Cedar Haven Operations LLC DBA Lake Forrest Health

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, relative to the use of electronic monitoring for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows:Review of a facility policy titled, Abuse Prohibition dated 10/31/2022 states in part, It is the policy of this facility to ensure that all residents are treated with respect and dignity.Review of a facility policy titled, Electronic Monitoring dated 1/30/2025 states in part, It is the policy of this facility to comply with the electronic monitoring in Nursing and Assisted Living facilities Act (the Act). We will honor the Resident's (or Representative's) choice when electronic monitoring is requested.The Act allows for installation and use of electronic monitoring devices, including any photo, video, and/or audio surveillance equipment with a fixed position, that broadcasts or…

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 designed to help prevent the development and transmission of communicable diseases and infections, relative to use of Enhanced Barrier Precautions (EBP, use of gown and gloves for high contact activities) for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows:Review of a facility policy titled, Guidelines for Management of MDROs [Multi-drug resistant organism] dated 4/15/2024 states in part, Enhanced Barrier Precautions expand the use of PPE [personal protective equipment] beyond which exposure to blood and body fluids is anticipated and refers to gown and glove use during high contact resident care.for those with wounds or indwelling medical devices.examples of resident care activities requiring gown and glove use.dressing, bathing/showering.providing hygiene, changing linens, changing briefs.Record review revealed that Resident ID #1 was admitted to the facility in December of 2024 with diagnoses…

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 keep a resident free from abuse for 1 of 1 resident reviewed, Resident ID #2.Findings are as follows:Review of a facility reported incident submitted to the Rhode Island Department of Health on 10/8/2025, revealed in part, that a Nursing Assistant (NA), Staff C was witnessed talking to Resident ID #2 telling her how pretty and sexy s/he was. Staff C, then proceeded to lift up her shirt and show the resident that she too is sexy. This incident was witnessed by NA, Staff D and reported to the Director of Nursing Services (DNS).Review of a facility policy titled, Abuse prohibition states in part, .It is the policy of this facility to identify abuse, neglect, and exploitation of residents .This includes but is not limited to identifying and understanding the different types of abuse and possible indicators .The resident has the right to be free from abuse .Sexual abuse is non-consensual sexual contact of any type…

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 meet professional standards of quality, relative to not following physician's orders for 1 of 3 residents reviewed regarding obtaining weights, Resident ID #1. Findings are as follows: Record review of two community reported complaints submitted to the Rhode Island Department of Health on 3/21/2025, revealed allegations that Resident ID #1 had not been eating and s/he had lost approximately 20 pounds since being admitted to the facility. 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 the orders are in error or would harm the clients . Record review revealed that the resident was readmitted to the facility in March of 2025 with diagnoses including, but not limited to, congestive heart failure (a condition where the heart can't pump blood as efficiently as it should), chronic obstructive pulmonary disease (a lung disease…

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, resident, and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed relative to a missed medication administration, Resident ID #2. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 3/10/2025 alleges that the resident has not received his/her Bictegravir-Emtricitabine-Tenofovir (BIKTARVY: a medication prescribed to treat, human immunodeficiency virus disease: HIV). Review of the manufacturer guidelines for Bictegravir-Emtricitabine-Tenofovir's states in part, .Inform patients that it is important to take BIKTARVY on a regular dosing schedule with or without food and to avoid missing doses as it can result in development of resistance . Record review revealed the resident was admitted to the facility in March of 2025 with diagnoses including, but not limited to, HIV and dialysis dependence (a life-sustaining treatment that is used to remove waste products and excess fluid…

