AdviniaCare Newport, LLC

Based on clinical record review and staff interview, the facility failed to provide appropriate treatment and services for 1 of 2 residents reviewed with an indwelling foley catheter (a flexible tube that collects urine from the bladder and empties into a drainage bag) related to urine output monitoring, Resident ID #10.Findings are as follows:According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing, Volume 2, 10th Edition, page 252 states, .the usual daily urine volume in the adult is 1-2 Liters or 1000-2000 cubic centimeters (cc) [milliliters] . Additionally, page 1282 states, For patients with indwelling catheters, the nurse assesses the drainage system to ensure that it provides adequate urinary drainage. The color, odor, and volume of urine are also monitored. An accurate record of fluid intake and urine output provides essential information about the adequacy of renal function and urinary drainage .Record review of a policy titled URINARY CATHETER CARE dated April of 2015 states in part, .empty drainage bag at least every 8 hours and as necessary.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.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure residents who are fed through a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed for a continuous feeding via a jejunal tube (J-tube, a surgically placed device used to give direct access to the small intestine for supplemental feeding, hydration or medicine), Resident ID #13. Findings are as follows: According to Lippincott Nursing Procedures Nineth Edition dated 2023, states in part, .Managing Enteral Tube Feeding Problems.Aspiration of gastric secretions.Elevate the head of the bed a minimum of 30 degrees.Review of a facility policy dated April 2015 titled Enteral Feeding [feeding provided through an alternative method via a J-tube] states in part, .Elevate head of bed 30-45 degrees.Label formula and administration set with date, time, resident's name and nurse initials.Always keep HOB [head of bed] elevated to prevent aspiration.Record review revealed that Resident ID #13 was admitted to the facility in August…

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 ensure that each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 25 opportunities for errors observed during the medication administration task, there were four errors resulting in an error rate of 16% affecting Resident ID #s 43, 81, 62 and 101.Findings are as follows: 1. Record review revealed Resident ID #43 has a physician's order for Carvedilol (a medication prescribed to treat several heart and blood vessel conditions by relaxing blood vessels and slowing the heart rate) 3.125 milligrams (mg) twice a day with parameters to hold for a heart rate less 60. During a surveyor observation on 12/18/2025 at 8:53 AM with Certified Medication Technician (CMT), Staff I, she was observed obtaining the resident's heart rate which was 42. Staff I then administered the Carvedilol to the resident. During a surveyor interview with Staff I, immediately following the above observation, she acknowledged the resident's heart rate was 42 and had…

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 maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to enhanced barrier precautions (EBP; refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO], for 4 of 4 residents observed on EBP, Resident ID #s 12, 13, 22 and 65. Findings are as follows: Review of the facility signage titled Enhanced Barrier Precautions states in part, .Wear Gown and Gloves prior to these activities .Dressing .bathing .transferring .providing hygiene . Device care or use of a device.feeding tubes.Clean their hands, including before entering and when leaving the room .1. Record review revealed Resident ID #22 was admitted to the facility in December of 2025 with a diagnosis including, but not limited to, a wound on the right hand. During a surveyor observation on 12/16/2025 at approximately 10:30 AM revealed signage posted outside of Resident ID #22's room indicating s/he…

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

Based on surveyor observation and staff interview, it has been determined that the facility failed to properly store and serve food under sanitary conditions relative to serving temperatures of a potentially hazardous food item, improper cooling procedures, sanitation of the main kitchen, and infection control practices.Findings are as follows: 1. Record review of the 2022 Food Code published by the U.S Food and Drug Administration Section 4-601.11 (C) reads in part, .non-contact surfaces of equipment shall be free of an accumulation of .dirt, FOOD residue, and other debris . During a surveyor observation on 11/19/2025 at approximately 10:30 AM of the main kitchen, the following was revealed:- a grease accumulation over hood of 6 burner stove- a grease and grime accumulation in corners of the tilt skillet- black sheeting on the shelves of three worktables with an accumulation of debris and food crumbs- a rusted bottom shelf of a worktable that the meat slicer was stored on 2. Record review of the 2022 Food Code published by the U.S. Food and Drug Administration Section 5-501.113…

