Elmhurst Rehabilitation and Healthcare Center

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 1 of 1 resident reviewed for a urology consult, Resident ID #1, and for 1 of 1 resident reviewed for dietary restrictions, Resident ID #103.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe that the orders are in error or would harm the clients.1) Record review revealed Resident ID #1 was readmitted to the facility in May of 2025 with a diagnosis including, but not limited to, fibromyalgia (chronic pain syndrome).Review of a Continuity of Care (COC) form dated 7/25/2025 revealed the resident attended a urology consult and returned with a recommendation including, but not limited to, increase fluid intake.Record review failed to reveal evidence of a physician's order…

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 and the comprehensive person-centered care plan for 1 of 1 resident reviewed for daily weights, Resident ID #192. Findings are as follows:Record review revealed that the resident was admitted to the facility in May of 2025 with a diagnosis including, but not limited to, congestive heart failure (CHF, a condition where the heart struggles to pump blood effectively, leading to excess fluid in the body). Additionally, the record revealed that s/he was transferred to an acute care hospital on 6/3/2025 due to an exacerbation of CHF.Record review of a care plan that was initiated on 5/12/2025, revealed a focus area for CHF. Interventions included to monitor for signs and symptoms of CHF, such as weight gain unrelated to meal intake.Record review of the hospital Continuity of Care documents which were received upon admission to the facility on 5/11/2025, revealed the following physician'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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each resident's medication regimen is free from medication error rates of 5% or greater. Based on 28 opportunities for error observed during the medication administration task, there were 3 errors resulting in a 10.71% error rate involving Resident ID #s 24 and 135.Findings are as follows:Review of the facility's policy titled, Administering Medications states the following in part, .Medications are administered in accordance with prescriber orders.Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.1. Record review revealed Resident ID #24 had a physician's order with start date of 7/28/2025 for Keppra oral tablet give 1250 milligrams (mg) by mouth two times a day to treat epilepsy (seizure disorder).During a surveyor observation of the medication administration task on 7/30/2025 at 8:27…

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 and document sufficient preparation and orientation to residents to ensure a safe and orderly discharge from the facility for 1 of 1 resident reviewed who left the facility, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 6/5/2025 alleged that a resident had gone missing from the facility the week prior, and the facility's management did not take appropriate action. The complaint further alleged that the resident said s/he wanted to go home, and it took hours for the facility to find him/her. Review of a facility policy titled, Discharging a Resident Without a Physician's Approval states in part, .Regardless of the resident or resident's representative's request to leave the facility against medical advice, the facility will provide a Notice of Discharge, discharge orientation, and a Discharge Summary .before the resident leaves the facility. Record review revealed Resident ID #1 was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive adequate supervision to ensure the safety of 1 of 1 resident reviewed who left the facility, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 6/5/2025 alleges that a resident had gone missing from the facility the week prior, and the facility's management did not take appropriate action. The complaint further alleged that the resident said s/he wanted to go home and it took hours for the facility to find him/her. Review of the facility policy titled, Wandering and Elopements states in part, .If a resident is missing, initiate the elopement/missing resident emergency procedure .If the resident is not located, notify .law enforcement officials . Record review revealed Resident ID #1 was admitted to the facility in May of 2025 with diagnoses including, but not limited to, aftercare following a hip…

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 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 relative to 1 of 1 resident reviewed who left the facility, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 6/5/2025 alleges that a resident had gone missing from the facility the week prior, and the facility's management did not take appropriate action. The complaint further alleged that the resident said s/he wanted to go home and it took hours for the facility to find him/her. Record review revealed Resident ID #1 left the facility at an unknown time on 5/29/2025. During a surveyor interview via telephone on 6/11/2025 at 11:34 AM with the resident, s/he stated that s/he left the facility around 11:00 AM on 5/29/2025 with his/her friend. Additionally, the resident indicated that s/he was not given any…

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 resident records are complete and accurately documented, relative to medication administration, for 1 of 1 resident reviewed who left the facility, Resident ID #1. Findings are as follows: Record review revealed Resident ID #1 was admitted to the facility in May of 2025 with diagnoses including, but not limited to, aftercare following a hip replacement, post-traumatic stress disorder, and osteoarthritis. Review of a Brief Interview for Mental Status evaluation dated 5/25/2025 revealed a score of 14 out of 15, indicating intact cognition. Record review revealed a physician's order dated 5/23/2025 for Acetaminophen 325 milligrams (mg) give two tablets three times a day. Record review of the May 2025 Medication Administration Record (MAR) revealed the Acetaminophen dose scheduled for 2:00 PM was documented as administered on 5/29/2025 by Licensed Practical Nurse (LPN), Staff B. During a surveyor interview via telephone on 6/11/2025 at 11:34 AM with the resident, s/he indicated…

