Crystal Lake Rehabilitation and Care Center

Based on record review, surveyor observation, and staff interview it has been determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 2 of 2 residents reviewed requiring pudding thick liquids, Resident ID #s 19 and 16 , for 40 of 48 residents reviewed relative to medication administration, Resident ID #s 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 21, 22, 23, 24, 25, 26, 27, 28, 30, 31, 32, 33, 34, 36, 37, 38, 39, 40, 41, 42, 43, 44, 99, 100, and 199, and for 1 of 1 resident reviewed for foley catheter (a flexible tube inserted into the bladder in order to drain urine) care, Resident ID #33. Findings are as follows: 1a. Record review revealed that Resident ID #19 was readmitted to the facility in December of 2023 with diagnoses including, but not limited to, dysphagia (a condition with difficulty in swallowing food or liquid), aspiration pneumonia (infection of the lungs caused by inhaling…

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 an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections relative to the disinfection of glucometers (a device used to monitor blood glucose). Additionally, the facility failed to ensure that staff utilized Personal Protective Equipment (PPE) properly for 2 of 2 residents reviewed relative to foley catheter (a device that drains urine from your bladder into a collection bag) care and multi drug resistant organism (MDRO), Resident ID #2 and #33. Findings are as follows: 1. Record review of a facility policy titled Glucose Monitoring Equipment states in part, .Glucometers will be cleaned with a bleach wipe and/or manufacturer guidelines after each use . During a surveyor observation on 4/26/2024 at approximately 9:28 AM, Registered Nurse, Staff E, was observed checking a resident's blood glucose level, she…

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 26, 29, and 39. Findings are as follows: According to the Centers for Disease Control and Prevention document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes states in part, Standardize the practices which should be applied during the care of any resident suspected of an infection or started on an antibiotic. These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic review process, also known as an antibiotic time-out, for all antibiotics…

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 provide a minimum of 12 hours per year of in-service training to ensure the continuing competence of nurse aides for 3 of 3 Nurse Aides (NA) reviewed, Staff H, I and J. Findings are as follows: Record review of Staff H, I and J's employee records revealed that they have all worked in the facility greater than one year. Additional review failed to reveal evidence of a minimum of 12 hours per year of in-service training. During a surveyor interview on 4/30/2024 at 12:39 PM with the Administrator during the staffing task she acknowledged that annual 12-hour in-service training for NAs was not provided for the above-mentioned staff members.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the assessment accurately reflected the resident's status for 1 of 1 resident assessed for falls, with major injury, Resident ID #19. Findings are as follows: Record review revealed Resident ID #19 was readmitted to the facility in December of 2023 with a diagnosis including, but not limited to, subarachnoid hemorrhage (brain bleed). Review of a progress note dated 11/14/2023 at 11:51 PM, revealed the resident was found on the floor in his/her room. The resident complained of headache, nausea, change in vision, and lethargy. Resident was assessed by the nurse, 911 was then called for emergency transfer to the hospital. Review of a progress note dated 11/15/2023 at 11:06 PM, states, Call placed to [hospital name], Resident was admitted with a brain bleed at 4:14 PM on 11/15/2023 Record review of hospital documentation dated 12/11/2023, titled Inpatient Summary states in part, .a new large right IPH [Intraparenchymal hemorrhage, bleeding within the brain] . Record review 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 surveyor observation, record review, and staff interview it has been determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 11 resident's reviewed, Resident ID #s 4, 29, and 100. Findings are as follows: 1. Record review revealed that Resident ID #4 was admitted to the facility in February of 2023 with diagnoses including, but not limited to, osteomyelitis (infection of the bone) of right ankle and foot and peripheral vascular disease. Review of an Annual Comprehensive Minimum Data Set (MDS) Assessment, Section V dated 3/3/2024, revealed that the resident triggered for the following care areas to be added to his/her care plan: Cognitive loss/dementia Activities of daily living Falls Pressure ulcer/injury Review of the physician's orders revealed that the resident has wounds to his/her right lower extremity requiring dressing…

