.5 mg two times a day at for behavioral disturbances.
- Flomax 0.4 mg (urinary retention medication) Give 1 capsule by mouth at bedtime for BPH.
Record review revealed the following progress notes:
- 4/23/2023 at 7:37 PM authored by Registered Nurse (RN), Staff C, revealed a physician medication order entry, thus indicating the resident was present in the facility at that time.
- 4/25/2023 at 10:59 AM revealed the resident presented with increased confusion, wandering behaviors, and required 1 to 1 supervision by staff and was subsequently transferred to an acute care hospital.
- 4/26/2023 at 1:42 AM revealed the resident returned from the hospital at 10:00 PM on 4/25/2023 with a diagnoses of UTI and was to start ciprofloxacin 250 milligrams (an antibiotic medication) twice daily for 10 days.
- 4/26/2023 at 6:34 AM revealed that the resident had a newly diagnosed UTI which contributed to his/her altered mental status and behavioral non-compliance.
Review of the hospital document dated 4/25/2023 titled, Patient Visit Information revealed in part, Patient was evaluated medically .Found to have a UTI .Please take antibiotics as prescribed .
Record review of the April 2023 Medication Administration Record (MAR) failed to reveal evidence that the antibiotic order was transcribed indicating the resident did not receive any of his/her ordered antibiotic medications to treat his/her newly diagnosed UTI.
Further record review of the April 2023 MAR failed to reveal evidence that the resident received the following medications as ordered:
- 4/23: Flomax, Seroquel 100mg, and Zyprexa evening dose.
- 4/24: Seroquel 25mg at 8:00 AM and 2:00 PM, and Zyprexa morning and evening doses.
- 4/25: Zyprexa morning dose.
During a surveyor interview on 5/2/2023 at approximately 2:30 PM with the DNS in the presence of the Regional Nurse, she acknowledged that Resident ID #1 did not receive the prescribed antipsychotic medications as ordered.
During an additional interview on 5/8/2023 at approximately 2:00 PM with the Regional Nurse, she could not provide evidence that the resident received the antibiotic medication prescribed by the physician on 4/25/2023.
Mar 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free 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 ensure that residents are free of any significant medication errors, for 1 of 1 resident reviewed who was hospitalized following a significant medication error, Resident ID #1.
Findings are as follows:
Record review of a community reported complaint received by the Rhode Island Department of Health on 3/29/2023 alleges that the resident was not provided with the ordered insulin and the physician was not aware that s/he was not receiving the insulin.
According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
Record review for the resident revealed that s/he was originally admitted to the facility in July of 2021 with diagnoses including, but not limited to, type 2 diabetes mellitus with diabetic autonomic neuropathy (nerve damage associated with diabetes), noninfective gastroenteritis and colitis (inflammation of the upper and lower intestinal tracts characterized by nausea, vomiting, and diarrhea), and gastroparesis (a disorder that slows or stops the movement of food from your stomach to your small intestines).
Record review of the Minimum Data Set assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status score of 11 out of 15, indicating moderately impaired cognition.
Review of the Medication Administration Record (MAR) for March 2023 revealed the following medications were not administered to the resident on the following dates and times:
3/26/2023
1) Insulin Lispro 100 Units/ml 15 units 3 times a day before meals - 11:30 AM and 4:30 PM
2) Lantus U100 insulin 100 Units/ml 60 units subcutaneous 2 times a day - 7:00 AM - 10:00 AM
3) Acetaminophen 1000 mg (milligrams) 3 times a day - 5:00 AM, 1:00 PM, and 8:00 PM
4) Acidophilus 1 capsule 2 times a day - 6:00 PM - 8:00 PM
5) Cranberry extract capsule 450 mg 2 times a day - 6:00 PM - 8:00 PM
6) Gabapentin 300 mg 3 times a day - 5:00 AM, 1:00 PM, and 8:00 PM
7) Gabapentin 100 mg 3 times a day - 5:00 AM, 1:00 PM, and 8:00 PM
3/27/2023
1) Acetaminophen 1000 mg 3 times a day - 5:00 AM
2) Gabapentin 300 mg 3 times a day - at 5:00 AM
3) Gabapentin 100 mg 3 times a day - at 5:00 AM
4) Omeprazole DR/EC (delayed release/enteric coated) 20 mg 1 tab daily - at 5:00 AM
Additional review of the March 2023 MAR revealed the medications mentioned above were held on 3/26/2023 and 3/27/2023, due to patient condition and or nausea, vomiting, and/or diarrhea. It also revealed that the resident's 7:30 AM blood sugar on 3/27/2023 was 435 mg/d (milligrams per deciliter; a blood sugar level reading of 70 mg/dl to 140 mg/dl is a normal blood sugar reading).
