Heritage Hills Nursing & Rehabilitation Center

Based on record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity (the severity of an illness), and diagnoses of the facility's resident population in accordance with the facility assessment as required for 4 staff members observed, affecting Resident ID #s 4, 19, 46, and 49.Findings are as follows:1A. Record review of the facility's diet manual titled, Thickened Liquids states in part, .Honey-like: Sticks to sides of a cup like honey. Pours very slowly, such as honey and cream soup.Record review revealed Resident ID #49 was admitted to the facility in January of 2025 with diagnoses including, but not limited to, aspiration pneumonia (infection of the lungs caused by inhaling saliva, food, liquid, or vomit)…

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 the facility-wide assessment that is used to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment.Findings are as follows:Record review of the facility's undated document Facility Assessment states in part, Staffing Guidelines.Our staffing pattern is further developed based on the assessed nursing care needs of our residents, acuity [the severity of an illness], and census [unit population]. The base staffing pattern represents typical staffing based upon the average daily census of the facility. The facility adjusts staffing based upon multiple factors, including but not limited to, shifts in resident census, acuity, communicable disease outbreaks, and admission or discharge…

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, comprehensive, data-driven, Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. Additionally, the facility failed to make a good faith attempt to correct the identified concerns of patient care relative to call lights being answered, incontinence care, and morning care being provided.Findings are as follows:Review of a facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program last revised in February 2020, states in part, This facility shall develop, implement, and maintain an ongoing, facility wide, data driven QAPI program that is focused on indicators of outcomes of care and quality of life for our residents.identifying and prioritizing quality deficiencies.developing and implementing corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of corrective action/performance improvement activities,…

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, surveyor observation, and staff interview it has been determined that the facility failed to provide care that meets professional standards for 1 of 1 resident reviewed with a Peripherally Inserted Central Catheter (PICC line, a thin tube inserted into a vein in the upper arm and advanced to a large vein near the heart to deliver long-term intravenous treatments), Resident ID #79 and for 1 of 3 residents observed for wound care, Resident ID #83.Findings are as follows:1. Review of a facility policy titled, Central Venous Catheter Flushing and Locking last revised 10/2024 states in part, .Flush the catheter and aspirate [the procedure of drawing blood or fluid the procedure of drawing blood or fluid] for blood return prior to each infusion to assess catheter function.Record review revealed that Resident ID #79 was admitted to the facility in August of 2025 with diagnoses including, but not limited to, sepsis (a life-threatening medical condition that occurs when the body's response to an…

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

Based on surveyor 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 a medication error rate of 5% or greater. Based on 26 opportunities for errors observed during the medication administration task. Two errors occurred, resulting in an error rate of 7.69%, involving Resident ID #4.Findings are as follows:Review of a facility policy titled, Administering Medications last revised in April of 2019, states in part, Medications are administered in a safe and timely manner, and as prescribed.Record review revealed that the resident was admitted to the facility in April of 2024 with diagnoses including, but not limited to, dementia and intellectual disabilities.A. Record review revealed a physician's order for Biotene Dry Mouth/Throat Liquid (Mouthwash) give 15 milliliters (ml) three times a day for comfort measures/dry mouth.Review of the Biotene Dry Mouth Oral Rinse label revealed a warning label that states, Do not swallow.During a surveyor observation on 9/17/2025 at…

