Coventry Operations RI LLC DBA Respiratory and Reh

Based on surveyor observation, clinical record review, and staff interviews, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infection, relative to maintaining Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities) for 1 of 1 resident observed on EBP, Resident ID #20. Additionally, the facility failed to maintain contact/droplet precautions (an infection control measure that is used when a resident is known or expected to be infected to prevent the spread of germs that can be transmitted through respiratory droplets expelled when a person coughs, sneezes, or speak) for 3 of 3 residents observed on contact/droplet precautions, Resident ID #s 41, 87, and 107.Findings are as follows:Review of the Center for Disease Control and Prevention document titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, the facility failed to develop, implement, and maintain an effective training program for annual training for existing employees consistent with their expected roles, relative to education per the facility assessment, for 10 of 11 employees reviewed, Staff I, J, K, L, M, T, Y, GG, HH, and II.Findings are as follows:Record review of the Facility Assessment, dated March 2026, states in part, .We utilize Health Stream services for increased/mandatory education on annual and quarterly bases.Staff competencies required.A full ledger of staff-specific courses/competencies can be found in Health Stream.Record review of the facility's Health Stream Annual Education Plan revealed the following required trainings:-Resident rights and abuse prevention-HIPAA (Health Insurance Portability and Accountability Act) and confidentiality-Corporate compliance and ethics-Safe resident handling and transfers-Fall prevention-Emergency preparedness-Skin integrity and pressure injury prevention-Pain assessment and management-Dementia and behaviors-Mental health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, the facility failed to ensure that the resident's formulated advance directive would be followed, as there were inconsistencies between the paper medical record and the Electronic Medical Record (EMR), for 1 of 1 resident reviewed who had recently changed his/her code status, Resident ID #4. Findings are as follows:Record review revealed the resident was re-admitted to the facility in April of 2025 with diagnoses including, but not limited to, end stage renal disease (the final stage of kidney failure) and dependence on renal dialysis (a life sustaining treatment that filters waste, toxins, and excess fluids from the blood when the kidneys have failed).Record review of the EMR advance directive banner, indicates a code status of Do Not Resuscitate (DNR)/Comfort Measures Only (CMO). Further review revealed a physician's order dated [DATE] indicating a code status of DNR/CMO. Record review of the most recent Medical Order for Life Sustaining Treatment (MOLST)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on surveyor observation, clinical record review, and staff interviews, the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to promote wound healing for 1 of 1 resident reviewed with actual pressure ulcers (localized injuries to the skin and/or underlying skin usually over a bony prominence), Resident ID #52.Findings are as follows:Record review revealed the resident was admitted to the facility in March of 2021 with diagnoses including, but not limited to, anoxic brain damage (caused by a lack of oxygen to the brain) and persistent vegetative state. Record review of a nursing progress note dated 4/8/2026 at 5:53 PM, revealed that resident has a new Stage 1 pressure injury to the dorsum (area of the foot on the top surface extending from the ankle to the toes) of his/her right foot.Review of a care plan last revised on 3/5/2026 revealed the resident is at risk for skin breakdown with interventions including, but not limited to, off loading and floating heels with pillows while in bed.Record review of a physician's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, clinical record review, and staff interviews, the facility failed to ensure a resident with limited range of motion (ROM) receives appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM for 1 of 2 residents reviewed with contractures (the shortening of muscles, tendons, skin, and nearby soft tissues that cause the joints to become very stiff, which prevents normal movement), Resident ID #52.Findings are as follows:Record review revealed Resident ID #52 was admitted to the facility in March of 2021 with diagnoses including, but not limited to, anoxic brain damage (caused by a lack of oxygen to the brain) and persistent vegetative state. Record review of a Minimum Data Set Assessment (MDS) dated [DATE] revealed the resident was in a persistent vegetative state with no discernible consciousness. Further review revealed the resident had impaired range of motion to both of his/her upper extremities. Additional review revealed that the resident is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality related to following physician's orders for 1 of 3 residents reviewed regarding flushes for through a gastrostomy tube (a flexible tube that allows for the delivery of liquid nutrition and medications directly into the stomach), Resident ID #1.