Harris Health Center LLC

Based on clinical record review and staff interview, the facility failed to establish an Infection Prevention and Control Program (IPCP) that includes, 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 use, Resident ID #s 11 and 22. 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, Perform antibiotic 'time outs.' .Nursing homes should have a process in place for a review of antibiotics by the clinical team two to three days after antibiotics are initiated to answer these key questions:Does this resident have a bacterial infection that will respond to antibiotics?If so, is the resident on the most appropriate antibiotic(s), dose, and route of administration?Can the spectrum of the antibiotic be narrowed or the duration of therapy shortened…

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, staff, and resident interviews, it has been determined that the facility failed to ensure that a resident received adequate supervision to prevent an elopement for 1 of 3 residents reviewed Resident ID #1.Findings are as follows:Review of a facility reported incident submitted to the Rhode Island Department of Health on 9/14/2025 reveals that Resident ID #1 left the facility without following the leave of absence policy and procedure. Record review revealed the resident was admitted to the facility in March of 2023 with diagnoses including, not limited to, bipolar disorder and epilepsy (a neurological disorder characterized by recurrent, unprovoked seizures).Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status score of 14 out of 15 indicating the resident's cognition is intact. Additional review of the MDS revealed the resident ambulates independently.Record review revealed a progress note dated…

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 maintain acceptable parameters of nutritional status, such as usual body weight for 1 of 4 residents reviewed for significant weight loss and/or gain, Resident ID #9. Findings are as follows: Record review of the facility's policy titled, Weight Monitoring and Weight Loss/Gain Protocol states in part, .Procedure: Residents who are at risk for a nutritional decline are to be weighed weekly .How to weigh the resident .6. Weights that are + [plus] or minus 3 pounds from the last reading must be reported to the nurse who will then be required to supervise an immediate re-weigh to double check the accuracy of the reading. The nurse is to initial the supervised reading to verify accuracy .a significant weight loss/gain is defined as a difference of 3 pounds or more in one week (if resident on weekly weights); a loss/gain of 5% or greater within one month .WHEN A SIGNIFICANT WEIGHT LOSS IS NOTED, THE FOLLOWING INTERVENTIONS MUST OCCUR:1 Reweigh the residents who are reported…

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 conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 3 of 4 residents reviewed for side rails, Resident ID #s 11, 21, and 25. Findings are as follows: Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities Last revised 8/8/2024, states in part, .Regardless of mattress width, length, and/or depth, the bed frame, bed rail and mattress should leave no gap wide enough to entrap a resident's head or body .Facilities must also conduct routine preventive maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair . 1. Record review revealed that Resident ID #11 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, osteoarthritis, and joint disorders. During surveyor observations on the following dates and times the resident was observed…

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 and implement a comprehensive person-centered care plan for falls for 1 of 1 resident reviewed who had actual falls, Resident ID #16. Findings are as follows: Record review revealed the resident was readmitted to the facility in December of 2023 with a diagnosis including, but not limited to, schizoaffective disorder. Record review of a facility document titled, Fall Prevention Program last revised 12/2010, states in part, .Fall risk assessments are performed as a part of the admission assessment, as part of the quarterly review, and as an annual and/or significant change of condition process of care plan review .Whenever a resident has a history of falls and/or scores high on the fall risk assessment form, or actually has a fall their record is to be reviewed .and a careplan is to be developed which establishes preventative measures or interventions to be taken to lower or eliminate the risk .any and all immediate fall prevention interventions are to be added to the resident'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 for 2 of 2 residents reviewed with physician orders for quarterly fall assessments, Resident ID #s 7 and 9, and 2 of 5 residents reviewed with psychiatric recommendations, Resident ID #s 9 and 21. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing page 314, states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. 1a. Record review revealed Resident ID #9 was admitted to the facility in December of 2011 with diagnoses including, but not limited to, dementia with mood disturbance and major depressive disorder. Review of a physician's order dated 1/30/2024 revealed an order for fall assessments to be completed quarterly and documented in the resident's record. Record review failed to reveal evidence that fall assessments…

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 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 2 medication storage rooms, and 1 of 2 medication carts observed. Findings are as follows: Review of a facility policy titled, .Storage and expiration dating of medication and biological's last revised on [DATE] states in part, .Facility should ensure that medications and biological's that .have an expired date on the label .have been retained longer than recommended by manufacturer or supplier guidelines .are stored separate from other medications until destroyed or returned to the pharmacy or supplier .Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container .when the medication has a shortened expiration date once…