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 appropriate treatment and services for 3 of 3 residents reviewed diagnosed with urinary tract infections (UTI), Residents ID #s 26, 29, and 39. Findings are as follows: Review of a facility policy titled, Urinary Tract Infections states in part, .If a resident presents with urinary tract symptoms, the nurse will .record intake and output for 72 hours .institute hydration program or increase fluids .the resident will be placed on intake and output and fluids will be encouraged . 1. Record review revealed that Resident ID #26 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, diabetes and chronic obstructive pulmonary disease. Review of a care plan dated 4/19/2024 revealed that the resident has a UTI with an interventions which include, but is not limited to, encourage fluids. Review of a progress note dated 4/19/2024 authored by the Nurse Practitioner states in part, Cipro 500 mg po [by mouth] daily x 7 [days] (UTI)…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate 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 3 of 3 nurses reviewed, Staff E, R, and S and for 3 of 3 Nursing Assistants (NA's) reviewed, Staff H, I, and J. Findings are as follows: 1) Multiple surveyor observations were made throughout the survey process from 4/25/2024 through 5/1/2024, nursing concerns were identified relative to wound care, clean dressing changes, glucometer (device used to assess blood glucose levels) cleaning and disinfection, foley catheter (a device that drains urine from your bladder into a collection bag) management, and suctioning (removal of secretions from the respiratory passages when the patient cannot remove them by coughing). Record review failed to reveal evidence that competencies 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.

Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident receives and is provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being, for 1 of 1 resident reviewed for initial psychiatric evaluation, Resident ID #39. Findings are as follows: Record review revealed that Resident ID #39 was admitted to the facility in July of 2023 with diagnoses including, but not limited to, malignant neoplasm of prostate (prostate cancer) and depression. Record review revealed a hospice visit note dated 1/4/2024 signed by the Medical Director, which states in part, Patient will be graduating from hospice with last covered date 1/6/2024. Patient reports depressed mood [and] is requesting to come off mirtazapine [antidepressant] as [s/he] feels this is contributing to [his/her] mood. Patient is also requesting something to help increase mood and would benefit from a geri psych [geriatric psychiatry] consult. Recommend .Please obtain geri psych consult…

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 each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 35 opportunities for error observed during the medication administration task, there were 10 errors resulting in an error rate of 28.57%, involving Resident ID #s 19, 20, 29, 45, and 99. Findings are as follows: According to, Mosby's Drug Guide Tenth Edition 2013, section, SAFE MEDICATION ADMINISTRATION GUIDE states in part, The 5 rights of medication administration. Always adhere to the 5 rights of medication administration when transcribing, preparing, administering, and documenting medications .2. Right drug: Verify the correct medication by comparing the name on the label on the drug container with that written on the MAR [Medication Administration Record] .5. Right time: All medications should be administered within 30 minutes of the scheduled time . 1a) Record review revealed Resident ID #19 has a physician's order for Propranolol (blood pressure medication)…

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

Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to keep residents free from significant medication errors for 40 of 48 residents reviewed for medication administration, Resident ID #s 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 21, 22, 23, 24, 25, 26, 27, 28, 30, 31, 32, 33, 34, 36, 37, 38, 39, 40, 41, 42, 43, 44, 99, 100, and 199. Findings are as follows: According to, Mosby's Drug Guide Tenth Edition 2013, section, SAFE MEDICATION ADMINISTRATION GUIDE states in part, The 5 rights of medication administration .5. Right time: All medications should be administered within 30 minutes of the scheduled time . During a surveyor observation on 4/26/2024 at approximately 10:00 AM during the medication administration task, concerns were identified with the timeliness of the distribution and administration of the resident's medications. Review of the Administration Compliance Report dated 4/26/2024 revealed that the following 40 residents failed to receive the listed medications below on 4/26/2024 as ordered by 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 treat each resident with respect and dignity in an environment that promotes maintenance of his or her quality of life for 1 of 1 resident reviewed relative to foley catheter (a tube that is placed in the body to drain and collect urine from the bladder) care, Resident ID #33. Findings are as follows: Review of a facility policy titled Urinary Catheter Irrigation- Intermittent (Indwelling) states in part, .explain the procedure and provide privacy . Record review revealed that Resident ID #33 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, urinary retention and low back pain. Review of a physician's order revealed the resident has a foley catheter with directions to flush the foley every shift. During a surveyor observation on 4/26/2024 at approximately 8:45 AM, the resident was observed with the door open while Licensed Practical Nurse (LPN), Staff A, and Registered Nurse (RN), Staff D, were observed flushing and then…

