Trinity Health and Rehabilitation Center
For profit - Corporation
185 Beds
Independent
Data: November 2025
8 Immediate Jeopardy citations
Trust Grade
0/100
#71 of 72 in RI
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Trinity Health and Rehabilitation Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided. It ranks #71 out of 72 facilities in Rhode Island, placing it in the bottom half of nursing homes in the state and #41 of 41 in Providence County, meaning it is the least favorable option in the local area. The facility's performance is worsening, with the number of reported issues increasing from 18 in 2024 to 21 in 2025. Staffing is a relative strength, earning a rating of 4 out of 5 stars, with a turnover rate of 36%, which is below the state average, suggesting that staff are more stable and familiar with residents. However, the facility has concerning fines totaling $150,979, which are higher than 76% of Rhode Island facilities, and it offers less RN coverage than 78% of its peers, which could impact the quality of medical care. Specific incidents include critical failures to maintain safe water temperatures throughout the facility, which poses a burn risk to residents, and deficiencies in providing proper respiratory care for residents requiring oxygen therapy, indicating a lack of adherence to professional standards. While the staffing situation is better than average, the overall safety and health conditions raise important red flags for families considering this nursing home for their loved ones.
- Trust Score
- F
- In Rhode Island
- #71/72
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 36% turnover. Near Rhode Island's 48% average. Typical for the industry.
- Penalties ○ Average
- $150,979 in fines. Higher than 67% of Rhode Island facilities. Some compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 31 minutes of Registered Nurse (RN) attention daily — about average for Rhode Island. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 66 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 2%
Review needed
18 → 21 violations
★☆☆☆☆
1.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 18 issues
2025: 21 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (36%)
12 points below Rhode Island average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
1-Star Overall Rating
Below Rhode Island average (3.0)
Significant quality concerns identified by CMS
Staff Turnover: 36%
Near Rhode Island avg (46%)
Typical for the industry
Federal Fines: $150,979
Well above median ($33,413)
Significant penalties indicating serious issues
The Ugly 66 deficiencies on record
8 life-threatening 5 actual harm
Aug 2025
3 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
Based on record review, staff and resident interview it has been determined that the facility failed to keep a resident free from neglect relative to 1 of 1 resident reviewed who was left unattended o...
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Based on record review, staff and resident interview it has been determined that the facility failed to keep a resident free from neglect relative to 1 of 1 resident reviewed who was left unattended outside of the facility for approximately 3 hours and 20 minutes during a heat advisory resulting in cardiac arrest, Resident ID #1. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 7/30/2025 alleged that Resident ID #1 was left unattended outside of the facility for an unknown amount of time on 7/30/2025. The complaint further alleged that the resident was found unconscious, without a pulse and required cardio-pulmonary resuscitation (CPR). Additionally, the resident was transferred to the hospital for further treatment.Review of the weather report on 7/30/2025 revealed a heat advisory was in effect for the facility's area. According to the National Weather Service, a heat advisory is issued when dangerously high temperatures are expected that could potentially be harmful. Record review revealed Resident ID #1 was admitted to the facility in April of 2025 with diagnoses including, but not limited to, diabetes mellitus type 2, heart failure, chronic obstructive pulmonary disease (COPD), and cognitive communication disorder. Review of a care plan last revised on 7/21/2025 revealed the resident has a level two PASRR evaluation (a person-centered comprehensive evaluation used for people with a mental illness or intellectual disability to determine the need for specialized services) related to mental illness with interventions including, but not limited to, assessing and anticipating the resident's needs such as food, thirst, toileting needs, comfort level, body positioning, and pain. Record review revealed a physician's order dated 7/4/2025 to administer Humalog injection solution (a fast-acting insulin) per the sliding scale (the nurse obtains the resident's blood sugar via a finger stick and then administers the appropriate dose of insulin ordered for that blood sugar range) three times a day, at 8:30 AM, 11:30 AM, and 4:30 PM. Record review of the July 2025 Medication Administration Record (MAR) revealed on 7/30/2025 the nurse documented N/A -1 for the 11:30 blood sugar check insulin injection. Further review revealed the code 1 on the MAR indicated that the resident was absent from home without [medications]. Additional review failed to reveal evidence that the resident refused any medications or treatments on 7/30/2025. Record review of a progress note dated 7/30/2025 at 1:50 PM indicated that the resident was found unresponsive, sitting outside in his/her wheelchair. The resident was brought in by staff at which time s/he stopped breathing, 911 was called and CPR was initiated. Further review indicated the resident became responsive at which time emergency medical services (EMS) took over.Review of the RI EMS Patient Care Report revealed EMS arrived at the facility on 7/30/2025 at 1:29 PM after a call for an unresponsive resident. Further review revealed Resident ID #1 was extremely hot to touch on arrival with shallow breathing and pinpoint pupils. Additional review revealed a facility nurse reported that the resident was outside when s/he became slumped over in his/her wheelchair for an unknown amount of time and then moved inside where staff could not find a pulse and started CPR. Resident ID #1 was transported to the hospital. Review of a hospital document dated 7/30/2025 revealed Resident ID #1 was admitted to the hospital for suspected heat stroke resulting in cardiac arrest, aspiration pneumonia (refers to adverse pulmonary consequences due to entry of gastric or oropharyngeal fluids), secondary to cardiac arrest and myocardial infarction (heart attack) in the setting of cardiac arrest. The hospital records indicate that the resident was outside in the heat for over 3 hours when s/he was found unresponsive by nursing home staff. The resident underwent multiple rounds of CPR in the field and obtained return of spontaneous circulation (ROSC). On arrival to the emergency department, the resident's heart monitor was showing pauses, and the resident was unresponsive requiring one round of CPR for which ROSC was obtained. During a surveyor interview on 7/31/2025 at approximately 2:30 PM with Nursing Assistant (NA), Staff A, in the presence of a translator, he indicated that he was assigned to perform care for Resident ID #1 on 7/30/2025. He further indicated that he provided morning care and served his/her breakfast. Additionally, he indicated that the resident went outside at approximately 10:00 AM and that he did not check on the resident after s/he went outside. Furthermore, he acknowledged that he did not look for the resident at lunch time to offer his/her meal. During a surveyor interview on 7/31/2025 at approximately 1:30 PM with Licensed Practical Nurse, Staff B, she indicated that Resident ID #1 went outside of the facility at approximately 10:00 AM on 7/30/2025. She further indicated that she did not go outside to check on the resident or attempt to complete the ordered blood sugar check that was scheduled for 11:30 AM. Additionally, she indicated that someone, she was unaware who, had told her that the resident refused to come inside so she didn't see him/her until she was alerted that s/he was outside unresponsive at approximately 1:30 PM. Furthermore, she indicated that the receptionist brought the resident inside and s/he was found to be pulseless, and CPR was initiated. Surveyor observations of the facility's surveillance camera footage of 7/30/2025, on 7/31/2025 at 9:05 AM in the presence of the Director of Nursing Services (DNS) and the Maintenance Director, revealed the resident exited the front door of the facility alone, self-propelling in his/her wheelchair at 9:56 AM. Further review revealed s/he remained in the parking lot, in the sun until 1:13 PM. At this time, another resident unsuccessfully attempted to arouse him/her and went back into the facility to get help. The receptionist then brought Resident ID #1 into the facility at 1:14 PM. Additionally, the surveillance camera footage failed to reveal evidence that any staff member was observed to approach the resident to check on him/her, offer lunch, or to obtain his/her scheduled blood sugar. Furthermore, the resident was observed to be slumped over in his/her wheelchair with his/her legs dragging on the ground when the receptionist brought him/her into the facility, 3 hours and 20 minutes after s/he exited the facility unattended, during a heat advisory. During a surveyor interview with the DNS immediately following the above observations, she acknowledged that the surveillance footage that had just been observed, did not reveal evidence that any staff members approached the resident to offer his/her lunch, obtain the blood sugar, or to encourage him/her to go back into the facility. The facility's failure to keep a resident free from neglect resulted in Resident ID #1 becoming unresponsive, requiring CPR, and subsequently being admitted to the hospital with concerns for heat stroke. This failure places Resident ID #1 at risk for serious injury, serious harm, serious impairment or death.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality relative to followin...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality relative to following physician's orders for 1 of 3 residents reviewed, Resident ID #1.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.Record review revealed Resident ID #1 was readmitted to the facility in August of 2025 with a diagnosis including, but not limited to, diabetes mellitus.1a. Record review revealed a physician's order dated 8/7/2025 for Humalog Insulin (a short acting insulin); 100 unit/milliliter (mL); before meals inject as per sliding scale:-Blood Sugar is 150 to 199, give 2 Units. -Blood Sugar is 200 to 249, give 4 Units. -Blood Sugar is 250 to 299, give 6 Units. -Blood Sugar is 300 to 349, give 8 Units. -Blood Sugar is greater than 350, call MD (medical doctor).Record review of the August 2025 Medication Administration Record (MAR) failed to reveal evidence that the resident's blood sugar was obtained to determine if the Humalog insulin was required to be administered on the following dates and times: -8/7/2025 at 11:30 AM -8/10/2025 at 6:30 AM 1b. Record review revealed a physician's order dated 8/20/2025 for a high protein snack at bedtime for nutritional support.Record review of the August 2025 MAR revealed the high protein snack was documented as not available and not provided to the resident on the following dates:-8/20/2025-8/21/2025During a surveyor interview on 8/22/2025 at 2:04 PM with Licensed Practical Nurse, Staff A, he was unable to explain why the resident did not receive his/her high protein snack as ordered and acknowledged that the items were available in the facility to provide to the resident. Additionally, he was unable to provide evidence that the resident blood sugar was obtained on 8/7/2025 at 11:30 AM and 8/10/2025 at 6:30 AM as ordered. During a surveyor interview at 8/22/2025 at 3:40 PM with the [NAME] President of Operations, she revealed that items are available in the facility to give residents high protein snacks and would have expected the snack to be given as ordered. Additionally, she was unable to provide evidence that the resident's blood sugar was obtained on 8/7/2025 at 11:30 AM and 8/10/2025 at 6:30 AM as ordered to determine if the resident required his/her insulin to be administered.Cross reference F760
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from significant medication errors for 1 of 1 resident reviewed receiving ...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from significant medication errors for 1 of 1 resident reviewed receiving amoxicillin-clavalanate (an antibiotic) and divalproex (a medication used to treat mood disorders) and 1 of 2 residents reviewed requiring insulin, Resident ID #1. Findings are as follows:Review of a facility policy titled, Medication Administration dated 10/11/2017 states in part, It is the intent of this policy to ensure that resident medication administration is managed to ensure for resident quality of life, timeliness and safety .When transcribing an order to the MAR [Medication Administration Record].the nurse will take into consideration the purpose of administering the medication and assign the appropriate time.Medications are administered within one hour of the time noted on MAR .Record review revealed Resident ID #1 was readmitted to the facility in August of 2025 with diagnoses including, but not limited to, diabetes mellitus, mood disorder, and sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock and death).1a. Record review revealed a physician's order dated 8/6/2025 for amoxicillin-clavalanate 875-125 milligram (mg), take one tablet by mouth in the morning for sepsis for 9 days.Record review of the August 2025 Medication Administration Record (MAR) revealed that the amoxicillin-clavalanate was documented as not administered as ordered on 8/7/2025 with a reason code of 5 which indicates to see the progress notes. Review of a progress note dated 8/7/2025 revealed the above medication was not administered due to being on order.1b. Record review of a hospital Discharge Summary document dated 8/6/2025 revealed a physician's order to continue divalproex ER (extended release) 2,000 mg by mouth nightly. Additionally, the hospital discharge document revealed the last time the medication was administered was on 8/5/2025 at 10:27 PM indicating the next required daily dose would be on 8/6/2025 in the evening. Record review of an undated Medication Reconciliation document revealed the resident was to continue with the divalproex ER upon his/her readmission to the facility.Record review revealed a physician's order dated 8/6/2025 for divalproex ER 500 mg- give four tablets (for a total dose of 2,000 mg) by mouth at bedtime.Additional review of the August 2025 MAR failed to reveal evidence that the resident received his/her divalproex ER 2,000 mg as ordered on 8/6 or 8/7/2025.1c. Record review revealed a physician's order dated 8/7/2025 for Lantus (a long-acting insulin) 100 unit/milliliter (mL); inject 5 units in the morningFurther review of the August 2025 MAR failed to reveal evidence that the Lantus insulin was administered as ordered on 8/7/2025.During a surveyor interview on 8/22/2025 at 2:04 PM with Licensed Practical Nurse, Staff A, he acknowledged that he worked the 7:00 AM to 3:00 PM shift on 8/7/2025 and was assigned to care for the resident. Additionally, he was unable to recall if he administered the Lantus insulin to the resident as ordered. Further, he acknowledged the amoxicillin-clavalanate was not administered as ordered 8/7/2025 and that there is an in house pyxis (an automated medication dispensing system) that contained the amoxicillin-clavalanate. Furthermore, he was unable to provide evidence that the resident received the divalproex ER 2,000 MG as ordered on 8/6/2025 and 8/7/2025.During a surveyor interview on 8/22/2025 at approximately 2:30 PM and 2:56 PM with the resident's Nurse Practitioner, Staff B, she acknowledged that she was unaware that the amoxicillin-clavalanate was not administered for the full 9-day course as ordered. Additionally, she revealed that she was not aware that the resident did not receive his/her divalproex ER and Lantus as ordered and would have expected the resident to have received the medications as ordered. During a surveyor interview on 8/22/2025 at 3:40 PM with the [NAME] President of Operations, she indicated it would have been her expectation that the medication aide would have asked the nurse to remove the amoxicillin-clavalanate from the pixus to administer the medication to the resident 8/7/2025 and that the resident would have received his/her Lantus as ordered on 8/7/2025. Further she was unable to provide evidence why the residents divalproex ER was not administered on 8/6/2025 and 8/7/2025.Cross Reference- F658
Mar 2025
17 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Safe Environment
(Tag F0584)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, resident, and staff interview, it has been determined that the facility failed to ensure a safe e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, resident, and staff interview, it has been determined that the facility failed to ensure a safe environment was maintained relative to unsafe water temperatures, for 4 of 4 floors observed.
Findings are as follows:
According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 8/8/2024, states in part, .Some States have regulations regarding allowable maximum water temperature .Water may reach hazardous temperatures in hand sinks, showers, tubs, and any other source or location where hot water is accessible to a resident. Burns related to hot water/liquids may also be due to spills and/or immersion .skin in relation to the temperature of the water and the length of time of exposure .Time Required for a 3rd Degree Burn to Occur .133° F, 15 seconds .
According to TITLE 216 - DEPARTMENT OF HEALTH, CHAPTER 40 - PROFESSIONAL LICENSING AND FACILITY REGULATION, SUBCHAPTER 10 - FACILITIES REGULATION, PART 1 - Licensing of Nursing Facilities, .In resident areas, hot water temperatures shall not be less than one-hundred degrees Fahrenheit (100 ºF) nor exceed one-hundred- and eighteen-degrees Fahrenheit (118 ºF). Thermometers [accuracy of which can be plus or minus two degrees Fahrenheit (±2 ºF)] shall be provided in each residential area to check water temperature periodically on that unit and at each site where residents are immersed or showered .
Record review of a facility document titled, Water Temperatures, states in part, Resident hot water usage temperature will be kept at a level of not less than 100 degrees Fahrenheit nor exceed 118 degrees Fahrenheit per State regulations .Maintenance personnel shall monitor equipment and water supply sources to ensure that malfunctions are not occurring .Water temperatures are to be monitored not less than weekly with the following: Maintenance personnel will take water temperatures weekly with random sample .Maintenance shall provide thermometers to each unit for nursing personnel to periodically check water temperatures on their unit and where residents are immersed or showered .In the event that a non-maintenance staff member discovers a temperature out of the range (note that the range may include a plus/minus two degrees) or by touch feels that the temperature is too high or low, maintenance will be notified .
During a surveyor observation on 2/24/2025 at approximately 9:33 AM on the 1st Floor, a surveyor was washing their hands in resident room [ROOM NUMBER]'s sink. The water became very hot to touch, reddening the skin of the surveyor's hands, and steam was rising from the sink. Following this observation, the water temperature was obtained using a digital thermometer and recorded a temperature of 137.5 °F.
During surveyor observations on 2/24/2025, immediately following the above observation, water temperatures were obtained and were found to exceed 120 degrees °F:
Ground Floor:
-Shower room, shower 132.0 °F
-Resident room [ROOM NUMBER], sink 136.5 °F
-Resident room [ROOM NUMBER], sink 137.1 °F
First Floor:
-Resident room [ROOM NUMBER], sink 137.1 °F
-Resident room [ROOM NUMBER], sink 137.7 °F
-Resident room [ROOM NUMBER], sink 137.5 °F
Second Floor:
-Resident room [ROOM NUMBER], sink 137.5 °F
-Resident room [ROOM NUMBER], sink 133.3 °F
-Resident room [ROOM NUMBER], sink 133.7 °F
Third Floor:
-Shower room, sink 133.9 °F
-Resident room [ROOM NUMBER], sink 135.5 °F
-Resident room [ROOM NUMBER], sink 136.0 °F
-Resident room [ROOM NUMBER], sink 133.0 °F
During a surveyor interview on 2/24/2025 at 9:50 AM with Nursing Assistant, Staff L, regarding the 2nd floor shower room, she acknowledged that the staff use both showers in the shower room for residents daily and stated, I don't want it to get too hot, so I only turn it up halfway.
During a surveyor interview on 2/24/2025 at approximately 10:08 AM with NA, Staff M, she revealed that at times the water can get too hot.
During a surveyor interview on 2/24/2025 at approximately 11:05 AM with Resident ID #9, s/he revealed that the maintenance staff recently fixed the hot water in his/her room sink and now it does not have any cold water. The resident further revealed that s/he could not use it because the water is too hot.
During a surveyor interview and observation on 2/24/2025 at approximately 10:40 AM, with the Maintenance Director, the following water temperatures were obtained and found to exceed 120 degrees °F:
Ground floor: Resident room [ROOM NUMBER], sink 133.1 °F
First Floor: Resident room [ROOM NUMBER], sink 132.8 °F
Second Floor: Resident room [ROOM NUMBER], sink 132.8 °F
Third Floor: Resident room [ROOM NUMBER], sink 131.0 °F
During a surveyor interview immediately following the above observation with the Maintenance Director, he acknowledged the above water temperatures exceeded 120 °F.
During a surveyor interview on 2/24/2025 at approximately 11:21 AM, with the Administrator in the presence of the Director of Nursing Services, she acknowledged that water temperatures should not exceed 120 °F. Additionally, they were unable to provide evidence that the facility to ensure a safe environment was maintained, relative to water temperatures.
The facility's failure to ensure safe water temperatures throughout the facility placed the residents at risk for serious injury, serious harm, serious impairment or death.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Employment Screening
(Tag F0606)
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 they not employ or otherwise engage individuals who have been found guilty of abuse or mistre...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that they not employ or otherwise engage individuals who have been found guilty of abuse or mistreatment by a court of law, for 1 of 1 personnel record reviewed for disqualifying information, Maintenance Assistant, Staff A.
Findings are as follows:
Review of a facility policy titled, Abuse prohibition states in part, .DEFINITIONS: Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish and included physical, verbal, sexual, and mental abuse .Any person seeking employment at this facility (which involves routine contact with a resident without the presence of other employees) shall be subject to a criminal background check, which is to initiated .The employee, through the employer, shall apply to the bureau of criminal identification [BCI] of the state or local police department for a statewide criminal records check .If the facility receives notice of disqualifying information regarding the employee, said employee will be disqualified from employment .
Record review revealed Staff A was hired on 1/27/2025 as a Maintenance Assistant.
Review of a document titled MAINTENANCE DEPT WEEKLY SCHEDULE revealed Staff A works at the facility Monday through Friday from 8:30 AM to 4:30 PM. It further revealed that he is on call during the fourth weekend of the month.
Review of a BCI dated 1/21/2025 states in part, As mandated by both federal and state law, the fingerprints of [Staff A] .were processed to determine if they have a criminal record containing disqualifying information. The results of their fingerprint based Comprehensive Criminal Background check shows that they HAVE DISQUALIFYING INFORMATION as delineated under federal and state law . Further review of the BCI revealed a handwritten note which states [Administrator] aware.
Review of a document titled, Case Summary filed on 4/14/2022 and closed on 4/6/2023 revealed, Staff A plead Nolo Contendere (when someone uses this phrase in a court setting, they are saying they do not wish to fight the charges against them. This plea is a way for a defendant to accept the consequences of their actions without admitting guilt) to the following charges and was convicted by a court of law:
- Domestic violence - simple assault (an intentional act that causes another person to fear imminent harmful or offensive contact, or causes minor bodily injury) and/or battery (unlawful physical contact), 1st offense
- Domestic violence - disorderly conduct, 1st offense
During a surveyor interview on 2/25/2025 at 2:31 PM with Administrator, in the presence of the Director of Nursing Services, she revealed that Staff A was hired at the end of January, and has since completed orientation, and is working independently on the 2nd floor as the team leader. She revealed that he was forthcoming with his disqualifying information on his BCI and indicated that when she spoke with him, he informed her that he had a domestic incident on his record. She revealed that she was under the impression, after speaking with him, that the charges were dismissed.
During a surveyor interview on 2/27/2025 at 8:08 AM, with the Administrator, she revealed that she had met with Staff A the previous night, and he indicated to her that he was under the impression the charges were resolved because he had completed all sentencing components, including probation and therapeutic services. She further revealed that he did go to court on 2/26/2024 and provided documentation which revealed he was charged and convicted of the crimes. Additionally, she revealed that he has not been back to the facility since this concern was identified by the surveyor and brought to the facility's attention and that a decision regarding his employment has not been determined.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice an...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive care plan relative to 1 of 3 wounds observed, Resident ID #137.
Findings are as follows:
Record review revealed Resident ID #137 was readmitted to the facility in October of 2024 with diagnoses including, but not limited to, acquired absence of right leg below the knee and acquired absence of left leg above the knee.
Review of a progress note dated 2/12/2025 revealed, the resident had an abrasion to his/her right knee.
Review of a progress note dated 2/19/2025 revealed, the resident has a wound to his/her right knee.
During a surveyor observation on 2/26/2025 at 10:00 AM, revealed a wound dressing to the resident's right knee wound with a date of 2/23/2025, 3 days prior to the wound observation.
Record review failed to reveal a physician's order to care for the right knee wound.
Record review failed to reveal evidence that at the time the wound was identified on 2/19/2025 that the wound documentation included the size of the wound, wound edges, the wound bed, shape, and the condition of surrounding tissue, per the regulation. Additional review failed to reveal evidence that the physician was notified of the wound or that an order was obtained to provide wound care.
During a surveyor interview on 2/26/2025 at 10:03 AM, with Licensed Practical Nurse, Staff H, she revealed that she was unable to find physician notification, a physician's order, or characteristics of the wound.
During a surveyor observation on 2/26/2025 at 10:04 AM, of the wound with Staff H, she removed the old dressing to reveal the right knee which was covered with blood. She then cleaned the area to reveal a U-shaped wound to the resident's right knee. Staff H acknowledged that the dressing she removed was dated 2/23/2025.
During a surveyor interview on 2/26/2025 at 2:45 PM, with the Director of Nursing Services, she acknowledged that there was no documentation regarding Resident ID #137's wound to his/her right knee and would expect there to be documentation of the characteristics per the regulation and an order for wound care and the physician to be notified of a new wound.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents with pressure ulcers receive the necessary treatment and ser...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents with pressure ulcers receive the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 1 resident observed with a pressure ulcer, Resident ID #3.
Findings are as follows:
According to Infection Control Assessment and Response (ICAR) Tool for General Infection Prevention and Control (IPC) Across Settings .Wound Care Facilitator Guide from the Centers for Disease Control and Prevention last revised on 1/27/2023, states in part, .Maintain separation between clean and soiled equipment to prevent cross contamination .Any unused disposable supplies that enter the patient/resident's care area should remain dedicated to that patient/resident or be discarded. They should not be returned to the clean supply area. If supplies are dedicated to an individual patient/resident, they should be properly labeled and stored in a manner to prevent cross-contamination or use on another patient/resident (e.g., in a designated cabinet in the patient/resident's room) .Containers entering patient/resident care areas should be dedicated for single-patient /resident use or discarded after use .
Review of a facility policy titled, Clean Dressing Technique dated January of 2018 states in part, .It is the policy of this facility to prevent the spread of infection by utilizing proper dressing change techniques .pour solutions into a clean container; prepare ointments, medication .using the no touch technique i.e., do not directly touch any item that will come in contact with the wound .
Record review revealed that Resident ID #3 was readmitted to the facility in October of 2024, with a diagnosis including, but not limited to, type 2 diabetes mellitus.
Review of a wound evaluation and management summary dated 2/18/2025, revealed that Resident ID #3 has a stage 3 pressure wound (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) of the left lateral foot for greater than 138 days. It further revealed that the wound had light serous drainage (clear to yellow fluid that leaks out of a wound).
Record review revealed a physician's order dated 2/13/2025 for the left lateral foot wound to cleanse the wound with wound cleanser, apply skin prep (skin protectant) to the surrounding wound, apply Silvadene (a cream used to treat or prevent serious infection on areas of skin) to the wound, and cover with island border gauze daily.
During a surveyor observation on 2/26/2025 at 9:03 AM, with Registered Nurse, Staff K, of Resident ID #3's wound care revealed, Staff K brought in the wound care supplies including a multiuse (a product used for more than one resident) Silvadene jar into Resident ID #3's room. He then proceeded to cleanse the wound and apply the Silvadene cream to the left lateral foot by sticking his gloved finger into the multiuse jar and then applied the Silvadene to the wound bed with his gloved finger. He failed to follow the no touch method described in the facility policy. After completion of the wound care, Staff K returned the multiuse jar into the treatment cart.
During a surveyor interview with Staff K immediately following the above-mentioned observation, he acknowledged that he brought a multiuse jar of Silvadene into Resident ID #3's room, utilized his gloved finger to apply the Silvadene on to the wound bed, and then returned the jar into the treatment cart. Additionally, he acknowledged that he did not follow the no touch method, per the facility policy.
During a surveyor interview on 2/26/2025 at approximately 3:00 PM, with the Director of Nursing Services, she revealed that she would expect the staff not to bring multiuse supplies into a resident's room. Additionally, she revealed that she would expect an applicator to be used when applying a cream to the wound.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed w...
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Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed with a nephrostomy tube (PCN, a catheter that is inserted through your skin and into your kidney), Resident ID #64.
Findings are as follows:
Record review revealed Resident ID #64 was admitted to the facility in February of 2025 with a diagnosis including, but not limited to, obstructive and reflux uropathy (a condition in which the flow of urine is blocked).
Record review of a hospital discharge document titled, Discharge Summary dated 2/6/2025 revealed an order to irrigate the PCN tube with 10 milliliters of normal saline daily and as needed.
Record review failed to reveal evidence that the PCN tube was flushed from 2/7/2025 until 2/27/2025, for a total of 21 days.
During a surveyor interview on 2/26/2025 at 10:29 AM with the resident, s/he indicated that his/her PCN tube was last flushed in the hospital prior to coming to the facility.
During a surveyor interview on 2/27/2025 at 1:06 PM, with Registered Nurse, Staff G, she revealed that the resident did not have an order to flush his/her PCN tube. She further acknowledged that the order from the hospital was never transcribed.
During a surveyor interview on 2/27/2025 at 1:34 PM with the Nurse Practitioner, Staff I, she indicated that the order was approved on admission and unaware it was not being completed, until brought to the facility's attention by the surveyor.
During a surveyor interview with the Administrator on 2/27/2025 at 2:40 PM she revealed that she would have expected the PCN tube to be flushed daily and the hospital order to be transcribed on admission.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 2 residents reviewed for war...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 2 residents reviewed for warfarin (Coumadin, a medication prescribed to prevent blood clots), Resident ID #23.
Findings are as follows:
Review of a policy titled Guidelines for Anticoagulation Management states in part, .When ordering the anticoagulant, the physician is to indicate the indication for the therapy and the desired therapeutic range .Whenever an anticoagulation therapy is administered it is to be monitored by evaluating the effect on the PT/INR [prothrombin time test/international normalized ratio, a test used to evaluate the therapeutic ranges for warfarin] .Any changes in coumadin dosage will be made accordingly. An order must be received from the MD [Medical Doctor] for the lab work .
Review of a document titled A Guide to Taking Warfarin created by the American Heart Association, states in part, .It's important to monitor the INR at least once a month and sometimes as often as twice weekly to make sure the level of warfarin remains effective. If the INR is too low, blood clots will not be prevented, but if the INR is too high, there is an increased risk of bleeding .
Record review revealed the resident was readmitted to the facility in August of 2024 with diagnoses including, but not limited to, lupus anticoagulant syndrome (an autoimmune disease characterized by malfunctioning antibodies) and a personal history of pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung).
Record review revealed a care plan focus area last revised 7/31/2024, the resident is on anticoagulant therapy with interventions that include, but not limited to; administer anticoagulant medications as ordered by the physician and to monitor for side effects and effectiveness routinely.
Record review revealed the following physician orders:
- 1/8/2025 for Warfarin, 3 milligram (mg) with instructions to administer one tablet, one time a day, and give 3 mg with 0.5 mg for a 3.5 mg total dose.
- 1/8/2025 for Warfarin, 1 mg with instructions to administer half a tablet one time a day and give 3 mg with 0.5 mg for a 3.5 mg total dose.
Review of document titled Lab Results Report dated 2/3/2025 revealed an INR value of 1.8 (therapeutic ranges for an oral anticoagulant is 2.0 - 3.0) indicating the resident had a low INR, increasing their risk for blood clot development.
Review of a progress note dated 2/5/2025 revealed the 2/3/2025 lab results were reviewed with the Nurse Practitioner (NP) and a new order was received to increase warfarin to 4 mg daily and to repeat the INR in 1 week.
Record review failed to reveal evidence that the resident's warfarin was increased to 4 mg daily, as ordered.
Further record review failed to reveal an INR was obtained one week later, as ordered by the provider. Additionally, record review failed to reveal evidence that an INR was obtained since 2/3/2025, 21 days after the order was received to recheck the INR.
During a surveyor interview on 2/26/2025 at 8:44 AM, with NP, Staff N, she revealed that she would have expected the facility to redraw the residents INR labs in one week and increase the warfarin to 4 mg when it was ordered.
During a surveyor interview on 2/26/2025 at 8:48 AM, with Licensed Practical Nurse, Staff J, he acknowledged that the resident was still receiving 3.5 mg of warfarin daily and acknowledged that the order to increase warfarin to 4 mg daily was not transcribed. Further, he acknowledged that the resident did not have another INR test completed one week after it was ordered by the NP on 2/5/2025.
During a surveyor interview on 2/26/2025 at 8:55 AM with the Director of Nursing Services, she acknowledged that the resident was still receiving warfarin 3.5 mg daily and that the order was not increased, as ordered by the NP on 2/5/2025. Further, she acknowledged that the resident's INR was not redrawn after one week, as ordered, and revealed it has not been drawn since 2/3/2025.
Review of document titled Lab Results Report dated 2/26/2025, obtained after this concern was brought to the facility's attention by the surveyor, revealed an INR value of 1.4, indicating the resident had a low INR further increasing the resident's risk for blood clot development.
Review of the February 2025 Medication Administration Record revealed the resident received a one-time dose of 7.5 mg of warfarin on 2/26/2025, after the lab results were reviewed by the physician.
Cross reference F 770
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
Laboratory Services
(Tag F0770)
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 obtain laboratory services to mee...
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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 obtain laboratory services to meet the needs of its residents for 1 of 2 reviewed for warfarin (Coumadin, a medication prescribed to prevent blood clots), Resident ID #23 and for 1 of 2 residents reviewed with an elevated white blood count (WBC), Resident ID #420.
Findings are as follows:
1. Review of a policy titled Guidelines for Anticoagulation Management states in part, .Whenever an anticoagulation therapy is administered it is to be monitored by evaluating the effect on the PT/INR [prothrombin time test/international normalized ratio, a test used to evaluate the therapeutic ranges for warfarin] .Any changes in Coumadin dosage will be made accordingly. An order must be received from the MD [Medical Doctor] for the lab work .
Review of a document titled A Guide to Taking Warfarin created by the American Heart Association, states in part, .It's important to monitor the INR at least once a month and sometimes as often as twice weekly to make sure the level of warfarin remains effective. If the INR is too low, blood clots will not be prevented, but if the INR is too high, there is an increased risk of bleeding .
Record review revealed the resident was readmitted to the facility in August of 2024 with diagnoses including, but not limited to, lupus anticoagulant syndrome (an autoimmune disease characterized by malfunctioning antibodies) and a personal history of pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung).
Record review revealed the resident is prescribed warfarin daily.
Review of document titled Lab Results Report dated [DATE] revealed an INR value of 1.8 (therapeutic ranges for an oral anticoagulant is 2.0 - 3.0) indicating the resident had a low INR increasing his/her risk for blood clot development.
Review of a progress note dated [DATE] revealed, Nurse Practitioner (NP), Staff N, gave an order to obtain an INR in 1 week.
Record review failed to reveal evidence that an INR test was obtained one week later, as ordered by the provider.
Further record review failed to reveal an INR was obtained since [DATE], 21 days after the order was received to recheck the INR.
During a surveyor interview on [DATE] at 8:44 AM, with NP, Staff N, she revealed that she would have expected the facility to redraw the resident's INR labs in one week, as ordered.
During a surveyor interview on [DATE] at 8:48 AM, with Licensed Practical Nurse, Staff J, he acknowledged that an INR test was not obtained one week after it was ordered by the NP on [DATE] and acknowledged that an INR test had not been obtained since [DATE].
During a surveyor interview on [DATE] at 8:55 AM with the Director of Nursing Services (DNS), she acknowledged that the resident's INR was not redrawn after one week, as ordered by the NP, and that an INR had not been obtained since [DATE].
Review of document titled Lab Results Report dated [DATE], obtained after this concern was brought to the facility's attention by the surveyor, revealed an INR value of 1.4, indicating the resident had a low INR further increasing Resident ID #23's risk for blood clot development.
2. Record review of a community reported complaint submitted to the Rhode Island Department of Health on [DATE], alleges concerns regarding quality of care related to the completion of a medical work up.
Review of an undated policy titled Notification of Clinicians states in part, .Purpose: This facility acknowledges that prompt follow up to abnormal results of lab tests, x-ray and other diagnostic testing is essential to the promote the highest physical well-being of our residents. It is the policy of this facility to ensure that prescribing practitioners (physician, physicians' assistants, nurse practitioner, or clinical nurse specialist) are notified of laboratory, radiology and other diagnostic test results that fall outside of clinical reference ranges in a timely manner/or as per physicians' orders. PROCEDURE: 1. The results of laboratory, radiology and other diagnostic tests will be reviewed by the unit nurse on the same day that they are received by the facility. 2. Any results of laboratory, radiology and other diagnostic tests that fall outside of the clinical reference range will require notification to the prescribing practitioner as per their specific orders or within the shift it was received. 3. When necessary if the results (outside of the clinical reference range) were not able to be reported to the prescriber on the shift they were received; they will be called/reported on the next shift .
