Cedar Haven Operations Holding LLC Valley View Hea

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to contact precautions (utilized when a resident is known or suspected to be infected with a Multidrug Resistant Organism [MDRO] that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces in the resident's room), for 3 of 3 residents reviewed on contact precautions, Resident ID #s 25, 38, and 83; for 3 of 5 residents reviewed for enhanced barrier precautions (EBP- refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) Resident ID #s 3, 123 and 161; and for the handling of soiled linen in the laundry room. Findings are as follows: 1. Review of a facility policy titled, Isolation states in part, .Contact precautions require the use of appropriate…

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 training program for all newly hired employees, consistent with their expected roles, relative to orientation education, as outlined in the facility assessment, for 4 of 5 newly hired employees, Staff J, X, Y, and the Food Service Director (FSD). Findings are as follows: Review of the Facility Assessment, dated 7/18/2024, states in part, .Training topics upon hire and annually for all staff: - Abuse, neglect, and mandatory reporting - Activities that constitute abuse, neglect, and misappropriation of resident property, Procedures for reporting incidents, of abuse, neglect, or the misappropriation of resident property - Corporate compliance - program overview; what to report and how to report noncompliance; standard of care/ensuring quality - Cultural competency - Customer service - Dementia care - person - centered care for the cognitively impaired .eight hours within 120 days of hire for all direct caregivers .two hours upon hire and annually for…

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 they not employ or otherwise engage individuals who have been found guilty of abuse or mistreatment by a court of law, for 1 of 1 personnel record reviewed for disqualifying information, Maintenance Assistant, Staff A. Findings are as follows: Review of a facility policy titled, Abuse prohibition states in part, .DEFINITIONS: Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish and included physical, verbal, sexual, and mental abuse .Any person seeking employment at this facility (which involves routine contact with a resident without the presence of other employees) shall be subject to a criminal background check, which is to initiated .The employee, through the employer, shall apply to the bureau of criminal identification [BCI] of the state or local police department for a statewide criminal records check .If the facility receives notice of disqualifying information regarding 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 ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive care plan relative to 1 of 3 wounds observed, Resident ID #137. Findings are as follows: Record review revealed Resident ID #137 was readmitted to the facility in October of 2024 with diagnoses including, but not limited to, acquired absence of right leg below the knee and acquired absence of left leg above the knee. Review of a progress note dated 2/12/2025 revealed, the resident had an abrasion to his/her right knee. Review of a progress note dated 2/19/2025 revealed, the resident has a wound to his/her right knee. During a surveyor observation on 2/26/2025 at 10:00 AM, revealed a wound dressing to the resident's right knee wound with a date of 2/23/2025, 3 days prior to the wound observation. Record review failed to reveal a physician's order to care for the right knee wound. Record review failed to reveal evidence that at the time the wound was identified 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 ensure that residents with pressure ulcers receive the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 1 resident observed with a pressure ulcer, Resident ID #3. Findings are as follows: According to Infection Control Assessment and Response (ICAR) Tool for General Infection Prevention and Control (IPC) Across Settings .Wound Care Facilitator Guide from the Centers for Disease Control and Prevention last revised on 1/27/2023, states in part, .Maintain separation between clean and soiled equipment to prevent cross contamination .Any unused disposable supplies that enter the patient/resident's care area should remain dedicated to that patient/resident or be discarded. They should not be returned to the clean supply area. If supplies are dedicated to an individual patient/resident, they should be properly labeled and stored in a manner to prevent…

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 provide appropriate treatment and services for 1 of 1 resident reviewed with a nephrostomy tube (PCN, a catheter that is inserted through your skin and into your kidney), Resident ID #64. Findings are as follows: Record review revealed Resident ID #64 was admitted to the facility in February of 2025 with a diagnosis including, but not limited to, obstructive and reflux uropathy (a condition in which the flow of urine is blocked). Record review of a hospital discharge document titled, Discharge Summary dated 2/6/2025 revealed an order to irrigate the PCN tube with 10 milliliters of normal saline daily and as needed. Record review failed to reveal evidence that the PCN tube was flushed from 2/7/2025 until 2/27/2025, for a total of 21 days. During a surveyor interview on 2/26/2025 at 10:29 AM with the resident, s/he indicated that his/her PCN tube was last flushed in the hospital prior to coming to the facility. During a surveyor interview on 2/27/2025 at 1:06…