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 following a physician's order for 1 of 1 resident reviewed for double portions, Resident ID #7. 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 #7 was admitted to the facility in October of 2023 with a diagnosis including, but not limited to, dementia. Further record review revealed the resident has a physician's order dated 2/29/2024 for .DOUBLE PORTIONS PLEASE Surveyor observations on 4/26/2024 and on 4/30/2024 at lunch revealed the resident failed to receive double portions. An additional observation on 5/1/2024 revealed the resident failed to receive double portions at breakfast, 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 a resident with pressure ulcers receives 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 for pressure ulcers, Resident ID #2. Findings are as follows: Record review revealed that the resident was readmitted to the facility in January 2023 with diagnoses including, but not limited to, need for assistance with personal care and dementia. Record review of a progress note dated 4/11/2024 revealed, the resident has a sacral (coccyx) wound with a treatment order to apply zinc and medihoney (wound treatment) daily and as needed. Further review revealed the Medical Director agreed with this treatment. Review of the April 2024 Medication Administration Record failed to reveal a treatment was in place from 4/14/2024 through 4/25/2024. During a surveyor interview on 4/25/2024 at 11:53 AM with the Wound Physician he revealed, the resident has a…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 5 residents reviewed for oxygen use, Resident ID #s 1 and 29, and 1 of 1 resident reviewed for suctioning, Resident ID #19. Findings are as follows: 1. Record review revealed Resident ID #19 was readmitted to the facility in December of 2023 with diagnoses including, but not limited to, dysphagia (a condition resulting in difficulty swallowing food or liquid), aspiration pneumonia (infection of the lungs caused by inhaling saliva, food, liquid, vomit) and stroke. Review of the physician's orders revealed the following: - suctioning as needed dated 1/15/2024 - aspiration (when food or liquid goes into the airway) precautions and to monitor for signs and symptoms of aspiration every shift dated 3/21/2024 - House, Pudding Thickened, Pureed Special Instructions: NO STRAWS. ONLY NURSE TO PREPARE THIN LIQUIDS TO PUDDING CONSISTENCY . dated 4/26/2024 Record review revealed a progress note…

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 biologicals in accordance with currently accepted professional principles for 1 of 2 nursing carts and 1 of 1 medication room observed. Findings are as follows: 1. Review of a facility provided document titled, Abridged List of Medications with Shortened Expiration Dates dated 4/2021 states in part, .eye drops/ointments beyond use date is 60 days after opening .Solutions .Lorazepam Solution (Ativan Intensol) beyond use by date 90 days after opening if refrigerated .Insulin Lantus beyond use date 28 days after opening .Insulin Lispro beyond use date 28 days . During a surveyor observation on 4/29/2024 at 9:40 AM in the presence of Licensed Practical Nurse, Staff A, of the nursing cart, revealed the following: -3 bottles of atropine 1% eye drops, open and undated -1 bottle of Ativan Intensol with a label to refrigerate, stored in the medication cart unrefrigerated -1 Lantus Insulin Pen with an open date of 3/19/2024 (indicating it is 13 days…