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

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following physician's orders for administering nutrition via a gastrostomy tube (G-tube, a tube that is inserted through the wall of the abdomen into the stomach to deliver nutrition, fluids, and medication) for 1 of 2 residents reviewed, Resident ID #1. 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 the orders are in error of would harm the clients. Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/26/2024 alleges that the resident is not receiving his/her G-tube nutrition, as ordered. Record review revealed the resident was admitted to the facility in December of 2024 with diagnoses including, but not limited 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 and staff interview, it has been determined that the facility failed to maintain medical records on each resident that are complete and accurately documented in accordance with accepted professional standards and practice for 1 of 2 residents reviewed receiving nutrition via a gastrostomy tube (G-tube, a tube that is inserted through the wall of the abdomen into the stomach to deliver nutrition, fluids, and medication), Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/26/2024 alleges that the resident is not receiving his/her G-tube nutrition as ordered. Record review revealed the resident was admitted to the facility in December of 2024 with diagnoses including, but not limited to, protein-calorie malnutrition, dysphagia (difficulty swallowing), and gastrostomy tube. Record review revealed the following physician's orders: - 12/23/2024 for Nutren 2.0 (a tube feeding formula used to provide complete or supplemental nutrition) 300 millimeters (ml)…

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

Based on surveyor observation, record review, resident and staff interviews, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 2 residents reviewed for a fall resulting in a hospitalization, Resident ID #21 and for 1 of 1 resident reviewed for an injectable anti-psychotic medication, Resident ID #35. Findings are as follows: 1. Review of a facility reported incident submitted to the Rhode Island Department of Health on 9/20/2024 revealed that Resident ID #21 fell in his/her room and was transferred to the hospital via 911. Record review revealed Resident ID #21 was admitted to the facility in June of 2024 with diagnoses including, but not limited to, mantle cell lymphoma (cancer) and anxiety disorder. Record review revealed the following progress notes: - 9/18/2024: The resident was found on the floor of his/her room and was sent to the Emergency Room. - 9/23/2024: The resident was readmitted to the facility with a left hip fracture with recommendations for toe touch…

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 interviews, it has been determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed relative to a scheduled orthopedic appointment, Resident ID #55. Findings are as follows: Record review revealed the resident was admitted to the facility in July of 2023 with diagnoses including, but not limited to, atherosclerosis (a common condition that occurs when plaque builds up in the walls of arteries, narrowing or blocking them) of bilateral legs and dementia. Record review of the resident's care plan dated 7/13/2023 revealed that s/he has chronic bilateral knee pain related to atherosclerosis. Record review of a Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 8 out of 15, indicating a moderately impaired cognition. Record review of a physician's order dated 11/22/2023 revealed an active order for an orthopedic…

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 Enhanced Barrier Precautions (EBP; which requires the donning of (putting on) a gown and gloves during high-contact resident care activities), for 5 of 6 residents reviewed, Resident ID #s 4, 37, 82, 86, and 304 and for 2 of 2 residents reviewed for Covid-19, Resident ID #s 14 and 94. Findings are as follows: 1. Review of a facility policy titled, Isolation last revised on 9/19 states in part, .It is the policy of this facility to prevent the spread of infection within the facility through the use of isolation precautions .Enhanced Barrier Precautions .the use of gown and gloves during high contact resident care .Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing .Bathing/showering .transferring .providing hygiene .changing linens .changing briefs or…

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 interviews, it has been determined that the facility failed to ensure that each resident receives adequate supervision to prevent accidents for 1 of 1 resident reviewed who requires frequent safety checks, Resident ID #21. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 9/20/2024 revealed that the resident fell in his/her room and was transferred to the hospital via 911. Review of an undated facility policy titled, Falls Prevention Program states in part, .It is the policy of this facility .to establish a care plan that identifies the risk factors exhibited by the resident and which directs staff re [regarding]: measures to be taken to mitigate or eliminate those risk factors . Record review revealed the resident was admitted to the facility in June of 2024 with diagnoses including, but not limited to, mantle cell lymphoma (cancer) and anxiety disorder. Record review of a Minimum Data Set assessment…