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 a resident with a known complicated feeding problem is assisted by a qualified staff member for 1 of 2 residents observed being assisted with feeding, Resident ID #46.Findings are as follows:Review of a policy titled, Assistance with Meals dated 3/2022 states in part, .All employees who provide resident assistance with meals will be trained and shall demonstrate competency.During the entrance conference on 9/15/2025 at 8:58 AM with the Administrator and the Director of Nursing Services (DNS), it was revealed that the facility does not have a paid feeding assistant program.Record review revealed that Resident ID #46 was readmitted to the facility in February of 2025 with a diagnosis including, but not limited to, dysphagia (difficulty swallowing). Record review revealed the resident requires a pureed textured diet.Review of the resident care plan dated 6/9/2023 revealed that the resident is at risk for aspiration (inhalation of something into the airway)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident and staff interview, it has been determined that the facility failed to explain the arbitration agreement to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands, for 2 of 12 residents reviewed for arbitration agreements, Resident ID #s 20 and 42.Findings are as follows:Review of a policy titled, Binding Arbitration Agreements last revised November 2023, states in part, .Upon admission, or any time during the resident's stay, the resident (or representative) may be presented with the opportunity to utilize a binding arbitration agreement to resolve disputes as long as the terms and conditions of the agreement comply with federal regulations.Binding arbitration agreements are voluntary for the residents. Residents are not compelled, pressured or coerced to enter into a binding arbitration agreement. It is unambiguously communicated to residents (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 record review, surveyor observation, and staff interview, it has been determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident reviewed for contact precautions (use of gown and gloves upon room entry), Resident ID #79, and for 1 of 1 resident reviewed for a suprapubic catheter (a device inserted through the abdomen into the bladder to drain urine), Resident ID #47. Findings are as follows:1. Review of an undated facility policy titled, Clostridium Difficile [C. Diff, is a bacterium that can cause severe diarrhea] dated 10/2018, states in part, .Resident with diarrhea associated with C. Difficile.are placed on contact precautions.When caring for residents with [C.Diff], staff is to maintain vigilant hand hygiene. Hand washing with soap and water is superior to [alcohol based hand sanitizer] for the mechanical removal of C.difficile spores from…

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 resident and staff interview, it has been determined that the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 3 units observed, the [NAME] Unit.Findings are as follows:Review of a facility policy titled, Answering the Call Light last revised 9/2022 states in part, .The purpose of this procedure is to ensure timely responses to the resident's requests and needs.During the resident council task completed on 9/16/2025 at approximately 2:00 PM, multiple residents complained about waiting for long periods of time for staff to respond to their call lights with an average wait time between 30 minutes to 1 hour. Additionally, one resident indicated it can take up to two hours.A surveyor observation on 9/17/2025 at approximately 9:25 AM of the [NAME] Unit, revealed two monitors at the Nursing Station. Additionally, the monitors were noted to be powered off.During a surveyor…

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, staff and resident interviews, it has been determined that the facility failed to ensure that each resident receives adequate supervision and care to prevent an accident for 2 of 3 residents reviewed who are at risk for falls, Resident ID #s 5 and 6. Findings are as follows:Record review of a United States Food and Drug Administration document titled A Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts states in part, to keep the bed in the lowest position with the wheels locked.1. Review of a community reported complaint submitted to the Rhode Island Department of Health on 7/30/2025 alleges that Resident ID #5 told a social worker at a local hospital that s/he was left unattended at the bedside while receiving care, sustained a fall and was sent to the hospital for an evaluation. Record review revealed Resident ID #5 was admitted to the facility in July of 2025 with a diagnosis that includes, but is not limited to, paraplegia (a type of paralysis that affects the lower half of the body, typically resulting in the loss…

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 residents with pressure ulcers/injury (localized damage to the skin and/or underlying soft tissue, usually over a bony prominence) receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 of 3 residents reviewed, Resident ID #s 1, 4 and 6. Findings are as follows: Record review of two community reported complaints dated 4/1/2025 and 4/2/2025 allege that Resident ID #4 arrived to the facility with a wound that worsened significantly, due to lack of adequate wound care while the resident was at the facility. According to the State Operations Manual, Appendix PP Guidance to Surveyors for Long Term Care Facilities, revised 8/8/2024, states in part, A pressure ulcer/injury (PU/PI) can occur wherever pressure has impaired circulation to the tissue. A facility must .If a PU/PI is present, provide treatment and services to heal it and to prevent .It is important that each…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following a physician's order for obtaining a urology consult for 1 of 1 resident 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 or would harm the clients. Review of a community reported complaint submitted to the Rhode Island Department of Health on 1/21/2025 alleged in part, .[Resident ID #1] was taken to [hospital name] .last night as [s/he] had a fever and an infection .they found [his/her] catheter extremely dirty, which in all probability, caused [him/her] to have a UTI . Record review revealed the resident was admitted to the facility in November of 2024 with a diagnosis including, but not limited to, retention of urine. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, and resident interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed who missed 2 of 3 appointments, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 1/8/2025, alleges a resident had missed appointments including, but not limited to, neurology and dental. The complaint further alleges that the family member called the facility to confirm a neurology appointment for 1/7/2025 and spoke with a nurse about the appointment. 1a. Record review revealed Resident ID #1 was admitted to the facility in July of 2024 with a diagnosis including, but not limited to, Parkinson's disease (a neurodegenerative disease). Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 10 out of 15, indicating the resident's cognition was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, resident, and resident representative interviews, it has been determined that the facility failed to ensure that a resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, for 1 of 1 resident reviewed who's primary language is Spanish, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 1/2/2025 alleged that a staff member had Resident ID #1 sign financial and admission documents, which s/he was not able to read, because the documents were not written in Spanish. Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident ID #1's preferred language is not English. Record review revealed a notice of health insurance non-coverage document, which was written in English, that outlines the resident's last day facility services would be covered by his/her insurance…

