Lincolnwood Rehabilitation and Healthcare Center

Based on record review, resident and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice relative to following physician's orders for 1 of 2 residents recently admitted to the facility, Resident ID #3. Findings are as follows:Record review revealed the resident was admitted to the facility in June of 2025 with diagnoses including, but not limited to, end stage renal disease, dependence on renal dialysis (a medical treatment to remove waste and fluids from the blood when the kidneys do not function properly) and constipation.Record review of the July 2025 admission Minimum Data Set Assessment revealed a Brief Interview for Mental Status score of 15 out of 15, indicating the resident is cognitively intact.Record review of the admission Transfer/Discharge Report dated 6/26/2025 revealed an order for Polyethylene Glycol 3350 (Miralax; a medication prescribed to treat constipation) 17 grams (gm) by mouth every 24 hours as needed (PRN) for constipation, hold for loose stools.Record review of 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 residents who require dialysis (a medical treatment that removes waste and fluids from the blood when the kidneys do not function properly) receive such services, consistent with professional standards of practice relative to following the physician's orders for a fluid restriction and medication administration for 1 of 3 residents reviewed, Resident ID #2. Findings are as follows: Record review revealed the resident was admitted to the facility in July of 2025 with diagnoses including, but not limited to, end stage renal disease, dependence on renal dialysis and fluid overload. Record review revealed the resident receives dialysis weekly every Tuesday, Thursday, and Saturday. 1a. Record review revealed a physician's order dated 7/7/2025 for a 1000 milliliter (ml) fluid restriction, indicating to provide the allowed fluid intake per the physician's order and document the total amount consumed every shift. Additionally, the order revealed a breakdown of fluids to include a total…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections for 4 out of 5 residents reviewed for droplet precautions, Resident ID #s 5, 29, 106, and 107 and for 1 of 1 resident reviewed with a peripherally inserted central catheter (PICC line, a long thin tube that is inserted through a vein in the arm and passed through to the larger veins in the heart), Resident ID #416. Findings are as follows: 1a) Record review revealed Resident ID #5 was readmitted to the facility in June of 2024 with a diagnosis including, but not limited to, end stage renal disease. Record review revealed a physician's order dated 1/8/2025 for isolation precautions; droplet precautions until 1/15/2025, due to testing positive for Flu A. Review of the signage posted outside of the resident's room from 1/13/2025 through 1/15/2025 revealed the resident was on special contact/droplet precautions which indicated to wear a gown,…

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

Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 3 of 3 residents reviewed for antibiotic use, Resident ID #s 15, 32, and 53. 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…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to care of a peripherally inserted central catheter (PICC line, a long thin tube that is inserted through a vein in the arm and passed through to the larger veins in the heart) for 1 of 1 resident reviewed with a PICC line, Resident ID #416. Findings are as follows: According to Lippincott Nursing Procedures, Ninth Edition page 653, states in part, .Make sure to follow evidence-based infection-prevention techniques, such as performing hand hygiene, using maximal barrier precautions, following sterile technique, and properly preparing the insertion site, to reduce the risk of vascular catheter-associated infections. Review of a facility policy titled, Peripheral and Midline IV [intravenous] Dressing Changes dated March 2022 states in part, .Maintain sterile dressing (transparent semi-permeable membrane [TSM] dressing or sterile gauze) for all peripheral…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following physician orders for 1 of 1 resident reviewed with a skin tear, Resident ID #79. 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 physicians' orders unless they believe the orders are in error or would harm the clients. Record review revealed Resident ID #79 was readmitted to the facility in September of 2024 with diagnoses including, but not limited to, Alzheimer's disease and adult failure to thrive. During a surveyor observation on 1/13/2025 at 9:09 AM, of the resident s/he was observed with a wound dressing to the back of his/her right hand dated 1/7/2025. Further observation revealed the dressing had visible dark soilage underneath. Record review of a physician's order dated 1/7/2025 revealed to cleanse 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 ensure that residents with pressure ulcers receive the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 1 resident reviewed who was admitted with a pressure ulcer, Resident ID #415. Findings are as follows: Record review revealed that Resident ID #415 was admitted to the facility in January of 2025 with diagnoses including, but not limited to, hemiparesis (one sided muscle weakness because of disruption to the brain or spinal cord) and hemiplegia (total or nearly complete paralysis on one side of the body). Record review of an admission assessment dated [DATE] revealed the resident has a pressure ulcer to his/her coccyx. Further review failed to reveal measurements or a description of the wound to include staging (classifying wounds based on their depth and severity), exudate…

