AdviniaCare Orchard, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and staff interview, it has been determined that the facility failed to have handrails securely affixed to the walls on 3 of 4 units in the facility. Findings are as follows: Surveyor observations on 6/23/2025 revealed the following handrails were not securely affixed to the wall: 1. [NAME] Unit - The handrail between rooms A7 and A9 was falling off the wall, with the screws exposed. - The handrail on right side of the door of room A9 was loose. Resident ID #12 was observed utilizing the handrails in the hallway while self-propelling in a wheelchair to get to his/her room. During a surveyor interview on 6/23/2025 at 2:58 PM with Nursing Assistant, Staff C, she acknowledged that the above-mentioned handrails were loose and not securely affixed to the wall. During a surveyor interview on 6/23/2025 at 3:01 PM with Licensed Practical Nurse (LPN), Staff D, she revealed that she was aware of the broken handrail between rooms A7 and A9, and has notified the maintenance department about it.…

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 ensure that adequate pain management was provided to a resident who required such services, for 1 of 1 resident reviewed for pain, Resident ID #330. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 6/25/2025 indicates the resident reported to the state surveyor s/he was abused by the Nurse Practitioner (NP), Staff H, related to changes in his/her medications. Record review of an untitled facility policy relative to medication reconciliation, last revised in August of 2022, states in part, .This facility reconciles medication frequently throughout a resident's stay to ensure the resident is free of significant medication errors .medication reconciliation refers to the process of verifying the resident's current medication list matches the physician's orders for the purposes of providing the correct medications to…

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 be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident relative to 1 of 1 resident reviewed with an order for methadone (a medication prescribed to reduce cravings and withdrawals from opiates and to treat chronic and severe pain), Resident ID #330. Findings are as follows: Record review of an untitled facility policy relative to medication reconciliation, last revised in August of 2022 states in part, .This facility reconciles medication .to ensure that the resident is free of any significant medication errors .'Medication reconciliation' refers to the process of verifying that the resident's current medication list matches the physician's orders for the purposes of providing the correct medications to the resident .Medication reconciliation involves . multiple disciplines,…

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 following a physician's order to obtain daily weights for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients . Record review revealed a physician's order with a start date of 3/27/2025 for the resident to be weighed daily. Record review failed to reveal evidence of documented weights from 3/28/2025 through 4/1/2025. Additional, record review failed to reveal evidence that the physician was notified of the missed weights. During a surveyor interview on 4/2/2025 at approximately 11:30 AM, with the DNS she was unable to provide evidence that daily weights were obtained for Resident ID #1 from 3/28/2025 through 4/1/2025.

Based on record review, surveyor observation, and staff interview, it has been determined that the facility failed to ensure a resident received a therapeutic diet as ordered by the physician for 1 of 2 residents reviewed who had orders for a therapeutic diet, Resident ID #1. Findings are as follows: Resident ID #1 was admitted to the facility in March of 2025 with diagnoses including, but not limited to, acute and chronic respiratory failure and diastolic heart failure (when the left ventricle of the heart becomes stiff and does not beat properly). Record review of a physician order with a start date of 3/26/2025 revealed a Low Sodium Diet (2-4 grams of Sodium) diet. During a surveyor observation of the resident on 4/2/2025 at approximately 12:30 PM, revealed that the lunch meal that was served to the resident contained a double portion of ham. Record review of the tray ticket that was on the resident's tray revealed the following in part: - Regular Texture, Low Sodium - Notes: Double Portions - No Ham During a surveyor interview on 4/2/2025 at approximately 2:00 PM with 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, resident and staff interview, it has been determined that the facility failed to maintain medical records in accordance with professional standards and practices for 1 of 1 resident reviewed for a fluid restriction and for a complete and accurate medical record, Resident ID #1. Findings are as follows: 1a. Record review of a facility policy titled, Nursing Policy & Procedure Manual, April 2015 reads in part maintain accurate intake and output and no water pitchers are to be left at the bedside. Record review for Resident ID #1 revealed that s/he was admitted to the facility in March of 2025 with diagnoses including, but not limited to, diastolic congestive heart failure (when the left ventricle of the heart becomes stiff and does not beat properly) and acute and chronic respiratory failure. Record review revealed a physician order dated 3/26/2025 for a fluid restriction of 2000 milliliters (ml) daily, to be as administered on the following nursing shifts: - 11:00 PM -7:00 AM 290 ml - 7:00 AM -3:00 PM 440 ml - 3:00 PM -11:00 440 ml -…

