Grand Islander Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff and resident interview, it has been determined that the facility failed to ensure that a resident receives care, consistent with professional standards of practice to prevent pressure ulcers (localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure) for 1 of 2 residents reviewed, Resident ID #43. Findings are as follows: Record review revealed the resident was admitted to the facility in April of 2025 with diagnoses including, but not limited to, right femur fracture and osteoarthritis. During a surveyor interview with the resident on 5/12/2025 at 11:27 AM, s/he revealed that s/he has bed sores on his/her buttocks and the areas are red. Additionally, s/he revealed that they sometimes apply a cream to both his/her butts. Record review revealed a care plan dated 4/28/2025 indicating that the resident is at risk for skin breakdown, with interventions that include, but are not…

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 acceptable parameters of nutritional status, such as usual body weight, for 1 of 5 residents reviewed, who experienced an actual weight loss and the facility failed to follow their own policy relative to weight monitoring, Resident ID #173. Findings are as follows: Review of a facility policy titled Weights and Heights states in part, .Obtaining and Documenting Weight: 1.1 A licensed nurse or designee will weigh the patient. 1.1.1 Admissions and re-admissions will be weighed within 24 hours of admission . 1.1.4 If the body weight is not expected, re-weigh the patient . 2.1 Significant weight changes will be reviewed by the licensed nurse for assessment . 2.2 The licensed nurse will: 2.2.1 Notify the physician .Dietitian of significant weight changes . Record review revealed the resident was admitted to the facility in April of 2025 with diagnoses including, but not limited to, sepsis due to Enterococcus (a bacteria that enters the bloodstream and may cause a widespread…

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

Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of practice, in accordance with physician orders and the comprehensive person-centered care plan, for 1 of 1 resident reviewed who was receiving antibiotics via a peripherally inserted central catheter (PICC; a long flexible tube that is inserted into a vein in the arm and threaded through a larger vein leading to the heart, used to administer intravenous (IV) fluids and medications), Resident ID #173. Findings are as follows: Record review revealed the resident was admitted to the facility in April of 2025 with a diagnosis including, but not limited to, enterococcal bacteremia (a bacteria that enters the bloodstream and may cause a widespread inflammatory response). Record review revealed the resident was receiving the following antibiotics: -Ampicillin (an antibiotic prescribed to treat various infections) 2 grams intravenously, every 4 hours. -Ceftriaxone (an antibiotic prescribed to treat various infections) 2 grams intravenously, every 12 hours. 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 staff interview, it has been determined that the facility failed to ensure that a resident who requires dialysis (a treatment that filters blood when kidneys fail to adequately remove fluids and waste) receive such services consistent with professional standards of practice and the comprehensive person-centered care plan, for 1 of 1 resident reviewed receiving dialysis, Resident ID #83. Findings are as follows: Record review of a facility policy titled, Dialysis: Hemodialysis External Catheter Evaluation and Maintenance last revised 5/1/2025, states in part, .The licensed nurse will ensure that the dialysis access site (e.g. AV shunt or graft [a synthetic tube used to surgically connect the artery and vein, used for dialysis access]) is checked before and after dialysis treatment and every shift for patency [free from blockage or open] by auscultating for bruit [whooshing or swishing sound heard with a stethoscope] and palpating [feeling] for a thrill [a vibration felt with the fingertips when touching the AV shunt or graft] . Record review revealed the…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure that the irregularities identified by the Clinical Consultant Pharmacist during the monthly pharmacist Medication Regimen Review (MRR) were acted upon for 3 of 6 residents reviewed, Resident ID #s 29, 76 and 96. Findings are as follows: 1. Record review for Resident ID #29 revealed a physician's order dated 2/21/2025 for Lantus insulin (a medication prescribed to lower blood sugar), 16 units daily at bedtime, and Sitagliptin (a medication prescribed to treat type 2 diabetes mellitus), 150 milligrams (mg) daily. Record review of the pharmacist's MRR, dated 4/15/2025, revealed the following recommendations: - to consider decreasing the resident's Lantus insulin 16 unit dose at bedtime, by 2 units - to evaluate the Sitagliptin 150 mg daily dose, as it exceeds the maximum recommended manufacturer's dosing of 100 mg daily 2. Record review for Resident ID #76 revealed a physician's order dated 2/6/2025 for lorazepam (a medication prescribed to treat anxiety disorders) 0.5 mg every 6 hours…