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, resident, and resident representative interviews, 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 obtaining a urine sample for 1 of 1 resident reviewed, Resident ID #1 and for 1 of 1 resident reviewed relative to obtaining weights, Resident ID #2. 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 or would harm the clients. 1. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 12/31/2024, alleged in part, that Resident ID #1 had a urine sample collected via a catheter (a flexible tube that is passed into the bladder to remove urine) when s/he could have urinated in a test cup for a urinalysis (when urine is collected and…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to scabies (an itchy skin rash caused by a tiny burrowing mite that can spread through close contact) management for 2 of 2 residents reviewed, Resident ID #s 42 and 45, and relative to Enhanced Barrier Precautions (EBP; involves using gown and gloves during high-contact resident care activities), Resident ID #s 78 and 192. Additionally, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to 2 of 3 wound care observations, Resident ID #s 5 and 192. Furthermore, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to the handling of soiled linen in the laundry room. Findings are as follows: 1. Review of a facility policy…

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

Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 2 of 2 residents reviewed for antibiotic use, Resident ID #s 78 and 194. Findings are as follows: Review of a facility policy titled, Antibiotic Stewardship last revised in December of 2016, states in part, .Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program .The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents . Review of a facility policy titled, Infection Preventionist [IP] last revised in September of 2022, states in part, .Responsibilities 1. The [IP] (or designee) coordinates the development and monitoring of the [IPCP] .The [IP] collects, analyzes 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 surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to meet professional standards of quality for 1 of 1 resident reviewed for the utilization of a Freestyle Libre sensor (a continuous glucose monitoring system that is designed to replace finger sticks and lessen the need for test strips for persons with diabetes), Resident ID #194, following a physicians order for daily dressing changes on a surgical site and daily weights for 1 of 1 resident reviewed, Resident ID #192 and 2 of 2 residents reviewed with non-pressure wounds, Resident ID #s 8 and 194. Findings are as follows: 1. Review of the Freestyle Libre 2 User Manual revealed that the sensor is to be changed every 14 days. Record review revealed that the resident was admitted to the facility in September of 2024 with diagnoses including, but not limited to, diabetes and acute kidney failure. During a surveyor interview with the resident on 9/11/2024 at 8:54 AM, s/he revealed that s/he…

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

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 care plan relative to 3 of 4 residents reviewed for specialist appointments, Resident ID #s 74, 79, and 194. Findings are as follows: Review of a facility policy titled, Resident Rights dated February 2021 states in part, Federal and state laws guarantee certain basic rights to all residents of this facility. The rights include the resident's right to .access to people and services, both inside and outside the facility . 1. Record review revealed that Resident ID #74 was admitted to the facility in June of 2024 with diagnoses including, but not limited to, traumatic brain injury and subarachnoid hemorrhage (bleeding within the area between the brain and the tissue covering the brain). Review of a hospital form titled Continuity of Care form dated 6/12/2024 revealed the resident was treated for a traumatic brain injury and started on Keppra (anticonvulsant medication)…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 2 residents reviewed for pressure ulcers, Resident ID #s 5 and 62. Findings are as follows: 1. Review of a policy titled Wound Care states in part, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify that there is a physicians order for this procedure . Record review revealed that Resident ID #5 was admitted to the facility in August of 2023 with diagnoses including, but not limited to, pressure ulcer of an unspecified site and adult failure to thrive. Record review revealed that the resident has a care plan dated 3/29/2024 that revealed the resident has actual and potential for pressure ulcer and alterations in skin integrity related to a history of pressure ulcers,…