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 maintain acceptable parameters of nutritional status, such as usual body weight for 1 of 2 residents reviewed for significant weight loss, Resident ID #30. Findings are as follows: Record review of a facility policy titled, Weight Assessment and Intervention, with a revision date of March 2022, states in part, .Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation .if the weight is verified, nursing will immediately notify the dietician in writing .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .a. 1 month - 5% weight loss is significant; greater than 5% is severe. b 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe .Undesirable weight change is evaluated by the treatment team whether or 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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents who are fed by a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 2 residents reviewed who require continuous feeding via a gastrostomy tube (G-tube, a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine), Resident ID #144. Findings are as follows: Review of a policy titled Enteral Nutrition dated November 2018 states in part, .Risk of aspiration [inhaling a substance into the lungs that may lead to coughing and infection] may be affected by .improper positioning of the resident during feeding . Record review revealed the resident was admitted to the facility in March of 2024 with diagnoses including, but not limited to, dysphagia (difficulty swallowing) and cognitive communication deficit. Review of a care plan dated 8/30/2024, revealed the resident required enteral tube feeding with a goal to remain free from complications 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 record review and staff interview it has been determined that the facility failed to maintain the resident's medical record in accordance with accepted professional standards and practices, for 1 of 1 resident reviewed with a skin tear, Resident ID #79. Findings are as follows: Record review revealed Resident ID #79 was readmitted to the facility in September of 2024 with diagnoses including, but not limited to, Alzheimer's disease and adult failure to thrive. During a surveyor observation on 1/13/2025 at 9:09 AM, of the resident s/he was observed with a wound dressing to the back of his/her right hand dated 1/7/2025. Further observation revealed the dressing had visible dark soilage underneath. Record review of a physician's order dated 1/7/2025 revealed to cleanse the wound on the back of the right hand with wound cleanser, skin prep surrounding area and cover with a dry clean dressing daily until resolved. During a surveyor interview on 1/13/2025 at 2:01 PM, with Licensed Practical Nurse (LPN), Staff B, she acknowledged that the wound dressing appeared soiled and 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 services provided by the facility meet professional standards of quality relative to following physician's orders for 1 of 4 residents reviewed, Resident ID #3. 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 Resident ID #3 was admitted to the facility in October of 2024 with diagnoses including, but not limited to, atrial fibrillation (an irregular heartbeat often causing inadequate blood flow through the heart) and pneumonia. Record review of the hospital Continuity of Care document dated 10/31/2024 revealed a physician's order to start Cefpodoxime (a medication prescribed to treat various infections) 200 milligrams(mg) twice a day for 3 days, with a stop date of 11/3/2024. Record review of the November 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.

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 receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed for a suprapubic catheter (a medical device that helps drain urine from your bladder into a collection bag outside of your body when you can't urinate on your own), Resident ID #3 and for 1 of 1 resident reviewed with an indwelling foley catheter (a device that drains urine from your urinary bladder into a collection bag outside of your body when you can't urinate on your own), Resident ID #4. Findings are as follows: According to [NAME] CoursePoint Enhanced for Taylor's Fundamentals of Nursing, 9th Edition the following are important nursing measures used to care for patients with an indwelling catheter: .make sure that the patient maintains a generous fluid intake, unless contraindicated by other health concerns. This helps prevent infection and irrigates the catheter naturally by…

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 relative to the decision to transfer a resident to an acute care hospital for one of one resident reviewed, Resident ID #3. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health, dated 9/12/2024 alleges that the resident was transferred to an acute care hospital and his/her family was not notified. Record review revealed the resident was readmitted to the facility in August of 2024 with diagnoses including, but not limited to, urinary tract infection, anemia, and Methicillin-Resistant Staphylococcus Aureus (MRSA). Review of a nursing progress note authored by Licensed Practical Nurse, Staff A, revealed that on 8/23/2024 at 9:00 PM the resident was noted to not have any urinary output from his/her suprapubic catheter (a medical device that helps drain urine from your bladder). Additionally, the note indicated that the resident was complaining of abdominal pain so s/he 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.