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 relative to lung sound documentation and suctioning, Resident #19. Findings are as follows: 1a. Record review revealed Resident ID #19 was readmitted to the facility in December of 2023 with diagnoses including, but not limited to, dysphagia (a condition with difficulty in swallowing food or liquid), aspiration pneumonia (infection of the lungs caused by inhaling saliva, food, liquid, vomit) and stroke. Record review of a physician's order dated 3/21/2024 states, VS [vital signs] Q [every] SHIFT Lung sounds every shift and Document in nurse's notes. Every Shift First, Second, Third. Record review of the nurse's notes from 4/1/2024 through 4/30/2024, revealed 84 out of 90 opportunities without documentation of lung sounds per the physician's order. During a surveyor interview on 4/30/2024 at 11:54 AM with the Infection Preventionist, she was unable to provide evidence of documented lung…

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 representative interview, it has been determined that the facility failed to protect and promote the rights of the resident for 5 of 5 residents reviewed who had their picture posted on social media, Resident ID #s 5,6, 7, 8, and 9. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health of [DATE] alleges that Resident ID #6's photograph was posted to Facebook without the consent of the resident or of the resident's representative. 1. Record review revealed that Resident ID #6 was admitted to the facility in December of 2021 with diagnoses including, but not limited to, dementia and major depressive disorder. Further review revealed that the resident expired at the facility on [DATE]. Record review failed to reveal evidence that a consent for photographs to be taken or posted on a social media platform was signed by the resident or the resident's representative. Review of the facility's public social media…

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 provide the necessary services to a resident who is unable to carry out activities of daily living (ADL) for 5 of 5 residents reviewed who are not independent with transfers and/or ambulation, Resident ID #s 1, 2, 3, 4, and 5. Findings are as follows: 1. Record review revealed that Resident ID #1 was re-admitted to the facility in January of 2024 with diagnoses including, but not limited to, Wernicke's encephalopathy (a neurological disorder marked by mental confusion and unsteady gait- a person's manor of walking), cognitive communication deficit, and abnormalities of gait and mobility. Review of a care plan dated 1/2/2023 revealed the resident was at risk for falls with an intervention to assist the resident when standing or ambulating. Review of a Physical Therapy [PT] Discharge Summary dated 2/16/2024 revealed the resident required supervision with transfers and ambulation with his/her rolling walker. This document was requested by the surveyor as the PT Discharge Summary is not 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 surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice for 1 of 2 new admissions reviewed, Resident ID #4. Findings are as follows: 1. Record review revealed that Resident ID #4 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, cytomegaloviral disease (CMV- which is a virus that can infect almost anyone, but if you have a weakened immune system, CMV can be serious or even fatal) and kidney transplant status. Review of the hospital discharge document titled After Visit Summary dated 3/20/2024 revealed the following medication orders for the facility: -Valganciclovir (antiviral for CMV) 450 milligram (mg) tablet, take 2 tablets by mouth for a total of 900 mg twice daily. -Gabapentin (used for neuropathy) 300 mg capsule, take 1 capsule by mouth at bedtime. With special instruction which states in part, Another medication with the same name was removed. Continue taking…

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 relative to Urinary Tract Infections (UTI) and/or Indwelling catheters (a flexible tube that collects urine from the bladder and leads to a drainage bag), for 3 of 3 residents reviewed, Resident ID #s 1, 2 and 4. Findings are as follows: Review of the facility's undated policy and procedure titled Urinary Incontinence and Indwelling catheter, states in part, .assessment should include the risks and benefits of an indwelling catheter .the potential for removal of the catheter .Documentation must support why the Foley catheter is necessary .With all indwelling catheter (temporary or permanent), the size and type of catheter must be written in the order . Review of the facility's undated policy titled UTI Protocol states, .Check resident for Constipation .Obtain CBC w/dif [Complete Blood Count with differential, a blood test that helps detect a range of disorders and conditions…

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 resident and staff interview, it has been determined that the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 2/28/2024 alleges that on 2/22/2024 Resident ID #1's mail was opened prior to him/her receiving it. The resident approached the Administrator about it and told her that it was an invasion of his/her privacy and she said that it was her right. The resident became very upset and she then made a comment that she was going to egg [him/her] on to get [him/her] out of here because this is not a psych ward. The Administrator continued to antagonize the resident and 911 was called. The police and rescue showed up and the responding officer told the Administrator…

