AdviniaCare Oakland Grove LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 2 residents reviewed for antibiotics, Resident ID #85, 1 of 2 residents reviewed for pain management, Resident ID #82, and 1 of 1 resident reviewed for divalproex sodium (Depakote, a medication prescribed for off-label use to manage agitation and other challenging behaviors in dementia patients), Resident ID #30.Findings are as follows:A. Record review revealed Resident ID #82 was readmitted to the facility in April of 2025 with diagnoses including, but not limited to, low back pain and polyneuropathy (a disorder that affects nerves throughout the body potentially causing pain).Review of a Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status Score (BIMS) of 12 out of 15, indicating moderately impaired cognition. Additionally, it revealed that s/he has pain almost constantly.Review of a care plan focus…

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, resident, and resident representative interview, it has been determined that the facility failed to ensure each resident is treated with respect and dignity relative to 2 of 3 residents reviewed who required staff assistance for incontinence, Resident ID #s 2 and 90.Findings are as follows:1. Record review revealed Resident ID #2 was re-admitted to the facility in March of 2025 with diagnoses including, but not limited to, hemiplegia and hemiparesis (weakness on one side of the body) affecting right dominant side and benign prostatic hyperplasia (noncancerous enlargement of the prostate gland) with lower urinary tract symptoms.Record review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed, the resident has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating s/he is cognitively intact. Additionally, s/he is always incontinent of bowel and is dependent on staff for toileting.During a surveyor interview with Resident…

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

Based on record review and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan for each resident relative to urinary catheters for 1 of 3 residents reviewed, Resident ID #16. Findings are as follows:Review of a Clinical Competency dated 11/2017 states in part, Emptying a Urinary Drainage Bag.carefully measure urine in measuring cylinder.Record review revealed that Resident ID #16 was admitted to the facility in August of 2016 with diagnoses including, but not limited to, multiple sclerosis and neurogenic dysfunction of the bladder.Record review of a care plan revealed a focus area dated 9/18/2024 indicating, s/he has a suprapubic catheter with an intervention to monitor output for odor, color, consistency, amount, blood and sediment.Review of the Bladder Continence Task, question 3: catheter output for the last 30 days revealed 10 out of 30 days with no output documented.During a surveyor interview on 10/1/2025 at 8:10 AM with Nursing Assistant (NA), Staff C, she revealed that if a resident has a catheter the output…

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 for 1 of 2 residents observed for wound care, Resident ID #14. Findings are as follows: Review of a facility policy titled, Clean Dressing Technique, states in part, .Procedure: Check physician order for current, correct treatment.Sanitize hands and apply clean gloves. Remove old dressing and discard.Remove gloves, sanitize hands and apply clean gloves.Record review revealed the resident was admitted to the facility in September of 2025 with diagnoses including, but not limited to, type I diabetes and pressure wounds to his/her left heel, right foot, right hip, and sacrum (the lower back/base of the spine).Review of a care plan focus area dated 9/4/2025 revealed, the resident has multiple pressure wounds and that s/he is seen by the wound physician weekly. Additionally, it indicates to treat the wounds, as…

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 floors observed, the 3rd floor. Findings are as follows:1. During the medication storage and labeling task on 9/29/2025 at approximately 9:25 AM, in the presence of Certified Medication Technician (CMT), Staff K, observation of the 3rd Floor Northwest CMT medication cart revealed, 3 medication cups labeled with residents' room numbers containing multiple medications in each cup.During a surveyor interview at the time of the above observation with Staff K, he indicated that he pre-poured the resident's medications and that the residents were unavailable at the time they were prepared.During a surveyor interview on 9/28/2025 at 1:28 PM with the Director of Nursing Services (DNS), she indicated that pre-pouring medications is against the facility's policy and would expect the medications to be disposed of if the residents were unavailable. 2a. 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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to 1 of 1 resident reviewed for a splint, Resident ID #1.Findings are as follows:Review of a facility policy titled, SPLINTS/ORTHOTICS/PROSTHETICS, dated April 2015 states in part, .Upon admission/readmission, and at least every shift, all residents with a splint.will have the affected extremity monitored for circulation, motion and sensation [CSM] as well as any signs of edema [swelling], redness, irritation, or pressure areas potentially caused by the device.Nursing staff will remove the device and notify the physician and the rehabilitation department if the resident has actual or potential alteration in skin integrity that may have been caused by the device.Document evaluations and notify MD [medical doctor] of any abnormalities.Record review revealed Resident ID #1 was admitted to the facility in May of 2025 with a diagnosis including, but not limited…

