Apple Rehab Clipper
For profit - Corporation
60 Beds
APPLE REHAB
Data: November 2025
4 Immediate Jeopardy citations
Trust Grade
0/100
#48 of 72 in RI
Photo by Apple Rehab Clipper
Photo by Apple Rehab Clipper
Photo by Apple Rehab Clipper
1 / 5 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Apple Rehab Clipper has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranked #48 out of 72 facilities in Rhode Island, they are in the bottom half of the state, and #8 out of 9 in Washington County, meaning only one local facility performs worse. The trend is stable, with 9 issues reported in both 2024 and 2025, which raises concerns about the facility's ability to improve. Staffing is a relative strength, with a 4 out of 5 star rating and turnover at 53%, higher than the state average, indicating some staff may not stay long enough to build relationships with residents. However, the facility has incurred $260,581 in fines, the highest in the state, suggesting repeated compliance problems. Critical incidents include a resident being sent home with another resident's medications and failures in ensuring nurses had the necessary competencies for resident care, highlighting serious lapses in both medication management and staff training. While there are strengths in staffing and RN coverage, the overall quality of care raises significant red flags for families considering this facility.
- Trust Score
- F
- In Rhode Island
- #48/72
- Safety Record
- High Risk
- Inspections
- Holding Steady
- Staff Stability ⚠ Watch
- 53% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $260,581 in fines. Higher than 97% of Rhode Island facilities. Major compliance failures.
- Skilled Nurses ✓ Good
- Each resident gets 76 minutes of Registered Nurse (RN) attention daily — more than 97% of Rhode Island nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 31 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 34%
Review needed
9 → 9 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 9 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, fire safety.
The Bad
2-Star Overall Rating
Below Rhode Island average (3.1)
Below average - review inspection findings carefully
Staff Turnover: 53%
Near Rhode Island avg (46%)
Higher turnover may affect care consistency
Federal Fines: $260,581
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: APPLE REHAB
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 31 deficiencies on record
4 life-threatening 2 actual harm
Jul 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident with a nephrostomy receives care, consistent with professional standards of practi...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident with a nephrostomy receives care, consistent with professional standards of practice relative to physician's orders, for 1 of 1 resident who has a percutaneous nephrostomy tube (PCN- an artificial opening created between the kidney and the skin which allows for urinary drainage), Resident ID #4.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 6/25/2025 alleges in part, that there were concerns with facility staffing and nursing medications errors.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 that the orders are in error or would harm the clients.Record review revealed the resident was admitted to the facility in June of 2025, with a diagnosis including, but not limited to, an artificial opening of urinary tract.1a. Review of a physician's order dated 6/11/2025 to empty Nephrostomy drain and record output every shift.Record review of the June 2025 Medication Administration Record (MAR) record failed to reveal evidence that the drain output was recorded as ordered on the following dates and times:-6/13/2025, 3:00 PM to 11:00 PM-6/14/2025, 7:00 AM to 3:00 PM-6/16/2025, 7:00 AM to 3:00 PM-6/17/2025, 7:00 AM to 3:00 PM-6/23/2025, 7:00 AM to 3:00 PM-6/24/2025, 3:00 PM to 11:00 PM1b. Additional review revealed a physician's order dated 6/12/2025 to use 10 milliliters of Normal Saline (NS) to flush the PCN every day and evening shift to maintain patency. Additional review of the June 2025 MAR failed to reveal evidence that the PCN was flushed as ordered on the following dates and times:-6/13/2025, 3:00 PM to 11:00 PM-6/16/2025, 3:00 PM to 11:00 PM-6/17/2025, 7:00 AM to 3:00 PM1c. Further record review revealed a physician's order dated 6/12/2025 to complete PCN care, remove old dressing, cleanse with normal saline and pat dry, cover with a split sponge gauze and secure with tape, every evening shift every two days. Further review of the June 2025 MAR failed to reveal evidence the above-mentioned treatment was completed on 6/16/2025 as ordered.During a surveyor interview with the Director of Nursing Services on 7/9/2025 at 2:13 PM, she indicated it would be her expectation for the resident's PCN orders to be completed 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
Deficiency F0710
(Tag F0710)
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 medical care of each r...
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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 medical care of each resident is supervised by a physician, relative to the providers failure to reconcile the resident's post and pre hospitalization orders relative to the administration of Aranesp (a medication prescribed to treat anemia caused by chronic kidney disease), for 1 of 1 resident reviewed, Resident ID #3. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 6/25/2025 alleges in part, there are concerns related to medication errors.Record review of an undated facility policy titled, Medication Administration, states in part, .To ensure safe, accurate, and effective administration of medication to the residents, promoting optimal health outcomes while minimizing medication errors .All medication shall be administered safely and accurately in accordance with physician orders . 1a. Record review revealed Resident ID #3 was admitted to the facility in April of 2025 with a diagnosis including, but not limited to, chronic kidney disease (progressive damage and loss of function of the kidneys). Record review revealed a physician's order dated 4/23/2025 for Aranesp 40 micrograms (mcg) to be administered every 28 days. Additionally, the order indicates that the resident's hemoglobin (hgb-the protein molecule in red blood cells that carries oxygen from the lungs to the body's tissues) is to be checked prior to administration and if the results are greater than 10.9 grams per deciliter (gm/dL), the medication is to be held. Additional record review revealed that the resident was re-hospitalized in April of 2025 and readmitted to the facility in May of 2025.Record review of a hospital document titled, Discharge summary dated [DATE], revealed a physician's order for Aranesp 25 mcg every 7 days, to be administered upon discharge from the hospital. Record review failed to reveal evidence that the above-mentioned order was reconciled by the nurse with the physician upon the resident's readmission to the facility on 5/6/2025.Record review of a progress note dated 5/7/2025, authored by the resident's physician states in part, .Visit Type: History and Physical .Medication List: medications review and reconciled, please see MARS [Medication Administration Records] .PCC [point click care-electronic medical record] and nursing notes and orders reviewed .Record review failed to reveal evidence that the physician's order for Aranesp 25 mcg every 7 days was reconciled by the physician from the hospital's Discharge summary dated [DATE].Record review of a progress note dated 5/8/2025, authored by the Nurse Practitioner states in part, .Medication List: medications review and reconciled, please see MARS .Record review failed to reveal evidence that the physician's order for Aranesp 25 mcg every 7 days was reconciled by the Nurse Practitioner from the hospital's Discharge summary dated [DATE].Record review of a pharmacy Consultation Report dated 5/8/2025 states in part, CLINICAL PRIORITY RECOMMENDATION: PROMPT RESPONSE REQUESTED .medication review process revealed the following medication dosing discrepancies on the admission orders . Aranesp inject 25 mcg .every 7 days listed on the dc [discharge] summary report reviewed in PCC as Aranesp .every 28 days .please consider clarifying these medication orders .During a surveyor interview on 7/8/2025 at 1:21 PM with the Nurse Practitioner, she indicated that it is her practice to compare the hospital's orders on the discharge summary with the current orders in PCC. Additionally, she revealed she was not aware that the order listed on the discharge summary was not transcribed into the resident's record and should have been. Additionally, she revealed that she did not recall reviewing the hospital discharge summary for Resident ID #3 when s/he was readmitted . Furthermore, she acknowledged that she provided and order on 5/20/2025 to administer Aranesp 25 mcg every 7 days with a with a parameter to hold the Aranesp if the resident's hgb is greater than 10.9 gm/dL. 1b. Record review failed to reveal evidence that a physician's order was in place to obtain a weekly hemoglobin value to determine if the Aranesp should be administered to Resident ID #3 or held.During a surveyor interview on 7/8/2025 at 9:00 AM with the physician, he revealed it is his practice to compare the hospital discharge summary with the current orders that are in Point Click Care (PCC- healthcare software). He acknowledged that he failed to reconcile the Aranesp order on the hospital discharge summary with the Aranesp order that was listed in PCC. Additionally, he revealed that he was not aware that Resident ID #3 did not have an order to routinely monitor his/her hgb, as the previous Aransep order from 4/23/2025 indicated to do so. He revealed that he would have expected an order to be in place. During a surveyor interview on 7/7/2025 at 4:11 PM, with the Director of Nursing Services, she indicated it would be her expectation that Resident ID #3's Aranesp order would have been reconciled by a provider and an order to monitor the resident's hgb weekly would have been implemented upon readmission to the facility.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**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 2 of 5 residents reviewed for medication administration, Resident ID #s 3 and 5.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 2 of 5 residents reviewed for medication administration, Resident ID #s 3 and 5.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 6/25/2025, alleges in part, that there were concerns with nursing errors.Record review of an undated facility policy titled, Medication Administration, states in part, .To ensure safe, accurate, and effective administration of medication to the residents, promoting optimal health outcomes while minimizing medication errors .All medication shall be administered safely and accurately in accordance with physician orders . 1. Record review revealed Resident ID #3 was admitted to the facility in April of 2025 with diagnoses including, but not limited to, chronic kidney disease (progressive damage and loss of function of the kidneys).Record review of a hospital document titled, Discharge summary dated [DATE], revealed a physician's order for Aranesp (a medication prescribed to treat anemia caused by chronic kidney disease) 25 micrograms (mcg) every 7 days, related to acute kidney injury (an abrupt decrease in kidney function) upon discharge from the hospital. Record review failed to reveal evidence that the above-mentioned order was entered into the resident's record upon his/her admission to the facility. Record review of a pharmacy Consultation Report dated 5/8/2025 states in part, CLINICAL PRIORITY RECOMMENDATION: PROMPT RESPONSE REQUESTED .medication review process revealed the following medication dosing discrepancies on the admission orders .Aranesp inject 25 mcg .every 7 days listed on the dc [discharge] summary report reviewed in PCC [point click care-electronic medical record] as Aranesp .every 28 days .please consider clarifying these medication orders .Record review revealed that the Nurse Practitioner provided an on 5/20/2025 to administer Aranesp 25 mcg every 7 days. Additionally, the order indicates to hold the medication if the resident's hemoglobin (hgb- the protein molecule in red blood cells that carries oxygen from the lungs to the body's tissues) is greater than 10.9 grams per deciliter (g/dl). (The normal range for hgb is 14.0-18.0).Review of the May, June and July 2025 Medication Administration Records (MAR) failed to reveal evidence that the Aranesp was administered as ordered on the following dates: -5/21/2025 -5/28/2025 -6/5/2025-6/13/2025-6/27/2025-7/4/2025 Record review failed to reveal evidence that the provider was notified of the above-mentioned missed medication administrations.Record review revealed a physician's order was provided to obtain a complete blood count (CBC- a blood test to obtain the levels of red blood cells and hemoglobin) on the following dates and times:-5/7/2025-5/13/2025-5/16/2025-6/14/2025Record review of the clinical laboratory results report for the above-mentioned orders revealed the following: -5/7/2025 hgb 9.3 (g/dl) -5/13/2025 hgb 9.3 (g/dl) -5/16/2025 hgb 9.4 (g/dl) -6/14/2025 hgb 10.6 (g/dl)These results indicate that the resident should have been administered the Aranesp per the physician's order. During a surveyor interview on 7/8/2025 at 9:00 AM with the physician, he indicated that he was aware of the above mentioned hgb values and that he would have expected the Aranesp to be administered as ordered. Additionally, he indicated that he was not notified that the resident had not received the medication as ordered.2. Record review revealed Resident ID #5 was admitted to the facility on [DATE] with diagnoses including, but not limited to, dementia and displaced fracture of the first and second vertebrae.Record review of a hospital document titled, Continuity of Care [COC] - Post-Acute Facility dated 6/24/2025, revealed the following physician's orders:- Heparin 5,000 units/milliliter (ml) inject 1 ml every 8 hours - Trazodone 50 milligrams (mg) once daily at bedtimeRecord review of the June 2025 Medication Administration Record (MAR) failed to reveal evidence that the resident received the above-mentioned medications on 6/24/2025.Record review failed to reveal evidence that the provider was notified of the above-mentioned missed medication administrations.During surveyor interviews on 7/7/2025 at 4:11 PM and 7/8/2025 at 11:41 AM and 2:13 PM, with the Director of Nursing Services, she indicated it would be her expectation that the physician's orders for Resident ID #s 3 and 5 to have been followed. Additionally, she was unable to provide evidence that Resident ID #s 3 and 5 were kept free from significant medication errors.