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 1 resident reviewed for Warfarin/Coumadin therapy (an anticoagulant medication prescribed to reduce the blood's ability to clot, preventing or treating blood clots), Resident ID #21. 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 Resident ID #21 was admitted to the facility in February of 2025 with diagnoses including, but not limited to, unspecified atrial…

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 disposed of garbage and refuse properly relative to 1 of 1 outside dumpster and the surrounding area. Findings are as follows: Surveyor observation of the outside dumpster area, in the presence of the Food Service Director on 5/14/2025 at 8:51 AM revealed the following: - Various sizes of cardboard boxes, broken down, on the ground surrounding the dumpster - Scattered used surgical and N95 masks on the ground - A tall, thin cardboard box containing 2 white wood wall baseboard pieces and 2 additional baseboard pieces on the ground - Used bubble wrap located on the ground - A mattress - 5 pieces of wood located on the ground - A large metal bed frame During a surveyor interview with the Maintenance Director on 5/14/2025 at 9:11 AM, he acknowledged the above-mentioned items and indicated that the area surrounding the dumpster needed to be cleaned and the items needed to be discarded.

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 for 2 of 3 residents, Resident ID #s 100 and 172. Findings are as follows: According to the Centers for Disease Control and Prevention (CDC) document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes states in part, Standardize the practices which should be applied during the care of any resident suspected of an infection or started on an antibiotic. These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed in your facility. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer…

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 immediately inform the resident's representative of an accident involving the resident, which resulted in injury and the decision to transfer the resident to an acute care hospital for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health, on 4/17/2025 alleged that the resident's representative was not informed of a fall with injury that required the resident to be transferred to an acute care hospital. Record review of a facility policy last revised on 7/1/2024 titled Change in Condition: Notification of . states in part, .A Center must immediately inform the patient, consult with the patient's physician, and notify, consistent with their authority, the patient's representative, where there is: An accident involving the patient which results in injury and has the potential for requiring physician intervention .A decision to transfer or discharge the patient from the Center .…

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 meet professional standards of quality relative to evaluating a resident's neurological status after a fall for 2 of 2 residents reviewed, Resident ID #s 1 and 3. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 4/17/2025 alleged that the facility did not complete neurological assessments (neuro check, a critical component of resident care, enabling nurses to evaluate and monitor the neurological system. This assessment helps in identifying changes in a resident's neurological status, which can be indicative of underlying conditions or responses to treatment. The assessment includes evaluating mental status, cranial nerves, motor function, sensory function, reflexes, and gait and balance) for Resident ID #1, after s/he sustained a fall with a head injury which required a transfer to an acute care hospital. Record review of a facility policy…