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 written notice of the bed-hold policy to the resident or resident representative, prior to the transfer of the resident to the hospital, 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 8/23/2024 alleges that, Resident ID #1 was discharged from the facility to the hospital on 8/8/2024. On 8/16/2024, the hospital case manager was informed by the facility that the resident was a short-term resident (the resident had been residing in the facility for 2 years), and the facility no longer had any available beds. Record review revealed that Resident ID #1 was admitted to the facility in August of 2022 with a diagnosis including, but not limited to, Alzheimer's disease. Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 00 out of 15,…

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 treatment and care in accordance with professional standards of practice relative to following physician orders for obtaining appointments with specialists for 1 of 3 residents reviewed, Resident ID #2. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 8/19/2024 alleges that Resident ID #2 was admitted to the facility in July of 2024 with several follow-up appointments scheduled for August 2024, including a cardiology follow-up appointment. Additionally, the complaint alleges that the facility was aware of these appointments and failed to obtain transportation for the resident to get to his/her appointments. Record review revealed that Resident #2 was admitted to the facility in July of 2024 with diagnoses including, but not limited to, heart failure, end stage renal disease and diabetes. Review of a hospital…

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 pharmaceutical services, including procedures that assure the accurate administration of all drugs, relative to chemotherapy medication for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a community reported complaint received by the Rhode Island Department of Health on 8/13/2024 alleged that Resident ID #1 did not receive the correct dosage of his/her chemotherapy medication. Record review revealed that the resident was admitted to the facility in June of 2024 with diagnoses including, but not limited to, malignant neoplasm of the brain (brain cancer) and bipolar disorder. Review of the July 2024 Medication Administration Record (MAR) revealed that the resident received Temozolomide (chemotherapy agent) 125 milligrams (mg) daily from 7/11 until 7/21/2024. Review of a progress note dated 7/22/2024 authored by Nurse Practitioner (NP), Staff A, revealed the resident was transferred…

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 residents are free from significant medication errors relative to administering the correct dosage and medication in the correct form for 1 of 3 residents reviewed for chemotherapy medication, Resident ID #1. Findings are as follows: A. Review of a facility policy titled, Reconciliation of Medications on Admission last revised in July 2017 states in part, The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility .Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR [Medication Administration Record], and the admitting orders .Review the list carefully to determine if there are discrepancies/conflicts. For example: a. The dosage on the discharge summary does not match the dosage…

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 ensure a resident's dignity was maintained for 1 of 3 residents reviewed, Resident ID #4. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/25/2024 revealed that Nursing Assistant (NA), Staff A, allegedly called Resident ID #4 a cripple, while providing care to the resident. Review of a facility policy titled Dignity states in part, .Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her .diagnosis, or care needs. Record review revealed that the resident was admitted to the facility in December of 2023 with diagnoses including, but not limited to, myopathy (a condition that affects the muscles connecting to your bones that control voluntary movements in the body), chronic pain syndrome, and anxiety. Record review of 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 food is stored, served and distributed, in accordance with professional standards for food service safety, relative to the main kitchen and the South 2 Nursing Unit kitchenette. Findings are as follows: 1. The Rhode Island Food Code 2018 Edition 5-202.13 reads in part, .an airgap between the water supply inlet and the flood level rim of the plumbing fixture equipment .shall be at least twice the diameter of the water supply inlet and may not be less than 25mm (1 inch) . During a surveyor observation on 1/28/2024 during the initial tour of the main kitchen, the ice machine in the dietary department did not have an air gap. During a surveyor observation on 1/28/2024 at approximately 10:00 AM, the ice machine located on the South 2 Nursing Unit kitchenette did not have an air gap. During a surveyor interview on 1/28/2024 at approximately 11:10 AM with the Regional Director of Maintenance, he acknowledged the ice machine for the main kitchen did not have 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.