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 that resident's receive treatment and care in accordance with professional standards of practice, for 1 of 1 resident reviewed for an ordered dermatology consult, Resident ID #1. Findings are as follows: Record review revealed that the resident was admitted to the facility in July of 2023 with diagnoses including, but not limited to, parkinsonism, anxiety disorder and psoriasis vulgaris (chronic skin disease which results in scaly, often itchy areas in patches). Review of a Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 12 out 15, indicating the resident has moderately impaired cognition. During a surveyor interview with the resident on 2/29/2024 at 8:42 AM, s/he revealed that s/he has been complaining about his/her skin for months and was told that s/he would be going to the dermatologist, however, s/he has not been yet. Further review of the record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident interview, it has been determined that the facility failed to treat each resident with respect and dignity in an environment that promotes maintenance of his or her quality of life for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 2/28/2024 alleges that on 2/22/2024 Resident ID #1's mail was opened prior to him/her receiving it. The resident approached the Administrator about it and told her that it was an invasion of his/her privacy and she said that it was her right. The resident became very upset and she then made a comment that she was going to egg [him/her] on to get [him/her] out of here because this is not a psych ward. The Administrator continued to antagonize the resident and 911 was called. The police and rescue showed up and the responding officer told the Administrator that he was shocked that she was behaving this way towards a resident. 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.

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 respect the residents right to personal privacy for 1 of 2 residents reviewed who receive mail at the facility, Resident ID #1. Findings are as follows: Review of a facility policy titled, Residents Rights undated, states in part, .15. You have the right to send and receive mail promptly and unopened . Review of a community reported complaint submitted to the Rhode Island Department of Health on 2/28/2024 alleges that on 2/22/2024 Resident ID #1's mail was opened prior to him/her receiving it. The resident approached the Administrator about it and told her that it was an invasion of his/her privacy and she said that it was her right. The resident became very upset and she then made a comment that she was going to egg [him/her] on to get [him/her] out of here because this is not a psych ward. The Administrator continued to antagonize the resident and 911 was called. The police and rescue showed up and 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 provide written notice of the facility's bed-hold policy to the resident or resident representative, prior to the transfer of the resident to the hospital, for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Record review revealed the resident was admitted to the facility in March of 2017 with diagnoses including, but not limited to major depressive disorder, visual hallucinations, low vision right eye, and blindness in left eye. Record review revealed the resident was transferred from the facility to the hospital on 2/19/2024. Record review failed to reveal evidence of a written bed-hold policy that was provided to the resident or the resident's representative. During a surveyor interview on 2/27/2024 at 10:30 AM with the Administrator, in the presence of the Director of Nursing Services, she was unable to provide evidence of a written notice of the facility's bed-hold policy being given to the resident or resident's representative. Cross reference: F 558 and F 684

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 that residents receive treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed for falls, Resident ID #1. Findings are as follows: Record review of a document titled Falls Management states in part .A fall risk evaluation will be conducted by the nurse on duty/supervisor on any resident/patient sustaining a fall with or without injury. Once the resident/patient is clinically evaluated as being stable, vital signs, neurological signs, range of motion, and evaluation of cognitive status will be documented . Record review revealed the resident was admitted to the facility in March of 2017 with diagnoses including, but not limited to major depressive disorder, visual hallucinations, low vision in the right eye and blindness in the left eye. Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status…

