Greenville Operations RI LLC DBA Greenville Skille

Based on clinical record review and staff interview, the facility failed to address pharmacy recommendations in a timely manner for 2 of 5 residents reviewed for the January pharmacy recommendations, Resident ID #s 11 and 52. Findings are as follows:Review of a facility policy titled, Medication Regimen Review and Reporting dated 1/2024 states in part, .The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly.The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations should be acted upon within 30 calendar days or per facility specific protocols.1. Record review revealed that Resident ID #11 was admitted to the facility in July of 2025 with diagnoses including, but not limited to, post-traumatic stress disorder and anxiety.Review of a Note to Attending Physician/Prescriber dated 1/27/2026, authored by the facility's contracted pharmacy, revealed a recommendation for Resident ID #30 to, .Please consider a trial dose reduction: trazadone 75 mg [milligram] HS [hour 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 clinical record review and staff interview, the facility failed to ensure that residents are free from any significant medication error, for 1 of 1 resident reviewed related to warfarin therapy (a medication prescribed to reduce the blood's ability to clot, preventing or treating blood clots), Resident ID #13.Findings are as follows:Review of a document titled, A Guide to Taking Warfarin created by the American Heart Association, states in part, .It's important to monitor the INR [International Normalized Ratio, a standardized way to measure the prothrombin time [PT] of a blood sample. The INR is used to monitor the effectiveness of Warfarin] at least once a month and sometimes as often as twice weekly to make sure the level of warfarin remains effective. If the INR is too low, blood clots will not be prevented, but if the INR is too high, there is an increased risk of bleeding .Record review revealed the resident was admitted to the facility in December of 2025 with diagnoses including, but not limited to, atrial fibrillation (an irregular heartbeat) and heart failure (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, clinical record review, and staff interview, the facility failed to store drugs and biologicals in accordance with currently accepted professional principles for 1 of 2 medication rooms and 1 of 3 medication carts observed. Findings are as follows:Review of a facility policy titled, Storage of Medication dated 1/2026 states in part, Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration.1. During a surveyor observation on 3/4/2026 at 8:07 AM, of the medication room on the Lilly Unit, in the presence of Registered Nurse (RN), Staff C and Licensed Practical Nurse, Staff K, revealed two bottles of Lorazepam 2 milligrams/milliliter (mg/ml) opened and undated. The manufacturer's instructions on the box state to discard the bottle 90 days after opening.During a surveyor interview immediately following the observation, Staff C and K acknowledged that the Lorazepam was opened and undated.2. During a surveyor observation on 3/4/2026…

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 and resident's family interview, the facility failed to provide dental services for 1 of 1 resident with dentures, Resident ID #1. Additionally, the facility failed to have a policy that addressed instances when a resident's dentures were lost or damaged.Findings are as follows:Record review of a community reported complaint submitted to Rhode Island Department of Health on 12/1/2025 by Resident ID #1's family member alleges, the resident's upper dentures were missing, and the facility did not know that s/he was supposed to have upper dentures. Record review of the policy titled, .Oral Health last reviewed on 9/15/2025, states in part, .A patient's oral health will be evaluated as part of the nursing assessment upon admission, annually, and with a change in oral health.1. Record review revealed the resident was admitted to the facility in February of 2025 with diagnoses including, but not limited to, dementia and mild protein calorie malnutrition.During a surveyor interview on 12/2/2025 at approximately 11:00 AM with the resident's family member,…

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, prepare, distribute, and serve food in accordance with professional standards for food service safety, relative to the main kitchen.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 11/5/2025 alleges in part that the kitchen is a mess: the walk-in refrigerator has mold on the walls, dirty racks where food is stored, and the food in the fridge has mold on it which goes unnoticed for weeks.Review of the 2022 Food and Drug Administration (FDA) Food Code, Section 3-202.15 Package Integrity states in part, Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants.Review of the 2022 FDA Food Code, Section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking states in part, .refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food…