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, resident and staff interview, it has been determined that the facility failed to maintain a safe, functional, and comfortable environment for residents, staff, and the public, relative to a cracked glass panel on the inner door of the facility's entrance. Findings are as follows: Surveyor observation on 4/2/2025 at approximately 12:30 PM, revealed that upon entering the facility, the lower glass panel of the main vestibule's inner door had approximately eight one foot by one-foot cracked glass segments. Further observation revealed that the cracked glass segments were covered with white medical tape. During a surveyor interview on 4/2/2025 at 2:00 PM with the Director of Nursing Services, she acknowledged the damage to the door. Additionally, she indicated that the damage occurred approximately three to four weeks ago. Furthermore, she was unable to provide evidence of a plan to repair the door.

Based on surveyor observation, record review, and staff 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 directly from each resident's bedside for 4 of 4 units reviewed, affecting Resident ID #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 3/24/2025 alleged that 23 residents do not have functioning call lights, and instead utilize a hand bell as an alternative. Additionally, the report alleged that this issue has been ongoing for months posing concerns for the safety of the residents. During a surveyor interview on 3/26/2025 at 9:40 AM and 10:40 AM with the Director of Nursing Services, she revealed that approximately 30 residents do not have functioning call lights and instead, they are provided with hand bells to communicate their…

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 residents receive treatment and care in accordance with professional standards of practice, relative to following physician's orders for 1 of 1 resident reviewed relative to X-ray orders, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 11/27/2024, alleges that the resident fell, experienced increased pain, and impaired mobility. New orders were given by the provider for x-rays. The resident was subsequently sent out to the hospital and was diagnosed with two new fractures to his/her back. According to Mosby's 4th Edition, Fundamentals of Nursing page 314, which states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients. Record review revealed that the resident was admitted to…

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 physician's orders for 1 of 1 resident reviewed who was a new admission, Resident ID #1. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing page 314, which 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 October of 2024 with diagnoses including, but not limited to, urinary tract infection (UTI) and dementia. Review of the hospital Continuity of Care- Post-Acute Facility document dated 10/9/2024, revealed an order for cephalexin (Keflex-an antibiotic) 500 milligrams (mg) twice a day for 2 days with instructions to contact the provider to ask if this medication should be continued. Review of a nursing admission note dated 10/9/2024…

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 1 resident reviewed, who has an actual pressure injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence), Resident ID #1. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 6/27/2024 alleges that Resident ID #1 was found to have concerns with the status of his/her left lateral lower leg wound while being evaluated in the Emergency Department of an acute care hospital. Record review revealed the resident was re-admitted to the facility in June of 2024 with diagnoses including, but not limited to, sepsis, pressure injuries to the left lateral lower leg, left buttocks, right great toe, osteomyelitis (bone infection) and muscle wasting. Record review of the facility's contracted Wound…

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 prepare, store, and distribute food according to professional standards of food service safety, relative to the main kitchen and 3 of 4 nourishment areas observed. Findings are as follows: 1a. Review of the Rhode Island Food Code, 2018 Edition, section 4-601.11 states in part, (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch . During the initial tour of the main kitchen with the [NAME] Supervisor on 6/24/2024 at 8:45 AM, the following was observed: - One of three chef's knives with dried brown food matter on the blade - The blade of the countertop can opener was covered in a black, sticky residue During a surveyor interview with the [NAME] Supervisor immediately following the above observation, she acknowledged that the above items were dirty and needed to be cleaned. 1b. Review of the Rhode Island Food Code, 2018 Edition, section 3-501.17 states in part, .(B)…

