Pawtucket Falls Healthcare Center

Based on record review and staff interview, it has been determined that the facility failed to provide written notice of bed-hold policy to the resident or resident representative, prior to the transfer of the resident to the hospital, for 1 of 5 residents reviewed, Resident ID #2. Findings are as follows: Record review of a community reported complaint reported to the Rhode Island Department of Health on 5/6/2024 alleges, Resident ID #2 was discharged from the facility on 5/2/2024 to the hospital. On 5/3/2024 the hospital case manager was informed by the facility that the resident did not place a bed hold and the facility had already filled his/her bed. The resident was not provided with a bed hold form prior to exiting the building. Record review for Resident ID #2 revealed s/he was admitted to the facility in April 2024 with diagnoses including, but not limited to, acute pyelonephritis (bacterial infection causing inflammation of the kidneys) morbid obesity, type 2 diabetes mellitus, major depressive disorder, and post-traumatic stress disorder. Record review of 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.

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 develop and implement a baseline care plan within 48 hours of the resident's admission that includes instructions needed to provide effective and person-centered care that meets professional standards of quality care, the resident's immediate health and safety needs, physician and dietary orders as well as therapy and social services for 1 of 2 residents reviewed, Resident ID # 2. Findings are as follows: Record review of a community reported complaint reported to the Rhode Island Department of Health on 5/6/2024, revealed that a resident was discharged from the facility on 5/2/2024 to the hospital and on 5/3/2024 the hospital case manager was informed by the facility that the resident did not place a bed hold and the facility had already filled his/her bed. Record review revealed Resident ID #2 was admitted to the facility on [DATE] with diagnoses including, but not limited to, acute pyelonephritis (bacterial…

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 that the facility failed to ensure that the resident's Advanced Directive requesting to refuse lifesaving treatment was followed for 1 of 5 residents reviewed, Resident ID #1. Findings are as follows: Review of the facility policy titled Resident's Rights Regarding Treatment and Advance Directives [a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity] states in part .ensure resident's wishes are met regarding Advanced Directives .it is the resident's right to accept or refuse medical or surgical treatment .on admission the facility will determine if the resident has executed an Advanced Directive . Closed record review for Resident ID #1 revealed diagnoses that include, but are not limited to, Gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection) and chronic obstructive…

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 comprehensive care plan was revised by the interdisciplinary team for 3 of 6 residents reviewed for advanced directives, Resident ID #s 2, 23, and 45. Findings are as follows: Review of the facility policy dated 1/2017 and titled, Advanced Directives states in part, .the resident has a right to refuse treatment and to formulate an Advanced Directive .the facility will abide by the resident's advanced directive .social services and/or medical staff must inform the Executive Director whenever a resident, family member, etc. expresses a desire to change advance directives . Review of a facility policy titled Care Planning dated 6/2023, states in part, .the facility will develop a comprehensive, resident centered care plan for each resident .the interdisciplinary team will meet when a change in condition occurs and annually to develop the comprehensive, resident centered plan of care for each resident .the goals shall be specific and agreed upon by the resident, family, and…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for care of a resident for 4 of 4 residents reviewed with catheters, Resident ID #s 2, 4, 35 and 54. Findings are as follows: According to The Center for Disease Control and Prevention (CDC) document titled, Guideline for Prevention of Catheter Associated Urinary Tract Infections [UTI] 2009, states in part, .Proper techniques for Urinary Catheter Maintenance .Do not rest the bag on the floor . Record review of a facility policy titled Catheter-Foley states in part, .empty the Foley bag every 8 hours, or when the drainage bag is 2/3 full to avoid traction on the catheter from the weight of the drainage bag to prevent infection . 1. Record review for Resident ID #2 revealed that s/he was readmitted to the facility in September of 2022 with diagnoses including, but not limited to, neuromuscular dysfunction of the bladder and urinary tract infections. Additional record review revealed the resident has a suprapubic catheter (a…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors, receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents experiences, and preferences, in order to eliminate, or mitigate triggers that may cause re-traumatization of the resident for 10 of 15 residents reviewed for Trauma Informed Care, Resident ID #s 2, 9, 23, 24, 35, 45, 49, 54, 58, and 59. Findings are as follows: Review of a facility policy titled, Trauma Informed Care, states in part, .on admission, upon significant change in condition that includes changes in mood state and behavior, evaluate for any history of a traumatic experience they may have experienced .when a resident is unable to complete the screening tool the representative will be interviewed and the Trauma Informed Questionnaire will be completed by the Representative .the Social Worker will document the findings of the Trauma Informed Questionnaire in the initial Psychosocial history . Review of…

