Tockwotton on the Waterfront

Based on clinical record review and staff interview, the facility failed to ensure that hospice services meet professional standards of principles that apply to individuals providing services in the facility for 2 of 2 residents reviewed who are receiving hospice services, Resident ID #s 6 and 8.Findings are as follows:1. Record review revealed that Resident ID #6 was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, dementia.Record review revealed the resident began receiving hospice services on 3/23/2026.a. Record review failed to reveal evidence that a Significant Change Minimum Data Set (MDS) Assessment was completed within 14 days from the date s/he began receiving hospice services, as per the regulation.During a surveyor interview on 4/15/2026 at 10:39 AM with the MDS Coordinator, Staff C, she revealed that Significant Change Assessments are completed when a resident begins receiving hospice services, and the assessment should be completed within 14 days. Additionally, she acknowledged that the Significant Change Assessment had not been…

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 clinical record review and staff interview, the facility failed to provide appropriate treatment and services related to monitoring output for 2 of 4 residents reviewed with an indwelling catheter (a flexible tube that collects urine from the bladder and leads to a drainage bag), Resident ID #s 9 and 10.Findings are as follows:According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing Volume 2, 10th Edition, page 1282 and 1284 states in part, .For patients with indwelling catheters, the nurse assesses the drainage system to ensure that it provides adequate urinary drainage. The color, odor, and volume of urine are also monitored. An accurate record of fluid intake and urine output provides essential information about the adequacy of renal function and urinary drainage .to reduce the risk of bacterial proliferation [rapid increase in numbers] empty the collection bag at least every 8 hours through the drainage spout - more frequently if there is a large volume of urine .Review of an undated facility policy titled, Emptying a Urinary Collection Bag states in part,…

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 follow a physician's order relative to a significant change in condition for 1 of 1 resident reviewed whom experienced bradycardia (a low heart rate), Resident ID #1. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 2/24/2025 revealed that Resident ID #1 received an overdose of Metoprolol (a medication prescribed for high blood pressure and to control heart rate) and was admitted to the hospital after receiving a dose of 62.5 milligrams (mg), instead of his/her prescribed dose of 37.5 mg on 2/23/2025. 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 physicians' 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 November of 2024 with diagnoses including, but not limited to, congestive heart failure (when…

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 prepare, store, and distribute food according to professional standards of food service safety, relative to the main kitchen. Findings are as follows: 1. Review of the Rhode Island Food Code, 2018 Edition, section 3-501.17 states in part, .(B) .refrigerated, ready-to-eat time/temperature control for safety food .shall be clearly marked, at the time the original container is opened in a food establishment .and: (1) the day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date . During the initial tour of the main kitchen on 2/10/2025 at approximately 8:30 AM of the reach in refrigerator unit 4 was observed with the following: -one 32 ounce jar of Sysco capers with an open date of 1/4/2025 and a use by date of 2/4/2025. -one jar of pepperoncini peppers with an open date of 12/25/2025 and a use by date of 1/25/2025. -six Styrofoam…

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 residents with pressure ulcers receive the necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 1 resident reviewed with a pressure ulcer (skin and tissue injuries caused by constant pressure to a specific area of the body), Resident ID #250. Findings are as follows: Record review revealed the resident was admitted to the facility in February of 2025 with diagnoses including, but not limited to, dementia and abnormalities of mobility. Review of a Safe Patient Handling assessment dated [DATE] revealed the resident was dependent on staff for bed mobility. Review of a document titled Skin Integrity Events dated 2/5/2025 revealed an unstageable pressure ulcer (characterized by full-thickness tissue loss where the depth cannot be assessed due to the presence of dead tissue) was observed to the resident's right heel measuring 1.5…