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 are free of any significant medication errors for 1 of 2 residents reviewed for warfarin (Coumadin, a medication prescribed to prevent blood clots), Resident ID #23. Findings are as follows: Review of a policy titled Guidelines for Anticoagulation Management states in part, .When ordering the anticoagulant, the physician is to indicate the indication for the therapy and the desired therapeutic range .Whenever an anticoagulation therapy is administered it is to be monitored by evaluating the effect on the PT/INR [prothrombin time test/international normalized ratio, a test used to evaluate the therapeutic ranges for warfarin] .Any changes in coumadin dosage will be made accordingly. An order must be received from the MD [Medical Doctor] for the lab work . Review of a document titled A Guide to Taking Warfarin created by the American Heart Association, states in part, .It's important to monitor the INR at least once a month and sometimes as often as twice weekly to make…

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 obtain laboratory services to meet the needs of its residents for 1 of 2 reviewed for warfarin (Coumadin, a medication prescribed to prevent blood clots), Resident ID #23 and for 1 of 2 residents reviewed with an elevated white blood count (WBC), Resident ID #420. Findings are as follows: 1. Review of a policy titled Guidelines for Anticoagulation Management states in part, .Whenever an anticoagulation therapy is administered it is to be monitored by evaluating the effect on the PT/INR [prothrombin time test/international normalized ratio, a test used to evaluate the therapeutic ranges for warfarin] .Any changes in Coumadin dosage will be made accordingly. An order must be received from the MD [Medical Doctor] for the lab work . Review of a document titled A Guide to Taking Warfarin created by the American Heart Association, states in part, .It's important to monitor the INR at least once a month and sometimes as often…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and resident and staff interviews, it has been determined that the facility failed to provide a safe, sanitary, and comfortable environment on 4 of 4 nursing units observed. Findings are as follows: Record review of community reported complaints submitted to the Rhode Island Department of Health on 1/2/2025 and 1/3/2025, alleged that the facility has mold in the windows and ceiling tiles that making the residents sick. During a surveyor interview with the Maintenance Director in the presence of the Administrator on 1/10/2025 at 9:00 AM, the Maintenance Director revealed that the maintenance staff conducts environmental rounds every month. The Maintenance Director further revealed that they have maintenance staff and housekeepers assigned on each nursing unit. Additionally, the Maintenance Director revealed that they have a maintenance logbook on each nursing unit that staff uses to communicate with maintenance staff and housekeepers. Furthermore, the Administrator…

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 nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety, relative to a peripherally inserted central catheter (PICC- which is inserted into a vein in the arm and passed through to the larger veins near your heart), for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Record review of the facility assessment, last revised in January of 2024, revealed that the facility has the ability to provide intravenous (IV) therapy to their residents. Record review revealed Resident ID #1 was admitted to the facility in June of 2024 with diagnoses including, but not limited to, type II diabetes mellitus, acute kidney injury, infection and inflammatory reaction due to internal fixation device of unspecified site, and sepsis (potentially life-threatening infection of the blood stream). Additionally record review revealed that upon admission, the resident had a PICC line and was prescribed to receive IV…

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

Based on record review and staff interview, it has been determined that the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) to meet the needs of each resident for 1 of 3 residents reviewed, Resident ID #1. Record review of a community reported complaint received by the Rhode Island Department of Health on 6/19/2024 alleges that Resident ID #1 has not received his/her methadone (a medication used to treat opioid use disorder) and other medications for two days. The complaint further indicates that the resident tried to speak with the facility staff about this and was told they were checking with the pharmacy. Record review for Resident ID #1 revealed s/he was admitted to the facility in June of 2024 with diagnoses including, but not limited to, sepsis (a potentially life-threatening infection in the blood), history of opioid abuse, type II diabetes mellitus, acute kidney injury, and infection and inflammatory reaction due to internal fixation device…