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

Based on surveyor observation, 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 2 of 2 medication storage rooms and 2 of 2 medication carts observed. Findings are as follows: Review of the facility policy titled, Storage of Medications, revised 8/2020, states in part, .Expiration Dating .Certain medications or package types, such as .multiple dose injectable vials .require an expiration date shorter than the manufacturer's expiration date once opened .When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated .all expired medications will be removed from the active supply . 1. During a surveyor observation of the School Street Unit medication cart on 12/12/2023 at 12:07 PM, in the presence of Licensed Practical Nurse (LPN), Staff A, the following was revealed: - 2 boxes (each containing three tubes) of Microdot Glucose Gel fast acting glucose gel 40% (used to treat low blood sugar…

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 necessary treatment and services, consistent with professional standards of practice, to promote wound healing for 1 of 1 resident reviewed who has an actual pressure injury, Resident ID #4. Findings are as follows: Review of the policy titled, Non-Sterile Dressing Change, states in part, .Procedure .If dressings need to be cut to size, use clean or sterile scissors .remove soiled dressing .remove gloves, wash hands, apply new gloves .clean wound .Remove gloves, wash hands, apply new gloves .apply wound dressing . Record review revealed the resident was admitted to the facility in September of 2018 with a diagnosis including, but not limited to, type 2 diabetes mellitus with skin complications. Review of the care plan, initiated on 5/17/2022, revealed the resident has an actual impairment to his/her skin integrity relative to a stage 4 pressure wound (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 3 residents reviewed for oxygen therapy, Resident ID #19. Findings are as follows: According to Brunner and Sudarth's textbook, Medical and Surgical Nursing, 7th Edition, 1992, p. 524, as with other medications, oxygen is administered with care, and its effects on each patient are carefully assessed. Oxygen is a drug and except in emergency situations is prescribed by a physician. Record review of a facility policy titled, Nasal Cannula states in part, .Procedure .verify physician orders .set flow meter per physician order . Record review revealed the resident was readmitted to the facility in December of 2017, with a diagnosis including, but not limited to, anxiety disorder. Surveyor observations of the resident while in his/her room on 12/11, 12/12 and 12/13/2023 revealed there was an oxygen concentrator by the resident's bedside with tubing dated 9/25 6:00 AM. Additional…

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's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for a blood pressure medications with parameters, Resident ID #4. Findings are as follows: Record review revealed the resident was readmitted to the facility in September of 2018 with a diagnosis including, but not limited to, hypertension. Record review revealed a physician's order, dated 10/31/2023, for Metoprolol Tartrate (medication used to treat high blood pressure) 50 mg (milligram) tablet to be administered twice daily with instructions to hold for a systolic blood pressure of less than 100. Further review revealed an additional parameter to hold this medication for the heart rate, however a heart rate parameter was not included in the order. Review of the Medication Administration Records, from November 2023 through 12/13/2023 revealed the metoprolol medication was administered twice daily. Review of the record failed to reveal evidence that the resident's blood pressure and heart rate…