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 honor a resident's right to request treatment for 1 of 1 resident reviewed for a hospital transfer, Resident ID #1. Findings are as follows: Review of a community reported complaint received by the Rhode Island Department of Health on 5/30/2025 alleged that Resident ID #1 requested to be sent out to the hospital for pain, however the facility refused the request because there was no order from a physician. Additionally Resident ID #1 called 911 from her/his personal cell phone and was transported to the hospital where a significant injury was identified. Record review revealed the resident was admitted to the facility in January of 2025 with diagnoses including, but not limited to, stroke, renal disease, and diabetes. Record review of a Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15 out of 15, indicating s/he is cognitively intact. Further review of the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following physician orders for antibiotic therapy and an for monitoring the output of an indwelling foley catheter (a device that drains urine from your urinary bladder into a collection bag outside of your body when you can't urinate on your own), for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Record review of two community reported complaints, both submitted to the Rhode Island Department of Health on 12/2/2024, allege that Resident ID #1 had been hospitalized 4 times in less than a month and was readmitted to the facility in November of 2024 with diagnoses of hypernatremia (sodium levels in the blood being too high. Common causes include inadequate fluid intake, or fluid loss), dehydration and sepsis pneumonia (a potentially life-threatening condition that arises when the body's…

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

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, relative to Enhanced Barrier Precautions (EBP; involves using a gown and gloves during high-contact resident care activities), an enteral feeding (a method of delivering nutrition directly into the gastrointestinal tract through a feeding tube) syringe and the storage of a nebulizer mask, for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Review of a facility policy titled, Enhanced Barrier Precautions Policy states in part, Enhanced Barrier precautions require the use of a gown and gloves for certain residents during high-contact resident care activities .High-contact resident care activities include bathing/showering, providing hygiene, dressing, transferring, linen changes, toileting, device care and wound care . Enhanced Barrier precautions will…

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 the resident's medical record in accordance with accepted professional standards and practices, for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Record review of two community reported complaints, both submitted to the Rhode Island Department of Health on 12/2/2024, allege that Resident ID #1 had been hospitalized and that the resident did not receive his/her prescribed antibiotic therapy at the facility after s/he was discharged from the hospital. Record review revealed Resident ID #1 was readmitted to the facility in November of 2024 with diagnoses including, but not limited to, hypernatremia, dehydration, and sepsis pneumonia. Record review of the hospital Continuity of Care document dated 11/27/2024 revealed a physician's order to continue Amoxicillin-Pot Clavulanate (an antibiotic) Oral Suspension Reconstituted 250-62.5 milligram (MG)/5 milliliters (ML) two times a day for sepsis, for 3 days. Record review of a physician's order dated 11/28/2024 revealed…

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 meet professional standards of quality relative to evaluating a resident after a suspected medication error occurred for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 10/5/2024 indicated that Resident ID #1 was transferred to an acute care hospital because s/he potentially received antipsychotic medication intended for another resident and was noted with a change in his/her mental status. Review of a facility policy and procedure dated April 2015 titled, MEDICATION ERROR REPORTING states in part, .A Medication error is any preventable event that may cause or lead to inappropriate medication use, which the medication is in the control of the health care professional . - A licensed nurse makes an immediate evaluation of the resident in relation to the nature of the error . - Follow-up notes are written…

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 by failing to implement appropriate precautions, documentation of follow-up activity in response and comply with state and local public health authority requirements for identification, reporting, and containing communicable diseases and outbreaks. Furthermore, the facility failed to don [put on] the required Personal Protective Equipment (PPE) prior to entering resident rooms that required precautions for 1 of 2 units reviewed. Findings are as follows: 1. Review of a facility policy titled, RI CORONAVIRUS (COVID-19) exposure states in part, This facility follows the professional standards and recommendations set forth by the Center of Disease Control [CDC], CMS [Centers for Medicare and Medicaid Services] and state health care agencies regarding coronavirus .The facility will actively screen all employees, vendors, and delivery personnel upon…