Record review revealed Resident ID #420 was readmitted to the facility in September of 2024 with diagnoses including, but not limited to, neutropenia (a condition characterized by low levels of white blood cells, which protect the body from infections) and sepsis (a condition that arises when the body's response to infection causes injury to its own tissues and organs).
Review of a lab results report dated [DATE] revealed the resident's WBC's count was 16.8 (normal range is 4.0 - 10.0 thousands per cubic milliliter (K/uL), elevated WBC could indicate an infection) indicating that Resident ID #420 could have an infection.
Record review revealed a physician order dated [DATE] for a urinalysis with culture and sensitivity (U/A C&S) to be obtained via clean catch (a method of collecting urine for testing that aims to prevent contamination) or straight catheter (a flexible tube inserted into the bladder to drain urine) method, per the provider, due to the resident's elevated WBC.
Review of the [DATE] Medication Administration Record revealed the UA C&S order was documented as 5 on [DATE], indicating it was not completed and to see progress notes.
Review of the progress notes revealed an administration note dated [DATE] indicating the U/A C&S was unable to be obtained.
Record review failed to reveal evidence that the U/A C&S ordered on [DATE] was obtained, or the provider was notified in a timely manner that the U/A C&S was unable to be obtained.
Review of a document titled medications not received revealed Resident ID #420's UA C&S was documented as not obtained on [DATE]. Further review revealed the NP signed the document on [DATE], 16 days after the UA C&S was ordered.
Review of a lab results report dated [DATE] revealed the resident's WBC was 15.1 K/uL.
Record review failed to reveal evidence that the physician or NP were notified of the residents WBC on [DATE].
Review of a lab results report dated [DATE] revealed the resident's WBC was 17.5 K/uL.
Record review revealed the NP was notified of the resident's high WBC on [DATE], two days after the value was identified, and not on the same day that they are received or the next shift, per the facility policy.
Further record review revealed that on [DATE] the resident was sent to the hospital.
Review of hospital documentation dated [DATE] revealed that the resident arrived at the hospital after an acute mental status change and was hypotensive (low blood pressure less than 90) in the 80's. S/he was given one liter of normal saline. Additionally, the document revealed that the history from the patient was limited due to his/her altered mentation (mental status), lethargy and confusion. Furthermore, the hospital documentation revealed that on [DATE] the resident had an elevated WBC of 18.9. The resident was eventually transitioned to hospice service and expired while at the hospital.
During a surveyor interview on [DATE] at 8:59 AM with Licensed Practical Nurse, Staff P, she revealed that she was the nurse on duty on [DATE] and reported the laboratory results to the provider. She revealed that the resident was more confused with increased weakness and was becoming more incontinent of urine. She revealed that she reported the laboratory results from [DATE] on [DATE] and the facility was going to obtain a complete workup including an additional U/A C&S. Additionally, she she was unable to provide evidence that the provider was notified of the laboratory results from [DATE] or that the U/A C&S was obtained as ordered on [DATE] or that the provider was notified of the inability to obtain the urine specimen.
During a surveyor interview on [DATE] at 9:40 AM with NP, Staff I, she revealed that when she is notified of abnormal laboratory results, she completes a workup, and indicated that if she had been notified, she would have done something in this scenario. Additionally, she revealed that she saw the resident on [DATE] but when she reviewed her documentation, she was unable to find evidence that the facility notified her of the increase in WBC on [DATE] or the increase in the WBC on [DATE] until [DATE]. Furthermore, she revealed that when she was reviewing her documentation that she was unable to provide evidence that she was notified that the U/A C&S was not obtained. Furthermore, she revealed she would expect to be notified if a resident had an elevated WBC or if there was an inability to obtain a U/A C&S.
During a surveyor interview on [DATE] at 10:15 AM, with the Administrator and the DNS, they were unable to provide evidence of documentation for the missing labs.
During a subsequent surveyor interview on [DATE] at 11:26 AM with the Administrator, she revealed that she would expect the staff to continue to attempt to obtain a U/A C&S if a urine is ordered. Additionally, she was unable to provide evidence Resident ID #420's laboratory results were reported in a timely manner, per the facility policy or obtained, per the regulation and physician orders.
Cross reference F 760
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
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 the assessment accura...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that the assessment accurately reflected the resident's status for 2 of 2 residents reviewed for dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to.), Resident ID #s 35 and 137, 1 of 2 residents reviewed for elopement, Resident ID #161, 1 of 2 residents reviewed for wounds infected with a Multidrug Resistant Organism (MDRO), Resident ID #83 and 1 of 2 closed records reviewed, Resident ID #169.
Findings are as follows:
1. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual last revised in October 2024 states in part, .Code peritoneal or renal dialysis which occurs at the nursing home or at another facility .
1a. Record review revealed Resident ID #35 was admitted to the facility in July 2018 with a diagnosis including, but not limited to, diabetes mellitus.
Review of a Minimum Data Set (MDS) assessment dated [DATE], Section O, titled, Special Treatments, Procedures, and Programs revealed the resident was checked off for receiving dialysis while a resident during the 7-day look-back period.
Record review failed to reveal evidence that Resident ID #35 was receiving dialysis treatments.
1b. Record review revealed Resident ID #137 was readmitted to the facility in October 2024 with diagnoses including, but not limited to, dependence on renal dialysis and end stage renal disease.
Record review of a care plan last revised 5/20/2024 revealed that Resident ID #137 requires dialysis related to renal failure.
Review of a physician's order dated 10/17/2024 revealed that Resident ID #137 receives dialysis 3 days per week.
Review of a MDS assessment dated [DATE], Section O, titled, Special Treatments, Procedures, and Programs revealed the resident was not checked off for dialysis while a resident during the 7-day look-back period.
2. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual last revised in October 2024 states in part, Identify all alarms that were used at any time (day or night) during the 7-day look-back period, code the frequency of use: Code 0, not used: if the device was not used during the 7-day look-back period. Code 1 used less than daily .Code 2, used daily .Wander/elopement alarm includes devices such as bracelets [wander guard] .that activate an alarm and/or alert the staff when the resident nears or exits .
Record review revealed Resident ID #161 was admitted to the facility in October 2024 with a diagnosis including, but not limited to, dementia.
Record review revealed the following physician's orders:
-10/30/2024 Check wander guard functionality every night for safety.
-10/30/2024 Check wander guard placement location-left wrist every shift.
-1/27/2025 Wander guard expires 2/24/2026.
Record review of the January and February 2025 Medication Administration Report revealed the above orders were signed off as completed daily from 1/30/2025 through 2/5/2025.
Review of a MDS assessment dated [DATE], Section P, titled, Alarms revealed the resident was not coded for the use of a wander guard during the 7-day look-back period.
3. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual last revised in October 2024 states in part, Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period .
Record review revealed Resident ID #83 was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, methicillin-resistant Staphylococcus aureus (MRSA is a MDRO that causes infections in different parts of the body).
Record review revealed that Resident ID #83 tested positive for MRSA in his/her leg wound on 3/4/2024.
Record review revealed that Resident ID #83's leg wound tested positive again for MRSA in November of 2024.
Review of a MDS assessment dated [DATE], Section I, titled, Active Diagnoses in the Last 7 Days revealed the resident was not coded for having an active diagnosis of an MDRO.
4. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual last revised in October 2024 states in part, Review the medical record including the discharge plan and discharge orders for documentation of discharge location .
Record review revealed Resident ID #169 was admitted to the facility in January of 2025 with diagnoses including, but not limited to, status post fall and pain.
Record review of a nursing progress note dated 1/27/2025 revealed that Resident ID #169 was discharged home with services on 1/27/2025.
Review of a MDS assessment dated [DATE], Section A, titled, Discharge Status revealed the resident was coded for a planned discharge to the hospital.
During a surveyor interview on 2/27/2025 at 11:04 AM, with the MDS Coordinator, she revealed that the MDS assessments for Resident ID #s 35, 83, 137, 161 and 169 were coded in error and would be modified with the correct information after being brought to the facility's attention by the surveyor.
During a surveyor interview on 2/27/2025 at 2:42 PM, with the Administrator, she acknowledged that the above MDS assessments for Resident ID #s 35, 83, 137, 161 and 169 were coded inaccurately.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to review and revise the resident's care plan by the interdisciplinary team after each assessment, including...
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Based on record review and staff interview, it has been determined that the facility failed to review and revise the resident's care plan by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments relative to 29 of 29 long term care residents reviewed, Resident ID #s, 3, 5, 6, 9, 10, 15, 21, 22, 23, 25, 29, 35, 38, 44, 67, 70, 75, 78, 83, 88, 95, 123, 129, 137, 139, 140, 142, 161, and 520.
Findings are as follows:
1. Record review revealed Resident ID #3 was originally admitted to the facility in May of 2024 with diagnoses including, but not limited to, diabetes mellitus type 2 and chronic heart failure.
Record review revealed the most recent Quarterly Minimum Data Set (MDS) Assessment was completed on 12/17/2024.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
2. Record review revealed Resident ID #5 was originally admitted to the facility in September of 2025 with diagnoses including, but not limited to, diabetes mellitus type 2 and chronic pain.
Record review revealed the most recent Quarterly MDS Assessment was completed on 1/17/2025.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
3. Record review revealed Resident ID #6 was originally admitted to the facility in December of 2022 with diagnoses including, but not limited to, anxiety disorder and high blood pressure.
Record review revealed the most recent Quarterly MDS Assessment was completed on 1/25/2025.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
4. Record review revealed Resident ID #9 was admitted to the facility in February of 2011 with diagnoses including, but not limited to, epilepsy and dementia.
Record review revealed the most recent Quarterly MDS Assessment was completed on 12/14/2024.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
5. Record review revealed Resident ID #10 was admitted to the facility in June of 2021 with diagnoses including, but not limited to, repeated falls and pulmonary infection.
Record review revealed the most recent Quarterly MDS Assessment was completed on 12/23/2024.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
6. Record review revealed Resident ID #15 was originally admitted to the facility in November of 2019 with diagnoses including, but not limited to, diabetes mellitus type 2 and muscle weakness.
Record review revealed the most recent Quarterly MDS Assessment was completed on 12/18/2024.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
7. Record review revealed Resident ID #21 was originally admitted to the facility in February of 2022 with diagnoses including, but not limited to, heart failure and acute respiratory failure.
Record review revealed the most recent Quarterly MDS Assessment was completed on 12/26/2024.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
8. Record review revealed Resident ID #22 was originally admitted to the facility in February of 2024 with diagnoses including, but not limited to, dementia and acute respiratory failure.
Record review revealed the most recent Comprehensive MDS Assessment was completed on 12/16/2024.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the comprehensive assessment.
9. Record review revealed Resident ID #23 was originally admitted to the facility in July of 2024 with diagnoses including, but not limited to, seizures and dementia.
Record review revealed the most recent Quarterly MDS Assessment was completed on 2/5/2025.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
10. Record review revealed Resident ID #25 was re-admitted to the facility in June of 2024 with diagnoses including, but not limited to, seizures and a history of falling.
Record review revealed the most recent Quarterly MDS Assessment was completed on 2/3/2025.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
11. Record review revealed Resident ID #29 was originally admitted to the facility in March of 2021 with diagnoses including, but not limited to, kidney failure and dementia.
Record review revealed the most recent Comprehensive MDS Assessment was completed on 1/14/2025.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the comprehensive assessment.
12. Record review revealed Resident ID #35 was originally admitted to the facility in July of 2018 with diagnoses including, but not limited to, diabetes mellitus type 2 and epilepsy.
Record review revealed the most recent Quarterly MDS Assessment was completed on 1/29/2025.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
13. Record review revealed Resident ID #38 was originally admitted to the facility in April of 2023 with diagnoses including, but not limited to, diabetes mellitus type 2 and end stage renal disease (kidney disease).
Record review revealed the most recent Quarterly MDS Assessment was completed on 12/9/2024.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
14. Record review revealed Resident ID #44 was originally admitted to the facility in December of 2020 with diagnoses including, but not limited to, diabetes mellitus and chronic obstructive pulmonary disorder (COPD).
Record review revealed the most recent Quarterly MDS Assessment was completed on 1/22/2025.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
15. Record review revealed Resident ID #67 was admitted to the facility in September of 2023 with diagnoses including, but not limited to, seizures and dementia.
Record review revealed the most recent quarterly MDS Assessment was completed on 12/25/2025.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
16. Record review revealed Resident ID #70 was originally admitted to the facility in November of 2023 with diagnoses including, but not limited to, COPD and muscle weakness.
Record review revealed the most recent Quarterly MDS Assessment was completed on 2/1/2025.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
17. Record review revealed Resident ID #75 was originally admitted to the facility in February of 2022 with diagnoses including, but not limited to, epilepsy and acute kidney failure.
Record review revealed the most recent Quarterly MDS Assessment was completed on 1/17/2025.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
18. Record review revealed Resident ID #78 was originally admitted to the facility in July of 2022 with diagnoses including, but not limited to, diabetes mellitus type 2 and seizures.
Record review revealed the most recent Quarterly MDS Assessment was completed on 1/1/2025.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
19. Record review revealed Resident ID #83 was originally admitted to the facility in December of 2023 with diagnoses including, but not limited to, acute kidney failure and difficulty walking.
Record review revealed the most recent Comprehensive MDS Assessment was completed on 12/23/2024.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the comprehensive assessment.
20. Record review revealed Resident ID #88 was originally admitted to the facility in September of 2023 with diagnoses including, but not limited to, chronic kidney disease and post-traumatic stress disorder.
Record review revealed the most recent Quarterly MDS Assessment was completed on 12/17/2024.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
21. Record review revealed Resident ID # 95 was originally admitted to the facility in July of 2020 with diagnoses including, but not limited to, COPD and mood disorder.
Record review revealed the most recent Quarterly MDS Assessment was completed on 2/5/2025.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
22. Record review revealed Resident ID #123 was originally admitted to the facility in December of 2022 with diagnoses including, but not limited to, diabetes mellitus type 2 and dementia.
Record review revealed the most recent Quarterly MDS Assessment was completed on 2/19/2025.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
23. Record review revealed Resident ID #129 was originally admitted to the facility in October of 2022 with diagnoses including, but not limited to, dementia and muscle weakness.
Record review revealed the most recent Quarterly MDS Assessment was completed on 12/24/2024.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
24. Record review revealed Resident ID #137 was originally admitted to the facility in July of 2024 with diagnoses including, but not limited to, end stage renal disease (kidney disease) and altered mental status.
Record review revealed the most recent Quarterly MDS Assessment was completed on 2/3/2025.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
25. Record review revealed Resident ID #139 was originally admitted to the facility in September of 2023 with diagnoses including, but not limited to, repeated falls and pulmonary infection.
Record review revealed the most recent Quarterly MDS Assessment was completed on 1/17/2025.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
26. Record review revealed Resident ID #140 was admitted to the facility in October of 2023 with diagnoses including, but not limited to, dementia and COPD.
Record review revealed the most recent Quarterly MDS Assessment was completed on 1/10/2025.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
27. Record review revealed Resident ID #142 was admitted to the facility in July of 2024 with diagnoses including, but not limited to, dementia and protein-calorie malnutrition.
Record review revealed the most recent Quarterly MDS Assessment was completed on 1/29/2025.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
28. Record review revealed Resident ID #161 was admitted to the facility in October of 2024 with a diagnosis including, but not limited to, dementia.
Record review revealed the most recent Quarterly MDS Assessment was completed on 2/5/2025.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment.
During a surveyor interview on 2/25/2025 at 8:19 AM, with Resident ID #161's family member, when asked by the surveyor if s/he attended the resident's care plan meetings, s/he revealed that s/he did not know what a care plan meeting was and indicated that s/he has never attended one.
29. Record review revealed Resident ID #520 was originally admitted to the facility in March of 2020 with diagnoses including, but not limited to, acute and chronic respiratory failure.
Record review revealed the most recent Comprehensive MDS Assessment was completed on 1/19/2025.
Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the comprehensive assessment.
During a surveyor interview with multiple residents, during the Resident Council task on 2/25/2025 at approximately 1:05 PM, they indicated that they were not typically involved in care plan meetings.
During a surveyor interview on 2/27/2025 at 12:46 PM with MDS Nurse, Staff B, she indicated that care plan meetings are held quarterly to review and revise the care plans for every resident and that documentation of the meetings are kept in a binder or documented in the resident's progress notes. She indicated that a physician isn't typically included in the care plan meetings. Furthermore, she indicated that sometimes she needs to work on the floor and doesn't have time to hold the care plan meetings, as required.
During a surveyor interview on 2/27/2025 at 1:03 PM with the Director of Nursing Services and the Administrator, they indicated that care plan meetings should be held quarterly. They further indicated that the Nursing Assistant's and the physicians aren't typically included in care plan meetings. Additionally, they could not provide evidence that the above mentioned residents' care plans were reviewed and revised, as required, by interdisciplinary team.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice for 1 of 1 resident reviewed ...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice for 1 of 1 resident reviewed relative to Narcan administration, Resident ID #25, 2 of 6 residents reviewed for following physician orders relative to unnecessary medication, Resident ID #s 44 and 123, 1 of 1 resident seen by the podiatrist, Resident ID #78, 1 of 2 residents observed with a non-pressure wound, Resident ID #83 and 1 of 3 residents receiving a medication that requires blood levels to be monitored, Resident ID #95.
Findings are as follows:
1. According to the facility policy titled Narcan Administration, states in part, .Policy: Narcan administration is for the occurrence of an opioid overdose. An opioid overdose is an acute condition in the case of excessive opioid use. Narcan should be administered in emergency cases of overdose .
PROCEDURE:
1. An assessment for substance use disorder (SUD) will be done upon admission for each resident .
2. Consideration of a clinical overdose could include: use of opioids, known history of substance use disorder, slow or no breathing, gurgling, gasping or snoring, cool/clammy skin, cyanosis [bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation] .
4. Attempt to verbally arouse the resident. Use a sternal rub if the resident is unconscious and is to be used prior to determining an opioid overdose .
7. Clinical Overdose is classified as having
-a respiratory rate of 8-10 or lower per minute
-inability to arouse/unconscious-pinpoint pupils .
9. If a resident meets criteria of clinical overdose, ensure there are 2 staff members present through the administration of Narcan
10. Procedure for initiating Narcan administration:
-Call 911 and report possible overdose with plan to administer Narcan & retrieve crash/emergency cart .
-Stay with resident until rescue arrives .
Record review revealed Resident ID #25 was readmitted to the facility in June of 2024 with diagnoses including, but not limited to, seizures and muscle weakness.
Record review revealed a nursing progress note dated 2/15/2025 indicating that the resident was noted with slurred speech, dilated pupils and leaning forward with his/her head down. The resident's vital signs were as follows; blood pressure 126/73 (normal range 100/65 to 120/80), heart rate 68 (normal range 60-100), respirations 16 (normal range 12-20), temperature 97.8 (normal range 97-99), pulse oximetry (blood oxygen level) was 94% (normal range 95-100%) on room air, and the blood sugar was 156 (normal level between 70-100). Upon further assessment, the resident had difficulty staying awake and was coughing with liquids. The on call provider was notified and orders were received to obtain blood work, a urine specimen, and to administer Narcan 0.4 milligram (mg) intranasally for a one time administration. Further review revealed the Narcan was administered, as ordered.
Record review failed to reveal evidence that an SUD Assessment was completed upon admission, per the facility policy. Further record review failed to reveal evidence that the resident had an order for an opioid medication.
During a surveyor interview on 3/3/2025 at 11:30 AM with Licensed Practical Nurse (LPN), Staff C, she was unable to provide evidence that an SUD Assessment was completed for the resident. Additionally, she acknowledged that the resident's clinical presentation on 2/15/2025, was not indicative of a narcotic overdose, per the facility policy.
During a surveyor interview on 3/3/2025 at 11:46 AM with LPN, Staff D, she revealed that when she went to administer the resident his/her medications on 2/15/2025, the resident was lethargic but arousable. She further revealed that she contacted the on-call provider, reviewed the resident's medications and the provider ordered lab work, diagnostic testing and Narcan. Staff D revealed she also performed a sternal rub and that the resident would awaken but then become lethargic again. Staff D revealed she was not familiar with the Narcan policy and after reviewing the policy with the surveyor, Staff D acknowledged that the resident's pupils were not pinpoint, rather very dilated, s/he was arousable at times and his/her vital signs were normal. Additionally, Staff D revealed she did not call 911 per the facility policy.
During a surveyor interview on 3/3/2025 at 11:43 AM with the Administrator, she was unable to provide evidence that the facility policy was followed related to a SUDs Assessment, the assessment of a resident to meet the criteria of an overdose, and to call 911 prior to the administration of Narcan.
2a. 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 Resident ID #44 was admitted to the facility in December of 2020 with a diagnosis including, but not limited to, ocular hypertension (a condition where the pressure in the eye is higher than normal).
Record review revealed a physician's order dated 11/11/2021 for Latanoprost Solution 0.005 % (a medication prescribed to reduction the fluid pressure inside the eye) eye drops, instill 1 drop in both eyes at bedtime.
During a surveyor interview and simultaneous observation with the resident in his/her room on 2/27/2025 at 9:24 AM, s/he revealed that s/he has not been receiving his/her Latanoprost eye drops at bedtime. S/he further revealed that the eye drops are left at his/her bedside for him/her to administer, but they have not been available for approximately two to four weeks. Additionally, s/he revealed that s/he has been told by staff that they have been waiting for the pharmacy to deliver the eye drops. Surveyor observation of the resident's room failed to reveal evidence of the Latanoprost eye drops.
Record review revealed a completed Self-Administer Screening document, dated 4/28/2023 for the Latanoprost eye drops. Further review of the document indicates the resident is completely safe to administer the medication and that the eye drops can be left at his/her bedside.
Record review of the February 2025 Medication Administration Record (MAR) from 2/1/2025 through 2/27/2025 revealed the Latanoprost eye drops were signed off as administered.
During a surveyor interview and simultaneous observation on 2/27/2025 at 9:50 AM with Registered Nurse, Staff E, she acknowledged that the Latanoprost eye drops were signed off as administered and according to the MAR documentation, the eye drops were last ordered from the pharmacy on 12/25/2024. During the interview with Staff E, she was unable to locate the Latanoprost eye drops.
During a surveyor interview on 2/27/2025 at approximately 9:55 AM with Medication Aide, Staff F, he acknowledged that the Latanoprost eye drops were not in the medication cart and that they are kept at the resident's bedside for him/her to administer.
During a subsequent interview on 2/27/2025 at approximately 10:00 AM with Staff E, she placed a call to the pharmacy in the presence of the surveyor, to inquire about the eye drops. Staff E was told by the pharmacist that the eye drops were last ordered on 12/25/2025 and that they were never re-ordered.
During a surveyor interview on 2/27/2025 at 11:39 AM with the Director of Nursing Services (DNS), she revealed that she would have expected the nurse to call the pharmacy to ensure the delivery of the medication. Additionally, she could not provide evidence that the Latanoprost eye drops were administered, as ordered, from 2/1/2025 through 2/27/2025.
2b. Record review revealed Resident ID #78 was readmitted to the facility in December of 2024 with diagnoses including, but not limited to, diabetes mellitus and a right hallux (great toe) infection.
Record review revealed the resident was evaluated by the podiatrist on 2/24/2025 and recommendations were made for a treatment to cleanse the wound with Betadine (an antiseptic solution used for skin disinfection) and to apply triple antibiotic ointment, twice daily for 10 days, then leave it open to air.
Record review of a nursing progress note dated 2/24/2025 revealed the resident's provider was notified and in agreement with the podiatrist's treatment recommendations.
Record review of the physician's orders failed to reveal evidence that the above podiatrist's recommendations were implemented.
During a surveyor interview on 3/3/2025 at 8:51 AM with Registered Nurse, Staff G, she acknowledged that the podiatrist's recommendations had not been implemented.
During a surveyor interview on 3/3/2025 at 9:02 AM with the DNS, she acknowledged that the podiatrist's recommendations were not implemented for the resident's wound, as ordered.
2c. Review of a facility policy titled, Clean Dressing Technique dated January of 2018 states in part, .It is the policy of this facility to prevent the spread of infection by utilizing proper dressing change techniques .Check the physician order for current, correct treatment .Open supplies onto the clean field .Remove gloves. Wash hands. (Hand sanitizer may be used) Apply clean gloves .using the no touch technique i.e., do not directly touch any item that will come in contact with the wound .Apply any medication ordered and dress wound. Remove gloves and wash hands .
Record review revealed Resident ID #83 was originally admitted to the facility in December of 2023 with diagnoses including, but not limited to, chronic venous hypertension with an ulcer (a condition characterized by elevated venous pressure, which leads to vein dilation, skin changes, and wounds) and a Methicillan Resistant Staphylococcus Aureus (multidrug resistant bacteria).
Record review of the physician's orders revealed a treatment order dated 2/13/2025 to cleanse the wound with Vashe Solution (wound cleanser to clean, irrigate, and remove infected or damaged tissue), apply A&D ointment around the wound, then apply Adaptic (a nonadherent petrolatum gauze that is applied in the base of the wound bed) followed by blue foam moistened with normal saline, cover with an absorbent pad, wrap with gauze roll, and then wrap with ACE bandages.
During a surveyor observation of a wound dressing change on 2/27/2025 at 10:03 AM with LPN, Staff H, revealed she failed to perform hand hygiene between glove changes and used a gloved finger to apply the A & D ointment rather than an applicator. Additionally, she failed to cut the Adaptic gauze to the size of the wound bed and failed to apply the ace bandages, as ordered.
During a surveyor interview on 2/27/2025 at 10:44 AM and at 11:26 AM with Staff H, she acknowledged that she failed to perform hand hygiene between glove changes, did not cut the Adaptic gauze, and used her gloved hand to apply the ointment as she left the applicator on the cart. Additionally, she acknowledged that she had forgotten to apply the resident's ace bandages.
2d. Record review revealed Resident ID #123 was admitted to the facility in December of 2022 with a diagnosis including, but not limited to, high cholesterol.
Record review revealed the resident had blood work obtained for a lipid panel (various levels of fats in the blood including cholesterol and triglyceride levels).
Record review of a provider progress note dated 2/7/2025 authored by the Nurse Practitioner (NP), Staff I, indicated the resident has slightly elevated cholesterol levels and she indicated in her plan to implement a low dose of Atorvastatin 20 mg, every night, at hour of sleep.
Record review of the physician's orders failed to reveal evidence of an order for Atorvastatin.
During a surveyor interview on 3/3/2025 at 11:21 AM with LPN, Staff J, he acknowledged that the resident does not have an order for Atorvastatin.
During a surveyor interview on 3/3/2025 at 11:24 AM with NP, Staff I, she acknowledged that she ordered for the resident to receive Atorvastatin 20 mg, at hour of sleep.
3. According to Mosby's Fundamentals of Nursing Concepts, Process and Practice, 4th Edition, on page 809, .A Registered Nurse checks all transcribed orders against the original order for accuracy and thoroughness.
Record review revealed Resident ID #123 was admitted to the facility in December of 2022 with a diagnosis including, but not limited to, conditions of the skin.
Record review revealed a physician's order dated 2/18/2025 for Triamcinolone Acetonide cream (a topical cream prescribed to treat skin conditions) 0.025 %, apply to rashes topically, two times a day, for rashes. Further review of the order failed to reveal evidence of a location indicated for the cream to be applied.
During a surveyor observation and simultaneous interview on 2/27/2025 at 10:57 AM with LPN, Staff B, she revealed that she was not certain where the Triamcinolone cream was to be applied. Staff B further revealed that the resident's previous cream order was for the top of the resident's feet and back of legs. During an observation of the resident's feet and their legs, no rash wash observed. Additionally, Staff B acknowledged that the Triamcinolone order did not indicate a location for where the cream is to be applied.
During a surveyor interview on 2/27/2025 at 11:47 AM with the DNS, she revealed that she would have expected the Triamcinolone order to include a location for the treatment and she acknowledged that it did not.
4. According to Lippincott Nursing Procedures, 9th edition, states in part, .Anticipate monitoring for therapeutic levels of any antiseizure medications that the patient is taking .
Record review revealed Resident ID #95 was initially admitted to the facility in August of 2020 with diagnoses including, but not limited to, major depressive disorder, psychotic disturbance, mood disturbance, and convulsions (involuntary, rhythmic muscle contractions that can be a symptom of seizures).
Record review of the physician's orders revealed the resident has been receiving Valproic Acid (a medication prescribed to treat seizures and certain behavioral disorders), delayed release 250 mg, twice daily, since 4/21/2024.
Record review failed to reveal evidence that a Valproic Acid level was obtained by the facility and monitored.
During a surveyor interview on 2/28/2025 at 3:08 PM with LPN, Staff C, she was unable to provide evidence that a Valproic Acid level had been obtained.
Record review of a nursing progress note dated 3/3/2025 at 10:05 AM, authored by Staff C, revealed that she had contacted the resident's provider relative to there not being a Valproic Acid level and that the provider ordered a Valproic Acid level to be obtained every 6 months with routine lab work, after it was brought to the facility's attention by the surveyor.
During a surveyor interview with the facility's Pharmacy Consultant on 3/3/2025 at 9:10 AM, she revealed that she would expect a Valproic Acid level to be ordered by the provider, every 6 months.
An attempt was made to conduct a telephone interview on 3/3/2025 at 9:44 AM by the surveyor with the resident's physician and NP. A message was left for both providers, however no return call was received.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, 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 suctioning, Resident ID #96.
Findings are as follows:
Record review revealed Resident ID #96 was admitted to the facility in January 2025 with diagnoses including, but not limited to, dysphagia (a condition resulting in difficulty swallowing food or liquid), aspiration pneumonia (infection of the lungs caused by inhaling saliva, food, liquid, vomit), and acute respiratory failure.
Record review of a facility document titled, Policy for Suctioning a Patient states in part, .The purpose of this policy is to establish clear and comprehensive guidelines for performing suctioning procedures to maintain airway patency, prevent respiratory distress and ensure patient safety .infection control: Use sterile technique for invasive suctioning. Dispose of used catheters and gloves appropriately. Clean and disinfect suction equipment after each use .
Record review of a physician's order dated 2/19/2025 revealed to suction as needed for increased secretions.
Record review of the February 2025 Medication Administration Record revealed the above order was signed off as completed on 2/19/2025.
Record review of a nursing progress note dated 2/19/2025 states in part, .Increased secretions noted, suctioned with good effect .
Record review of a medication administration note dated 2/19/2025 states, suction as needed for increased secretions as needed: large amount of viscus[sic] sputum (thick, sticky sputum).
During multiple surveyor observations from 2/24/2025 through 2/26/2025 revealed a suction canister and tubing with no date. The canister contained multi-colored secretions with floating sediment and tan colored fluid within the tubing.
During a surveyor interview on 2/26/2025 at 10:01 AM following the above-mentioned observation with Registered Nurse, Staff G, she revealed that she was unsure what date/time the suction machine was last used or how long the secretions had been in the canister. Additionally, she was unsure of when to clean or change the equipment.
Record review failed to reveal evidence of when to change, clean or replace the suction equipment.
During a surveyor interview with the Director of Nursing Services on 2/26/2025 at 2:40 PM, she revealed that she would have expected the canister and the tubing to be dated and discarded after 24 hours.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principl...
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Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 3 of 8 medication carts observed on 3 of 4 units and 1 of 2 medication storage rooms observed.
Findings are as follows:
1. During a surveyor observation on 2/26/2025 at 3:57 PM of the 3rd floor medication room, in the presence of Licensed Practical Nurse, Staff J the following was revealed:
-One bottle of Lorazepam Intensol, opened without a date. Review of the manufacturer's instructions indicate to discard the Lorazepam 90 days after opening.
During a surveyor interview with Staff J, he acknowledged that the Lorazepam Intensol was opened without a date and revealed medications should be dated when opened.
2. During a surveyor observation on 2/26/2025 at approximately 10:30 AM of a 2nd floor unit medication cart, in the presence of Certified Medication Technician (CMT), Staff F, the following was revealed:
-One bottle of Active Critical Care Protein supplement, opened without a date. Review of the manufacturer instructions indicates the protein supplement expires 90 days after opening.
-One Incuse inhaler 62.5 micrograms (mcg), opened without a date. Review of the manufacturer's instructions indicate to discard the inhaler 6 weeks after opening.
-One Fluticasone propionate 500/50 mcg inhaler, opened without a date. Review of the manufacturer's instructions indicate to discard the inhaler 6 weeks after opening.
During a surveyor interview immediately following the above observations with Staff F, he revealed that medications should be dated when opened.
3. During a surveyor observation on 2/26/2025 at approximately 11:00 AM of a ground level unit medication cart, in the presence of CMT, Staff O the following was revealed:
-One Wixela 500/50 mcg inhaler, opened without a date. Review of the manufacturer's instructions indicate to discard the inhaler one month after opening.
During a surveyor interview on 2/26/2025 immediately following the observation with Staff O, she acknowledged the inhaler was opened without a date and should have been dated when opened.
4. During a surveyor observation on 2/26/2025 at 3:43 PM in the presence of Registered Nurse, Staff K, of the controlled substance locked box located in a 1st floor medication cart, the following was revealed:
Record review of the narcotic book indicated Resident ID #151 has an order to receive Oxycodone 5 mg every 6 hours, as needed for pain. Record review of the resident's available Oxycodone revealed the narcotic count log indicated s/he had 27 tablets remaining. Review of the pharmacy blister pack, containing the Oxycodone medication, revealed the resident had 26 tablets remaining, indicating there was 1 tablet that was not accounted for.
During a surveyor interview immediately following the observation with Staff K, he revealed that he had administered the resident his/her Oxycodone earlier at approximately 8:00 AM this morning and forgot to sign the medication out of the narcotic count log. When Staff K was asked to provide evidence of when he administered the Oxycodone in the Electronic Medication Administration Record (EMAR), he was unable to do so, stating he had forgotten to sign the medication off as administered in the EMAR.
During a surveyor interview on 2/26/2025 at 4:38 PM with the Administrator, she revealed that when a controlled medication is administered, she would expect the 5 rights and checks to be followed, and that the medication is signed off as administered in both the EMAR and the narcotic book.
During a surveyor interview on 2/27/2025 at approximately 11:30 AM with the Director of Nursing Services, she revealed that she would expect that the above medications listed to be dated when opened.
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 F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide food that is palatable, attractive, and at an appetizing temperature.
Findings are as follows:
Record review of a community reported complaint submitted to the Rhode Island Department of Health on 2/25/2025 alleges concerns regarding hot food items that are being served cold and at an unappetizing temperature.
Record review of the Rhode Island Food Code 2018 edition, Section 3-501.16 Time/Temperature Control for Safety, Hot and Cold Holding states, .(A) Except during preparation, cooking or cooling .time/temperature control for safety food shall be maintained: (1) At 57 degrees Celsius (135 degrees Fahrenheit, F) or above .
1. Record review revealed Resident ID #10 was readmitted to the facility in June of 2021 with a diagnosis including, but not limited to, moderate protein-calorie malnutrition.
Review of a Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired cognition.
During a surveyor interview on 2/27/2025 at 3:07 PM with Resident ID #10, s/he revealed that hot food items are cold, and that s/he would like his/her hot foods to be served hot.