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 a safe environment relative to smoking, smoking areas, and smoking safety. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health, on 2/27/2024 alleges that smoking has been observed outside of the door of the nursing facility. There have been observations of cigarette butts littered all over the property and a smoldering ashtray. Review of a policy and procedure titled Smoking Policy states in part, .residents that wish to smoke must be in a designated area and may be limited to specific times . During a surveyor observation on arrival at the facility on 2/28/2024 at approximately 8:05 AM revealed the following: -Approximately 100 cigarette butts littered on the ground at the North and East entrances - An ashtray tower leaning against the North exterior wall of the facility with folding chairs - An ashtray observed in the mulch at the South bulkhead entrance; 5 feet from building During 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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed, in accordance with professional standards for food service safety, relative to the main kitchen. Findings are as follows: 1. The Rhode Island Food Code 2018 Edition 3-501.16 reads in part, Time/Temperature Control for Safety Food, Hot and Cold Holding .food shall be maintained .57 degrees C(135 degrees Fahrenheit) .at 5 degrees C (41 degrees Fahrenheit) . During a surveyor observation of the lunch meal in the main kitchen on 11/9/2023 at approximately 11:45 AM, the baked chicken had a hot holding temperature of 130 degrees Fahrenheit. 2. The Rhode Island Food Code 2018 Edition 4.601.11(A) reads in part, .(A) equipment food contact surfaces .shall be clean to sight and touch . During a surveyor observation on 11/7/2023 at approximately 9:15 AM the following observations were made of equipment not being clean to sight: - The spray holes of the juice dispensing gun had a red debris accumulation and the cup holder that 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 and staff interview, it has been determined that the facility failed to measure success and track performance of Quality Assurance and Performance Improvement (QAPI) actions to ensure that problem areas are identified, and good faith efforts for improvements are achieved and sustained demonstrated by measurable objectives with statistical data documented. Findings are as follows: Review of the facility QAPI/QAA 2023 schedule and committee attendance sheet identified that QAPI/QAA meetings were held on the following dates: - January 23, 2023 - April 17, 2023 - July 24, 2023 - October 23, 2023 During a surveyor interview on 11/10/2023 at approximately 12:30 PM with the Director of Nursing Services (DNS) in the presence of the Administrator, she revealed the following focus areas that are actively being followed by the QAPI committee: - Facility reported incidents - Falls - Wounds - Medication errors - Elopement - Safety - Psychotropic medications - Covid vaccinations - Influenza vaccinations - Psychiatric services - Social services Record review 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.

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 6 of 10 months reviewed. Findings are as follows: Review of the facility policy titled Antibiotic Stewardship Program states in part, .This facility recognizes the need to monitor antibiotics use in order to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The antibiotic stewardship program is directed towards the correct use of antibiotics- the five D's -right diagnosis, the right medication, the right dose, the right duration, and the right deceleration . Review of the antibiotic stewardship monthly records during the Infection Control Task on 11/9/2023 failed to reveal evidence of complete documentation of tracking information for 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 staff interview, it has been determined that the facility failed to ensure that the Infection Preventionist completed specialized training in infection prevention and control. Findings are as follows: During the Infection Control Task with the Director of Nursing Services (DNS) on 11/9/2023 at 11:48 AM, she revealed that the facility does not have a certified infection preventionist (IP) on staff and indicated she was the designated individual who assumed the responsibilities of the IP, however she is not certified. She further revealed that the facility hired an infection preventionist, but they have not completed their certification or required education. During a surveyor interview on 11/10/2023 at approximately 11:18 AM with the DNS, she was unable provide evidence of an Infection Preventionist in the facility that has completed specialized training in infection prevention and control prior to the completion of the survey.

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 review and revise the resident's care plan, for 1 of 3 residents reviewed for a wound, Resident ID #14 and 1 of 1 resident reviewed for intentional weight loss, Resident ID #20. Findings are as follows: Review of The State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities, last revised on 2/3/2023, states in part, .care planning drives the type of care and services that a resident receives .the intent is that each resident will have a person-centered comprehensive care plan developed and implemented to meet his/her other preferences and goals and address the resident's medical needs .facilities are required to develop care plans that describe the resident's medical, nursing, and physical needs . 1. Record review revealed Resident ID #14 was readmitted to the facility in September of 2023 with a diagnosis including, but not limited to, non-pressure chronic ulcer of the right foot. Record…

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 resident and staff interviews, it has been determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice for 1 of 3 residents observed for assessments and documentation relative to wound care, Resident ID #25. Findings are as follows: According to Wound Care Education Institute, 2020, wound care documentation should be carried out weekly including type of wound, measurements, type of tissue, symptoms of infection, presence of drainage, wound edges, pain, and current treatment. Review of a facility policy titled Clean Dressing Technique dated 1/2018, states in part, .15. Observe the wound for size, color, drainage, appearance, and amount of drainage. This is the best time to measure the area, before any medication is applied . Record review revealed Resident ID #25 was readmitted to the facility in August of 2023 with a diagnosis including, but not limited to, malignant neoplasm of overlapping sites of rectum, anus, and anal canal. Review of a physician's order dated…