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 and resident interview, it has been determined that the facility failed to ensure the resident has the right to choose his or her attending physician for 3 out of 4 residents reviewed related to physician choice, Resident ID #s 2, 3, and 5.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 8/7/2025 alleges in part, .My facility has a new policy of switching providers when residents go to the hospital. They don't inform the family or resident of the change .1) Record review revealed Resident ID #2 was admitted to the facility in April of 2023 with diagnoses including, but not limited to, Parkinson's disease, anxiety disorder, and major depressive disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score (BIMS) of 15 out of 15, indicating that the resident is cognitively intact.Record review revealed that the resident was under the care of Physician,…

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 nursing staff have the appropriate competencies and 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 for 2 of 2 Registered Nurses (RNs) reviewed, Staff B and Staff D and 4 of 6 Nursing Assistants (NAs) reviewed, Staff E, F, G and H. Findings are as follows: Record review failed to reveal evidence of any competencies that were completed for the following nursing staff : -RN, Staff B -RN, Staff D -NA, Staff E -NA, Staff F -NA, Staff G -NA, Staff H During a surveyor interview on 9/5/2024 at 3:45 PM with the Infection Preventionist, during the Staffing Task, she was unable to provide evidence of any completed nursing competencies for the above-mentioned staff.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the menus meet the nutritional needs of the residents in accordance with established national guidelines, that are reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy. Findings are as follows: Record review of the facility's diet manual titled, US Foods Menu Solutions 2015, failed to meet the current established national guidelines (the United States Department of Agriculture established and reviewed national guidelines every 5 years, to promote health, meet nutrient needs and provide guidance for healthy dietary patterns by life stages). The diet manual provided to the surveyor from the facility was from 2010 to 2015, indicating the guidelines were outdated as the current national guidelines were revised in 2020 with new recommendations. Record review of the facility's menu, failed to reveal evidence of the therapeutic exchanges (in the exchange system, foods with a similar nutritional…

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

Based on record review and staff interview it has been determined that the facility failed to develop, implement, and maintain an effective training program for annual training for existing employees consistent with their expected roles, relative to education involving abuse, resident rights, infection control, dementia, behavioral health management, trauma informed care, communication and QAPI (Quality Assurance and Performance Improvement), per the facility assessment, for 8 of 8 employees, Staff B, D, E, F, G, H, S and T. . Findings are as follows: Review of the Facility Assessment, dated 7/19/2024, revealed in part, training and competencies are completed upon hire, annually and on an as needed basis. Additional review of the assessment indicated the following training are required for direct care staff: Abuse Resident Rights Infection Control Dementia & Alzheimer's Disease Behavioral Health Communication QAPI program Record review revealed Registered Nurse (RN), Staff B was hired on 3/12/2015. Review of his training records failed to reveal evidence that he received education…

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 being provided meet professional standards of quality relative to following physician's orders for 1 of 1 resident reviewed for obtaining and documenting weights on dialysis treatment days, Resident ID # 61, 1 of 10 residents reviewed with a pressure relieving device, Resident ID #62, and 1 of 2 residents reviewed who receives TED [thrombo-embolis deterrent- a type of compression stocking designed to help prevent blood clots and swelling in the legs] stockings daily, Resident ID # 67. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. 1. Record review revealed Resident ID #61 was initially admitted to the facility in October of 2019 with diagnoses including, but not limited to, end stage renal disease and dependence…

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 residents with limited range of motion receive appropriate treatment to prevent further decline in range of motion for 3 of 4 residents reviewed, Resident ID #s 18, 61 and 70. Findings are as follows: 1. Record review revealed Resident ID #18 was re-admitted to the facility in December of 2023 with diagnoses including, but not limited to, stroke and hemiplegia (paralysis on one side of the body). Record review revealed a physician's orders dated 4/23/2024 for Left resting hand orthosis [splint] may be worn during day hours, as tolerated. Surveyor observations on the following dates and times revealed the resident was without his/her left hand splint applied as ordered: -9/3/2024 at approximately 9:45 AM and 12:00 PM -9/4/2024 at approximately 10:00 AM -9/6/2024 at 8:53 AM and 10:15 AM Record review of the nursing progress notes failed to reveal evidence that the resident removed or refused to wear his/her hand splint. During a surveyor interview on 9/6/2024 at…