2. Record review revealed Resident ID #15 was readmitted to the facility in April of 2024, with a diagnosis including, but not limited to, type 2 diabetes.
Review of an MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition.
During a surveyor interview on 2/24/2025 at 1:35 PM with Resident ID #15, s/he revealed that the food is not cooked well. S/he revealed that the meals are cold and not fully cooked.
3. Record review revealed Resident ID #16 was readmitted to the facility in February of 2025 with a diagnosis including, but not limited to, anxiety disorder.
Review of an MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition.
During a surveyor interview on 2/26/2025 at 2:51 PM with Resident ID #16, s/he revealed that hot food items are served cold all the time and that the food does not taste good. S/he further revealed that s/he would expect his/her hot foods to be served hot.
During the resident council meeting on 2/25/2025 at 1:04 PM it was identified by multiple residents in attendance that the food is always cold and that they would prefer their hot foods to be hot.
During a surveyor observation on 2/26/2025 at 11:25 AM of the lunch meal plating process, revealed 10 serving trays were set up on the food service line, each containing a portion of macaroni and cheese alongside zucchini. At the time of the observation, the plated food was uncovered and exposed. The trays were observed to be stationary for greater than 90 seconds while additional items were added to each tray before slowly continuing down the assembly line for the plate to be covered and then placed into carts that transport the prepared meal trays to residents across various units.
During a surveyor interview 2/26/2025 at 11:36 AM with the Food Service Director (FSD), he indicated that this procedure was the standard practice used for plating all meals. The surveyor requested the FSD to take a sample of temperatures of the plated meals on the line, which revealed the following:
-A plated sliced ham steak was 128℉ (Fahrenheit)
-A plated portion of macaroni and cheese was 125℉
Immediately following the above observation, the surveyor requested the FSD to obtain additional holding temperatures of plated meals that were being placed inside of a food cart, that were going to be delivered to one of the units for lunch service. A tray with macaroni and cheese had a temperature of 110º F, another tray of macaroni and cheese had a temperature of 102º F and a tray of sliced ham steak had a temperature of 115º F. The FSD indicated that he was unaware of that the safe holding temperature was 135ºF or greater for hot food, prior to being informed by the surveyor.
During a surveyor interview on 2/26/2025 at 11:46 AM with the FSD following the above observations, he acknowledged that temperatures obtained were below the safe holding temperatures of 135 ºF.
Cross Reference F 812.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmiss...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to contact precautions (utilized when a resident is known or suspected to be infected with a Multidrug Resistant Organism [MDRO] that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces in the resident's room), for 3 of 3 residents reviewed on contact precautions, Resident ID #s 25, 38, and 83; for 3 of 5 residents reviewed for enhanced barrier precautions (EBP- refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) Resident ID #s 3, 123 and 161; and for the handling of soiled linen in the laundry room.
Findings are as follows:
1. Review of a facility policy titled, Isolation states in part, .Contact precautions require the use of appropriate PPE [Personal Protective Equipment], including a gown and gloves upon entering the contact precaution room .
Record review revealed Resident ID #83 was readmitted to the facility in December of 2024, with a diagnosis including, but not limited to, cellulitis (a skin infection) of the right lower limb.
Record review revealed that Resident ID #83 tested positive for Methicillin-resistant Staphylococcus Aureus, (MRSA, an MDRO) in his/her leg wound on 3/4/2024.
Record review revealed that the resident's leg wound tested positive again in November of 2024 for MRSA.
Surveyor observations on 2/24/2025, revealed signage posted on the resident's door indicating that s/he was on contact precautions and indicated that staff/visitors are to wear a gown and gloves prior to entering the room.
During a surveyor observation on 2/24/2025 at 11:19 AM, Nursing Assistant (NA), Staff T, entered Resident ID #83's room without wearing a gown or gloves.
During a surveyor interview with Staff T, immediately following this observation, she acknowledged the sign posted on the resident's door and acknowledged that she failed to wear a gown and gloves prior to entering the room.
During a surveyor interview on 2/26/2025 at 8:31 AM with Licensed Practical Nurse, Staff H, she revealed that Resident ID #83 was on contact precautions for MRSA and that a gown and gloves are required prior to entering the room.
During a surveyor interview on 2/26/2025 at 12:49 PM, with the Infection Preventionist, she revealed that she would expect all staff to follow the signage posted outside all of the residents' rooms.
2. Review of a facility policy titled, Policy for Discontinuance of Isolation Precautions states in part, .If a resident has been placed on isolation precautions for the following MDRO (Multi-Drug Resistant Organism) infections (MRSA .ESBL [Extended-spectrum beta-lactamases]) he/she may be downgraded to standard precautions if there is a negative screening confirmed for all above infections .The screen should be obtained 48 hours after antibiotic treatment .
2a. Record review revealed Resident ID #25 was readmitted to the facility in June of 2024, with a diagnosis including, but not limited to, urinary tract infection.
Record review revealed that Resident ID #25 tested positive for ESBL in November of 2024. S/he was placed on contact precautions and was treated with antibiotic therapy.
Surveyor observations on 2/24, 2/25, 2/26, 2/27, and 2/28/2025, failed to reveal signage posted outside of Resident ID #25's room indicating that s/he was on contact precautions.
Record review failed to reveal evidence that Resident ID #25 had a negative screening for MRSA 48 hours after the completion of antibiotic therapy to remove the resident from precautions, per the facility's policy.
During a surveyor interview on 2/28/2025 at 1:22 PM, with the Infection Preventionist, she was unable to provide evidence that a negative screening 48 hours after antibiotic therapy completion was performed indicating to remove the resident from precautions. Additionally, she acknowledged that per the facility policy, Resident ID #25 required a negative screening prior to removal of precautions. Furthermore, she acknowledged that Resident ID #25 was not on contact precautions, per the facility policy.
2b. Record review revealed Resident ID #38 was readmitted to the facility in June of 2024, with diagnoses including, but not limited to, chronic hepatitis and local infection of the skin and subcutaneous tissue.
Record review revealed Resident ID #38 has an active wound to his/her right third finger and was being followed by a wound physician. Further record review revealed the resident tested positive for MRSA in his/her finger wound on 1/14/2025 and was treated with antibiotic therapy.
Surveyor observations on 2/24/2025 failed to reveal signage posted outside of Resident ID #38's room indicating that s/he was on contact precautions.
Record review failed to reveal evidence that Resident ID #38 had a negative screening 48 hours after the completion of antibiotic therapy to remove the resident from precautions, per the facility's policy.
During a surveyor interview on 2/26/2025 at 12:37 PM and 2/28/2025 at 1:14 PM, with the Infection Preventionist, she was unable to provide evidence that a negative screening 48 hours after antibiotic therapy completion was performed indicating to remove the resident from precautions. Additionally, she acknowledged that per the facility policy, Resident ID #38 required a negative screening for removal of precautions. Furthermore, she acknowledged that Resident ID #38 was not on contact precautions, per the facility policy.
During a surveyor interview on 2/26/2025 at approximately 3:00 PM, with the DNS, she was unable to provide evidence that negative screening's for Resident ID #s 38 and 25 after completion of their antibiotics were completed to remove the residents from contact precautions.
3. Review of the Center for Disease Control and Prevention (CDC) document titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) last reviewed 8/1/2023, states in part, Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities .The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents .with wounds .
Review of a facility policy titled, Isolation states in part, .Enhanced Barrier Precautions [EBP]-This level of precaution expands the use of PPE beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for .residents with chronic wounds or indwelling medical devices regardless of their MDRO colonization status will be on Enhanced Barrier Precautions for the duration of their stay or until the resolution of the wound or discontinuation of the indwelling medical device. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing .bathing/showering .providing hygiene .wound care .
3a. Record review revealed Resident ID #3 was readmitted to the facility in October of 2024, with a diagnosis including, but not limited to, type 2 diabetes mellitus.
Review of a wound evaluation and management summary dated 2/18/2025 revealed, Resident ID #3 has a stage 3 pressure wound (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) of the left lateral foot for greater than 138 days. It further revealed that the wound had light serous drainage (a clear to yellow fluid that leaks out of a wound).
Record review failed to reveal evidence that Resident ID #3 was placed on EBP related to a chronic wound to his/her lateral foot.
During a surveyor observation on 2/26/2025 at 9:03 AM with Registered Nurse, Staff K, wound care was performed to Resident ID #3's left lateral foot. Staff K, did not wear a gown to perform wound care. During a surveyor interview immediately following the wound care, Staff K acknowledged that he did not wear a gown during wound care, although it was a stage 3 pressure wound.
During a surveyor interview on 2/26/2025 at 12:39 PM, with the Infection Preventionist, she revealed that a chronic wound is defined as a wound that is greater than 30 days in duration. Additionally, she acknowledged that Resident ID #3 has had a wound for greater than 138 days and should be placed on EBP.
3b. Record review revealed Resident ID #123 was readmitted to the facility in February of 2025, with diagnoses including, but not limited to, type 2 diabetes mellitus and other specified disorders of the skin and subcutaneous tissue.
Record review revealed a care plan last revised on 2/21/2025 revealed, Resident ID #123 is on EBP related to a wound with interventions that include, but is not limited to, gloves and gown to be worn prior to high-contact care activities.
During a surveyor observation on 2/24/2025 at 2:26 PM revealed signage posted outside Resident ID #123's room for EBP.
During a surveyor observation on 2/24/2025 at 2:27 PM revealed NA, Staff U, providing care to Resident ID #123 without a gown on.
During a surveyor interview on 2/24/2025 at 2:41 PM with Staff U, she acknowledged that she provided care to Resident ID #123 without wearing a gown. Additionally, Staff U, acknowledged the signage outside of Resident ID #123's room and that she should have worn a gown during care.
During a surveyor interview on 2/26/2025 at 12:41 PM, with the Infection Preventionist, she revealed that she would expect staff to follow the signage posted outside of Resident ID #123's room.
3c. Record review revealed Resident ID #161 was admitted to the facility in October of 2024, with a diagnosis including, but not limited to, dementia.
Record review revealed the resident has a non-pressure wound to his/her left first toe for greater than 66 days. Additionally, it revealed that the wound had light serous drainage with the wound progress not at goal.
Surveyor observations on 2/24, 2/25, 2/26, 2/27, and 2/28/2025 failed to reveal signage posted outside of Resident ID #161's room indicating that s/he was on EBP related to a chronic wound to his/her left toe.
During a surveyor interview on 2/26/2025 at 12:39 PM and 2/28/2025 at 1:18 PM, with the Infection Preventionist, she revealed that a chronic wound is defined as a wound that is greater than 30 days in duration. Additionally, she acknowledged that the wound has been active for greater than 66 days. Furthermore, she was unable to provide evidence that the resident was placed on EBP for a chronic wound.
During a surveyor interview on 2/26/2025 at approximately 3:00 PM, with the DNS, she was unable to provide evidence that EBP was followed per the facility policy and CDC.
4. Review of a facility policy titled Laundry Guidelines dated 10/18 states in part, POLICY: It is the policy of this facility to handle, store, process, and transport linen so as to prevent the spread of infection .Laundry Handling .All laundry will be handled as if it is potentially infectious and/or capable of transmitting infectious disease .Laundry workers will wear appropriate personal protective equipment when handling contaminated laundry .
During a surveyor observation and interview on 2/28/2025 at 1:41 PM with Laundry Aid, Staff V, she was observed folding clean laundry. During the laundry room tour she revealed that she works on both the clean and dirty side. She revealed that she loaded the soiled linen that was currently running. She revealed that she only wears gloves when sorting and loading the washer with soiled laundry and that she does not wear a gown. Additionally, she revealed that when the laundry is bagged in blue bags that means that a resident is on precautions.
During a surveyor observation and interview on 3/3/2025 at 8:56 AM revealed Laundry Aid, Staff W, sorting soiled laundry and wearing only gloves. She then dumped out a blue bag of soiled linen. When asked by the surveyor what the blue bag meant, she revealed that the blue bags were just heavily soiled linen. Furthermore, she revealed that there are gowns available to wear but that she does not wear them.
During a surveyor interview on 3/3/2025 at 8:59 AM with Licensed Practical Nurse, Staff P, she revealed that the blue laundry bags are used for the rooms on precautions.
During a surveyor interview with the Administrator on 2/28/2025 at 1:45 PM and 3/3/2025 at 11:26 AM and 2:30 PM, she revealed that blue bags are utilized for precautions rooms. Additionally, she revealed that gowns are not optional when sorting laundry and should be worn when sorting and loading the washing machine. Furthermore, she was unable to provide evidence that the laundry was handled, stored, processed, and transported to prevent the spread of infections, per the facility's policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0940
(Tag F0940)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to implement and maintain an effective training program for all newly hired employees, consistent with their...
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Based on record review and staff interview, it has been determined that the facility failed to implement and maintain an effective training program for all newly hired employees, consistent with their expected roles, relative to orientation education, as outlined in the facility assessment, for 4 of 5 newly hired employees, Staff J, X, Y, and the Food Service Director (FSD).
Findings are as follows:
Review of the Facility Assessment, dated 7/18/2024, states in part, .Training topics upon hire and annually for all staff:
- Abuse, neglect, and mandatory reporting - Activities that constitute abuse, neglect, and misappropriation of resident property, Procedures for reporting incidents, of abuse, neglect, or the misappropriation of resident property
- Corporate compliance - program overview; what to report and how to report noncompliance; standard of care/ensuring quality
- Cultural competency
- Customer service
- Dementia care - person - centered care for the cognitively impaired .eight hours within 120 days of hire for all direct caregivers .two hours upon hire and annually for non-direct caregivers .
- Disaster planning, procedures, codes .
- Emergency preparedness - lock out/tag out, fire safety
- Heimlich maneuver (all staff upon hire .) encouraged
- HIPAA - overview; how to maintain; resident rights; mandatory reporting
- Infection control - standard, contact and droplet precautions; personal protective equipment; hand hygiene; post-exposure to body fluids; tuberculosis; pandemic flu plan
- Residents' rights and (prevention of) fear of retaliation
- Workplace safety, body mechanics - overview and reporting
- Workplace violence and harassment; sexual harassment
- Covid-19 .
Record review revealed the FSD was hired on 11/5/2024. Review of his training records failed to reveal evidence that he received education or training upon hire relative to abuse, neglect, and mandatory reporting, corporate compliance, cultural competency, customer service, dementia care, disaster planning, emergency preparedness, Heimlich maneuver, HIPPA, infection control, residents' rights, workplace safety, or Covid-19.
Record review revealed Dietary Aide, Staff X, was hired on 12/22/2024. Review of her training records failed to reveal evidence that she received education or training upon hire relative to abuse, neglect, and mandatory reporting, corporate compliance, cultural competency, customer service, dementia care, disaster planning, emergency preparedness, Heimlich maneuver, HIPPA, infection control, residents' rights, workplace safety, or Covid-19.
Record review revealed Licensed Practical Nurse, Staff J, was hired on 1/10/2025. Review of his training records failed to reveal evidence that he received education or training upon hire relative to abuse, neglect, mandatory reporting, corporate compliance, cultural competency, customer service, dementia care, disaster planning, emergency preparedness, Heimlich maneuver, HIPPA, infection control, residents' rights, workplace safety, or Covid-19.
Record review revealed Dietary Aide, Staff Y, was hired on 1/31/2025. Review of her training records failed to reveal evidence that she received education or training upon hire relative to abuse, neglect, mandatory reporting, corporate compliance, cultural competency, customer service, dementia care, disaster planning, emergency preparedness, Heimlich maneuver, HIPPA, infection control, residents' rights, workplace safety, or Covid-19.
During surveyor interviews with the Administrator on 2/26/2025 at 12:41 PM and 2:44 PM, 2/27/2025 at 11:05 AM, 2/28/2025 at 1:02 PM and 3/3/2025 at 1:01 PM, she revealed that when an employee is hired, they meet with Human Resources to complete all necessary forms and indicated that the only education they receive that day is on workplace violence, harassment and sexual harassment. She revealed that all staff are required to attend an orientation where they will receive the remainder of the mandatory education, as outlined in the Facility Assessment. Further, she acknowledged that Staff J, X, Y, and the FSD did not attend an orientation after they were hired. Additionally, she was unable to provide evidence that the above-mentioned in-services were completed for Staff J, X, Y, and the FSD, upon hire, as per the Facility Assessment.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
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 ensure the director of food and nutrition services met the minimum qualifications of ...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed ensure the director of food and nutrition services met the minimum qualifications of a Certified Food Safety Manager.
Findings are as follows:
Record review of the Rhode Island Food Code, 2018 Edition, Section 2-102.12 Certified Food Protection Manager states in part .at least one employee that has supervisory and management responsibility and the authority to direct and control food preparation and service shall be a certified food protection manager .
During the initial tour of the main kitchen on 2/24/2025 at 8:50 AM, surveyor observations failed to reveal evidence of a certification of a Food Safety Manager for the Food Service Director (FSD). Subsequently the FSD indicated that he had obtained the required education and certification and would present it at a later date.
During a surveyor interview on 2/25/2025 at approximately 9:30 AM, the FSD presented a Certificate of Completion for a Food Handler Training Course. The surveyor informed the FSD that the document provided does not meet the requirement of a Certified Food Safety Manager as required per regulations. Additionally, the Food Handlers Certificate provided had expired on 3/8/2024.
During a surveyor interview on 2/25/2025 at 2:37 PM with the FSD revealed that he was unaware he did not have the required Certified Food Safety Manager certification, until brought to his attention by the surveyor.
During a surveyor interview on 2/26/2025 at 1:42 PM with the Administrator, she presented a Certificate of Completion for a Food Handler Training Course. She indicated that she was unaware of the expiration date of 3/8/2024, and that the certification was for a Food Handler, not a Food Safety Manager, as required, until brought to her attention by the surveyor. She revealed that she was unaware the FSD did not have the required certifications upon hire in November of 2024.
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 the Director of Food and Nutrition Services met the minimum qualificat...
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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 Director of Food and Nutrition Services met the minimum qualifications of a Certified Food Safety Manager for 1 of 1 Food Service Director (FSD) reviewed. Additionally, the facility failed to ensure that food is stored and distributed, in accordance with professional standards for food safety relative to the main kitchen and 4 of 4 kitchenettes.
Findings are as follows:
1. Record review of the Rhode Island Food Code, 2018 Edition, Section 2-102.12 Certified Food Protection Manager states in part .at least one employee that has supervisory and management responsibility and the authority to direct and control food preparation and service shall be a certified food protection manager .
During the initial tour of the main kitchen on 2/24/2025 at 8:50 AM, surveyor observations failed to reveal evidence of a certification of a Food Safety Manager for the FSD. Subsequently the FSD indicated that he had obtained the required education and certification and would present it at a later date.
During a surveyor interview with the FSD on 2/25/2025 at approximately 9:30 AM, he presented a Certificate of Completion for a Food Handler Training Course with an expiration date of 3/8/2024. The surveyor informed the FSD that the document provided does not meet the requirement of a Certified Food Safety Manager, per regulation.
During a surveyor interview on 2/25/2025 at 2:37 PM with the FSD, he revealed that he was unaware that he did not have the required Food Safety Manager certification.
During a surveyor interview on 2/26/2025 at 8:32 AM with the Dietitian, she revealed that she is at the facility 3 days per week on average. She indicated that she does not provide oversight of meal service including, preparing, cooking, and serving food to the residents.
Record review of the facility time sheets for the dietary department for 1/1/2025 through 1/31/2025, and 2/1/2025 through 2/22/2025, revealed the following:
- January time sheets failed to reveal evidence that a Certified Food Safety Manager was present during all three meal services for 20 out of 31 calendar days
- February time sheets failed to reveal evidence that a Certified Food Safety Manager was present during all three meal services for 14 out of 22 calendar days
During a surveyor interview on 2/26/2025 at approximately 9:30 AM with the Administrator, she was unable to provide evidence that a Certified Food Safety professional was in the kitchen during all three meal services for the months of January and February 1, 2025, through February 22, 2025.
During a surveyor interview on 2/26/2025 at 1:42 PM with the Administrator, she revealed that she was unaware that the FSD did not have the required certifications upon hire in November of 2024.
2. Record review of the Rhode Island Food Code 2018 edition, Section 3-501.16 Time/Temperature Control for Safety, Hot and Cold Holding states in part, .(A) Except during preparation, cooking or cooling time/temperature control for safety food shall be maintained: (1) At 57 degrees Celsius (135 degrees Fahrenheit) or above .
During a surveyor observation on 2/26/2025 at 11:25 AM of the lunch meal plating process, revealed 10 serving trays were set up on the food service line, each containing a portion of macaroni and cheese alongside zucchini. At the time of the observation, the plated food was uncovered and exposed. The trays were observed to be stationary for greater than 90 seconds while additional items were added to each tray before slowly continuing down the assembly line for the plate to be covered and then placed into carts that transport the prepared meal trays to residents across various units.
During a surveyor interview and observation on 2/26/2025 with the FSD at 11:36 AM, he indicated that this procedure was the standard practice used for plating all meals. The surveyor requested the FSD to take a sample of temperatures of the plated meals on the line, which revealed the following:
-A plated sliced ham steak was 128º Fahrenheit (F)
-A plated portion of macaroni and cheese was 125º F
Immediately following the above observation, the surveyor requested the FSD to obtain additional holding temperatures of the plated meals that were observed plated on the service line for extended time prior to being placed inside of a food cart, that was going to be delivered to one of the units for lunch service revealed the following:
-Two trays containing plated portions of macaroni and cheese had temperatures of 110º F and 102 º F
-A tray containing a plated portion of sliced ham steak meal had a temperature of 115º F
The FSD indicated that he was unaware that food holding temperatures below 135ºF were potentially hazardous until informed by the surveyor. Once he was informed, he acknowledged the low holding temperatures and proceeded to push the affected cart off to the side and he then stepped away from the service area.
During a surveyor observation and interview on 2/26/2025 at 11:44 AM revealed Dietary Aide, Staff Z was placing the affected cart onto the elevator and was stopped by a surveyor. Staff Z revealed to the surveyor that he was delivering the cart to the 2nd floor for lunch service. He indicated that he had not been informed by the FSD of the unsafe holding temperatures of the plated meals in the affected cart.
During a surveyor interview on 2/26/2025 at 11:46 AM with the FSD, he acknowledged that the temperatures obtained for meals in the cart were below the safe holding temperature of 135 ºF for hot foods and he directed the dietary staff and cooks to prepare an alternate meal for the 2nd floor lunch service.
3. Record review of Rhode Island Food Code, 2018 Edition, Section 3-501.17 states in part, n .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 .
Review of the facility's policy titled, Use and Storage of Food Brought in by Visitors, states in part, .the dietary staff members assigned to routine rounds to stock/clean unit refrigerators/nutrition pantry will monitor status of food and discard perishable items that appear unsafe for consumption or older than 3 days .
During the initial tour of the kitchen and 3 of 4 kitchenettes in the presence of the FSD, on 2/24/2025 at 8:20 AM, the following was observed:
Main kitchen:
-1 unlabeled and undated large blue bag, approximately 1/3 full of frozen croissants
Ground Floor kitchenette:
-2 full 64-ounce (oz) pitchers of orange juice labeled with a discard date of 2/21/2025
-2 full 64 oz pitchers of cranberry juice without a label indicating a discard date
-1 half full 64 oz pitcher of orange juice without a label indicating a discard date
1st floor kitchenette:
-one banana black in color in the refrigerator drawer
-5 covered soup style bowls containing apple sauce, 3 labeled with discard dates of 2/19/2025 and 2 labeled with discard dates of 2/21/2025
-2 full 64 oz pitchers of apple juice with labels indicating a discard date of 2/21/2025
-1 half gallon of coffee ice cream approximately 1/4 full of substantial freezer burn without a label or indicating a discard date
-1 covered soup style bowl containing diced pineapple without a label or indicating a discard date
-A foil pack containing 4 slices of bread without a label or indicating a discard date
-1 large Styrofoam to go container containing fried clams and French fries without a label or indicating a discard date
-1 22 oz personal glass container of soup without a label or indicating a discard date
-1 22 oz personal glass container of pasta without a label or indicating a discard date
During a surveyor interview on 2/24/2025 at 8:50 AM with Certified Medication Technician, Staff R, following the above observations of the kitchenette, she acknowledged the food items should have been labeled, dated, or thrown away as indicated per facility policy.
During a surveyor observation of the 3rd floor kitchenette on 2/25/2025 at 8:39 AM, in the presence of the FSD, the following was observed:
-An unlabeled package containing 4 frozen waffles without a discard date
-An 8 oz to go coffee of cup in the freezer
-1 unlabeled covered soup style bowl of apple sauce with a discard date of 2/21/2025
During a surveyor interview on 2/25/2025 at 9:52 AM with the FSD, he acknowledged the above observations, and he indicated that he was unaware of the facility's policy Use and Storage of Food Brought in by Visitors.
4. Record review of the Rhode Island Food Code, 2018 Edition, section 4-601.1 1 states in part, .(A) equipment food contact surfaces .shall be clean to sight .(B) The FOOD CONTACT SURFACES of cooking EQUIPMENT .shall be kept free of encrusted grease deposits and other soil accumulations. (C) NON-FOOD CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris .
During the initial tour of the main kitchen and 1st floor kitchenette on 2/24/2025 at 8:20 AM, the following was observed:
-The microwave had an accumulation of a black matter splattered on the inside of the glass door, above the cooking area, and on the glass turn plate
-The hoses connecting the bag-in-box juice dispensing system that is used for residents to dispense apple juice, cranberry juice, orange juice, a diet beverage with lemon flavor, and strawberry kiwi beverages were observed to have an accumulation of a dried, sticky substance on the connection pieces, hoses, and on the shelf where the boxes were resting
-2 unlabeled large storage bins approximately 27 gallons in size, both more than half full containing a white powdered substance, visibly dirty with an accumulation of residue on the outside of the bins
-The microwave on first floor kitchenette was observed with an accumulation of light brown matter on the inside of the glass door, above the cooking areas and on the glass turn plate
During a subsequent surveyor interview with the FSD following the above observations, he acknowledged the observations and indicated that the dietary staff were responsible for the cleanliness of the kitchen and kitchenettes. However, he was unable to provide evidence that routine cleaning and maintenance was performed.
Cross Reference 804
Jan 2025
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
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 resident and staff interviews, it has been determined that the facility failed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and resident and staff interviews, it has been determined that the facility failed to provide a safe, sanitary, and comfortable environment on 4 of 4 nursing units observed.
Findings are as follows:
Record review of community reported complaints submitted to the Rhode Island Department of Health on 1/2/2025 and 1/3/2025, alleged that the facility has mold in the windows and ceiling tiles that making the residents sick.
During a surveyor interview with the Maintenance Director in the presence of the Administrator on 1/10/2025 at 9:00 AM, the Maintenance Director revealed that the maintenance staff conducts environmental rounds every month. The Maintenance Director further revealed that they have maintenance staff and housekeepers assigned on each nursing unit. Additionally, the Maintenance Director revealed that they have a maintenance logbook on each nursing unit that staff uses to communicate with maintenance staff and housekeepers. Furthermore, the Administrator and the Maintenance Director revealed that they were unaware of any mold, leaks, or stains on the ceiling tiles.
During surveyor observations of the common shower rooms on all 4 nursing units with the Administrator on 1/10/2025 between 9:10 AM through 12:00 PM, the following was revealed:
- several ceiling tiles with yellow and brown stains
- several vents with a heavy accumulation of dust
- several metal frames for the drop ceilings had an accumulation of rust
- the lower part of the walls adjacent to the floors and in the corners had a heavy accumulation of yellow and brown matter
Additionally, surveyor observation of the second floor common shower room revealed that the door frame had broken plaster on the lower part of the door frame (approximately 5 inches in width by 10 inches in length) with approximately 1 inch by 2 inches of metal protruding out. Furthermore, black matter was scattered on the floor in one of the shower stalls.
During a surveyor observation with the Administrator on 1/10/2025 at 10:20 AM, she identified that the black matter on the floor in the shower stall was feces.
Surveyor observations of resident rooms, revealed the following:
room [ROOM NUMBER] and 103
- ceiling vent in the hall between the two rooms with numerous amounts of black spots
room [ROOM NUMBER]
- several ceiling tiles with several yellow and brown stains
- ceiling vent with a heavy accumulation of dust
room [ROOM NUMBER]
- ceiling tiles with several yellow and orange stains
- ceiling vent with a heavy accumulation of dust
- the windowsill with scattered black spots (approximately 0.5 inches in width by 2.5 feet in length)
room [ROOM NUMBER]
- several ceiling tiles with yellow stains
- ceiling vent with a heavy accumulation of dust
room [ROOM NUMBER]
- ceiling vent with a heavy accumulation of dust
room [ROOM NUMBER]
- ceiling vent with a heavy accumulation of dust
room [ROOM NUMBER]
- ceiling vent with a heavy accumulation of dust
room [ROOM NUMBER]
- ceiling vent with a heavy accumulation of dust
- approximately 0.5 feet in width by 2.5 feet in length yellow stains on the corner of the bathroom
room [ROOM NUMBER]
- ceiling vent with a heavy accumulation of dust
room [ROOM NUMBER]
- ceiling vent with a heavy accumulation of dust
Record review of a facility document titled Facility Environmental Inspection for December 2024, failed to reveal evidence that the common shower rooms on all four of the nursing units as well as ceiling vents were part of the monthly inspection.
Record review of the facility documents titled Maintenance Floor Log Sheets, failed to reveal evidence that the ceiling vents, ceiling tiles, door frames, or the floors and walls of the common shower rooms were documented as needing cleaning or repairs, for any of the units.
During a surveyor observation and interview on 1/10/2025 at 9:20 AM, with Resident ID #4, s/he revealed that s/he has been residing in the same room for the past several months. Resident ID #4 further revealed that s/he has several stains on the ceiling in his/her room since s/he moved in the room. Resident ID #4 further revealed that the common shower rooms were dirty and in need of cleaning. Surveyor observation at this time confirmed that there were several stains on the ceiling of the resident's room.
During a surveyor observation and interview on 1/10/2025 at 10:30 AM, with Resident ID #3, s/he revealed that s/he has had several stains on the ceiling in his/her room for the last several months. Surveyor observation at this time confirmed that there were several stains on the ceiling of the resident's room.
During surveyor interviews on 1/10/2025 at 9:50 AM and 10:20 AM with the first floor unit nurse, Licensed Practical Nurse (LPN), Staff A. and the second floor unit nurse, LPN, Staff B, they both revealed that they were unaware that the common shower rooms had vents with a heavy accumulation of dust, rust on the metal frames of the drop ceilings, an accumulation of yellow and brown matter on the walls and floor, and stains on the ceiling tiles.
During a surveyor interview on 1/10/2025 at approximately 3:00 PM with the Administrator, she acknowledged the common shower rooms had vents with a heavy accumulation of dust, rust on the metal frames of the drop ceilings, an accumulation of yellow and brown matter on the walls and floor and stains on the ceiling tiles. She also acknowledged the broken door frame in the second floor common shower room.
Nov 2024
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident received a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident received adequate supervision for 1 of 1 resident reviewed who was assessed to be a moderate risk for wandering, previously displayed exit seeing behavior and was able to successfully elope from the facility, Resident ID #1.
Findings are as follows:
Record review of a facility policy titled Elopement dated 4/10/2018, states in part, .Elopement - leaving the facility without permission and/or notification to the facility .An assessment will be completed within 24-hours of admission. 1. A re-assessment will be completed for any resident who demonstrates any of the following: Verbalizing a desire to leave the building .exit seeking .A resident assesses to be at risk. The following actions may be employed: 1. Application of a wanderguard 2. Initiation of frequent checks 3. Initiate Care Plan 4. Room transfer to a secure area 5. Residents at risk for elopement identified to appropriate staff .
Record review of a facility reported incident sent to the Rhode Island Department of Health on 11/12/2024, revealed that on 11/11/2024 Resident ID #1 left the building and was found in the parking lot next door. A neighbor called the police, and the resident was taken to the hospital for safety. Although during the complaint survey it was determined by record review and interview that the resident was located approximately 1.5 miles from the facility, found by a jogger. Emergency services were called and s/he was transported to the hospital.
During a surveyor observation on 11/18/2024 at approximately 11:00 AM revealed the facility is equipped with a wander guard system. When a resident wearing bracelet attempts to leave the facility an alarm will go off alerting the staff.
Record review revealed the resident was admitted to the facility in October of 2024 with a diagnosis including, but not limited to, dementia. Further review revealed that the resident resides on the facility's secured/locked unit.
Review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 6 out of 15, indicating s/he has severely impaired cognition.
Record review of a Wander Risk assessment dated [DATE] revealed the resident scored a 9, indicating s/he is a moderate risk for wandering behaviors.
Record review of a nursing progress note dated 11/10/2024 at 12:37 PM states in part, Resident with some agitation this shift .Asks why we are keeping [him/her] here. Trying to get on the elevator x2. Redirected with difficulty.
Record review failed to reveal evidence that a Wander Risk Assessment was completed after the resident displayed exit seeking behaviors, that a wanderguard was placed on the resident or that the resident was placed on frequent checks per the facility policy. Additionally, the care plan was not updated with interventions to mitigate the resident's exit seeking behavior following the incident on 11/10/2024.
Record review of facility investigation statements for the 11/11/2024 incident indicated that staff last recall seeing the resident between 4:45 PM and 5:15 PM, eating dinner, but no one witnessed the resident exit the facility.
Record review of a progress note authored by Registered Nurse, Staff A, on 11/11/2024 at 9:40 PM, revealed that the last time staff saw the resident on the evening of 11/11/2024, prior to his/her elopement was at approximately 5:15 PM, when s/he was observed sitting in the dayroom eating dinner. At approximately 6:58 PM the facility received a phone call from the hospital indicating that the resident was in the emergency room. Additionally, two staff members from the facility went to the hospital to pick up the resident and return him/her to the facility.
Record review of hospital documentation titled ED [emergency department] Triage Note dated 11/11/2024, revealed that the resident was brought in by emergency medical services, after a jogger called 911 and reported a Spanish speaking person who was confused about his/her location. The resident was assessed in the ED and was unsure of the date and where s/he was. The resident reported s/he was from [NAME] (a city located approximately 20 miles away from the facility) and lived at a local school. Additionally, the document revealed that the secretary from the hospital called the facility to see if they were missing a resident. Per the report the facility sent staff to the hospital to identify and pick up the resident.
The surveyor made two attempts to contact Staff A. Staff A failed to return any of these phone calls.
During a surveyor interview on 11/18/2024 at 2:35 PM with the Administrator, she acknowledged that the facility was not aware that Resident ID #1 left the faciity on [DATE] until the hospital called to notify them. She further acknowledged that the staff were unaware how the resident made his/her way off of the secured unit and exited the facility. Additionally, the Administrator was unable to determine when the resident had left facility and how long s/he had been gone.
The facility's failure to implement interventions for a resident who was identified on their admission assessment as a moderate risk for wandering and to follow their policy relative to wandering behaviors placed a cognitively impaired resident at risk for more than minimal harm, injury, impairment, or death. These failures resulted in this resident making his/her way off of the secured unit, exiting the facility unsupervised and being found by a jogger approximately 1.5 miles away from the facility.