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 are free from any significant medication errors for 1 of 2 residents reviewed with a sliding scale insulin (Insulin dosage based on blood glucose reading), Resident ID #6, and 1 of 4 residents observed during the medication administration task, Resident ID #13. Findings are as follows: Review of a policy titled Administering Medications states in part, .Medications are administered in accordance with prescriber orders, including any required time frame .within one (1) hour of their prescribed time, unless otherwise specified . 1. Record review revealed Resident ID #6 was admitted to the facility in August of 2017 with a diagnosis including, but not limited to, diabetes mellitus. Record review of the physician's orders revealed the following: -11/4/2024- Novolog (insulin) 100 unit/milliliter(ml) administer 6 units three times a day, hold for blood glucose reading less than 65. -11/5/2024-Novolog (insulin) 100 unit/ml to be given three times daily before eating if: -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 and prepare food in a form designed to meet individual needs for 1 of 2 residents reviewed with a physician's order for thickened consistency fluids, Resident ID #301. Findings are as follows: Record review revealed the resident was admitted to the facility in February of 2025 with diagnoses including, but not limited to, dysphagia (difficulty in swallowing), pneumonia (infection of the lungs), and dementia. Record review revealed the following physician's orders: - 2/4/2025: Aspiration precaution (guidelines to prevent food or liquid from entering the airway while eating or drinking) - 2/6/2025: 120 milliliters (ml) of nectar (mildly thick) house supplement (nutritional supplement) once in the morning - 2/10/2025: Diet order for honey thick (moderately thick) liquids Record review of the Medication Administration Record (MAR) for February 2025 revealed the order for the house supplement nectar thick consistency was signed off by the staff on 2/11/2025 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 ensure that medical records are accurately documented for 1 of 2 residents reviewed for sliding scale insulin (Insulin dosage based on blood glucose reading), Resident ID #6, and for 1 of 4 residents observed during the medication administration task, Resident ID #13. Findings are as follows: 1. Record review revealed Resident ID #6 was admitted to the facility in August of 2017 with a diagnosis including, but not limited to, diabetes mellitus. Record review revealed the following physician's orders dated 11/5/2024: -Novolog (insulin) 100 units/milliliters (u/ml) to be given three times daily before eating if: -the blood glucose reading is between 0-180- give no insulin -the blood glucose reading is between 181- 250- give two units of insulin -the blood glucose reading is between 251-300- give four units of insulin -the blood glucose reading is between 301-400- give eight units of insulin -the blood glucose reading is above 400- add ten units of insulin Record review of the February 2025…

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 infection, relative to droplet/contact precautions (utilized 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 speaks) for 1 of 2 residents reviewed on droplet/contact precautions for influenza (a highly contagious respiratory illness caused by the influenza viruses which spreads through respiratory droplets), Resident ID #19. Findings are as follows: Review of the facility's policy titled, Isolation-Categories of Transmission-Based Precautions states in part, Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection .and is at risk of transmitting the infection to other residents .Contact Precautions: are implemented for residents known or suspected to be infected…

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 1 of 1 resident reviewed relative to a respiratory diagnosis, Resident ID #19. 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 admitted to the facility in January of 2024 with a diagnosis including, but not limited, to Respiratory Syncytial Virus (RSV, a virus that affects the respiratory tract). Record review revealed a physician's order dated 2/1/2024 for Mucinex tablet extended release, 600 milligrams, with instructions to administer 2 tablets, twice a day. Record review of the Medication Administration Record (MAR) for February 2024 revealed, the resident missed 11 out of 14 opportunities for the administration 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 maintain medical records on each resident that are accurately documented and complete for 1 of 1 resident reviewed for falls, Resident ID #18, and 1 of 1 resident reviewed for a Foley catheter, Resident ID #18. Findings are as follows: 1a) Record review revealed the resident was admitted to the facility in September of 2023 with diagnoses including, but not limited to, cerebral infarction (stroke) and neuromuscular dysfunction of the bladder. Record review of a progress note dated 1/4/2024 at 2:15 PM, revealed that the Nurse Practitioner (NP) entered a new order to remove the resident's Foley catheter and to proceed with a trial void (an assessment of the resident's ability to spontaneously urinate). During a surveyor interview on 2/29/2024 at 10:47 AM with the Unit Manager, Licensed Practical Nurse, Staff A, she revealed that the resident had a successful trial void on 1/4/2024 and s/he no longer has a Foley catheter. Record review revealed the following progress notes: - 1/23/2024 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.