May 2025
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident with a pressure ulcer (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 that a resident with a pressure ulcer (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 1 of 2 residents reviewed with wounds, Resident ID #31.
Findings are as follows:
Review of a facility policy titled, Dressing, Dry Clean (NON-STERILE) states in part, Procedure .Put on gloves .remove soiled dressings, remove gloves, wash or sanitize hands with sanitizer and apply gloves .Apply dressing and secure .
Record review revealed the resident was readmitted to the facility in September of 2024 with a diagnosis including, but not limited to a stage 4 pressure ulcer (the most severe type of pressure ulcer characterized by full-thickness tissue loss with exposed bone, tendon, or muscle) to the sacral region (located at the base of the spine).
Review of a physician's order dated 5/1/2025 revealed an order to clean the stage 4 pressure ulcer with vashe wash (a wound cleanser), pack with alginate AG (silver; an absorbent wound treatment) then apply a collagen sheet (a wound dressing that promotes wound healing by supporting a moist environment and stimulates new tissue growth) daily and as needed.
During a surveyor observation of Registered Nurse, Staff A, completing a dressing change of the resident's wound, on 5/7/2025 at 11:00 AM, Staff A put on a pair of gloves, removed the soiled dressing from the resident's wound and did not remove the soiled gloves or perform hand hygiene before applying the clean dressing to the resident's wound. Additionally, Staff A applied a collagen sheet that contained silver; not the collagen sheet that was ordered.
During a surveyor interview immediately following the above-mentioned observation, Staff A acknowledged that she did not remove the soiled gloves and did not perform hand hygiene after removing the soiled dressing. She further acknowledged she was wearing the same dirty gloves to apply the clean dressing to the resident's wound. Additionally, Staff A acknowledged that she did not apply the collagen sheet to the resident's wound that was ordered.
During a surveyor interview on 5/7/2025 at 1:10 PM with the Director of Nursing Services (DNS), she indicated that she would have expected Staff A to change her gloves, perform hand hygiene, and put on clean gloves before applying the clean dressing to the resident's wound. The DNS was unable to provide evidence that the physician's order for the wound dressing was followed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to maintain acceptable parameters of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight, for 2 of 6 resident reviewed, who experienced actual weight loss, Resident ID #s 17 and 23. Additionally, the facility failed to follow it's own policy relative to weight monitoring, for 3 of 6 residents reviewed, Resident ID #s 17, 22, and 23.
Findings are as follows:
Review of a facility policy titled Weight Monitoring states in part, .Accurate and timely measurement of weight changes in all residents is an important tool in assessing their nutritional status .Residents will be weighed weekly for 4 weeks, upon admission and readmission, then monthly .If there is a 5 lbs. [pounds] weight discrepancy (plus or minus) a reweight should be obtained .Significant weight changes will be reported to a physician .
1A. Record review revealed Resident ID #23 was re-admitted to the facility in January of 2025 with a diagnosis including, but not limited to, dementia.
Review of a care plan dated 1/20/2025 revealed the resident has a potential for nutritional decline with an intervention including, but not limited to, weigh as ordered.
Record review of hospital discharge paperwork dated 1/16/2025 revealed the resident weighed 179.1 pounds on 1/14/2025.
Additional record review revealed the resident weighed 179.0 lbs. on re-admission to the facility on 1/16/2025.
Record review revealed the following weights were obtained for Resident ID #23:
- 1/16/2025: 179 lbs.
- 2/6/2025: 163.8 lbs.
- 4/3/2025: 161.8 lbs.
- 5/2/2025: 154.6 lbs.
Record review revealed the resident experienced an 8.5% (15.2 lbs.) severe weight loss in less than one month from 1/16/2025 to 2/6/2025.
Record review revealed a progress note authored by Registered Dietitian (RD), Staff D which indicated that he had assessed the resident on 2/7/2025 following the above-mentioned severe weight loss. Further review of his note revealed that he believed the resident's weight of 179 lbs. obtained on 1/16/2025 was an error and did not implement any interventions.
Additional record review failed to reveal evidence that the physician was notified of Resident ID #23's severe weight loss, as indicated per the facility's policy.
Further record review revealed the resident continued to lose weight and had experienced an additional weight loss of 7.2 lbs. in one month, from 4/3/2025 to 5/2/2025, without the facility implementing any interventions.
Additional record review revealed a progress note dated 5/5/2025, authored by Staff D, that states in part, Weight: 154.6 lbs (5/2/25). No significant 1 or 6 month change. Slightly below recent usual body weight range. Tolerating meals with good intake. Appears adequately nourished. Monitor for restart of scheduled supplement.
During a surveyor interview with Staff D, on 5/8/2025 at 10:03 AM, he revealed that he assessed the resident on 2/7/2025 and did not implement any interventions at that time. He indicated that he felt s/he appeared adequately nourished and that the weight that was obtained on 1/16/2025 was an error. However, he was unable to provide evidence that Resident ID #23 was reweighed to verify the accuracy of the weight that was obtained on 1/16/2025, or to determine if interventions should have been implemented following the resident's documented severe weight loss on 2/6/2025. Additionally, he acknowledged he did not implement any interventions following his/her weight loss on 5/2/2025.
B. Record review revealed Resident ID #17 was admitted to the facility in April of 2025 with a diagnosis including, but not limited to, type 2 diabetes.
Record review of a care plan dated 4/14/2025 revealed the resident has the potential for a nutritional decline and a history of weight loss. Staff interventions include to obtain weights as ordered.
Record review of a physician's order for Resident ID #17 dated 4/14/2025 revealed to obtain weekly weights every Monday for 4 weeks.
Record review revealed the following weights were obtained for Resident ID #17:
- 4/14/2025: 155.0 lbs.
- 4/28/2025: 143.6 lbs.
- 5/2/2025: 143.0 lbs.
- 5/4/2025: 148.2 lbs.
- 5/5/2025: 143.0 lbs.
Record review revealed the resident experienced a 7.74% (12 lbs.) severe weight loss in less than one month from 4/14/2025 to 5/5/2025.
Record review failed to reveal evidence that any interventions were implemented by the facility after the resident's 7.74% severe weight loss, in less than one month. Additional record review failed to reveal evidence that the physician was notified of the severe weight loss, per the facility's policy.
2A. Record review failed to reveal evidence that Resident ID #23's weights were obtained weekly on 1/23/2025 and 1/30/2025 as indicated in the facility's policy.
Additional record review failed to reveal evidence that the facility reweighed the resident for a 5 lbs. weight discrepancy on 2/6/2025.
B. Record review failed to reveal evidence that Resident ID #17's weight was obtained upon admission on [DATE], as indicated in the facility's policy. The first weight was obtained two days after admission, on 4/14/2025.
Additional record review failed to reveal evidence that a weekly weight was obtained on 4/21/2025, as ordered.
C. Record review revealed Resident ID #22 was admitted to the facility in June of 2021 with diagnoses including, but not limited to [NAME]-[NAME] disease (a rare progressive inherited neurogenerative disorder that primarily affects the brain), adult failure to thrive and dysphagia (difficulty swallowing).
Record review revealed the following weights were obtained for Resident ID #22:
- 1/16/2025: 90.8 lbs.
- 2/6/2025: 85.8 lbs.
- 2/16/2025: 85.8 lbs.
- 2/24/2025: 83.6 lbs.
- 3/7/2025: 81.2 lbs.
- 3/24/2025: 87.0 lbs.
Record review revealed the resident experienced a weight loss of 5 lbs. (5.5%) on 2/6/2025 from the previous weight that was obtained on 1/16/2025. Record review failed to reveal evidence that the resident was reweighed after a 5 lbs. weight discrepancy was observed, until 2/16/2025, one month later.
Record review revealed a physician's order dated 2/16/2025 for weekly weights x 4.
Record review failed to reveal evidence that a weekly weight was obtained on 3/16/2025, as ordered.
During a surveyor interview on 5/8/2025 at 1:33 PM with Registered Nurse, Staff B, she was unable to provide evidence of the above-mentioned missing weights.
During surveyor interviews on 5/7/2025 at 1:18 PM and at 1:42 PM with the Director of Nursing Services (DNS), she was unable to provide evidence that interventions had been implemented to address Resident ID #s 17 and 23's severe weight losses.
Additionally, the DNS was unable to provide evidence that Resident ID #s 17, 22, and 23's weekly weights were obtained as ordered, or that the facility's Weight Monitoring policy was followed.
During a surveyor interview on 5/8/2025 at 9:00 AM and at 9:15 AM with the Medical Director, he indicated that he was not made aware of Resident ID #s 17 and 23's severe weight loss, but would have expected to have been notified, as per the facility's policy. Additionally, the Medical Director indicated that he would expect the residents' weights to be obtained as ordered and per the facility's policy.
As the facility's Registered Dietitian failed to identify severe weight losses, no interventions were put in place to maintain acceptable parameters of nutritional status, such as usual body weight, for two residents, Resident ID #s 17 and 23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and ...
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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 and label drugs and biologicals in accordance with currently accepted professional principles for 2 of 2 medication carts observed.
Findings are as follows:
Review of a facility's policy titled Storage and Expiration Dating of Medications and Biologicals dated [DATE], states in part, .Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container when the medication has a shortened expiration date once opened .
1a. During a surveyor observation on [DATE] at 9:40 AM of the Portside Unit medication cart, in the presence of Registered Nurse (RN), Staff A, revealed the following:
- One Breo Ellipta Inhaler, opened with a date of 3/22. Review of the manufacturer's instructions indicate to discard the inhaler 6 weeks after opening.
During a surveyor interview with Staff A immediately following the above observation, she acknowledged that the inhaler had a date of 3/22, and that the inhaler was expired.
1b. During a surveyor observation on [DATE] at 8:57 AM of the Starboard Unit medication cart, in the presence of RN, Staff C, revealed the following:
-One Treligy Ellipta inhaler, opened and not dated. Review of the manufacturer's instructions indicate to discard the inhaler 6 weeks after opening.
-One Breyna Inhaler, opened and not dated. Review of the manufacturer's instructions indicate to discard the inhaler 3 months after opening.
-One Flovent inhaler, opened and not dated. Review of the facility policy indicates medications should be dated when opened.
- One Fluticasone propionate nasal spray, opened and not dated. Review of the manufacturer's instructions indicate to discard the nasal spray after using 120 sprays.
- Two Albuterol Inhalers, opened and not dated. Review of the facility policy indicates medications should be dated when opened.
During a surveyor interview with Staff C immediately following the above observation, she acknowledged that the above-mentioned medications were opened and not dated.
During a surveyor interview on [DATE] at approximately 4:00 PM with the Director of Nursing Services (DNS), she was unable to provide evidence the expired Breo Ellipta inhaler was not removed from the Portside Unit medication cart. Additionally, the DNS was unable to provide evidence the above-mentioned medications were dated when opened.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
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 provide a dietary menu that meets the nutritional needs of residents in accordance with established natio...