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

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 residents that are fed through a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed receiving nutrition via a gastrostomy tube (a feeding tube that delivers nutrition, hydration and medication to your stomach through the abdomen), Resident ID #197. Findings are as follows: Review of a facility policy titled, Enteral Feeding states in part, Enteral feeding provides an alternative method of nutritional support via a gastrostomy .tube and is used to enhance and maintain nutritional status when there is an inability to take adequate nutrients orally .PROCEDURE Check physician order for formula, rate and water flushes .Check feeding tube placement with stethoscope .Aspirate [a process to use a syringe to check for contents remaining] stomach contents to check for residual [quantity of tube feed remaining in the stomach] .Hold…

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 respiratory care consistent with professional standards of practice for 1 of 2 residents reviewed for respiratory care, Resident ID #49. Findings are as follows: Record review of a facility policy, with a revision date of November 2020, titled, Oxygen Administration Nasal Cannula states in part, .Replace and date cannula [tubing that delivers oxygen through the nose] and tubing weekly or when visibly soiled or damaged . Record review revealed the resident was admitted to the facility in May of 2023 with a diagnosis including, but not limited to, chronic obstructive pulmonary disease (a condition caused by damage to the airways or other parts of the lungs that blocks airflow and makes it difficult to breathe). Review of a physician's order dated 6/24/2024 revealed an order for the resident to receive supplemental oxygen at 1-2 liters/minute via nasal cannula as needed every shift. During surveyor observations on the following dates and times, 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 record review and staff interview, it has been determined that 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 8 residents reviewed for monthly drug regimen reviews, Resident ID #59. Findings are as follows: Record review of a facility policy titled Drug Regimen Review- Monthly revealed in part, .the consultant Pharmacist shall review the medical record of each resident and perform a Drug Regimen Review at least once each calendar month. The Consultant Pharmacist shall identify, document and report possible medication irregularities for review and action by the attending Physician, where appropriate .Consultant Pharmacist .Shall perform Medication Regimen Review for each resident at least monthly. This review shall be performed by evaluating the medical record of each resident, which contains the current Medication Regimen as documented on the most recent Physician's Order Sheets or electronic record of current orders . Record review revealed Resident ID #59 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 record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 4 residents reviewed receiving insulin, Resident ID #59 and 1 of 4 residents reviewed receiving an Antipsychotic medication (medications that mainly treat psychosis and, related conditions and symptoms), Resident ID #74. Findings are as follows: 1. Record review revealed Resident ID #59 was admitted to the facility in April of 2023 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Record review revealed a physician's order dated 6/7/2024 for Fiasp (insulin) 100 unit/milliliter (ml) sliding scale. Special instructions: Per sliding scale if blood sugar is less than 70, call MD [medical doctor] If blood sugar is 150 to 199, give 1 units. If blood sugar is 200 to 249, give 2 units If blood sugar is 250 to 300, give 3 units If blood sugar is 301 to 349, give 4 units If blood sugar is 350 to 399, give 6 units If blood sugar is 400 to 449, give 8 units If blood sugar is 450 to 500, give 10 units.…

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 store drugs and biological's in accordance with currently accepted professional principles relative to 1 of 2 medication rooms observed, 2 of 2 medication carts observed on unit 2, and 2 residents observed with medications at the bedside, Resident ID #s 22 and 63. Findings are as follows: 1. Surveyor observation on 9/5/2024 at 9:39 AM in the presence of Medication Aide, Staff I, of the basement medication storage room revealed the following: -Six medication bottles of Calcium 600 mg (milligram) with Vitamin D 10 mcg (microgram) with an expiration date of 8/2024. -Two medication bottles of Acetaminophen 160 mg/5 ml (milliliter), one with an expiration date of 1/2024 and the other with an expiration date of 2/2024. During a surveyor interview at time of observation with Staff I, she acknowledged the medications were expired and indicated they should be discarded. 2. During a surveyor observation on 9/4/2024 from 12:25 PM to 12:55 PM of the second floor revealed the following:…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 2 of 4 residents reviewed with a splint (a device used to prevent decreased range of motion), Resident ID #s 61 and 70, and 1 of 2 residents reviewed who has an order for TED stockings (thrombo-embolis deterrent- a type of compression stocking designed to help prevent blood clots and swelling in the legs) daily, Resident ID #67. Findings are as follows: 1. Record review revealed Resident ID #61 was admitted to the facility in October of 2019 with diagnoses which include, but are not limited to, stroke and hemiplegia (paralysis on one side of the body). Record review of the physician's orders revealed an order dated 10/24/2023 for Right resting hand splint to be donned [to put on] during the day, as tolerated every shift. Surveyor observation on 9/5/2024 at 1:20 PM revealed the resident lying in the bed, without his/her right-hand splint applied as…