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

Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care affecting 2 of 3 units including, 1 of 3 residents observed to be saturated in urine prior to a wound dressing change, Resident ID #5 (on the South Unit), 1 of 1 observation made for timeliness of staff response to a call light triggered for Resident ID #291 (on the [NAME] Unit), and complaints of long response times to call lights and untimely assistance for morning care identified during the Resident Council task affecting residents on the East, West, and South Units on various shifts, including Resident ID #s 18, 27, and 196. Findings are as follows: Review of the Facility Assessment states in part, .in the event of staffing challenges, our facility may utilize contracted staff to ensure that…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident relative to the administration of hypodermoclysis (a method of infusing fluids into the fatty tissue below the skin by means of gravity and a dial flow meter to approximate the infusion rate) for Resident ID #191 for 3 of 3 staff reviewed, Staff A, B, E, and 2 of 3 staff reviewed for wound dressing changes observed for Resident ID #s 5 and 192, Staff A and E. Findings are as follows: Review of the Facility Assessment revealed that the facility provides services including hypodermoclysis and wound care. Additionally, it indicates that department specific training and competencies are completed with staff throughout employment to ensure that they can safely and competently provide the level and types of care required…

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 address pharmacy recommendations in a timely manner for 3 of 6 residents reviewed, Resident ID #s 15, 58, and 63. Findings are as follows: Review of a facility policy titled, Consultant Pharmacist Reports dated November 2021 states in part, .Recommendations are acted upon and documented by the facility staff and/or the prescriber. Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing .The Director of Nursing or designated licensed nurse address and document recommendations that do not require a physician intervention, e.g., monitor blood pressure . 1. Record review revealed that Resident ID #15 was readmitted to the facility in June of 2024 with diagnoses including, but not limited to, bipolar disorder, anxiety, and depression. Review of a document titled, Consultant Pharmacist Recommendations to Nursing dated 6/26/2024 revealed to complete the diagnoses for use on orders lacking reason entered into the Electronic Medical Record (EMAR). 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.

Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 25 opportunities for error observed during the medication administration task, there were 14 errors resulting in a medication error rate of 56%, involving Resident ID #s: 74, 83, 191, and 241. Findings are as follows: Review of a facility policy titled, Administering Medications states in part, .Medications are administered in a safe and timely manner, and as prescribed .3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with prescriber orders, including any required time frame .7. Medications are administered within one (1) hour of their prescribed time . 1a) Record review revealed Resident ID #241 has physician's orders for the following medications: - Guaifenison 600 milligrams (mg) give 2 tablets for congestion at 8:00 AM and 8:00 PM - Acetaminophen…

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 provide services to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing for 1 of 1 resident reviewed for use of an external catheter (a flexible tube that collects urine and leads to a drainage bag), Resident ID #8. Findings are as follows: Record review revealed the resident was admitted to the facility in June of 2024 with diagnoses including, but not limited to, type II diabetes mellitus and heart failure. Review of an admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 10 out of 15, indicating moderate cognitive impairment. Review of a progress note dated 8/27/2024 states, Resident requesting [external] cath [catheter] at night for quality of life. [Nurse Practitioner] in agreement order entered Resident pleased. During a surveyor interview on 9/12/2024 at 11:03 AM with the resident, s/he revealed that s/he wants…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 residents reviewed for oxygen use, Resident ID #58. Findings are as follows: Review of a facility policy titled, Oxygen Administration states in part, .Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated . Record review revealed that Resident ID #58 was admitted to the facility in November of 2023 with diagnoses including, but not limited to, Alzheimer's disease and dementia. Record review revealed the resident was admitted to hospice care on 7/21/2024. Record review revealed that the resident was evaluated by hospice services on 9/11/2024 and the resident was placed on oxygen therapy related to abnormal breath sounds and inability to obtain an oxygen level, with an oxygen delivery rate of 2 to 3 liters (L), per minute. Record review revealed a physician's order dated 9/11/2024 for oxygen via nasal cannula (a lightweight plastic tube…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 wound treatments observed, Resident ID #5. Findings are as follows: Record review revealed that Resident ID #5 was admitted to the facility in August of 2023 with diagnoses including, but not limited to, pressure ulcer of unspecified site and adult failure to thrive. Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 1 out of 15, indicating severely impaired cognition. Review of a document titled, WOUND EVALUATION & MANAGEMENT SUMMARY dated 9/4/2024 revealed the resident has the following wounds; - Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) to his/her right heel…