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 2 residents reviewed for significant weight loss and/or gain, Resident ID #1. Findings are as follows: Record review of a facility's policy titled, Procedure: Weights and Heights states in part, .Admissions and re-admissions will be weighed within 24 hours of admission .If the body weight is not as expected, reweigh the patient .Significant weight change is defined as .5% in one month .10% in 6 months .notify the physician .Dietitian of significant weight changes . Record review of a facility policy titled, Nutrition/Hydration Care and Services states in part, .Staff will provide nutritional and hydration care and services to each patient .Observe and document oral intake of meals, supplements and snacks . 1. Record review revealed the resident was re-admitted to the facility in October of 2024, with diagnoses including, but not limited to, malignant neoplasm of the brain (brain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident's Advanced Directive to refuse lifesaving treatment was followed for 1 of 4 residents reviewed, Resident ID #1. Findings are as followings: Review of a facility reported incident received by the Rhode Island Department of Health on [DATE], revealed that a resident passed away in the facility within 24 hours of admission. Record review revealed the resident was readmitted to the facility in August of 2024 with diagnoses including, but not limited to, Atrial Fibrillation (a heart condition that causes irregular and often rapid heartbeat), acute osteomyelitis (an infection in the bone) of the left hand, and diabetes. Record review revealed a document titled, Medical Orders for Life Sustaining Treatment (MOLST) dated [DATE] states in part, .Do Not Attempt Resuscitation [a person who has decided not to allow cardiopulmonary resuscitation (CPR) in an event their breathing or heart stops] .(Allow…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice for 1 of 2 residents reviewed relative to wound care, Resident ID #1. Findings are as follows: According to Mosby's Fundamentals of Nursing Concepts, Process and Practice, 4th Edition, page 809, states in part, .a Registered Nurse checks all transcribed orders against the original order for accuracy and thoroughness . Record review revealed the resident was admitted to the facility in June of 2024 with diagnoses including, but not limited to, bacteremia (an infection in the bloodstream), methicillin susceptible staphylococcus infection (a bacterial infection) and a wound to the left ischium (the lower and back part of the hip bone). Record review of a hospital document provided to the surveyor, titled, Wound Care Note dated 6/24/2024, indicated the resident has a Stage IV (full thickness loss of skin and tissue exposing muscle, tendon, bone) pressure injury (localized injury to the skin and underlying tissue]) to…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed receiving intravenous (medication administered via the vein) antibiotics, Resident ID #1. Findings are as follows: Record review revealed the resident was admitted to the facility in June of 2024 with diagnoses including, but not limited to, bacteremia (an infection in the bloodstream), methicillin susceptible staphylococcus infection (a bacterial infection) and osteomyelitis (an infection of the bone). Record review of the physician's orders revealed the following: -6/28/2024 for Meropenem Intravenous Solution, use 1 gram intravenously every 8 hours for osteomyelitis for 49 doses. Record review of the July 2024 Medication Administration Record revealed the Meropenem was administered beyond the ordered 49 doses, indicating the resident received 4 additional doses on the following dates and times: -7/15/2024 at 10:00 PM -7/16/2024 at 6:00 AM -7/16/2024 at 2:00 PM -7/16/2024 at 10:00 PM During an…

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 ensure that food is stored and distributed in accordance with professional standards for food service safety, relative to the main kitchen and 3 of 3 kitchenettes observed. Findings are as follows: 1. Record review of the Rhode Island Food Code, 2018 Edition, Section 3-501.17 states in part, .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees Celsius or 41 degrees Fahrenheit or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 . During the initial tour of the kitchen in the presence of the Food Service Director (FSD), on 5/28/2024 at 8:45 AM, the following was observed in the walk-in refrigerator: - 1 large package of hot dogs, opened with approximately 6…

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 assist residents in obtaining routine dental services for 2 of 2 residents reviewed, Resident ID #s 37 and 69. Findings are as follows: 1. Record review revealed Resident ID #69 was admitted to the facility in July of 2020 with diagnoses including, but not limited to, cognitive communication deficit and dysphagia (difficulty swallowing food or liquid). Review of an annual Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 5 out of 15 indicating his/her cognition is severely impaired. A surveyor observation of the resident on 5/29/2024 at 8:32 AM revealed that the s/he had multiple missing teeth. The resident was unable to answer questions related to his/her cognition. Record review revealed a physician's order dated 7/1/2020 for Podiatry, Dental and Ophthalmology consult, and treatment as needed for patient health and comfort. Record review of a progress…