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 interviews, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed for withdrawal symptoms, Resident ID #98. Findings are as follows: Record review revealed the resident was admitted to the facility in February of 2024 with a diagnosis including, but not limited to, opioid dependence. Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. Review of a document titled, PHYSICIAN'S ORDER dated 10/3/2024, revealed an order for Lorazepam (an anti-anxiety medication), 0.5 milligrams (mg), by mouth, two times a day for 7 days. Review of the October 2024 Medication Administration Record (MAR) revealed the lorazepam was not administered and to See Progress Notes on 10/4/2024 at night and on 10/5/2024 in the morning. Review of the progress notes dated 10/4/2024 at 10:46 PM and 10/5/2024 at 12:42…

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 keep a resident free from physical abuse for 1 of 6 residents reviewed, Resident ID #1. Findings are as follows: Review of a facility policy titled, Abuse Prohibition last revised on 10/31/2022 states in part, It is the policy of this facility to ensure that all residents are treated with respect and dignity and that all residents are free from abuse, mistreatment, neglect .Abuse: willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish . Review of a facility reported incident received by the Rhode Island Department of Health on 8/3/2024 states in part, .2:15 PM [Resident ID #2] ambulating throughout the hallway entered [Resident ID #1]'s room via a closed door, [Resident ID #1] ordered [Resident ID #2] to get out and [Resident ID #2] went forward and grabbed [Resident ID #1] by the neck. [Resident ID #2] was instantly removed and [Resident ID #1] attended to. No apparent injuries on either party on [Resident ID…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observations, record review, staff and resident interview, it has been determined that the facility failed to provide an environment that promotes maintenance or enhancement of his or her quality of life relative to providing activities of daily living (ADL) for resident's whose primary language is not the dominant language of the employee that was providing care for 2 of 4 residents reviewed, Resident ID #s 1 and 2. Findings are as follows: Record review of a community reported complaint sent to the Rhode Island Department of Health on 7/18/2024 alleges that Resident ID #s 1 and 2 have a Nursing Assistant (NA) on the 3:00 PM to 11:00 PM shift who does not not speak English. Therefore, they are unable to communicate their needs. 1. Record review revealed that Resident ID #1 was readmitted to the facility in June of 2023 with diagnoses including, but not limited to, dysphagia, contractor of the right and left feet, anarthria (a speech disorder that makes speaking difficult due to central nervous…

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 promote and facilitate self-determination through support of resident choice relative to weekly showers for 2 of 4 residents reviewed, Residents #1 and 3. Findings are as follows: 1. Record review revealed that Resident ID #1 was readmitted to the facility in June of 2023 with diagnoses including, but not limited to, dysphagia, contractures of the right and left feet, anarthria (a speech disorder that make speaking difficult due to the central nervous system damage). Record review of the resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating the resident's cognition is intact. It further revealed that the resident is totally dependent on staff for transfers and requires extensive assistance for bathing, hygiene, dressing and eating. Review of the resident's care plan dated 1/7/2019 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.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide an ongoing program to support the residents in their choice of activities designed to meet their interests and support the well-being of each resident, based on the comprehensive assessment, care plan and preferences for 4 of 4 residents reviewed for activities who reside on the North B Unit ( a secured/locked unit), Resident ID #s 4, 5, 6 and 7. Findings are as follows: 1. Record review of the Facility Assessment states in part, .Staffing for a 24-hour period includes: Dementia: North B .1-2 Activity Aides . Record review for the North B Unit failed to reveal evidence of an Activities calendar available or posted for the residents. During a surveyor interview with the Director of Recreation on 6/21/2024 at 2:51 PM, she provided a monthly Activities calendar for the month of June 2024 upon the surveyor's request. Record review of the June 2024 Activities Calendar revealed the following scheduled activities for the North B Unit: - 6/20/2024: 10:00 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.