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 address the nutritional needs of every resident, including but not limited to, a resident at risk or already experiencing impaired nutrition for 1 of 2 residents reviewed with a severe weight loss, Resident ID #1. Findings are as follows: Record review of a facility policy titled, Weight Loss/Gain Protocol states in part: .Policy .to assess for underlying causes of weight loss or gain and to intervene accordingly .rule out medical reasons for weight loss .review for depression .review for change in behavior .review medications .report all findings to physicians, if weight loss/gain desirable, document in care plan . Record review revealed the resident was admitted to the facility in November of 2013 with diagnoses which includes, but is not limited to, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease (lung disease that blocks air flow), and hemiplegia (paralysis of one side of the body). Review of the weight summary report revealed the following: - 5/8/2023 weight…

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 1 medication storage rooms observed and 2 of 2 medication carts observed. Findings are as follows: A. Record review of a facility policy titled, Storage and Expiration of Medications, Biological's, Syringes, and Needles last revised 1/1/2013, states in part, .Facility should ensure that medication and biological's: 4.1 Have an Expiration Date on the label; 4.2 Have not been retained longer than recommended by manufacturer or supplier guidelines .Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medication. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date when opened . During a surveyor observation of the nurse medication and treatment cart on 11/9/2023 at approximately 9:51 AM, in 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 record review and staff interview, it has been determined that the facility failed to ensure the resident's medical record includes documentation that the resident either received the pneumococcal vaccination or did not receive the vaccination due to medical contraindications or refusal, for 8 of 8 residents reviewed, Residents ID #s 1, 2, 12, 13, 14, 19 and 20. Findings are follows: According to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, Revised 2/3/2023 states in part, .The resident's medical record includes documentation that indicates, at a minimum, the following: .That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal . According to the Centers for Disease Control and Prevention (CDC), pneumococcal vaccination for all adults 19 through [AGE] years old who have certain chronic medical conditions or 65 years or older who have only received PPSV23 [23…

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 meet professional standards of quality relative to following a physician's order for laboratory testing for 1 of 3 residents reviewed, Resident ID #8. 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 revealed the resident was re-admitted to the facility in February of 2022 with diagnoses which include, but are not limited to, diabetes mellitus and peripheral vascular disease. Record review revealed a physician order dated 9/6/2023 entered by the Director of Nursing Services (DNS), to obtain the following labs: - Complete blood count (CBC, a blood test used to look at overall health and find a wide range of conditions). - Hemoglobin A1C (a blood test that measures the average blood sugar level over the past two to three months).…

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 receive and consume food in the appropriate form for 2 of 3 residents reviewed for modified diet textures, Resident ID #s 1 and 7. Findings are as follows: A. Record review revealed a physician's order for Resident ID #1 which revealed s/he was to receive a pureed diet. Record review revealed a physician's order for Resident ID #7 which revealed s/he was to receive a NAS (No Added Salt) diet with pureed texture. Record review of the facility menu for Thursday, 11/9/2023, stated that the pureed diet textures were to receive pureed ham, mashed potatoes, and pureed carrots. During a surveyor observation on 11/9/2023 at approximately 11:20 AM, Resident ID #s 1 and 7 were served whole kernel corn which was not pureed. During a surveyor interview on 11/9/2023 at approximately 11:25 AM with a Dietary Cook, Staff C, regarding the diet textures for Resident ID #s 1 and 7, she revealed they were incorrect and should not have been served the whole kernel…

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 adequate supervision to prevent an accident hazard for 1 of 3 residents reviewed for elopement, Resident ID #1. Findings are as follows: Record review of a facility reported incident sent to the Rhode Island Department of Health on 10/16/2023 alleges in part, .resident of [facility name] left facility and did not return. This writer, NHA [Administrator], and [police department] have been notified of the incident . Review of a facility policy titled, Elopement Procedure, last revised on 9/1/2023, states in part, .It is the policy of this facility to provide a safe and secure environment for all residents. In order to achieve this goal, residents are to be monitored at all times. Their presence within (or absence from) the facility is to be accounted for. The charge nurse is responsible to know the whereabouts of the residents on his/her unit . Review of the resident's record revealed s/he…

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 adequate supervision to prevent an accident hazard for 1 of 3 residents reviewed for elopement, Resident ID #1. Findings are as follows: Review of the facility policy titled, Leave of Absence Policy states in part, .Leaves of Absences will be approved by physician order .The Leave of Absence log is to be filled out in the presence of a staff member . Record review of a facility reported incident sent to the Rhode Island Department of Health on 8/1/2023 indicates that Resident ID #1 left the facility in his/her wheelchair, was approached by the local police 0.2 miles away from the facility, and was transported to the hospital for evaluation. Record review revealed that Resident ID #1 was admitted to the facility in April of 2023, with diagnoses including, but not limited to, major depressive disorder, paralytic syndrome following a cerebral infarction (stroke) affecting the left side, and transient alteration in awareness. Record review of the Minimum Data Set…

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.