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 that are accurately documented in accordance with professional standards and practices for 1 of 3 residents reviewed for vascular wounds, Resident ID #8. Findings are as follows: Record review revealed the resident was admitted to the facility in June of 2024 with diagnoses including, but not limited to, type II diabetes mellitus and heart failure. Record review revealed the following physician's orders to the resident's right lower extremity: - Apply Unna Boot - 2-layer compression system (a type of compression bandage that is specifically designed to treat and manage venous leg ulcers. It consists of a layer of zinc-impregnated, semi-rigid gauze wrapped around the affected leg, followed by an outer layer of cohesive compression bandage) twice weekly on Monday and Friday, with a start date of 6/24/2024. - Apply A+D ointment to leg along with clobetasol (a medicated cream). Cover with foam dressing. Apply tubi grip (an elastic bandage that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice and failed to follow physician's orders relative to daily wound dressing changes for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Record review of a facility document titled Dressings, Dry/Clean states in part; .The purpose of this procedure is to provide guidelines for the application of dry, clean dressing .The following information should be recorded in the resident's medical record, treatment sheet or designated wound form .The date and time the dressing was changed .The name and title (or initials) of the individual changing the dressing . Review of a document titled Competency Assessment Skin Tears-Abrasions and Minor Breaks, Care of states in part: .The purpose of this procedure is to guide the prevention and treatment of .skin tears .Apply the ordered dressing .Label with date 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 provide adequate supervision to prevent accidents for 1 of 1 resident reviewed for falls, Resident ID #1. Findings are as follows: Record review of an agreement between the facility and Rhode Island College School of Nursing revealed in part, .The School of Nursing .referred as the College and [facility name redacted] .referred as the Agency .enters in the following agreement which relates to those portions of the educational program in Nursing of the College which are conducted at the Agency .The Agency's responsibilities .The Agency is responsible for client care .The Agency shall delegate to appropriate members of its staff the responsibility of assisting with the planning and coordination of the learning experiences afforded students of the College . Record review of a community reported complaint sent to The Rhode Island Department of Health on 8/8/2024 alleges that Resident ID #1 fell in the shower while 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.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain appropriate infection control practices to help prevent the transmission of communicable diseases and infections for 1 of 1 resident reviewed for isolation precautions, Resident ID #2. Findings are as follows: Review of a facility document titled Isolation-Categories of Transmission-Based Precautions states in part, Policy Statement Transmission-based precautions are initiated when a resident develops signs and symptoms of an infection: or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents .Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected .When a resident is placed on transmission based precautions, appropriate notifications is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution .The signage informs the staff of the type of CDC [Center of…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following physician's orders for 1 of 4 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 or would harm the clients. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/28/2024 alleged that the resident did not receive some of his/her medications and other medications were administered late on 7/26/2024. Record review revealed the resident was admitted to the facility in July of 2024 with diagnoses including, but not limited to, urinary tract infection (UTI) and Deep Vein Thrombosis (DVT; a blood clot that forms in one or more of the deep veins in the body). Record review of the…

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

Based on record review and staff interview, it has been determined that the facility failed to store medications in accordance with currently accepted professional principles relative to maintaining safe and secure storage of all medications, including limited access and mechanisms to minimize loss or diversion, for 1 of 4 residents reviewed, Resident ID #3. Findings are as follows: Record review of the facility policy titled Controlled Substances dated November 2022 states in part, .The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1975) .Controlled substances are counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals sign the designated controlled substance record . Record review of a facility reported incident received by the Rhode Island Department of Health on 5/14/2024,…

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 nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident, as determined by resident assessments and individual plans of care, for 1 of 3 residents reviewed for medication administration, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 4/1/2024 alleges in part, On March 21st [Resident ID #1] was given the wrong medications .because there were people in training .[Resident ID #1] was given oxycodone and a blood pressure medicine .[Resident ID #1's] blood pressure is low so that was not good and also the oxycodone put [him/her] in a bad state of mind . According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised…

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 interviews, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 4/1/2024 alleges in part, On March 21st [Resident ID #1] was given the wrong medications .because there were people in training .[Resident ID #1] was given oxycodone and a blood pressure medicine .[Resident ID #1's] blood pressure is low so that was not good and also the oxycodone put [him/her] in a bad state of mind . The facility policy titled Administering Medications, states in part, .Medications are administered in accordance with prescriber orders .The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include .checking identification band .checking photograph attached to medical record .verifying resident identification with other facility personnel…