Further record review failed to reveal evidence that the physician was notified on 3/26/2023 and/or on 3/27/2023 that the above-mentioned medications were held.
Record review of the progress notes revealed the physician was contacted on the morning of 3/27/2023 as the resident's blood sugar level was elevated at 435 mg/dl. The physician then gave an order to transfer the resident. The resident was transferred to an acute care hospital.
Record review of the hospital emergency room paperwork revealed that upon arrival there was evidence that the resident was found to be hyperglycemic (elevated blood sugar level).
During a surveyor interview with Registered Nurse, Staff A, on 3/30/2023 at approximately 12:40 PM, she revealed that she left a message for the physician on Sunday, (March 26, 2023), to inform him that the resident had been having vomiting and diarrhea. Additionally, she revealed she did not make the physician aware that the resident's medications had been held.
During an interview with the resident's physician on 3/30/2023 at 1:44 PM, he revealed he did not recall being notified by staff that the facility had been holding multiple medications for the resident on both 3/26/2023 and 3/27/2023.
During an interview with the Director of Nursing Services on 3/30/2023 at approximately 2:00 PM, she was unable to provide evidence that the physician was notified prior to staff holding the resident's medications on 3/26 and 3/27/2023. Additionally, she was unable to provide evidence that Resident ID #1 was free of any significant medication errors.
Feb 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure residents are free from ac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure residents are free from accident hazards for resident's who require assistance devices to prevent accidents for 1 of 3 resident's reviewed, Resident ID #1.
Review of a community reported complaint submitted to the Rhode Island Department of Health on 2/18/2023 alleges, per EMS [emergency medical services] on February 17, 2023 while patient was being transferred to a bed in a nursing home [his/her] right leg was caught between the rail and was twisted and also sustained an open compound wound.
Findings are as follows:
Review of a facility policy titled, Safe Patient Handling states in part, .In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .2. Manual lifting of residents shall be eliminated when feasible .
Record review revealed that the resident was admitted to the facility in June of 2018 and has diagnoses including, but not limited to, lack of coordination, difficulty walking, osteoarthritis, other abnormalities with gait and mobility, and localized edema of the lower extremities.
Review of the quarterly Minimum Data Set (MDS) Assessment (entails a comprehensive, standardized assessment of each resident's functional capabilities and health needs) dated 2/7/2023 revealed a Brief Interview for Mental Status score of 13 indicating that the resident is cognitively intact. The MDS further indicates that the resident is totally dependent, requiring the assistance of two persons for transfers.
Review of a Safe Patient Handling assessment dated [DATE] revealed that the resident is dependent and requires more than 50% assistance or is unpredictable in the amount of assistance offered and assistive devices should be used. The assessment further revealed in part, .if any caregiver is required to lift more than 35 pounds of a patient's weight, then the patient should be considered to be fully dependent, assistive devices should be used .Patient is cooperative, stand and pivot technique with a powered stand assist lift with 2 caregiver .
Record review revealed a progress note dated 2/17/2023 at 9:21 PM that states in part, .writer was calling to help two staff members with a transfer, elder right leg got twisted during transfer while [s/he] tried to turn to seat in bed, elder screamed my leg when checked writer noticed blood and skin tear .
Review of a hospital document dated 2/17/2023 states in part, .Per EMS, patient was at NH [nursing home] being transferred from bed to bed when [his/her] R [right] foot got stuck in the rail, [his/her] leg twisted, and [his/her] leg broke. Patient has open tib-fib [tibia/fibular] fracture to RLE [right lower extremity] .