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 due to the facility's failure to utilize appropriate Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes), for 4 of 8 residents reviewed, Resident ID #s 84, 28, 42, and 163. Additionally, the facility failed to conduct appropriate infection control practices relative to the handling of soiled linen. Findings are as follows: Record review of the facility policy titled Enhanced Barrier Precautions Policy states in part, .implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms .MDROs are organisms that are resistant to all or most antibiotics .MRDOs may include, but are not limited to: Methicillin-resistant Staphylococcus aureus (MRSA) .ESBL [Extended Spectrum Beta Lactimase]…

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 a resident free from physical abuse for 1 of 3 residents reviewed, Resident ID #45. Findings are as follows: According to State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last revised 2/2023, .Abuse is the willful infliction of injury .with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Resident to Resident Abuse of Any Type A resident to resident altercation should be reviewed as a potential situation of abuse .Also, when investigating an allegation of abuse between residents, the surveyor should not automatically assume that abuse did not occur, especially in cases where either or both residents have a cognitive impairment or mental disorder. Having a mental…

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 being provided meet professional standards of practice relative to following physicians orders for 2 of 4 residents reviewed relative to obtaining weekly weights, Resident ID #s 53 and 96. 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 #53 was re-admitted to the facility in May of 2024 with diagnoses including, but not limited to, dysphagia and severe protein calorie malnutrition. Record review revealed a physician's order dated 5/2/2024 with a start date of 5/6/2024 for weekly weights. Record review of the documented weights revealed the following: 5/7/2024 123.4 lbs. (pounds) 5/14/2024 not obtained 5/21/2024 not obtained 5/27/2024 123.3 lbs. 6/3/2024 not obtained Record review of the nursing…

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 provide treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed with a history of a deep vein thrombosis (DVT), Resident ID # 36. Findings are as follows: According to Nursing Health Assessment: A clinical Judgement Approach 4th edition, 2023 published by Wolters Kluwer, it has been revealed that characteristics of a Deep Vein Thrombosis, (DVT) also known as a blood clot, include, but are not limited to, pain and swelling at the site. Review of the facility policy titled, Condition: Significant Change states in part, .Staff will communicate with the physician .regarding changes in condition to provide timely communication of resident/patient status change which is essential to quality care management . Record review revealed Resident ID #36 was readmitted to the facility in May of 2024 with a diagnosis including, but not limited to, acute embolism and thrombosis of deep…

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 3 residents reviewed for pressure ulcers (a localized injury to the skin or underlying tissue due to pressure), Resident ID #42. Findings are as follows: Record review revealed Resident ID #42 was admitted to the facility in January of 2023 with diagnoses including, but not limited to, Alzheimer's disease, and pressure ulcers to the coccyx (tail bone), and left heel. Record review revealed a physician's treatment order dated 6/14/2024 which states in part, .Skin prep periwound [area around the wound]. Apply medihoney f/b [follwed-by] calcium alginate [an absorbent dressing] and cover with foam dressing .Location: left heel every evening shift . Record review revealed a physician's treatment order dated 6/19/2024 which states .Pat dry. Apply medihoney and bordered foam dressing .Location: coccyx [every]…

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 blood purifying treatment given when kidney function is not optimum) receive such services consistent with professional standards of practice for 1 of 1 resident reviewed for dialysis, Resident ID #36. Findings are as follows: Review of the facility policy titled Hemodialysis states in part, .To provide comprehensive care to residents/patients .Communication between the facility and the hemodialysis center will occur using a communication book/sheet that consists of .Any change of condition from last hemodialysis treatment . Record review revealed Resident ID #36 was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, acute kidney failure and chronic kidney disease, stage 4 (severe). Record review of a care plan last revised on 6/3/2024 revealed, the resident has a diagnosis of chronic kidney disease and started on dialysis. Further review revealed an intervention including, but not limited to, monitor lab…