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 treat each resident with respect and dignity in an environment that promotes maintenance of his or her quality of life for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of the facility policy titled, Resident Rights Under Federal Law, states in part, .To promote and protect the rights of the resident .the right to request, refuse, and/or discontinue treatment . Record review of a facility reported incident submitted to the Rhode Island Department of Health on 4/14/2025 indicated that Resident ID #1 reported that s/he was held down by a staff member after refusing medications. The report further alleges that the nurse administered the medications via the resident's gastrostomy (G-Tube- a tube that is surgically inserted through the abdomen and placed directly into the stomach) after s/he had refused the medications multiple times. Record review revealed that the resident 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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety relative to the main kitchen. Findings are as follows: 1. Record review of the Rhode Island Food Code 2018 Edition 4-601-11 states in part, .Nonfood contact surfaces shall be kept free of an accumulation of dirt, dust, food residue and other debris . Surveyor observations made during the initial tour of the main kitchen on 12/2/2024 at approximately 8:40 AM revealed the following: - the walls in the main kitchen and dish room had an accumulation of black matter - a fan located in the dish room had a significant built up of dust and debris, approximately one inch thick - a floor drain in front of the steamer had a buildup of approximately 1.5 inches of thick, grayish black colored grime. 2. Record review of the State Operations Manual Appendix PP-Guidance to Surveyors for Long term care Facilities 483.60(i)(1)-(2) states in part, .chemical products 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.

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 who require dialysis (a procedure to remove waste products and excess fluids from the blood when the kidneys stop working properly) receive such services, consistent with professional standards of practice for 2 of 2 residents reviewed, Resident ID #s 11 and 32. Findings are as follows: 1. Record review revealed Resident ID #32 was admitted to the facility in September of 2024 with diagnoses including, but not limited to, end stage renal disease and dependence on renal dialysis. Further record review revealed the resident receives outpatient dialysis three times a week on Tuesday, Thursday, and Saturday. Record review revealed the resident has an Arteriovenous Fistula (AVF; a connection between an artery and a vein for dialysis access) to his/her right upper extremity for dialysis treatments. a) Review of the care plan revealed interventions to monitor his/her AVF for bruit…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for a medication with parameters, Resident ID #23. Findings are as follows: Record review revealed that the resident was readmitted to the facility in July of 2023 with diagnoses including, but not limited to, dementia and hypotension (low blood pressure; blood pressure lower than 90/60). Review of a physician's order dated 9/16/2024 revealed Midodrine 5 milligrams (mg), give one tablet three times daily for hypotension with parameters to hold the medication if the systolic blood pressure (SBP; top number/pressure when the heart beats) is greater than 120. Review of the November and December 2024 Medication Administration Records (MAR) revealed that the resident was administered the Midodrine when the resident's SBP indicated it should be held based on the parameters on the following dates and times: 11/2/2024 - Evening (Blood Pressure (BP) 132/80) 11/3/2024 - Evening (BP 124/80) 11/4/2024 -…

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 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 an antibiotic stewardship program for antibiotic use protocols and a system to monitor antibiotic usage for 2 of 3 residents, Resident ID #s 23 and 27. Findings are as follows: 1. Review of a facility policy titled, Antimicrobial Stewardship Program Long Term Care last reviewed 7/1/2024 refers to the Centers for Disease Control and Prevention (CDC) document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes regarding the facility's antibiotic stewardship procedure. This revealed that all antibiotics prescribed in the facility must be reviewed for the ongoing need for and choice of an antibiotic when the clinical picture is clearer, and more information is available (antibiotic time-out). a) Record review revealed that Resident ID #23 was readmitted to the facility in July of 2023 with diagnoses including, but not limited to, sepsis (blood infection) and urinary tract infection. Record review…

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

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 accommodate residents' food preferences for 2 of 5 residents, Resident ID #s 28 and 30. Findings are as follows: Record review of the facility policy titled, Dining and Food Preferences revised on 10/2022, revealed that individual dining, food, and beverage preferences are identified for all residents. The individual tray assembly ticket will identify all food items appropriate for the residents based on diet order and preferences. 1. Record review revealed that Resident ID #28 was admitted to the facility in September of 2021 with a diagnosis including, but is not limited to, anxiety disorder. Record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. During a surveyor interview at the resident council meeting on 12/3/2024 at approximately 1:00 PM with Resident ID…