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 physicians' orders for 4 of 4 residents reviewed for intake and output (I&O), Resident ID #s 26, 30, 61, and 104. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing page 314, 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 the facility's policy and procedure for INTAKE AND OUTPUT MONITORING dated April, 2015 states in part, .Intake and Output will be monitored, as indicated by the resident's hydration status, risk for dehydration, and/or per physician's order .Intake and Output is documented for each shift, beginning with the 11 to 7 shift .Intake and Output is totaled daily by the 3 to 11 shift nurse and the 24 hour totals are transcribed to the Medication Administration Record . 1. Record…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight, for 3 of 6 residents reviewed for significant weight loss and/or gain, Resident ID #s 76, 96, and 104. Findings are as follows: Record review of the policy titled, Weights, last revised in August 2015, states in part, The following residents/patients are weighed weekly X4 [for four weeks] .Residents/patients with an MD [doctor] order for weekly weights .The same scale should be used for each weighing of a particular resident/patient to ensure consistency and more accurate weights .All weight loss/gain of 3 pounds or more on a resident weighing 100 pounds or less and weight loss/gain of 5 pounds or more on a resident weighing 100 pounds or more requires a reweigh for verification. A reweigh is done on the same scale with a licensed nurse present. Weights are documented in the resident's/patient's medical record and/or weight book. If a significant weight loss/gain is…

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 residents who are trauma survivors receive culturally competent, trauma-informed care, in accordance with professional standards of practice and accounting for residents' experiences and preferences, in order to eliminate or mitigate triggers that may cause re-traumatization for 1 of 1 resident reviewed, relative to a resident with history of post traumatic stress disorder (PTSD), Resident ID #96. Findings are as follows: Record review revealed the resident was admitted to the facility in October of 2023, with diagnoses including, but not limited to, PTSD, bipolar disorder, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition. Review of a document titled Social Service Trauma-Informed Care Screening Tool dated 10/3/2023, revealed a series of 7 questions…

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 who are fed by a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 2 residents reviewed relative to a gastrostomy tube (G-tube, which is a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine), Resident ID #76. Findings are as follows: Review of the policy titled Enteral Feeding dated April 2015 states in part, PROCEDURE .Elevate head of bed 30-45 degrees . Record review revealed the resident was re-admitted to the facility in February of 2024 with diagnoses including, but not limited to, dysphagia (difficulty swallowing) and Alzheimer's disease. Record review revealed a physician's order dated 2/17/2024 to elevate the resident 30-45 degrees at all times during feeding and for one hour after gravity feeds or resident must be elevated at all times with continuous feeding. Further record review revealed a physician's order dated 8/1/2024 to…

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

Based on record review, and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed for the use of Humira (a medication used to treat rheumatoid arthritis), Resident ID #1. Findings are as follows: Record review revealed that Resident ID #1 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, infection following a surgical procedure, rheumatoid arthritis and diabetes. Review of a community reported complaint submitted to the Rhode Island Department of Health on 6/26/2024 revealed that the resident had multiple concerns relative to the care s/he received while at the facility. Review of the physician orders revealed the following: -Humira subcutaneous pen -injector kit 40 MG (milligram)/0.8ML(milliliter) inject 1 application subcutaneously one time a day every 2 weeks on Friday. With a start date of 3/29/2024 and a discontinue (dc) date of 5/4/2024. -Humira subcutaneous pen-injector kit 40 MG/0.8ML…