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 provide treatment and care in accordance with professional standards of practice, for 1 of 2 residents reviewed for wound care and 1 of 1 resident reviewed for antibiotic use Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 11/1/2023 alleges that the resident does not receive adequate care and is neglected by staff. Record review revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, cellulitis (skin infection) of the left lower limb and diabetes mellitus due to an underlying condition with a foot ulcer. 1. Review of the resident's hospital summary revealed the resident has the following wounds: - Wound 1: Right pretibial venous ulcer (shin) that was documented as being present on 10/15/2023 during his/her hospital stay - Wound 2: skin tear to left pretibial leg…

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 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 10/10/2023 at approximately 8:35 AM, during the initial tour of the main kitchen and on 10/12/2023 at approximately 10:30 AM, the following observations were made: - The hood over the stove was noted to have grease accumulation along the inner rim - Two reach in refrigerator units were noted to have a black substance on the back wall of each unit, accumulation of debris in the cover of the circulating fan within the unit, and were noted to have dust accumulation along the inner ridges of the grates covering the tops of the units. 2.) The Rhode Island Food Code 2018 Edition 3-501.16 states in part, (D)…

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

Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use, for 3 of 3 residents reviewed for antibiotic use, Resident ID #s 17, 37, and 51. Findings are as follows: Review of a facility provided policy titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, states in part, .1. As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist, or designee .All resident antibiotic regimens will be documented on the facility - approved antibiotic surveillance tracking form. The information gathered will include: a. resident name and medical record number; b. unit and room number; c. date symptoms appeared; d. name of antibiotic .e. start date of antibiotic; pathogen identified .g. site of infection; h. date of culture; i. stop…

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 or did not receive the vaccination due to medical contraindications or refusal, for 5 of 8 residents reviewed, Residents ID #'s 5, 9, 10, 19 and 42. 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 . According to the Centers for Disease Control and Prevention (CDC), pneumococcal vaccination for all adults 19 through [AGE] years old who have certain chronic medical conditions or 65 years or older who have only received PPSV23 [23…

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 keep a resident free from physical and verbal abuse for 1 of 4 residents reviewed for staff to resident abuse, Resident ID #71. Findings are as follows: Record review revealed that the resident was admitted to the facility in October of 2022 with diagnoses including, but not limited to, dementia, anxiety, urinary incontinence, and major depressive disorder. Review of a Quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 1 out of 15, indicating that the resident has severe cognitive impairment. Additional review revealed the resident requires extensive assistance of 2 staff members for bed mobility, dressing, eating, toilet use and personal hygiene. Further review revealed the resident is totally dependent on two staff with transfers and bathing. Review of the resident's care plan dated 6/23/2023 revealed a focus area for a history of rejection of care related 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 assess the need for a physical restraint, assess for the least restrictive alternative, the amount of time the restraint is needed and re-evaluation of the need for restraints for 1 of 1 resident reviewed for physical restraints, Resident ID #286. Findings are as follows: According to the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual last updated 10/4/2023, states in part, .Limb restraints include any manual method or physical or mechanical device, material or equipment that the resident cannot easily remove, that restricts movement of any part of an upper extremity (i.e., hand, arm, wrist) or lower extremity (i.e., foot, leg) that either restricts freedom of movement or access to his or her own body. Hand mitts/mittens are included in this category . Review of a facility policy titled, Use of Restraints dated April 2017, states in part, .6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to…