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 and sanitary environment to help prevent the transmission of infections related to a wound dressing change for 1 of 2 residents, Resident ID #329. Additionally, the facility failed to maintain Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) for 4 of 5 residents reviewed, Resident ID #s 75, 97, 115, and 329. Finding are as follows: Review of the Center for Disease Control and Prevention document titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) Last Reviewed: August 1, 2023, states in part, Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .MDROs may be indirectly transferred from resident-to-resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following physician's order for 2 of 2 residents reviewed for fortified diets, Resident ID #s 63 and 88. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing page 314 states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review of a document titled Corporate Recipe-Fortified Foods provided to the surveyor by the Food Service Director, revealed the facility offers three items as fortified food choices; Fortified Cinnamon Oatmeal, Fortified Pudding Parfait, and Fortified Mashed Potatoes. 1. Record review revealed Resident ID #63 was admitted to the facility in November of 2022 with diagnoses including, but…

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 observations, record review, staff and resident representative interview, it has been determined that the facility failed to ensure that a resident receives assistive devices to maintain hearing abilities for 1 of 1 resident reviewed, Resident ID #63. Findings are as follows: Record review revealed Resident ID #63 was re-admitted to the facility in November of 2022 with a diagnosis including, but not limited to, sensorineural hearing loss (hearing loss from damage to cells or nerve fibers in the inner ear). Record review of a care plan dated 4/28/2023 revealed the resident .has impaired communication as evidence by .impaired hearing .assist resident/patient with proper care and maintenance of hearing aids . Further record review of the care plan revealed it is important to the resident that s/he has the opportunity to engage in daily routines that are meaningful relative to his/her preferences. Additional record review revealed the resident enjoys listening to music and keeping up with the news by listening to the radio. Review of the May 2024 Medication…

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

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide a resident with limited range of motion appropriate treatment and services to increase range of motion and or to prevent further decrease in range of motion for 1of 3 residents reviewed for a mobility device, Resident ID #89. Findings are as follows: Record review revealed the resident was re-admitted to facility in April of 2024 with diagnoses including, but not limited to, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side and weakness. Record review of the care plan dated 4/3/2024 revealed, the resident is expected to be discharged due to his/her admission for a skilled short-term stay for rehabilitation. Further record review revealed interventions including, but not limited to, functional mobility and a need for an assistive device. Record review of a physical therapist note dated 4/24/2024 revealed, Physical Therapist (PT) was to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident interviews, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 2 residents reviewed with constipation, Resident ID #103. Findings are as follows: Record review revealed the resident was admitted to the facility in August 2023 with diagnoses including, but not limited to, muscle weakness and urinary incontinence. Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 13 out of 15, indicating intact cognition. Further review revealed the resident was occasionally incontinent of bowels and was dependent on staff for toileting. Review of a care plan dated 8/8/2023 revealed, the resident exhibits or is at risk for gastrointestinal symptoms or complications related to constipation. Further review revealed interventions including, but not limited to, monitoring, and recording of bowel movements, and to assess and report signs and symptoms of decreased bowel movements. During…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a blood purifying treatment given when kidney function is not optimum) receive such services consistent with professional standards of practice for 1 of 2 residents reviewed for dialysis, Resident ID #64. Findings are as follows: Review of the facility policy titled Dialysis: Hemodialysis (HD) Provided by a Certified End-Stage Renal Facility [ESRD] revealed in part, .Professional standards of practice include .Ongoing communication and collaboration with the certified ESRD facility . Record review revealed the resident was admitted to the facility in March of 2024 with diagnoses including, but not limited to, end stage renal disease (when your kidneys can no longer support your body's needs) and hypertension. Record review of a care plan dated 3/26/2024 revealed, the resident exhibits or is at risk for impaired renal (kidney) function and is at risk for complications related to hemodialysis. Further review of the care plan revealed, the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to provide specialized rehabilitation services such as physical therapy that were required per the resident's comprehensive plan of care for 1 of 1 resident reviewed for rehabilitation services, Resident ID #93. Findings are as follows: Record review revealed that the resident was admitted to the facility in January of 2023 and has diagnoses including, but not limited to, cerebral infarction (stroke), hemiplegia (paralysis of one side of the body) affecting left dominant side, and abnormalities of gait and mobility. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15 indicating intact cognition. The MDS further indicated that the resident requires total dependence for bed mobility and transfer. During a surveyor interview on 5/28/2024 at 11:11 AM with the resident, s/he revealed that s/he would like to receive more…