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 protect and keep residents free from physical abuse relative to an incident that occurred between Resident ID #1 and Resident ID #5. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 5/9/2024 revealed a nursing assistant (NA) entered Resident ID #5's room at 4:00 PM and observed Resident ID #1 with his/her hands around Resident ID #5's neck. The residents were immediately separated, and Resident ID #1 was sent to the hospital for an evaluation. Record review of the facility policy titled Resident Abuse, Neglect, Mistreatment and Misappropriation Prevention Policy dated April, 2015 states in part, Policy: Each resident has the right to be free from abuse .Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish . Record review revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections for 1 of 1 resident reviewed for the management of a Multidrug-resistant Organism (MDRO), Resident ID #1. Findings are as follows: Review of the Centers for Disease Control and Prevention (CDC) document titled, Multidrug-resistant organisms management (MDRO) 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] .Implement Contact Precautions (CP) routinely for all patients colonized or infected with a target MDRO .modify CP to allow MDRO .colonized/infected patients whose site of colonization or infection can be appropriately contained and who can observe good hand hygiene practices to enter common areas 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 keep a resident free from sexual abuse for 1 of 1 resident reviewed, Resident ID #4 and for 1 of 2 residents reviewed for physical abuse, Resident ID #2. Findings are as follows: 1. The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023, states in part, .sexual contact is nonconsensual if the resident .lacks the cognitive ability to consent .CMS is not requiring facilities to adopt a specific approach in determining a resident's capacity to consent .in order to assist in the development and implementation of policy related to aspects of .intimacy and relationships .Allegations of Sexual Abuse .There are additional considerations when investigating allegations of sexual abuse involving .Resident to resident sexual abuse . For any alleged violation of sexual abuse, the facility must: - Immediately implement safeguards to prevent further potential abuse; -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident, and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made to the State Agency in accordance with State law for 1 of 1 resident reviewed for sexual abuse, Resident ID #4. Findings are as follows: The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023, states in part, .sexual contact is nonconsensual if the resident .lacks the cognitive ability to consent . Review of a facility policy titled, Abuse Prevention, Neglect, mistreatment and misappropriation prevention policy dated April 2015, states in part, .Each resident has the right to be free from abuse .It is the policy of all [NAME] Health Care Systems facilities to implement policies to .identify, investigate and report allegations of abuse .employees are expected to identify and report potential or actual occurrences of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review 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 1 of 1 resident reviewed with inappropriate sexual behaviors, Resident ID #1. Findings are as follows: According to the State Operations Manual, Appendix PP- Guidance to Surveyors for Long Term Care Facilities, revised on 2/3/2023, §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- (A) Initial goals based on admission orders. (B)…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored, served, and distributed, in accordance with professional standards for food service safety, relative to the main kitchen and for 3 of 3 unit kitchenettes observed. Findings are as follows: 1. The Rhode Island Food Code 2018 Edition 2-402.11 states in part, .food employees shall wear hair restraints, beard restraints that are designed and worn to effectively keep their hair from contacting exposed food . During surveyor observations in the main kitchen revealed the following: -9/25/2023 at approximately 8:40 AM dietary staff, Staff M and N, were observed without beard restraints. -9/25/2023 at approximately 2:30 PM, dietary staff, Staff O, was observed without a beard restraint. -9/26/2023 at approximately 11:20 AM dietary staff, Staff M and N were observed without beard restraints. -9/27/2023 at approximately 1:15 PM, dietary staff, Staff M, was observed without a beard restraint. -9/27/2023 at approximately 3:30 PM, dietary staff, Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident, and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to other officials (Department of Health), in accordance with State law for 1 of 1 resident reviewed for misappropriation, and 1 of 1 resident reviewed for injury of unknown origin, Resident ID #s 7 and 20. Findings are as follows: Record review of the facility policy titled, ABUSE PROHIBITION POLICY states in part, .Reporting/Documentation Requirements .The Administrator, Director of Nursing or their designee assumes responsibility for the immediate verbal notification of the incident to the following .3. The Department of Public Health: All alleged…

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 2 residents with recommendations from an outside consultant, Resident ID #35, 1 of 7 residents reviewed for medication administration, Resident ID #107, 4 of 13 residents with an air mattress, Resident ID #s 11, 58, 73, and 102, and 1 of 1 resident observed during a wound treatment, Resident ID# 88. Findings are as follows: A. 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 revealed Resident ID #35 was admitted to the facility in June of 2022 with diagnoses including, but not limited to, adult failure to thrive and moderate protein-calorie malnutrition (under nutrition). Review of a physician's order dated 4/10/2023 states, Consult- GI [gastroenterology]…

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 the necessary care and services to ensure that a resident's abilities in activities of daily living (ADL's) do not diminish unless circumstances of the individual's clinical condition demonstrate that such a diminution was unavoidable, relative to transfer, ambulation, toileting and incontinence care for 1 of 4 residents reviewed, Resident ID# 9. 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, schizoaffective disorder (a mental health condition), adult failure to thrive (FTT), neuroleptic induced parkinsonism (parkinsonism caused by antipsychotic, neuroleptic, medication) and major depressive disorder. Record review of the Annual Minimum Data Set Assessment (MDS), dated [DATE], revealed s/he required supervision assistance of one staff member for bed mobility, transfer, 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, resident and staff interview, it has been determined that the facility failed to provide the necessary services to a resident who is unable to carry out activities of daily living (ADLs), relative to showers for 2 of 4 residents reviewed, Resident ID #s 35 and 73. Findings are as follows: 1. Record review for Resident ID #35 revealed s/he was readmitted to the facility in December of 2022 with medical diagnoses including, but not limited to, spinal stenosis (the narrowing of the spine which puts pressure on the spinal cord and nerves and can cause pain) and difficulty walking. Record review of an Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that it is very important for him/her to choose between a tub bath, shower, bed bath, or sponge bath. Record review of a Quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Additionally, s/he is documented as requiring the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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, the comprehensive person-centered care plan, and the residents' choices, for 1 of 7 residents reviewed for positioning, Resident ID #73. Findings are as follows: Record review revealed the resident was readmitted to the facility in July of 2021 with diagnoses including, but not limited to, stroke, hemiplegia and hemiparesis affecting the left side (weakness and paralysis on one side of the body). Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. Additionally, the MDS revealed s/he requires total assistance of two or more staff members for transferring and locomotion. Record review of a care plan dated 8/31/2022 revealed the resident has contractures (tightening of the muscle causing difficulty with movement)…