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Based on record review and staff interview, it has been determined that the facility failed to provide a dietary menu that meets the nutritional needs of residents in accordance with established national guidelines.
Findings are as follows:
1. Record review of the facility's diet manual titled, Maryland Department of Health and Mental Hygiene Diet Manual for Long Term Care Residents 2014 Revision, failed to meet the current established national guidelines (the United States Department of Agriculture (USDA) establishes and reviewes national guidelines every 5 years, to promote health, meet nutrient needs and provide guidance for healthy dietary patterns by life stages). The diet manual provided to the surveyor by the facility was from 2005 to 2010, indicating the guidelines were outdated as the current national guidelines were revised in 2020 with new recommendations.
During a surveyor interview with Registered Dietitians, Staff D and E on 5/8/2025 at 10:03 AM, they revealed that the facility's menus are generated from corporate each month and each facility's dietitian is responsible for reviewing the menu for nutritional adequacy. Additionally, they indicated they use the Maryland Diet Manual, 2014 Revision as a standard to review menus each month.
2. Record review of a document published by the USDA, revealed that a standardized recipe is utilized in a food service establishment to ensure the nutritional values per serving are valid and consistent, as the same products and quantities are being used every time the recipe is produced.
Record review of the menu served from 5/4/2025 through 5/10/2025 failed to reveal evidence that standardized recipes were on file. Further record review revealed a binder titled, Apple Rehab Recipes Spring/Summer Menus 2016, containing several recipes from Allrecipes.com and other internet sources, which did not contain caloric or nutrient information.
During a surveyor interview with the Food Service Director on 5/8/2025 at 11:50 AM, he revealed that he does not use standardized recipes when preparing meals for residents.
During a surveyor interview via telephone with the Director of Nutrition Services on 5/8/2025 at 12:36 PM, she revealed that she would expect the dietitian at each facility to follow the company's diet manual, Maryland Department of Health and Mental Hygiene Diet Manual for Long Term Care Residents 2014 Revision, to review menus for nutritional adequacy. She was unaware that the facility's diet manual was out of date. Additionally, she indicated that standardized recipes are not used in the facility. Further, she was unable to provide evidence that the facility's menus met the nutritional needs of residents in accordance with established national guidelines.
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 food is stored and distributed in accordance with professional standards for food service safety, relative to the main kitchen and 2 of 2 units observed during meal service.
Findings are as follows:
1. Record review of the United States (U.S.) Food and Drug Administration (FDA) Food Code, 2022 Edition, section 4-601.11 states in part, .Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris .
Record review of the U.S. FDA Food Code, 2022 Edition, Section 3-501.17 states in part, .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees Celsius or 41 degrees Fahrenheit or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 .
During the initial tour of the main kitchen with the Food Service Director (FSD) on 5/5/2025 at 9:24 AM, the following was observed in the walk-in refrigerator:
- One 46 ounce (oz.) bottle of nectar thickened orange juice, opened and not dated. Manufacturer's instructions indicate to use the product within 10 days once opened.
- One 46 oz. bottle of nectar thickened apple juice, opened and dated 4/6. Manufacturer's instructions indicate to use the product within 10 days once opened.
Additional observations of the main kitchen during the initial tour revealed the ceiling of the microwave had clumps of yellow food matter stuck to it.
During a surveyor interview immediately following the above observations with the FSD, he acknowledged that the juices should be marked with the date they are opened and discarded after 10 days. Additionally, he acknowledged that the microwave had food debris inside.
2. Record review of the U.S. FDA Food Code, 2022 Edition, section 3-301 states in part, .Food employees shall minimize bare hand and arm contact with exposed food that is not in a ready-to-eat form .
During a follow up visit to the kitchen during lunch preparation on 5/6/2025 at 11:47 AM, Cook, Staff F, was observed handling two slices of white bread and sliced cheese, assembling a sandwich without using gloves.
During a surveyor interview with the FSD immediately following the observation, he acknowledged that Staff F should have been wearing gloves prior to handling food and discarded the sandwich.
3. Record review of the U.S. FDA Food Code, 2022 Edition, section 3-307.11 states in part, .Food shall be protected from contamination .
During surveyor observations of the breakfast meal service on 5/6/2025 at 8:00 AM, a steam table cart was stationed at the beginning of the Portside Unit. Breakfast plates containing hot food were carried from the steam table to resident rooms, up to approximately 50 feet away.
During surveyor observations of the lunch meal service on 5/7/2025 at 11:59 AM, a steam table cart was stationed adjacent to the clean linen closet on the Portside Unit. Uncovered lunch plates containing hot food were carried from the steam table to room [ROOM NUMBER] (the furthest resident room from the steam table) approximately 42 feet from the right, and to rooms approximately 37 feet away from the left by Dietary Aides, Staff L and M.
During surveyor observations of the lunch meal service on 5/7/2025 at 12:45 PM, a steam table cart was stationed adjacent to room [ROOM NUMBER] on the Starboard Unit. Uncovered lunch plates containing hot food were carried from the steam table down to rooms approximately 68 feet down the hallway to room [ROOM NUMBER] (the furthest resident room from the steam table) by Staff L and M.
During a surveyor interview with Staff L and M, immediately following the above observations, they acknowledged that they were carrying uncovered plates of hot food down the hall to serve residents. Additionally they reavealed that plates of food are only covered if the residents aren't going to be eating their meals right away.
During a surveyor interview with the FSD on 5/7/2025 at 12:57 PM, he indicated that carrying uncovered meals down the halls has been the facility's practice. He was unable to provide evidence that the meals were being protected from potential contamination.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0567
(Tag F0567)
Minor procedural issue · This affected multiple residents
Based on record review, and resident and staff interviews, it has been determined that the facility failed to obtain written authorization for residents whom the facility is holding personal funds for...
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Based on record review, and resident and staff interviews, it has been determined that the facility failed to obtain written authorization for residents whom the facility is holding personal funds for 2 of 5 residents reviewed, Resident ID #s 4 and 12.
Findings are as follows:
1. Record review of Resident ID #4 revealed a personal funds balance report dated 5/5/2025 indicating the personal funds account had a balance of $1.86.
Review of the Personal Needs Fund Authorization document revealed the resident had signed the document and it was witnessed on 9/26/2024, directing that his/her personal needs funds be given to him/her.
Further record review failed to reveal evidence of a Resident Personal Needs Authorization form authorizing the facility to hold the resident's funds.
2. Record review of Resident ID #12 revealed a personal funds balance report dated 5/5/2025 indicating the personal funds account had a balance of $138.13.
Review of the Personal Needs Fund Authorization document revealed the resident had signed the document and it was witnessed on 7/21/2021 directing that his/her personal needs funds be given directly to him/her.
Further record review failed to reveal evidence of a Resident Personal Needs Authorization form authorizing the facility to hold the resident's funds.
During a surveyor interview with the Business Office Manager on 5/6/2025 at 1:05 PM, she was unable to provide evidence that the Resident Personal Needs Authorization forms were followed for Resident ID #s 4 and 12.
May 2024
9 deficiencies
1 Harm
SERIOUS
(H)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected multiple residents
Based on surveyor observation, 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 and...
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Based on surveyor observation, 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 and weight monitoring for 7 of 8 residents reviewed, Resident ID #s 4, 10, 12, 17, 38, 41 and 44.
Findings are as follows:
Review of the facility's undated policy titled, Weight Monitoring, states in part,
PURPOSE: To establish a reference for a resident's body weight that is realistic and individually appropriate and to effectively monitor and communicate weight changes.
CLINICAL POLICY:
.Accurate and timely measurement of weight changes in all residents is an important tool in assessing their nutritional status.
Residents will be weighed weekly for 4 weeks on admission and readmission then monthly, unless otherwise indicated by the MD [Medical Doctor] order and/or recommended by the RD [Registered Dietitian].
The following procedure is intended to assure that weight changes are identified and assessed as needed.
PROCEDURE:
.2. Residents will be weighed during the first seven days of the month and upon admission every week x 4 weeks. It is the responsibility of the charge nurse to assure that weights are taken.
3. Weights will be taken ad recorded on the weight sheet .or in Point Click Care. If there is a 5 lb. [pound] weight discrepancy (plus or minus) a reweight should be obtained. The Charge Nurse should then review the weight and compare this to the previous weights to determine a 5% weight change in 30 days or 10% change in 180 days.
4. Significant weight changes will be reported to:
a. Physician/APRN [Advance Practice Registered Nurse]
b. Responsible party
c. RD
d. DNS [Director of Nursing] .
e. Care Plan Coordinator
5. Residents who have experienced significant weight loss will be reviewed by the RD to evaluate the need for changes in the plan of care. The resident's care plan will be updated accordingly.
During a surveyor interview with Registered Nurse Practitioner (RNP), Staff E, on 5/22/2024 at 9:29 AM, she revealed her expectation is that weights will be obtained upon admission and then weekly for 4 weeks. Staff E also revealed her expectation is that if those weekly weights are stable, staff will then obtain monthly weights, unless there is a specific physician's order that states otherwise.
During a surveyor interview with the Staff Development Coordinator, Registered Nurse, Staff D, on 5/21/2024 at 2:59 PM, she revealed if residents do not have a physician's order for obtaining weights, staff are to follow the facility's policy and procedure.
During a surveyor interview with the DNS on 5/22/2024 at 9:02 AM, she revealed if there is a 5 lb. weight discrepancy (plus or minus), a reweigh should be obtained within 1 day. Additionally, she revealed if the resident is unavailable or refusing to be reweighed, staff should try to reweigh the resident on the following day.
1. Record review revealed Resident ID #12 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, Parkinson's disease (a chronic and progressive movement disorder that initially causes tremors, stiffness or slowing of movement) dementia and dysphagia (difficulty swallowing), and s/he has a gastrostomy tube (G-tube, a tube that delivers nutrition directly into the stomach).
Record review revealed the resident has a physician's order dated 4/17/2024 for, NPO [nothing by mouth] diet .
Further record review revealed the resident has a physician's order dated 4/18/2024 for, Jevity 1.5 Cal/Fiber Oral Liquid (Nutritional Supplement) give 474 ml [milliliter] via G-Tube three times a day for nutrition flush with 250ml water post jevity .
Review of care plan revealed a focus dated 4/22/2024 which states in part, I have the potential for a nutritional decline R/T [related to] multiple problems .dysphagia, need for tube feeding . with interventions including, but not limited to, .weigh me as ordered .
Record review of the resident's weights revealed the following:
4/17/2024 179 lbs.
4/24/2024 176.3 lbs.
4/26/2024 153.9 lbs.
5/2/2024 168 lbs.
Record review of the resident's weight record revealed the resident experienced a weight loss of 22.4 lbs. (12.7%) on 4/26/2024 from his/her previous weight obtained on 4/24/2024.
Record review revealed the resident experienced a weight gain of 14.1 lbs. (9.6%) on 5/2/2024 from his/her previous weight obtained on 4/26/2024.
Record review revealed the resident experienced a weight loss of 14.7 lbs. (8.7%) on 5/21/2024 from his/her previous weight obtained on 5/2/2024.
Additionally, the record failed to reveal evidence that the resident was reweighed when s/he had a weight loss/gain of 5 lbs. or more, per the facility's policy on 4/26/2024 and 5/2/2024.
Subsequently, on 5/21/2024 at approximately 4:00 PM, the facility staff was asked to provide a weight for Resident ID #12, which was 153.3 lbs.
Further review of the weight record revealed that the resident experienced an overall weight loss of 25.7 lbs. (14.3%) from his/her admission weight of 179 lbs. on 4/17/2024 to his/her current weight obtained on 5/21/2024 of 153.3 lbs., (approximately 1 month).