During a surveyor interview with Certified Nursing Assistant (CNA) Staff A on 2/21/2023 at 12:01 PM, she revealed that she, another CNA and the nurse were transferring the resident from the wheelchair to the bed when the resident screamed and she noted that the resident had a large skin tear. Staff A further indicated that the resident requires a two person assist and the staff do not use any mechanical devices for transfers for this resident.
During a surveyor interview with CNA Staff B on 2/21/2023 at 1:03 PM, she revealed that she, another CNA and the nurse were transferring the resident from the wheelchair to the bed, the resident screamed and was bleeding. Staff B further indicated that they did not use a mechanical device to assist with the transfer.
During a surveyor interview with Licensed Practical Nurse Staff C on 2/21/2023 at 10:05 AM, she revealed that she and two CNA's transferred the resident from the wheelchair to the bed without the use of a mechanical device for assistance. Staff C further indicated that during the transfer, the resident reported that his/her leg was twisted and there was a lot of blood noted.
During a surveyor interview with the Director of Nursing Services (DNS) on 2/21/2023 at 10:15 AM, she acknowledged that the Safe Patient Handling assessment indicated that the resident required a stand and pivot technique with the use of a powered stand assist lift and two caregivers for transfers. The DNS further indicated that the staff did not utilize any mechanical devices for the transfer and the resident was sent out to the hospital for an open leg wound.
Jan 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from significant medication errors for 1 of 6 residents reviewed...
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Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from significant medication errors for 1 of 6 residents reviewed for medication administration, Resident ID #6.
Findings are as follows:
Record review revealed the resident was admitted to the facility in December of 2022 with diagnoses including, but not limited to, end-stage renal disease (a condition where the kidneys can no longer support the body's needs), hypothyroidism (low levels of thyroid hormone), epilepsy (seizure disorder), transient ischemic attack (brief stroke-like attack), and essential hypertension (high blood pressure).
Further record review revealed the resident received dialysis on the following dates, 12/29/2022, 12/31/2022, 1/3/2023, 1/5/2023, 1/7/2023, and 1/10/2023.
1. Record review revealed the following physician orders:
-aspirin (medication used to prevent cardiovascular events) chewable tablet 81 milligrams (mg), once daily, dated 12/29/2022
-carvedilol (medication used to manage hypertension) tablet 6.25 mg, twice daily, dated 12/28/2022
-lacosamide (medication used to treat seizures) tablet 100 mg, two tablets every morning Tuesday, Thursday, Saturday, dated 12/28/2022
-sertraline (antidepressant medication) tablet 50 mg, once daily, dated 12/29/2022
-vitamin B complex-folic acid (medication used to treat vitamin B deficiency) tablet 0.4 mg, once daily, dated 12/29/2022.
Record review of the December 2022 Medication Administration Record (MAR) revealed the above-listed medications were not administered to the resident as ordered on 12/31/2022.
Record review of the January 2023 MAR revealed the above-listed medications were not administered to the resident as ordered on 1/3/2023, 1/5/2023, 1/7/2023, and 1/10/2023.
2. Record review revealed the following physician orders:
-levothyroxine (medication used to treat thyroid hormone deficiency) capsule 50 micrograms, once daily, dated 12/29/2022
-omeprazole magnesium (medication used to treat acid reflux) delayed-release capsule 20 mg, once daily, dated 12/29/2022.
Record review of the December 2022 MAR revealed the above-listed medications were not administered to the resident as ordered on 12/31/2022.
Record review of the January 2023 MAR revealed the above-listed medications were not administered to the resident as ordered on 1/3/2023 and 1/5/2023.
3. Record review revealed a physician order for valproic acid (medication used to treat seizure disorders) capsule 250 mg, take two twice daily, dated 12/28/2022.
Record review of the December 2022 MAR revealed valproic acid was not administered to the resident as ordered on 12/31/2022 at 7:00 AM to 11:00 AM.
Record review of the January 2023 MAR revealed valproic acid was not administered to the resident as ordered on the following dates and times:
1/3/2023 at 7:00 AM to 11:00 AM.