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

Based on record review and staff interview, it has been determined that the facility failed to develop and implement a baseline care plan for each resident within 48 hours of a resident's admission, that includes the instructions needed to provide effective and person-centered care for the resident that meets professional standards of quality care relative to urinary catheter, use of a helmet, use of a right hand restraint and a stage 4 pressure wound, for 1 of 4 residents reviewed for baseline care plans, Resident ID #286. Findings are as follows: Record review revealed that the resident was admitted to the facility in October of 2023 with diagnoses including, but not limited to, compression of brain and nontraumatic intracerebral hemorrhage (a blood vessel in the brain ruptures and causes bleeding inside the brain). A. During a surveyor observation on 10/10/2023 at 9:58 AM revealed a foley catheter bag hanging on the right side of the bed. Record review of the physician's orders failed to reveal an order for a foley catheter. Record review of the baseline 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 3 residents reviewed for assistance with meals, Resident ID #51. Findings are as follows: Record review revealed the resident was admitted to the facility in April of 2023 with diagnoses including, but not limited to, intellectual disability, dementia, gerd (reflux), and dysphagia (difficulty in swallowing food or liquid). Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 9 out of 15, indicating moderately impaired cognition. Additionally, the MDS revealed the resident is totally dependent on one staff member for eating. Record review of a care plan dated 4/14/2023 and updated 4/25/2023 revealed, the resident has a self-care performance deficit related to physical limitations due to impaired mobility. 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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 3 residents observed for wound care, Resident ID #s 32 and 286. Findings are as follows: 1. Record review revealed that Resident ID #32 was admitted to the facility in August of 2023 with diagnoses including, but not limited to, type II diabetes mellitus and protein calorie malnutrition. Review of a Wound Evaluation & Management Summary dated 10/9/2023 revealed the resident has a stage 4 pressure ulcer (stage 4 sores are the most serious, affecting the muscles and ligaments) to his/her left lateral foot and a deep tissue injury (DTI) to his/her left lateral ankle. Record review revealed the following wound care orders with a start date of 10/3/2023: Left Lateral Foot - apply silver sulfadiazine [topical is used to treat or prevent serious…

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 acceptable parameters of nutritional status, such as usual body weight for 2 of 6 sample residents reviewed, Resident ID#s 46 and 15. Findings are as follows: Record review of a facility policy titled, Weight Assessment and Intervention dated 2001 MED-PASS, Inc, revised March 2022 states in part: .individual care plans shall address the identified causes of weight loss .undesirable weight change is evaluated by the treatment team .the physician and multi disciplinary team identify conditions and medications that may be causing weight loss . 1. Record review revealed Resident ID #46 was re-admitted to the facility in June of 2023 with diagnoses including, but not limited to, acute kidney failure and cerebral infarction (stroke). Review of a document titled weight summary revealed the resident had a documented weight of 149.0 lbs.(pounds) on 8/4/2023 and had a documented weight of 112.4 lbs. on 10/4/2023, which is a weight loss of 36.6 lbs., indicating a significant weight loss of…

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

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure residents who are fed through a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 2 residents reviewed who receive nutrition via a feeding tube, Resident ID #286. Findings are as follows: Record review revealed the resident was admitted to the facility in October of 2023 with a diagnosis including, but not limited to, pneumonitis (inflammation of the lung tissue) due to inhalation of food and vomit. Review of a care plan revealed a focus dated 10/10/2023 which states in part, I have a nutritional problem or potential nutritional problem [related to] requires feeding tube to meet nutrition needs. Interventions include, but are not limited to, monitor tube feeding tolerance per protocol and speech therapy consult for chewing and swallowing problems. Review of a physician order dated 10/7/2023 revealed the resident's head of bed (HOB) should be elevated 30-45 degrees during enteral feeding, flushing, medication…

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

Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to meet professional standards of practice, in accordance with physician orders and the comprehensive person-centered care plan, relative to a peripherally inserted central catheter (PICC), for 1 of 2 residents observed for intravenous (IV) antibiotic administration via a PICC line, Resident ID #17. Findings are as follows: Review of a facility provided policy titled Peripheral and Midline IV Dressing Changes, which states in part, .General Guidelines 1. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened or visibly soiled) .4. Change the dressing if it becomes damp, loosened or visibly soiled and .immediately if the dressing or site appears compromised .6. Assess the peripheral/midline access device with each infusion and at least daily. a. Visually inspect the entire infusion system (solution, administration set, and dressing); b. Check expiration dates of the infusion,…

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 and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 1 of 3 medication carts. Findings are as follows: During a surveyor observation of the medication cart on the [NAME] unit (cart 2), on 10/13/2023 at 9:38 AM revealed a bottle of medication for Resident ID #333, indicating the drug contained within the bottle was Tafamidis (a medication used to treat heart failure) 61 MG (milligrams) oral capsule. Further review of the bottle of medication revealed a label visible underneath the Tafamidis label indicating the bottle contained Carbidopa-Levodopa 25-100 MG oral tablets (a medication to treat Parkinson's Disease). During a surveyor interview on 10/13/2023 at approximately 9:50 AM, with Registered Nurse, Staff L, she acknowledged that the medication bottle had two different medication labels, one on top of the other. During a surveyor interview on 10/13/2023 at 10:09 AM with the Director of Nursing Services, she was unable to explain…