Record review of the care plan, failed to reveal evidence of any new interventions implemented to prevent the resident from further weight loss.
During a surveyor interview with the RD on 5/21/2024 at 11:15 AM, he revealed that he reviewed the resident's weight record on 4/26/2024 and asked staff to obtain a reweigh. The RD further revealed there was no reweigh documented and he did not push them to obtain a reweigh to verify the weight change. Additionally, he did not add any interventions as the resident is receiving nutrition via the G-Tube. Further, the RD revealed that the facility's policy is to obtain weights upon admission and weekly for 4 weeks and if the weight is stable, staff will obtain monthly weights thereafter.
During a surveyor interview with the Minimum Data Set Coordinator on 5/21/2024 at 12:31 PM, she revealed she was unaware of the above-mentioned weight loss. Additionally, she was unable to provide evidence of any new interventions added to the resident's care plan for nutrition.
During a surveyor interview with the RNP, Staff E, on 5/21/2024 at 12:35 PM, she revealed she is aware of the resident's weight loss and is waiting for the RD to assess the resident and make any recommendations. Staff E further revealed when a weight loss is identified, she will usually communicate with staff to have the RD assess the resident or she will ask staff to enter the weight loss in the Dietitian Communication log for the RD to review. Additionally, Staff E revealed due to Resident ID #12 having a G-tube, she wants to ensure the resident is receiving enough nutrition/calories. Further, she expects staff to continue to monitor the resident's weight, especially for a recently admitted resident or a resident with a weight discrepancy.
During a surveyor interview with the DNS on 5/22/2024 at 4:00 PM, she was unable to provide evidence that the resident was reweighed per the facility policy or that any new interventions were implemented to prevent the resident from having further weight loss.
2. Record review revealed Resident ID #4 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (chronic lung disease) and atrial fibrillation (an irregular and often very rapid heart rhythm).
Review of a care plan dated 12/11/2023, .I have the potential for a nutritional decline R/T multiple medical problems . with interventions including, but not limited to, .weigh me as ordered .
Record review of the resident's weights revealed the following:
1/16/2024 141.6 lbs.
2/19/2024 154.9 lbs.
Record review of the resident's weight record revealed the resident experienced a weight gain of 13.3 lbs. on 2/19/2024 from his/her previous weight obtained on 1/16/2024. Further, the record failed to reveal evidence of a reweigh when s/he had a weight loss/gain of 5 lbs. or more, per the facility's policy.
Additionally, the record failed to reveal evidence of a weight after 2/19/2024, as per the facility policy which indicates monthly weights will be obtained in the first 7 days of the month, until it was brought to the facility's attention on 5/21/2024. Subsequently, the resident was weighed on 5/21/2024 at approximately 3:30 PM with a weight of 153.4 lbs.
During a surveyor interview with the DNS on 5/22/2024 at 10:04 AM, she revealed the resident was admitted on hospice services and that staff usually do not obtain monthly weights for hospice residents, although, the facility's policy does not specify. Additionally, the DNS was unable to provide evidence of a physician's order to discontinue the resident's weights and she was unable to provide his/her monthly weights, after February of 2024.
3. Record review revealed Resident ID #10 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, Alzheimer's Disease, paraplegia (paralysis of the legs and lower body), unstageable pressure ulcer (a full-thickness injury with a wound base covered by a layer of dead tissue) to the left buttocks and hypothyroidism (abnormally low activity of the thyroid gland).
Record review of the care plan revised on 4/8/2024, revealed the resident has the potential for a nutritional decline related to a history of multiple medical problems, including recent hospitalization with interventions including, but not limited to, weigh him/her as ordered.
Review of the resident's weights revealed the following:
-3/23/2024 130.0 lbs.
-3/25/2024 124.4 lbs.
-4/1/2024
117.6 lbs.
-4/1/2024
117.8 lbs.
-4/2/2024
117.6 lbs.
-4/8/2024
120.2 lbs.
-4/15/2024 122.2 lbs.
Record review of the resident's weight record revealed the resident experienced a weight loss of 5.6 lbs. on 3/25/2024 from his/her previous weight obtained on 3/23/2024. Additionally, the record failed to reveal evidence of a reweigh when s/he had a weight loss/gain of 5 lbs. or more, per the facility's policy.
Further review failed to reveal evidence of a monthly weight for May 2024, per the facility policy, which indicates monthly weights will be obtained in the first 7 days of the month.
During a surveyor interview with the DNS on 5/23/2024 at approximately 8:30 AM, she was asked to provide a weight for Resident ID #10. Subsequently, the resident was weighed that morning with a weight of 119 lbs.
During an interview with the DNS on 5/22/2024 at 11:30 AM, she was unable to explain why the resident was not reweighed after s/he lost 5.6 lbs. and she would expect a reweigh to be obtained within 24 hours. Additionally, she was unable to explain why there was no weight obtained in May of 2024 and she further revealed she would expect the weight policy to be followed.
4. Record review revealed Resident ID #17 was admitted to the facility in June of 2021 with diagnoses including, but not limited to, vascular dementia and high cholesterol.
Record review of the care plan initiated on 6/14/2021 revealed the resident has the potential for a nutritional decline related to a history of multiple medical problems, including dementia and weight loss, with interventions including, but not limited to, weigh him/her as ordered.
Record review of the resident's weight record revealed the following:
-1/4/2024
182.2 lbs.
-2/2/2024 163.8 lbs.
-2/5/2024
182.2 lbs.
-4/2/2024
162.5 lbs.
-4/8/2024
171.9 lbs.
-5/13/2024 177.2 lbs.
Record review of the resident's weight record revealed the resident experienced a weight loss of 18.4 lbs. on 2/2/2024 from his/her previous weight obtained on 1/4/2024.
Record review revealed the resident experienced a weight loss of 19.7 lbs. (10.8%) on 4/2/2024 from his/her previous weight obtained on 2/5/2024.
Record review revealed the resident experienced a weight gain of 9.4 lbs. (5.78%) on 4/8/2024 from his/her previous weight obtained on 4/2/2024.
Record review revealed the resident experienced a weight gain of 5.3 lbs. (3%) on 5/13/2024 from his/her previous weight obtained on 4/8/2024.
Additionally, the record failed to reveal evidence that the resident was reweighed when s/he had a weight loss/gain of 5 lbs. or more, per the facility's policy on 4/2/2024, 4/8/2024 and 5/13/2024. Additionally, the record failed to reveal evidence of a monthly weight obtained in March 2024.
During a surveyor interview on 5/22/2024 at 9:31 AM with RNP, Staff E, she reviewed the above-mentioned weights and revealed there were large fluctuations in the resident's weights and indicated the resident should have been reweighed the day the weight fluctuations were identified.
During a surveyor interview on 5/22/2024 at 10:53 AM with the DNS, she could not explain why a reweigh was not obtained when the resident had a 5 lb. or greater weight loss/gain and she further revealed she would expect the reweigh to be obtained within 24 hours. Additionally, she acknowledged that there was no weight obtained in March 2024 and would expect the policy to be followed.
5. Record review revealed Resident ID #38 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, dementia and hypertension (high blood pressure).
Record review revealed a care plan dated 4/8/2024 for .I have the potential for a nutritional decline R/T multiple medical problems ., with interventions including but not limited to .weight me as ordered . Further review of the care plan revealed s/he is at risk for cardiac compensation related to hypertension with interventions including but not limited to .Encourage weight loss and/or maintaining a healthy weight in accordance with height .
Record review of the resident's weight record revealed the following:
4/21/2024 127.1 lbs.
4/28/2024 133.0 lbs.
Record review revealed the resident experienced a weight gain of 5.9 lbs. on 4/28/2024 from his/her previous weight obtained on 4/21/2024. Additionally, the record failed to reveal evidence that the resident was reweighed when s/he had a weight loss/gain of 5 lbs. or more, per the facility's policy.
Further record review failed to reveal evidence that a monthly weight was obtained in May 2024.
Record review failed to reveal evidence of new interventions implemented to prevent the resident from further weight gain.
During a surveyor observation of Resident ID #38 in the presence of Registered Nurse, Staff C, on 5/22/2024 at 1:25 PM, she acknowledged the resident had bilateral lower leg edema (swelling).
During a surveyor interview with the DNS on 5/22/2024 at 10:00 AM, she was unable to provide evidence that the reweigh was obtained when the resident had a weight loss/gain of 5 lbs. or more per the facility's policy. Additionally, the DNS was unable to provide evidence that the monthly weight for May 2024 was obtained within the first seven days of the month per the facility's policy. Furthermore, the DNS was unable to provide evidence that new interventions were implemented to prevent the resident from further weight gain.
6. Record review revealed Resident ID #41 was readmitted to the facility in April of 2024 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (chronic lung disease) and hypertension.
Record review of the physician's orders revealed an order dated 4/13/2024 for weekly weights for 4 weeks, then monthly.
Record review of the resident's weight record revealed the following:
-4/6/2024 141.8 lbs.
-4/15/2024 135.0 lbs.
-4/21/2024 140.6 lbs.
-5/13/2024 133.2 lbs.
Record review of the resident's weights failed to reveal evidence that the weekly weights were obtained for 2 of 4 opportunities, on 4/28/2024 and 5/5/2024:
Record review revealed the resident experienced a weight loss of 6.8 lbs. on 4/15/2024 from his/her previous weight obtained on 4/6/2024.
Record review revealed the resident experienced a weight gain of 5.6 lbs. on 4/21/2024 from his/her previous weight obtained on 4/15/2024.
Record review revealed the resident experienced a weight gain of 7.4 lbs. on 5/13/2024 from his/her previous weight obtained on 4/21/2024.
Additionally, the record failed to reveal evidence that the resident was reweighed when s/he had a weight loss/gain of 5 lbs. or more, per the facility's policy on 4/15/2024, 4/21/2024 and 5/13/2024.
During a surveyor interview on 5/22/2024 at 9:45 AM with the DNS, she acknowledged that a reweigh was not obtained when the resident had a weight loss/gain of 5 lbs. or more per the facility's policy.
7. Record review revealed Resident ID #44 was admitted to the facility in November of 2023 with diagnoses including, but not limited to, hypertension, gastroesophageal reflux disease (GERD, a condition where the stomach acid repeatedly flows back up into the esophagus, causing irritation and discomfort) and chronic kidney disease.
Record review revealed the resident has a care plan initialed on 11/29/2023 for .I have the potential for a nutritional decline R/T multiple medical problems ., with interventions including, but not limited to, .weigh me as ordered .
Record review of the resident's weight record revealed the following:
11/18/2023 135.0 lbs.
12/12/2023 131.1 lbs.
1/4/2024 125.6 lbs.
3/1/2024 128.6 lbs.
4/2/2024 123.4 lbs.
4/11/2024 123.4 lbs.
Record review revealed the resident experienced a weight loss of 5.5 lbs. on 1/4/2024 from his/her previous weight obtained on 12/12/2023.
Record review revealed the resident experienced a weight gain of 5.2 lbs. on 4/2/2024 from his/her previous weight obtained on 3/1/2024.
Additionally, the record failed to reveal evidence that the resident was reweighed when s/he had a weight loss/gain of 5 lbs. or more, per the facility's policy on 1/4/2024 and 4/2/2024.
Further record review failed to reveal evidence that a monthly weight was not obtained in May 2024.
Record review failed to reveal evidence of any new interventions implemented to prevent the resident from further weight loss.
During a surveyor interview with the DNS on 5/22/2024 at 4:00 PM, she was unable to provide evidence that the reweighs were obtained or that a monthly weight for May 2024 was obtained per the facility policy. Additionally, the DNS was unable to provide evidence that new interventions were implemented to prevent the resident from further weight loss.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to implement a comprehensive person-centered care plan for each resident to meet a res...