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's Quality Assessment and Assurance Improvement (QAPI) committee failed to develop and implement appropriate plans of action to correct the identified quality deficiencies relative to resident abuse and resident rights. Findings are as follows: Record review revealed the facility received a pattern of deficiencies relative to resident abuse and resident rights on the following dates: - 1/24/2024: F 600 for the failure to protect a resident from abuse by a staff member (a housekeeper was observed kissing a resident) and F 609 for the failure to report an allegation of abuse in a timely manner, as required by state law. -2/19/2024 F 600 for the failure to protect a resident's right to be free from abuse by a staff member, relative to staff not providing incontinence care. Record review revealed that the facility provided education to only nursing staff relative to resident abuse and resident rights on 3/4/2024 and audited incontinence care. Further record review failed to reveal evidence 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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident, as determined by resident assessments and individual plans of care, relative to restraints, for 5 of 7 staff reviewed, Staff D, E, G, H, and I. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/26/2024 revealed an allegation of abuse that occurred on 4/24/2024 with Resident ID #2 and two staff members, Nursing Assistant (NA), Staff D and Certified Medication Technician (CMT), Staff E. A surveyor observation on 5/2/2024 at 1:51 PM, of video footage from 4/24/2024 at 9:49 PM, in the presence of the Administrator and the Human Resource Director, Staff L, revealed Resident ID #2 was seated upright in a recliner chair, with the wall on his/her left side and a table on his/her right side.…

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 pharmacist failed to report irregularities to the attending physician, the facility's Medical Director, and the Director of Nursing Services (DNS) for 1 of 3 residents reviewed for monthly drug regimen reviews, Resident ID #8. Findings are as follows: Record review revealed the resident was admitted to the facility in January of 2021 with diagnoses including, but not limited to, dementia, anxiety, and depression disorder. Record review revealed the resident has a physician's order dated 12/1/2023 for Lorazepam (a medication used to treat anxiety disorders or for serious seizures that do not stop) Oral Concentrate 2 milligrams (MG)/milliliter (ML), with instructions to give 1 ML by mouth every 24 hours as needed for a seizure lasting more than 5 minutes. Further review of the order failed to reveal evidence of an end date or a documented rationale for extending the duration of use for this as needed medication. Record review of the May 2024 Medication Administration Record revealed that the resident received 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 ensure a resident's drug regimen is free from unnecessary psychotropic drugs who have as needed psychotropic medication orders extending beyond 14 days, for 1 of 3 residents reviewed for unnecessary medication, Resident ID #8. Findings are as follows: Record review revealed the resident was admitted to the facility in January of 2021 with diagnoses including, but not limited to, dementia, anxiety and depression disorder. Record review revealed the resident has a physician's order dated 12/1/2023 for Lorazepam (a medication used to treat anxiety disorders or for serious seizures that do not stop) Oral Concentrate 2 milligrams (MG)/milliliter (ML), with instructions to give 1 ML by mouth every 24 hours as needed for a seizure lasting more than 5 minutes. Further review of the order failed to reveal evidence of an end date or a documented rationale for extending the duration of use for this as needed medication. Record review of the May 2024 Administration Record revealed that the resident…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure that all direct care staff completed mandatory effective communication training, for 5 out of 7 staff reviewed, Staff D, E, G, H, and I. Findings are as follows: Record review failed to reveal evidence that the following staff completed the mandatory effective communication training or education for 2023: - NA, Staff D, hired on 9/22/2009 - Certified Medication Technician, Staff E, hired on 8/18/2009 - NA, Staff G, hired on 6/12/2022 - NA, Staff H, hired on 10/6/2016 - NA, Staff I, hired on 6/10/2016 During a surveyor interview on 5/6/2024 at 2:03 PM, with the Regional Nurse, in the presence of the Administrator and Director of Nursing Services, they were unable to provide evidence that the training was completed for the above-mentioned staff.

Based on record review and staff interview, it has been determined that the facility failed to provide mandatory training to all their staff, that outlines and informs staff of the elements and goals of the facility's QAPI (Quality Assurance and Performance Improvement) program, for 5 out of 7 staff reviewed, Staff D, E, G, H, and I. Findings are as follows: Record review failed to reveal evidence that the following staff completed QAPI training or education for 2023: - NA, Staff D, hired on 9/22/2009 - Certified Medication Technician, Staff E, hired on 8/18/2009 - NA, Staff G, hired on 6/12/2022 - NA, Staff H, hired on 10/6/2016 - NA, Staff I, hired on 6/10/2016 During a surveyor interview on 5/6/2024 at 2:03 PM, with the Regional Nurse, in the presence of the Administrator and Director of Nursing Services, they were unable to provide evidence that the training was completed for the above-mentioned staff.