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 assure residents who have authorized the facility in writing to manage any personal funds have ready and reasonable access to those funds, relative to petty cash. Findings are as follows: Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities dated 2/3/2023, states in part, Residents should have access to petty cash on an ongoing basis and be able to arrange for access to larger funds. Although the facility need not maintain $100.00 ($50.00 for Medicaid residents) per resident on its premises, it is expected to maintain petty cash on hand to honor resident requests . Record review of a community reported complaint sent to the Rhode Island Department of Health on 1/3/2024, alleges that the resident's do not have access to their funds in a timely manner and the accounts are not up to date. Record review of Funds Balance Report for 1/8/2024 revealed, that the facility manages personal funds for 30 residents equaling 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 surveyor observation, record review and staff interview it has been determined that the facility failed to provide an ongoing program which includes group activities and/or one-on-one visits (1:1), on 1 of 4 units reviewed for activities for residents with cognitive impairment that resided on the Subacute Unit, including those residents that were admitted on the unit and recently discharged , Resident ID #s 1, 2, 3, 4 and 5. Findings are as follows: Review of the facility document titled, RECREATION POLICIES/PROCEDURES with a revision date of 9/2015, states in part, I. PURPOSE The facility provides a recreation program suited to the abilities, needs, and interests of each individual resident in effort to encourage resumption and maintenance of normal activities .The recreation program is designed to improve and maintain the physical and mental health of each resident through individual and group activities. Interdisciplinary resident care planning sessions act as the medium whereby each resident's…

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 all newly hired employees, consistent with their expected roles, relative to orientation education involving abuse, dementia and behavioral health management per the facility assessment, for 4 of 5 newly hired employees, Staff G, H, I, and J. Findings are as follows: According to the Facility Assessment, dated 4/13/2023, which states in part, Existing Competency process (Type and Time Frames i.e , on hire, quarterly, annually) .Dementia- Orientation .Behavioral Management .Abuse . Record review revealed Registered Nurse (RN), Staff G, was hired on 10/24/2023. Additionally, her personnel file failed to reveal evidence that she received education or training upon hire relative to abuse, dementia and behavioral health management. Record review of RN, Staff H, was hired on 11/6/2023. Additionally, her personnel file failed to reveal evidence that she received education or training upon hire relative to abuse, dementia and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff and resident interview, it has been determined that the facility failed to ensure residents are free from neglect for 11 of 14 residents reviewed, Resident ID #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11. Findings are as follows: Record review of a facility reported incident received by the Rhode Island Department of Health on 9/9/2023 states in part, On 9/9/23 when [staff] came on shift they noted a strong odor of urine, which is not the norm for us . Record review of a facility policy titled, Abuse Neglect Exploitation Mistreatment and Misappropriation of Property Prevention last revised on 3/16/2023, states in part, .Neglect occurs when facility staff fails to monitor and/or supervise the delivery of patient/resident care and services to assure care is provided as required . During a surveyor interview on 9/12/2023 at approximately 9:00 AM with the Director of Nursing Services (DNS), she revealed that a contracted agency employee, Nursing Assistant (NA), Staff A, was assigned to…

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

Based on record review and staff interview it has been determined that the facility failed to ensure that residents are free from significant medication errors for 2 of 3 residents reviewed related to medication delivery, Resident IDs #1 and 2. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 8/11/2023 alleges in part, Patient [Resident ID #1] was discharged to SNF [skilled nursing facility] on 8/8 on IV [intravenous] antibiotics. SNF was notified in the referral about the antibiotic and accepted patient. Two days later, patient sent back to the ED [emergency department] at [hospital] and had not received the antibiotic since discharge. Informed due to price, the SNF would not obtain the med and asked the resident to pay out of pocket which [s/he] could not afford. 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.…

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

Based on surveyor observations, record review, 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 2 medication storage rooms. Findings are as follows: Record review of a facility policy titled, POLICY: MEDICATION STORAGE states in part, .Discontinued, outdated, or deteriorated drugs or biological's are returned to the dispensing pharmacy or destroyed. Record review of a facility policy titled, POLICY: MEDICATION ADMINISTRATION states in part, 7. Expired medications are to be properly discarded. Medications are labeled and expiration dates are checked regularly. 1. Record review revealed that Resident ID #34 was admitted to the facility in November of 2021 with a diagnosis including, but not limited to, dementia. Record review revealed a physician's order dated 6/22/2023 for Ativan Intensol 2 milligrams per milliliter (mL) administer 0.125 mL for agitation/restlessness/anxiety every 8 hours as needed. During a surveyor observation of the long-term…