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 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 out of 2 residents related to determining if a resident was a registered sex offender prior to admission from June of 2023 until September of 2023, Resident ID #s 1 and 7. Findings are as follows: Record review of the facility assessment dated [DATE] revealed known sex offenders would be denied admission to the facility. Record review revealed Resident ID #1, was admitted to the facility in September of 2023 with diagnoses including, but not limited to, altered mental status, and cognitive communication deficit. Record review failed to reveal evidence that the National Sex Offender Public Website was checked prior to the facility admitting Resident ID #1. Additional record review revealed that Resident ID #1 was a…

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

Based on record review and staff interview, it has been determined that the facility failed to conduct a comprehensive assessment using the resident assessment instrument (RAI), for 10 of 33 residents reviewed, Resident ID #s 9, 36, 38, 56, 62, 65, 69, 208, 357, and 360. Findings are as follows: 1. Record review for Resident ID #9 revealed that a significant change Minimum Data Set (MDS) Assessment that was due on 11/8/2022 was incomplete. 2. Record review for Resident ID #36 revealed that an admission MDS that was due on 6/28/2022 was incomplete. 3. Record review for Resident ID #38 revealed that an annual MDS that was due on 11/19/2022 was incomplete. 4. Record review for Resident ID #56 revealed that an admission MDS that was due on 5/20/2022 was incomplete. 5. Record review for Resident ID #62 revealed that an annual MDS assessment that was due on 9/21/2022 was incomplete. 6. Record review for Resident ID #65 revealed that an admission MDS that was due on 12/14/2022 was incomplete. 7. Record review for Resident ID #69 revealed that an admission MDS that was due on 6/12/2022 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 assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for 18 of 33 residents, Resident ID #s 8, 9, 11, 15, 24, 31, 36, 45, 50, 51, 57, 62, 78, 80, 155, 206, 216 and 360. Findings are as follows: 1. Record review for Resident ID #8 revealed the quarterly Minimum Data Set (MDS) assessments that were due on 5/14/2022 and 11/10/2022 were incomplete. 2. Record review for Resident ID #9 revealed the quarterly MDS assessment that was due on 5/25/2022 was incomplete. 3. Record review for Resident ID #11 revealed the quarterly MDS assessments that were due on 5/27/2022 and 11/25/2022 were incomplete. 4. Record review for Resident ID #15 revealed the quarterly MDS assessment that was due on 10/9/2022 was incomplete. 5. Record review for Resident ID #24 revealed the quarterly MDS assessment that was due on 11/10/2022 was incomplete. 6. Record review for Resident ID #31 revealed the quarterly MDS assessment that…

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 electronically transmit data after a facility completed a resident's assessment for 14 of 33 residents, Residents ID #s 4, 9, 31, 44, 56, 67, 70, 73, 77, 78, 83, 84, and 110. Findings are as follows: 1. Record review for Resident ID #4 revealed the quarterly Minimum Data Set (MDS) assessments, dated 5/10/2022 and 11/8/2022, were completed but not electronically transmitted as required. 2. Record review for Resident ID #9 revealed the discharge MDS, dated [DATE], was not completed or transmitted. 3. Record review for Resident ID #31 revealed the discharge MDS, dated [DATE], was not completed or transmitted. 4. Record review for Resident ID #44 revealed the discharge MDS, dated [DATE], was not completed or transmitted. 5. Record review for Resident ID #56 revealed the Comprehensive MDS, dated [DATE], and the discharge MDS, dated [DATE], was not completed or transmitted. 6. Record review for Resident ID #66 revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the facility stores, distributes, and serves food in accordance with professional standards for food safety relative to the main kitchen and 4 of 4 unit kitchenettes. Findings are as follows: 1. Record review of the Rhode Island Food Code 2018 edition, section 3-501.17 states in part, .(B) Except as specified paragraphs (E)-(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combination specified in paragraph (A) of this section and: (1) The day the original container is opened and the FOOD ESTABLISHMENT shall be counted as Day…