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 #51 and foley catheter care relative to it leaking on the floor, Resident ID #286. Findings are as follows: 1. Review of the CDC's 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 in addition to Standard Precautions .For MDRO colonized or infected patients without draining wounds, diarrhea, or uncontrolled secretions, establish ranges of permitted ambulation, socialization, and use of common areas based on their risk to other patients and on…

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 meet professional standards of quality relative to physician's orders, for 1 of 3 residents reviewed with a diagnosis of diabetes, and 1 of 1 residents reviewed with an order for a consultation with a specialist, Resident ID #1. Findings are as follows: Record review of two community reported complaints submitted to the Rhode Island Department of Health on 10/2/2023 alleges that the resident was left in bed for 5 hours soaked in urine which resulted in a urinary tract infection, and that the facility forgets to give the resident his/her insulin. 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 September 2022 with a diagnosis including, but not limited to, diabetes. A. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident, and staff interview, it has been determined that the facility failed to provide the necessary services to residents who are unable to carry out activities of daily living (ADL) relative to incontinence care for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 10/2/2023 alleges that the resident does not receive incontinence care or assistance with toileting every 2 hours. Record review revealed that the resident was readmitted to the facility in September 2022 with diagnoses including, but not limited to, diabetes and chronic kidney disease. Record review of a quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 13 out of 15, indicating intact cognition. Additionally, the resident experiences bowel and bladder incontinence and requires the extensive assistance of one staff member for toileting needs which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, and resident interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality for 1 of 2 residents reviewed relative to following a physician's order for medication parameters, Resident ID #1. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Review of a community reported complaint, received by the [NAME] Department of Health on 9/11/2023, alleged quality of care concerns relative to medication errors. Record review of the resident revealed that s/he was admitted to the facility in July of 2021 with diagnoses including, but not limited, to hypertension (when the pressure in your blood vessels is too high). Review of a Minimum Data Set Assessment, dated 7/6/2023, revealed a Brief Interview for Mental…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure that the Clinical Consultant Pharmacist identified irregularities during the monthly pharmacist Medication Regimen Review (MMR) for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Record review for the resident revealed that s/he was admitted to the facility in July of 2021 with diagnoses including, but not limited, to hypertension (when the pressure in your blood vessels is too high). Review of a document titled, Order Summary Report revealed a 7/17/2023 physician's order for Metoprolol Succinate (a beta-blocker medication used to treat chest pain, heart failure, and high blood pressure) 50 mg (milligram) Extended Release 24-hour tablet. Further review of the order revealed instructions to hold if the systolic blood pressure (measures the pressure in your arteries when your heart beats) is less than 110 and if the apical pulse (a pulse point on your chest at the bottom tip of your heart) is less than 70. Review of the 7/18/2023 through 9/13/2023 Medication…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to following a physician's order for daily weights and obtaining laboratory testing for 1 of 3 residents reviewed, Residents ID #1. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states: The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. 1a. Record review of a community reported complaint sent to The Rhode Island Department of Health on August 23, 2023 alleges that Resident ID #1 presented to the hospital with limited responsiveness and went downhill fast since arrival to [skilled nursing facility]. Record review revealed that Resident ID #1 was admitted to the facility in August of 2023 with diagnoses to include, but are not limited to, urinary tract infection and heart failure. Review of the August 2023 Medication…

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

Based on record review and staff interview it has been determined that the facility failed to ensure that the residents are free from significant medication errors for 2 of 3 residents reviewed, Resident ID #s 1 and 2. Findings are as follows: 1. Record review of a community reported complaint sent to The Rhode Island Department of Health on August 23, 2023 alleges that Resident ID #1 presented to the hospital with limited responsiveness and went downhill fast since arrival to [skilled nursing facility] Record review revealed that Resident ID #1 was admitted to the facility in August of 2023 with diagnoses to include, but is not limited to, urinary tract infection (UTI) and heart failure. Record review of a Continuity of Care - Post-Acute Facility form dated 8/13/2023 revealed the following physicians' orders: Cephalexin (antibiotic) 250 milligrams (MG) take one tablet by mouth every 6 hours for 5 days. Review of the August 2023 Medication Administration Record (MAR) revealed the following physician's order: -Cephalexin Oral Tablet 250 MG Give 250 mg by mouth every 6 hours for UTI…

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