Based on surveyor observations and staff interview, it has been determined that the facility failed to dispose of garbage and refuse properly relative to 1 of 1 dumpster and the surrounding area. Findings are as follows: During surveyor observations on the following dates and times revealed a recliner, 5 oxygen concentrators, multiple white trash bags, empty cigarette cartons, and broken cardboard boxes surrounding the outside of the dumpster: - 1/31/2024 at approximately 2:00 PM - 2/1/2024 at approximately 2:30 PM - 2/2/2024 at approximately 2:30 PM Additionally, an uncovered Rubbermaid tilt truck (a utility cart that can be dumped by one person) was observed overflowing with disposable gloves and Styrofoam cups sitting atop ice in the truck. During a surveyor interview on 2/2/2024 at approximately 2:45 PM with the Regional Director of Maintenance, he acknowledged the dumpster area was in need of cleaning.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice relative to the assessment of the resident before dialysis treatments and ongoing communication and collaboration with the dialysis facility for 3 of 3 residents reviewed, Resident ID #s 75, 157, and 381. Findings are as follows: Review of the State Operations Manual Appendix PP-Guidance for Surveyors for Long Term Care Facilities revised 2/3/2023 states in part, .the facility assures that each resident receives ongoing assessment of the resident's condition and monitoring for complications before .dialysis treatments received at a certified dialysis facility .Ongoing communication and collaboration with the dialysis facility . Review of the facility policy titled, End-Stage Renal Disease, Care of a Resident with, states in part, .Agreements between this facility and the contracted ESRD [end stage renal disease] facility include .how information will be exchanged between…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections for 2 of 3 resident's reviewed for Multidrug-resistant Organisms (MDRO), Resident ID #s 6 and 170. Findings are as follows: Review of the CDC's (Centers for Disease Control and Prevention) document titled, Multidrug-resistant organisms management states in part, .For ill residents (e.g., those totally dependent upon healthcare personnel for healthcare and activities of daily living .use Contact Precautions [use of gown and gloves when entering a resident's room] in addition to Standard Precautions .For MDRO colonized or infected patients without draining wounds, diarrhea, or uncontrolled secretions, establish ranges of permitted ambulation, socialization, and use of common areas based on their risk to other patients and on the ability of the colonized or infected patients . Review of the CDC's document titled, Infection Control . states 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 protect the residents' right to be free from neglect for 1 of 2 residents reviewed, Resident ID #236. Findings are as follows: Record review of a facility reported incident submitted the Rhode Island Department of Health on 1/25/2024 indicated that Resident ID # 236 stated that his/her call light was removed and put out of reach, and the Nursing Assistant (NA), (later identified as Staff A) acknowledged removing the call light from the resident's reach. Record review revealed that the resident was admitted to the facility in January of 2024 with diagnoses including, but not limited to, acute respiratory failure, end stage renal disease requiring dialysis, gastrostomy status (tube feeding), cognitive communication deficit, and insomnia. Record review of a care plan initiated on 1/23/2024 revealed a focus area for activities of daily living with an intervention in place to encourage the use of the call bell for assistance. Additional review revealed interventions in place for anti-anxiety…

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 appropriate treatment and services for 1 of 2 residents reviewed with foley catheters relative to a urinary tract infection (UTI), Resident ID #170. Findings are as follows: Review of a facility policy titled, Catheter Care, Urinary states in part, .The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .observe the resident's urine level for noticeable increases or decreases .follow the facility procedure for measuring and documenting input and output . Record review revealed Resident ID #170 was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, neuromuscular dysfunction of bladder. Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. Review of the care plan revealed a focus area dated 12/6/2023 indicating…

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

Based on record review and staff interview it has been determined that the facility failed to maintain medical records on each resident that are accurately documented for 1 of 1 resident reviewed for as needed (PRN) medication for blood pressure, Resident ID #157; and for 1 of 2 residents with foley catheters reviewed for antibiotic treatment for urinary tract infections (UTI), Resident ID #170. 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 the physician's orders unless they believe the orders are in error or would harm the clients. Review of a facility policy titled, Administering Medications states in part, .Medications are administered in accordance with prescriber orders . 1) Record review revealed Resident ID #157 was admitted to the facility in July of 2023 with diagnoses including, but not limited to, end stage renal disease and hypotension (low blood pressure, generally a blood pressure reading lower than 90 millimeters of…

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

Based on record review and staff interview it has been determined that the facility failed to ensure that the residents are free from significant medication errors for 4 of 6 resident's reviewed for medication administration, Resident ID #s 4, 2, 1, and 3. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 1/11/2024 alleges in part that residents do not receive their medications on time. 1a. Record review revealed that Resident ID #4 was admitted to the facility in August of 2022 with diagnoses including, but not limited to, vascular dementia and atrial fibrillation (irregular and often very rapid heart rhythm that can lead to blood clots, stroke, heart failure and other complications). Record review revealed the resident attended a dermatology appointment on 12/6/2024 related to scabies and was ordered the following medications: -Ivermectin 3 milligrams (MG) by mouth, take 5 tablets today and repeat in 2 weeks. -Permethrin 5% topical cream, apply to the entire body neck down to feet overnight for 8 hours, wash off…

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

Based on record review and staff interview it has been determined that the facility failed to ensure that residents receive proper treatment and care to maintain mobility and good foot health, for 1 of 2 residents reviewed, Resident ID #4. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 1/17/2024, alleges, concerns with Resident ID #4 not being seen by the podiatrist. According to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities last revised 2/3/2023 states in part, .Facilities are responsible for providing the necessary treatment and foot care to residents. Treatment also includes preventive care to avoid podiatric complications in residents with diabetes and circulatory disorders who are prone to developing foot problems. Foot care that is provided in the facility, such as toe nail clipping for residents without complicating disease processes, should be provided by staff who have received education and training to provide this service. Foot care and treatment…