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 has failed to set priorities for its performance improvement activities that focus on problem-prone areas, consider the incidence, prevalence, and severity of problems in those areas and take actions aimed at performance improvement, measure its success, and track performance to ensure improvements are realized and sustained related to resident Minimum Data Set (MDS) assessment completion and timing. Findings are as follows: Record review of the MDS assessments of 33 discharged and current residents revealed MDS assessments which were not completed or submitted timely. During a surveyor interview on 1/19/2023 at 3:17 PM with the MDS Coordinator, she acknowledged that the facility was aware that there was a problem with completing MDS assessments. During a surveyor interview on 1/20/2023 at approximately 10:00 AM with the Administrator, she revealed that a decision is made about a concern going to QAPI when a problem spans throughout the facility and that areas are tracked until they reach a 95%…

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 follow the manufacturer's instructions when COVID-19 rapid testing residents, for 14 of 14 residents observed, Resident ID #'s 11, 24, 27, 38, 45, 62, 85, 315, 316, 355, 356, 357, 359, and 362. Findings are as follows: The Centers for Disease Control document titled, Guidance for SARS-CoV-2 Rapid Testing Performed in Point-of-Care Settings, updated on 4/4/2022, states in part: .During the test .When processing multiple specimens successively in batches, ensure proper timing for each specimen .as specified by the test manufacturer .After the test .Read and record results only within the amount of time specified in the manufacturer's instructions. Do not record results from tests that have not been read within the manufacturer's specified timeframe . Review of the [NAME] BinaxNow COVID-19 Ag card (a type of test called an antigen test. Antigen tests are designed to detect proteins from the virus…

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 necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 3 of 8 residents reviewed for pressure ulcers (a localized injury to the skin or underlying tissue due to pressure), Resident ID #s 4, 72, and 155. Findings are as follows: 1. Record review for Resident ID #4 revealed s/he was admitted to the facility in October of 2022 with diagnoses including, but not limited to, diabetes mellitus (high blood sugar) and muscle weakness. Review of the WOUND EVALUATION & MANAGEMENT SUMMARY revealed the resident has a stage 4 pressure ulcer (the most serious wound, that extends into the deep tissues, including muscle, tendons, and ligaments) to the resident's left ischium (lower and back of hip bone) and a skin tear to the left lower buttock. Further record review of the above wound evaluation revealed the following recommendations by the wound physician: -12/7/2022 .ISCHIUM .Peri wound 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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight and failed to follow their policy relative to weight loss and weight gain for 2 of 11 residents reviewed, Resident ID #s 31 and 69. Findings are as follows: Review of the facility policy titled, Weight Loss/Gain Protocol, states in part . PROCEDURE .a significant weight discrepancy is defined as: 1. A weight change of 3 pounds or more in one week (if resident on weekly weights); 2. A loss/gain of 5% or greater within one month .1. WHEN A SIGNIFICANT WEIGHT LOSS/GAIN IS NOTED .THE FOLLOWING INTERVENTIONS MUST OCCUR: .All monthly weights must be done by the end of the first two (2) weeks of the month. 1. Reweigh all residents who are reported to have a significant weight discrepancy in order to assess the accuracy of the weight. The reweigh shall be done within 48 hours .2. If the re-weigh is accurate and there has been a significant weight…