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 complete an annual performance review for every nurse aide (nursing assistant; NA), at least once every 12 months, for 4 of 7 NA personnel records reviewed, Staff F, G, H, I. Findings are as follows: Record review of the personnel files failed to reveal evidence that an annual performance evaluation was completed for the following NAs: -Staff F, Date of hire 11/18/2022 -Staff G, Date of hire 1/21/2020 -Staff H, Date of hire 1/30/2013 -Staff I, Date of hire 9/22/2020 During a surveyor interview with the Director of Nursing Services on 6/26/2024 at 10:45 AM, she was unable to provide evidence of a completed performance evaluation within the last 12 months for the above-mentioned employees.

Based on record review and staff interview, it has been determined that the facility failed to address pharmacy recommendations in a timely manner for 2 of 5 residents reviewed for unnecessary medications. Resident ID #s 22 and 97. Findings are as follows: Record review of the facility policy titled, Drug Regimen Review-Monthly states in part, .The attending Physician or licensed designee shall respond to the Drug Regimen Review within 7-14 days or more promptly, whenever possible . 1a. Review of the 4/9/2024 pharmacy recommendations for Resident ID #22 revealed a recommendation to reduce the resident's Pravastatin (a medication used to treat high cholesterol) from 20 milligrams (mg) to 10 mg. Additionally, it revealed that the recommendation was not signed by the provider until 6/20/2024. In addition, the recommendation had not been implemented until it was brought to the facility's attention by the surveyor, indicating that it had been over 2 months since the recommendation was made. 1 b. Review of the 6/10/2024 pharmacy recommendations for Resident ID #22 revealed 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 the facility failed to develop and implement a baseline care plan for each resident within 48 hours of a resident's admission, that includes the instructions needed to provide effective and person-centered care for 3 of 3 residents reviewed. Resident ID #s 1, 2, and 3. Findings are as follows: According to the State Operations Manual, Appendix PP- Guidance to Surveyors for Long Term Care Facilities, revised on 2/3/2023, §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR…

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 observations, record review, staff and resident interview, it has been determined the facility failed to treat each resident with respect and dignity, and is cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life relative to assistance with eating during meals for 1 of 1 hospice resident reviewed, Resident ID #5. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/27/2023 alleges in part, .patients .called nursing staff for [his/her] roommate who had woken up hungry. Apparently, the roommate was sleeping when dinner was served, and staff didn't save [his/her] dinner or wake [him/her] to eat . Record review revealed the resident was admitted to the facility in August of 2023 with diagnoses including, but not limited to, cerebral infarction (stroke) and mild cognitive impairment. Review of a Minimum Data Set (MDS) assessment dated [DATE] 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 1 hospice resident reviewed for the breakfast meal, Resident ID #5. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/27/2023 alleges in part, .patients .called nursing staff for [his/her] roommate who had woken up hungry. Apparently, the roommate was sleeping when dinner was served, and staff didn't save [his/her] dinner or wake [him/her] to eat . Record review revealed the resident was admitted to the facility in August of 2023 with diagnoses including, but not limited to, cerebral infarction (stroke) and mild cognitive impairment. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident requires extensive assistance of one staff member for eating. Surveyor observations on…

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 a resident's environment remains as free of accident hazards as possible for 1 of 3 residents reviewed for falls, Resident ID #1. Findings are as follows: Record review reveals the resident was admitted to the facility in September of 2021 with diagnoses to include, but not limited to, acute and chronic respiratory failure with hypoxia (a low level of oxygen in the blood) and hypercapnia (a higher than normal level of carbon dioxide in the blood), chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, and morbid obesity. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15 indicating that the resident is cognitively intact. It further revealed that the resident requires 2+ person assist for bed mobility, including turning side to side, and positioning while in bed. Record review of the resident's care…

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 and resident interviews, it has been determined that the facility failed to ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene for 1 of 3 residents reviewed for showers, Resident ID #2. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 11/5/2023 alleged, that the resident .wasn't being washed well and certain areas were even rarely being washed . Review of the facility's policy titled SHOWERS states in part, Resident .will receive a shower .as desired . Record review revealed the resident was re-admitted to the facility in August of 2023 with diagnoses including, but not limited to, morbid obesity and osteoarthritis (a degenerative joint disease). Record review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 15 out of 15, indicating 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.