1/5/2023 at 7:00 AM to 11:00 AM.
1/7/2023 at 7:00 AM to 11:00 AM.
1/10/2023 at 7:00 AM to 11:00 AM.
4. Record review revealed a physician order for Phoslyra solution (calcium acetate(phosphate-binding); medication used to reduce serum phosphorus in patients with end-stage renal disease) 667 mg, twice daily, dated 12/28/2022 to 1/4/2023.
Record review of the December 2022 MAR revealed Phoslyra was not administered to the resident on the following dates and times:
12/28/2022 at 4:00 PM to 8:00 PM
12/29/2022 at 7:00 AM to 11:00 AM
12/29/2022 at 4:00 PM to 8:00 PM
12/31/2022 at 7:00 AM to 11:00 AM
12/31/2022 at 4:00 PM to 8:00 PM
Record review of the January 2023 MAR revealed Phoslyra was not administered to the resident on the following dates and times:
1/1/2023 at 7:00 AM to 11:00 PM
1/2/2023 at 7:00 AM to 11:00 PM
1/2/2022 at 4:00 PM to 8:00 PM
1/3/2023 at 7:00 AM to 11:00 PM
During a surveyor interview on 1/12/2023 at 12:16 PM with the Director of Nursing Services (DNS), she acknowledged the resident did not receive any of the above-listed medications in the facility as ordered. She was also unable to provide evidence that the provider was notified of the missed medications.
During a subsequent interview on 1/12/2023 at 12:37 PM with the DNS, she indicated that the resident receives the above-listed medications at the dialysis center.
During a surveyor interview on 1/12/2023 at 12:52 PM with the outpatient dialysis Registered Nurse, Staff A, she revealed the resident does not receive any of the above-listed medications at the dialysis center.
During a surveyor interview on 1/12/2023 at 1:28 PM with the DNS and Administrator, they were unable to provide evidence that the resident received any of the above-listed medications as ordered.
Nov 2022
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
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary psychotropic drugs for 1 of 2 residents reviewe...
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Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary psychotropic drugs for 1 of 2 residents reviewed who have as-needed psychotropic medication orders extending beyond 14 days without a rationale or indication for an intended duration, Resident ID #2.
Findings are as follows:
Record review revealed the resident was admitted to the facility in September of 2022 with diagnoses including, but not limited to, anxiety disorder, and altered mental status.
Record review revealed a current physician's order dated 10/13/2022 for lorazepam .tablet; 0.5 mg [milligrams] .as needed for anxiety once qd [every day] . without a stop date, which is beyond the 14 days.
Record review of the October 2022 Medication Administration Record (MAR) revealed the resident received as-needed lorazepam beyond the 14 days on 10/28/2022, 10/29/2022, and 10/31/2022.
Record review of the November 2022 MAR revealed the resident received as-needed lorazepam beyond the 14 days on 11/2/2022, 11/3/2022, 11/4/2022, 11/5/2022, and 11/6/2022.
During a surveyor interview on 11/7/2022 at 1:55 PM with the prescribing physician, he acknowledged that the above-mentioned as-needed lorazepam order had no end date. Additionally, he was unable to provide evidence of documentation or rationale for the extended time period.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that the medical records f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that the medical records for each resident are maintained in accordance with professional standards and practices regarding accurate documentation for 1 of 4 residents reviewed, Resident ID #4.
Findings are as follows:
Record review revealed the resident was readmitted to the facility in November of 2022 with diagnoses including, but not limited to, adult failure to thrive, difficulty in walking, and muscle weakness.
Record review revealed a document titled admission & re-admission Packet dated 11/2/2022 at 5:00 PM, with a skin assessment indicating the resident has no ulcers.
Record review of a document titled Skin Ulcer Documentation dated 10/25/2022, revealed the resident had a stage 3 (wound affecting the top two layers of skin and fat tissue) pressure ulcer to the coccyx.
During a surveyor interview on 11/9/2022 at 9:05 AM, with the Wound Nurse, Staff A, she revealed she identified the coccyx wound on 10/25/2022. She further revealed that the resident currently has that identified pressure wound on the coccyx.