Based on record review and staff interview, it has been determined that the facility failed to provide mandatory training to all their staff, that outlines compliance and ethics, including an effective way to communicate the program's standards, policies, and procedures, for 5 out of 7 staff reviewed, Staff D, E, G, H, and I. Findings are as follows: Record review failed to reveal evidence that the following staff completed training or education on compliance and ethics for 2023: - NA, Staff D, hired on 9/22/2009 - Certified Medication Technician, Staff E, hired on 8/18/2009 - NA, Staff G, hired on 6/12/2022 - NA, Staff H, hired on 10/6/2016 - NA, Staff I, hired on 6/10/2016 During a surveyor interview on 5/6/2024 at 2:03 PM, with the Regional Nurse, in the presence of the Administrator and Director of Nursing Services, they were unable to provide evidence that the training was completed for the above-mentioned staff.

Based on record review and staff interview, it has been determined that the facility failed to provide all staff with behavioral health training, for 5 out of 7 staff reviewed, Staff D, E, G, H, and I. Findings are as follows: Record review failed to reveal evidence that the following staff completed the mandatory behavioral health training or education for 2023: - NA, Staff D, hired on 9/22/2009 - Certified Medication Technician, Staff E, hired on 8/18/2009 - NA, Staff G, hired on 6/12/2022 - NA, Staff H, hired on 10/6/2016 - NA, Staff I, hired on 6/10/2016 During a surveyor interview on 5/6/2024 at 2:03 PM, with the Regional Nurse, in the presence of the Administrator and Director of Nursing Services, they were unable to provide evidence that the training was completed for the above-mentioned staff.

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 treat each resident with respect and dignity in a manner and in an environment that promotes maintenance of his or her quality of life, for 2 of 2 residents reviewed, Resident ID #s 2 and 7. Findings are as follows: 1. Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/26/2024 revealed that a Nursing Assistant (NA), Staff B, reported an allegation of abuse that occurred on 4/24/2024 involving Resident ID #2. During a surveyor observation of video footage from 4/24/2024 at 9:48 PM, revealed the resident was seated upright in a recliner chair, with the wall on his/her left side and a table on his/her right side. Additionally, a chair was placed in front of the elevated footrest, preventing the footrest of the recliner from releasing and another resident (Resident ID #7) was noted to be lying in a recliner behind Resident ID #2's recliner chair.…

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 protect the residents' right to be free from neglect for 1 of 3 residents reviewed relative to incontinence care, Resident ID #2. Findings are as follows: Record review revealed the resident was readmitted to the facility in October of 2021 with diagnoses including but not limited to, dementia, major depressive disorder, and constipation. Record review of the care plan initiated on 11/25/2019 indicates the resident requires assistance for activities of daily living. Further review revealed a care plan initiated on 2/24/2023 which indicates the resident is incontinent of bowels. The goal indicates that s/he will have incontinence care needs met by the staff to maintain his/her dignity and comfort. During surveyor observations on 2/19/2024 revealed the following: - 9:22 AM the resident was observed in the dining room participating in a group activity when s/he abruptly stopped participating in the activity and yelled out bowel movement, bowel movement, bowel movement. - 9:32 AM 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 surveyor observation, record review, resident and staff interview it has been determined that the facility failed to protect the resident's right to be free from staff to resident abuse for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 1/17/2024 revealed that on 1/4/2024 a facility contracted staff member, Housekeeper, Staff B, was observed passionately kissing Resident ID #1 in his/her room. Review of a facility policy titled Abuse Prohibition states in part, .the center will implement abuse prohibition program through the following .protect of patients during investigations; and reporting of incidents, investigations, and the center response to the result of their investigations .5. Actions to prevent abuse, neglect, exploitation, or mistreatment .will include .evaluating whether the patient has capacity to consent to sexual activity . 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 record review, resident and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made to the State Agency in accordance with State law for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a facility policy titled Abuse Prohibition states in part, .all reports of suspected abuse must be reported .Report allegations to appropriate state and local authority(s) .within 24 hours if the event does not result in serious bodily injury . Record review of a facility reported incident submitted to the Rhode Island Department of Health on 1/17/2024 revealed that on 1/4/2024 a facility contracted staff member, Housekeeper, Staff B, was observed passionately kissing Resident ID #1 in his/her room. Additional record review revealed that on 1/4/2024 four staff members informed the facility that they witnessed Staff B kissing Resident ID #1 in his/her room on 1/4/2024. Further review revealed that the initial report 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 immediately consult with the resident's physician when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention, for 1 of 1 resident reviewed for falls, Resident ID #2. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health (RIDOH) on 1/10/2024, alleges that while the Licensed Practical Nurse (LPN) Staff A, was escorting the resident in the hallway in a wheelchair, his/her foot dropped, causing him/her to lean forward. Additionally, the report alleges that Staff A held the resident by his/her jacket, lowered him/her to the floor then assisted him/her back into the wheelchair. Furthermore, the report states in part, .Resident has baseline pain in left leg. Oxycodone [narcotic pain medication] .was already given prior to incident for transport. Resident doesn't use foot rests as [s/he] self propels ad lib [as desired]. Resident denied…