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 are free significant medication errors for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 6/19/2024 alleges that Resident ID #1 has not received his/her methadone (a medication used to treat opioid use disorder) and other medications for two days. The complaint further indicates that the resident tried to speak with the facility staff about this and was told they were checking with the pharmacy. Record review revealed Resident ID #1 was admitted to the facility in June of 2024 with diagnoses including, but not limited to, sepsis (a potentially life-threatening infection in the blood), history of opioid abuse, type II diabetes mellitus, acute kidney injury, and infection and inflammatory reaction due to internal fixation device (surgical procedure used to internally set and stabilize fractured bones). Review of a physician's order dated 6/17/2024 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 food is stored and distributed, in accordance with professional standards for food safety relative to the main kitchen and 2 of 2 ice machines. Findings are as follows: 1. Record review of the Rhode Island Food Code 2018 edition, Section 3-602.11 Food Labels states, .(B) Label information shall include: (1) The common name of the food . During the initial tour of the main kitchen on 3/10/2024 at 8:18 AM, in the presence of the Food Service Director (FSD), the following food items were observed with no label: - In the walk-in refrigerator, two bags of hard-boiled eggs were sitting in clear liquid. - In the walk-in freezer, one opened plastic bag of French toast, noted to have white covering the edges, indicating freezer burn. During a surveyor interview, immediately following the above observations, the FSD acknowledged both items and indicated they should be discarded. 2. The Rhode Island Food Code 4.601.11 reads in part, .the non-food contact surfaces 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 surveyor observation, record review, 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 relative to incontinence care for 1 out of 1 incidence of incontinence care observed, Resident ID #129 and relative to the weekly scheduled showers for 9 out of 32 residents reviewed, Resident ID #s 1, 11, 38, 41, 46, 63, 82, 112, and 118. Findings are as follows: 1. Record review revealed Resident ID #129 was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, pressure ulcer of the sacral region (tail bone area), stage 4 (severe type of pressure ulcer, the skin is severely damaged, and the surrounding tissue begins to die (necrosis) may extend to muscle and bone), muscle weakness, and dementia. Record review of a Minimum Data Set Assessment (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating severely…

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

Based on record review and staff interview it has been determined that the facility failed to keep residents free from significant medication errors for 6 of 32 residents reviewed, Resident ID #s 7, 42, 48, 70, 112 and 123. Findings are as follows: Review of a facility policy titled, Medication Administration states, It is the intent of this policy to ensure that resident medication administration is managed to ensure for resident quality of life, timeliness and safety. 1. Record review revealed Resident ID #48 was readmitted to the facility in December of 2020 with diagnoses including, but not limited to, schizoaffective disorder and borderline personality disorder. Record review revealed the following physician orders: Ambien oral tablet 5 milligram (MG, hypnotic), give 1 tablet by mouth at bedtime for insomnia. Oxycodone oral tablet 10 MG, give one tablet by mouth every 6 hours for pain. Review of the March 2024 Medication Administration Record (MAR) revealed the medication was not administered and coded as 9, (see nurses note) on the following dates: Ambien on 3/6, 3/7, 3/8,…

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 2 of 3 residents observed for a wound dressing change, Resident ID #s 87 and 105. Additionally, the facility staff failed to conduct appropriate infection control practices relative to hand hygiene for 4 of 4 residents observed during the medication administration task, Resident ID #s 7, 33, 86, and 443. Findings are as follows: Review of a facility policy titled, Wounds - Dressing Changes states in part, .Procedure for Dressing Change .7. Nurse will remove soiled dressing and dispose of properly .9. Remove the dirty gloves and dispose of properly 10. Hand hygiene will be performed and the nurse will don clean gloves 11. Cleanse the incision [wound] . 1a) Record review revealed Resident ID #87 was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, chronic venous hypertension with ulcer 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 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 an injury of unknown origin, Resident ID #129. Findings are as follows: Record review of an undated facility policy titled, Resident Abuse Prohibition, states in part, .Any instance .including injuries of unknown origins .must be reported immediately to the DNS [Director of Nursing Services]/designee .The Department of Health and the Alliance for Better Long Term Care will be contacted to report all alleged violations .including injuries of unknown source .immediately, but not later than 2 hours after the allegation is made, if 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 ensure that services provided meet professional standards of quality relative to following a physician's order for 1 of 1 resident reviewed for carbon dioxide retention, Resident ID #3, 1 of 1 resident reviewed for off-loading heel booties, Resident ID #66, 1 of 1 resident reviewed for knee splints, Resident ID #75, and 1 of 2 residents reviewed for edema (swelling), Resident ID #105. Findings are as follows: According to 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. 1. Record review revealed Resident ID #3 was readmitted to the facility in February of 2024 with a diagnosis including, but not limited to, chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of a document titled Lab Results Report dated 2/5/2024…