During a surveyor interview on 11/9/2022 at 11:25 AM with the Director of Nursing Services, she was unable to explain why the above-mentioned coccyx pressure wound was not documented on the readmission skin assessment dated [DATE].
Aug 2022
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
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 immediatel...
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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 immediately consult with the resident's physician when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention, for 1 of 4 residents reviewed for non-pressure skin conditions, Resident ID #20.
Findings are as follows:
Record review revealed the resident was admitted to the facility in March of 2021 with diagnoses of, but not limited to, Parkinson's disease, dementia, and type 2 diabetes mellitus.
During a surveyor observation on 8/9/2022 at approximately 2:00 PM, a gauze with bloody drainage was noted to the top of the resident's right hand.
During subsequent surveyor observations on 8/11/2022 at approximately 11:00 AM and on 8/12/2022 at 11:19 AM, the resident was noted to have a bandage on the top of his/her right hand.
Record review of a care plan initiated on 10/20/2021 revealed the resident is at risk for impaired skin integrity with interventions in place to monitor for skin breakdown during daily care and to report any abnormal findings.
Record review of a weekly skin assessment dated [DATE] revealed the resident had an abrasion to the top of his/her right hand.
Additional review of the resident's record failed to reveal evidence that the physician was notified of the injury to the top of the resident's right hand.
Review of the physician orders failed to reveal evidence of a treatment in place for the wound to the right hand.
During a surveyor interview with Registered Nurse, Staff A, at the time of the above observation, she revealed that she was unaware of the resident having an injury requiring a bandage to his/her right hand until notified by the surveyor. She then assessed the area by removing the bandage and indicated it was a skin tear with dried blood to the right hand. She was unable to provide evidence that there was an order in place for the treatment of the skin tear and that the physician had been notified.
During a surveyor interview on 8/12/2022 at approximately 12:00 PM with the Director of Nursing Services, she revealed that she would expect staff to document in the record, notify the physician, and obtain a physician's order for treatment immediately upon visualization of a new skin issue.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident receives t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice relative to 1 of 1 resident reviewed for steroid use, Resident ID #50.
Findings are as follows:
Record review revealed the resident was admitted to the facility in January of 2021 with diagnoses including, but not limited to, hypereosinophilic syndrome (HES, rare condition caused by an overload of white blood cells called eosinophils) and heart failure.
Record review of a Continuity of Care form dated 3/14/2022 from the resident's primary care physician indicates the resident receives steroids chronically due to HES. Additionally, the resident is to follow up in 3 months.
Record review of a Continuity of Care form dated 6/13/2022 from the resident's visit with the hematologist indicates to continue with prednisone 10 milligram (MG) daily with a follow up hematology appointment scheduled for 10/24/2022 at 10:00 AM.
Record review revealed a hospital Discharge summary dated [DATE], indicating the resident was sent out to the hospital on 7/13/2022 after experiencing increased generalized swelling and increased weight gain. The resident was admitted to the hospital.
Additional record review of the hospital's discharge summary revealed the resident was currently being treated for HES and was on daily prednisone. The document also states in part, .Hospital Course: .Patient continued to have persistent leukocytosis [high white blood cell count] .Hematology was consulted and had recommended increasing prednisone dose to 40 mg once daily due to worsening eosinophilia. Prednisone will be tapered by 10 mg every 5 days until the dose of 20 mg daily had reached, patient has a follow-up appointment with [his/her] hematologist [name redacted] .
Further record review revealed the resident was discharged from the hospital and returned to the facility on 7/22/2022 with the following physician orders in place:
- Prednisone 10 MG tablet; Take 4 tabs (40 mg) a day for 2 more days, then 3 tabs (30 mg) a day for 5 days, then 2 tabs (20 mg) a day until seen by Hematology on 8/4/2022.
Review of the resident's Medication Administration Record (MAR) revealed a physician order dated 7/30/2022 for 20 mg of prednisone to be administered daily with an end date of 8/4/2022. Additionally, the order included special instructions to consult with hematology on 8/4/2022 about continuing prednisone or not. The resident's last dose of prednisone was administered on 8/4/2022.