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 the necessary care and services to attain or maintain the highest practicable physical well-being for 4 of 5 residents reviewed relative to follow up appointments, Resident ID #s 71, 111, 117, and 19, and for 1 of 2 residents reviewed for non-pressure wounds, Resident ID #135. Findings are as follows: 1a. Record review revealed Resident ID #117 was admitted to the facility with a diagnosis including, but not limited to, dementia. Review of the progress notes revealed the following: - 10/2/2024: .skin area to L [left] nipple resolved . - 12/2/2024 at 10:00 AM: .seen today following reports of left nipple redness and swelling . - 12/2/2024 at 3:16 PM: .noted to have redness and discharge from L nipple .recommendations to monitor and a Mammogram consult . - 12/13/2024 at 6:32 AM: .left nipple area pink .scant amt [amount] dried yellow drainage at site . Record review revealed the following physician's orders: - 12/2/2024: Mammogram consultation of the left…

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 complete resident assessments and entrapment assessments (an assessment which determines the risk of a resident being caught, trapped, or entangled in the space in or around the bed/side rail) in their entirety for 3 of 3 floors affecting Resident ID #s 4, 20, 23, 25, 40, 43, 48, 50, 55, 57, 61, 65, 71, 73, 87, 93, 105, 109, 111, 114, 117, 120, 129, 137, 156, 157, 178, 333, and 387. Findings are as follows: Review of a facility policy titled Bed Safety and Bed Rails last revised in August of 2022, states in part, Residents beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met .Maintenance staff routinely inspect all beds and related equipment to identify risks and problems including potential entrapment risks .Bed rails are properly installed and used according to the manufacturer's instructions, specifications and other pertinent safety guidance…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to contact precautions (utilized when a resident is known or suspected to be infected with a Multidrug Resistant Organism [MDRO] that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces in the resident's room, and for Respiratory Syncytial Virus [RSV; a common virus that infects the lungs and respiratory tract]) for 2 of 5 residents reviewed on contact precautions, Resident ID #s 120 and 148, and for 1 of 1 resident reviewed with a known history of Extended Spectrum Beta-Lactamase (ESBL an MDRO) observed without any isolation precautions (contact precautions or enhanced barrier precautions [EBP]) in place when it requires such, Resident ID #19. Findings are as follows: Review of a facility policy titled, Isolation-Categories of Transmission-Based Precautions states in part, .Contact…

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, resident and staff interview, it has been determined that the facility failed to ensure that a resident's right to communication and access to persons and services inside and outside the facility to promote a dignified existence was promoted for 1 of 2 residents reviewed for reviewed for communication, Resident ID #333. Findings are as follows: Record review revealed that Resident ID #333 was admitted to the facility on [DATE] with a diagnosis including, but not limited to, hearing loss. During a surveyor interview with the Administrator on 2/3/2025 at approximately 8:15 AM, she revealed that there is respiratory illness on the floor where Resident ID #333 resides. Additionally, she revealed that the facility is requiring masks to be worn on that floor until further notice. Review of a document titled, Rhode Island Department of Human Services Level I Identification for MI [Mental Illness] and DD [Developmental Disability] (PASARR) dated 1/28/2025 revealed that the resident is hard 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview, it has been determined that the facility failed to ensure that each baseline care plan included PASARR recommendations for 1 of 2 residents reviewed for Preadmission Screening and Resident Review (PASARR), Resident ID #333. Findings are as follows: Review of a facility policy titled, Care Plans-Baseline, last revised March 2022, states in part, .A base line plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission .The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following .initial goals based on admission orders and discussion with the resident/representative .PASARR recommendations, if applicable . Record review revealed that Resident…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a treatment that removes excess fluid, waste, and toxins from the blood when the kidneys are no longer functioning properly) receive such services, consistent with professional standards of practice for 1 of 1 resident reviewed for dialysis, Resident ID #43. Findings are as follows: Record review revealed Resident ID #43 was readmitted to the facility with diagnoses including, but not limited to, end stage renal disease and the dependence on renal dialysis. Record review revealed the resident receives hemodialysis three times a week, Tuesdays, Thursdays, and Saturdays. Record review of a nursing progress note dated 1/9/2025 revealed the resident returned from dialysis with a bottle of Velphoro 500 milligrams (mg) (a phosphate binder indicated for the control of serum phosphorus levels for patients with chronic kidney disease on dialysis). It further included instructions from the dialysis center that another pharmacy will be shipping 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 pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) to meet the needs of each resident for 1 of 1 resident reviewed for dialysis (a treatment that removes excess fluid, waste, and toxins from the blood when the kidneys are no longer functioning properly), Resident ID #43. Record review revealed Resident ID #43 was readmitted to the facility with diagnoses including, but not limited to, end stage renal disease and the dependence on renal dialysis. Record review of a nursing progress note dated 1/9/2025 revealed, the resident returned from dialysis with a bottle of Velphoro 500 milligrams: (mg- a phosphate binder prescribed to control phosphorus levels in the blood for patients with chronic kidney disease who receive on dialysis). It further included instructions from the dialysis center that another pharmacy will be shipping the prescription directly to the facility going forward.…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide a scoop plate (a plate with raised, curved edges that helps guide food onto a utensil) for 1 of 1 resident reviewed who requires adaptive eating equipment, Resident ID #4. Findings are as follows: Record review revealed the resident was admitted to the facility with diagnoses including, but not limited to, dementia, muscle weakness, and legal blindness. Review of the care plan revealed a focus area indicating that the resident has a nutritional problem related to his/her dementia progression, blindness, and requires more staff assistance with eating. Further review revealed an intervention for a scoop plate with all meals. Additionally, it indicates that his/her weight has decreased. Review of physician's diet order dated 4/1/2024 indicated that the resident is to have a scoop plate with all meals. Record review of the resident's lunch meal diet slip dated 2/3/2025 revealed the resident uses a scoop plate. During a continuous surveyor observation of the lunch…