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Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical and nursing needs that are identified in the comprehensive assessment for 1 of 1 resident reviewed with lower leg edema (swelling), Resident ID #38.
Findings are as follows:
Record review revealed the resident was admitted to the facility in April of 2024 with diagnoses including, but not limited to, Alzheimer's disease and hypertension (high blood pressure).
Review of the care plan initiated on 4/8/2024, revealed the resident experienced lower extremity edema, with interventions including, but not limited to, apply ACE wraps (compression bandage) to both lower legs in the morning and remove the ACE wraps at bedtime.
Surveyor observations of the resident on 5/20/2024 at 1:16 PM and 5/22/2024 at 12:40 PM, failed to reveal evidence that the resident was wearing his/her ACE wraps, instead s/he was observed wearing non skid socks.
During a surveyor interview with the resident on 5/22/2024 at approximately 12:45 PM, the resident revealed s/he has been wearing the non skid socks since s/he has been admitted to the facility. The resident further revealed if s/he was provided the ACE wraps, s/he would wear them.
During a surveyor interview with Nursing Assistant (NA), Staff B, on 5/22/2024 at 12:46 PM, she revealed that she is the resident's primary NA and that the resident has been wearing the non skid socks since s/he was admitted to the facility in April of 2024. Additionally, she was unaware that the resident had a care plan for ACE wraps.
During a surveyor interview with Registered Nurse, Staff C, on 5/22/2024 at 1:18 PM, she revealed that she was unaware of the resident's care plan for bilateral leg edema to apply the ACE wraps every morning and to remove them at bedtime.
During a surveyor interview with the Director of Nursing Services on 5/22/2024 at 4:31 PM, she acknowledged that the above care plan for the resident's lower leg edema had not been implemented.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and services in accordance with professional standards of practic...
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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 services in accordance with professional standards of practice, relative to following physician's orders for weekly body audits for 1 of 7 residents reviewed, Resident ID #12.
Findings are as follows:
According to Mosby's 4th Edition, Fundamentals of Nursing page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
Record review revealed the resident was admitted to the facility in April of 2024 with diagnoses including, but not limited to, Parkinson's disease ( a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement) and dementia.
Further record review revealed a physician's order dated 4/17/2024 for Body Audit on admission and Q [every] week by Licensed Nurse on Shower Day. Document on Body Audit Form .
Record review of the Body Audit form failed to reveal evidence that the weekly body audits were completed and documented on the Body Audit forms for 4 out of 5 opportunities, between 4/17/2024 through 5/21/2024.
During a surveyor interview with Registered Nurse, Staff C, on 5/22/2024 at 8:37 AM, she acknowledged the weekly body audits were not completed and documented on the Body Audit Forms, per the physician's order.
During a surveyor interview with the Director of Nursing Services on 5/23/2024 at 8:49 AM, she was unable to provide evidence that the weekly body audits were completed and documented on the Body Audit forms, as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that the irregularities identified by the Clinical Consultant Pharmacist during the monthly pharma...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that the irregularities identified by the Clinical Consultant Pharmacist during the monthly pharmacist Medication Regimen Review (MRR) were acted upon for 2 of 2 residents reviewed, Resident ID #s 10 and 12.
Findings are as follows:
1. Record review for Resident ID #10 revealed a physician's order dated 5/3/2024 for Seroquel (an antipsychotic medication that treats several kinds of mental health conditions) 25 mg (milligrams) daily in the morning, Seroquel 50 mg daily in the evening. Additional review revealed a physician's order dated 5/20/204 for Seroquel 25 mg PRN (as needed) once daily for anxiety.
Record review of the pharmacist's Consultation Report dated 4/19/2024 states in part, Recommendation: Please include the following guidance for Seroquel in the interdisciplinary care plan and ensure the following are monitored and documented in the medical record:
- Identify common behavioral expressions and describe how the behaviors impact the resident and others (e.g., increases resident distress, dangerous to the resident or others) .Implement and periodically reassess appropriate, individualized, person centered interventions, documenting the results.
- Communicate to the interdisciplinary team anything that may contribute to the observed behaviors (e.g., noise, hearing
deficit) .
- Perform ongoing monitoring for neuroleptic malignant syndrome (e.g., fever, muscle cramps, tremors, unstable blood pressure, delirium) .
- Monitor for metabolic complications such as weight gain, hyperlipidemia, and hyperglycemia.
- Monitor routinely for other medication specific side effects (e.g., anticholinergic effects, irregular heartbeat, falls, drowsiness, signs/symptoms of trans ischemic attack [a brief episode of neurological dysfunction resulting from an interruption in the blood supply to the brain]. or stroke).
Response required.
Record review for Resident ID #10 failed to reveal evidence that the Consultation Report, with noted irregularities, was reviewed and acted upon by the resident's provider. Additionally, the record failed to reveal evidence of ongoing monitoring for neuroleptic malignant syndrome, evidence of monitoring for metabolic complications, evidence of monitoring routinely for medication specific side effects or that the resident's behaviors were monitored and documented.
2. Record review for Resident ID #12 revealed a physician's order dated 4/27/2024 for Haloperidol (antipsychotic medication) 2 ml (milliliter) via peg tube (a feeding tube that is inserted into the stomach) twice daily. Additional review revealed a physician's order dated 5/16/2024 for Haloperidol 1 ml via peg tube every 8 hours PRN for increased restlessness.
Record review of the pharmacist's Consultation Report dated 4/19/2024 states in part, Recommendation: Please include the following guidance for Haloperidol in the interdisciplinary care plan and ensure the following are monitored and documented in the medical record:
- Identify common behavioral expressions and describe how the behaviors impact the resident and others (e.g., increases resident distress, dangerous to the resident or others).
- Implement and periodically reassess appropriate, individualized, person centered interventions, documenting the results.
- Communicate to the interdisciplinary team anything that may contribute to the observed behaviors (e.g., noise, hearing
deficit).
- Discuss with the prescriber the clinical appropriateness of a gradual dose reduction (at least quarterly)
- Perform ongoing monitoring for neuroleptic malignant syndrome (e.g., fever, muscle cramps, tremors, unstable blood pressure, delirium) .
- Monitor for metabolic complications such as weight gain, hyperlipidemia, and hyperglycemia.
- Monitor routinely for other medication specific side effects (e.g., anticholinergic effects, irregular heartbeat, falls, drowsiness, signs/symptoms of trans ischemic attack or stroke).
Response required.
Record review of Resident ID #12's care plan failed to reveal evidence that a care plan was developed relative to mood or behavior.
Further record review failed to reveal evidence that the Consultation Report, with noted irregularities, was reviewed and acted upon by the resident's provider. Additionally, the record failed to reveal evidence of ongoing monitoring for neuroleptic malignant syndrome, evidence of monitoring for metabolic complications, monitoring routinely for medication specific side effects or that the resident's behaviors were monitored and documented.
During a surveyor interview on 5/21/2024 at 12:40 PM and again on 5/22/2024 at 9:10 AM with the residents' provider, Registered Nurse Practitioner (RNP), Staff E, she was unsure if she had reviewed the above-mentioned consultation reports with the recommendations. Additionally, Staff E revealed she would expect that the pharmacist's recommendations would be followed. Lastly, she was unable to provide evidence that she reviewed the Consultation Reports.
During a surveyor interview on 5/22/2024 at 12:34 PM with the Director of Nursing Services, she was unable to provide evidence that the pharmacy consultation reports were reviewed by the provider and revealed the pharmacy medication irregularity reports are placed in the provider's folder for review.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to store drugs and biological...
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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 drugs and biologicals in accordance with currently accepted professional principles for 1 of 1 medication room observed.
Findings are as follows:
Review of a facility policy titled, Storage and Expiration Dating of Medications, Biological's revealed in part, .Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened .
Surveyor observation on [DATE] at 12:20 PM of the medication storage room in the presence of Registered Nurse, Staff C, revealed the following:
-1 vial of tuberculin purified protein derivative (used to test for the diagnosis of tuberculosis) opened and undated. Manufacturer's instructions states, vial once entered should be discarded after 30 days.
-1 bottle of lorazepam intensol (a medication used to treat anxiety) 2 milligram/milliliter (mg/ml) unopened with a manufacturer expiration date of [DATE].
-1 bottle of lorazepam intensol 2 mg/ml unopened with a manufacturer expiration date of [DATE].
-1 bottle of lorazepam intensol 2 mg/ml opened, with the open date of [DATE] documented on the box. Manufacturer's instructions states, discard opened bottle after 90 days.
During a surveyor interview immediately following the above observation, Staff C acknowledged that the vial of tuberculin purified protein derivative was open and undated. She further revealed that the above lorazepam intensol bottles were expired and could not explain why they were not discarded.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide a safe and sanitary environment to help prevent the transmission of infecti...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide a safe and sanitary environment to help prevent the transmission of infections related to disinfecting blood glucose meters (a device used to monitor blood glucose) for 1 of 1 resident observed, Resident ID #28. Additionally, the facility failed to help prevent the transmission of infections related to Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) for 4 of 5 residents reviewed, Resident ID #'s 4, 12, 46, and 152.
Findings are as follows:
Record review of an undated facility policy titled, .Blood Glucose Monitoring Via Glucometer/Accu-Check revealed in part, .Points to keep in mind .
1. All components that come into contact with blood samples should be considered to be biohazards capable of transmitting viral diseases between patients and healthcare professionals .4. The meter should be cleaned and disinfected after use on each patient with any one of any EPA approved disinfectants and/or any of the ones listed below [Manufacturer Clorox] .Dispatch Hospital Cleaner Disinfectant with bleach, Clorox Healthcare Bleach Germicidal wipes, Clorox Healthcare Hydrogen Peroxide Cleaner .[Manufacturer PDI] .Super Sani Cloth germicide .[Manufacturer Medline] .Medline Micro-Kill Disinfecting, deodorizing, cleaning wipes with alcohol .5. Cleaning and Disinfecting Using either the Clorox OR PDI OR Medline product
a. Use two wipes (Clorox OR PDI OR Medline) use the first wipe for cleaning the glucometer and the second wipe for disinfecting the strip/meter site .
Surveyor observation on 5/20/2024 at approximately 11:45 AM during the medication administration task with Registered Nurse, Staff C, revealed the following:
Staff C obtained Resident ID #28's blood sugar with a blood glucose meter. After obtaining the resident's blood sugar, Staff C proceeded to clean the glucometer with an alcohol wipe and placed the glucometer into a basket filled with clean supplies including lancets and alcohol wipes, on the medication cart.
During a surveyor interview immediately following the observation with Staff C, she revealed that the glucometers are utilized for more than one resident. She further revealed that it is her practice to use alcohol wipes to clean the glucometer after each use.
Record review of the May 2024 Medication Administration Record revealed Staff C obtained the resident's blood sugar on the following dates and times:
-5/2/2024 at 7:30 AM and 11:30 AM
-5/3/2024 at 7:30 AM and 11:30 AM
-5/6/2024 at 7:30 AM and 11:30 AM
-5/8/2024 at 7:30 AM and 11:30 AM
-5/9/2024 at 7:30 AM and 11:30 AM
-5/12/2024 at 7:30 AM and 11:30 AM
-5/14/2024 at 7:30 AM and 11:30 AM
-5/20/2024 at 7:30 AM and 11:30 AM
During a surveyor interview on 5/20/2024 at approximately 2:30 PM with the Director of Nursing Services (DNS), she acknowledged that the glucometer is used for more than one resident. Additionally, she could not provide evidence that the glucometer was disinfected per the facility policy.