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 11/14/2025 alleges in part, that staff was not consistent with following physician orders related to the resident's tube feeding and flushes. The complaint further revealed that the issues began approximately 4 weeks prior to the complaint being filed.According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients . Record review revealed Resident ID #1 was readmitted to the facility in July of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it has been determined that the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment.Findings are as follows:Review of a community reported complaint received by the Rhode Island Department of Health on 10/24/2025 alleges that Resident ID #5 sustained 2 falls and did not get the appropriate care related to his/her injuries. Additionally, the complaint alleges that the facility does not have enough staff or qualified staff.Review of a document titled, Facility Assessment dated March 2025-2026 states in part, .Acuity-Sufficiency Analysis Summary.4. Please document total #[number]/average/range of staff required to ensure sufficient number of qualified staff are available to meet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 for a physician referral for an appointment, Resident ID #5.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.Record review revealed that the resident was admitted to the facility in August of 2022 with diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction (weakness and paralysis of one side of the body following a stroke), dependence on ventilator, use of tracheostomy (a surgically created opening in the windpipe to assist with breathing) and gastrostomy (a surgical opening into the stomach for purposes of feeding).Review of a progress noted dated 8/3/2025 revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 resident's physician completed a medication reconciliation upon readmission. This failure resulted resulted in a resident receiving the medication Metolazone (a medication prescribed to treat fluid retention) in error, Resident ID #1.Findings are as follows:Record review of a facility reported incident submitted to the Rhode Island Department of Health on [DATE] revealed that Resident ID #1 had experienced a fall on [DATE] and was transferred to an acute care hospital. Additionally, the resident subsequently died.Record review revealed Resident ID #1 was readmitted to the facility in October of 2025 with a diagnosis including, but not limited to, heart failure, pulmonary hypertension (a condition where the blood pressure in the arteries of the lung is high), and chronic kidney disease.Review of the progress notes revealed the resident was transferred to an acute care hospital and was admitted for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it has been determined that the facility failed to ensure that resident's records are complete and accurately documented, relative to 1 of 1 resident reviewed who received Metolazone (medication to treat fluid retention) inaccurately, Resident ID #1. Findings are as follows:Record review of a facility reported incident submitted to the Rhode Island Department of Health on 10/14/2025 revealed that Resident ID #1 had experienced a fall and was transferred to an acute care hospital to be treated. However, the facility was later informed that the resident had passed away.Record review revealed the resident was readmitted to the facility in October of 2025 with diagnoses, including but not limited to, heart failure (a condition in which the heart muscle cannot pump blood effectively), pulmonary hypertension (a condition where the blood pressure in the arteries of the lung is high) and chronic kidney disease.Record review of a hospital document titled Continuity of Care Adult Discharge dated 10/9/2025 revealed that the resident was discharged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it has been determined that the facility failed to ensure a resident with pressure ulcers (localized damage to the skin and/or underlying soft tissue, usually over a bony prominence) receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 4/14/2025 alleged neglect and that a resident had developed two additional bed sores while residing in the facility. 1. Review of a facility policy titled, Skin Integrity and Wound Management dated 10/15/2024, states in part, .The licensed nurse will .Complete wound evaluation upon admission/readmission .weekly .Implement special wound care treatment as ordered . Record review revealed the resident was admitted to the facility in December of 2024 with diagnoses including, but not limited to, sepsis (a life-threatening…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident was given a written accounting of his/her deposits, withdrawals, and balances at least quarterly for 5 of 7 residents reviewed, Resident ID #s 36, 41, 58, 69, and 252. Findings are as follows: 1. Record review revealed that Resident ID #36 was admitted to the facility in February of 2017. Review of a facility provided document titled, Trial Balance dated 3/18/2025, revealed that Resident ID #36 has funds being held by the facility. Record review failed to reveal evidence of a quarterly statement for Resident ID #36. 