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 implement and maintain an effective Quality Assurance and Performance Improvement (QAPI) program with a focus related to medication administration. Additionally, the facility failed to provide evidence that new orders were audited per their QAPI plan. Findings are as follows: Review of a document titled, Quality Assurance and Performance Improvement Plan revealed a focus area on ensuring residents are free from unnecessary medications with interventions including, but not limited to, auditing all new medications routinely with a start date of 9/24/2024 and a goal date of 12/24/2024. Additional review of the QAPI document revealed that the goal date for the above-mentioned focus area was extended to 3/24/2025 as a result of a medication error that was identified by the facility on 1/2/2025. Further review revealed an additional QAPI document dated 1/3/2025 with a focus area for medication errors, due to a medication transcription error that was identified on 1/2/2025. The interventions…

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 resident records are complete and accurately documented, relative to medication transcription errors, for 1 of 4 residents reviewed, Resident ID # 1. Findings are as follows: 1. According to the document released by the Food and Drug Administration, revised 8/2021, Abiraterone Acetate in combination with prednisone is indicated for the treatment of patients with metastatic prostate cancer. Additionally, for patients with baseline moderate hepatic (liver) impairment, reduce the recommended dose of Abiraterone Acetate to 250 mg once daily and to monitor liver function tests prior to the start of the medication and weekly for the first month. In patients with severe hepatic impairment, this medication is to be avoided. Abiraterone Acetate may cause high blood pressure, low potassium level and fluid retention. Additional review of the document revealed an adverse reaction of this medication includes, but is not limited to fatigue, high blood pressure, nausea, vomiting,…

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, resident and staff interview, it has been determined that the facility failed have sufficient nursing staff to assure resident safety for 1 of 2 residents reviewed related to call light response, Resident ID #4. Findings are as follows: Record review of a complaint submitted to the Rhode Island Department of Health on 12/17/2024 alleges that Resident ID #2 failed to receive care for 24 hours. During a surveyor interview on 12/26/2024 at 11:20 AM with Resident ID #4, Resident ID #2's roommate, s/he revealed that at times, staff takes 30 minutes to 1 hour to respond to his/her call light. Further surveyor interview with Resident ID #4 revealed that s/he would like to have a glass of water and this surveyor recommended that the resident use the call light system for assistance. The resident asked the surveyor to press the call light for him/her at 11:28 AM and was not answered by staff until 12:04 PM, 36 minutes later. During a surveyor interview on 12/26/2024 at 12:05 PM with Licensed Practical Nurse, Staff A, she acknowledged that it took her awhile 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 surveyor observation, record review, staff, and resident interview, it has been determined that the facility failed to ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence and prevent a urinary tract infection (UTI), for 1 of 1 resident reviewed for continence, Resident ID #539. The facility further failed to provide appropriate treatment and services for 2 of 3 resident's reviewed with a suprapubic catheter (SP catheter - a device inserted through the abdomen into the bladder to drain urine), Resident ID #s 10 and 68. Findings are as follows: 1a. Record review revealed that Resident ID #539 was admitted to the facility in August of 2024 with a diagnosis including, but not limited to, left knee arthroplasty (a surgical procedure to resurface a knee damaged by arthritis). Record review of a facility policy titled, Urinary Incontinence- Clinical Protocol last revised April 2018 states in part, .As part of the initial assessment, the physician will help identify individuals with impaired urinary…