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 1 of 1 resident reviewed related to an as needed blood pressure medication, Resident ID #20. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states: The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review revealed that Resident ID #20 was admitted to the facility in April of 2021 with a diagnosis including, but not limited to, hypertension (high blood pressure). An additional diagnosis was added to the resident's record in May 2023 for hypertensive urgency (defined as a blood pressure of more than 180/120. The normal blood pressure is 120/80). Record review revealed a physician's order dated 6/12/2023 for Hydralazine (a medication used to lower blood pressure) administer 25 milligrams (mg) daily as needed for systolic blood pressure (pressure 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff interview, it has been determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life relative to assistance with eating during meals, for 1 of 3 residents reviewed, Resident ID #34. Findings are as follows: Review of the resident's record revealed s/he was admitted to the facility in November of 2021 with diagnoses including, but not limited to, cerebral infarction (stroke) and dementia. Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has a Brief Interview for Mental Status score of 2 out of 15, indicating severe cognitive impairment. Further review of the MDS revealed the resident requires limited assistance of one staff member for eating. Surveyor observations of the resident during meal times revealed the following: - 7/11/2023 at 9:22 AM, observed alone 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 surveyor observations, 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 a physician's order for a fluid restriction for 1 of 1 resident reviewed, Resident ID #213. Findings are as follows: Review of the facility policy titled FLUID RESTRICTIONS states in part, Policy: Restricted fluid intake will be maintained for an individual resident, as ordered by the physician, as part of a treatment protocol for certain medical conditions .Maintain accurate Intake .Document, as necessary, the resident's compliance with the fluid restriction, and notify MD [Medical Doctor] if any issues . Record review revealed Resident ID #213 was admitted to the facility in July of 2023 with diagnosis including, but not limited to, acute respiratory failure. Record review of the Continuity of Care form dated 6/29/2023 revealed that the resident has severe aortic stenosis (a condition that prevents the aortic valve from opening properly) with a plan for strict intake…

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 for 1 of 1 resident reviewed relative to the failure to administer an as needed blood pressure medication, Resident ID #20. Findings are as follows: Record review revealed that Resident ID #20 was admitted to the facility in April of 2021 with a diagnosis including, but not limited to, hypertension (high blood pressure). An additional diagnosis was added to the resident's record in May 2023 for hypertensive urgency (defined as a blood pressure of more than 180/120. The normal blood pressure is 120/80). Record review revealed a physician's order dated 6/12/2023 for Hydralazine (a medication to regulate blood pressure) administer 25 milligrams (mg) daily as needed for systolic blood pressure (pressure in your arteries when your heart beats) above 180 or diastolic blood pressure (pressure in your arteries between each heartbeat) above 100. Record review revealed the resident's blood…

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 observations, record review, and staff interview, it has been determined that the facility failed to ensure that a residents environment remains as free from accident hazards as possible for 1 of 1 resident reviewed, Resident ID #34. Findings are as follows: Record review revealed that Resident ID #34 was admitted to the facility in November of 2021 with diagnoses including, but not limited to, cerebral infarction (stroke) and dementia. Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 2 out of 15, indicating severe cognitive impairment. Further review of the MDS revealed that the resident requires limited assistance of one staff member for eating. Record review of the resident's care plan last revised on 5/13/2023 revealed that the resident has been noted to put inedible items in his/her mouth. Further review of the care plan revealed an intervention that includes, but not limited to, no styrofoam cups with meals,…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections relative to following contact precautions for 1 of 2 residents reviewed, Resident ID #47. Findings are as follows: Record review of a facility policy titled, TITLE: Guidelines for Management of MDROs [Multi-drug resistant organism] states in part, .Vancomycin resistant enterococci [VRE] .bacteria usually found in the bowel .VRE is spread by direct patient-to-patient via transient carriage on the hands of personnel or indirect contact on contaminated surfaces or equipment .can persist for weeks on environmental surfaces .Contact Precautions should be considered and would be indicated for .MDRO urinary tract infection or colonization . Record review revealed that Resident ID #47 was admitted to the facility in April of 2023 with a diagnosis…

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.