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 ensure that each resident receives adequate supervision to prevent accidents relative to smoking for 4 of 4 residents reviewed, Resident ID #s 26, 78, 103, 112; 1 of 1 resident reviewed relative to the water temperature for bathing, Resident ID #55; 1 of 1 resident reviewed relative to wandering, Resident ID #5; and 1 of 1 resident reviewed for supervision while eating, Resident ID #8. Findings are as follows: 1. Review of the facility policy titled, Smoking states in part, .Smoking will take place under the supervision of a staff member .All cigarettes, igniting and smoking materials will be kept in a secure location designated at the facility, residents are not permitted to retain such items .Smoking will take place under the supervision of a staff member. The staff member will have the responsibility of lighting all cigarettes. a) Record review for Resident ID #103 revealed s/he was…

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 residents who are trauma survivors receive trauma informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences for 5 of 5 residents reviewed, Resident ID #s 5, 11, 50, 76 and 86. Findings are as follows: Record review of a facility policy titled, Trauma Informed Care states in part, .It is the policy of this facility to ensure resident's who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice .4. Documentation regarding the resident's psychosocial well-being including their response to stressful life events/trauma and coping mechanisms will be reflected in the initial Social Service Assessment and/or social service progress notes .5.a trauma informed care plan will be documented in the resident's medical record by social service . 1a) Record review revealed Resident ID #5 was admitted to the facility in March of 2018…

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 ensure that food is stored, served and distributed, in accordance with professional standards for food service safety relative to the main kitchen and nursing unit kitchenettes. Findings are as follows: 1a. Record review of the manufacturer's instructions for the use of Ready Care Strawberry and Vanilla shakes reads in part .once thawed, refrigerate up to fourteen days . During a surveyor observation on 6/29/2023 at approximately 12:50 PM the refrigerator located on the [NAME] Drive nursing unit revealed eight strawberry shakes without a use by date. During a surveyor observation on 6/29/2023 at approximately 12:55 PM the refrigerator located on the [NAME] Avenue nursing unit revealed four strawberry and eight vanilla shakes without a use by date. An additional surveyor observation on 6/29/2023 at approximately 1:00 PM on the [NAME] Drive nursing unit, a medication cart had a opened eight-ounce…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections relative to the handling of a multi-use glucometer for 2 of 2 residents observed, Resident ID #s 333 and 8; and 1 of 1 residents reviewed, Resident ID #7, with a positive wound culture for Methicillin-Resistant Staphylococcus Aureus (MRSA) who was not on proper precautions, and relative to improper technique for a clean dressing change. Findings are as follows: 1. Record review of the Center for Disease Control frequently asked questions for providers safety blood glucose monitoring guidance for providers states, .FDA [Federal Drug Administration] has recently released guidance for manufacturers regarding appropriate products and procedures for cleaning and disinfection of blood glucose meters .The disinfection solvent you choose should be…

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, staff, and resident representative interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 4 residents reviewed with an indwelling catheter, Resident ID #57. Findings are as follows: Review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument Manual v1.17.1 dated October of 2019, states in part, Indwelling catheters should not be used unless there is valid medical justification. Assessment should include consideration of the risk and benefits of an indwelling catheter, the anticipated duration of use, and consideration of complications resulting from the use of an indwelling catheter. Complications can include an increased risk of urinary tract infection [UTI] .Incontinence also may lead to the potentially troubling use of indwelling catheters, which can increase the risk of life threatening infections .Because of the risk of substantial complications with the use of indwelling urinary…