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 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, relative to intravenous (IV) administration of fluids, for 2 of 4 staff reviewed, Staff A and B. Findings are as follows: During a surveyor interview on 5/21/2024 at approximately 9:25 AM with Resident ID #2, s/he indicated that s/he felt that the nursing staff at the facility did not know how to properly care for his/her IV. Record review revealed Resident ID #2 was admitted to the facility in May of 2024 with diagnoses including, but not limited to, candidiasis (fungal infection) and an abscess of the lung. Record review revealed the resident had a peripherally inserted central catheter (PICC line- a long, flexible tube that's inserted into a vein in the upper arm and guided into a large vein…

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 maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections for 1 of 1 resident reviewed for the Multidrug-resistant Organism (MDRO), Methicillin-resistant Staphylococcus aureus (MRSA), Resident ID #1. Findings are as follows: Review of a facility policy titled, Multidrug-Resistant Organisms states in part, .the following strategies are adopted from the Centers for Disease Control and Prevention and provide current recommendations for MDRO prevention and control .implement contact precautions routinely for all residents colonized or infected with a target MDRO .because environmental surfaces and medical equipment, especially those in close proximity to the resident, may be contaminated, don gowns and gloves before or upon entry to the resident's room . 1. Record review revealed that Resident ID #1 was re-admitted to the facility 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 resident 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 1 of 3 residents reviewed for Trauma-informed care, Resident ID #3. Findings are as follows: According to, Centers for Medicare and Medicaid Services, State Operations Manual, Appendix PP Guidance to Surveyors for Long Term Care Facilities last revised 2/3/2023, states in part, .'Trauma' results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being .…

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 interviews, 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 1 resident reviewed who exhibited symptoms of an opioid overdose, which required a hospitalization in the critical care unit after being administered medication, methadone [an opioid pain medication used to treat substance abuse] 60 mg [milligrams], intended for another resident, Resident ID #1, and for 1 of 1 resident who missed a dose of medication, causing the resident to experience symptoms of opiate withdrawal, Resident ID #2. Findings are as follows: Record review of a facility reported incident relative to accident resulting in hospital admission, that was submitted to the Rhode Island Department of Health (RIDOH) on 11/8/2023, states in part, Resident is a 70-year [old] .with a BIMS [Brief Interview…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored, served and distributed, in accordance with professional standards for food service safety, relative to the main kitchen. Findings are as follows: 1) The Rhode Island Food Code 2018 Edition 4-601.11 states in part, .nonfood contact surfaces of equipment shall be kept free of an accumulation of dirt .and other debris . During surveyor observations on 9/5/2023 at approximately 9:30 AM, 9/6/2023 at approximately 11:00 AM, and 9/7/2023 at approximately 9:15 AM, a fan in a window that was directly above the dishmachine was observed with a high dust accumulation. The fan was blowing in the direction of clean dishes. 2) The Rhode Island Food Code 2018 Edition 2-402.11 reveals in part, .food employees shall wear hair restraints, beard restraints that are designed and worn to effectively keep their hair from contacting exposed food . During a surveyor observation on the initial walk through of the main kitchen on 9/5/2023 at approximately 9:43 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 record review and staff interview, it has been determined that the facility failed to ensure that the residents' drug regimens were reviewed and acted upon when irregularities were identified during the monthly pharmacist Medication Regimen Review (MRR) for 2 of 5 residents reviewed, Resident ID #s 62 and 105. Findings are as follows: Record review of a facility policy titled, Medication Monitoring Medication Regimen Review and Reporting dated 1/2023 states in part, .2. The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly .Recommendations shall be acted upon within 30 calendar days .If prescriber intervention is required, facility staff will ensure proper communication is provided to the attending physician, nurse practitioner or physician's assistant to ensure resolution by midnight of the next calendar day . 1) Record review revealed Resident ID #105 was admitted to the facility in June of 2021 and readmitted in August of 2023 with diagnoses including, but not limited to, Alzheimer's disease and depression. Record…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to staff wearing appropriate personal protective equipment (PPE) for COVID-19 (SARS-CoV-2) for 3 of 4 Covid-19 positive residents observed, Resident ID #s 22, 395, and 399. Findings are as follows: According to the Centers for Disease Control and Prevention guidance updated on May 8, 2023, the recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection include the following: Personal Protective Equipment Health care personal who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). 1. Record review revealed Resident…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of quality relative to following physician's orders, for 1 of 1 resident reviewed relative to medications administered via a gastrostomy tube (a surgically placed device used to give direct access the stomach for supplemental feeding, hydration or medicine), Resident ID #23. Findings are as follows: Record review of the facility policy titled, Administering Medications,states in part, .Medications are administered in accordance with prescriber orders, including any required time frame .administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . An attempt was made to observe the gastrostomy tube medication administration for Resident ID #23 with Licensed Practical Nurse, Staff A on 9/8/2023 at 7:41 AM, however she indicated that she had administered all the resident's medications earlier in the shift. Record review of the resident revealed s/he was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice to promote wound healing and prevent new ulcers from developing for 1 of 7 residents reviewed for pressure ulcers (a localized injury to the skin or the underlying tissue due to pressure), Resident ID #135. Findings are as follows: According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023 states in part, .With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the [pressure ulcer/pressure injury] PU/PI should be documented. At a minimum, documentation should include the date observed and: ·Location and staging; ·Size (perpendicular measurements of the greatest extent of length and width of the PU/PI), depth; and the presence, location 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 interview, it has been determined that the facility failed to ensure that a resident's environment remains as free of accident hazards as possible for 1 of 6 residents reviewed for falls, Resident ID #23 and 1 of 1 residents reviewed for supervision with meals, Resident ID #55. Findings are as follows: 1) Record review reveals that Resident ID #23 was admitted to the facility in March of 2022, with diagnoses to include, but not limited to muscle wasting and atrophy, protein calorie malnutrition and contractures of the left knee, right upper arm, and left upper arm. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating that the resident was unable to complete the interview due to cognitive status. It further revealed that the resident requires 2+ person assist for bed mobility, including turning side to side in bed, and positioning while in bed. Record review of the resident's care plan, initiated 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 that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles, for 2 of 4 medication storage rooms and 1 of 6 medication carts observed. Findings are as follows: Review of the facility policy titled, Medication Labeling and Storage, states in part, .If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items . 1. Surveyor observation of the Unit 6 [NAME] Bend South medication storage room, in the presence of Registered Nurse, Staff E during the medication storage task on 9/7/2023 at approximately 8:11 AM, revealed one 1,000 milliliters (mL) intravenous bag of 5% Dextrose and 0.9% Sodium Chloride (provides electrolytes and calories and are a source of water for hydration) solution that was stored in the pharmacy emergency supply kit with an expiration date of 6/2023. During an interview with Staff E,…