Review of the resident's progress note dated 8/4/2022 at 2:51 PM revealed the resident's hematology appointment was canceled by the facility, due to not having staff or a family member available to accompany the resident to the appointment.
Further record review of the resident's record failed to reveal documentation that the physician was notified of the missed appointment or that it was rescheduled. After being notified by the surveyors, the resident's hematologist was notified of the missed appointment, bloodwork was ordered and obtained, and the appointment was rescheduled.
During a surveyor interview on 8/12/2022 at 9:02 AM with Registered Nurse Staff A, she was unable to locate a current order for the resident's prednisone or evidence of attempts to obtain a new hematology appointment.
During a surveyor interview on 8/12/2022 at 12:57 PM with the Director of Nursing Services (DNS), she was unable to provide evidence that the physician's order to consult with hematology on 8/4 was followed. Additionally, she was unable to provide evidence that the physician was notified of the missed hematology appointment and the discontinued prednisone order until it was brought to her attention by the surveyor.
During a phone interview with the DNS on 8/15/2022 at 2:05 PM she acknowledged that the resident's blood work results were completed and that the resident was ordered for 10 mg of Prednisone daily.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to preve...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections (UTIs) for 1 of 1 resident reviewed for UTIs, Resident ID #68.
Findings are as follows:
Review of the facility's protocol titled Questionable UTI? updated on 11/5/2021, states in part, .Please follow this protocol for 3 Full days .Resident is to have fluids increased .to a minimum of 1500cc's [cubic centimeters] per day. Obtain order from physician for UTI-Stat [a medical food for urinary tract health] 30cc's BID [twice a day] PO [by mouth] per day X3 [times 3] days .
Record review revealed the resident was admitted to the facility in March of 2022 with diagnoses which include, but are not limited to, dementia with behavioral disturbance and urinary retention.
Record review of a care plan dated 6/13/2022 revealed the resident is at risk for a UTI with an intervention dated 8/4/2022 to initiate the UTI protocol.
Record review revealed a physician's order dated 8/4/2022, for the UTI protocol for 3 days.
Record review of the Medication Administration Record (MAR) for August 2022 revealed that the UTI protocol was implemented.
Record review failed to reveal evidence that an order for the UTI Stat was obtained per the facility's protocol or that the resident received the UTI Stat. Additional record review failed to reveal evidence that the residents fluid intake was increased to 1500 cc's per the facility's protocol.
During a surveyor interview with the Director of Nursing Services on 8/11/2022 at 1:59 PM, she acknowledged that the UTI protocol was not followed, the resident did not receive the UTI Stat, or that his/her fluid intake was increased per the protocol.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional sta...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan, for 1 of 1 resident reviewed for respiratory care, Resident ID #50.
Findings are as follows:
Review of the facility's policy titled Oxygen Administration states in part .masks, cannulas and tubing are to be changed as needed and at least weekly .
Record review for the resident revealed s/he was admitted to the facility in January of 2021 with diagnoses including, but not limited to: heart failure, eosinophilia (rare condition caused by an overload of white blood cells called eosinophils) and anxiety disorder.
Review of the resident's care plan dated 5/20/2022 revealed in part .is at risk for alteration in respiratory status due to diagnosis of heart failure and exhibits with shortness of breath, resulting dependent on supplemental oxygen; remove, clean and replace oxygen filter and change tubing every Friday on 11-7 shift.
During surveyor observations on 8/9/2022 and 8/10/2022, the resident was observed on multiple occasions with the oxygen tubing dated 7/29/2022, the nasal cannula (the part that is inserted in the resident's nose) had brown dry matter at the tip while in his/her nose.
During a surveyor interview with Registered Nurse, Staff B on 8/10/2022 at 1:22 PM, she acknowledged the oxygen tubing was dated 7/29/2022 and the nasal cannula had an accumulation of brown matter and should be changed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, and staff interview, it has been determined that the facility failed to provide the necessary ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, and staff interview, it has been determined that the facility failed to provide the necessary services to residents who are unable to carry out activities of daily living relative to showers for 2 of 2 residents reviewed, Resident ID #'s 50 and 79.