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 provide appropriate treatment and services for 2 of 5 residents reviewed with an indwelling catheter (a flexible tube that collects urine from the bladder and leads to a drainage bag), Resident ID #s 79 and 129. Findings are as follows: According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing Volume 2, 10th Edition, page 252 states the usual daily urine volume in the adult is 1-2 Liters or 1000-2000 cubic centimeters (cc). According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing Volume 2, 10th Edition, page 1282 states, For patients with indwelling catheters, the nurse assesses the drainage system to ensure that it provides adequate urinary drainage. The color, odor, and volume of urine are also monitored. An accurate record of fluid intake and urine output provides essential information about the adequacy of renal function and urinary drainage. 1. Record review revealed Resident ID #79 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 ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 25 opportunities for errors observed during the medication administration task there were 2 errors resulting in an error rate of 8%, involving Resident ID #s 7 and 86. Findings are as follows: 1. Record review revealed Resident ID #86 has a physician's order for Eliquis 5 milligrams give 1 tablet every morning and night related to septic pulmonary embolism (infected blood clot in the lung). During a surveyor observation of the medication administration task on 3/11/2024 at 10:15 AM with Registered Nurse, Staff O, she failed to administer the morning dose of Eliquis to the resident as ordered. During a surveyor interview immediately following the above observation with Staff O, she acknowledged that Resident ID #86 did not receive his/her Eliquis. 2. Record review revealed Resident ID #7 has a physician's order for Fluticasone Proprionate nasal suspension 50…

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

Based on record review and staff interview it has been determined that the facility failed to maintain medical records on each resident that are accurately documented for 1 of 1 resident reviewed for heel boots, Resident ID #66 and 1 of 1 resident reviewed for off-loading wounds and elevating legs, Residents ID #105. Findings are as follows: 1. Record review revealed Resident ID #66 was readmitted to the facility in September of 2022 with diagnoses including, but not limited to, stage 4 pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of the right buttock, fusion of the spine and abnormal posture. Further record review revealed a physician's order dated 10/25/2023 for heel boots to bilateral feet every shift as tolerated for wound care. During surveyor observations on the following date and times there was no evidence of the bilateral heel boots observed: - 3/10/2024 at 9:18 AM - 3/10/2024 at 11:00 AM - 3/10/2024 at 12:05 PM - 3/11/2024 at 8:42 AM - 3/11/2024 at 11:14 AM - 3/11/2024 at 1:00 PM Review of March 2024 Treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and resident and staff interview, it has been determined that the facility failed to maintain a safe, clean, sanitary, homelike environment relative to mouse droppings in resident rooms for 2 of 4 units reviewed. Findings are as follows: Record review of two community reported complaints submitted to the Rhode Island Department of Health (RIDOH) on 2/5/2024 and on 2/7/2024 allege that mice are present in the resident rooms and throughout the building. During a surveyor interview with Resident ID #1 on 2/6/2024 at 9:54 AM, s/he revealed that on the second day of his/her admission, s/he saw a mouse run across the room and since then s/he has seen up to three mice at once in his/her room. The resident further revealed s/he is uncomfortable with the mouse droppings in the room which s/he indicated is unsanitary. The resident's roommate also revealed similar concerns. 1. Surveyor observations on the First floor and Second floor on 2/6/2024 at 10:00 AM revealed the…