2. Review of the facility's policy dated 4/1/2024 for Enhanced Barrier Precautions [EBP] states in part, .The facility will implement enhanced barrier precautions to include any resident with an indwelling medical device (e.g .urinary catheters, feeding tube .Appropriate signage for EBP will be visible).
During surveyor observations during the initial tour on 5/20/2024 revealed the following residents were identified as requiring EBP. Additionally, the residents identified as requiring EBP, were not observed with the required visible signage.
a. Record review for Resident ID #4 revealed s/he was admitted to the facility in December of 2023 and has a supra-pubic tube (a drainage tube that is inserted into the bladder through the abdominal wall to continuously drain urine from the bladder).
b. Record review for Resident ID #12 revealed s/he was admitted to the facility in April of 2024 with a gastrostomy tube (G-tube, tube that delivers nutrition directly to stomach).
c. Record review for Resident ID #46 revealed s/he was admitted to the facility in March of 2024 and has a urinary catheter (a flexible tube that collects urine from the bladder and empties the urine into a drainage bag).
d. Record review for Resident ID #152 revealed s/he was admitted to the facility in April of 2024 and has a Peripherally Inserted Central Catheter (a thin, soft tube that is inserted into a vein in the arm, leg, or neck for long-term IV antibiotics, nutrition, medications, and blood draws).
Furthermore, during a surveyor observation of the medication administration task on 5/20/2024 at approximately 1:50 PM, revealed the DNS was administering a medication via the resident's G-tube without wearing a gown.
Additional surveyor observation on 5/21/2024 at approximately 4:00 PM, revealed Nursing Assistant, Staff I, and Registered Nurse Staff D, enter the resident's room to transfer the resident via a Hoyer lift (a transfer device) without donning ( putting on) a gown or gloves.
During a surveyor interview with the DNS on 5/23/2024 at approximately 9:00 AM, she was unable to explain why staff did not follow the infection control policy for EBP.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 2 residents reviewed with an indwelling catheter (a f...
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Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 2 residents reviewed with an indwelling catheter (a flexible tube that collects urine from the bladder and empties the urine into a drainage bag), Resident ID #4.
Findings are as follows:
According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing, Volume 2, 10th Edition, page 252 states, .the usual daily urine volume in the adult is 1-2 Liters or 1000-2000 cubic centimeters (cc). Additionally, page 1282 states, For patients with indwelling catheters, the nurse assesses the drainage system to ensure that it provides adequate urinary drainage. The color, odor, and volume of urine are also monitored. An accurate record of fluid intake and urine output provides essential information about the adequacy of renal function and urinary drainage .
Record review revealed the resident was admitted to the facility in December of 2023 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (chronic lung disease) and atrial fibrillation (an irregular and often very rapid heart rhythm).
Review of a care plan dated 1/6/2024, revealed the resident requires an SP (supra-pubic, a drainage tube that is inserted into the bladder through the abdominal wall to continuously drain urine from the bladder) tube related to urinary retention unresolved by other interventions. Further review of the care plan failed to reveal evidence of an intervention that includes measuring and recording the urinary output every shift.
Record review of the documented urinary output from 5/9/2024 through 5/21/2024, failed to reveal evidence that the output was measured and recorded each shift and only revealed documentation for 9 of 39 opportunities on the following dates and times:
-5/9/2024 at 2:36 PM, 0 milliliter (ml)
-5/10/2014 at 2:17 PM, 0 ml
-5/15/2024 at 6:39 AM, 100 ml
-5/15/2024 at 2:03 PM, 1450 ml
-5/17/2024 at 1:44 PM, 150 ml
-5/18/2024 at 2:00 PM, 0 ml
-5/19/2024 at 2:49 PM, 0 ml
-5/20/2024 at 1:59 PM, 0 ml
-5/21/2024 at 2:16 PM, 150 ml
During a surveyor interview with the Staff Development Coordinator, Staff D, on 5/22/2024 at 12:09 PM, she acknowledged that the resident's urinary output was not documented every shift.
During a surveyor interview with the Director of Nursing Services on 5/23/2024 at 8:51 AM, she was unable to provide evidence that the facility provided appropriate treatment and services for a resident with a urinary catheter, including documenting the urinary output to assess for adequacy of renal function.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
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 complete an annual performance review for every nurse aide (nursing assistant), at least once every 12 mo...
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Based on record review and staff interview, it has been determined that the facility failed to complete an annual performance review for every nurse aide (nursing assistant), at least once every 12 months, for 3 of 3 nursing assistants personnel records reviewed, Staff F, G, and H.
Findings are as follows:
Record review of the personnel files failed to reveal evidence that an annual performance evaluation was completed for the following nursing assistants:
-Staff F, Date of hire 11/23/2022
-Staff G, Date of hire 7/17/2007
-Staff H, Date of hire 12/4/2000
During a surveyor interview on 5/22/2024 at 3:25 PM with the Director of Nursing Services, she was unable to provide evidence of a completed performance evaluation wihtin the last 12 months for the above-mentioned employees.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0944
(Tag F0944)
Minor procedural issue · This affected most or all residents
Based on record review and staff interview, it has been determined that the facility failed to include a part of Quality Assurance Performance Improvement (QAPI) mandatory training, which outlines and...
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Based on record review and staff interview, it has been determined that the facility failed to include a part of Quality Assurance Performance Improvement (QAPI) mandatory training, which outlines and informs staff of the elements and goals of the facility's QAPI program for all staff.
Findings are as follows:
Record review failed to reveal evidence that the mandatory QAPI training was completed for the following staff:
-Registered Nurse (RN), Staff C - Date Of hire 8/6/2022
-RN, Staff P - Date of hire 8/3/2020
-RN, Staff Q - Date of hire 12/20/2017
-Nursing Assistant (NA), Staff F - Date of hire 11/23/2022
-NA, Staff G - Date of hire 7/17/2007
-NA, Staff H - Date of hire 12/4/2000
Further record review failed to reveal evidence that any current staff had received the mandatory QAPI training.
During a surveyor interview with the Director of Nursing Services on 5/23/2024 at 10:45 AM, she was unable to provide evidence that the facility provided the mandatory QAPI training to all staff.
Nov 2023
2 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
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Based on record review and resident and staff interviews, it has been determined that the facility failed to protect a resident's right to be free from physical and psychological abuse for 3 of 3 resi...
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Based on record review and resident and staff interviews, it has been determined that the facility failed to protect a resident's right to be free from physical and psychological abuse for 3 of 3 residents reviewed for staff to resident abuse, Resident ID #s 1, 2, and 3.
Findings are as follows:
Record review of a facility incident report submitted to the Rhode Island Department of Health (RIDOH), dated 11/16/2023, revealed allegations of physical abuse by Nursing Assistant (NA), Staff B, on behalf of Resident ID #s 1 and 2 and psychological abuse of Resident ID #3. The incident report indicated that the Administrator received the complaint on 11/16/2023. The report alleges during the second shift on 11/15/2023 Nursing Assistant (NA), Staff A, and Agency NA, Staff B, were providing care together to two residents; Staff A witnessed Staff B put a pillow on Resident ID #1's face and bend Resident ID #2's legs incorrectly. Additionally, Resident ID #3 revealed Staff B purposefully and loudly banged utensils on the bedside table while s/he was asleep causing him/her to startle, and wake; Staff B allegedly laughed at the resident.
Record review of the facility policy updated on 7/23/2023 and titled, ABUSE/RESIDENT states in part, .abuse or mistreatment of any kind toward a resident is strictly prohibited .Abuse shall be defined as: Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish.
1. Record review of Resident ID #1 revealed s/he was admitted to the facility in November of 2023, with diagnoses including, but not limited to, encounter for orthopedic aftercare following surgical amputation, open wound of the right foot, and type 2 diabetes.
Review of a Brief Interview for Mental Status (BIMS) dated 11/10/2023 revealed a score of 3 out of 15, indicating severely impaired cognition.
Further record review revealed a care plan dated 11/17/2023 which states in part, .resident allegedly abused by a staff member .resident will not experience trauma related to alleged incident.
2. Record review of Resident ID #2 revealed s/he was readmitted to the facility in July of 2022 with diagnoses including, but not limited to, dementia, depression, and osteoarthritis.
Review of a BIMS dated 6/17/2023 revealed a score of 12 out of 15, indicating moderately impaired cognition.
3. Record review for Resident ID #3 revealed s/he was admitted to the facility in September of 2023 with diagnoses including, but not limited to, congestive heart failure, depression, and anxiety.
Review of a BIMS dated 10/4/2023 revealed a score of 15 out of 15 indicating intact cognition.
Further review of Resident ID #3's record revealed a progress note dated 11/16/2023 at 12:23 PM, authored by the social worker, which states in part, .resident stated [s/he] was shook up after the incident last night .stated [s/he] was dosing[SIC] off around dinner time and agency staff member, Staff B, entered [his/her] room and slammed [his/her] silverware on the bedside table extremely loudly and purposefully which woke [him/her] up .Staff B laughed .resident stated it triggered a past trauma .resident felt scared and angry that this had happened .resident then overheard another resident screaming and later overheard gossip that Staff B had hit the resident in the face with a pillow .
During a surveyor interview with the resident on 11/17/2023 at 12:15 PM, s/he revealed after speaking with the social worker, s/he is relieved in knowing that Staff B is not returning to the facility. The resident revealed a past history of trauma which includes physical and sexual abuse. Review of the resident's record revealed a social work assessment that revealed the resident was physically and sexually abused as a child by a family member and when s/he hears loud noises, it triggers his/her past abuse.
During a surveyor interview on 11/17/2023 at 11:02 AM with Staff A, she revealed when she entered Resident ID #3's room on 11/15/2023 at approximately 5:45 PM, to collect the dinner trays, the resident revealed what Staff B had done and confirmed what is documented in the above progress note written by the social worker.
Additionally, Staff A revealed while she and Staff B were providing Resident ID #1 with evening care at approximately 7:30 PM, she witnessed Staff B hit the resident in the face with the bed pillows. Staff A further revealed that around 10:20 PM while walking by Resident ID #2's, room she witnessed Staff B inappropriately stretching the resident's legs upward which caused the resident to scream out in pain. Staff A indicated that Staff B exited the resident's room when she arrived. Staff A indicted that she immediately notified Registered Nurse, Staff C, after each incident involving Staff B and the above-mentioned residents.
During a surveyor interview with Staff C, on 11/17/2023 at 10:24 AM, she acknowledged that she was made aware of the abuse allegations by Staff A. Staff C acknowledged that she failed to call the DNS or Administrator upon learning of the abuse allegations and indicated that she left a handwritten note under the Administrators door. Additionally, Staff C failed to remove the alleged perpetrator from the schedule upon learning of the abuse allegations nor did she report the abuse allegations within 2 hours, as required.
Review of a facility document titled 5-day Investigation Report states in part, RN that received the initial complaint on 11/15/2023 was educated and warned on immediate notification of any abuse directly to the Administrator and DNS and removing the suspected abuser immediately from the facility .facility started abuse in-servicing and reporting requirements with staff emphasizing the need for immediate action.
During a surveyor interview with the Administrator on 11/17/2023 at 9:45 AM, she revealed that Staff B will not be returning to the facility and the agency to which she is employed with was notified of the suspected abuse allegations. The Administrator further revealed that her expectation is that Staff C would have removed Staff B upon receiving the report of suspected abuse and was unable to provide evidence that the facility kept Resident ID #s 1, 2, and 3 free from abuse.
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
Based on record review and resident and staff interviews, it has been determined that the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later ...