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 that 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 #85. Findings are as follows: Record review revealed the resident was admitted to the facility in February of 2023 with diagnoses including, but not limited to, adult failure to thrive and Alzheimer's disease. Record review of a physician order dated September 2023 states in part, .Jevity 1.2 Cal (a high protein, fiber fortified liquid nutritional supplement) Oral Liquid Nutritional Supplement Bolus (a method of manually providing formula through a feeding tube) 240 ml (milliliters) four times a day . Record review of the manufacturer instructions on the Jevity 1.2 Cal 1000 ml container states in part, .once opened, reclose, refrigerate, and use within 48 hours . Surveyor observation on 9/26/2023 at approximately 2:30 PM revealed Licensed Practical Nurse, Staff…

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 receives necessary respiratory care and services that are in accordance with professional standards of practice for 2 of 2 residents reviewed for respiratory care, Resident ID #s 10 and 41. Findings are as follows: Record review of the facility policy titled, OXYGEN ADMINISTRATION NASAL CANNULA states in part, .To deliver low flow oxygen, per the physician's order .via nasal cannula .Set the Oxygen liter flow to the prescribed liters flow per minute .Replace and date cannula and tubing weekly or when visibly soiled or damaged . 1. Record review revealed Resident ID #10 was admitted to the facility in October of 2022 with diagnoses including, but not limited to, chronic obstructive pulmonary disease with acute exacerbation. Surveyor observations of the resident revealed s/he was receiving oxygen therapy via nasal cannula at 1 liter per minute on the following dates and times: 9/25/2023 at 10:12 AM 9/26/2023 at 9:09 AM 9/27/2023 at 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 record review and staff interview, it has been determined that the facility has failed to ensure that residents are free of any significant medication errors for 1 of 7 residents reviewed relative to medication administration, Resident ID #103. 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, hyperosmolality (condition where the blood has a high concentration of solutes) and Hypernatremia (increased sodium concentration in the blood), alcohol abuse with alcohol -induced psychotic disorder, and liver disease. Record review of a laboratory report dated 9/26/2023, states in part, .L[low] potassium 3.1 MEQ/L [milliequivalents/liter]. Additionally, instructions handwritten at the bottom of the report reads, Potassium 40 MEQ tonight only .Potassium 10 MEQ [NAME] [daily] . Record review of the September 2023 Medication Administration Record (MAR) revealed an order dated 9/26/2023 to administer Potassium…

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 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 1 resident observed to have their call light placed out of their reach, Resident ID #23. Findings are as follows: According to the facility policy titled, Call Light, Use Of, dated April 2015, states in part, .resident/patients will have a call light or alternative communication device within his/her reach when unattended .When providing care to residents/patients be sure to position the call light conveniently, telling/showing resident/patient where the call light is located . Record review revealed the resident was admitted to the facility in June of 2011 with diagnoses including, but not limited to, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following a stroke affecting the right dominant side. Record 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.

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 meet professional standards of quality relative to following physician's orders for 1 of 1 resident reviewed, Resident ID #2. 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 the resident's record revealed s/he was admitted to the facility in March 2023 with diagnoses including, but not limited to, heart failure and shortness of breath. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12 out of 15 indicating that his/her cognition is moderately impaired. Record review revealed the following physician's orders: - 3/17/2023 -Ted Stocking (socks to help prevent blood clots and swelling in the legs) on during…

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 maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 1 resident reviewed for inaccurate documentation, relative to the use of a compression sleeve, [NAME] stockings and offloading the resident's heels, Resident ID #2. Findings are as follows: Review of the resident's record revealed s/he was admitted to the facility in March 2023 with diagnoses including, but not limited to, heart failure and shortness of breath. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12 out of 15 indicating that his/her cognition is moderately impaired. Record review revealed the following physician's orders: - 3/17/2023 -Ted Stocking (socks to help prevent blood clots and swelling in the legs) on during the day and off at night for history of pulmonary embolism (condition in…

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