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

Based on record review and staff interview it has been determined that the facility failed to ensure that residents receive routine dental services for 1 of 2 residents reviewed, Resident ID #4. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 1/17/2024, alleges, concerns with Resident ID #4 being seen by the dentist. According to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities last revised 2/3/2023 states in part, .Routine dental services .means an annual [yearly] inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g., taking impressions for dentures and fitting dentures . Record review revealed that Resident ID #4 was admitted to the facility in August of 2022 with diagnoses including, but not limited to, vascular dementia and atrial fibrillation…

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 interviews, it has been determined that the facility failed to provide a comfortable and homelike environment relative to cold water temperatures in shower rooms and resident room sinks for 2 of 2 floors observed. Findings are as follows: Record review of two anonymous community reported complaints submitted to the Rhode Island Department of Health on 12/12/2023, alleged that there is no hot water in the facility and residents are being bathed with cold water. During surveyor observations on 12/13/2023 of the 1st floor shower room and resident room sinks revealed the following: - 10:40 AM, the shower room's first shower stall's water had a temperature reading of 92.0 degrees Fahrenheit (F) and a second shower stall had a water temperature reading of 91.7 degrees F - 10:45 AM, resident room [ROOM NUMBER], had a sink water temperature reading of 94.3 degrees F - 10:50 AM, resident room [ROOM NUMBER], had a sink water temperature reading of 91.9…

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 necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 1 resident who has an actual pressure injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence), Resident ID #2. Findings are as follows: Review of The State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities, last revised on 2/3/2023, states in part, .Assessment and Treatment of Pressure Ulcer [PU]/Injury[PI] It is important that each existing PU/PI be identified, whether present on admission or developed after admission .the potential for development of additional PU/PIs or the deterioration of the PU/PIs be recognized, assessed and addressed .When assessing the PU/PI itself, it is important that documentation addresses: -The type of injury (pressure-related versus…

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 fluids and medications prepared in a form designed to meet the individual needs of the resident for 1 of 1 resident reviewed who was ordered pudding thick consistency liquids, Resident ID #1. Findings are as follows: Review of a community reported complaint allegation submitted to the Rhode Island Department of Health on 10/25/2023 states in part, .the rn [Registered Nurse] just gave pt [patient, Resident ID #1] pills and water and walked away. Per this pts health records, [s/he] needs to have all fluids thickened . 1a) Record review revealed the resident was admitted to the facility in October of 2023 with diagnoses including, but not limited to, Parkinson's disease (a neurological disorder) and dysphagia (a condition with difficulty swallowing food or liquid). Review of a physician's diet order dated 10/12/2023 revealed in part, pureed texture, and pudding consistency liquids. Review of a care plan initiated on 10/12/2023 states in part, I have 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.

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 the necessary treatment and care in accordance with professional standards of practice relative to following physician's orders for 1 of 1 resident reviewed with an ileostomy (a surgical procedure that brings one end of the intestine out through an opening or stoma made in the abdominal wall for stool elimination into a colostomy bag), Resident ID #3. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 8/15/2023 alleges that the complainant is concerned for the overall care provided by the facility. Record review revealed the resident was readmitted to the facility in February of 2023 with a diagnosis including, but not limited to, volvulus (a condition when a loop of intestine twists around itself and causing a bowel obstruction). Record review of an admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental…

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 ensure that a resident is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet for 1 of 1 resident reviewed for fluid restrictions, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 8/15/2023 alleges a concern regarding the resident's overall quality of care at the facility. Record review revealed that the resident was admitted to the facility in August of 2023 with diagnoses including, but not limited to, chronic kidney disease and arteriosclerotic heart disease (a condition where the arteries become narrowed and hardened due to fat buildup in the artery wall). Record review of an admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition.…

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 significant medication errors for 1 of 2 residents reviewed who missed a dose of a prescribed antibiotic medication, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 8/15/2023 alleges in part, .concerned about the overall care .and that [his/her] infection will worsen . Record review revealed that the resident was admitted to the facility from an acute care hospital in August of 2023, with diagnoses including, but not limited to, sepsis (also referred to as blood poisoning, a potentially life-threatening condition that arises when the body's response to an infection causes injury to its own tissues and organs) and cellulitis (a bacterial infection involving the inner layers of the skin). Record review revealed a physician's order with a start date of 8/12/2023 for cephalexin (antibiotic medication) 250 milligrams (mg), two capsules to be administered by mouth…

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.