Jun 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
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 nursing staff have the appropriate competencies and skill sets to provide nursing and related...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety, relative to a peripherally inserted central catheter (PICC- which is inserted into a vein in the arm and passed through to the larger veins near your heart), for 1 of 1 resident reviewed, Resident ID #1.
Findings are as follows:
Record review of the facility assessment, last revised in January of 2024, revealed that the facility has the ability to provide intravenous (IV) therapy to their residents.
Record review revealed Resident ID #1 was admitted to the facility in June of 2024 with diagnoses including, but not limited to, type II diabetes mellitus, acute kidney injury, infection and inflammatory reaction due to internal fixation device of unspecified site, and sepsis (potentially life-threatening infection of the blood stream).
Additionally record review revealed that upon admission, the resident had a PICC line and was prescribed to receive IV antibiotics through the PICC line once every 24 hours.
Review of the 2024 Education Series for Registered Nurses and Licensed Practical Nurses failed to reveal education, competencies and skills sets related to PICC line care or the administration of IV therapy.
Record review of a document sent after the surveyor exited the facility revealed a 2022 RIHCA [Rhode Island Health Care Association] Competency Training which revealed that 6 of the facility's 60 nurses were trained in midline and PICC dressing and removal.
During a surveyor interview on 6/21/2024 at approximately 4:00 PM, with the Director of Nursing Services, he was unable to provide evidence that PICC line competencies and skill sets were completed for all Registered Nurses and Licensed Practical Nurses.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, disp...
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Based on record review and staff interview, it has been determined that the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) to meet the needs of each resident for 1 of 3 residents reviewed, Resident ID #1.
Record review of a community reported complaint received by the Rhode Island Department of Health on 6/19/2024 alleges that Resident ID #1 has not received his/her methadone (a medication used to treat opioid use disorder) and other medications for two days. The complaint further indicates that the resident tried to speak with the facility staff about this and was told they were checking with the pharmacy.
Record review for Resident ID #1 revealed s/he was admitted to the facility in June of 2024 with diagnoses including, but not limited to, sepsis (a potentially life-threatening infection in the blood), history of opioid abuse, type II diabetes mellitus, acute kidney injury, and infection and inflammatory reaction due to internal fixation device (surgical procedure used to internally set and stabilize fractured bones).
Record review of the June 2024 Medication Administration Record (MAR) revealed s/he did not receive the following medications as ordered on the following dates and times:
- Methadone HCL Oral Concentrate 10 mg/ml. Give 11 ml (110 mg) by mouth two times a day. Not administered on , 6/18/2024 AM and PM doses, 6/19/2024 AM and PM doses, and 6/20/2024 AM dose. This indicates the resident missed a total of five doses of methadone over a three day period.
Further review of the MAR notes for the above-mentioned medication revealed it was not administered to the resident as they were unavailable.
Record review failed to reveal evidence that a pharmacy obtained and delivered the above-mentioned medication for the resident.
During a surveyor interview on 6/21/2024 at 10:45 AM with an employee of the pharmacy that provides methadone to the facility, Staff A, she revealed that the pharmacy received the paperwork from the facility on 6/18/2024 at approximately 11:00 AM. She indicated that 11:00 AM was too late to fill the methadone order because the courier who delivers the methadone is on the road by noon and they deliver once every day.
During a surveyor interview on 6/21/2024 at approximately 1:00 PM with the Director of Nurses and Licensed Practical Nurse, Staff B, they indicated that they use one pharmacy to deliver methadone to the facility. Additionally, they acknowledged that the resident never received his/her methadone, as neither were available for administration due to the pharmacies not delivering them.
Cross Reference F 760
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on record review and staff interview it has been determined that the facility failed to ensure that residents are free significant medication errors for 1 of 1 resident reviewed, Resident ID #1....
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Based on record review and staff interview it has been determined that the facility failed to ensure that residents are free significant medication errors for 1 of 1 resident reviewed, Resident ID #1.
Findings are as follows:
Record review of a community reported complaint received by the Rhode Island Department of Health on 6/19/2024 alleges that Resident ID #1 has not received his/her methadone (a medication used to treat opioid use disorder) and other medications for two days. The complaint further indicates that the resident tried to speak with the facility staff about this and was told they were checking with the pharmacy.
Record review revealed Resident ID #1 was admitted to the facility in June of 2024 with diagnoses including, but not limited to, sepsis (a potentially life-threatening infection in the blood), history of opioid abuse, type II diabetes mellitus, acute kidney injury, and infection and inflammatory reaction due to internal fixation device (surgical procedure used to internally set and stabilize fractured bones).
Review of a physician's order dated 6/17/2024 at 8:42 PM revealed an order for methadone HCL Oral Concentrate 10 milligrams/milliliters. Give 11 ml (110 mg) by mouth two times a day.
Review of the June 2024 Medication Administration Record failed to reveal evidence that the methadone was administered on 6/18/2024 AM and PM doses, 6/19/2024 AM and PM doses, and 6/20/2024 AM dose. This indicates the resident missed a total of five doses of methadone over a three day period.
During a surveyor interview on 6/21/2024 at 10:45 AM with an employee of the pharmacy that provides methadone to the facility, Staff A, she revealed that the pharmacy received the paperwork from the facility on 6/18/2024 at approximately 11:00 AM. She indicated that 11:00 AM was too late to fill the methadone order because the courier who delivers the methadone is on the road by noon and they deliver once every day.
During a surveyor interview with the Director of Nursing Services and Licensed Practical Nurse, Staff B, on 6/21/2024 at approximately 11:00 AM, they acknowledged that the resident never received methadone.
Cross Reference F 755
Mar 2024
13 deficiencies
3 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
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide ne...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 3 wound treatments observed, Resident ID #129.
Findings are as follows:
Record review of an undated facility policy titled, Wounds - Dressing Changes, states in part, .This policy and procedure intent is to ensure that .resident's skin integrity is addressed appropriately. Dressing changes will be done based on the physician orders using clean dressing change procedure .1. Upon discovery of a new skin integrity issue, the nurse will .Assess and measure the wound .The charge nurse will notify the physician, resident representative .and wound nurse .Order entered for treatment for wound .Nurse note written with a description of alteration in skin integrity, treatment initiated, and notification to the physician .
Review of the facility policy, revised on 3/12/2022 titled, Skin Care Protocol, states in part, .For those residents identified as 'at risk' interventions must be carried out in a timely manner. Interventions to consider include but may not be limited to .Pressure-relieving .cushion .Repositioning .Minimize exposure to moisture; keep resident dry and clean .
Record review revealed the resident was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, pressure ulcer of the sacral region (tail bone area), stage 4 (severe type of pressure ulcer, the skin is severely damaged, and the surrounding tissue begins to die [necrosis] may extend to muscle and bone), muscle weakness, and dementia.
Record review of a Minimum Data Set Assessment (MDS) dated [DATE], revealed a Brief Interview for Mental Status score of 0 out of 15, indicating severely impaired cognition. Additionally, s/he does not walk and is dependent on staff members for mobility which includes transferring from bed to chair. The MDS assessment further revealed that the resident was admitted to the facility with the stage 4 pressure area to his/her sacrum area. It is documented that the treatment included, but is not limited to, a .Pressure reducing device for chair .
Additional record review revealed a care plan dated 1/15/2024, which indicates that the resident has a pressure ulcer to his/her sacrum area and has the potential for pressure ulcer development related to immobility. Interventions include, but are not limited to, follow the facility policies and protocols for the prevention and treatment of skin breakdown. Further review of the care plan did not identify any additional pressure areas.
During a surveyor observation on 3/12/2024 at 11:11 AM, the following was revealed:
- The resident was receiving assistance with transferring from his/her recliner chair to his/her bed with a mechanical lift and Nursing Assistant (NA), Staff G and by Staff H.
- The resident was noted to be incontinent of loose stool. His/her adult incontinence brief was saturated with loose stool which extended out of the brief and continued to his/her back.
- The sacrum wound was covered with a dressing which was also saturated with stool.
- A white, soiled adhesive dressing was observed to his/her right lower buttocks area (ischium).
- There was no cushion observed to his/her recliner chair.
- A non-blanchable (discoloration of the skin that does not turn white when pressed) red/purple area was observed to his/her right hip and left lateral thigh.
During a surveyor interview on 3/12/2024 at 11:20 AM, immediately following the above-mentioned observation with Staff G, she revealed that she was the NA assigned to provide care for Resident ID #129 during the 7:00 AM to 3:00 PM shift. She further revealed that when she arrived on shift at approximately 7:30 AM, the resident was already out of bed sitting in his/her recliner chair. Staff G indicated that she did not transfer the resident out of the recliner or provide him/her with incontinence care until the above-mentioned observation, indicating s/he sat in his/her recliner for approximately 4 hours.
Record review revealed the following physician's orders relative to the resident's skin conditions:
- 1/17/2024, Body check weekly every Wednesday evening
- 2/15/2024, Off load wound; reposition as tolerated every shift
- 2/23/2023, Coccyx [sacrum] wound to be cleansed with ¼ strength Dakins (a solution used to treat or prevent wound infections) moisten kerlix (bandage) with Dakins and gently pack the wound, cover with island border gauze twice daily and as needed every day and evening shift.
During a surveyor interview on 3/12/2024 at 11:36 AM with Licensed Practical Nurse, Staff L, she revealed that the resident was out of bed sitting in his/her recliner chair when she arrived on shift at approximately 7:30 AM. Additionally, she was unable to say if the non-blanchable areas noted to the resident's right hip and lateral left thigh were new. Furthermore, she was unable to explain why a dressing was in place to the resident's right ischium without a physician's order.
Further record review failed to reveal evidence that the areas to Resident ID #129's right hip, left lateral thigh and right ischium existed prior to this observation. Furthermore, the record revealed that the weekly body check was conducted on 3/6/2024 on the Treatment Administration Record (TAR) , however, the record failed to reveal documentation of the findings.
During a surveyor observation and simultaneous interview on 3/12/2024 at 12:20 PM with the Wound Physician and the facility's Wound Nurse/Infection Preventionist revealed the following:
The wound physician revealed that he would expect that a pressure reducing device would be in place to Resident ID #129's chair. Additionally, he would expect staff to reposition the resident at least every 2 hours. He also acknowledged that the wounds to Resident ID #129's right hip, left lateral thigh, and right ischium were new.
Further record review failed to reveal evidence that the physician was notified of the wound to the resident's right ischium.
During a surveyor interview on 3/14/2024 at 9:20 AM, with Registered Nurse (RN), Staff B, she revealed that she found the wound to the resident's right ischium on 3/11/2024. Staff B acknowledged that she did not document the wound description or obtain measurements of the wound. Furthermore, she revealed that she failed to notify the physician and obtain treatment orders prior to applying a treatment to the resident's right ischium wound.
During surveyor interviews on 3/12/2024 at 1:12 PM and 3/14/2024 at 11:12 AM with the Director of Nursing Services, she revealed that she would expect staff to protect the resident's skin and check him/her at least every half to one hour and report any new areas to the physician and the resident's family. She also indicated that she would expect documentation of a weekly body check findings to be in the progress notes as well as signed off on the (TAR). Furthermore, she revealed that she was the assigned nurse for Resident ID #129 on 3/6/2024 during the 3:00 PM - 11:00 PM shift and revealed that she documented his/her weekly body check findings as a late entry on 3/13/2024, after it was brought to her attention by the surveyor.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**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 maintain ac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 2 of 11 residents reviewed for nutrition, Resident ID #s 98 and 129.
Findings are as follows:
Review of a facility policy titled, Weight Monitoring Policy dated 2/24/2017, states in part, .All residents are to be weighed on a monthly basis between the first and the sixth of the month .If the weight is +/- [greater than/less than] 3 pounds from the previous weekly weight or +/- 5% on a monthly the resident is to be removed from the scale and reweighed (this needs to be done no later than within 24 hours for the questionable weight) .The dietician will review the weights and determine if additional intervention may need to be added .
1. Record review revealed that Resident ID #98 was readmitted to the facility in February of 2024 with diagnoses of, but not limited to, mild neurocognitive disorder and acute kidney failure.
Review of the Weights and Vitals Summary Report revealed the following weights:
2/6/2024 - 136.2 pounds (lbs)
2/27/2024 - 128.6 lbs
Review of the progress notes revealed the Dietician made the following recommendations on 2/28/2024:
Notify the doctor of weight loss and poor appetite, question using an appetite stimulant, add 8-ounce house supplement two times per day.
Record review failed to reveal evidence that an appetite stimulant or a house supplement was initiated per the dietician's recommendations.
Further review of the resident's recorded weights revealed a weight on 3/12/2024 of 125 lbs, indicating the resident experienced an additional 3.6 lb weight loss in the 14 days following the dietician's recommendations that were never implemented.
During a surveyor interview on 3/13/2024 at 8:20 AM with the Registered Dietician, she acknowledged that neither the appetite stimulant or the house supplement had been initiated for the resident. Additionally, she acknowledged the resident continued to lose weight.
During a surveyor interview on 3/13/2024 at 10:08 AM via telephone with Nurse Practitioner, Staff N, she revealed that she was never made aware of the dietician's recommendations. Additionally, she revealed that she would have ordered both an appetite stimulant and a supplement for the resident if she had been made aware.
During a surveyor interview on 3/13/2024 at approximately 2:00 PM with the Director of Nursing Services (DNS) she revealed that she would expect the staff to report the Dieticians recommendations to the provider and obtain orders.
2. Review of a facility provided document titled, March 2024 Monthly Weights states, reweigh all residents with a 3 pound difference immediately. Weight due by the 6th of each month.
Record review revealed that Resident ID #129 was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, dementia and atrial fibrillation (abnormal heart rate).
Record review revealed the resident's weight was 169 lbs on 2/11/2024.
Review of the March 2024 Monthly Weights revealed the resident's weight was 188.4 lbs. A weight gain of 19.4 lbs or 11.8%.
Record review failed to reveal evidence of a re-weight per the facility policy. Further review failed to reveal evidence that the resident's provider or dietician were notified of his/her weight gain per the facility policy.
Review of an admission Minimum Data Set assessment dated [DATE] revealed that the resident is at nutritional risk and would require a nutrition care plan.
Record review failed to reveal evidence that a care plan was initiated for the resident to address his/her nutritional risk.
During a surveyor interview on 3/13/2024 at 9:35 AM with the Registered Dietician she acknowledged that a nutritional care plan was not initiated to address the resident's nutrition risk. Additionally, she was unaware of the residents 19.4 lb weight gain since the previous month.
During a surveyor interview on 3/13/2024 at 2:09 PM with the DNS, she was unable to provide evidence of a reweight or notification to the physician and dietician of the weight gain per the policy. Additionally, she was unable to provide evidence that the facility ensured that residents maintain acceptable parameters of nutritional status for the above-mentioned residents.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
Based on surveyor observation, record review, and staff interviews, it has been determined that the facility failed to ensure that pain management was provided to a resident who required such services...
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Based on surveyor observation, record review, and staff interviews, it has been determined that the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 wound treatments observed, Resident ID #79.
Findings are as follows:
According to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities last revised on 2/3/2023 states in part, .Because pain can significantly affect a person's well-being, it is important that the facility recognize and address pain promptly. The facility's evaluation of the resident at admission and during ongoing assessments helps identify the resident who is experiencing pain or for whom pain may be anticipated during specific procedures, care, or treatment .
Record review revealed the resident was re-admitted to the facility in March of 2024 with diagnoses including, but not limited to, sepsis (an infection in the blood stream) and epilepsy.
Review of a document titled, WOUND EVALUATION & MANAGEMENT SUMMARY dated 3/12/2024, revealed the resident has a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) to his/her sacrum (base of the spine) measuring 5 centimeters (cm) by 1.9 cm by 1 cm. Further review revealed a recommendation to administer pain medication prior to wound care.
During a surveyor observation on 3/13/2024 at approximately 9:16 AM, revealed Licensed Practical Nurse, Staff M, performing wound care of the resident's stage 4 pressure ulcer. Throughout the duration of the wound treatment, the resident was noted to be yelling, swearing, and complaining of pain. Further, the nurse proceeded with the wound treatment and did not stop until the treatment was completed.
During a surveyor interview on 3/13/2024 at 9:18 AM, with Staff M, she revealed that the resident does not have any pain medication available and further indicated that the resident is only in pain during wound treatments.
During a subsequent interview on 3/13/2024 at 9:21 AM, with Staff M, she acknowledged the resident did not receive any pain medication prior to the observed wound treatment. She further revealed that she does not medicate the resident before wound treatments.
Record review revealed a physician's order dated 6/14/2023 for Acetaminophen tablet, 650 milligrams, every six hours, as needed for temperature and pain.
Review of the March 2024 Medication Administration Record failed to reveal evidence that the above pain medication was administered to the resident on 3/13/2024, prior to his/her wound treatment.
During a surveyor interview on 3/13/2024 at 1:59 PM, with the Director of Nursing Services, she indicated that she would expect the resident to be medicated for pain prior to wound treatments. She further revealed that she would have expected the nurse to stop the wound treatment and administer the resident pain medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse, including injuries of unknown source are reported imm...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to other officials (Department of Health), in accordance with State law, for 1 of 1 resident reviewed for an injury of unknown origin, Resident ID #129.
Findings are as follows:
Record review of an undated facility policy titled, Resident Abuse Prohibition, states in part, .Any instance .including injuries of unknown origins .must be reported immediately to the DNS [Director of Nursing Services]/designee .The Department of Health and the Alliance for Better Long Term Care will be contacted to report all alleged violations .including injuries of unknown source .immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .
Record review revealed the resident was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, pressure ulcer of the sacral region (base of the spine), stage 4 (severe type of pressure ulcer, the skin is severely damaged, and the surrounding tissue begins to die [necrosis] may extend to muscle and bone), muscle weakness, and dementia.
Record review of an x-ray result report dated 3/13/2024 at 3:59 PM, revealed in part, .FINDINGS .There is a fracture of the upper portion of the patella [kneecap] .
Further record review failed to reveal evidence that the fracture, an injury of unknown origin, was reported to The Rhode Island Department of Health, per policy.
During a surveyor interview on 3/14/2024 at 9:20 AM with Registered Nurse, Staff B she revealed that Resident ID #129 was transferred to an acute care hospital on 3/13/2024 after a portable x-ray revealed a fracture to his/her left knee. Staff B was unable to provide evidence that this injury of unknown origin was reported to the Rhode Island Department of Health as required.
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 services provided meet professional standards of quality relative to following a physician's ...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to following a physician's order for 1 of 1 resident reviewed for carbon dioxide retention, Resident ID #3, 1 of 1 resident reviewed for off-loading heel booties, Resident ID #66, 1 of 1 resident reviewed for knee splints, Resident ID #75, and 1 of 2 residents reviewed for edema (swelling), Resident ID #105.
Findings are as follows:
According to Mosby's 4th Edition, Fundamentals of Nursing page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
1. Record review revealed Resident ID #3 was readmitted to the facility in February of 2024 with a diagnosis including, but not limited to, chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs).
Review of a document titled Lab Results Report dated 2/5/2024 revealed the resident's carbon dioxide level was 37 (normal range 19-32).
Review of a provider note dated 2/7/2024 states in part, .Member also has COPD and chronic respiratory failure w/ [with] hypoxia [below-normal level of oxygen in your blood] and hypercapnia [higher than normal level of carbon dioxide in the blood]; order placed to titrate O2 [oxygen] to maintain saturation 88-92% .Gave order to titrate O2 to maintain saturation of 88-92% .
Record review failed to reveal evidence of a physician's order to titrate the resident's oxygen.
Record review revealed a physician's order dated 2/5/2024 for oxygen at 2-4 Liters (L) via nasal cannula, as tolerated, every shift for shortness of breath.
Further record review revealed a physician order dated 2/9/2024 to keep oxygen saturation between 88-92% due to carbon dioxide retention, three times a day.
Review of the February 2024 Medication Administration Record (MAR) revealed 5 out of 73 opportunities, the resident's oxygen saturation levels were documented within the indicated parameter of 88-92%.
Review of the March 2024 MAR revealed 0 out of 39 opportunities, the resident's oxygen saturation levels were documented within the indicated parameter of 88-92%.
Review of the resident's oxygen saturation vitals summary dated 2/8/2024 through 3/13/2024 revealed 8 out of 133 documented oxygen saturation levels were within the indicated parameter of 88-92%.
During a surveyor observation on 3/13/2024 at 9:14 AM, revealed the resident was utilizing 3L of oxygen.
During a surveyor observation on 3/14/2024 at 12:09 PM, in the presence of Licensed Practical Nurse (LPN), Staff C, revealed the resident was utilizing 3L of oxygen with an oxygen saturation level of 100%.
During a surveyor interview, immediately following the above observation, Staff C acknowledged the resident was utilizing 3 L of oxygen, with an oxygen saturation level of 100%. She further acknowledged that the resident's oxygen saturation level of 100% does not fall within the intended parameters.
During a surveyor interview on 3/14/2024 at 12:43 PM, with the Director of Nursing Services (DNS), she indicated that it is her expectation that staff would follow physician orders.
A surveyor interview was attempted on 3/14/2024 at 12:43 PM with Nurse Practitioner, Staff D, but she did not answer, a voicemail was left, and the surveyor did not receive a call back.
2. Record review revealed Resident ID #66 was readmitted to the facility in September of 2022 with diagnoses including, but not limited to, stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) of the right buttock, fusion of the spine and abnormal posture.
Further record review revealed a physician's order dated 10/25/2023 for heel booties to bilateral feet every shift, as tolerated for wound care.
During surveyor observations on the following dates and times the resident was observed without bilateral heel booties in place:
- 3/10/2024 at 9:18 AM
- 3/10/2024 at 11:00 AM
- 3/10/2024 at 12:05 PM
- 3/11/2024 at 8:42 AM
- 3/11/2024 at 11:14 AM
- 3/11/2024 at 1:00 PM
Record review failed to reveal evidence that the resident was unable to tolerate wearing the heel booties to his/her bilateral feet.
During a surveyor observation and simultaneous interview on 3/11/2024 at 1:40 PM with the LPN, Staff E, she acknowledged that the resident was not wearing the bilateral heel booties. Additionally, Staff E was unable to locate one of the heel booties in the resident's room.
During a surveyor interview on 3/12/2024 at approximately 9:00 AM with the DNS, she indicated that she would expect the staff to follow the physician's order.
3. Record review revealed Resident ID #75 was admitted to the facility in March of 2022 with diagnoses including, but not limited to, contracture of the right hip and right knee, stage 4 pressure ulcer of the right ankle and muscle weakness.
Further record review revealed a physician's order dated 10/12/2023 for application of a right knee splint for 2 to 5 hours a day following morning care for right lower extremity contracture management.
During surveyor observations on the following dates and times revealed the resident was not wearing the right knee splint:
- 3/10/2024 at 10:00 AM
- 3/11/2024 at 9:18 AM
- 3/11/2024 at 11:18 AM
- 3/11/2024 at 1:30 PM
- 3/11/2024 at 2:45 PM
- 3/12/2024 at 9:00 AM
- 3/12/2024 at 11:22 AM
- 3/12/2024 at 2:18 PM
- 3/13/2024 at 9:16 AM
- 3/13/2024 at 11:30 AM
- 3/13/2024 at 2:00 PM
- 3/14/2024 at 9:11 AM
Record review failed to reveal evidence that staff was documenting the application of the right knee splint.
During a surveyor interview on 3/14/2024 at 9:24 AM with LPN, Staff F, she acknowledged that the resident did not have the right knee splint on. Additionally, she indicated that she was not aware of the right knee splint order.
During a surveyor interview on 3/14/2024 at 9:36 AM with the Assistant Director of Rehabilitation, she acknowledged that there is an order for the resident to have a right knee splint, relative to his/her right knee contracture. She further indicated that the nursing staff are aware of the order and the splint is located near the window in the resident's room.
During a surveyor interview on 3/14/2024 at approximately 11:00 AM with Nursing Assistant, Staff G, she stated that the resident's knee splint is applied when she has the resident on her assignment. She further revealed that it has not been applied because she has not had the resident on her assignment since the start of the survey.
4. Record review revealed Resident ID #105 was readmitted to the facility in December of 2023 with diagnoses including, but not limited to, varicose veins of left lower extremity with ulcer of calf, open wound to left ankle and lower leg, open wound to right lower leg, and lymphedema (swelling).
Record review revealed a physician's order dated 1/5/2024 to encourage leg elevation, as tolerated, every shift.
Further record review revealed a physician's order dated 1/25/2024, to off-load wounds, as tolerated, every shift for wound care.
During surveyor observations on the following dates and times failed to reveal evidence that the resident's wounds were off loaded or his/her legs were elevated:
- 3/10/2024 at 9:17 AM
- 3/10/2024 at 11:00 AM
- 3/10/2024 at 12:05 PM
- 3/11/2024 at 8:30 AM
- 3/11/2024 at 11:45 AM
- 3/11/2024 at 1:36 PM
- 3/11/2024 at 2:24 PM
- 3/12/2024 at 9:43 AM
- 3/12/2024 at 11:29 AM
- 3/12/2024 at 12:49 PM
- 3/12/2024 at 2:37 PM
Record review failed to reveal evidence that the resident was unable to tolerate his/her wounds being off loaded or his/her legs being elevated.
During a surveyor interview on 3/12/2024 at approximately 1:00 PM with the resident, s/he revealed that s/he has not been elevating his/her legs because staff expects him/her to elevate them in bed at all times. Additionally, s/he indicated that s/he would elevate his/her legs, but staff have not provided him/her with an alternative method to do so. S/he further indicated that s/he would like a recliner or a chair so s/he does not remain in bed all day.
During a surveyor interview on 3/12/2024 at approximately 3:00 PM with LPN Staff F, she revealed that the resident has been refusing to elevate his/her legs because s/he does not like to stay in bed all day. Staff F further indicated she was not aware of the resident's preference to have a recliner in order to comply with off-loading his/her wounds and elevating his/her legs.
During a surveyor interview on 3/13/2024 at 2:05 PM with the DNS, she indicated that she would expect staff to follow the physician's orders. She further stated that she was not aware of the resident not being provided a recliner or a chair to off-load his/her wounds and elevate his/her legs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 2 of 5 residents reviewed with an indwelling catheter (a flexible tube that collects urine from the bladder and leads to a drainage bag), Resident ID #s 79 and 129.
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).
According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing Volume 2, 10th Edition, 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.
1. Record review revealed Resident ID #79 was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, retention of urine and obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional).
Further record review revealed the resident was hospitalized from [DATE] to 3/4/2024 when s/he returned to the facility.
Review of the resident's care plan revealed a focus initiated on 6/16/2023 and revised on 2/7/2024 that revealed the resident has an indwelling catheter in place related to obstructive uropathy and kidney stones. An intervention includes, but is not limited to, monitor and document intake and output as per facility policy.
Record review revealed the resident has a percutaneous nephrostomy tube (PCN, a tube that is inserted through a small surgical incision in the skin and runs from the kidney to a valve, which connects to a drainage bag that collects urine).
Record review revealed the following physician orders:
- Flush catheter with 60 cc of sterile water, with a start date of 7/3/2023 and a hold date of 3/2/2024.
- Flush PCN tube with 10 cc of normal saline, change outer dressing with each flush, every Tuesday, Friday, and Saturday day shift, for PCN maintenance and monitor output, with a start date of 2/9/2024 and a hold date of 3/2/2024.
Further record review failed to reveal evidence that the above orders were re-initiated upon the residents return to the facility on 3/4/2024, until it was brought to the facility's attention by the surveyor on 3/12/2024.
Additional record review failed to reveal documentation of urinary output for the month of March 2024, to monitor for urine output.
During a surveyor interview on 3/12/2024 at 11:33 AM, with Licensed Practical Nurse (LPN), Staff M, she revealed that the resident did not have any recommendations or orders from the physician to empty the resident's PCN drainage bag or record urinary output. Further, she revealed that she does not empty the PCN drainage bag and indicated that the Nursing Assistants (NA) will tell her if it needs to be emptied.
During a subsequent interview on 3/12/2024 at 11:35 AM, with NA, Staff I, in the presence of Staff M, she revealed that she does not have the ability to chart the resident's urinary output and indicated that it should be documented every shift. Additionally, both Staff I and Staff M acknowledged that there is no documentation of urinary output from the resident's catheter or PCN tube.
During a surveyor interview on 3/12/2024 at 12:26 PM, with the Assistant Director of Nursing Services, she revealed that the physician's orders to flush the foley catheter and PCN tube should not have been on hold, after the resident returned from the hospital and indicated she told the provider, after it was brought to her attention by the surveyor. Additionally, she acknowledged that there are no measurements for the output of the foley catheter or PCN tube in the resident's record.
During a surveyor interview on 3/12/2024 at 1:22 PM, with the Director of Nursing Services (DNS), she revealed that the urinary output of the resident's foley catheter and PCN tube should be documented in his/her record. Further, she indicated that she would have expected the physician orders, relative to flushing the foley catheter and PCN tube, to have been reinstated after the resident was hospitalized , given the resident's history of having multiple blockages in them.
2. Record review revealed Resident ID #129 was admitted to the facility in January of 2024 with diagnoses including, but not limited to, urinary tract infection and obstructive and reflux uropathy.
Review of the resident's care plan revealed a focus area last revised on 1/24/2024 that revealed the resident has a foley catheter due to obstructive uropathy.
Record review failed to reveal documentation of urinary output, to monitor for urine output.
During a surveyor interview on 3/14/2024 at 11:16 AM, with the DNS, she acknowledged that the resident does not have a physician's order to monitor urinary output. She further revealed that the nurses should be monitoring the urinary output, but indicated they only have to document urinary output if there is a physician's order. Furthermore, she was unable to explain how staff are monitoring the day to day urinary output for residents with a diagnosis of obstructive and reflux uropathy if there is not documentation in their records to review.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
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 each resident's medication regimen is free from a medication error rate of 5...
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Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 25 opportunities for errors observed during the medication administration task there were 2 errors resulting in an error rate of 8%, involving Resident ID #s 7 and 86.
Findings are as follows:
1. Record review revealed Resident ID #86 has a physician's order for Eliquis 5 milligrams give 1 tablet every morning and night related to septic pulmonary embolism (infected blood clot in the lung).
During a surveyor observation of the medication administration task on 3/11/2024 at 10:15 AM with Registered Nurse, Staff O, she failed to administer the morning dose of Eliquis to the resident as ordered.
During a surveyor interview immediately following the above observation with Staff O, she acknowledged that Resident ID #86 did not receive his/her Eliquis.
2. Record review revealed Resident ID #7 has a physician's order for Fluticasone Proprionate nasal suspension 50 micrograms give 1 spray in each nostril in the morning for nasal congestion.
Further surveyor observation of the medication administration task on 3/11/2024 at approximately 10:30 AM with Staff O, she failed to administer the above medication to Resident ID #7 as ordered.
During a surveyor interview immediately following the above observation with Staff O, she acknowledged that Resident ID #7 did not receive his/her Fluticasone.
During a surveyor interview with the Director of Nursing Services on 3/12/2024 at 1:44 PM, she revealed that she would expect that the residents receive their medication as ordered. Additionally, she was unable to provide evidence that the facility ensured each resident's medication regimen is free from a medication error rate of 5% or greater.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and staff interview it has been determined that the facility failed to maintain medical records on each resident that are accurately documented for 1 of 1 resident reviewed for ...
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Based on record review and staff interview it has been determined that the facility failed to maintain medical records on each resident that are accurately documented for 1 of 1 resident reviewed for heel boots, Resident ID #66 and 1 of 1 resident reviewed for off-loading wounds and elevating legs, Residents ID #105.
Findings are as follows:
1. Record review revealed Resident ID #66 was readmitted to the facility in September of 2022 with diagnoses including, but not limited to, stage 4 pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of the right buttock, fusion of the spine and abnormal posture.
Further record review revealed a physician's order dated 10/25/2023 for heel boots to bilateral feet every shift as tolerated for wound care.
During surveyor observations on the following date and times there was no evidence of the bilateral heel boots observed:
- 3/10/2024 at 9:18 AM
- 3/10/2024 at 11:00 AM
- 3/10/2024 at 12:05 PM
- 3/11/2024 at 8:42 AM
- 3/11/2024 at 11:14 AM
- 3/11/2024 at 1:00 PM
Review of March 2024 Treatment Administration Record (TAR) revealed that the bilateral heel boots were documented as being in place when they were not;:
- 3/10/2024 day shift (7:00 AM to 3:00 PM)
- 3/11/2024 day shift (7:00 AM to 3:00 PM)
During a surveyor interview on 3/11/2024 at approximately 11:00 AM, with Licensed Practical Nurse, Staff E, she acknowledged that the heel boots were not in place. Additionally, she was unable to locate one of the boots in the resident's room. Further, Staff E was unable to explain why they were signed off as applied when they were not on the resident.
2. Record review revealed Resident ID #105 was readmitted to the facility in December of 2023 with diagnoses including, but not limited to, varicose veins of left lower extremity with ulcer of calf, open wound to left ankle and lower leg, open wound to right lower leg, and lymphedema (swelling).
Additional record review revealed a physician's order dated 1/25/2024 to off-load wounds as tolerated.
During surveyor observations on the following dates and times there was no evidence of his/her wounds being off-loaded:
- 3/10/2024 at 9:17 AM
- 3/10/2024 at 11:00 AM
- 3/10/2024 at 12:05 PM
- 3/11/2024 at 8:30 AM
- 3/11/2024 at 11:45 AM
- 3/11/2024 at 1:36 PM
- 3/11/2024 at 2:24 PM
- 3/12/2024 at 9:43 AM
- 3/12/2024 at 11:29 AM
- 3/12/2024 at 12:49 PM
- 3/12/2024 at 2:37 PM
Review of March 2024 TAR revealed that the off-loading of the wounds were documented as being completed on the following dates:
- 3/10/2024 day shift (7:00 AM - 3:00 PM)
- 3/11/2024 day shift (7:00 AM - 3:00 PM)
- 3/12/2024 day shift (7:00 AM - 3:00 PM)
During a surveyor interview on 3/12/2024 at approximately 3:00 PM with LPN, Staff F, she was unable to explain why the TAR indicated that the resident's wounds were offloaded when they were not.
During a surveyor interview on 3/13/2024 at 2:05 PM with the Director of Nursing Services, she was unable to explain why the staff have been inaccurately documenting in the residents' medical records.
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
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide the necessary services to a resident who is unable to carry out activities of daily living relative to incontinence care for 1 out of 1 incidence of incontinence care observed, Resident ID #129 and relative to the weekly scheduled showers for 9 out of 32 residents reviewed, Resident ID #s 1, 11, 38, 41, 46, 63, 82, 112, and 118.
Findings are as follows:
1. Record review revealed Resident ID #129 was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, pressure ulcer of the sacral region (tail bone area), stage 4 (severe type of pressure ulcer, the skin is severely damaged, and the surrounding tissue begins to die (necrosis) may extend to muscle and bone), muscle weakness, and dementia.
Record review of a Minimum Data Set Assessment (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating severely impaired cognition. Additionally, s/he is dependent on staff members for toileting hygiene.