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Based on record review and resident and staff interviews, it has been determined that the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to other officials (Rhode Island Department of Health-RIDOH) in accordance with State law for 3 of 3 residents reviewed for abuse, Resident ID #s 1, 2, and 3.
Findings are as follows:
Record review of the facility policy updated on 7/23/2023 and titled, ABUSE/RESIDENT states in part, .V./VI Investigation/protection .anyone witnessing, and/or having knowledge of the abuse or mistreatment of any kind toward a resident will report the incident immediately to the supervisor, DNS [Director of Nursing Services] and Administrator .document a description of the incident in each resident's nursing notes .contact the Administrator and the DNS .the DNS or designee shall notify the resident's family, physician, RIDOH, and local police .the Administrator/DNS or designee will immediately conduct an investigation upon submission of a report to the .within 2 hours of notification of alleged allegation of abuse .
Record review of a facility incident report submitted to the Rhode Island Department of Health, on 11/16/2023 at 4:02 PM indicates allegations of physical abuse by Nursing Assistant (NA), Staff B, on behalf of Resident ID #s 1 and 2 and psychological abuse of Resident ID #3 that occurred on 11/15/2023 during the second shift (3 PM-11 PM).
Further record review reveals that Staff A reported these allegations to Registered Nurse, Staff C immediately after they occurred. Staff C, failed to report these allegations immediately to the State Agency or Administrator within two hours, as required per regulation and facility policy. Staff C instead left a written note for the Administrator and placed it under her office door.
During a surveyor interview with Staff C on 11/17/2023 at 10:24 AM, she was unable to provide evidence she reported the abuse allegations involving Resident ID #s 1, 2, and 3 and Staff B within two hours.
During a surveyor interview with the Administrator on 11/17/2023 at 9:45 AM, she revealed that she was not made aware of the above-mentioned allegations of staff to resident abuse until 11/16/2023 at which time she began an investigation and reported the allegations to the RIDOH. The Administrator further revealed her expectation is that staff would follow the regulation and facility policy regarding reporting allegations of abuse or suspected abuse.
See F 600
Apr 2023
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store all drugs and biological's in locked compartments for 3 of 3 residents obser...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store all drugs and biological's in locked compartments for 3 of 3 residents observed on the Port unit during the Medication Administration task, Resident ID #'s 21, 51, and 212.
Findings are as follows:
Surveyor observation of the Medication Administration task on 4/5/2023 on the Port side unit in the presence of Registered Nurse, Staff B, revealed the following:
1. Staff B prepared Resident ID #212's medications at 8:43 AM including; Spirlactone, Losartan, Folic Acid, Dexamethasone, Amlodipine, Allopurinol, and Glipizide, then brought the medications in a plastic medication cup and placed the cup on the bedside table. Staff B told the resident to take his/her medications then proceeded to walk away from the resident. Staff B was observed emptying the urinal in the bathroom, washing the urinal and washing her hands, out of the line of sight of the resident. Staff B did not observe the resident take his/her medications. The medications were left at the bedside without the nurse present.
2. Staff B prepared Resident ID #21's medications at 8:57 AM including; Buproprion, and Duloxetine, then brought the medications in a plastic medication cup and placed the cup on the bedside table. Staff B told the resident to take his/her medications then proceeded to walk away towards the medication cart in the hallway with a privacy curtain blocking the view of the resident. The resident was asking how many pills were there because s/he said they were unable to see them. Staff B did not observe the resident taking their medications. The medications were left at the bedside without the nurse present.
3. Staff B prepared Resident ID #51's medications at 9:10 AM including; Lasix, Magnesium Oxide, and a Multivitamin, then brought them in a plastic medication cup and placed the cup on the bedside table. Staff B did not tell the resident to take the medications, she just walked away from the resident. The privacy curtain was closed, and she assisted the roommate with his/her bed. Staff B did not observe the resident take his/her medications. The medications were left at the bedside without the nurse present.
During a surveyor interview with Staff B on 4/5/2023 at 12:39 PM, she revealed that she normally stays in the room while the residents are taking their medications, but sometimes she does other things such as wash her hands or assist the roommate. She further indicated that residents do not always like when she watches them take their medications.
During a surveyor interview with the Director of Nursing on 4/5/2023 at 12:44 PM, she revealed that all residents should be observed while taking their medications and no medications should be left at the bedside.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the menu was followed for Resident ID#s 4,12, 35 and 57 as these resid...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the menu was followed for Resident ID#s 4,12, 35 and 57 as these resident did not receive a protein with their meal.
Findings are as follows:
Record review revealed the menu to be served on 4/3/2023 for the lunch meal was tomato garlic chicken, baked potato, and chef's of a choice vegetable.
During a surveyor observation on 4/3/2023 at approximately 12:15 PM revealed the lunch meal served to Resident ID#'s 4,12, 35 and 57 consisted of a baked potato and a mixed vegetable blend.
During a surveyor interview on 4/3/2023 at approximately 12:25 PM with the dietary cook, Staff C, she revealed they did not have enough chicken available to serve to all of the residents.
During a surveyor interview on 4/3/2023 at approximately 3:30 PM with the Food Service Director, she revealed she was not informed by Staff C that Resident ID#'s 4,12, 35 and 57 did not receive the tomato garlic chicken or an alternate protein choice.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to assess a resident using a quarterly review instrument specified by the State and approved by CMS not less...
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Based on record review and staff interview, it has been determined that the facility failed to assess a resident using a quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for 4 of 6 residents, Resident ID #'s 1, 18, 22, and 39.
Findings are as follows:
1. Record review for Resident ID #1 revealed that the Minimum Data Set (MDS) Assessment that was due on 3/6/2023 was still in the process of being completed.
2. Record review for Resident ID #18 revealed that the MDS Assessment that was due on 3/6/2023 was still in the process of being completed.
3. Record review for Resident ID #22 revealed that the MDS Assessment that was due on 3/8/2023 was still in the process of being completed.
4. Record review for Resident ID #39 revealed that the MDS Assessment that was due on 3/6/2023 was still in the process of being completed.
During a surveyor interview on 4/6/2023 at 11:02 AM with the MDS Coordinator, she acknowledged that the above mentioned assessments were still in the process of being completed and was unable to provide evidence that the above MDS Assessments were completed as required.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0710
(Tag F0710)
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 the medical care of each resident is supervised by a physician for 3 of 5 residents reviewed for m...
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Based on record review and staff interview, it has been determined that the facility failed to ensure the medical care of each resident is supervised by a physician for 3 of 5 residents reviewed for maintaining nutritional parameters, Resident ID #'s 1, 27 and 55.
1. Record review for Resident ID #1 revealed a weight of 102 pounds on 2/3/2023 and a weight of 95.4 pounds on 3/26/2023 indicating that the resident had a 6.47% weight loss in 7 weeks. Further record review failed to reveal evidence that the physician was notified of the weight loss.
2. Record review for Resident ID #27 revealed a weight of 184.2 pounds on 12/28/2022 and a weight of 170.3 pounds on 3/2/2023 indicating that the resident had a 7.55% weight loss in 9 weeks. Further record review failed to reveal evidence that the physician was notified of the weight loss.
3. Record review for Resident ID #55 revealed a weight of 121 pounds on 3/21/2023 and a weight of 113.5 pounds on 4/1/2023 indicating that the resident had a 6.20% weight loss in 11 days. Further record review failed to reveal evidence that the physician was notified of the weight loss.
During a surveyor interview on 4/4/2023 at 1:17 PM and again on 4/5/2023 at approximately 12:15 PM with the Director of Nursing, she was unable to provide evidence that the physician was notified about the above mentioned resident's weight loss.
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 2-402.11 reveals in part, .food employees shall wear hair restraints, beard restraints that are designed and worn to effectively keep their hair from contacting exposed food .
During a surveyor observation of the main kitchen on 4/3/2023 at approximately 9:47 AM a Dietary Cook, Staff D was observed not wearing a beard restraint. Two dietary aides were noted were not wearing hair restraints. Dietary Aide, Staff E, was wearing a baseball cap that failed to restrain all of their hair. Additionally, Dietary Aide, Staff F, was wearing a knitted cap that failed to restrain all of their hair.
During a surveyor observation on 4/3/2023 at approximately 11:55 AM a Dietary Cook, Staff C was observed serving the lunch meal from the main dining room with a knitted hat that failed to restrain all of their hair. Staff D was observed not wearing a beard restraint.
During a surveyor observation on 4/5/2023 at approximately 10:00 AM revealed Staff E wearing a baseball cap that failed to restrain all of their hair. Staff D was observed without a beard restraint.
2) The Rhode Island Food Code 2018 Edition 3-602.11 Food Labels, states in part, .Label Information shall include .the common name of the FOOD .
During a surveyor observation on 4/3/2023 at approximately 9:50 AM the reach in refrigerator unit had approximately 20 1-ounce souffle cups without a label identifying the product.
Additional surveyor observations revealed the dry storage room had a five-gallon container without a label to identify the food product and seven 6-ounce containers without a label to identify the food product.
Further surveyor observation of the walk-in freezer revealed three packages of a product that was round and breaded that did not have a label to identify the food product.
3) The Rhode Island Food Code 2018 Edition 3-501.19 Time as a Public Health Control reveals in part; .the food shall have an initial temperature of 5 degrees Celsius (41 degrees Fahrenheit) or less when removed from cold holding temperature control.
During a surveyor observation on 4/4/2023 at 11:55 AM the milk that was served at the lunch meal had a temperature reading of 47 degrees Fahrenheit.
An additional surveyor observation on 4/4/2023 at approximately 12:20 PM the ham and cheese sandwiches that were an alternate meal choice had a temperature reading of 52 degrees.
4) Record review of a document titled: Use of Leftovers reads in part, .leftovers must be used within three days or discarded .
During a surveyor observation on 4/5/2023 at approximately 10:15 AM stored in the reach in refrigerator was a container with ham salad dated 3/29/2023 and a container of egg salad dated 3/31/2023.
During a surveyor interview on 4/6/2023 at approximately 12:00 PM with the Food Service Director she acknowledged the food items stored did not have product labels, milk and sandwiches were not served at the appropriate temperatures, food items stored beyond the three days and dietary employees were not wearing hair restraints properly, including beard nets.
Feb 2023
6 deficiencies
4 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0661
(Tag F0661)
Someone could have died · This affected 1 resident
Based on record review, resident, and staff interview, it has been determined that the facility failed to reconcile all pre-discharge medications with the resident's post-discharge medications, for 1 ...
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Based on record review, resident, and staff interview, it has been determined that the facility failed to reconcile all pre-discharge medications with the resident's post-discharge medications, for 1 of 5 reviewed, Resident ID #1.
Findings are as follows:
Record review of the facility's discharge policy titled, Discharge/Community states in part, Nursing will complete .interdisciplinary form and medication list .a review of medication regime, medication and treatments with the resident and/or family is conducted prior to discharge .
Record review of a community complaint reported to the Rhode Island Department of Health on 1/23/2023, alleges Resident ID #1 was sent home with another resident's medications, (Resident ID #2).
Record review for Resident ID #1 revealed s/he was admitted to the facility in January of 2023 with diagnoses including but are not limited to, after care following joint replacement and presence of left artificial knee joint.
During a surveyor interview with Resident ID #1 on 1/25/2023 at approximately 1:25 PM, s/he revealed s/he was discharged home on 1/20/2023 with 9 bubble packs of medication that belonged to another resident, in addition to her/his own medications. The resident further revealed that s/he did not receive discharge instructions or education by the nurse. The resident further revealed that s/he called the facility to inform them that s/he has someone else medications.