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 the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 7 residents reviewed, Resident ID #65. Findings are as follows: Review of the resident's record revealed s/he was re-admitted to the facility on [DATE] with diagnoses including, but not limited to, closed hip fracture, pelvic fracture, and Alzheimer's Disease. Record review of a document titled, Continuity of Care [COC]- Post-Acute Facility dated 11/5/2022, revealed the following medication order that was to continue upon re-admission to the facility: - Omeprazole (medication used to treat certain stomach and esophagus problems) 20 milligrams (mg) delayed release tablet, take one tablet, 20 mg total by mouth daily. Record review of the physician orders revealed an order dated 11/5/2022 for Omeprazole 20 mg delayed release tablet, give 20 mg by mouth before meals. Record review of the November and December 2022 and the January 2023 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, upon a resident's death, to convey within 30 days the resident's funds and a final accounting of those funds to the individual or probate jurisdiction administering the resident's estate, in accordance with state law for 2 of 2 residents reviewed for personal needs funds handled by the facility, Resident ID #'s 108 and 109. Findings are as follows: Rhode Island State Regulation under section 2.4 (H) of the Uniform Accountability Procedures for Title XIX Resident Personal Needs Funds in Community Nursing Facilities, ICF/DD Facilities, and Assisted Living Residences' requires that the facility shall: .(c) Upon the death of a Medicaid resident, a facility shall, within 10 days, transmit a notarized statement (see form available for downloading on the EOHHS website: www.eohhs.ri.gov) indicating the amount of personal needs money on hand after funeral expenses. Funeral expenses are designated to be the first paid. Copies 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 communicate the appropriate information to the receiving health care institution or provider to ensure a safe and effective transition of care for 1 of 2 residents reviewed, Resident ID #105. Findings are as follows: Review of the resident's record revealed that s/he was admitted to the facility in November of 2022, with diagnoses including, but not limited to, chronic atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) and old myocardial infarction (heart attack). Further review of the record revealed that s/he was discharged from the facility on 12/31/2022. Review of the care plan, revised on 12/12/2022, revealed that the resident is at risk for developing complications secondary to having anticoagulant therapy with an intervention to obtain and report labs as ordered. Additional record review revealed that s/he has impaired cognitive function with an intervention to communicate with his/her family members/caregivers regarding…

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 accurate assessments reflecting the residents' status for 2 of 8 residents reviewed relative to weekly skin assessments, Residents ID #s 62 and 155. Findings are as follows: 1. Record review revealed Resident ID #62 was admitted to the facility in September of 2021 with diagnoses including, but not limited to, stroke and status post Gastrostomy (G-tube; A tube inserted through the wall of the abdomen directly into the stomach. It allows air and fluid to leave the stomach and can be used to give drugs and liquids, including liquid food, to the patient). Record review revealed a physician's order dated 11/14/2022 for Weekly Skin Checks Every Saturday on Day . Record review of the SKIN OBSERVATION TOOL revealed the following: -1/7/2023 .Skin CDI [clean, dry, intact] . -1/14/2023 .Skin CDI . During a surveyor observation on 1/19/2023 at 2:05 PM of the resident in the presence of the Registered Nurse, Staff B, revealed the resident has a G-tube surgical site on…

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

Based on surveyor observation, record review, and staff interview, it has been determined the facility failed to provide the necessary services to a resident who is unable to carry out activities of daily living (ADLs) relative to personal hygiene for 3 of 6 sample residents observed, Resident ID #'s 8, 57, and 106. Findings are as follows: 1. Record review for Resident ID #8 revealed the resident was admitted to the facility in October of 2017 with diagnoses to include, but are not limited to, muscle weakness and chronic kidney disease. Record review of a care plan dated 12/9/2020 and revised on 2/18/2021 revealed, The resident has an ADL self-care performance deficit r/t [related to] Activity Intolerance and Disease process .Resident requires staff assist to complete ADL tasks daily. Fluctuations are expected r/t Diagnosis . This care plan has interventions including, but not limited to, .HYGIENE/GROOMING: LIMITED ASSIST X 1 .PERSONAL HYGIENE: The resident requires limited assistance by 1 staff with personal hygiene . During surveyor observations of the resident's finger nails on…

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

Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to ensure that residents receive proper treatment and care to maintain good foot health and assistance with making appointments with a qualified person for 1 of 1 residents reviewed relative to foot care, Resident ID #72. Findings are as follows: Record review for the resident revealed that s/he was re-admitted to the facility in October of 2022 with diagnoses including, but not limited to, type 2 diabetes mellitus with other circulatory complications and need for assistance with personal care. Review of the order summary report revealed a current order, dated 10/25/2022, stating podiatry may be consulted as needed. Further review of this documentation revealed an order, dated 12/13/2022, to provide diabetic foot care every day at night including observation of feet, toes, ankles, and soles. Review of wound consultation documentation, dated 11/30/2022, revealed in part, .Please have podiatry cut patient's toenails . Record review failed to reveal evidence that…