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

Based on record review and staff interview, it has been determined that the facility failed to document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies which must be reviewed and updated as necessary, and at least annually. Additionally, the facility failed to review and update the assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. Findings are as follows: Review of a facility provided document titled, Facility Assessment dated 10/17/2023 through 12/30/2023 failed to reveal the following components required according to Appendix PP: - The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population - The staff competencies that are necessary to provide the level and types of care needed for the resident population - The physical…

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 each resident receives the necessary care and services to maintain the highest practicable physical well-being for 3 of 7 residents observed on the dementia unit, Resident ID #s 35, 43, and 61. Findings are as follows: Review of a facility policy titled, Activities of Daily Living [ADL] dated 5/1/2023, states in part, .Purpose to ensure ADLs are provided in accordance with accepted standards of practice, the care plan, and the patient's choices and preferences . Review of a policy titled, Continence Management dated 6/15/2022, states in part, Practice Standards .Provide routine incontinence care . 1. Record review revealed that Resident ID #43 was admitted to the facility in June of 2023 with diagnoses including, but limited to, dementia and muscle weakness. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 out 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 and staff interview, it has been determined that the facility failed to ensure that medication bottles were dated and discarded per the manufacturer's instructions when expired in 2 of 3 medication carts and 2 of 3 medication rooms observed, and that the refrigerator in 1 of 3 medication rooms observed was kept clean. Findings are as follows: 1. During a surveyor observation on 12/20/2023 at 8:34 AM following the medication administration task on the [NAME] Unit, the following medications were found to be expired and undated: - 2 bottles of natural tear drops were opened and undated - 1 bottle of Fish oil expired 9/2023 - 1 bottle of Mucinex 400 milligram (mg) expired 11/2023 - 1 bottle of Oyster shell expired 11/2023 - 1 pack of loperamide hydrochloride tablet 2 mg expired 11/2023 2. During an observation on 12/20/2023 at approximately 9:00 AM of the medication room on [NAME] Unit, the following medications were observed to be expired: - 1 bottle of vitamin D expired 11/2023 - 1 bottle of Mucinex expired 11/2023 During a surveyor interview 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.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the facility stores, distributes, and serves food in accordance with professional standards for food safety relative to the main kitchen and 2 of 3 dining areas. Findings are as follows: 1. Record review of the Rhode Island Food Code 2018 edition, section 4-602.11 states in part, .(C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris . During the initial tour of the main kitchen on 12/18/2023 at 8:10 AM revealed the following observations: a. In the dishroom, a wall fan with a heavy accumulation of dust, currently in use, facing the dish machine in the direction of the clean pans b. In the walk-in refrigerator, there was built up debris on the condenser fan c. The hood slats above the stove had an accumulation of brown debris and grease During a follow up visit to the main kitchen on 12/19/2023 at 8:19 AM revealed the same wall fan with a heavy accumulation of dust, currently in use,…