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 in accordance with professional standards and practices for 1 of 2 residents reviewed relative to the controlled substances record, Resident ID #247. Findings are as follows: Review of a facility policy titled, Controlled Substances states in part, .Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up .waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet . Record review revealed the resident was admitted to the facility in April of 2022 with diagnoses including, but not limited to, seizures, contractures of the right and left ankles, and spinal stenosis (narrowing that can cause pressure on the spinal cord or the nerves that go from your spinal cord to your muscles). Record review revealed the following physician's orders: - 7/6/2023, Lorazepam Oral…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs, for 1 of 3 residents reviewed for readmission, Resident ID #1. Findings are as follows: Record review revealed the resident was readmitted to the facility in August of 2023 and returned with a diagnosis including, but not limited to, bleeding of the stomach and intestines. Review of the hospital discharge paperwork revealed an order for pantoprazole (used to treat certain stomach and esophagus conditions), 40 milligrams (mg), twice a day for eight weeks. Review of the residents August 2023 Medication Administration Record (MAR) revealed the following orders: - Pantoprazole 40 mg to be administered at 8:00 AM, with a start date of 4/1/2023 - Protonix (pantoprazole sodium), 40 mg by mouth, twice daily at 7:30 AM and 4:00 PM, with a start date of 8/12/2023 Further review of the August MAR revealed both orders were signed off as being administered, for a total dose of 80 mg in the morning, on the following dates: - 8/12/2023 -…

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 and resident interviews, it has been determined that the facility failed to ensure that the residents are free from significant medication errors for 3 of 8 residents reviewed for medication administration, Resident ID #s 1, 2, and 3. Findings are as follows: 1a. Review of a community reported complaint submitted to the Rhode Island Department of Health, alleges that Resident ID #2's family supplies the resident's medication and is not told in advance that the resident needs a refill of his/her medication until the resident is out of his/her medication. This results in the resident missing his/her medications. Record review revealed Resident ID #2 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, human immunodeficiency virus (HIV), acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease (COPD). Review of the July 2023 Medication Administration Record (MAR) revealed the resident receives Raltegravir Potassium (medication used for HIV) 400 milligrams (mg) every 12 hours. Further review…

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