During a surveyor observation on 3/12/2024 at 11:11 AM, the following was revealed:
- The resident was receiving assistance with transferring from his/her recliner chair to his/her bed with a mechanical lift and Nursing Assistant (NA) Staff G and NA, Staff H.
- The resident was noted to be incontinent of loose stool. His/her adult incontinence brief was saturated with loose stool which extended out of the brief and continued to his/her back.
- The sacrum wound was covered with a dressing which was also saturated with stool.
During a surveyor interview on 3/12/2024 at 11:20 AM, immediately following the above-mentioned observation with Staff G, she revealed that she was the NA assigned to provide care to Resident ID #129 for the 7:00 AM - 3:00 PM shift. She further revealed that when she arrived on shift at approximately 7:30 AM, the resident was already out of bed sitting in his/her recliner chair. Staff G indicated that she did not transfer the resident out of the recliner or provide him/her with incontinence care until the above-mentioned observation, indicating s/he sat in his/her recliner for approximately 4 hours without receiving incontinence care.
During surveyor interviews on 3/12/2024 at 1:12 PM and 3/14/2024 at 11:12 AM, with the Director of Nursing Services (DNS) she revealed that she would expect staff to protect the resident's skin and check him/her at least every half to one hour for incontinence.
2. Record review revealed Resident ID #1 was readmitted to the facility in March of 2023 with diagnoses including, but not limited to, lymphedema (swelling), muscle weakness, and paranoid schizophrenia.
Record review of an Annual MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition. Further review revealed that s/he requires the total assistance of two or more staff members for bathing which includes showers. Additionally, the MDS revealed that s/he answered that it is Somewhat important, for him/her to choose his/her preferred bathing method.
During a surveyor interview on 3/13/2024 at 1:14 PM with Resident ID #1, s/he revealed that s/he has not had a shower in a year because of a broken shower chair and staff do not offer him/her a shower. Additionally, s/he indicated that his/her shower days are scheduled on Tuesday and Friday during the 3:00 PM - 11:00 PM shift. S/he indicated she did not have a shower on Tuesdays 3/12/2024.
Record review of the Nursing Assistant (NA) Activities of Daily Living (ADL) documentation for the dates between 2/14/2024 - 3/12/2024 failed to reveal evidence that Resident ID #1 received a shower. Additionally, the record failed to reveal evidence that s/he was offered and or refused a shower.
3. Record review revealed Resident ID #11 was admitted to the facility in April of 2011 with diagnoses including, but not limited to, unsteadiness on feet, legal blindness, and dry eye syndrome.
Review of a quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15, indicating moderately impaired cognition. Further review revealed that s/he requires the total assistance of 1 staff member for bathing, which includes showers. Additionally, the MDS revealed that s/he answered that it is very important for him/her to choose his/her preferred bathing method.
During a surveyor interview on 3/11/2024 at 9:50 AM, with Resident ID #11, s/he indicated that s/he has not been given his/her scheduled shower by the NAs. Additionally, s/he revealed that they don't follow the shower schedule and s/he has to ask them about it. Further s/he revealed s/he would like to have a shower twice a week.
Record review of the weekly shower schedule revealed that Resident ID #11 is scheduled to receive a shower on Tuesdays and Fridays on the 7:00 AM to 3:00 PM shift.
Record review of the facility's document titled Adls-Bathing revealed Resident ID #11 last received a shower on 2/28/2024 at 2:59 PM. Further review revealed the resident was not showered for 7 out of 8 opportunities for a shower, from 2/13/2024 to 3/13/2024. Additionally, the record failed to reveal evidence that s/he was offered and or refused a shower.
4. Record review revealed Resident ID #38 was readmitted to the facility in October of 2018 with diagnoses including, but not limited to, unsteadiness on feet, muscle weakness, and colostomy status (a surgical opening to the abdomen to pass the stool or gas).
Review of a State Optional MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition. Further review revealed that s/he requires the total assistance of 1 staff member for bathing, which includes showers. Additionally, the MDS revealed that s/he answered that it is somewhat important for him/her to choose his/her preferred bathing method.
During a surveyor interview on 3/11/2024 at 10:00 AM, with Resident ID #38, s/he indicated that s/he would like to have a shower more often, but the staff do not offer it.
Record review of the weekly shower schedule revealed that Resident ID #38 is scheduled to receive a shower on Tuesdays and Wednesdays.
Record review of the facility's document titled Adls-Bathing for Resident ID #38 failed to reveal evidence that the resident had a shower from 2/13/2024 to 3/13/2024, missing 8 out of 8 opportunities for a shower. Additionally, the record failed to reveal evidence that s/he was offered and or refused a shower.
5. Record review revealed Resident ID #41 was readmitted to the facility in December of 2020 with diagnoses including, but not limited to, major depressive disorder, muscle weakness, and need for assistance for personal care.
Review of a quarterly MDS assessment dated [DATE] revealed a BIMS score of 7 out of 15, indicating severely impaired cognition. Further review revealed that s/he requires the total assistance of 1 staff member for bathing, which includes showers. Additionally, the MDS revealed that s/he answered that it is somewhat important for him/her to choose his/her preferred bathing method.
During a surveyor interview on 3/11/2024 at 10:16 AM, with Resident ID #41, s/he indicated that s/he would like to have a shower and have his/her hair washed to feel good. Additionally, s/he revealed that they only give him/her a sponge bath. S/he further indicated that when s/he requests a shower, the NAs tell him/her the following shift will assist him/her with a shower.
Record review of the resident's weekly shower schedule revealed that s/he is scheduled to receive a shower on Mondays and Thursdays on the 3:00 PM to 11:00 PM shift.
Record review of the facility's document titled Adls-Bathing revealed Resident ID #41 received a shower on 2/15/2024, 2/27/2024 and on 3/7/2024 missing 5 out 8 opportunities from 2/13/2024 to 3/13/2024. Additionally, the record failed to reveal evidence that s/he was offered and or refused a shower.
6. Record review revealed Resident ID #46 was readmitted to the facility in March of 2024 with diagnoses including, but not limited to, mood disorder, skin excoriation disorder and shortness of breath.
Review of a quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition. Further review revealed that s/he requires the total assistance of 1 staff member for bathing, which includes showers. Additionally, the MDS revealed that s/he answered that it is somewhat important for him/her to choose his/her preferred bathing method.
During a surveyor interview on 3/11/2024 at 10:22 AM, with Resident ID #46, s/he indicated that even though s/he has trouble breathing sometimes, s/he would like to have a shower. Additionally, s/he revealed that the staff do not ask nor follow the twice a week shower schedule and when s/he asks staff for a shower, they make it difficult and still do not provide him/her with a shower.
Record review of the weekly shower schedule revealed that Resident ID #46 is scheduled to receive a shower on Tuesdays and Fridays on the 7:00 AM to 3:00 PM shift.
Record review of the facility's document titled Adls-Bathing revealed Resident ID #46 did not receive a shower from 2/13/2024 to 3/13/2024, missing 8 out of 8 opportunities for a shower. Additionally, the record failed to reveal evidence that s/he was offered and or refused a shower.
7. Record review revealed Resident ID #63 was admitted to the facility in October of 2023 with diagnoses including, but not limited to, major depressive disorder, insomnia, and muscle weakness.
Review of a quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition. Further review revealed that s/he requires the total assistance of 1 staff member for bathing, which includes showers. Additionally, the MDS revealed that s/he answered that it is somewhat important for him/her to choose his/her preferred bathing method.
During a surveyor interview on 3/11/2024 at 9:32 AM, with Resident ID #63, s/he indicated that s/he does not take shower because the shower room floor has mold and cracked tiles on it. S/he further revealed that staff do not offer him/her a shower.
Record review of the shower schedule revealed that Resident ID #63 is scheduled to receive a shower on the 3:00 PM to 11:00 PM shift but it failed to reveal what days the resident was scheduled to receive a shower.
Record review of the facility's document titled Adls-Bathing revealed Resident ID #63 did not receive a shower from 2/13/2024 to 3/13/2024, missing 8 out of 8 opportunities for a shower. Additionally, the record failed to reveal evidence that s/he was offered and or refused a shower.
8. Resident ID #82 was readmitted to the facility in June of 2023 with diagnoses including, but not limited to, diabetes and major depressive disorder.
Record review of a Significant Change in Status MDS assessment dated [DATE], revealed a BIMS score of 5 out of 15, indicating severely impaired cognition. Further review revealed that s/he requires the total assistance of one staff member for bathing, which includes showers. Additionally, the MDS revealed that it is Somewhat important, for him/her to choose his/her preferred bathing method.
During a surveyor interview on 3/13/2024 at 1:49 PM, with Resident ID #82, s/he revealed that s/he has never been offered or received a shower.
Record review of the ADL documentation between 2/14/2024 to 3/12/2024 failed reveal evidence that s/he received a shower. Additionally, the record failed to reveal evidence that s/he was offered and or refused a shower.
9. Record review revealed Resident ID #112 was admitted to the facility in January of 2024 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and pain in lower leg.
Review of an admission MDS assessment dated [DATE] revealed a BIMS score of 13 out of 15, indicating intact cognition. Further review revealed s/he requires substantial/maximal assistance of staff for bathing, which includes showers. Additionally, the MDS revealed that it is Somewhat important, for him/her to choose his/her preferred bathing method.
During a surveyor interview on 3/11/2024 at 11:28 AM with Resident ID #112, s/he revealed that s/he hasn't received a shower in a couple of weeks and it bothers him/her. S/he further revealed that his/her hair is a mess and feels knotted from not taking a shower.
During a surveyor interview on Wednesday, 3/13/2024 at 11:19 AM with NA, Staff I, in the presence of NA, Staff J, she revealed that the resident told her this morning that s/he had asked for a shower. Staff J revealed that the resident's shower schedule is on Mondays and Thursdays.
Record review of the ADL documentation between 2/1/2024 to 3/13/2024 revealed that Resident ID #112 received one shower on 2/23/2024, indicating s/he missed 7 out of 8 opportunities to receive a shower. Further review of the documentation revealed the resident did not receive a shower on 3/13/2024, after bringing it the attention to Staff I. Additionally, the record failed to reveal evidence that s/he was offered and or refused showers.
10. Record review revealed Resident ID #118 was readmitted to the facility in September of 2013 with diagnoses including, but not limited to, legal blindness, major depressive disorder, and anxiety disorder.
Review of a quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15, indicating moderately impaired cognition. Further review revealed that s/he requires the total assistance of 1 staff member for bathing, which includes showers. Additionally, the MDS revealed that s/he answered that it is somewhat important for him/her to choose his/her preferred bathing method.
During a surveyor interview on 3/11/2024 at approximately 11:00 AM, with Resident ID #118, s/he indicated that the staff do not help him/her take shower, even though s/he is aware of the schedule that they are supposed to follow. Additionally, Resident ID #118 revealed that s/he must fight with the NAs most of the times to help him/her with a shower, even when s/he has his/her concerns with personal hygiene.
Record review of the weekly shower schedule revealed that ID #118 is scheduled to received daily showers.
Record review of the facility's document titled Adls-Bathing revealed Resident ID #118 received a shower on 3/2/2024 and 3/7/2024, indicating s/he missed 28 out of 30 opportunities for a shower, from 2/13/2024 to 3/13/2024. Additionally, the record failed to reveal evidence that s/he was offered and or refused a shower.
During a surveyor interview on 3/12/2024 at approximately 1:30 PM with the Lead NA, Staff K, she was unable to provide evidence that these residents shower schedules were being followed by the staff.
During a surveyor interview 3/13/2024 at approximately 3:00 PM with the DNS, she indicated that she would expect staff to give the residents a shower according to their schedule. Additionally, she was unable to provide evidence that the facility provided the necessary services to a resident who is unable to carry out activities of daily living.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
Based on record review and staff interview it has been determined that the facility failed to keep residents free from significant medication errors for 6 of 32 residents reviewed, Resident ID #s 7, 4...
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Based on record review and staff interview it has been determined that the facility failed to keep residents free from significant medication errors for 6 of 32 residents reviewed, Resident ID #s 7, 42, 48, 70, 112 and 123.
Findings are as follows:
Review of a facility policy titled, Medication Administration states, It is the intent of this policy to ensure that resident medication administration is managed to ensure for resident quality of life, timeliness and safety.
1. Record review revealed Resident ID #48 was readmitted to the facility in December of 2020 with diagnoses including, but not limited to, schizoaffective disorder and borderline personality disorder.
Record review revealed the following physician orders:
Ambien oral tablet 5 milligram (MG, hypnotic), give 1 tablet by mouth at bedtime for insomnia.
Oxycodone oral tablet 10 MG, give one tablet by mouth every 6 hours for pain.
Review of the March 2024 Medication Administration Record (MAR) revealed the medication was not administered and coded as 9, (see nurses note) on the following dates:
Ambien on 3/6, 3/7, 3/8, 3/9, 3/10 and 3/11/2024
Oxycodone on 3/1, 3/2, 3/3, 3/4 and 3/12/2024
Review of the progress notes on the above-mentioned dates revealed the medications were unavailable to be administered.
During a surveyor interview on 3/12/2024 at 10:08 AM with Nurse Practitioner (NP), Staff P, she revealed that she was not aware of the resident not receiving the above-mentioned medications until 3/12/2024.
2. Record review revealed that Resident ID #7 was admitted to the facility in December of 2022 with diagnoses including, but not limited to, anxiety and adult failure to thrive.
Record review revealed the following physician orders:
Lexapro oral tablet 10 MG, give 1 tablet by mouth in the morning for anxiety.
Fluticasone Propionate Nasal Suspension 50 MCG/ACT (micrograms/activation), 1 spray in each nostril in the morning for nasal congestion.
Artificial Tears Ophthalmic Solution, instill 1 drop in both eyes every morning and at bedtime for dry eyes.
Review of the March 2024 MAR revealed the following medications were not administered and coded as 9 (see nurses note) on the following dates:
Lexapro oral tablet 10 MG on 3/3 and 3/4/2024
Artificial Tears Ophthalmic Solution on 3/4, 3/5, 3/6, 3/7, and 3/9/2024
Fluticasone Propionate Nasal Suspension 50 MCG/ACT on 3/8 and 3/11/2024
Review of the progress notes on the above-mentioned dates revealed the medications were unavailable to be administered.
Record review failed to reveal evidence that the practitioner was notified of the above noted missed medications.
3. Record review revealed that Resident ID #42 was readmitted to the facility in March of 2020 with diagnoses including, but not limited to, schizophrenia and major depressive disorder.
Record review revealed the following physician orders:
Zoloft Tablet 100 MG, give 1 tablet by mouth in the morning for depression.
Review of the March 2024 MAR revealed the following medication was not administered and coded as 9 (see nurses note) on the following dates:
Zoloft on 3/6 and 3/7/2024
Review of the progress notes on the above-mentioned dates revealed the medication was unavailable to be administered.
Record review failed to reveal evidence that the practitioner was notified of the above noted missed doses of medication until after it was brought to the facility's attention by the surveyor.
4. Record review revealed that Resident ID #70 was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, hypertension and schizoaffective disorder.
Record review revealed the following physician orders:
Carvedilol (antihypertensive) Oral Tablet 3.125 MG, give 1 tablet by mouth two times a day for hypertension.
Hypromellose Ophthalmic Solution, instill 1 drop in both eyes three times a day for dry eyes.
Review of the March 2024 MAR revealed the following medications were not administered and coded as 9 (see nurses note) on the following dates:
Carvedilol Oral Tablet 3.125 MG on 3/3/2024 and 3/4/2024
Hypromellose Ophthalmic Solution on 3/1, 3/2, 3/4, 3/5, 3/6, 3/7, and 3/9/2024
Review of the progress notes on the above mentioned dates revealed the medications were unavailable to be administered.
Record review failed to reveal evidence that the practitioner was notified of the above noted missed doses of medications.
5. Record review revealed that Resident ID #112 was readmitted to the facility in January of 2024 with diagnoses including, but not limited to, anxiety disorder and major depressive disorder.
Record review revealed the following physician order:
Lorazepam oral tablet 0.5 MG, give 1 tablet one time a day for anxiety disorder.
Review of the March 2024 MAR revealed the following medication was not administered and coded as 9 (see nurses note) on the following dates:
Lorazepam Oral Tablet 0.5 MG on 3/9 and 3/10/2024
Review of the progress notes on the above-mentioned dates revealed the medication was unavailable to be administered.
Record review failed to reveal evidence that the practitioner was notified of the above noted missed doses of medication.
6. Record review revealed that Resident ID #123 was admitted to the facility in September of 2022 with diagnoses including, but not limited to, anxiety disorder and traumatic brain injury.
Record review revealed the following physician orders:
Buspirone oral tablet 5 MG, give 1 tablet two times a day related to anxiety.
Review of the March 2024 MAR revealed the following medication was not administered and coded as 9 (see nurses note) on the following dates:
Buspirone 5 MG, the AM dose on 3/1 and 3/2/2024 and the PM dose on 3/3/2024
Review of the progress notes on the above mentioned dates revealed the medication was unavailable to be administered.
Record review failed to reveal evidence that the practitioner was notified of the above noted missed doses of medication.
During a surveyor interview on 3/12/2024 at 9:56 AM with Licensed Practical Nurse, Staff M, she revealed that the facility does have an emergency kit available to utilize if medications do not come in from the pharmacy timely. Additionally, she acknowledged that the above medication was not administered as ordered and there is no evidence of the provider being notified.
During a surveyor interview on 3/12/2024 at 1:39 PM with the Director of Nursing Services she acknowledged that the above-mentioned medications were not administered and coded as not available. Additionally, she was unable to provide evidence that the facility kept residents free from significant medication errors.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmiss...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to 2 of 3 residents observed for a wound dressing change, Resident ID #s 87 and 105. Additionally, the facility staff failed to conduct appropriate infection control practices relative to hand hygiene for 4 of 4 residents observed during the medication administration task, Resident ID #s 7, 33, 86, and 443.
Findings are as follows:
Review of a facility policy titled, Wounds - Dressing Changes states in part, .Procedure for Dressing Change .7. Nurse will remove soiled dressing and dispose of properly .9. Remove the dirty gloves and dispose of properly 10. Hand hygiene will be performed and the nurse will don clean gloves 11. Cleanse the incision [wound] .
1a) Record review revealed Resident ID #87 was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, chronic venous hypertension with ulcer of lower extremity (wound with delayed healing due to poor circulation).
Record review revealed a physician's order dated 1/17/2024 to cleanse with Vashe (wound cleanser) and perform a daily dressing change to his/her left medial calf wound. Additional review of the physician's orders revealed that the resident was on contact precautions (utilizing additional personal protective equipment in addition to standard precautions) due to methicillin-resistant staphylococcus aureus (MRSA, an infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics) in his/her wound.
During a surveyor observation on 3/11/2024 at 10:49 AM of the resident's left calf wound dressing change, Registered Nurse (RN), Staff B, was observed to remove the soiled dressing. She proceeded to cleanse the wound using the same gloves she had used to remove the soiled dressing. Staff B failed to remove her dirty gloves, conduct hand hygiene, and don new gloves prior to cleansing the wound as per policy.
During a surveyor interview on 3/11/2024 at approximately 11:00 AM with Staff B, she acknowledged that she did not remove her dirty gloves, perform hand hygiene, nor apply clean gloves prior to cleansing the resident's wound.
During a surveyor interview on 3/13/2024 at 2:09 PM with the Director of Nursing Services (DNS), she revealed that she would expect the nurse to remove her dirty gloves, perform hand hygiene, and don new gloves prior to cleansing the resident's wound.
1b) Record review revealed Resident ID #105 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, varicose veins (enlarged veins close to the skin surface) of the left lower extremity with ulcer of calf and open wound to right lower leg.
Record review revealed two physician orders dated 1/26/2024 to cleanse with Vashe and perform daily dressing changes to his/her left lower extremity and right posterior calf wounds.
During a surveyor observation on 3/13/2024 at 9:21 AM of the resident's left lower calf wound dressing change, Licensed Practical Nurse, Staff F, was conducting the resident's wound dressing change with the assistance of Nursing Assistant, Staff G. The resident's wound was observed to have copious amounts of yellow colored drainage. Staff G was observed to place her gloved hand directly on the resident's exposed wound while lifting the resident's leg. Staff F completed the resident's left lower calf dressing change and proceeded to his/her right posterior calf wound. Staff F, was observed to be using both gloved hands while conducting the resident's right calf wound dressing change. Staff F using the same dirty gloves she had used while performing the dressing change, was then noted to be touching a bottle of Vashe (that is used for multiple residents) to cleanse the resident's wound. Upon completion of the dressing change, Staff F was attempting to return the multi-use Vashe bottle to the treatment cart without first having disinfected the bottle until she was stopped by the surveyor.
During a surveyor interview on 3/13/2024 following the above observation with Staff F, she acknowledged that she did not change her dirty gloves after touching the resident's right posterior calf wound and used those same gloves while handling the Vashe bottle. Additionally, she revealed that the Vashe cleanser is used for multiple residents on the unit, including a resident with MRSA in his/her wound.
During a surveyor interview on 3/13/2024 at approximately 2:00 PM with the DNS, she revealed that she would expect staff would adhere to proper infection control practices relative to the wound dressing changes and handling of a multi-use wound cleanser.
2. Review of a facility policy titled, Medication Administration states in part, .Medication Administering: Wash hands (or alcohol gel) between each resident .before and after the application of gloves. This applies to all medication administration and treatment procedures .
During a surveyor observation of the medication administration task on 3/11/2024 at 10:15 AM with RN, Staff O, the following observations were made:
- 10:15 AM Staff O prepared medication for Resident ID #86. She entered and exited his/her room without performing hand hygiene. She returned to the medication cart and failed to perform hand hygiene.
- 10:20 AM Staff O prepared medication for Resident ID #443. She entered and exited his/her room without performing hand hygiene. Additionally, a sign was posted outside the resident's door that indicated everyone must clean their hands, including before entering and when leaving the room. Staff O then returned to the medication cart and failed to perform hand hygiene.
- 10:25 AM Staff O prepared medication for Resident ID #7. She entered and exited his/her room without performing hand hygiene. Additionally, a sign was posted outside the resident's door that indicated everyone must clean their hands, including before entering and when leaving the room. Staff O then returned to the medication cart and failed to perform hand hygiene.
- 10:40 AM Staff O prepared medication for Resident ID #33. She donned gloves without first performing hand hygiene. She entered the resident's room, administered an injection, and exited the resident's room without first disposing of the dirty gloves prior to exiting. Additionally, a sign was posted outside the resident's door that indicated everyone must clean their hands, including before entering and when leaving the room. Staff O proceeded down the hallway wearing the dirty gloves until she was stopped by the surveyor.
During a surveyor interview on 3/11/2024 at approximately 10:45 AM following the above observations, Staff O acknowledged that she failed to perform hand hygiene throughout the duration of the medication administration task. Additionally, she acknowledged exiting Resident ID #33's room with dirty gloves. She revealed that the dirty gloves should have been disposed of prior to exiting the resident's room and that she should have performed hand hygiene between each resident encounter during the medication pass.
During a surveyor interview on 3/12/2024 at 3:08 PM with the Infection Preventionist, she revealed that she would expect staff to perform hand hygiene before and after each resident encounter and that the nurse should have discarded her gloves and performed hand hygiene prior to exiting Resident ID #33's room.
During a surveyor interview on 3/13/2024 at 10:53 AM with the DNS, she revealed that she would expect staff to follow proper infection control practices. She was unable to explain why the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
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 safety relative to the main kitchen and 2 of 2 ice machines.
Findings are as follows:
1. Record review of the Rhode Island Food Code 2018 edition, Section 3-602.11 Food Labels states, .(B) Label information shall include: (1) The common name of the food .
During the initial tour of the main kitchen on 3/10/2024 at 8:18 AM, in the presence of the Food Service Director (FSD), the following food items were observed with no label:
- In the walk-in refrigerator, two bags of hard-boiled eggs were sitting in clear liquid.
- In the walk-in freezer, one opened plastic bag of French toast, noted to have white covering the edges, indicating freezer burn.
During a surveyor interview, immediately following the above observations, the FSD acknowledged both items and indicated they should be discarded.
2. The Rhode Island Food Code 4.601.11 reads in part, .the non-food contact surfaces of equipment shall be kept free of an accumulation of .residue .
During the initial tour of the main kitchen on 3/10/2024 at 8:18 AM, in the presence of the FSD, the hood slats were noted to have a heavy accumulation of dust.
During a surveyor interview, immediately following the above observation, the FSD acknowledged the heavy accumulation of dust on the hood slats.
3. During a surveyor observation on 3/10/2024 at 8:48 AM of Dietary Aide, Staff Q, he was noted to be washing hotel pans and sheets in the 3 bay sink. When the surveyor asked Staff Q to use a test strip in the sanitizer sink, he was unable to provide the test strips. He revealed he did not know he needed to use test strips to test the chemicals.
During a surveyor interview on 3/10/2024 at 8:55 AM with the FSD she found test strips labeled, Hydrion QT-40 and tested the chemicals in the sanitizer sink. The test strip did not change color. She revealed that Staff Q added water after dispensing the chemicals. It was later revealed that the test strips she used were not appropriate for the sink and surface cleaner sanitizer chemicals that they were using.
During a surveyor interview on 3/15/2024 at 1:35 PM with a representative from Ecolab, he revealed the facility switched chemicals recently. He further revealed they just need to fill the sink with the chemical dispenser, and indicated that it is not recommended for water to be added.
4. The Rhode Island Food Code 2018 Edition 5-202.13 reads in part, .an airgap between the water supply inlet and the flood level rim of the plumbing fixture equipment .shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch) .
During a surveyor observation on 3/12/2024 at 12:24 PM, of the second-floor ice machine, revealed it did not have an air gap. Additionally, the drain below the air pipe was noted to have a dark substance.
During a surveyor observation on 3/12/2024 at 12:26 PM, of the main kitchen's ice machine, revealed it did not have an air gap.
During a surveyor interview on 3/12/2024, immediately following the observation of the main kitchen ice machine, with the FSD and Maintenance Director, they acknowledged it did not have an air gap.
During a surveyor interview on 3/12/2024 at approximately 2:20 PM with the Maintenance Director, he revealed the ice machine on the second floor is used frequently. He further revealed the ice machine did not have an air gap.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0582
(Tag F0582)
Minor procedural issue · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to properly provide notice to residents and/or representatives informing when changes in coverage are made t...
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Based on record review and staff interview, it has been determined that the facility failed to properly provide notice to residents and/or representatives informing when changes in coverage are made to items and services covered by Medicare and/or the state medical plan related to the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) of Non-coverage Form for 2 of 4 residents discharged from Medicare Part A Services that remained in the facility, Resident ID #s 111 and 143.
Findings are as follows:
Review of the Center for Medicare and Medicaid Services (CMS) Form, CMS 100-55, titled Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage, states in part:
Medicare requires SNFs [Skilled Nursing Facilities] to issue the SNFABN to Original Medicare, also called fee-for-service (FFS) beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is:
- not medically reasonable and necessary.
- or considered custodial.
The SNFABN provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must use the SNFABN when applicable for SNF Prospective Payment System services (Medicare Part A) .
1. Record review revealed that Resident ID #111's last covered day of Medicare Part A Services was on 10/20/2023. Further record review failed to reveal evidence that the resident or resident representative was issued the SNFABN form.
2. Record review revealed that Resident ID #143's last covered day of Medicare Part A Services was on 11/3/2023. Further record review failed to reveal evidence that the resident and/or resident representative was issued the SNFABN form.
During a surveyor interview on 3/11/2024 at 10:15 AM with the Minimum Data Set Coordinator, Staff A, she revealed that the above residents should have been issued the SNFABN form and was unable to provide evidence that the SNFABN form was completed.
During a surveyor interview on 3/12/2024 at 1:40 PM with the Director of Nursing Services, she was unable to provide evidence that the facility provided the SNFABN notice to the above residents or the resident representatives.
Feb 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and resident and staff interview, it has been determined that the facility failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and resident and staff interview, it has been determined that the facility failed to maintain a safe, clean, sanitary, homelike environment relative to mouse droppings in resident rooms for 2 of 4 units reviewed.
Findings are as follows:
Record review of two community reported complaints submitted to the Rhode Island Department of Health (RIDOH) on 2/5/2024 and on 2/7/2024 allege that mice are present in the resident rooms and throughout the building.
During a surveyor interview with Resident ID #1 on 2/6/2024 at 9:54 AM, s/he revealed that on the second day of his/her admission, s/he saw a mouse run across the room and since then s/he has seen up to three mice at once in his/her room. The resident further revealed s/he is uncomfortable with the mouse droppings in the room which s/he indicated is unsanitary. The resident's roommate also revealed similar concerns.
1. Surveyor observations on the First floor and Second floor on 2/6/2024 at 10:00 AM revealed the following:
-room [ROOM NUMBER], mouse trap in room, several mouse droppings on the floor in the corner of the headboard of B bed and between the two residents' wardrobe.
-room [ROOM NUMBER], several mouse droppings on the floor at each end of the radiator.
-room [ROOM NUMBER], several mouse droppings near B bed's wardrobe.
-room [ROOM NUMBER], a few mouse droppings behind the door and near the closet along the wall.
-room [ROOM NUMBER], mouse trap in room, several droppings on the floor between the B bed's wardrobe and B bed.
During a surveyor observation of room [ROOM NUMBER] in the presence of Maintenance, Staff A, on 2/6/2024 at 10:20 AM he acknowledged the mouse droppings in the resident's room.
2. Further observations on the First and Second floors on 2/7/2024 at approximately 1:00 PM revealed the following:
-room [ROOM NUMBER], several mouse droppings on the floor to the right side of A beds bureau.
-room [ROOM NUMBER], several mouse droppings on the floor to the right and left edges of the radiator.
-room [ROOM NUMBER], several mouse droppings on the floor to the right corner of the radiator and behind B bed's chair.
During a subsequent interview on 2/6/2024 at 1:43 PM with Staff A, he revealed that he was aware of the facility having mice in the building. Additionally, he was unable to provide evidence that the rooms were thoroughly cleaned to eliminate the presence of mouse droppings.
During a surveyor interview on 2/6/2024 at approximately 3:00 PM with the Administrator she revealed that there was a change to a new pest control company a month ago, and is aware that mice remain an issue.
Dec 2023
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide ad...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide adequate supervision to prevent an accident hazard for 1 of 2 residents reviewed for elopement, Resident ID #1.
Findings are as follows:
Record review of a facility reported incident sent to the Rhode Island Department of Health on [DATE] stated in part, Resident was noted to be missing from unit .Resident found by staff on nearby street.
Review of a facility policy titled, Elopement, states in part, It is the intent of this policy to ensure the resident's right to a safe and secure environment .
Review of an additional facility policy titled ELOPEMENT POLICY CODE PURPLE, states in part, It is the policy of [NAME] Health and Rehabilitation Center to prevent elopement of residents, particularly with Dementia .
Review of the resident's record revealed s/he was admitted to the facility in February of 2023 with diagnoses including, but not limited to, unspecified dementia, major depressive disorder, and diabetes mellitus.
Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 0 out of 15, indicating s/he has severe cognitive impairment. Further review of the MDS revealed s/he requires supervision secondary to his/her wandering behavior.
Review of the resident's care plan revealed s/he was identified as an elopement risk/wanderer, and that s/he wears a Wanderguard bracelet on his/her wrist.
Further review of the resident's progress notes revealed a Health Status note dated [DATE] indicated that the low side fire door was alarming and that the resident was found outside the building and s/he was placed on 15 minute checks.
Additionally, a Health Status note dated [DATE] indicated that the resident took the elevator along with another residents' visitor and s/he was located on the 1st floor.
Record review of an incident note dated [DATE] at 9:46 PM, authored by Registered Nurse, Staff A, revealed that the activity aide approached her after an attempt was made to deliver the resident's supper tray at 5:10 PM, and that the resident was not in his/her room. The note indicated that the entire facility was searched and that 911 was called after 5 minutes when the resident was not found. This incident note further indicated that the resident was picked up by the Assistant Director of Nursing (ADON) who located the resident, a few streets away from the facility. The resident was found to be wearing multiple layers of clothing.
Review of AccuWeather for Woonsocket, Rhode Island revealed that on the day the resident went missing, the high temperature on [DATE] was 36 degrees Fahrenheit (F) with a low of 21 degrees F.
During a surveyor interview with Certified Medication Technician, Staff B, on [DATE] at approximately noon, she indicated that she saw the resident last at 4:00 PM when the resident was administered medication.
During a surveyor interview with the Administrator on [DATE] at 11:50 AM, she indicated that she's presently working on her investigation because it has not been determined how this resident was able to exit the facility from a locked unit. She further indicated that it was believed that the resident snuck on the elevator with another resident's family.
During a surveyor interview with Staff A on [DATE] at 12:45 PM, she revealed that a Code Purple (resident elopement) was initiated and that the resident was returned by the ADON shortly before 6:00 PM.
During a surveyor interview with the Receptionist, Staff C, on [DATE] at approximately 2:00 PM, she revealed that she was at the reception desk on [DATE]. When the resident was returned, the receptionist recognized the resident's clothing and his/her large bag. The receptionist believes she observed the resident coming out of the stairwell which is across from the reception desk before suppertime but that she was unable to identify him/her as a resident under all the clothes, and allowed him/her to exit via the front door of the facility.
During surveyor interviews with the ADON on [DATE] and [DATE] at approximately 8:30 AM, she revealed that she checked both wanderguards to make sure they were properly functioning and that they were. She also revealed that she was able to get the resident into her car and safely back to the facility on the evening s/he eloped. She then revealed on [DATE] that she was concerned that the resident's multiple layers of clothing interfered with the wanderguard's capability but during our interview on [DATE], she was unable to determine this to be true. Additionally, the ADON revealed that the wanderguard alarm sounded when the resident was returned to the facility.
During a surveyor interview with the Director of Maintenance on [DATE] at approximately 11:00 AM, he revealed that he observed footage from a camera by the 3rd floor elevator and nurse's station and indicated that there were three blind spots and they could not see if the resident had exited via the elevator or a fire door. He also determied that the wanderguard system was fully functioning, as were all the fire door exits, on [DATE], the day the resident eloped.
During an exit interview on [DATE] with the Regional Administrator at approximately 1:00 PM, she was unable to provide evidence that this resident received adequate supervision.
Due to the failure of the facility to provide adequate supervision to ensure a safe and secure environment, this resident eloped from a secured unit with a wanderguard in place and put his/her health and safety at risk. S/he was exposed to the cold, s/he could have been struck by a vehicle, and she could possibly have died.
Oct 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to maintain acceptable parameters of nutritional status for 2 of 3 residents reviewed for weight loss, Resid...
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Based on record review and staff interview, it has been determined that the facility failed to maintain acceptable parameters of nutritional status for 2 of 3 residents reviewed for weight loss, Resident ID #s 2 and 3.
Findings are as follows:
Review of the facility provided document titled Weight Monitoring Policy states in part, .all residents are to be weighed on a monthly basis .Some residents are weighed daily or weekly. Residents with orders for daily weights will have resident-specific parameters within the order to notify the MD [Medical Doctor] if weight variance of (i.e, 3-pound discrepancy in one day or 5-pound discrepancy in one week). Residents will be weighted on either a stand/sit scale or a Hoyer scale. If the weight is +/- 3 pounds from the previous weekly weight or +/- 5% on a monthly the resident is to be removed from the scale and reweighed (this needs to be no later than 24 hours of the questionable weight) .If the re-weight is accurate and there has been a significant weight loss, the nursing must notify the following .