2. Record review revealed that Resident ID #41 was readmitted to the facility in December of 2023. Review of a facility provided document titled, Trial Balance dated 3/18/2025, revealed that Resident ID #41 has funds being held by the facility. Record review failed to reveal evidence of a quarterly statement for Resident ID #41. 3. Record review revealed that Resident ID #58 was readmitted to the facility in February of 2024. Review of a facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 them of 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 64 and 402. Additionally, the facility failed to provide notice of Medicare Non-Coverage (NOMNC), in a timely manner for 2 of 4 residents reviewed who were discharged from a Medicare covered Part A stay with benefit days remaining, Resident ID #s 93 and 253. Findings are as follows: 1. 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)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 1 of 1 resident reviewed with a diagnosis of schizophrenia, Resident ID #66. Findings are as follows: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual last revised in October of 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 #66 was admitted to the facility in February of 2024 with a diagnosis including, but not limited to, bipolar disorder. Record review revealed a Preadmission Screening and Resident Review (PASRR) dated in January of 2024, with a diagnosis of bipolar disorder. Further review of the document revealed that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to failure to follow a physician's order for 1 of 1 resident reviewed for daily weights, Resident ID #23. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients . Record review revealed the resident was admitted to the facility in February of 2022 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (a lung condition caused by damage to the lungs) and type 2 diabetes mellitus with diabetic chronic kidney disease (when the kidneys are damaged over time due to high blood sugar). Record review revealed an active physician's order with a start date of 7/31/2024, that states daily weights in the morning for monitoring. Record review failed to reveal evidence that daily weights were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it has been determined that the facility failed to ensure the irregularities identified by the Consultant Pharmacist during the monthly pharmacist Medication Regimen Review (MRR) were acted upon for 1 of 2 residents reviewed for admission medication reconciliation, Resident ID #93. Findings are as follows: Record review revealed that the resident was admitted to the facility in January of 2025 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD, a lung condition caused by damage to the lungs.) and bacterial pneumonia. Record review revealed the following physician's orders: -1/7/2025 prednisone (a medication prescribed to decrease inflammation) 40 milligrams (mg), give one tablet once daily for COPD -1/7/2025 doxycycline (a medication prescribed to treat infection), 100 mg, give one tablet two times daily for pneumonia Record review of a new admission MRR form dated 1/8/2025, authored by the pharmacist, revealed a recommendation to the facility to clarify a stop date for the doxycycline. Additionally,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to enhanced barrier precautions (EBP; refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and glove use during high contact resident care activities), for 4 of 4 residents reviewed on EBP, Resident ID #s 15, 60, 74, and 92. Findings are as follows: Review of the facility signage titled Enhanced Barrier Precautions states in part, .Wear Gown and Gloves prior to these activities .Dressing .bathing .transferring .providing hygiene .Device care or use of a device (i.e. central lines (a long, flexible tube that inserted into a vein in the neck, chest, arm or groin, and passed through until it reaches a large vein near the heart), urinary catheters, feeding tubes, tracheostomies (an opening a surgeon makes through your neck and into your trachea…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 2 of 5 residents reviewed for antibiotic orders, Resident ID #s 89 and 93. Findings are as follows: According to the Centers for Disease Control and Prevention (CDC) document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes states in part, Standardize the practices which should be applied during the care of any resident suspected of an infection or started on an antibiotic. These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 inform the resident's appointed representative, in advance, of the care to be furnished by the physician or other provider, of the risks and benefits of proposed care or treatment alternatives relative to the ordering of, and administration of, an antipsychotic medication for 1 of 2 residents reviewed for the use of Rexulti (an atypical antipsychotic medication), Resident ID #101. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 3/17/2025 alleges that the resident was started on Rexulti in January of 2025 and the resident was unable to provide consent. Additionally, a family member was never contacted about the addition of Rexulti nor advised of any risks or adverse reactions related to its use. Review of the facility policy titled, .Informed Consent last reviewed 2/1/2023 states in part, .Informed consent will be obtained from the patient or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 keep a resident free from neglect for 1 of 1 resident reviewed for activities of daily living (ADLs), Resident ID #452. Findings are as follows: Review of a facility policy titled, Abuse Prohibition last reviewed on 2/23/2021 states, in part, .Neglect is defined as the failure of the Center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Review of a facility policy titled, .Activities of Daily Living (ADLs) last revised 5/1/2023 states in part, .Activities of daily living (ADLs) include: Hygiene - bathing, dressing, grooming, and oral care; Mobility - transfer and ambulation, including walking; Elimination - toileting .A patient who is unable to carry out ADLs will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it has been determined that the facility failed to implement and revise a care plan after each assessment for 1 of 2 residents reviewed for falls, Resident ID #21. Findings are as follows: Review of a facility policy titled Falls Management last revised on 3/15/2024 states in part, .Implement and document patient centered interventions according to individual risk factors in the patients care plan . Record review revealed Resident ID #21 was readmitted to the facility in April of 2024, with diagnoses including, but not limited to, dementia, difficulty walking, and unsteadiness on feet. Record review revealed the following: -1/5/2025 - The resident sustained an unwitnessed fall, s/he was found lying on his/her back on the floor in his/her room. Review of a care plan with a focused area for risk for injury related to falls, revealed an intervention initiated on 1/5/2025, for a bedside mat on floor to right side of the bed at all times while resident is in bed. -2/11/2025 - The resident sustained an unwitnessed fall while attempting to get…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a treatment that removes excess fluid, waste, and toxins from the blood when the kidneys are no longer functioning properly) receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident reviewed for communication with the dialysis center, Resident ID #64. Findings are as follows: Review of a facility policy titled, Dialysis: Hemodialysis [HD] . states in part, .Shared Communication Between the Center and the Certified ESRD [End-stage renal disease] Facility .Communication topics .Declines in functional status, falls, the identification of symptoms such as anxiety, depression, confusion .Changes and/or decline in conditions unrelated to HD . Record review revealed that Resident ID #64 was readmitted to the facility in February of 2025, with a diagnosis including, but not limited to, ESRD. Record review revealed that the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 2 residents reviewed for admission medication reconciliation, Resident ID #93. Findings are as follows: Record review revealed that the resident was admitted to the facility in January of 2025 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD, a lung condition caused by damage to the lungs) and bacterial pneumonia. Record review of a Continuity of Care Discharge/Transfer of Patient Form (COC) dated 1/1/2025 revealed an attached communication form titled Discharge summary with the following physician's orders: -prednisone 40 milligrams (mg), give one tablet once daily for 4 days, which indicates the medication would be discontinued on 1/5/2025. -doxycycline 100 mg, give one tablet two times daily for 2 days which indicates the medication would be discontinued on 1/3/2025. Record review revealed the following physician's orders: -1/7/2025 prednisone 40 mg, give one tablet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it has been determined that the facility failed to document all required components of the facility-wide assessment. Additionally, the facility failed to review and update the assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. Findings are as follows: Review of an undated and unsigned facility document titled, Facility Assessment, for the year of 2025, failed to reveal evidence of the active involvement of the following participants in the process: 1. Nursing home leadership and management, including but not limited to, a member of the governing body, the Medical Director, an Administrator, and the Director of Nursing Services (DNS). Record review of the Assessment Contributors section, revealed of the 13 management staff listed including the Administrator, the DNS, and the Medical Director, 11 of them were no longer employed at the facility. 2. The facility must also solicit and consider input received from residents, resident representatives,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to implement and maintain an effective, comprehensive, data-driven, Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. Additionally, the facility failed to make a good faith attempt to correct the identified concern of antibiotic stewardship (the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients) and personal protective equipment (PPE) related to enhanced barrier precautions (EBP; refers to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and glove use during high contact resident care activities). Findings are as follows: A. Record review of the document titled Quality Assurance and Performance Improvement Projects (QAPI) Infection Control/Education Topic: HH [hand hygiene]/PPE, dated 11/12/2024 through 3/14/2025, revealed that, relative to infection…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain a safe, clean, comfortable, and homelike environment relative to window air conditioners and exposed pipes in the hallway ceiling for 4 of 4 occupied facility units. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/27/2024, alleges that the facility .has mold on the AC units [Air conditioner units] Water dropping from the ceiling, mold on the carpeting . During a surveyor observation on 8/21/2024 at 9:02 AM of the facility's window air conditioners and unit ceilings revealed the following: -1 North Unit, air conditioner in rooms 146, 147, 148, and 151 were observed with diffuse black matter on the air flaps and inside. Additionally, an air conditioner unit in the dining room across from 158 was observed with black matter on outside and inside of the air flaps. -2 South Unit, multiple air conditioner in rooms…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview it has been determined that the facility failed to develop, implement, and maintain an effective training program, for existing staff, consistent with their expected roles, relative to education involving smoking per the facility assessment, for 5 of 5 staff reviewed, Staff A, D, E, F and G. Findings are as follows: According to the Facility Assessment, dated February 2024, which indicates the facility will provide care for resident who smoke. Record review failed to reveal evidence that the following staff completed smoking education: - Registered Nurse, Staff A, hired on 9/19/2023 - Registered Nurse, Staff D, hired on 7/5/2024 - Nursing Assistant, Staff E, hired on 9/18/2023 - Nursing Assistant, Staff F, hired on 2/3/2023 - Nursing Assistant, Staff G, hired on 3/14/2024 During a surveyor interview on 8/16/2024 at 3:02 PM, with the Director of Nursing Services, he was unable to provide evidence that training relative to smoking was completed for the above-mentioned staff.

Based on record review and staff interview, it has been determined that the facility failed to provide mandatory training to their staff, that outlines and informs staff of the elements and goals of the facility's QAPI (Quality Assurance and Performance Improvement) program, for 3 of 5 staff reviewed, Staff A, D, and E. Findings are as follows: Record review failed to reveal evidence that the following staff completed QAPI training or education: - Registered Nurse, Staff A, hired on 9/19/2023 - Registered Nurse, Staff D, hired on 7/5/2024 - Nursing Assistant, Staff E, hired on 9/18/2023 During a surveyor interview on 8/16/2024 at 3:02 PM, with the Director of Nursing Services, he was unable to provide evidence that the QAPI training was completed for the above-mentioned staff.

Based on record review and staff interview, it has been determined that the facility failed to provide all staff with behavioral health training, for 3 of 5 staff reviewed, Staff, A, D, and E. Findings are as follows: Record review failed to reveal evidence that the following staff completed the mandatory behavioral health training or education: - Registered Nurse, Staff A, hired on 9/19/2023 - Registered Nurse, Staff D, hired on 7/5/2024 - Nursing Assistant, Staff E, hired on 9/18/2023 During a surveyor interview on 8/16/2024 at 3:02 PM, with the Director of Nursing Services, he was unable to provide evidence that the behavioral health training was completed for the above-mentioned staff.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following physician's orders for 7 of 9 residents reviewed, Resident ID #s 1, 2, 3, 4, 5, 6, and 7. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing page 314 states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/17/2024 alleges multiple residents did not receive their medications, as ordered. 1. Record review revealed Resident ID #1 was readmitted to the facility in July of 2024 with diagnoses including, but not limited to, Chronic Obstructive Respiratory Disease (COPD, a group of lung diseases that block airflow and makes it difficult to breathe), acute and chronic respiratory failure (a condition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it has been determined that the facility failed to keep residents free from significant medication errors for 4 of 4 residents reviewed, Resident ID #s 1, 2, 3, and 4. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/17/2024 alleges multiple residents did not receive their medications, as ordered. 1. Record review revealed Resident ID #1 was admitted to the facility in March of 2024 and readmitted in July of 2024 with diagnoses including, but not limited to, Chronic Obstructive Respiratory Disease (COPD, a group of lung diseases that block airflow and makes it difficult to breathe) acute and chronic respiratory failure (a condition where there in not enough oxygen in the tissues in your body) with hypercapnia (when there is too much carbon dioxide in the blood). Record review of the July 2024 Medication Administration Record (MAR) revealed the following physician's orders: - 7/14/2024 Spiriva Respimat inhaler 2.5 Microgram (MCG) 2 puff once daily at 9:00 AM (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 3 residents reviewed for pressure ulcers, Resident ID #s 1 and 3. Findings are as follows: Record review of a facility reported incident submitted to The Rhode Island Department of Health on 7/5/2024 revealed, that Resident ID #1's .Wound care treatment was outdated and not completed per MD [medical doctor] order. Resident was seen by wound care MD today . Record review of a facility policy titled, Skin Integrity and Wound Management states in part, .To Provide safe and effective care to promote optimal skin health, prevent pressure injuries, and promote healing .Perform daily monitoring of wounds or dressings for presence of complications or declines . 