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 a safe, sanitary, and comfortable environment for residents, staff, and the public for 4 of 4 units observed. Findings are as follows: Review of community reported complaints submitted to the Rhode Island Department of Health on 4/29/2024 and 4/30/2024 alleged the facility exhibits issues with a lack of cleanliness resulting in an uncomfortable and unsanitary environment. The complainants also alleged that the bathrooms and the toilets are consistently unclean with the persistent odor of urine. 1. Surveyor observations on 4 of 4 units within the facility on 4/30/2024 between 8:30 AM and 2:30 PM revealed the following bathrooms with heavy accumulation of yellow and brown stains in the toilet bowls: - room [ROOM NUMBER] - room [ROOM NUMBER], including a strong urine odor - room [ROOM NUMBER] - room [ROOM NUMBER] - room [ROOM NUMBER] - room [ROOM NUMBER] - room [ROOM NUMBER], including a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, staff interview, and record review, it has been determined that the facility failed to provide an ongoing program which includes group activities and/or one-on-one visits (1:1), on 3 of 4 units reviewed for activities including the specialized dementia unit, for 7 of 7 residents reviewed, Resident ID #s 7, 33, 65, 78, 86, 95 and 111. Findings are as follows: Record review of a document titled, The Activities Department welcomes you to The [NAME] Health Center, which states in part .Residents who are unable to participate, the activities department offers 1-1 personal room visits .these visits may include poetry, crafts, trivia, cards, exercise, staff interaction, hand massage, sensory music, touch, smell. Additional review of a document entitled, Facility Assessment, dated 2/2023, states in part .activities are provided to accommodate the needs of our residents .further review of the Facility Assessment revealed staffing for the Dementia Unit (North B) which includes 1-2 Activity…

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 respiratory care consistent with professional standards of practice for 3 of 5 residents reviewed for respiratory care, Resident ID #s 7, 15, and 62. Findings are as follows: Review of the facility policy titled OXYGEN POLICY states in part, .Change oxygen tubing every week .have a bag available for storing tube, cannula, masks, etc. at the bedside to ensure storage and prevention of equipment being found on the floor. 1. Record review revealed Resident ID #7 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, acute respiratory syndrome, and anxiety disorder. Review of a physician order dated 5/9/2023, revealed change oxygen tubing weekly. Review of the October 2023 Medication and Treatment Administration Records (MAR/TAR) revealed the oxygen tubing was documented as being changed…

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 2 of 2 resident's reviewed for Extended Spectrum Beta-Lactamases (ESBL, an infection that is resistant to specific types of antibiotics), Resident ID #s 174 and 107, 1 of 6 residents reviewed for wound treatments, Resident ID #19 and the handling of soiled linen for 1 of 4 units and 1 of 1 laundry room. Findings are as follows: 1a. Review of the CDC's (Center for Disease Control and Prevention) document titled, Multidrug-resistant organisms (MDRO) management states in part, .For ill residents (e.g., those totally dependent upon healthcare personnel for healthcare and activities of daily living .) .use Contact Precautions [use of gown and gloves when entering a resident's room] in addition to Standard Precautions .For MDRO colonized or infected patients without draining…

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 the resident's medical record includes documentation that the resident either received the pneumococcal vaccination, did not receive the vaccination due to medical contraindications, or refusal for 5 of 7 residents reviewed, Residents ID #s 33, 34, 58, 66 and 104. Findings are follows: According to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, revised 2/3/2023 states in part, .The resident's medical record includes documentation that indicates, at a minimum, the following .That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal . Review of the facility policy titled Resident Vaccination (Flu and pneumonia) dated 1/18 states in part, .follow CDC (Centers for Disease Control and Prevention) Vaccination for Elders guidelines . According to the Centers for Disease…

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 to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public relative to 3 of 4 units observed, affecting Resident ID #s 15, 22, and 47. Findings are as follows: Record review of a facility policy titled, Housekeeping Department Infection Control Guidelines Dated 1/18 states in part, .It is the policy of this facility to maintain a clean and sanitary environment in order to preserve the health and safety of the residents, staff and visitors. For this reason, the following guidelines are to be scrupulously carried out by all members of the housekeeping department .All horizontal surfaces such as tabletops, window ledged, bedside stands, counters, sinks, tubs, shower floors, toilet seats, floors etc. are to be cleaned daily .Horizontal surfaces are to be cleaned as needed when spills or soiling occur .Friction (scrubbing) will be used in addition to a germicide to remove surface dirt from contaminated items prior to disinfection .…