Physician
Dietician
DNS
Administrator .
A. Record review revealed Resident ID #3 was admitted to the facility in September of 2023 with diagnoses to include, but are not limited to, schizophrenia and unsteadiness on feet.
Review of a physician's order dated 9/18/2023 revealed, obtain weekly weight every day shift Tuesdays for 4 administrations. If weight is plus or minus 3 pounds from previous week, must re-weight immediately. IF weight loss or gain is correct, notify MD and supervisor, and a progress note must be written.
Review of the resident's recorded weights from 9/18/2023 to 10/10/2023 revealed the following: 9/18/2023 - 180.6 pounds (lbs) 9/19/2023 - 176.6 lbs 9/19/2023 - 176.6 lbs 9/26/2023 -169 lbs 10/3/2023 - 168.4 lbs 10/10/2023 - 162.2 lbs
Record review revealed the resident had a weight loss of 4 pounds from 9/18/2023 to 9/19/2023 and a weight loss of 6.2 pounds from 10/3/2023 to 10/10/2023. Additionally, record review failed to reveal evidence that a re-weigh was obtained when s/he had a weight loss of more than 3 pounds as indicated in the facility's weight policy.
Further record review of the medical record failed to reveal evidence that the physician was notified or a progress note was written to address the weight loss as stated in the physician's order on 9/26/2023 and 10/10/2023.
During a surveyor interview on 10/12/2023 at approximately 10:45 AM with Registered Nurse, Staff A, she revealed that the weekly weight order for Resident ID #3 was implemented because the resident was a new admission. She further acknowledged that the resident experienced a weight loss on the above dates and a re-weigh should have been obtained, but was not.
B. Record review revealed Resident ID #2 was re-admitted to the facility in August of 2023 with diagnoses including, but not limited to, dementia, fracture of the neck of the right femur and unsteadiness on feet.
Review of the resident's recorded weights from 8/16/2023 to 9/12/2023 revealed the following:
8/16/2023 -107.8 8/17/2023 - 107.8 8/18/2023 - 102.6 8/22/2023 - 110.0 8/29/2023 - 100.2 9/5/2023 - 97.8 9/12/2023 91.0
Record review revealed that the resident had a weight loss of 5.2 pounds from 8/17/2023 to 8/18/2023, a weight gain of 7.4 pounds from 8/18/2023 to 8/22/2023, a weight loss of 9.8 pounds from 8/22/2023 to 8/29/2023 and a weight loss of 6.8 pounds from 9/5/2023 to 9/12/2023.
Additional record review failed to reveal evidence that the resident was re-weighed on 8/18, 8/22, 8/29 and 9/12/2023 when s/he had a weight loss and/or gain of more or less than 3 pounds as indicated in the facility's policy.
During a surveyor interview on 10/12/2023 at approximately 10:45 AM with Staff A, she revealed that the weekly weight order for Resident ID #2 was implemented upon his/her re-admission to the facility. She further acknowledged that the resident experienced a weight loss and gain of more than 3 pounds on the above dates and a re-weigh should have been obtained, but was not.
During a surveyor interview on 10/12/2023 at approximately 12:00 PM with the Administrator, the Director of Nursing Services and the Assistant Director of Nursing, they were unable to provide evidence that the physician was contacted following a weight change greater than 3 pounds or more for the above-mentioned residents.
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards o...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 1 resident reviewed with pressure ulcers, Resident ID # 1.
Findings are as follows:
Record review revealed that the resident was admitted to the facility in December of 2022 with diagnoses including, but not limited to, unspecified dementia and diabetes mellitus, type II.
Review of a physician order dated 7/26/2023 revealed to cleanse right lateral heel wound with normal saline, apply house barrier cream to the skin surrounding the wound, then place calcium alginate with silver (highly absorbent wound dressing) to the wound bed and cover with island bordered gauze followed by tubi-grip (self adhesive ACE bandage), daily.
Review of a document titled WOUND EVALUATION & MANAGEMENT SUMMARY, dated 8/15/2023, revealed the resident has a stage 4 pressure ulcer (a localized injury to the skin and/or underlying skin usually over a boney prominence with full thickness and tissue loss) to his/her right heel for a duration of over 181 days. His/her wound measures 0.7 centimeters (cm) x 0.9 cm x 0.4 cm with a moderate amount of serous exudate (watery, clear, or slightly yellow/tan/pink fluid that has separated from the blood and presents as drainage) and maceration (a condition that occurs when the skin is exposed to excessive moisture for too long) noted to the edge of the wound.
Further review of the WOUND EVALUATION & MANAGEMENT SUMMARY revealed the dressing treatment plan is to discontinue calcium alginate with silver and tubi-grip and to add Hydrofiber with silver (highly absorbent wound dressing with wicking capabilities that decreases maceration to the wound bed).
Review of a progress note dated 8/15/2023, authored by the Director of Nursing Services (DNS) states in part, Resident was seen by the wound doctor today. Right lateral heel wound measurements are: 0.7cm X 0.9cm X 0.4cm. Treatment is
as follows: Cleanse right lateral heel wound with NS [normal saline], apply house barrier cream periwound [skin surrounding the wound], place calcium alginate [with] silver to woundbed. Cover with island bordered gauze.
Further record review of the physician's order failed to reveal implementation of the wound recommendations provided by the [NAME] wound care physician on 8/15/2023.
During a surveyor interview on 8/21/2023 at 1:41 PM with the DNS, she revealed she was under the impression that calcium alginate with silver and Hydrofiber with silver were interchangeable and acknowledged the recommendation was not implemented.
During a subsequent interview on 8/21/2023 at 2:12 PM, with the Administrator and DNS, they were unable to provide evidence that the wound treatment recommendations from 8/15/2023 were implemented, prior to the surveyor bringing it to the facility's attention.
During a surveyor interview on 8/21/2023 at 2:16 PM with the [NAME] wound care physician, he revealed he made the recommendation to add Hydrofiber with silver due to the maceration of the resident's wound, indicating it would absorb more than calcium alginate with silver. He indicated that he would have expected the treatment recommendation to be implemented.
Jul 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Notification of Changes
(Tag F0580)
A resident was harmed · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to immediately consult with the physician when there is a significant change in the resident's physical stat...
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Based on record review and staff interview, it has been determined that the facility failed to immediately consult with the physician when there is a significant change in the resident's physical status for 1 of 3 residents reviewed related to a significant weight gain, Resident ID #1.
Findings are as follows:
Record review revealed a community reported complaint dated 7/26/2023 alleging that Resident ID #1 was not permitted to return to the facility following a hospitalization due to his/her current weight. An investigation completed on 7/27/2023 revealed that the resident's weight had increased to a level where s/he was unable to be accommodated by the facility.
Record review for the resident revealed s/he was originally admitted to the facility in March of 2023 with diagnoses including, but not limited to, lymphedema (localized swelling), morbid obesity, and chronic obstructive pulmonary disease.
Record review of a physician order with a start date of 4/5/2023 revealed, OBTAIN WEEKLY WEIGHT TIMES 4 WEEKS every day shift every [Wednesday] for 4 Administrations until finished IF WEIGHT IS PLUS OR MINUS 3 POUNDS [lbs.] FROM PREVIOUS WEEK MUST RE-WEIGH IMMEDIATELY IF WEIGHT LOSS OR GAIN IS CORRECT NOTIFY MD AND SUPERVISOR, AND A PROGRESS NOTE MUST BE WRITTEN.
Record review of the resident's weights revealed the following:
- 553.2 lbs. on 3/30/2023
- 553 lbs. on 4/5/2023
- 553 lbs. on 4/8/2023
- 611 lbs. on 4/12/2023
- 596 lbs. on 4/19/2023
- 599 lbs. on 4/19/2023
- 599 lbs. on 5/1/2023
Review of the above weights revealed that the resident had a 58 pound weight gain from 4/8/2023 to 4/12/2023. Additionally, a 45.8 pound weight gain was noted from 3/30/2023 to 5/1/2023 indicating a significant weight gain.
Record review revealed Licensed Practical Nurse, Staff A, recorded the weight gain of 611 lbs. on 4/12/2023.
During a surveyor interview with Staff A on 7/27/2023 at 2:53 PM, she stated that any weight discrepancy must be reported to the physician. Additionally, she indicated that she would have to re-weigh the resident if there was a significant change in the resident's weight. She was unable to provide evidence that she re-weighed the resident or reported the significant weight gain of 58 lbs. from 3/30/2023 to 4/12/2023 to the physician.
Record review failed to reveal evidence that the physician or dietitian were notified, or that an intervention was put in place, related to the significant weight gain on 4/12/2023. Further review failed to reveal evidence that his/her plan of care was updated or that s/he received education regarding the risks of his/her weight gain.
During a surveyor interview with the Nurse Practitioner, Staff B, on 7/27/2023 at approximately 3:00 PM, she revealed that she would have expected to be notified of the resident's weight gain. She further indicated that she could not recall if the staff informed her of Resident ID #1's significant weight gain. She stated, whatever is in my progress note is what I know.
Record review of a progress note authored by Staff B dated 4/14/2023 failed to reveal evidence that she was made aware of Resident ID #1's 58 pound weight gain.
During a surveyor interview with the Director of Nursing Services on 7/27/2023 at 3:15 PM, she stated that she would expect the physician to be notified and was unable to provide evidence that the physician was notified or that an intervention was implemented after the resident's significant weight gain.
Jul 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Notification of Changes
(Tag F0580)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to immediately consult with the resi...
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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 immediately consult with the resident's physician when there is a significant change in the resident's physical status for 1 of 1 residents who experienced delayed treatment for a deterioration in health, Resident ID #7.
Findings are as follows:
Record review of a facility reported incident submitted to the Rhode Island Department of Health on [DATE] indicates that the resident had an accident which resulted in a transfer to the hospital with a diagnosis of respiratory failure.
Record review revealed that the resident was admitted to the facility in April of 2023 with diagnoses including but not limited to, obstructive sleep apnea (a disorder in which a person frequently stops breathing during his or her sleep), and acute and chronic respiratory failure. An admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition.
Record review of a care plan dated [DATE] indicates that s/he has altered respiratory status and difficulty breathing related to sleep apnea. Interventions include but are not limited to, monitor for the following signs and symptoms of respiratory distress and report to the doctor as needed; increased rate of breathing, decreased pulse oximetry (oxygen in the blood), increased heart rate, confusion, and lethargy. The care plan also indicates to monitor, document, and report abnormal breathing patterns such as, increased or decreased rate of breathing, to the physician.
Record review revealed a physician's order with a start date of [DATE] for BIPAP (bilevel positive airway pressure which is a type of device that helps with breathing), to be applied every bedtime and removed every morning.
Additional record review revealed the following progress notes:
[DATE] at 1:56 AM - The note indicates that at 1:50 AM the Nursing Assistant (NA) informed the nurse that the resident was found on his/her knees on the floor of his/her room. The resident was noted with hallucinations and did not know where his/her bed was. The note further indicates that when the nurse entered the room the resident had returned to bed with the assistance from his/her roommate. Additionally, the resident's vital signs were documented as, blood pressure 146/100 (normal blood pressure is 120/80), heart rate 105 (normal range 60 - 100), blood oxygen level of 90% (normal range 95 - 100%).
[DATE] at 10:46 AM - The note indicates that the resident was noted to have a blood oxygen level of 86-88%. S/he was provided with oxygen at 3 liters per minute via a nasal cannula (oxygen tubing that delivers oxygen through the nose). Additionally, s/he was transferred to the emergency department via rescue.
During a surveyor interview on [DATE] at approximately 3:30 PM, with Licensed Practical Nurse (LPN), Staff A, she revealed that she was the nurse on duty during the 11:00 PM - 7:00 AM shift on [DATE]. Additionally, she indicated that a Nursing Assistant informed her of the resident being found on his/her knees at 1:50 AM. She further indicated that when she entered the room the resident was already back in bed but was lying with his/her head at the lower end of the bed and his/her feet at the head of the bed. Staff A revealed that the resident did not have the BIPAP mask on at that time and indicated that the resident was hallucinating. She stated that Resident ID #7's vital signs were good, and indicated that hallucinations were not his/her baseline. Furthermore, Staff A acknowledged that the resident was having a change in condition. Additionally, she acknowledged that she did not speak with the physician but left a voice message for the physician to report the fall and not the change in the resident's condition. When the surveyor asked about the documented vital signs, Staff A, indicated that she checked on the resident however she was unable to provide evidence of a reassessment of his/her vital signs or respiratory status as indicated in the care plan.
During a surveyor interview on [DATE] at 9:00 AM with LPN, Staff B, she revealed that she was the nurse on duty on [DATE] during the 7:00 AM - 3:00 PM shift. She indicated that on the morning of [DATE] she was told that the resident fell during the night shift and was hallucinating. She indicated that the resident was confused during breakfast with a low blood oxygen level. She indicated that the resident was transferred to the hospital.
Further record review failed to reveal evidence that the resident was monitored for respiratory distress or that the above-mentioned change in the resident's condition; hallucinations and abnormal vital signs, were reported to the physician or nurse practitioner until [DATE] at 10:46 AM.
Record review of the hospital document dated [DATE] at 11:15 AM indicates that the resident presented to the hospital for respiratory failure after an unwitnessed fall while receiving blood thinning medication at the nursing facility. S/he was unable to receive a diagnostic scan of the head due to body size. Additionally, the hospital documents revealed that the resident required intubation (a tube inserted through a person's mouth or nose into the airway to provide oxygen) and ultimately expired on [DATE].
During a surveyor interview on [DATE] at 10:15 AM with the Director of Nursing Services (DNS), she was unable to provide evidence that the facility immediately consulted the physician when Resident ID #7 experienced a change in condition on [DATE] at 1:50 AM. Additionally, she was unable to provide evidence that the resident's medical condition was reassessed between 1:55 AM and 10:46 AM. The DNS further indicated that she would have expected the nurse to reassess the resident due to the change in condition, notify the physician, and document in the resident's medical record.
Jul 2023
4 deficiencies
4 IJ (2 affecting multiple)
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to protect and keep residents free fr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to protect and keep residents free from physical abuse relative to an incident that occurred between Resident ID #1 and 2.
Findings are as follows:
On [DATE] the Rhode Island Department of Health received a community reported complaint that indicates Resident ID #2 removed his/her roommate's [Resident ID #1's] supplemental oxygen supply. Resident ID #1 subsequently decompensated and died at the hospital.
Record review for Resident ID #1 revealed s/he was initially admitted and re-admitted to the facility in June of 2023. The resident had medical diagnoses including, but not limited to, atrial fibrillation (irregular and often rapid heart rate), shortness of breath, chronic obstructive pulmonary disease, (COPD), acute on chronic congestive heart failure (CHF-heart pumps inadequately), systolic (your heart isn't contracting well during heartbeats) and diastolic (your heart can't relax normally between beats) heart failure, obstructive sleep apnea, and sick sinus syndrome (a group of heart rhythm problems due to problems with the sinus node).
1. Record review reveals Resident ID #1 (alleged victim) was originally admitted to the facility on [DATE] from an acute care hospital with diagnoses of multiple contusions and falls. During the hospitalization the resident wanted to be discharged home against medical advice but subsequently agreed to a skilled nursing facility (SNF) for rehabilitation. S/he was evaluated by therapy with recommendations for short term rehab and further management of care.
Record review of Resident ID #1's care plan dated [DATE] indicates that the resident utilizes oxygen therapy related to congestive heart failure (CHF), respiratory illness and COPD, 2-4 liters as needed. The goal of the care plan is that the resident will have no signs or symptoms of poor oxygen [O2] absorption through the next review date.
Record review reveals the following progress notes regarding the health status of Resident ID #1:
-
[DATE] - Nurse Practitioner (NP), initial encounter note authored by NP, Staff I indicates the resident had clear lung sounds and was in no acute distress.
-
[DATE] 4:09 AM- a note authored by Registered Nurse (RN), Staff J, indicates that Resident ID #1 is alert and requires assistance with care. S/he was in bed most of the shift. The resident did not complain of any pain or discomfort and no respiratory or cardiac distress were noted.
-
[DATE] at 12:09 PM- a note authored by the Activities Director, indicates that Resident ID #1 stated s/he was only here for a short stay and wants to return home.
-
[DATE] at 9:01 AM- a note authored by RN, Staff F, indicates that Resident ID #1 was complaining of shortness of breath. S/he had an audible wheeze and blue tinged lips. His/her lung sounds were diminished bilaterally, and the resident was unable to cough effectively. The resident's oxygen level was 92 to 94% (normal oxygen saturation is 95%-100%) on 2 liters of oxygen. (Although, record review reveals that the resident did not have an active order for oxygen at this time).
-
[DATE] at 12:43 PM- a note authored by Staff F indicates that Resident ID #1 continued to become more lethargic and required more oxygen. The resident was on 3 liters of oxygen via nasal cannula (NC) [oxygen tubing that delivers oxygen through the nose] with an oxygen saturation level at 92% (Although, record review reveals that the resident did not have an active order for oxygen at this time). The resident was unable to take his/her medications secondary to lethargy. The resident was sent out to the hospital via 911 and subsequently admitted with a diagnosis of CHF exacerbation.
-
[DATE]- a note authored by Staff J indicates that Resident ID #1 returned back to the SNF from the hospital after being admitted for CHF exacerbation. On assessment the resident was noted to have an oxygen saturation level of 97% on room air. The resident was comfortable in bed at this time.
-
[DATE] at 3:17 AM- a note authored by Licensed Practical Nurse (LPN), Staff B, indicates that Resident ID #1 was sleeping comfortably in his/her bed. The resident's respirations were 18 (normal respirations 16-20) with some episodes of chest breathing. Resident ID #1's oxygen saturation level was 91 to 92% on room air.
-
[DATE] at 7:15 AM - a note authored by Staff B indicates the resident had no cardiac or respiratory distress noted.
-
[DATE]- a note authored by LPN, Staff A, indicates the resident was more alert this shift. Family in to visit and pleased that Resident ID #1 was able to hold short conversations with them.
2. Record review for Resident ID #2 (alleged perpetrator) revealed s/he was admitted to the facility in October of 2022. The resident has medical diagnoses including, but not limited to, dementia, stroke, and anxiety disorder.
Record review of a Quarterly MDS Assessment, Section C, dated [DATE] revealed a Brief Interview for Mental Status Assessment which the resident scored a 7 out of 15 indicating s/he had severe cognitive impairment.
Record review of Resident ID #2's care plan developed on [DATE] states in part, [Resident] has a behavior problem as evidenced by physically remove [ing] other residents from their seat in the dining room, can be very territorial. Has difficulty with roommates, complains about noise, TV and can be paranoid at times .
The care plan interventions include, but are not limited to, .Intervene as necessary to protect the rights and safety of others .Divert attention. Remove from situation and take to alternate location as needed .
Further record review of the care plan for Resident ID #2 failed to reveal evidence of a level of supervision that was required if/when s/he had behaviors with other residents and/or roommates.
Record review revealed that on [DATE] Resident ID #1 was found without his/her oxygen on numerous occasions. Record review revealed the following events/incidents occurred on [DATE] thorugh [DATE]:
-
[DATE] at approximately 5:30 PM Resident ID #2 had lined up juice and milk cups at the foot of Resident ID #1's bed. Nursing Assistant (NA), Staff D, asked Resident ID #2 to not put his/her cups on Resident ID #1's bed. Resident ID #2 responded, go f*** yourself.
-
[DATE] at approximately midnight Resident ID #1's oxygen concentrator was alarming. Staff D entered the room and turned the oxygen concentrator off and then back on and the concentrator stopped alarming.
-
[DATE] at 12:15 AM Resident ID #1's oxygen concentrator was again alarming. Staff D replaced the concentrator.
-
[DATE] at approximately 2:00 AM Staff D went to answer a call light and on the way back, she checked on Resident ID #1. [His/her] oxygen was off, so I put it back on.
-
[DATE] at 2:30 AM- Resident ID #2 rang his/her call bell and said, this f****** [ guy/gal] is making a lot of noise. Upon observation Resident ID #1's O2 was off again.
-
[DATE] at 3:30 AM- Resident ID #1's call bell was ringing. Staff D asked Resident ID #2 if s/he had pressed the call light. Resident ID #2 indicated that Resident ID #1 needed help and s/he pulled the call light him/herself. At this time Staff D noted that the nasal cannula was again off. Staff D questioned Resident ID #2 and asked if s/he has been taking off Resident ID #1's oxygen. Resident ID #2 responded it's not me .It's f******* [him/her] .I have put up with [his/her] f****** noise all night I want [him/her] f****** out of here now .I'll f****** push [him/her] into the hallway myself .
-
[DATE] at 4:53 AM -a note authored by Staff B states, Resident upset about roommate making noise all night (roommate is a mouth breather and snores). Resident stated that [s/he] can not stand the noise [s/he] is going to push [him/her] out in the hall. Resident has been taking roommates oxygen off and stating to get [him/her] out of here. Resident has been found standing over roommate multiple times, just staring at roommate.
-
[DATE] at 5:15 AM- Staff B observed Resident ID #1's nasal cannula tubing off his/her nose. It was nicely rolled up at the foot Resident ID #1's bed.
-
[DATE] at approximately 6:15 AM- Resident ID #2 was standing over his/her roommate, Resident ID #1's nasal cannula was off again.
-
[DATE] at 6:34 AM- a note authored by Staff B, states in part, Resident told this writer that [s/he] was going down to get something to snack from the vending machine. Staff member found resident in dining room taking sugar. When staff member told [him/her] that [s/he] is not supposed to be behind the double doors at this time, resident swung [his/her] cane at him. Resident refused to have [his/her] blood sugar checked this morning .
-
[DATE] at 7:15 AM- a note authored by Staff B, states in part, .behaviors during the night was reported to [name redacted] on call .She also stated that we should keep resident and roommate separate until then.
-
[DATE] at 9:22 AM - a note authored by LPN, Staff A, states in part, Resident noted to be cyanotic upon arrival to facility this morning. SPO2 [peripheral oxygen saturation] noted to be 90% @ [at] 2L [LPM; Liters per minute] via NC. Resident appeared to be struggling to breathe. O2 removed and resident was placed on a non-rebreather @5L. Spo2 up to 96% but slowly started to drop down to 88%. Resident sent out 911. NP notified, family notified. This writer called [acute care hospital] and report was given to ER [emergency room] nurse .
-
[DATE] at 10:54 AM - a note authored by Staff B, (this note was written by Staff B after Resident ID #1 had already been transported to the hospital) states in part, Resident does not realize that removing [his/her] roommates oxygen is harmful to the roommate .Resident believed the oxygen was what was making all the loud noises .After this talk room was closely monitored, by door being left open. Staff member within could see roommate clearly from the hallway due to roommat's bed being close to door. Resident did leave unit to go to vending machine and upon return went into day room.
-
[DATE] at 12:57 PM - a note authored by Staff A, states in part, .told by ER nurse that resident had passed away r/t [related to] end stage COPD.
During a surveyor interview with Staff B on [DATE] at 9:37 AM she indicated that she felt Resident ID #1 was not end of life during her shift. [S/he] was [his/her]
normal self all night long].
During a surveyor interview with Registered Nurse, Staff C, who worked the 3 PM to 11 PM shift on [DATE], she indicated that Resident ID #1 took his/her evening medications and was not in respiratory distress. Staff C had no concerns that Resident ID #1 was at end of life.
During a surveyor interview with Staff D on [DATE] at 2:20 PM she revealed that she cared for Resident ID #1 on [DATE] on the 3 PM to 11 PM shift and [DATE] on the 11 PM to 7 AM overnight shift. She indicated that at approximately 5:30 PM on [DATE] Resident ID #2 was standing at the foot of Resident ID #1's bed and was lining up juice and milk cups at the foot of the bed. Staff D indicated that when she questioned Resident ID #2 on what s/he was doing s/he replied with go f*** yourself. She indicated that at approximately 12:00 AM Resident ID #1's oxygen concentrator was alarming. She went into the room and turned the concentrator off and then on and the beeping stopped. She further indicated at 12:15 AM the concentrator started alarming again and she replaced the old concentrator with a new concentrator. Staff D indicated that she went to answer a call light at approximately 2:30 AM and on her way back she noticed that the nasal cannula for Resident ID #1 was not in his/her nose. The nasal cannula was located on the side of Resident ID #2. Staff D indicated that at this time Resident ID #2 was standing at the head of Resident ID #1's bed. At 2:30 AM Resident ID #2 rang his/her call light and at that time she noticed that the nasal cannula for Resident ID #1 was laying on the bed. Staff D further indicated that at 3:30 AM Resident ID #1's nasal cannula was again off his/her nose and by his/her stomach. Staff D indicated the last time she saw Resident ID #1's nasal cannula off was at approximately 6:30 AM on [DATE] when Resident ID #2 was again standing over Resident ID #1. The surveyor questioned Staff D on if Resident ID #1 could remove his/her own oxygen and she replied no way [s/he] could do that.
During a surveyor interview on [DATE] at 8:35 AM with Staff B she revealed that she cared for Resident ID #1 on [DATE] 3-11 PM shift and [DATE] on the 11-7 overnight shift. She revealed that during the overnight shift it was reported to her by Staff D, that Resident ID #1 was noted without his/her oxygen tubing, further revealing the tubing was rolled up at the foot of Resident ID #1's bed. She further revealed that she suspected that Resident ID #2, had removed Resident ID #1's oxygen tubing as s/he was unable to remove his/her own tubing. Staff B further revealed that Resident ID #2 was observed by staff standing over Resident ID #1 during the night and that s/he was subsequently escorted out of the room in the early morning at approximately 5:15 AM. Lastly, she revealed that LPN, Staff E came in for the morning shift at approximately 7:00 AM and she reported to him that Resident ID #1 was snoring and that she was unable to administer his/her medications because she could not wake him/her. She also revealed that she told Staff E that the resident's skin was looking darker than usual. Staff E then attended to the resident.
During a surveyor interview on [DATE] at 11:02 AM with LPN, Staff E, he revealed that on the morning of [DATE] he arrived at the facility minutes before 7:00 AM for his shift and he was alerted to Resident ID #1's room by the overnight staff due to concerns that the resident was mottled in appearance (discoloration of the skin due to a decrease in blood flow). Staff E and another nurse Staff F, entered the resident's room to find the resident in respiratory distress, cyanotic, with an SPO2 of 91% on 2 liters of oxygen via nasal cannula. Staff E revealed the resident's respiratory distress worsened, further describing that the resident displayed agonal breathing (insufficient breathing that may sound like gasping, labored breathing, snoring, or snorting). Staff E then obtained vital signs in which he reported to the oncoming nurse, Staff A, who was assigned to care for Resident ID #1, and that she needed to call 911.
Record review of Resident ID #1's hospital records dated [DATE] indicated that his/her venous blood gas levels resulted as panic with a pCO2 result of 77.9 and his/her blood pH was 7.130 (normal range is 7.310-7.4500), indicating the resident was in respiratory acidosis, (a condition that occurs when your lungs can't remove all of the carbon dioxide produced by your body. This causes the blood and other body fluids to become too acidic. Acute respiratory acidosis occurs when carbon dioxide builds up very quickly). Further review of this document revealed that Resident ID #1 expired on [DATE] at 12:22 PM.
During a surveyor interview on [DATE] at approximately 10:00 AM with the Administrator and Director of Nursing Services they were unable to provide evidence that Resident ID #1 was kept free from abuse as evidenced by Resident ID #2 removing Resident ID #1's supplemental oxygen.
Although the facility care planned Resident ID #2 as being very territorial, physically removing others from seats, having difficulty with roommates, complaining about noise, and has paranoia, the care plan failed to reveal evidence of a level of supervision that was required if/when s/he had behaviors with other residents and/or roommate. Additionally, the facility was aware of Resident ID #2's history with roommates, and they placed Resident ID #1, a compromised and vulnerable individual as his/her roommate. Record review failed to reveal evidence that the facility provided appropriate interventions or increased supervision for Resident ID #1 and Resident ID #2 when Resident ID #1 was found without his/her supplemental oxygen or when Resident ID #2 was found standing over his/her roommate and staff was concerned that Resident ID #2 was removing Resident ID # 1's supplemental oxygen on the following dates and times:
- [DATE] at 2:00 AM
- [DATE] at 2:30 AM
- [DATE] at 3:30 AM
- [DATE] at 5:15 AM
- [DATE] at 6:15 AM
Additionally, when Resident ID #2 complained about the noise and indicated s/he was going to physically remove the resident from the room on [DATE] the facility failed to intervene and provide appropriate interventions for Resident ID #1 and 2 which had the potential to cause serious injury, impairment, or death.
Refer to F 689
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to ensure that each resident receives...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to ensure that each resident receives adequate supervision based on the resident's assessed needs, care plan, risks, and current professional standards of practice relative to an incident that occurred between Resident ID #1 and Resident ID #2.
Findings are as follows:
On [DATE] the Rhode Island Department of Health received a community reported complaint that indicates Resident ID #2 removed his/her roommate's [Resident ID #1's] supplemental oxygen supply. Resident ID #1 subsequently decompensated and died at the hospital.
1. Record review for Resident ID #1 (alleged victim) revealed s/he was initially admitted and re-admitted to the facility in June of 2023. The resident had medical diagnoses including, but not limited to, atrial fibrillation (irregular and often rapid heartrate), shortness of breath, chronic obstructive pulmonary disease, (COPD), acute on chronic congestive heart failure (CHF-heart pumps inadequately), systolic (your heart isn't contracting well during heart beats) and diastolic (your heart can't relax normally between beats) heart failure, obstructive sleep apnea, and sick sinus syndrome (a group of heart rhythm problems due to problems with the sinus node).
Record review reveals Resident ID #1 was originally admitted to the facility on [DATE] from an acute care hospital with diagnoses of multiple contusions and falls. During the hospitalization the resident wanted to be discharged home against medical advice but subsequently agreed to a skilled nursing facility (SNF) for rehabilitation. S/he was evaluated by therapy with recommendations for short term rehab and further management of care.
Record review of Resident ID #1's care plan dated [DATE] indicates that the resident utilizes oxygen therapy related to congestive heart failure, respiratory illness and COPD, 2-4 liters as needed. The goal of the care plan is that the resident will have no signs or symptoms of poor oxygen [O2] absorption through the next review date.
Record review reveals the following progress notes regarding the health status of Resident ID #1:
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[DATE] - Nurse Practitioner (NP), initial encounter note authored by NP, Staff I indicated the resident had clear lung sounds and was in no acute distress.
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[DATE] 4:09 AM- a note authored by Registered Nurse (RN), Staff J, indicates that Resident ID #1 is alert and requires assistance with care. S/he was in bed most of most of the shift. The resident did not complain of any pain or discomfort and no respiratory or cardiac distress were noted.
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[DATE] at 12:09 PM- a note authored by the Activities Director, indicates that Resident ID #1 stated s/he was only here for a short stay and wants to return home.
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[DATE] at 9:01 AM- a note authored by RN, Staff F, indicates that Resident ID #1 was complaining of shortness of breath. S/he had an audible wheeze and blue tinged lips. His/her lung sounds were diminished bilaterally, and the resident was unable to cough effectively. The resident's oxygen level was 92 to 94% (normal oxygen saturation is 95%-100%) on 2 liters of oxygen. (Although, record review reveals that the resident did not have an active order for oxygen at this time).
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[DATE] at 12:43 PM- a note authored by Staff F indicates that Resident ID #1 continued to become more lethargic and required more oxygen. The resident was on 3 liters of oxygen via nasal cannula (NC) [oxygen tubing that delivers oxygen through the nose] with an oxygen saturation level at 92% (Although, record review reveals that the resident did not have an active order for oxygen at this time). The resident was unable to take his/her medications secondary to lethargy. The resident was sent out to the hospital via 911 and subsequently admitted with a diagnosis of CHF exacerbation.
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[DATE]- a note authored by RN; Staff J indicates that Resident ID #1 returned back to the SNF from the hospital after being admitted for CHF exacerbation. On assessment the resident was noted to have an oxygen saturation level of 97% on room air. The resident was comfortable in bed at this time.
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[DATE] at 3:17 AM- a note authored by Licensed Practical Nurse (LPN), Staff B, indicates that Resident ID #1 was sleeping comfortably in his/her bed. The resident's respirations were 18 (normal respirations 16-20) with some episodes of chest breathing. Resident ID #1's oxygen saturation level was 91 to 92% on room air.
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[DATE] at 7:15 AM - a note authored by Staff B indicates the resident had no cardiac or respiratory distress noted.
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[DATE]- a note authored by LPN, Staff A, indicates the resident was more alert this shift. Family in to visit and pleased that Resident ID #1 was able to hold short conversations with them.
2. Record review for Resident ID #2 revealed s/he was admitted to the facility in October of 2022. The resident has medical diagnoses including, but not limited to, dementia, stroke, and anxiety disorder.
Record review of a Quarterly MDS Assessment, Section C, dated [DATE] revealed a Brief Interview for Mental Status Assessment which the resident scored a 7 out of 15 indicating s/he had severe cognitive impairment.
Record review of Resident ID #2's care plan developed on [DATE] states in part, [Resident] has a behavior problem as evidenced by physically remove [ing] other residents from their seat in the dining room, can be very territorial. Has difficulty with roommates, complains about noise, TV and can be paranoid at times .
The care plan interventions included, but are not limited to, .Intervene as necessary to protect the rights and safety of others .Divert attention. Remove from situation and take to alternate location as needed .
Further record review of the care plan for Resident ID #2 failed to reveal evidence of a level of supervision that was required if/when s/he had behaviors with other residents and/or roommates.
Record review revealed that on [DATE] Resident ID #1 was found without his/her oxygen on numerous occasions. Record review revealed the following events/incidents occurred on [DATE] thorough [DATE]:
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[DATE] at approximately 5:30 PM Resident ID #2 had lined up juice and milk cups at the foot of Resident ID #1's bed. Nursing Assistant (NA), Staff D, asked Resident ID #2 to not put his/her cups on Resident ID #1's bed. Resident ID #2 responded, go f*** yourself.
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[DATE] at approximately midnight Resident ID #1's oxygen concentrator was alarming. Staff D entered the room and turned the oxygen concentrator off and then back on and the concentrator stopped alarming.
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[DATE] at 12:15 AM Resident ID #1's oxygen concentrator was again alarming. Staff D replaced the concentrator.
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[DATE] at approximately 2:00 AM Staff D went to answer a call light, and on the way back, she checked on Resident ID #1. [His/her] oxygen was off, so I put it back on.
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[DATE] at 2:30 AM- Resident ID #2 rang his/her call bell and said, this f****** [ guy/gal] is making a lot of noise. Upon observation Resident ID #1's O2 was off again.