Findings are as follows:
1. Record review revealed Resident ID #50 was admitted to the facility in January of 2021 with diagnoses which include, but are not limited to, unspecified intellectual disabilities and muscle weakness.
Record review of a quarterly Minimum Data Set Assessment (MDS) dated [DATE], revealed the resident is totally dependent with bathing and showering and requires the assistance of one staff to complete this task.
Record review of a care plan dated 7/25/2022 revealed Resident ID #50 is unable to be independent with self care secondary to physical limitations and balance deficits.
Record review of a document titled South Wing Shower list revealed this resident is scheduled to receive showers weekly, on Mondays on the first shift.
Record review of the nursing assistant task titled Point of Care History revealed the resident last received a shower on 4/5/2022.
During a surveyor interview with the Director of Nursing Services (DNS), on 8/12/2022 at 11:34 AM, she was unable to provide evidence that Resident ID #50 received showers weekly or refused showers since 4/5/2022.
2. Record review revealed Resident ID #79 was admitted to the facility in July of 2021 with diagnoses which include, but are not limited to, cerebral infarction (stroke), muscle weakness, and cognitive communication deficit.
Record review of the admission MDS assessment dated [DATE], revealed the resident is totally dependent with bathing and showering and requires the assistance of one staff to complete this task.
Record review of a care plan dated 7/7/2022 revealed the resident is unable to be independent with self care related to cognitive and physical impairment.
Record review of a document titled West Shower list revealed this resident is scheduled to receive showers weekly, on Wednesdays on the second shift.
Record review of the nursing assistant task titled Point of Care History revealed the resident received a shower on 7/18/2022 which is only once since his/her admission.
During a surveyor interview with the Assistant Director of Nursing Services on 8/12/2022 at 9:32 AM, she indicated that Resident ID #79 should have received showers weekly. Additionally, she was unable to provide evidence that the resident had received showers prior to, or after 7/18/2022 as documented by the staff.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to store all drugs and biolog...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to store all drugs and biologicals in accordance with currently accepted professional principles for 2 of 3 medication storage rooms observed (West and South Wings) and 1 of 3 medication carts observed (West Wing).
Findings are as follows:
1. During a surveyor observation of the [NAME] Wing medication cart on [DATE] at 8:45 AM in the presence of the Licensed Practical Nurse, Staff C revealed a bottle of Pantoprazole 40 MG (milligrams) tablet (a medication used to decrease the amount of acid in the stomach) with an expiration date of [DATE].
During a surveyor interview with Staff C immediately following the above observation, she acknowledged the Pantoprazole was expired.
2. During a surveyor observation of the [NAME] Wing medication room on [DATE] at 9:21 AM in the presence of Staff C revealed the following:
- Two bottles of Lorazepam Intensol (a medication used to treat anxiety) open, in use, and not dated. Manufacturer's instructions state in part, .date when opened and discard 90 days after opening .
During a surveyor interview with Staff C immediately following the above observation, she acknowledged the two bottles of Lorazepam Intensol were open, in use, and not dated.
3. During a surveyor observation of the South Wing medication room on [DATE] at 10:28 AM in the presence of Licensed Practical Nurse, Staff D revealed one bottle of Lorazepam Intensol open, in use, and not dated.
During a surveyor interview with Staff D immediately following the above observation, she acknowledged the bottle of Lorazepam Intensol was open, in use, and not dated.
During a surveyor interview with the Director of Nursing Services on [DATE] at 11:40 AM, she indicated that she would expect the Lorazepam Intensol to be dated when opened. Additionally, she indicated that she would expect the expired medication to be discarded.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure tha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the facility stores, distributes, and serves food in accordance with professional standards for food service safety relative to 2 of 3 unit kitchenettes.
Findings are as follows:
Review of the facility's policy titled, Dietary Department Infection Control states in part, .All foods are to be labeled and dated to allow for rotation of stock .All items stored in the refrigerator will be covered and labeled with the contents and the date. All stock items will be monitored for expiration dates, used and discarded as necessary .