1. Record review revealed that Resident ID #1 was readmitted to the facility in May of 2024 with diagnoses including,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 licensed nurses had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident, as determined by resident assessments and individual plans in accordance with the facility assessment for 3 of 3 nurses reviewed, Staff A, I, and J who worked on the Ventilator Unit. Findings are as follows: Record review of a facility reported incident submitted to The Rhode Island Department of Health on 5/23/2024 revealed in part that a resident alleged that on 5/22/2024 the second shift nurse shoved mouthwash two times in his/her mouth with no suction. Record review failed to reveal evidence that the facility has a policy or procedure on how to perform oral care on residents with a tracheostomy (a medical procedure that involves creating an opening in the neck to place a tube into a person's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following a physician's order for 2 of 2 residents reviewed with an indwelling suprapubic catheter (a flexible tube that collects urine from the bladder and empties the urine into a drainage bag), Resident ID #'s 7 and 8. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing page 314 states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review of a community reported complaint submitted to The Rhode Island Department of Health on 5/21/2024 alleges in part, that treatments were not completed as ordered on the day shift of 5/20/2024. 1. Record review revealed that Resident ID #7 was admitted to the facility in May of 2023 with diagnosis including, but not limited to, obstructive uropathy (excess urine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on 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 3 of 3 residents reviewed for pressure ulcers, Resident ID #'s 4, 5 and 6. Findings are as follows: Record review of a community reported complaint submitted to The Rhode Island Department of Health on 5/21/2024 alleges in part, treatments were not completed as ordered on the day shift 5/20/2024. 1. Record review revealed that Resident ID #4 was readmitted to the facility in April 2024 with a diagnosis including, but not limited to, unstageable pressure ulcer (characterized by full-thickness skin and muscle loss, with slough (moist dead tissue) or eschar (dry dead tissue) obstructing the wound bed). Record review revealed the following physician's orders dated 5/16/2024: -pressure injury sacrum (pelvic area) cleanse with wound cleanser, skin prep (skin protection wipe)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview it has been determined that the facility failed to keep residents free from significant medication errors for 1 of 1 resident reviewed for insulin, Resident ID #2. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 5/21/2024 alleges the Director of Nursing Services worked on 5/20/2024 from 7:00 AM through 11:00 PM and failed to administer insulin, as ordered. Record review revealed Resident ID #2 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, diabetes and morbid obesity. Review of a physician's order dated 5/20/2024 revealed Semglee insulin, inject 16 units once per day for diabetes. Review of the May 2024 Medication Administration Record failed to reveal evidence the Semglee insulin was administered as ordered on 5/20/2024. Review of a physician's order dated 5/8/2024 revealed Lispro insulin inject subcutaneously (below the skin) per sliding scale before meals for diabetes. Review of the May 2024 Medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on surveyor observation, record review, resident, and staff interview it has been determined that the facility failed to protect the resident's right to be free from neglect for 1 of 1 residents reviewed for neglect, Resident ID #5. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 4/26/2024 alleges in part that a Licensed Practical Nurse (LPN) does not administer Resident ID #5's medication when they are due. Record review of a 2/23/2021 facility policy titled Abuse Prohibition, states in part, .prohibit abuse, mistreatment, neglect .for all residents .Neglect is defined as the failure of .employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Record review revealed that the resident was admitted to the facility in February of 2024 with diagnoses including, but not limited to, Guillain-Barre syndrome (a rare disorder in which your body's immune system attacks your nerves), gastroesophageal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview it has been determined that the facility failed to ensure that a resident who displays or is diagnosed with a mental disorder receives appropriate treatment and services to attain the highest practicable mental and psychosocial well-being for 1 of 1 residents reviewed who exhibited behavioral symptoms, Resident ID #4. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 4/24/2024 alleges in part that Resident ID #4 exhibited uncontrollable combative behaviors. Record review revealed the resident was admitted to the facility in April of 2024 with diagnoses including, but not limited to, dementia and anxiety. Record review of a care plan dated 4/17/2024 revealed a focus area indicating s/he exhibits distressed/fluctuating mood symptoms related to anxiety and dementia. Interventions include but are not limited to; refer to behavioral health specialist as needed, observe for signs and symptoms of worsening anxiety, anger and agitation. Record review revealed a telehealth…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 properly store, distribute, and serve food in accordance with professional standards for food service safety relative to 3 of 5 kitchenettes, 1 of 2 resident room refrigerators, and the cleanliness of 3 of 4 kitchenette ice machines. Findings are as follows: 1. Surveyor observation of the North 3 unit kitchenette on 4/2/2024 at 10:22 AM, revealed 1 two ounce (oz) package of non-individually wrapped Fig [NAME] cookies stored in the refrigerator, opened and not dated. During a surveyor interview on 4/2/2024 at approximately 10:30 AM with Nursing Assistant (NA), Staff E she acknowledged the above observation. - Surveyor observation of the North 1 unit kitchenette on 4/2/2024 at approximately 10:38 AM, revealed a box of ice cream bars that were opened and not dated. Additional observation revealed a 1.5 quart sized container of Breyers chocolate ice cream with freezer burn and was approximately ¾ consumed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it has been determined that the facility failed to ensure the medical care of each resident is supervised by a physician for 1 of 1 resident reviewed for abnormal laboratory results, Resident ID #94. Findings are as follows: Record review revealed the resident was admitted to the facility in May of 2021 with diagnoses including, but not limited to, hypothyroidism (a condition which the thyroid gland does not produce enough thyroid hormone), stroke and hypertensive heart disease. Further record review revealed the resident was admitted to hospice services (hospice care-focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life) on 3/1/2024. Record review of a lab report dated 12/27/2023 revealed a TSH (thyroid stimulating hormone-test to see how well your thyroid is working) result of 0.23 IU (normal range 0.400-4.100 International Unit per Milliliter, indicating a low TSH level. Record review of a progress note dated 12/27/2023 and authored by the APRN (Advanced Practice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 sufficient nursing staffing to ensure resident safety and attain the highest practicable, physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care relative to Activities of Daily Living (ADL) for 2 of 2 residents reviewed for ADL care needs, Resident ID #s 21 and 77. Findings are as follows: 1. Record review revealed that Resident ID #21 was readmitted to the facility in April of 2023 with diagnoses including, but not limited to, dependence on respirator (a machine used to support or replace breathing) and stroke. Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed the resident requires the assistance of two staff members for bed mobility including turning from side to side, to and from a lying position, and transferring from bed to chair. Review of a care plan dated 5/2/2023 revealed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, resident representative interview, and staff interview, it has been determined that the facility failed to store medications in accordance with currently accepted professional principles for 1 of 10 residents reviewed relative to breaking the chain of custody of medications and administering said medications to a resident, Resident ID #2. Findings are as follows: According to U.S. Pharmacist article, published June 11, 2021 titled Uncovering the Impact of Storage on Generic Medications, states in part .Storage conditions are vitally important to the overall integrity and quality of medications, and the United States Pharmacopeial Convention, the FDA (Federal Drug Administration), and drug manufacturers provide guidelines for proper storage .From the point of manufacture to the distribution of a medication to a patient, many factors can directly impact the integrity of a drug product, which may result in an avoidable decrease in treatment efficacy or even cause harm. One of the most easily overlooked factors that can directly impact the quality of a drug…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 1 of 3 residents reviewed with an indwelling catheter, Resident ID #1. Findings are as follows: 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 . Review of a facility policy titled, Catheter: Indwelling Urinary-Care Of , states in part, .13. Secure tubing to keep the drainage bag below the level of the patient's bladder and off the floor. Record review for Resident ID #1 revealed that s/he was readmitted to the facility in January of 2024 with diagnoses including, but not limited to, urinary tract infection, Extended Spectrum Beta-Lactamase [ESBL a type of infection in the urinary tract], congestive heart failure, and anxiety. Review of a Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview it has been determined that the facility failed to obtain specialized rehabilitation services for 1 of 1 resident reviewed relative to rehabilitative services, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 11/08/2023 alleges in part, .On October 18, 2023, I contacted [Social Worker] and left a voicemail in regard to the August 14, 2023 referral for OT [Occupational therapy] and PT [Physical Therapy] from the office of the [physiatrist, a medical doctor who treats pain and mobility]. As of today's date, she has not returned my call and [the resident] has not been scheduled for OT or PT . Record review of Resident ID #1 revealed s/he was admitted to the facility in March of 2022 with diagnoses including, but not limited to, history of traumatic brain injury, cerebral infarction (stroke), hemiplegia (weakness on one side of the body), hemiparesis (paralysis on one side of the body) following cerebral infarction and stage IV pressure ulcer to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 2 residents reviewed for pressure ulcers (a localized injury to the skin or underlying tissue due to pressure), Resident ID #1. Findings are as follows: 1. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 11/8/2023 alleges in part, .On multiple occasions Resident ID #1 has had oozing bed sores and blisters on [his/her] body due to lack of repositioning of his/her body [Resident ID #1] currently has a 4x3 pressure ulcer on [his/her] left heel . Record review of Resident ID #1 revealed s/he was admitted to the facility in March of 2022 with diagnoses including, but not limited to, history of traumatic brain injury, cerebral infarction (stroke), hemiplegia (weakness on one side of the body), hemiparesis (paralysis on one side of the body) following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it has been determined that the facility failed to ensure the medical care of each resident is supervised by a physician for 2 of 5 residents reviewed for a change in condition and abnormal lab values, Resident ID #'s 1 and 4. Findings are as follows: 1. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 11/08/2023 alleges in part, .On multiple occasions Resident ID #1 has had oozing bed sores and blisters on [his/her] body due to lack of repositioning of his/her body [Resident ID #1] currently has a 4x3 pressure ulcer on his/her left heel . Record review of Resident ID #1 revealed s/he was admitted to the facility in March of 2022 with diagnoses including, but not limited to, history of traumatic brain injury, cerebral infarction (stroke) hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body) following cerebral infarction, and a stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) to the sacrum (area located at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident, and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to following physician's orders for 3 of 4 residents reviewed for medication administration, Resident ID #'s 3, 4, and 5. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. 1. Review of a community reported complaint received by the Rhode Island Department of Health on 11/2/2023 alleges that Resident ID #3 used delivery services to order his/her own MiraLAX (medication used to treat constipation) because s/he had not had a bowel movement in 10 days. - Record review revealed Resident ID #3 was admitted to the facility in April of 2023 with diagnoses including, but are not limited to, chronic respiratory failure, dysphagia and constipation. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on surveyor interview and record review, 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 the use of a low air loss mattress, Resident ID #4. Findings are as follows: Record review revealed the resident was readmitted to the facility in August of 2019 with diagnoses including, but are not limited to, persistent vegetative state, chronic respiratory failure, brain damage, and constipation. Review of a physician's order dated 7/1/2022 revealed Low air loss mattress to bed every shift Settings 4 Bars Check settings and functions every shift. Review of the care plan initiated on 6/24/2022 and revised on 11/2/2022 indicates [Resident] is at risk for skin breakdown as evidenced by history of pressure ulcer, has actual skin breakdown .and chronic excoriation .[Resident] has contractures, decreased activity, frail fragile skin . with intervention which include but are not limited to low air loss mattress as ordered . During a surveyor observation on 11/6/2023 at 2:44 PM and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to following a physician's order for humidified air tubing for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states: The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review of a physician's order dated 6/2/2023 reveals to change the humidified air tubing, date and initial every day shift every Friday. During a surveyor observation of the resident's room on 8/4/2023 at approximately 12:00 PM, revealed blue humidified air tubing, dated 6/30. During a surveyor interview with the Assistant Director of Nursing on 8/4/2023 at approximately 2:50 PM, she acknowledged that the tubing was dated 6/30. Record review of the July Medication Administration Record (MAR), revealed that the above…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.