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[DATE] at 3:30 AM- Resident ID #1's call bell was ringing. Staff D asked Resident ID #2 if s/he had pressed the call light. Resident ID #2 indicated that Resident ID #1 needed help and s/he pulled the call light him/herself. At this time Staff D noted that the nasal cannula was again off. Staff D questioned Resident ID #2 and asked if s/he has been taking off Resident ID #1's oxygen. Resident ID #2 responded it's not me .It's f******* [him/her] .I have put up with [his/her] f****** noise all night I want [him/her] f****** out of here now .I'll f****** push [him/her] into the hallway myself .
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[DATE] at 4:53 AM -a note authored by Staff B states, Resident upset about roommate making noise all night (roommate is a mouth breather and snores). Resident stated that [s/he] can not stand the noise [s/he] is going to push [him/her] out in the hall. Resident has been taking roommates oxygen off and stating to get [him/her] out of here. Resident has been found standing over roommate multiple times, just staring at roommate.
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[DATE] at 5:15 AM- Staff B observed Resident ID #1's nasal cannula tubing off his/her nose. It was nicely rolled up at the foot Resident ID #1s feet.
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[DATE] at approximately 6:15 AM- Resident ID #2 was standing over his/her roommate, Resident ID #1's nasal cannula was off again.
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[DATE] at 6:34 AM- a note authored by Staff B, states in part, Resident told this writer that [s/he] was going down to get something to snack on from the vending machine. Staff member found resident in dining room taking sugar. When staff member told [him/her] that [s/he] is not supposed to be behind the double doors at this time, resident swung [his/her] cane at him. Resident refused to have [his/her] blood sugar checked this morning .
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[DATE] at 7:15 AM- a note authored by Staff B, states in part, .behaviors during the night was reported to [name redacted] on call .She also stated that we should keep resident and roommate separate until then.
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[DATE] at 9:22 AM Authored by Staff A, states in part, Resident noted to be cyanotic upon arrival to facility this morning. SPO2 [peripheral oxygen saturation] noted to be 90% @ [at] 2L [LPM; Liters per minute] via NC. Resident appeared to be struggling to breathe. O2 removed and resident was placed on a non-rebreather @5L. Spo2 up to 96% but slowly started to drop down to 88%. Resident sent out 911. NP notified; family notified. This writer called [acute care hospital] and report was given to ER [emergency room] nurse .
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[DATE] at 10:54 AM - a note authored by Staff B, (this note was written by Staff B after Resident ID #1 had already been transported to the hospital) states in part, Resident does not realize that removing [his/her] roommates oxygen is harmful to the roommate .Resident believed the oxygen was what was making all the loud noises .After this talk room was closely monitored, by door being left open. Staff member within could see roommate clearly from the hallway due to roommates' bed being close to door. Resident did leave unit to go to vending machine and upon return went into day room.
-[DATE] at 12:57 PM - a note authored by Staff A, states in part, .told by ER nurse that resident had passed away r/t [related to] end stage COPD.
Record review failed to reveal evidence that the facility provided appropriate interventions or increased supervision for Resident ID #1 and Resident ID #2 on the following dates and times when Resident ID #1 was found without his/her supplemental oxygen or when Resident ID #2 was found standing over his/her roommate and staff was concerned s/he was removing Resident ID #'1 supplemental oxygen:
- [DATE] at 2:00 AM
- [DATE] at 2:30 AM
- [DATE] at 3:30 AM
- [DATE] at 5:15 AM
- [DATE] at 6:15 AM
During a surveyor interview with Staff D on [DATE] at 2:20 PM she revealed that she cared for Resident ID #1 on [DATE] on the 3 PM to 11 PM shift and [DATE] on the 11 PM to 7 AM overnight shift. She indicated that at approximately 5:30 PM on [DATE] Resident ID #2 was standing at the foot of Resident ID #1's bed and was lining up juice and milk cups at the foot of the bed. Staff D indicated that when she questioned Resident ID #2 on what s/he was doing s/he replied with go f*** yourself. She indicated that at approximately 12:00 AM Resident ID #1's oxygen concentrator was alarming. She went into the room and turned off and on the concentrator and the beeping stopped. She further indicated at 12:15 AM the concentrator started alarming again and she replaced the old concentrator with a new concentrator. Staff D indicated that she went to answer a call light at approximately 2:30 AM and on her way back she noticed that the nasal cannula for Resident ID #1 was not in his/her nose. The nasal cannula was located on the side of Resident ID #2. Staff D indicated that at this time Resident ID #2 was standing at the head of Resident ID #1's bed. At 2:30 AM Resident ID #2 rang his/her call light and at that time she noticed that the nasal cannula for Resident ID #1 was laying on the bed. Staff D further indicated that at 3:30 AM Resident ID #1's nasal cannula was again off his/her nose and by his/her stomach. Staff D indicated the last time she saw Resident ID #1's nasal cannula off was at approximately 6:30 AM on [DATE] when Resident ID #2 was again standing over Resident ID #1. The surveyor questioned Staff D on if Resident ID #1 could remove his/her own oxygen and she replied, no way [s/he] could do that.
During a surveyor interview on [DATE] at 8:35 AM with Staff B she revealed that she cared for Resident ID #1 on [DATE] 3-11 PM shift and [DATE] on the 11-7 overnight shift. She revealed that during the overnight shift it was reported to her by Staff D, that Resident ID #1 was noted without his/her oxygen tubing, further revealing the tubing was rolled up at the foot of Resident ID #1's bed. She further revealed that she suspected that Resident ID #2, had removed Resident ID #1's oxygen tubing as s/he was unable to remove his/her own tubing. Staff B further revealed that Resident ID #2 was observed by staff standing over Resident ID #1 during the night and that s/he was subsequently escorted out of the room in the early morning at approximately 5:15 AM. Lastly, she revealed that LPN, Staff E came in for the morning shift at approximately 7:00 AM and she reported to him that Resident ID #1 was snoring and that she was unable to administer his/her medications because she could not wake him/her. She also revealed that she told Staff E that the resident's skin was looking darker than usual. Staff E then attended to the resident.
During a surveyor interview on [DATE] at 11:02 AM Staff E, revealed that on the morning of [DATE] he arrived at the facility minutes before 7:00 AM for his shift and he was alerted to Resident ID #1's room by the overnight staff due to concerns that the resident was mottled in appearance (discoloration of the skin due to a decrease in blood flow). Staff E and another nurse, Registered Nurse, Staff F, entered the resident's room to find the resident in respiratory distress, cyanotic, with an SPO2 of 91% on 2 liters of oxygen via nasal cannula. Staff E revealed the resident's respiratory distress worsened, further describing that the resident displayed agonal breathing (insufficient breathing that may sound like gasping, labored breathing, snoring, or snorting). Staff E then obtained vital signs in which he reported to the oncoming nurse assigned to care for Resident ID #1, and that she needed to call 911. Lastly, Staff E was asked by this surveyor if he had administered a nebulizer treatment (liquid medication inhaled to assist with opening the airway) to the resident when s/he was found in respiratory distress, he responded that he did not.
Record review of the document titled RI EMS [Emergency Medical Services] Patient Care Report dated [DATE] with a time of 7:50 AM for Resident ID #1 revealed, EMS was dispatched to the nursing home for Resident ID #1 for difficulty breathing. Upon arrival the resident was short of breath. Staff reported SPO2 of 88% and the patient was noted to be on a nonrebreather mask at 4 liters per minute on a compressor with a deflated bag. Resident ID #1 was then switched to a nonrebreather mask at 15 liters via a portable tank and his/her SPO2 increased to 100%. The patient was then moved to a stretcher and wheeled to the rescue for transport to the hospital. The patient was administered a nebulizer treatment via aerosol mask at 6 liters. The patient was then taken into the emergency room, and [s/he] became unresponsive.
Record review of Resident ID #1's hospital records dated [DATE] indicated that his/her venous blood gas levels resulted as panic with a pCO2 result of 77.9 and his/her blood pH was 7.130 (normal range is 7.310-7.4500), indicating the resident was in respiratory acidosis, (a condition that occurs when your lungs can't remove all the carbon dioxide produced by your body. This causes the blood and other body fluids to become too acidic. Acute respiratory acidosis occurs when carbon dioxide builds up very quickly). Further review of this document revealed that Resident ID #1 expired on [DATE] at 12:22 PM.
During a surveyor interview on [DATE] at approximately 10:00 AM with the Administrator and Director of Nursing Services they were unable to provide evidence that each resident received adequate supervision to prevent the incidents that occurred between Resident ID #1 and Resident ID #2.
Although the facility care planned Resident ID #2 as being very territorial, physically removing others from seats, having difficulty with roommates, complaining about noise, and has paranoia, the care plan failed to reveal evidence of a level of supervision that was required if/when s/he had behaviors with other residents and/or roommate. Additionally, the facility was aware of Resident ID #2's history with roommates, and they placed Resident ID #1, a compromised and vulnerable individual as his/her roommate. Record review failed to reveal evidence that the facility provided appropriate interventions or increased supervision for Resident ID #1 and Resident ID #2 when Resident ID #1 was found without his/her supplemental oxygen or when Resident ID #2 was found standing over his/her roommate and staff was concerned that Resident ID #2 was removing Resident ID # 1's supplemental oxygen on the following dates and times:
- [DATE] at 2:00 AM
- [DATE] at 2:30 AM
- [DATE] at 3:30 AM
- [DATE] at 5:15 AM
- [DATE] at 6:15 AM
Additionally, when Resident ID #2 complained about the noise and indicated s/he was going to physically remove the resident from the room on [DATE] the facility failed to intervene and provide appropriate interventions for Resident ID #1 and 2 which had the potential to cause serious injury, impairment, or death.
Refer to F 600
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Respiratory Care
(Tag F0695)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide re...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 3 residents reviewed who received oxygen therapy via a nonrebreather mask, Resident ID #s 1 and 6.
Findings are as follows:
According to the ScienceDirect Journal article, titled Emergency Oxygen Administration, dated 2008, states in part, .Non-Rebreather Mask 1. The non-rebreather mask is the first choice when considering constant flow supplemental O2 in an acute medical emergency. It consists of a mask, reservoir bag, and two or three one-way valves, one separating the reservoir from the mask and the other one or two on the sides of the mask. Oxygen flows into the reservoir bag so that when the victim inhales, he or she inhales O2 from the reservoir. The one-way valves on the sides of the mask keep air from coming into the mask and diluting the O2. When the victim exhales, expired air goes out of the mask through the one or two valves on the face and is prevented from entering the reservoir .3. To use the mask, it is attached to the O2 supply at a flow rate of 10 to 15 L/minute. The reservoir bag must be inflated or primed before placing it on the person .Care must be taken to not allow the O2 supply to be depleted while the mask is on the person. Because of the one-way valves, if there is no O2 supply, suffocation may result .
According to an article published by Osmosis from Elsevier titled, Non-Rebreather Mask, What Is It, When Is It Used, and More, states in part, .A non-rebreather mask requires a sufficient oxygen flow rate to ensure that the oxygen reservoir bag does not collapse when the individual inspires .Therefore, a flow rate of 12-15 liters per minute is generally recommended .The mask is connected to an oxygen tank via tubes .The minimal flow rate of non-rebreather masks is typically 12 liters per minute to prevent collapse of the bag upon inhalation .
Record review for Resident ID #1 revealed s/he was admitted to the facility in June of 2023. The resident has medical diagnoses including, but not limited to, atrial fibrillation (irregular and often rapid heart rate), shortness of breath, chronic obstructive pulmonary disease, (COPD), acute on chronic congestive heart failure (CHF-heart pumps inadequately), systolic (your heart isn't contracting well during heartbeats) and diastolic (your heart can't relax normally between beats) heart failure, obstructive sleep apnea, and sick sinus syndrome (a group of heart rhythm problems due to problems with the sinus node).
Record review of the nursing progress notes revealed the following:
-[DATE] at 5:30 AM authored by Licensed Practical Nurse (LPN), Staff B states in part, Resident lethargic. Unable to get resident to wake up. Medications held.
-[DATE] at 9:22 AM Authored by LPN, Staff A, states in part, Resident noted to be cyanotic upon arrival to facility this morning. SPO2 [peripheral oxygen saturation] noted to be 90% [normal range is 95-100%] @ [at] 2L [LPM; Liters per minute] via NC [nasal cannula]. Resident appeared to be struggling to breathe. O2 removed and resident was placed on a non-rebreather @5L. Spo2 up to 96% but slowly started to drop down to 88%. Resident sent out 911. [nurse practitioner] NP notified, family notified. This writer called [acute care hospital] and report was given to ER [emergency room] nurse .
-[DATE] at 12:57 PM authored by Staff A, states in part, .told by ER nurse that resident had passed away r/t [related to] end stage COPD.
During a surveyor interview on [DATE] at 8:35 AM with Staff B, she revealed that she cared for the resident on [DATE] 3-11 PM shift and [DATE] the 11-7 overnight shift. She revealed that she had placed the resident on 2 liters of oxygen via nasal cannula that night and monitored his/her SPO2 levels, which were maintained between 93-95%. She further revealed that during the overnight shift it was reported to her by Nursing Assistant, Staff D, that Resident ID #1 was noted without his/her oxygen tubing, further revealing the tubing was rolled up at the foot of Resident ID #1's bed. She further revealed that she suspected that Resident ID #1's roommate, Resident ID #2, had removed his/her tubing as Resident ID #1 was unable to remove his/her own tubing. Staff B further revealed that Resident ID #2 was observed by staff standing over Resident ID #1 during the night and that s/he was subsequently escorted out of the room in the early morning at approximately 5:15 AM. Additionally, Staff B revealed at approximately 5:30 AM she obtained Resident ID #1's fingerstick blood sugar, however she was unable to administer the resident's medications. Lastly, she revealed that Staff E came in for the morning shift at approximately 7:00 AM and she reported to him that Resident ID #1 was snoring and that she was unable to administer his/her medications because she could not wake him/her. She also revealed that she told Staff E that the resident's skin was looking darker than usual. Staff E then attended to the resident.
During a surveyor interview on [DATE] at 11:02 AM with LPN, Staff E, he revealed that on the morning of [DATE] he arrived at the facility minutes before 7:00 AM for the morning shift and he was alerted to Resident ID #1's room by the overnight staff due to concerns that the resident was mottled in appearance (discoloration of the skin due to a decrease in blood flow). Staff E and another nurse, Registered Nurse, Staff F, entered the resident's room to find the resident in respiratory distress, cyanotic, with an SPO2 of 91% on 2 liters of oxygen via nasal cannula. Staff E revealed the resident's respiratory distress worsened, further describing that the resident displayed agonal breathing (insufficient breathing that may sound like gasping, labored breathing, snoring, or snorting). Staff E then obtained vital signs in which he reported to the oncoming nurse assigned to care for Resident ID #1, and that she needed to call 911. Lastly, Staff E was asked by this surveyor if he had administered a nebulizer treatment (liquid medication inhaled to assist with opening the airway) to the resident when s/he was found in respiratory distress, he responded that he did not, and was not aware if the resident had an order for one.
Record review of Resident ID #1's Medication Administration Record (MAR) revealed s/he had a physician's order for an Albuterol nebulizer treatment to be administered every six hours as need for shortness of breath. Further review of the MAR failed to reveal evidence that this nebulizer treatment was administer to Resident ID #1 when s/he was found to be cyanotic and in respiratory distress by Staff E on [DATE].
During a subsequent surveyor interview and simultaneous observation on [DATE] at approximately 2:00 PM with Staff E, he was asked about his statement provided for the facility investigation in which he mentioned that a non-rebreather mask was applied to the resident on the morning that s/he was sent to the hospital. Staff E was asked if he could provide this surveyor with the mask that he applied to Resident ID #1 on [DATE]. Staff E revealed there was only one mask, and he retrieved a non-rebreather mask from a container located in the medication room behind the nurse's station. The container was observed with only non-rebreather masks. Staff E further revealed that the resident was on oxygen at 2 liters via NC, Staff E replaced the NC tubing with the nonrebreather mask and tubing and attached that to the concentrator. Additionally, he indicated that when he applied the non-rebreather mask to Resident ID #1, he did not adjust/increase the oxygen flow rate from 2 liters. Of note, the oxygen concentrator does not deliver more than 5 liters of oxygen per minute.
During a surveyor interview on [DATE] at 12:20 PM with Staff F, she revealed on [DATE] she was made aware by staff that Resident ID #1 did not look well and was mottling. Staff F revealed that she and Staff E went into Resident ID #1's room. Upon entering the room Resident ID #1 was noted on oxygen via NC, in moderate respiratory distress, with his/her fingers and toes blue in appearance. Additionally, she revealed the resident would only open his/her eyes to a hard rub to the chest and then close them.
During a surveyor interview on [DATE] at 2:10 PM with Staff A, she revealed when she arrived to the facility it was approximately 7:20 AM. Staff A revealed upon arriving to Resident ID #1's room, s/he was already cared for by Staff E and in a non-rebreather mask with his/her SPO2 at 95-96%, gasping for breath and struggling to breath. Staff A revealed that Staff E obtained another set of vital signs and the resident's SPO2 was now at 88%. Lastly, Staff A revealed she notified the provider at 7:35 AM that the resident needed to go out and she was not sure of the time when 911 arrived.
Record review of the document titled RI EMS [Emergency Medical Services] Patient Care Report dated [DATE] with a time of 7:50 AM for Resident ID #1 revealed EMS was dispatched to the nursing home for Resident ID #1 for difficulty breathing. Upon arrival the resident was short of breath. Staff reported SPO2 of 88% and the patient was noted to be on a nonrebreather mask at 4 liters per minute on a compressor with a deflated bag. Resident ID #1 was then switched to a nonrebreather mask at 15 liters via a portable tank and his/her SPO2 increased to 100%. The patient was then moved to a stretcher and wheeled to the rescue for transport to the hospital. The patient was administered a nebulizer treatment via aerosol mask at 6 liters. The patient was then taken into the emergency room, and s/he became unresponsive.
Record review of Resident ID #1's hospital records dated [DATE] indicated that his/her venous blood gas levels resulted as panic with a pCO2 result of 77.9 and his/her blood pH was 7.130 (normal range is 7.310-7.4500), indicating the resident was in respiratory acidosis, (a condition that occurs when your lungs can't remove all of the carbon dioxide produced by your body. This causes the blood and other body fluids to become too acidic. Acute respiratory acidosis occurs when carbon dioxide builds up very quickly). Further review of this document revealed that Resident ID #1 expired on [DATE] at 12:22 PM.
Further review of all the documentation surrounding this incident revealed that Resident ID #1 was noted to be in respiratory distress at the facility by Staff E and Staff F moments before 7:00 AM. Staff A arrived at approximately 7:20 AM, she also noted the resident was in respiratory distress, she was given details of what occurred and was told 911 needed to be called. The on-call provider was contacted at 7:35 AM (which was approximately 15 minutes later) to notify them that the resident needed to go to the hospital for further evaluation. According to the EMS Report, EMS was contacted by the facility at 7:48 AM to transport the resident to the hospital for difficulty breathing. It is also noted that EMS arrived at the facility at 7:54 AM to observe the resident in a nonrebreather mask at only 4 liters, with the reservoir bag deflated and the mask supplying the resident with insufficient oxygen. In conclusion, from the time the resident was noted to be in respiratory distress to the time s/he received adequate oxygenation and a nebulizer treatment to increase his/her oxygen status, was approximately 50 minutes.
2. Record review for Resident ID #6 revealed s/he was re-admitted to the facility in May of 2023. The resident has medical diagnoses including, but not limited to, pneumonia, stroke, atrial fibrillation, and hypertension.
Record review of the nursing progress notes revealed the following:
-[DATE] at 8:50 AM, authored by LPN, Staff G, states in part, .vs [vital signs] 114/74, 97.4 91 spo2 in 2 L [liters], neb treatment given with pain med with very little relief, call placed to doctor on call again, awaiting call back .
-[DATE] at 10:32 AM, authored by Staff G, states in part, .NP called back for [physician], order obtain[ed] for Augmentin [antibiotic] 875-125 bid x 7 days .
-[DATE] at 11:38 AM, authored by Staff G, states in part, .send by 911 due to increase congestion, with pt [patient] continue to d-sat [desaturatetion-amount of oxygen drops below the normal level], non re breather on with very little result .
-[DATE] at 3:47 PM, states in part, .Resident was admitted at [hospital name redacted] with DX [diagnosis] Acute Respiratory Failure with Hypoxia.
Record review of the document titled RI EMS [Emergency Medical Services] Patient Care Report dated [DATE] with a time of 11:22 AM for Resident ID #6 revealed EMS was dispatched to the nursing home for the resident due to him/her having difficulty breathing. Upon arrival the resident was found lying in bed with audible gurgling. The document further revealed that the patient had been recently diagnosed with pneumonia and s/he had a nonrebreather mask placed prior to EMS arrival, with the reservoir bag empty. The nonrebreather was removed by EMS and the resident was placed in a CPAP [a device that provides pressured air to keep breathing airways open] and his/her oxygen level rose from 72% to 80%. Additionally, the document revealed that the resident was then given a nebulizer treatment with the CPAP at 6 liters per minute and the patient's oxygen level rose to 94% with treatment. Lastly, the report revealed a documented SPO2 of 98% after treatment.
During a surveyor interview with Staff G on [DATE] at approximately 11:00 AM she indicated that she placed Resident ID #6 on 10 liters of oxygen via a non- rebreather mask on [DATE] and the bag was fully inflated on the mask. However, when the surveyor revealed that the EMS had reported that the bag of the mask was deflated on arrival to the facility on [DATE], she recanted her statement. She then indicated that she placed the non-rebreather mask on Resident ID #6 with the bag deflated stating she was fighting with the mask to try to get the bag inflated. Additionally, she revealed that the resident's Spo2 level did not increase when the mask was placed on him/her and that she did not try switching out the mask for another one. She further revealed that she left the deflated non-rebreather mask on Resident ID #2 until s/he was transported to the hospital by EMS.
During a surveyor interview on [DATE] at 11:18 AM with Nursing Assistant, Staff H, she revealed she was providing care to Resident ID #6 and noticed his/her breathing had changed and went to get the nurse. She further revealed that Staff G came in to assess the resident, brought the oxygen cylinder in the room and applied the non-rebreather mask and hooked it up the oxygen tank. She further revealed that the bag wouldn't inflate. Staff H then left the room to get the supervisor.
Record review of the Hospital Emergency Department Code/Rapid Response report revealed the resident's diagnoses that were active upon admission were as follows, acute respiratory failure with hypoxia, atrial fibrillation with rapid ventricular response (rapid atrial contractions of the heart that cause the ventricles to beat too quickly resulting in a lack of oxygenated blood) pleural effusion (buildup of fluid between the tissues that line the lungs and the chest), pneumothorax (collapsed lung) and sepsis (a life-threatening complication from an infection). The report indicated that the resident was noted to be ill-appearing and toxic-appearing with tachypnea (breathing that is abnormally rapid and shallow with decreased breath sounds). Further review of the hospital report revealed the resident's lab results indicated the resident was in respiratory acidosis (a state in which there is usually ventilation failure and an accumulation of carbon dioxide). Additionally, review of the report indicates that when EMS arrived to the nursing home the resident was diaphoretic and hypoxic in the 70's on a nonrebreather. EMS also noted when then they arrived to the nursing home, nursing home staff had not connected the tubing to the nonrebreather appropriately. His/her SPO2 levels immediately improved into the 90's when EMS places him/her on CPAP during transport to the hospital.
Additional review of the hospital record dated [DATE] revealed Resident ID #6's venous blood gas results were abnormal with a pCO2 level of 60.5 and his/her blood pH was 7.023, indicating s/he was in respiratory acidosis and that s/he expired on [DATE].
During a surveyor interview on [DATE] at 1:24 PM with the Medical Director, he revealed that he would expect that staff would know how to use the nonrebreather masks.
During a surveyor interview on [DATE] at approximately 2:15 PM with the Administrator and Director of Nursing Services, they were unable to provide evidence that respiratory services were provided consistent with professional standards of practice.
Resident ID #'s 1 and 6 were placed at serious harm, impairment or death by the facility. The facility failed to provide respiratory care consistent with professional standards of practice potentially contributing to their deaths.
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0726
(Tag F0726)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to ensure its nursing staff had the a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to ensure its nursing staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 6 of 6 licensed nursing staff reviewed for competencies relative to the use of non-rebreather masks, Staff A, B, C, E, F and G.
Findings are as follows:
According to the ScienceDirect Journal article, titled Emergency Oxygen Administration, dated 2008, states in part, .Non-Rebreather Mask 1. The non-rebreather mask is the first choice when considering constant flow supplemental O2 [oxygen] in an acute medical emergency. It consists of a mask, reservoir bag, and two or three one-way valves, one separating the reservoir from the mask and the other one or two on the sides of the mask. Oxygen flows into the reservoir bag so that when the victim inhales, he or she inhales O2 from the reservoir. The one-way valves on the sides of the mask keep air from coming into the mask and diluting the O2. When the victim exhales, expired air goes out of the mask through the one or two valves on the face and is prevented from entering the reservoir .3. To use the mask, it is attached to the O2 supply at a flow rate of 10 to 15 L/minute. The reservoir bag must be inflated or primed before placing it on the person .Care must be taken to not allow the O2 supply to be depleted while the mask is on the person. Because of the one-way valves, if there is no O2 supply, suffocation may result .
According to an article published by Osmosis from Elsevier titled, Non-Rebreather Mask, What Is It, When Is It Used, and More, states in part, .A non-rebreather mask requires a sufficient oxygen flow rate to ensure that the oxygen reservoir bag does not collapse when the individual inspires .Therefore, a flow rate of 12-15 liters per minute is generally recommended .The mask is connected to an oxygen tank via tubes .The minimal flow rate of non-rebreather masks is typically 12 liters per minute to prevent collapse of the bag upon inhalation .
The article, Respiratory Acidosis, published by the National Library of Medicine on [DATE] states in part, .Respiratory acidosis typically occurs due to failure of ventilation and accumulation of carbon dioxide. The primary disturbance is an elevated arterial partial pressure of carbon dioxide (pCO2) and a decreased ratio of arterial bicarbonate to arterial pCO2, which results in a decrease in the pH of the blood .
Review of the facility assessment revealed that the facility provides care to resident's that require Special Equipment/Needs of oxygen tanks and concentrators. The staff responsible for this are Nursing Management and the Environmental Director. Further review of the facility assessment failed to provide details on how staff are to provide oxygen therapy to its residents, such as nasal cannula or masks.
1. Record review for Resident ID #1 revealed s/he was initially admitted and re-admitted to the facility in June of 2023. The resident had medical diagnoses including, but not limited to, atrial fibrillation (irregular and often rapid heart rate), shortness of breath, chronic obstructive pulmonary disease, (COPD), acute on chronic congestive heart failure (CHF-heart pumps inadequately), systolic (your heart isn't contracting well during heartbeats) and diastolic (your heart can't relax normally between beats) heart failure, obstructive sleep apnea, and sick sinus syndrome (a group of heart rhythm problems due to problems with the sinus node).
Review of a progress note dated [DATE] at 9:22 AM Authored by Licensed Practical Nurse (LPN), Staff A, states in part, Resident noted to be cyanotic upon arrival to facility this morning. SPO2 [peripheral oxygen saturation] noted to be 90% [normal range is 95-100%] @ [at] 2L [LPM; Liters per minute] via NC [nasal cannula]. Resident appeared to be struggling to breathe. O2 removed and resident was placed on a non-rebreather @5L. Spo2 up to 96% but slowly started to drop down to 88%. Resident sent out 911. [nurse practitioner] NP notified, family notified. This writer called [acute care hospital] and report was given to ER [emergency room] nurse .
Record review of the emergency medical services (EMS) Patient Care Report dated [DATE] states in part, .911 call for difficulty breathing and arrived to find [resident] .alert to pain. Patient was short of breath. Staff reported spo2 of 88. Patient was on a non-rebreather at 4LPM .with a deflated bag. Patient switched to non rebreather at 15lpm on portable tank. SpO2 increased to 100 .
During a surveyor interview on [DATE] at 11:02 AM, LPN, Staff E, revealed that on the morning of [DATE] he arrived at the facility minutes before 7:00 AM for the start of his shift. He stated that during report about Resident ID #1's from the overnight staff, LPN Staff B, who indicated that the resident was mottled in appearance (discoloration of the skin due to a decrease in blood flow). Staff E indicated that he went to Resident ID #1's room immediately and assessed that s/he was not mottled but cyanotic, with an SPO2 of 91% on 2 liters of oxygen via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help. This device consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows). He further revealed that he placed a mask on the resident and left the oxygen liter flow at 2 LPM. Additionally, he revealed that he was not assigned to care for Resident ID # 1 that day and that Staff A took over his/her care when she arrived at the facility at approximately 7:20 AM.
During a surveyor interview on [DATE] at 2:10 PM with Staff A, she revealed that when she arrived at the facility on [DATE] to start her shift it was approximately 7:20 AM. Staff A indicated that when she went in to assess Resident ID #1 a non-rebreather mask was on him/her and s/he was noted to be, gasping for breath and struggling to breath. Additionally, she revealed that the resident's SPO2 had dropped to 88%.
Additional review of the EMS Patient Care Report dated [DATE] revealed that EMS was contacted by the facility at 7:48 AM to transport the resident to the hospital and that they arrived at the facility at 7:54 AM to observe the resident in a nonrebreather mask set at only 4 liters, with the reservoir bag deflated. This indicated that for approximately 50 minutes Resident ID #1 had the non-rebreather mask on him/her with a deflated bag.
Record review of Resident ID #1's hospital records dated [DATE] indicated that his/her venous blood gas levels resulted as panic with a pCO2 result of 77.9 and his/her blood pH was 7.130 (normal range is 7.310-7.4500), indicating the resident was in respiratory acidosis. Further review of this document revealed that Resident ID #1 expired on [DATE] at 12:22 PM.
2. Record review for Resident ID #6 revealed s/he was originally admitted to the facility in September of 2020 with diagnoses including but not limited to cerebral infarction (stroke), aphasia following cerebral infarction (loss of ability to understand or express speech, caused by brain damage), dysphagia (difficulty swallowing ), hemiplegia (paralysis of one side of the body) affecting left non-dominant side.
Review of a progress note dated [DATE] at 11:38 AM Authored by LPN, Staff G, states in part, .pt [patient] send by 911 due to increase congestion, with pt continue to d-sat [desaturate; when the amount of oxygen bound to the hemoglobin in your blood drops below the normal levels], non re breather [mask] on with very little result, NP called to send pt Out .report given to nurse in ER.
Further record review revealed that the resident was transferred to the local acute care hospital on [DATE].
Review of Resident ID #6's hospital record for the above-mentioned date states in part, .in from [his/her] facility due to concern for increased shortness of breath this morning. No reported recent fevers documented but patient was diaphoretic per staff. Patient was hypoxic in the 70s on a non rebreather but EMS noted that when they arrived, staff not connected the tubing to the nonrebreather appropriately. [S/he] immediately had improvement to the 90s when they placed [him/her] on CPAP during transport.
During a surveyor interview with Staff G on [DATE] at approximately 11:00 AM she indicated that she placed Resident ID #6 on 10 liters of oxygen via a non- rebreather mask on [DATE] and the bag was fully inflated on the mask. However, when the surveyor revealed that the EMS had reported that the bag of the mask was deflated on arrival to the facility on [DATE], she recanted her statement. She then indicated that she placed the non-rebreather mask on Resident ID #6 with the bag deflated stating she was fighting with the mask to try to get the bag inflated. Additionally, she revealed that the resident's Spo2 level did not increase when the mask was placed on him/her and that she did not try switching out the mask for another one. She further revealed that she left the deflated non-rebreather mask on Resident ID #2 until s/he was transported to the hospital by EMS.
Additional review of the hospital record dated [DATE] revealed Resident ID #6's venous blood gas results were abnormal with a pCO2 level of 60.5 and his/her blood pH was 7.023, indicating s/he was in respiratory acidosis.
Record review of the EMS Patient Care Report reveals that EMS was called to the facility on [DATE] at 11:20 AM and they arrived at the facility at 11:28 AM. Upon arrival, EMS noted Resident ID #6's SPO2 level was 72% and s/he was found with a non-rebreather mask on with an empty reservoir bag. Additionally, the document further reveals that when EMS placed the resident on CPAP and his/her oxygen level increased to 80% and then to 94% after they administered a nebulizer treatment and placed the CPAP on 6 liters of oxygen.
Additional review of Resident ID #6's hospital record revealed s/he expired on [DATE] at 7:26 PM.
As a result of the concerns that were identified during this survey a review of licensed nursing staff, A, B, C, E, F and G's competencies were conducted. Record review failed to reveal evidence of completed competencies or education were provided to the above mentioned staff, relative to the use of non-rebreather masks.
During a surveyor interview with the Staff Educator on [DATE] at 2:12 PM she was unable to provide evidence that Staff A, B, C, E, F and G had received competency training on the use of non-rebreather masks.
During a surveyor interview on [DATE] at 1:24 PM with the Medical Director, he revealed that he would expect that staff would have been provided the necessary training to use the equipment supplied to them by the facility to care for the residents.
During a surveyor interview with the Administrator on [DATE] at 2:51 PM she was unable to provide evidence that Staff A, B, C, E, F and G had the specific skill sets necessary to care for Resident ID #1 and 6's needs pertaining to the use the non-rebreather mask.
During a surveyor interview on [DATE] at approximately 2:15 PM with the Administrator and Director of Nursing Services, they acknowledged that the nursing staff had not been provided with competencies relative to the use of non-rebreather masks until after it was brought to their attention by the surveyors.
As a result of the system failure to ensure licensed nursing staff had the appropriate competencies and skill sets to assure resident safety, Resident ID #s 1 and 6 were placed at serious harm, impairment, or death by the facility.
Refer to F 695
Mar 2023
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to properly provide notice to residents and/or representatives informing where changes in coverage are made ...
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Based on record review and staff interview, it has been determined that the facility failed to properly provide notice to residents and/or representatives informing where changes in coverage are made to items and services covered by Medicare and/or the medical state plan related to the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) for 2 of 3 residents discharged from Medicare Part A Services, Resident ID#s 87 and 123.
Findings are as follows:
Review of the Center for Medicare and Medicaid Services (CMS) document (Form CMS-10055), titled, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN), states in part:
Medicare requires SNFs [Skilled Nursing Facilities] to issue the SNFABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is:
- not medically reasonable and necessary;
- or considered custodial.
The SNFABN provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must use the SNFABN when applicable for SNF Prospective Payment System services (Medicare Part A) .
1. Record review revealed that Resident ID #87's last covered day of Part A Services was on 6/14/2022. The facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Additionally, the facility failed to provide the SNFABN form to the resident or resident representative.
2. Record review revealed that Resident ID #123's last covered day of Part A Services was on 12/23/2022. The facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Additionally, the facility failed to provide the SNFABN form to the resident or resident representative.
During a surveyor interview on 2/27/2023 at 11:11 AM with the Minimum Data Set Nurse, she acknowledged that the SNFABN form was not provided to the above residents or their representatives.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse, including injuries of unknown source are reported imm...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to other officials (Department of Health), in accordance with State law for 2 of 3 residents reviewed for abuse and injury of unknown origin, Residents ID #s 100 and 21.
Findings are as follows
The facility policy and procedure titled, Abuse Prohibition revised on 10/31/2022, states in part; .All allegations of violations defined in this policy must be reported immediately to the Department of Health, Division of Facility Regulation .This means as soon as possible not to exceed 2 hours after the discovery .