Review of a facility document titled Continuity of Care Discharge/Transfer of Patient Form indicated that the resident's medication list was attached to this document. Further review of this document failed to reveal a list of discharge medications, or that it was signed as completed by the discharging nurse, Registered Nurse, Staff A, or that it was signed off as reviewed by the resident.
During a surveyor interview with Staff A on 1/26/2023 at 1:20 PM she acknowledged that she mistakenly provided Resident ID #2's medications to Resident ID #1 upon his/her discharge. She further revealed that she failed to reconcile the medication list as indicated on the Continuity of Care Form per the facility's discharge policy with the resident or the family member during the discharge.
During a surveyor interview with the Administrator on 1/26/2023 at approximately 11:00 AM she was unable to provide evidence that all pre-discharge medications were reconciled with the resident's post-discharge medications prior to Resident ID #1 being discharged home from the facility.
Please refer to F 726, F 761, and F 835.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0726
(Tag F0726)
Someone could have died · This affected 1 resident
Based on record review, resident, and staff interview, it has been determined that the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care fo...
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Based on record review, resident, and staff interview, it has been determined that the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through the plan of care for 1 of 5 residents reviewed for discharge services, Resident ID #1.
Findings are as follows:
Record review of a community complaint reported to the Rhode Island Department of Health on 1/23/2023, alleges that Resident ID #1 was sent home with another resident's medications (Resident ID #2).
Record review for Resident ID #1 revealed s/he was admitted to the facility in January of 2023 with the diagnoses including but are not limited to, after care following joint replacement and presence of left artificial knee joint.
During a surveyor interview with Resident ID #1 on 1/25/2023 at approximately 1:25 PM, s/he revealed s/he was discharged home on 1/20/2023 with 9 bubble packs of medication that belonged to another resident, in addition to her/his own medications. The resident further revealed that s/he did not receive discharge instructions or education pertaining to medication administration by the discharging nurse, Registered Nurse, Staff A. The resident further revealed that s/he called the facility to inform them that s/he had someone else's medications.
Record review of Staff A's personnel file failed to reveal any competencies or skill sets relative to medication reconciliation prior to or after this incident was brought to the facility's attention by Resident ID #1 on 1/20/2023.
During a surveyor interview with Staff A on 1/26/2023 at 1:20 PM, she acknowledged that she mistakenly provided Resident ID #2's medications to Resident ID #1 upon discharge. She further revealed that she failed to reconcile Resident #1 's pre-discharge medications with the resident's post-discharge medications. Additionally, she stated that she needed to acclimate herself to long term care and on how to properly conduct a discharge.
During a surveyor interview with the Administrator on 1/26/2023 at approximately 11:00 AM, she acknowledged that the nurse should have reviewed and reconciled all medications prior to discharging the resident. Additionally, she was unable to provide evidence that Staff A had the competencies or skill sets relative to medication reconciliation as she discharged Resident ID #1 home with Resident ID #2's medications.
Please refer to F 661, F 761, and F 835.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0761
(Tag F0761)
Someone could have died · 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 for 1 of 10 residents rev...
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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 for 1 of 10 residents reviewed relative to breaking the chain of custody of medications and administering them to a resident, Resident ID #2.
Findings are as follows:
According to U.S. Pharmacist article, published June 11, 2021 titled Uncovering the Impact of Storage on Generic Medications, states in part .Storage conditions are vitally important to the overall integrity and quality of medications, and the United States Pharmacopeial Convention, the FDA(Federal Drug Administration), and drug manufacturers provide guidelines for proper storage .From the point of manufacture to the distribution of a medication to a patient, many factors can directly impact the integrity of a drug product, which may result in an avoidable decrease in treatment efficacy or even cause harm. One of the most easily overlooked factors that can directly impact the quality of a drug product is the condition in which medications are stored. From fluctuating temperatures to improper sealing to potential contamination during transportation from place to place, medications are often subjected to conditions that are less than optimal. Most drugs require specific storage conditions to ensure that their integrity remains intact .
Record review of a community complaint reported to the Rhode Island Department of Health on 1/23/2023, alleges that Resident ID #1 was sent home with another resident's medications (Resident ID #2).
Record review for Resident ID #1 revealed s/he was admitted to the facility in January of 2023 with diagnoses including but are not limited to, after care following joint replacement and presence of left artificial knee joint.
Record review reveals Resident ID #2 is a current resident at the facility. Record review for Resident ID #2 revealed s/he was admitted to the facility in July of 2020 with diagnoses including, but are not limited to, hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness of the body), aphasia (disorder that affect your communication), and back pain.
During a surveyor interview with Resident ID #1 on 1/25/2023 at approximately 1:25 PM, s/he revealed s/he was discharged home on 1/20/2023 with 9 bubble packs of medication that belonged to another resident (Resident ID #2), in addition to her/his own medications. The resident further revealed that s/he called the facility to inform them that s/he had someone else's medications. Resident ID #1 then indicated that the Administrator came to his/her home to retrieve Resident ID # 2's medications.
During a surveyor interview with the Administrator on 1/26/2023 at 11:00 AM, she acknowledged that Resident ID #1 was discharged with Resident ID # 2's medications. She further indicated that she retrieved the medications from Resident ID #1's home and returned them to Registered Nurse, Staff A. The Administrator was unable to recall or provide evidence of which medications she retrieved from Resident ID #1's home. She further indicated that because the facility lost the chain of custody for Resident ID #2's medications they should have been destroyed and re-ordered.
During a surveyor interview with Staff A, on 1/26/2023 at 1:20 PM, she revealed she received the medications from the Administrator and placed them back in the medications cart. Additionally, she revealed that those medications were administered to Resident ID #2 that day.
During a surveyor interview with the Nurse Practitioner on 1/30/2023 at 12:00 PM, she revealed that the medications should not have been administered to the resident once they were taken out of the facility.
Please refer to F 661, F 726, F 835
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
Administration
(Tag F0835)
Someone could have died · This affected 1 resident
Based on record review, resident, and staff interview, it has been determined that the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently t...
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Based on record review, resident, and staff interview, it has been determined that the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 5 residents reviewed, Resident ID #1.
Findings are as follows:
Record review of a community complaint reported to the Rhode Island Department of Health on 1/23/2023, alleges that Resident ID #1 was sent home with another resident's medications (Resident ID #2).
Record review for Resident ID #1 revealed s/he was admitted to the facility in January of 2023 with the diagnoses including but are not limited to, after care following joint replacement and presence of left artificial knee joint.
During a surveyor interview with Resident ID #1 on 1/25/2023 at approximately 1:25 PM, s/he revealed s/he was discharged home on 1/20/2023 with 9 bubble packs of medication that belonged to another resident (Resident ID #2), in addition to her/his own medications. The resident further revealed that s/he did not receive discharge instructions or education pertaining to medication administration by the nurse. The resident further revealed that s/he called the facility to inform them that s/he had someone else's medications. The facility asked the resident is s/he could return Resident ID #2's medications. The resident explained that s/he could not drive as s/he was recovering from knee surgery, therefore the Administrator elected to pick up the medications from Resident ID #1's home.
During a surveyor interview with the Administrator on 1/26/2023 at 11:00 AM, she acknowledged that Resident ID #1 was discharged with Resident ID # 2's medications. She further indicated that she retrieved the medications from Resident ID #1's home and returned them to Registered Nurse, Staff A. The Administrator was unable to recall or provide evidence of which medications she retrieved from Resident ID #1's home. She further indicated that the medications should have been destroyed and re-ordered for Resident ID #2
Please refer to F661, F761, and F835.
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
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 1 resident reviewed for oxygen therapy, Resident ID #8.
Findings are as follows:
According to Brunner and Suddarth's textbook, Medical and Surgical Nursing, 10th Edition, 1992, p.524, states in part, as with other medications, oxygen is administered with care, and its effects on each patient are carefully assessed. Oxygen is a drug and except in emergency situations is prescribed by a physician.
Record review revealed the resident was admitted to the facility in December of 2022 with a readmission date of January 2023, with diagnoses including but are not limited to, pneumonia, osteomyelitis of vertebra (backbones), malignant neoplasm (cancer) of prostate and dysfunction of bladder.
During a surveyor interview on 1/30/2023 at approximately 2:00 PM, Resident ID #8's family had voiced concerns to the surveyor regarding his/her care.
Record review of a physician's order dated 1/18/2023 revealed oxygen 2 liters via nasal cannula [NC] continuously every shift.
Review of a progress note dated 1/29/2023 revealed in part, .patient .continues on 3 Liters of O2 [oxygen] via NC .
During a surveyor observation on 1/30/2023 at 2:25 PM, the resident was observed on 4 liters of oxygen via NC.
During a surveyor interview with Registered Nurse Staff B, on 1/30/2023 at approximately 2:30 PM, she acknowledged that the resident's oxygen flow rate was not administered per the physician's order.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on a record review and surveyor interview it has been determined that the facility failed to ensure the QAPI/QAA committee meets on a quarterly basis and that each meeting includes the required ...
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Based on a record review and surveyor interview it has been determined that the facility failed to ensure the QAPI/QAA committee meets on a quarterly basis and that each meeting includes the required committee members consisting at a minimum of, the Director of Nursing, the Medical Director, Infection Preventionist and at least three other members of the facility staff.
Findings are as follows:
Review of the facility QAPI/QAA 2022 schedule and committee minutes identified that QAPI/QAA meetings were held on the following dates:
-February 14
-May 9
-August 25
-November 30
Review of the attendance signature sheets for each of the above meetings failed to reveal evidence that the Medical Director attended any of the meetings.
Further review of the attendance signature sheets failed to reveal evidence that the Infection Preventionist attended the November meeting.
During a surveyor interview with the Administrator on 1/31/2023 at 11:00 AM, she was unable to provide evidence that the required interdisciplinary team members attended the QAPI/QAA committee meetings.
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: 4 life-threatening violation(s), 2 harm violation(s), $260,581 in fines. Review inspection reports carefully.
- • 31 deficiencies on record, including 4 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $260,581 in fines. Extremely high, among the most fined facilities in Rhode Island. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has 4 Immediate Jeopardy findings. Serious concerns require careful evaluation.
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About This Facility
What is Apple Rehab Clipper's CMS Rating?
CMS assigns Apple Rehab Clipper an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Rhode Island, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Apple Rehab Clipper Staffed?
CMS rates Apple Rehab Clipper's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 53%, compared to the Rhode Island average of 46%.
What Have Inspectors Found at Apple Rehab Clipper?
State health inspectors documented 31 deficiencies at Apple Rehab Clipper during 2023 to 2025. These included: 4 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, 23 with potential for harm, and 2 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Apple Rehab Clipper?
Apple Rehab Clipper 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 APPLE REHAB, a chain that manages multiple nursing homes. With 60 certified beds and approximately 43 residents (about 72% occupancy), it is a smaller facility located in Westerly, Rhode Island.
How Does Apple Rehab Clipper Compare to Other Rhode Island Nursing Homes?
Compared to the 100 nursing homes in Rhode Island, Apple Rehab Clipper's overall rating (2 stars) is below the state average of 3.1, staff turnover (53%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Apple Rehab Clipper?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Apple Rehab Clipper Safe?
Based on CMS inspection data, Apple Rehab Clipper has documented safety concerns. Inspectors have issued 4 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Rhode Island. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Apple Rehab Clipper Stick Around?
Apple Rehab Clipper has a staff turnover rate of 53%, which is 7 percentage points above the Rhode Island average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Apple Rehab Clipper Ever Fined?
Apple Rehab Clipper has been fined $260,581 across 3 penalty actions. This is 7.3x the Rhode Island average of $35,685. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Apple Rehab Clipper on Any Federal Watch List?
Apple Rehab Clipper 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.