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 provide a safe, sanitary, and comfortable environment for residents, staff and the public related to the basement conference room. Findings are as follows: Surveyor observation in the basement conference room on 9/5/2024 at 12:07 PM, revealed a large amount of water pouring down from the ceiling light onto a table below, spraying liquid droplets in an approximate four foot radius, saturating a surveyor's computer, resident records and personnel training records. During a surveyor interview on 9/5/2024 at 12:09 PM with the Assistant Director of Maintenance, Staff R, he revealed the cause of the water coming from the ceiling was due to a toilet on the second floor that was clogged by a large bowel movement and was overflowing. Additionally, he revealed this happened on two previous occasions last week. Staff R further revealed that he did not inform anyone of issue with the toilet overflowing because he felt that he had fixed the issue by plunging the toilet. During a surveyor…

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 residents receive and consume food in the appropriate form, for 1 of 3 residents observed with physician orders for a mechanical soft diet, Resident ID #39. Findings are as follows: Record review revealed the resident was admitted to the facility in January of 2018 with a diagnosis including, but not limited to, dementia. Record review of a physician's diet order 9/13/2023 states in part, .LCS [Low Concentrated Sweets]; Mechanical soft [proteins that are ground or cut up] . Record review of the lunch menu for Thursday September 6, 2024 revealed the following: -Salisbury Steak -Mashed Potatoes -Peas During a surveyor observation during the lunch meal on 9/5/2024 at approximately 12:30 PM, the resident was eating his/her lunch. Record review of the resident's diet ticket during the above observation revealed in part, .LCS/Chopped . Further observation of the resident's meal tray revealed that the Salisbury Steak was cut in strips that were approximately 1 1/2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview it has been determined that the facility failed to ensure that residents receive adequate supervision to prevent an accident for 1 of 3 residents reviewed for elopement, Resident ID #1. Findings are as follows: Record review of a facility policy titled elopement dated July 2015 states in part, .elopement is defined as the ability for a resident who is not capable of protecting himself or herself from harm to successfully leave the facility unsupervised . Record review of a facility reported incident submitted to the Rhode Island Department of Health on 6/11/2024 indicated, that Resident ID #1 was found outside of the facility on 6/10/2024. Record review revealed that the resident was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, dementia, delusional disorder (psychotic disorder), and paranoid personality disorder. Review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 7 out…

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 it stores, distributes, and serves food in accordance with professional standards for food safety relative to the main kitchen and 1 of 3 unit kitchenettes. Findings are as follows: 1. Review of Rhode Island Food Code, 2018 edition, section 3-501.17 states in part, .refrigerated 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 C [degrees Celsius] (41 F [degrees Fahrenheit]) or less for a maximum for 7 days. The date of preparation shall be counted as day 1 . During the initial tour of the main kitchen on 9/11/2023 at 8:50 AM, there were two, 6 inch by 6 inch pans underneath the prep counter. One was filled with white, viscous food matter and the other pan contained crumbled, white food matter. Both pans were observed to be covered in…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality for 2 of 7 residents reviewed relative to physician orders, Resident ID #s 49 and 85. 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 physicians' orders unless they believe the orders are in error or would harm the clients. 1. Record review for Resident ID #49 revealed s/he was admitted to the facility in October of 2022 with diagnoses including, but not limited to, pain, history of venous thrombus (blood clot in the vein), spinal stenosis, and vertebral compression fractures. Record review revealed a physician's order dated 6/7/2023, which states May have Palliative care consult for pain management. Record review revealed the palliative care consult was completed on 8/2/2023, indicating the consult was completed almost 2 months from the order date. Further review of the palliative care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 2 of 5 residents reviewed with pressure ulcers (a localized injury to the skin and/or underlying skin usually over a boney prominence), Resident ID #s 37 and 73. Findings are as follows: Record review of the facility policy dated 7/2017 and titled, Prevention & Management of Pressure Injuries states in part, Standard .The necessary treatment and services will be provided to promote healing, prevent infection, and prevent new pressure injuries from developing. POLICY: Residents with pressure injuries and those at risk for skin breakdown are identified, assessed, and provided appropriate treatment to encourage healing and/or maintenance of skin integrity. Ongoing monitoring and evaluation are provided . PROTOCOL: Assessment: Ulcer/Risk…