1. During a surveyor observation of the East unit kitchenette on 8/11/2022 at 10:55 AM, the following was observed:
- 1 of 5 eight-ounce bottles of Glucerna, vanilla flavor, opened and not dated. Manufacturer's instructions revealed that the product should be refrigerated and then discarded 48 hours after opening.
- 1 of 2 thirty two-ounce cartons of [NAME] Readycare high calorie, high protein nutritional drink, vanilla flavor, opened and not dated. Manufacturer's instructions revealed the product should be refrigerated after opening and used within 72 hours.
- 3 of 8 eight-ounce bottles of Nepro with carbsteady, vanilla flavor; one bottle opened and dated 7/25, one bottle opened and dated 8/8, and another bottle opened and not dated. Manufacturer's instructions state in part, .Once opened, reclose, and use within 48 hours.
- 2 of 15 eight-ounce bottles of Ensure clear, mixed berry flavor, opened and not dated. Manufacturer's instructions on the label state in part, .once opened, reclose, refrigerate, and use within 48 hours.
- 1 of 1 eleven-ounce bottle of Glucerna Proteinsmart nutritional supplement, chocolate flavor, opened and not dated.
During a surveyor interview with Nursing Assistant Staff E immediately following the above observation, she acknowledged that the above liquid supplements were opened and not dated and that the two bottles of Nepro should have been thrown out per the manufacturer's instructions.
2. During a surveyor observation of the [NAME] unit kitchenette on 8/11/2022 at 11:26 AM in the presence of Licensed Practical Nurse Staff C, the refrigerator was observed to have 1 of 2 eight-ounce bottles of Glucerna, opened and not dated.
During a surveyor interview immediately following the above observation with Staff C, she acknowledged that the above supplement should have been dated when opened.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 2 harm violation(s), $25,376 in fines. Review inspection reports carefully.
- • 69 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $25,376 in fines. Higher than 94% of Rhode Island facilities, suggesting repeated compliance issues.
- • Grade F (33/100). Below average facility with significant concerns.
Bottom line: Trust Score of 33/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Heritage Hills Nursing & Rehabilitation Center's CMS Rating?
CMS assigns Heritage Hills Nursing & Rehabilitation Center an overall rating of 3 out of 5 stars, which is considered average nationally. Within Rhode Island, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Heritage Hills Nursing & Rehabilitation Center Staffed?
CMS rates Heritage Hills Nursing & Rehabilitation Center's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 50%, compared to the Rhode Island average of 46%. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Heritage Hills Nursing & Rehabilitation Center?
State health inspectors documented 69 deficiencies at Heritage Hills Nursing & Rehabilitation Center during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 66 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Heritage Hills Nursing & Rehabilitation Center?
Heritage Hills Nursing & Rehabilitation Center is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by MARQUIS HEALTH SERVICES, a chain that manages multiple nursing homes. With 100 certified beds and approximately 85 residents (about 85% occupancy), it is a mid-sized facility located in Smithfield, Rhode Island.
How Does Heritage Hills Nursing & Rehabilitation Center Compare to Other Rhode Island Nursing Homes?
Compared to the 100 nursing homes in Rhode Island, Heritage Hills Nursing & Rehabilitation Center's overall rating (3 stars) is below the state average of 3.1, staff turnover (50%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Heritage Hills Nursing & Rehabilitation Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Heritage Hills Nursing & Rehabilitation Center Safe?
Based on CMS inspection data, Heritage Hills Nursing & Rehabilitation Center has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Rhode Island. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Heritage Hills Nursing & Rehabilitation Center Stick Around?
Heritage Hills Nursing & Rehabilitation Center has a staff turnover rate of 50%, which is about average for Rhode Island nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Heritage Hills Nursing & Rehabilitation Center Ever Fined?
Heritage Hills Nursing & Rehabilitation Center has been fined $25,376 across 3 penalty actions. This is below the Rhode Island average of $33,333. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Heritage Hills Nursing & Rehabilitation Center on Any Federal Watch List?
Heritage Hills Nursing & Rehabilitation Center is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.