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 services provided by the facility failed to meet professional standards of quality relative to a dressing observed on a resident, without a physician's order for 1 of 6 residents reviewed with a wound, Resident ID #73. 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 . Record review revealed the resident was admitted to the facility in March of 2023 with diagnoses including, but not limited to, dementia and encounter for orthopedic aftercare. During a surveyor observation on 10/16/2023 at 12:05 PM, revealed the resident with an undated dressing to the back of his/her left hand, which was visibly stained at the center of the dressing with sanguineous (bloody) drainage and lifting along the edges. Record review failed to reveal any documentation relative to a wound to the resident's left hand. Further record review failed to reveal evidence of a physician's order for 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 a resident's drug regimen is free from unnecessary drugs for 1 of 6 residents reviewed for unnecessary medications, Resident ID #50. Findings are as follows: Record review revealed the resident was admitted to the facility in August of 2022 with a diagnosis including, but not limited to, chronic kidney disease, stage 5. Record review revealed a physician's order for Amoxicillin-Potassium Clavulanate 875-125 milligrams (antibiotic) with a start date of 9/22/2023, to give 1 tablet every 8 hours for pneumonia for 5 days. Record review of the September 2023 Medication Administration Record (MAR) revealed that the resident was administered the antibiotic on the following dates and times: - 9/22/2023 at 2:00 PM and 10:00 PM - 9/23/2023 at 6:00 AM Additional record review of the September 2023 MAR revealed that the above-mentioned order was discontinued on 9/23/2023. During a surveyor interview on 10/19/2023 at 9:59 AM with Licensed Practical Nurse, Staff B, he revealed that 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 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 relative to notification of a practitioner for 1 of 7 residents reviewed, Resident ID #60. Findings are as follows: Review of a facility policy titled Notification of Change dated 3/31/17 states in part, This facility acknowledged that prompt follow up to abnormal results of lab tests .is essential to the promote the highest physical well-being of our residents. It is the policy of this facility to ensure that prescribing practitioners .are notified of laboratory .test results that fall outside of clinical reference ranges in a timely manner/or as per physicians' order .2. Any results of laboratory radiology and other diagnostic tests that fall outside of the clinical reference range will require notification to the prescribing practitioner as per their specific…

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, staff and resident interviews, it has been determined that the facility failed to ensure that each resident receives adequate supervision to prevent accidents for 7 of 7 residents reviewed for smoking, Resident ID #s 1, 2, 3, 4 ,5, 6, and 7. Findings are as follows: Record review of a community reported complaint reported to the Rhode Island Department of Health on 9/5/2023 alleges that On September 3 2023 at [NAME] health center there was no smoking monitor from early morning til 4 in the afternoon. The receptionist was handing out cigarettes from the window. There was also an incident with a couple of residents who were fighting over a lighter. One resident trying to pull the other out of wheelchair. Record review of the facility's smoking policy reveals, .Residents who are identified as smokers are to have a Comprehensive Care Plan for smoking developed by the Interdisciplinary Care Team .If the Interdisciplinary Team assesses the resident to potentially unsafe or…

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, staff, and resident interview, it has been determined that the facility failed to maintain a safe and clean environment relative to 1 of 3 resident bathrooms observed, Resident ID #4. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 8/22/2023, alleges that an anonymous resident reported dirty/unsafe environmental conditions in the facility. Record review revealed the resident was admitted to the facility in September of 2022 with diagnoses which include, Alzheimer's disease and vascular dementia. During a surveyor observation of the resident's bathroom on 8/22/2023 at 8:04 AM revealed the following: -Build up of brown, black and red debris accumulated in the corners, perimeter of the walls, as well as on the flooring tiles -Items of trash on the floor -Toilet water was brown with staining on the inner rim of the toilet bowl -Brown matter near the toilet handle and on the toilet seat -3 razors on the top of the toilet tank -3 opened used toothbrushes and a tube of toothpaste on 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.