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 the residents receive treatment relative to foot care for 2 of 8 residents observed, Resident ID #s 81 and 80. Findings are as follows: 1. Record review for Resident ID #81 revealed s/he was admitted to the facility in September of 2022 with a diagnosis that includes, but is not limited to, Parkinson's disease. Record review of a quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating his/her cognition is intact. Record review revealed a physician's order dated 1/31/2023 for podiatry services as needed (PRN). During a surveyor interview on 9/11/2023 at approximately 9:17 AM with the resident, s/he revealed that s/he would like to see a podiatrist to have his/her nails cut. During a surveyor observation of the resident's toenails on 9/12/2023 at approximately 3:30 PM revealed long, thickened, and…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 2 of 3 medication carts reviewed, and 2 of 3 medication rooms reviewed. Findings are as follows: Record review of an undated facility policy titled Medication Storage states in part, .Medications must be stored in accordance with manufacturer's specifications . A. Medication Carts 1. During a surveyor observation on 9/12/2023 at 8:50 AM of the 3rd floor Medication Cart B, in the presence of Licensed Practical Nurse (LPN), Staff D, revealed the following: - One box of Budesonide 0.5 milligrams (mg)/2 milliliters (mL) ampule vial neb inhaler, containing 3 sealed foil envelopes and one single ampule in the box, not in the foil envelope and not labeled with a date. Manufacturer's guidance indicates store ampules in the foil envelope. Date once the foil envelope is opened and discard after 2 weeks. During a surveyor interview with Staff D immediately following the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interview it has been determined that the facility failed to provide or obtain from an outside resource, emergency dental services for 1 of 1 resident reviewed for dental pain, Resident ID #49. Findings are as follows: Record review revealed the resident was admitted to the facility in October of 2022 with diagnoses including, but not limited to, morbid obesity, other specified nutritional deficiencies, and protein calorie malnutrition (a deficit of protein). Record review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS; an assessment tool used to evaluate a resident's cognitive function) score of 12 out of 15, indicating the resident has a moderate cognitive impairment. Further review of the MDS assessment revealed under section L, Oral/Dental status, that the resident was assessed to have obvious or likely cavities or broken natural teeth. Record review revealed a physician order dated 10/6/2022 for…

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 all alleged violations are thoroughly investigated for 1 of 1 residents reviewed who was noted to have bruising to his/her genital area, Resident ID #85. Findings are as follows: According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023 states in part, .Possible indicators of physical abuse include an injury that is suspicious because the source of the injury is not observed, the extent or location of the injury is unusual .Examples of injuries that could indicate abuse include, but are not limited to .Bruises, including those found in unusual locations .The location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) .Examples of Injuries of Unknown Source .Unobserved/Unexplained bruising or other injuries in the genital area . Record review of the facility policy dated September 2020, titled, ABUSE…

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 each resident receives necessary respiratory care and services that are in accordance with professional standards of practice for 1 of 5 residents reviewed for respiratory care, Resident ID #49. Findings are as follows: Record review revealed the resident was admitted to the facility in May of 2023 with a diagnosis including, but not limited to, stage four chronic obstructive pulmonary disease (a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation). Surveyor observations of the resident on the following dates and times revealed s/he was receiving oxygen therapy via nasal cannula at 2 liters per minute: -9/11/2023 at 9:17 AM -9/12/2023 at 8:26 AM -9/12/2023 at 10:12 AM During a surveyor interview with the resident on 9/12/2023 at 10:12 AM s/he revealed that s/he has not been receiving oxygen therapy for very long, but that s/he does get out of breath sometimes. Record review failed to reveal evidence of a…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to following a physician's order for medication for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 8/3/2023, alleges in part, that the resident complained of abdominal pain, nausea and episodes of frequent bloody vomit and had been requesting to go to the hospital for two days. 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 readmitted to the facility in June of 2023 with diagnoses including, but not limited to, end stage renal disease (a disease where the kidneys reach an advanced state of loss of function) and hypertension. Record review revealed a…

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