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 ensure that self-administration of medications was clinically appropriate for 1 of 3 residents observed with medications at bedside, Resident ID #74. Findings are as follows: Record review of a facility's policy and procedure titled, Self-Administration of Medication states in part, .If the resident elects to self-administer his/her own medications, an evaluation of their cognitive, physical and visual ability to perform this task is conducted to ensure accurate and safe medication management .Upon admission, readmission, annually, quarterly and change of condition, provide the resident/responsible party with a two-part document entitled SELF-ADMINISTRATION OF MEDICATIONS INFORMED CONSENT AND EVALUATION .Mark the MAR (Medication Administration Record) for each medication being self-administered for daily compliance monitoring purposes. (Indicate that the resident has self-administered) .If there is a change in the resident's status, re-evaluate his/her…

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 assessed for physical restraints/alarms, Resident ID #5, 1 of 1 resident assessed for weight gain; Resident ID #36, and 1 of 1 resident reviewed for special treatment/procedures, Resident ID #79. Findings are as follows: 1. Record review revealed Resident ID #5 revealed s/he was admitted to the facility in September of 2019 with diagnoses that includes, but are not limited, to schizoaffective disorder (mental health disorder) and borderline personality disorder. During a surveyor observation on 6/27/2023 at approximately 11:30 AM, a wander guard bracelet was observed on his/her wheelchair. Record review of a Treatment Administration Record dated 6/1/2023, through 6/27/2023, revealed the function of the wander guard was checked daily. Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], Section P,…

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, staff and resident interview, it has been determined that the facility failed to ensure that a resident receives proper treatment to maintain vision abilities for 1 of 1 resident reviewed, Resident ID #5. Findings are as follows: Record review revealed the resident was readmitted to the facility in September of 2019 with diagnosis including, but not limited to, type 2 diabetes mellitus. During a surveyor interview with the resident on 6/26/2023 at 1:21 PM, s/he revealed that his/her eyeglasses were broken. Record review of the resident's Minimum Data Set assessment dated [DATE] revealed that s/he was coded as, yes for needing corrective lenses (contacts, glasses, or magnifying glass). Record review of the progress note written by the Social Worker, Staff I, on 5/16/2023 revealed that the resident's problem with glasses has been brought to her attention that day. Further review revealed that it was to be followed up with the facility's nurse secretary in the morning. Record review of 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 meet professional standards of practice for care related to a peripherally inserted central catheter (PICC) for 1 of 1 residents reviewed for PICCs, Resident ID #330. Findings are as follows: According to an article in the Journal of Infusion Nursing dated 2021, states in part, .1. During the initial flush, slowly aspirate the VAD [Vascular Access Device] for free-flowing blood return that is the color and consistency of whole blood, an important component of assessing catheter function prior to administration of medications and solutions . Record review of a facility provided document titled, Infusion Therapy Nursing Manual states in part, .10 .Attach flushing agent and flush and confirm VAD patency by ease of flushing and verifying a brisk blood return is observed upon aspiration . Record review revealed that the resident was admitted to the facility in June of 2023 with diagnoses including, but not limited to, osteomyelitis (bone infection) and local infection 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 surveyor observation, record review, 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 1 of 6 medication carts reviewed and 1 of 3 resident rooms reviewed relative to medication storage for self-administration, Resident ID #74. Findings are as follows: Record review of a facility policy titled, Medication Administration and Documentation-General, states in part, .12. Administers medication at the time it is prepared. (Never pre-pours medications.) . 1. During a surveyor observation on 6/28/2023 at 9:01 AM of Certified Medication Technician (CMT), Staff O during the medication administration task, revealed a clear medication cup within the top drawer of the medication cart labeled, 23B containing 2 pink, oblong tablets and 1 white, oblong tablet. Staff O revealed she found the cup with the 3 medication tablets in the medication cart that morning and was not the individual that pre-poured the medication. She further revealed that she was unsure what…

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.