1. Record review for Resident ID #100 revealed the resident was admitted to the facility in June of 2022 with diagnoses including, but not limited to, paraplegia (paralysis of all or part of your trunk, legs, and pelvic organs) and Cauda Equina Syndrome (bundle of nerves below the end of the spinal cord that are damaged).
Record review revealed a progress note dated 2/16/2023 at 10:47 PM that states in part, .resident showed nurse a fist size bruise to right upper ribs. With gentle palpation, [s/he] could feel some pain. Spoke with on call MD [physician] at .office who approved x-ray to ribs on 2-17-23 .
Record review revealed x-ray results dated 2/17/2023 which stated in part, .Right rib bruising .Old fracture of the right eighth rib .
Further record review failed to reveal evidence of the origin of the above-mentioned bruise and old rib fracture.
During a surveyor interview on 2/28/2023 at 10:35 AM with the [NAME] President of Operations and the Director of Nursing (DON), they were unable to provide evidence that the cause of the bruise was investigated or reported immediately to the Department of Health, as required.
2. Record review for Resident ID #21 revealed the resident was admitted to the facility in September of 2022 with diagnoses including, but not limited to, bipolar disorder, major depression and anxiety.
Record review of a progress note dated 2/17/2023 revealed in part, .Resident caused a scene outside of [his/her] room. Verbally attacked one of the aids [Nursing Assistant (NA), Staff A], confessed to threatening the aid by slitting his throat and watching him bleed out . Further record review revealed the police came to speak with the resident and eventually, the resident was sent to the hospital to be evaluated.
During a surveyor interview with the DON on 2/24/2023 at 9:11 AM, she revealed that on 2/17/2023 at approximately at 9:30 AM, they were in a conference room for a morning meeting. They overheard the resident yelling in the hall and when they left the conference room, the resident was observed yelling and threatening to kill Staff A. Additionally, the DON further revealed the resident left the area, and then stated Staff A pushed him/her.
Additionally, the DON revealed that she spoke with the resident and the resident stated Staff A pushed him/her while s/he was in a wheelchair outside his/her room and the resident was hit by the door. The resident revealed the door hit both of his/her knees, left elbow and his/her head. The DON revealed she checked the resident and there were no marks, no redness, nothing, anywhere .
During the same surveyor interview with the DON, she revealed that the above allegation of abuse was not reported to the Department of Health because they did not witness any physical contact between the resident and Staff A.
During a surveyor interview with Staff A on 2/24/2023 at 9:56 AM, he revealed that on 2/17/2023, during the incident the resident was yelling, you pushed me. you pushed me. and said something about the door .I said I did not touch you .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide the necessary services to residents who are unable to carry out activities of daily living, relative to nail care for 1 of 3 residents observed, Residents ID #70.
Findings are as follows:
Record review of Resident ID #70 revealed s/he was admitted to the facility in March of 2022 with diagnoses including, but not limited to, muscle weakness, altered mental status and cerebral infarction (stroke).
Record review of a quarterly Minimum Data Set assessment dated [DATE] revealed s/he is coded as requiring Total dependence for personal hygiene and requires one person physical assistance.
During a surveyor observation on 2/22/2023 at approximately 10:00 AM, the resident was observed with all fingernails approximately 1 centimeter long. There was brown and black matter underneath all of the fingernails.
During a surveyor interview immediately following the observation, the resident revealed s/he would like her/his fingernails cut.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interview, it has been determined that the facility has failed to ensure ...
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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 has failed to ensure that each resident receives adequate supervision and assistive devices to prevent accidents for 2 of 5 residents reviewed for falls, Resident ID #s 127 and 89.
Findings are as follows:
1. Review of a facility policy titled, Falls Prevention Program states in part, Procedure: .6. Any and all immediate fall prevention interventions are to be added to the resident's care plan at that time .
Record review revealed that Resident ID #127 was admitted to the facility in January of 2023 with diagnoses including, but not limited to, unsteadiness on feet and lack of coordination.
Review of a Morse Fall Scale dated 2/5/2023 revealed s/he is a high fall risk.
Review of the resident's care plan revealed s/he is a high risk for falls related to confusion and poor comprehension.
Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed the resident utilized a walker and required limited assistance of one staff member for ambulation.
During surveyor observations on the following dates and times the resident was observed ambulating around the unit without the use of a walker or staff assistance:
- 2/23/2023 at 11:38 AM and 11:56 AM
- 2/24/2023 at 7:44 AM
- 2/28/2023 at 9:11 AM
During a surveyor interview on 2/23/2023 with Registered Nurse (RN), Staff E, she acknowledged that the resident was ambulating without his/her walker and told the surveyors they could get the resident's walker if they wanted to.
Review of a progress note dated 2/26/2023 at 11:39 AM revealed that the resident sustained an unwitnessed fall and was transferred to the hospital to rule out injury.
Review of a progress note dated 2/27/2023 at 3:35 PM revealed that the resident sustained a fall while attempting to self-transfer.
Review of the resident's care plan following the above-mentioned falls failed to reveal evidence that the care plan had been updated with interventions to prevent further falls per the facility policy.
During a surveyor interview with the Director of Nursing and the [NAME] President of Operations (VPO), they acknowledged that the resident should be utilizing a walker when ambulating and that the staff should assist him/her to obtain his/her walker or redirect the resident to a safe place. Additionally, they acknowledged that the resident's care plan had not been updated immediately following the falls as the policy states.
2. Record review revealed that Resident ID #89 was admitted to the facility in December of 2019 with diagnoses including, but not limited to, Alzheimer's disease and stroke.
Review of a MDS assessment dated [DATE] revealed that the resident required extensive assistance of one staff member to get dressed.
Review of the resident's care plan revealed s/he is a high risk for falls related to poor insight and being unaware of his/her safety needs with an intervention dated 5/26/2022 to ensure the resident is wearing appropriate footwear including shoes/slippers or gripper socks.
Review of a Morse Fall Scale dated 6/02/2022, revealed the resident is at high risk for falls.
During surveyor observations on the following dates and times the resident was observed with regular socks on without shoes/slippers or gripper socks:
- 2/22/2023 at 9:54 AM and 11:51 AM
- 2/23/2023 at 8:32 AM, 9:07 AM and 11:18 AM
- 2/24/2023 at 10:52 AM
During a surveyor interview on 2/24/2023 at 10:55 AM with RN, Staff C, she acknowledged that the resident was wearing regular socks and should be wearing shoes/slippers or gripper socks according to his/her care plan.
During a surveyor interview on 2/27/2023 at 9:16 AM, with the VPO she revealed that the resident should have on shoes/slippers or gripper socks to prevent an accident per the resident's care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional and hydration statu...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional and hydration status, such as usual body weight and failed to follow their policy relative to weight loss and weight gain for 2 of 9 residents reviewed, Resident ID #s 123 and 32.
Findings are as follows:
1. Review of a facility policy titled, Weight Monitoring Policy dated 2/24/2017, states in part, All residents are to be weighed at least monthly so as to monitor for weight loss, to assess for underlying causes of weight loss and to intervene accordingly in a timely manner to allow for an optimal level for well-being .if the weight is +/-3 pounds from previous month, the resident is to be removed from scale and reweighed immediately .If the re-weight is accurate and there has been a significant weight loss, nursing must notify the following: physician, dietician .After the unit manager reviews the report and a weight loss has been confirmed, the resident will be placed on weekly weights. The dietician will review the weights and determine if additional intervention may need to be added .
Record review revealed Resident ID #123 was admitted to the facility in December of 2022 with diagnoses including, but not limited to, dementia and type 2 diabetes mellitus. The resident's weight on admission was 170 pounds.
Review of the Weights and Vitals Monitoring revealed a weight recorded on 1/1/2023 of 172.4 pounds and a weight recorded on 2/16/2023 of 149.6 pounds. This is a 22.8 pound weight loss or a 13.23% weight loss in one month, which constitutes a significant weight loss.
Further record review failed to reveal evidence of a re-weight after the significant weight loss from 1/2/2023 to 2/16/2023 per facility policy.
Additionally, record review failed to reveal evidence that the physician or dietician were notified until 2/23/2023 when the surveyor brought the significant weight loss to the facility's attention.
During a surveyor interview on 2/23/2023 at 12:55 PM with the Director of Nursing (DON) and the [NAME] President of Operations (VPO), they were unable to provide evidence that the physician or dietician had been notified of the significant weight loss or that a reweigh had been obtained per the facility policy.
During a surveyor interview on 2/23/2023 at 1:12 PM, with Nursing Assistant (NA), Staff J, she revealed that she obtained the residents weight that day and it was 150.2 pounds.
During a surveyor interview on 2/24/2023 at approximately 10:00 AM with the Dietician, she revealed that she was not made aware of the resident's significant weight loss until 2/24/2023. Additionally, she revealed that she would have expected to be made aware on 2/16/2023 to be able to implement interventions.
During a surveyor interview on 2/28/2023 at approximately 9:30 AM with the VPO, she acknowledged that weekly weights had not been implemented and that the facility did not follow the policy regarding a significant weight loss.
2. Record review revealed Resident ID #32 was admitted to the facility in March of 2014 with diagnoses including, but not limited to, heart failure and chronic kidney disease.
Additionally, record review revealed a care plan revised on 12/27/2022 for The resident has nutritional problem or potential nutritional problem r/t [related to] leaves >25 % food uneaten at meals . with interventions including but not limited to .Monitor weight/report weight .
Review of a document titled, Weights and Vitals Summary revealed a weight recorded on 1/6/2023 of 120.8 pounds and a weight recorded on 2/6/2023 of 128 pounds, which indicates a 7.1 pound or 5.9% weight gain in one month.
Further record review of the physician's orders revealed an order dated 2/15/2023, that states, daily weight in the morning for CHF [congestive heart failure] monitoring.
Record review failed to reveal evidence that daily weights were obtained as ordered.
During a surveyor interview with the DON on 2/28/2023 at 11:50 AM, she was unable to provide evidence that daily weights were obtained from 2/16/2023 until 2/23/2023 per the physician's order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 ...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 residents reviewed for oxygen therapy, Resident ID #43.
Findings are as follows:
Record review of a facility policy titled Oxygen Administration states in part, .Procedure .Check the physician's order for liter flow and method of administration .Documentation .Ensure that a physician's order has been obtained .
Record review revealed the resident was admitted to the facility in April 2022 with a diagnosis including, but not limited to, chronic obstructive pulmonary disease (COPD, chronic inflammatory lung disease that causes obstructed airflow from the lungs).
Record review revealed a care plan dated 4/20/2022 which states in part, .has oxygen therapy r/t [related to] COPD .Give medications as ordered by physician .
During surveyor observations on 2/22/2023 at 9:04 AM, 2/23/2023 at 8:21 AM, and 2/24/2023 at approximately 8:20 AM revealed the resident receiving oxygen therapy at 2 liters via nasal cannula (a device to deliver oxygen).
Record review failed to reveal evidence of a physician's order for oxygen therapy.
During a surveyor interview on 2/24/2023 at 8:52 AM with Registered Nurse, Staff E, she acknowledged that the resident was receiving 2 liters of oxygen via nasal cannula and there was no physician's order in place.
During a surveyor interview on 2/24/2023 at 12:40 PM with the [NAME] President of Operations, she revealed that she would expect the resident to have a physician's order when receiving oxygen therapy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to provide routine medication to its residents for 1 of 26 residents reviewed, Resident ID #5.
Findings are ...
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Based on record review and staff interview, it has been determined that the facility failed to provide routine medication to its residents for 1 of 26 residents reviewed, Resident ID #5.
Findings are as follows:
Record review revealed the resident was admitted to the facility in December of 2022 with diagnoses including, but not limited to, generalized anxiety and weakness.
Record review revealed a physician's order dated 1/2/2023 for Fluticasone Propionate Nasal Suspension 50 MCG [micrograms]/ACT (fluticasone Propionate Nasal) 1 spray in each nostril in the morning for nasal congestion .
Record review for January and February 2023 revealed the medication was not administered per the physician's order.
During a surveyor interview with Licensed Practical Nurse, Staff F on 2/27/2023 at 9:57 AM, she revealed the above medication has not been administered since it was ordered on 1/2/2023.
During a surveyor interview with the Director of Nursing on 2/27/2023 at 12:17 PM, she acknowledged that the medication was unavailable and it was not administered as ordered.
During a surveyor interview with the Pharmacist on 2/28/2023 at 1:48 PM, he revealed that the pharmacy received the prescription for the medication on 1/3/2023. The Pharmacist further revealed that the resident had an allergy to steroids according to a pharmacy document. The pharmacy contacted the facility on 1/3/2023 but did not receive a response until 2/16/2023. Additionally, he indicated that the medication was supposed to be delivered on 2/16/2023 but was not.
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
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to obtain laboratory services to meet the needs of its residents relative to the timeliness of the services ...
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Based on record review and staff interview, it has been determined that the facility failed to obtain laboratory services to meet the needs of its residents relative to the timeliness of the services for 1 of 5 residents reviewed, Resident ID #98.
Findings are as follows:
Record review revealed the resident was admitted to the facility in November of 2022 with diagnoses including, but not limited to, dementia and major depressive disorder.
Review of a pharmacy consultation report dated 12/23/2022 revealed a recommendation to obtain a Fasting A1C (a blood test to obtain the three-month average of blood sugar) on the next convenient lab day and then annually following that result. Additionally, the recommendation was signed by the physician on 12/31/2022 to be implemented with added instruction to check the A1C every six months following the initial test.
Review of a physician's order dated 1/17/2023 revealed an order to obtain a fasting A1C on 2/1/2023.
Record review failed to reveal evidence that the fasting A1C was obtained as ordered.
During a surveyor interview on 2/27/2023 at 11:45 AM with the Director of Nursing, she acknowledged that the lab was not drawn as ordered and the facility failed to obtain laboratory services in a timely manner.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0777
(Tag F0777)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined the facility failed to promptly notify the practitioner of results that fall outside of clinical reference ranges for 1 of 1 resident...
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Based on record review and staff interview, it has been determined the facility failed to promptly notify the practitioner of results that fall outside of clinical reference ranges for 1 of 1 residents reviewed relative to abnormal X-ray results, Resident ID #100.
Findings are as follows:
Record review revealed the resident was admitted to the facility in June 2022 with diagnoses including, but not limited to, paraplegia (paralysis of all or part of your trunk, legs, and pelvic organs) and Cauda Equina Syndrome (when a bundle of nerves below the end of the spinal cord is damaged).
Record review revealed a progress note dated 2/16/2023 at 10:47 PM that states in part, .resident showed nurse a fist size bruise to right upper ribs. With gentle palpation, [s/he] could feel some pain. Spoke with on call MD [physician] at .office who approved x-ray to ribs on 2-17-23 .
Record review of x-ray results dated 2/17/2023 revealed in part, .Right rib bruising .Old fracture of the right eighth rib .
Additional record review failed to reveal evidence that the x-ray results dated 2/17/2023 were reported to the practitioner.
During a surveyor interview on 2/27/2023 at 12:45 PM with Licensed Practical Nurse, Staff K, she acknowledged that the X-ray results were not reported to the practitioner.
During a surveyor interview on 2/27/2023 at 1:21 PM with the Nurse Practitioner, Staff I, she revealed that if she had been made aware of the results, she would have completed an assessment for the resident.
During a surveyor interview on 2/27/2023 at 1:33 PM with the Director of Nursing, she acknowledged that the results were not reported to the practitioner.
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
Notification of Changes
(Tag F0580)
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 immediately consult with the resi...
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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 immediately consult with the resident's physician, and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical status or a need to alter treatment significantly for 2 of 2 residents reviewed, Resident ID #s 13 and 94.
Findings are as follows:
1. Record review revealed Resident ID #13 was admitted to the facility in August 2010 with a diagnosis including, but is not limited to, urinary incontinence.
Record review revealed a progress note dated 11/11/2022 at 9:02 AM which states in part, Resident had minimal menstrual bleeding today after years of not .
Additional record review failed to reveal evidence that the Nurse Practitioner (NP) or Physician were notified of the resident having bleeding.
Additional record review revealed a progress note dated 12/26/2022 at 2:59 PM which states in part, 911 called due to resident showing signs of a stroke. [S/he] is being transported to [hospital]. [His/Her] [family] accompanied [him/her] to the hospital.
Review of a hospital discharge summary revealed a note dated 12/26/2022 at 4:24 PM which states in part, Talked with [facility] .[DATE] .had .bleeding (no work up)
Additional review of the hospital discharge summary revealed Resident ID #13's urine sample was positive for a urinary tract infection and s/he was discharged to the facility on an antibiotic.
During a surveyor interview on 2/27/2023 at 11:26 AM with Nursing Assistant, Staff H, she revealed that the resident no longer has his/her menses.
During a surveyor interview on 2/27/2023 at 12:49 AM with Register Nurse, Staff E, she was unable to provide evidence the NP or physician were notified of the bleeding on 11/11/2022.
During a surveyor interview on 2/27/2023 at 1:29 PM with the Director of Nursing (DON), she revealed she would expect the staff to notify the practitioner if a resident was experiencing bleeding.
During a surveyor interview on 2/27/2023 at 4:14 PM with the NP, Staff O, she revealed that she was unaware the resident had bleeding on 11/11/2022 and that if she had been made aware she would have completed an assessment of the resident to attempt to find the source of the bleeding and complete a medical work up to rule out a urinary tract infection.
During a surveyor interview on 2/28/2023 at 10:44 AM with the [NAME] President of Operations (VPO) and the DON, they were unable to provide evidence that the practitioner was made aware of the resident's bleeding.
2. Record review of Resident ID #94 revealed s/he was admitted to the facility in July of 2020 with diagnoses including, but are not limited to, type 2 diabetes mellitus and chronic kidney disease.
Review of a physician's order dated 7/15/2020 revealed Humalog solution 100 Unit/ML [Milliliter} (insulin Lispro) inject as per sliding scale (a term to determine insulin administration based on blood glucose level):
if 100-140 = 6 units
141- 180 = 8 units
181- 220 = 10 units
221- 260 = 12 units
261- 300 = 14 units
301- 340 = 16 units
341- 380 = 18 units
381+ = 20 units give 20 units, wait 1 hour then re-check, if still outside of parameters then call MD/NP .
Review of January and February 2023 Medication Administration Records (MAR) failed to reveal evidence that the resident's blood glucose was obtained due to her/his refusals.
Further record review failed to reveal evidence that the facility notified the provider regarding the resident's continuous refusals.
During a surveyor interview with the NP, Staff I on 2/27/2023 at 1:50 PM, she was unable to provide evidence of notifications regarding the resident's refusal of blood glucose testing.
During a surveyor interview with the VPO on 2/28/2023 at approximately 2:00 PM, she was unable to provide evidence of a provider notification of the resident's continuous refusals.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and servic...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 4 residents reviewed for pressure ulcers, Resident ID #123.
Findings are as follows:
Record review revealed Resident ID #123 was admitted to the facility in December of 2022 with diagnoses including, but not limited to, dementia and type 2 diabetes mellitus.
A. Review of the documents titled, Wound Evaluation and Management Summary dated 1/31/2023, 2/7/2023, 2/14/2023 and 2/21/2023, revealed that the resident has an unstageable DTI (deep tissue injury) to the right lateral heel and right lateral foot. Additionally, the summaries revealed that s/he has an unstageable DTI to the left lateral heel, left lateral foot and left plantar foot with a recommendation to off-load wound, float heels in bed and elevate legs.
Review of the physician's orders revealed an order dated 1/24/2023 that stated, Apply bilat [bilateral] off-loading boots every shift for wounds.
During surveyor observations of the resident on the following dates and times revealed the resident's heels were resting directly on the mattress without offloading boots:
- 2/23/2023 at 1:16 PM and 1:31 PM
- 2/24/2023 at 10:49 AM
- 2/27/2023 at 8:03 AM, 8:48 AM and 1:28 PM
During a surveyor interview on 2/27/2023 at 8:55 AM, with Registered Nurse (RN), Staff C, she acknowledged the resident was not utilizing off-loading boots as ordered and did not have his/her feet elevated as recommended by the wound doctor.
During a surveyor interview on 2/27/2023 at 9:16 AM, with the [NAME] President of Operations (VPO), she acknowledged that the resident's heels should have been elevated off the mattress to promote healing of current pressure ulcers and prevent new pressure ulcers from forming.
B. During a surveyor observation on 2/23/2023 at 8:55 AM of RN, Staff D, providing wound care to Resident ID #123, revealed she cleansed the wounds on his/her right lateral heel and right lateral foot with normal saline and then placed the resident's foot on the floor without a barrier. She then cleansed the wounds on his/her left lateral heel, left lateral foot, and left plantar foot and then placed the resident's foot on the floor without a barrier.
During a surveyor interview with Staff D immediately following the above observation, she acknowledged that she should have provided a barrier between the floor and the resident's wounds to prevent potential infection.
During a surveyor interview on 2/23/2023 at approximately 1:00 PM, with the Director of Nursing and the VPO they revealed they would have expected the nurse to utilize a barrier between the resident's wounds and the floor to help prevent infection of the pressure ulcers.
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
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide ap...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for care of a resident for 3 of 7 residents reviewed with an indwelling catheter, Resident ID #s 41, 32 and 5.
Findings are as follows:
1. The Center for Disease Control and Prevention (CDC) document titled, Guideline for Prevention of Catheter Associated Urinary Tract Infections 2009, states in part, .Proper techniques for Urinary Catheter Maintenance .Do not rest the bag on the floor .
Record review for Resident ID #41 revealed that s/he was readmitted to the facility in April of 2020 and has diagnoses including, but not limited to, hydronephrosis with renal and ureteral calculous obstruction (swelling of the kidney due to build up of urine), urinary tract infections, and retention of urine.
During surveyor observations revealed the resident's urinary drainage bag was resting on the floor on the side of the bed on 2/23/2023 at 9:01 AM, 1:09 PM, and 1:18 PM.
During a surveyor interview with the Assistant Director of Nursing during the 1:18 PM observation, she acknowledged that the urinary bag was resting directly on the floor.
Additional surveyor observations revealed the resident's urinary drainage bag was resting on the floor on the side of the bed on the following dates and times:
- 2/24/2023 at 9:32 AM
- 2/27/2023 at 8:32 AM
- 2/28/2023 9:47 AM and 9:53 AM
During a surveyor interview with Registered Nurse (RN), Staff G, during the 2/28/2023 at 9:53 AM observation, he acknowledged the urinary bag was resting on the floor and revealed that it shouldn't be.
During a surveyor interview with the [NAME] President of Operations (VPO) on 2/28/2023 at 10:05 AM, she revealed that she would expect that urinary drainage bags should not be resting directly on the floor.
2. Record review revealed Resident ID #32 was admitted to the facility in March of 2014 with diagnoses including, but not limited to, heart failure and chronic kidney disease.
Review of the physician's orders revealed an order dated 2/15/2023, that stated, daily weight in the morning for CH [congestive heart failure] monitoring.
Record review revealed a care plan revised on 4/20/2022 for [Resident] has Suprapubic Catheter (a urinary catheter used to drain urine from the bladder through a small incision just above the pubic bone): Neurogenic bladder (a condition caused by the nerves along the pathway between the bladder and the brain not working properly) with an intervention including but not limited to monitor and document intake and output as per facility policy .
Record review of the facility's policy and procedure titled, Urinary Incontinence and Indwelling Catheters dated 1/1/2016 failed to specify how often staff will monitor fluid intake and/or urine output.
Record review failed to reveal evidence that the fluid intake was monitored.
Further record review revealed that the resident's output was not monitored every shift.
During a surveyor interview with the Director of Nursing (DON) on 3/1/2023 at 8:57 AM, she was unable to provide evidence that the resident's fluid intake was monitored or that the resident's output was monitored every shift. The DON also acknowledged that the above policy failed to specify how often the fluid intake and/or urine output should be monitored.
3. Record review revealed Resident ID #5 was admitted to the facility in December of 2022 with diagnoses including, but not limited to, generalized anxiety and weakness.
Record review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was coded for Indwelling catheter and Ostomy. Review of the Outcome Summary Report dated 1/9/2023 revealed Urinary Incontinence and Indwelling Catheter will be addressed in a care plan.
Further record review failed to reveal evidence to support the usage (diagnosis), physician's order and/or a care plan relative to catheter use.
During a surveyor interview with the resident on 2/23/2023 at 11:01 AM, the resident revealed s/he has been self catheterizing prior to and since s/he was admitted to the facility. The resident further revealed s/he self catheterizes approximately 8 times per day.
During a surveyor interview with Licensed Practical Nurse (LPN), Staff F, on 2/23/2023 at 11:28 AM, she revealed the resident has been self catheterizing but is unaware of the medical necessity. When further questioned, Staff F stated she does not know how often the resident does the self catheterization.
During a surveyor interview with the MDS Coordinator on 2/23/2023 at 1:33 PM, she acknowledged that there is no diagnosis, no physician's order and/or a care plan in place for self catheterization.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure that medical records on each resident are accurately documented for 1 of 26 residents reviewed rel...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that medical records on each resident are accurately documented for 1 of 26 residents reviewed relative to medication administration, Resident ID #5.
Findings are as follow:
Record review revealed the resident was admitted to the facility in December of 2022 with diagnoses including, but not limited to, generalized anxiety and weakness.
Record review revealed a physician's order dated 1/2/2023 for Fluticasone Propionate Nasal Suspension 50 MCG [micrograms]/ACT (fluticasone Propionate Nasal) 1 spray in each nostril in the morning for nasal congestion .
During a surveyor interview with Licensed Practical Nurse, Staff L, on 2/27/2023 at 9:33 AM, she revealed that the resident did not receive the medication due to it not being available but she documented it as being administered.
During a surveyor interview with Licensed Practical Nurse, Staff I, on 2/27/2023 at 9:57 AM, she revealed the Fluticasone Propionate has not been administered since it was ordered on 1/2/2023 because it was unavailable. Additionally, she acknowledged that she has documented that she administered the medication on the morning of 2/27/2023 and she had not.
Record review of the Medication Administration Records (MAR) revealed staff inaccurately documented that the medication was administered 14 of 29 opportunities in January 2023 and 9 of 27 opportunities in February 2023.
During a surveyor interview with the Director of Nursing on 2/27/2023 at 12:17 PM, she was unable to explain why staff inaccurately documented on the MAR that they administered the medication when the medication was not available in the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to b...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 2 of 26 residents reviewed, Resident ID #s 107 and 94.
Findings are as follows:
Record review of the facility's policy titled Call Light Policy states in part .The purpose of this procedure is to respond to the resident's request and needs .when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .
1. Record review for Resident ID #107 revealed s/he was originally admitted to the facility in November of 2020 and has diagnoses including, but not limited to, hemiplegia (paralysis of one side one the body), muscle weakness and chronic respiratory failure.
Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment.
During a surveyor observation on 2/23/2023 at approximately 8:45 AM, the resident asked the surveyor for the call light stating, they don't .hook it up, I have to scream all day long . The call light was observed to be tied to the bottom of the bed rail and out of the resident's reach.
During a surveyor observation on 2/23/2023 at 8:45 AM with Licensed Staff Nurse, Staff M, she acknowledged that the call light was out of the resident's reach. She further indicated that the surveyor will find more call lights that will not be within the resident's reach.
During a surveyor observation in the presence of Certified Nursing Assistant, Staff N, on 2/24/2023 at 9:24 AM, Resident ID #107's call light was observed to be attached to the wall, out of the resident's reach.
During a surveyor interview with Staff N immediately following the observation, she revealed that the 3rd shift staff must have attached the call light to the wall.
2. Record review for Resident ID #94 revealed s/he was admitted to the facility in July of 2020 with diagnoses including, but not limited to, type 2 diabetes mellitus and chronic kidney disease.
Review of the resident's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment.
During a surveyor observation of the resident on 2/24/2023 at approximately 8:50 AM, revealed the resident laying in bed and the call light was behind the nightstand, out of the resident's reach.
During a surveyor interview on 2/24/2023 at approximately 9:30 AM with Staff N, she acknowledged that the call light was out of the resident's reach. She further revealed the 3rd shift staff must have placed it there.
During a surveyor interview with the [NAME] President of Operations on 2/28/2023 at approximately 2:00 PM, she indicated that the call lights should be placed within the residents reach to be able to call staff for assistance.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed, in accordance with professional standards for food ser...
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Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed, in accordance with professional standards for food service safety, relative to the main kitchen.
Findings are as follows:
During the initial tour of the main kitchen on 2/22/2023 at 8:42 AM in the presence of the Food Service Director (FSD) revealed the following observations:
- 1 black hot beverage pitcher shelved with all clean ready to use pitchers which had approximately 1 inch of brown liquid inside of it.
- 1 La Choy 1 gallon Soy sauce bottle, opened, in use and not dated
- Scrambled eggs in a metal hotel pan dated 2/15 in the walk-in refrigerator
- Tuna salad in a metal hotel pan dated 2/14 in the walk-in refrigerator
- Ice build-up approximately 8 inches in length and 5 inches in width on top of plastic covered pies.
The unit with fan above the pies had noted icicles formed approximately 2 inches in length dripping towards the pies.
During a surveyor interview with the FSD immediately following each observation, she acknowledged the pitcher with a brown liquid being stored with the clean ready to use pitchers. The FSD further revealed that the gallon bottle of Soy Sauce should have been dated when opened. She also indicated that the scrambled eggs and tuna salad should have been discarded stating that she only keeps prepared food in refrigerator for 3 days at the most. Additionally, the FSD acknowledged the ice formation on top of the pies in the freezer and the unit above leaking, stating that it needs to be fixed.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiot...
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Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic.
Findings are as follows:
Review of the antibiotic stewardship monthly records failed to reveal documentation of tracking information for the months of October, November, December of 2022 and January 2023, which included diagnostic tests including, but not limited to, laboratory results, x-rays, or cultures and test results to ensure the appropriate antibiotics were prescribed. Further review failed to reveal evidence of a system for monitoring or reviewing each resident's response to antibiotics.
During a surveyor interview on 2/27/2023 at 10:40 AM with the Acting Infection Control Nurse, she was unable to provide evidence of an antibiotic stewardship program from October 2022 through January 2023.
Nov 2022
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to assure that services being provided meet professional standards of quality relative to following physician's orders for 1 of 4 residents reviewed for medication administration, Resident ID #3
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 for the resident revealed s/he was initially admitted to the facility in January of 2018 with diagnoses including, but not limited to, type 2 diabetes mellitus with diabetic neuropathy and osteoarthritis.
Review of the quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating the resident is cognitively intact.
Record review revealed a physician's order dated 4/6/2020 for Lidocaine Patch 4% Apply to mid back topically in the morning for Pain.
During surveyor observation and simultaneous interview with the resident on 11/21/2022 at 2:00 PM, revealed multiple boxes of medicated topical pain patches stored on the resident window sill, which included Icy Hot, Salonpas and Lidocaine. The resident revealed that the staff applies the patches to where s/he has pain i.e., his/her shoulders, knees and back.
During a surveyor interview on 11/21/2022 at approximately 3:00 PM with Licensed Practical Nurse, Staff A, he revealed the resident only has an order for the Lidocaine 4% patch to be applied to the mid back. Additionally, Staff A revealed that he places the other patches where the resident chooses, i.e., shoulders and upper back between the shoulder blades. Additionally, he revealed that the order has not been modified to include the additional areas where the patches are applied.
During a surveyor observation of the resident on 11/21/2022 at approximately 4:40 PM revealed 1 Salonpas patch to both shoulders, 1 patch to the upper back between the shoulder blades, and 1 patch to the mid lower back. Additionally, the resident indicated the patches were placed by the nurse to the above-mentioned areas.
During a surveyor interview on 11/21/2022 at 4:50 PM with the Administrator, he was unable to provide evidence of an order to include application of the topical patches to the additional locations on the resident, other than the mid back.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**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 store all d...
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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 store all drugs and biologicals in locked compartments for 1 of 1 resident reviewed relative to medications left at the bedside, Resident ID #3.
Findings are as follows:
Record review for the resident revealed s/he was initially admitted to the facility in January of 2018 with diagnoses including, but not limited to, type 2 diabetes mellitus with diabetic neuropathy and osteoarthritis.
Review of the quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating the resident is cognitively intact.
During a surveyor observation and simultaneous interview with the resident on 11/21/2022 at 2:00 PM revealed 9 boxes of medicated topical pain patches at the resident's bedside on the window sill which included 2 Salonpas, 3 Lidocaine, and 4 Icy Hot. Additionally, the resident revealed those patches were purchased by him/her, and that staff applies the patches wherever s/he has pain ie. shoulders, back and knees.
During a surveyor observation of the resident on 11/21/2022 at approximately 4:40 PM, s/he was observed with 1 Salonpas patch to each shoulder, one large white patch to his/her upper back between his/her shoulder blades and one white patch to his/her lower/mid back. During the observation the resident acknowledged the patches were placed in those areas by the nurse.
During a surveyor interview with Licensed Practical Nurse, Staff A, on 11/21/2022 at 3:00 PM, he acknowledged that the patches stored are at the bedside.
During a surveyor interview on 11/21/2022 at 4:50 PM with the Administrator he acknowledged that the topical patches were at the resident's bedside.
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?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 36% turnover. Below Rhode Island's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 8 life-threatening violation(s), Special Focus Facility, 5 harm violation(s), $150,979 in fines, Payment denial on record. Review inspection reports carefully.
- • 66 deficiencies on record, including 8 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $150,979 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 a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Trinity Health And Rehabilitation Center's CMS Rating?
CMS assigns Trinity Health and Rehabilitation Center an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Rhode Island, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Trinity Health And Rehabilitation Center Staffed?
CMS rates Trinity Health and Rehabilitation Center's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 36%, compared to the Rhode Island average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Trinity Health And Rehabilitation Center?
State health inspectors documented 66 deficiencies at Trinity Health and Rehabilitation Center during 2022 to 2025. These included: 8 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 5 that caused actual resident harm, 52 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Trinity Health And Rehabilitation Center?
Trinity Health and Rehabilitation Center is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 185 certified beds and approximately 157 residents (about 85% occupancy), it is a mid-sized facility located in Woonsocket, Rhode Island.
How Does Trinity Health And Rehabilitation Center Compare to Other Rhode Island Nursing Homes?
Compared to the 100 nursing homes in Rhode Island, Trinity Health and Rehabilitation Center's overall rating (1 stars) is below the state average of 3.0, staff turnover (36%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Trinity Health And Rehabilitation Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the substantiated abuse finding on record.
Is Trinity Health And Rehabilitation Center Safe?
Based on CMS inspection data, Trinity Health and Rehabilitation Center has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 8 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Rhode Island. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Trinity Health And Rehabilitation Center Stick Around?
Trinity Health and Rehabilitation Center has a staff turnover rate of 36%, which is about average for Rhode Island nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Trinity Health And Rehabilitation Center Ever Fined?
Trinity Health and Rehabilitation Center has been fined $150,979 across 7 penalty actions. This is 4.4x the Rhode Island average of $34,589. 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 Trinity Health And Rehabilitation Center on Any Federal Watch List?
Trinity Health and Rehabilitation Center is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.