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 respiratory care, Resident ID #s 262 and 357. Findings are as follows: According to Brunner and Sudarth's textbook, Medical and Surgical Nursing, 7th Edition, 1992, p. 524, as with other medications, oxygen is administered with care, and its effects on each patient are carefully assessed. Oxygen is a drug and except in emergency situations is prescribed by a physician. Record review of the facility policy titled, Oxygen Administration revealed in part, .verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen [O2] administration .Documentation .The date and time that the procedure was performed .The name and title of the individual who performed the procedure .the rate of oxygen flow, route, and rationale .The frequency and duration of the treatment .reason for p.r.n. [as needed] administration…

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 physician, physician assistant, nurse practitioner, or clinical nurse specialist provide orders for the resident's immediate care needs and that the medical care of each resident is supervised by a physician for 1 of 7 residents reviewed for medication orders, Resident ID #69. Findings are as follows: Record review for the resident revealed a physician's order dated 1/4/2023 for olanzapine (antipsychotic used to treat mental disorders) 2.5 milligrams (mg) by mouth one time a day for anxiety for 14 days then re-evaluate. Further record review revealed a progress note dated 1/16/2023, authored by the Registered Nurse Practitioner, Staff J, that states in part, .Assessment and Plan .Restlessness/agitation/anxiety - c/w [continue with] .olanzapine, monitor for behavioral disturbances . Record review of the January 2023 Medication Administration Record revealed that the olanzapine order failed to be continued after 1/17/2023. During a surveyor interview on 1/20/2023 at 1:46 PM…

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 as needed (PRN) orders for psychotropic drugs are limited to 14 days for 1 of 6 residents reviewed relative to unnecessary medications, Resident ID #62. Findings are as follows: Record review revealed the resident was admitted to the facility in September of 2021 with diagnoses including, but not limited to, stroke and muscle weakness. Record review revealed a physician's order dated 12/20/2022 for, LORazepam Intensol Concentrate 2 MG [milligram]/ML [milliliter] .Give 0.5 mg via G-tube [feeding tube] every 6 hours as needed for Anxiety . Further record review failed to reveal evidence that the above PRN order was limited to 14 days. Additionally, there was no documentation relative to the rationale or duration of the PRN order by the physician or prescribing practitioner in the resident's medical record. Additional record review revealed the resident received 3 doses of Lorazepam (after 14 days) on the following dates and times: - 1/4/2023 at 3:02 AM - 1/14/2023 at 6:00 AM -…

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

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 1 of 1 nursing stations observed. Findings are as follows: Review of a policy titled, Storage of Medications revised in November of 2020, states in part, .Drugs and biological's used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications . A continuous surveyor observation on 1/19/2023 from 8:34 AM until 9:21 AM of the first-floor Central unit revealed the following medication cards left unsecured and unattended on the nurses' desk: -A medication blister pack of Mirtazapine 15 Milligram (mg) (antidepressant) for Resident ID #69 containing 14 tablets. -A medication blister pack of Atorvastatin 10 mg (medication to treat high cholesterol) for Resident ID #65 containing 14 tablets. -A medication blister pack of Mycophenolat…

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 promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 of 2 residents reviewed, Resident ID #105. Findings are as follows: Review of the resident's record revealed that s/he was admitted to the facility in November of 2022, with diagnoses including, but not limited to, heart failure, chronic atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), old myocardial infarction (heart attack), and hypertension. Review of the care plan, revised on 12/12/2022, revealed an intervention to obtain and report labs as ordered. Review a document titled Order Summary Report, revealed in part, the following orders: - 12/28/2022 order for PT/INR lab (Used to measure the time it takes for blood 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.