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: Record review of the facility document titled, Labeling and Dating Inservice, states in part, .All foods should be dated upon receipt before being stored. Food labels must include .The date of preparation/receipt/removal from freezer .The 'use by' date .Leftovers must be labeled and dated with the date they are prepared and the 'use by' date . During the initial tour of the main kitchen in the presence of the Food Service Director (FSD) on 4/25/2023 at 8:48 AM, revealed the following: 1. The walk-in freezer: - one 10-pound (lbs.) bag of sliced pepperoni open and not dated 2. The walk-in refrigerator: - two approximately ¼ lbs. packages of sliced deli meats labeled salami, dated 4/14/2023 - one container of lettuce and tomato salad labeled with the date 4/20 and use by date 4/23. Additionally, the lettuce…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff and resident interviews, it has been determined that the facility failed to ensure that a residents environment remains as free from accident hazards as possible for 2 of 4 housekeeping closets observed on the Homestead Unit and Transitional Care Units (TCU). Findings are as follows: Review of a facility policy titled, ENV101 Storage last revised on 7/15/2022 states in part, .Storage areas are locked when not in operation to prevent unauthorized access . 1. During surveyor observations of the secured memory care unit, Homestead Unit, on 4/25/2023 at 9:10 AM, 9:57 AM, 10:36 AM, and 11:09 AM, the housekeeping storage closet door was unlocked. Additionally, this closet contained multiple chemicals including, but not limited to, peroxide multi surface and disinfectant, toilet cleaner, and floor cleaner on low shelving. During a surveyor observation on 4/25/2023 at 11:09 AM, Resident ID #53 began to open the unlocked housekeeping closet door where the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan for 1 of 2 residents reviewed, relative to wandering, Resident ID #53. Findings are as follows: Record review revealed the resident was initially admitted to the facility in December of 2017 with diagnoses including, but not limited to, dementia with other behavioral disturbances, restlessness and agitation, psychotic disorder with delusions, and major depressive disorder. Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating the resident's cognition is severely impaired. Record review of a behavioral health assessment note dated 3/28/2023 revealed the resident has a history of exit seeking behaviors. During a surveyor observation on the following dates and times the resident was observed wandering on the unit, attempting to open the unit exit…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of quality related to following physician's orders for 1 of 4 residents relative to blood sugar monitoring, Resident ID #47. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review revealed the resident was re-admitted to the facility in October of 2022 with diagnoses including, but not limited to, type 2 diabetes mellitus and long term (current) use of insulin. Record review of the April 2023 Medication Administration Record (MAR) revealed a physician order with a start date of 3/16/2023 for fingerstick monitoring (blood sugar) two times a day at 6:00 AM and 4:00 PM and notify the physician if blood sugar value is less than 70 or more than 400. Further record review of the MAR failed to…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 2 of 3 residents reviewed for cardiac medications with parameters, Resident ID #s 36 and 417. Findings are as follows: 1. Record review revealed Resident ID #36 was re-admitted to the facility in March of 2023 with diagnoses including, but not limited to, chronic diastolic congestive heart failure (abnormal heart condition characterized by an improper filling of blood in the heart causing a reduced amount of blood pumped out to the body), and hypertension (high blood pressure). Record review of the April 2023 Medication Administration Record (MAR) revealed a physician's order with a start date of 4/4/2023, revised on dates 4/25/2023 and 4/26/2023, for metoprolol tartrate (a medication used to treat high blood pressure by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure) oral tablet 12.5 mg (milligrams) by mouth every 6 hours for hypertension, hold for heart rate (HR) less than…

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.