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, surveyor observation, staff and resident interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to an unidentified respiratory illness for 2 of 3 nursing units and affecting Resident ID #s 5, 7, 8, 16, 34, 46, 54, 63, 68, 72, 77, and 285. Findings are as follows: 1. Review of a facility policy titled Infection Control Outcome and Process Surveillance and Reporting reviewed on 2/1/2023 states in part, .to detect possible communicable diseases or infections, plan control activities before communicable disease or infections can spread to others, and identify and manage potential outbreaks of disease . Review of a facility policy titled Patient Placement in Transmission Based Precautions revised on 5/1/2023 revealed in part, Purpose to prevent the transmission of infectious disease .Empirically initiate Transmission Based Precautions based on signs and symptoms that are consistent with a communicable disease .If laboratory…

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 maintain a safe, clean, comfortable, and homelike environment relative to 1 of 3 units, the [NAME] unit. Findings are as follows: During a surveyor observation on 12/18/2023 at 9:30 AM on the [NAME] Unit, room [ROOM NUMBER], revealed an extension cord attached to the air conditioner that was connected to the wall socket next to the sink. Further observation revealed linens and a pillow that were on top of the extension cord. During a subsequent surveyor observation on 12/18/2023 at 10:20 AM on the [NAME] unit revealed ceiling paint that was peeling in the common bathroom, approximately 2 feet by 2 feet. During a subsequent surveyor observation and interview to room [ROOM NUMBER], and to the common bathroom on the [NAME] unit on 12/20/2023 at 8:30 AM, in the presence of the Maintenance Director, Regional Maintenance Director, and the Interim Administrator, they acknowledged the above findings and were unable 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 surveyor observation, record review and staff interview, it has been determined that 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 the resident that meets professional standards of quality care relative to MRSA (methicillin-resistant Staphylococcus aureus - a bacteria that does not get better with the type of antibiotics that usually cure staph infections) in a vascular wound (wounds on your skin that develop because of problems with blood circulation) and a condom catheter (a urine collection device), for 1 of 2 residents reviewed for baseline care plans, Resident ID #235. Findings are as follows: Record review revealed that the resident was admitted to the facility in December of 2023 with diagnoses including, but not limited to, benign prostatic hyperplasia (prostate gland enlargement that can cause urination difficulty) and urinary tract infection. A. During a surveyor observation on 12/18/2023 at 10:40…

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 revie, 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 3 residents reviewed for behaviors, Resident ID #2. Findings are as follows: Review of the CMS [Centers for Medicare and Medicaid Services] RAI [Resident Assessment Instrument] 3.0 Manual, states in part, .The items in this section identify behavioral symptoms in the last seven days that may cause distress to the resident, or may be distressing or disruptive to facility residents, staff members or the care environment .behaviors include those that are potentially harmful to the resident himself or herself .identification of the frequency and the impact of behavioral symptoms on the resident and on others is critical to distinguish behaviors that constitute problems .once the frequency and impact of behavioral symptoms are accurately determined, follow-up evaluation and care plan interventions can be developed to improve the symptoms or reduce their impact .Frequency .Steps for Assessment 1. Review the medical…

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, surveyor observation, and staff interview, it has been determined that the facility failed to maintain a safe, clean, sanitary, homelike environment relative to bed sheets and privacy curtains for 2 of 3 resident rooms observed, Resident ID #s 2 and 3. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 8/7/2023, alleges that the facility .has blood on the floors and privacy curtains on the [D] unit and is filthy with fruit flies everywhere . 1. Record review revealed Resident ID #2 was readmitted to the facility in July of 2023, with diagnoses to include, but not limited to, vascular dementia and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). Multiple surveyor observations on 8/9/2023 between the hours of 1:30 PM through 4:15 PM, revealed the resident's bed sheets were stained with brown colored matter on the bottom fitted sheet, as well as on the top flat sheet. During a surveyor interview on 8/9/2023 at 2:30 PM with…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to following a physician's order for 1 of 1 resident reviewed, Resident ID #2. 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 Resident ID #2 was readmitted to the facility in July of 2023, with diagnoses to include, but not limited to, vascular dementia and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). Review of a physician order dated 5/10/2022, revealed the resident is to have Prevalon booties (a boot with a cushioned bottom that floats the heel off the surface of the mattress, helping to reduce pressure) to bilateral feet when lying in bed. Upon further review a physician's order…

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.