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

Based on record review and staff interview, it has been determined that the facility failed to maintain acceptable parameters of nutritional status for 2 of 3 residents reviewed for weight loss, Resident ID #s 2 and 3. Findings are as follows: Review of the facility provided document titled Weight Monitoring Policy states in part, .all residents are to be weighed on a monthly basis .Some residents are weighed daily or weekly. Residents with orders for daily weights will have resident-specific parameters within the order to notify the MD [Medical Doctor] if weight variance of (i.e, 3-pound discrepancy in one day or 5-pound discrepancy in one week). Residents will be weighted on either a stand/sit scale or a Hoyer scale. If the weight is +/- 3 pounds from the previous weekly weight or +/- 5% on a monthly the resident is to be removed from the scale and reweighed (this needs to be no later than 24 hours of the questionable weight) .If the re-weight is accurate and there has been a significant weight loss, the nursing must notify the following . Physician Dietician DNS Administrator .…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 1 resident reviewed with pressure ulcers, Resident ID # 1. Findings are as follows: Record review revealed that the resident was admitted to the facility in December of 2022 with diagnoses including, but not limited to, unspecified dementia and diabetes mellitus, type II. Review of a physician order dated 7/26/2023 revealed to cleanse right lateral heel wound with normal saline, apply house barrier cream to the skin surrounding the wound, then place calcium alginate with silver (highly absorbent wound dressing) to the wound bed and cover with island bordered gauze followed by tubi-grip (self adhesive ACE bandage), daily. Review of a document titled WOUND EVALUATION & MANAGEMENT SUMMARY, dated 8/15/2023, revealed the resident has a stage 4 pressure ulcer (a localized injury to the skin and/or underlying…

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 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: During the initial tour of the main kitchen on 2/22/2023 at 8:42 AM in the presence of the Food Service Director (FSD) revealed the following observations: - 1 black hot beverage pitcher shelved with all clean ready to use pitchers which had approximately 1 inch of brown liquid inside of it. - 1 La Choy 1 gallon Soy sauce bottle, opened, in use and not dated - Scrambled eggs in a metal hotel pan dated 2/15 in the walk-in refrigerator - Tuna salad in a metal hotel pan dated 2/14 in the walk-in refrigerator - Ice build-up approximately 8 inches in length and 5 inches in width on top of plastic covered pies. The unit with fan above the pies had noted icicles formed approximately 2 inches in length dripping towards the pies. During a surveyor interview with the FSD immediately following each observation, she acknowledged…

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. Findings are as follows: Review of the antibiotic stewardship monthly records failed to reveal documentation of tracking information for the months of October, November, December of 2022 and January 2023, which included diagnostic tests including, but not limited to, laboratory results, x-rays, or cultures and test results to ensure the appropriate antibiotics were prescribed. Further review failed to reveal evidence of a system for monitoring or reviewing each resident's response to antibiotics. During a surveyor interview on 2/27/2023 at 10:40 AM with the Acting Infection Control Nurse, she was unable to provide evidence of an antibiotic stewardship program from October 2022 through January…

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 immediately consult with the resident's physician, and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical status or a need to alter treatment significantly for 2 of 2 residents reviewed, Resident ID #s 13 and 94. Findings are as follows: 1. Record review revealed Resident ID #13 was admitted to the facility in August 2010 with a diagnosis including, but is not limited to, urinary incontinence. Record review revealed a progress note dated 11/11/2022 at 9:02 AM which states in part, Resident had minimal menstrual bleeding today after years of not . Additional record review failed to reveal evidence that the Nurse Practitioner (NP) or Physician were notified of the resident having bleeding. Additional record review revealed a progress note dated 12/26/2022 at 2:59 PM which states in part, 911 called due to resident showing signs of a…

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

Based on 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 1 of 4 residents reviewed for pressure ulcers, Resident ID #123. Findings are as follows: Record review revealed Resident ID #123 was admitted to the facility in December of 2022 with diagnoses including, but not limited to, dementia and type 2 diabetes mellitus. A. Review of the documents titled, Wound Evaluation and Management Summary dated 1/31/2023, 2/7/2023, 2/14/2023 and 2/21/2023, revealed that the resident has an unstageable DTI (deep tissue injury) to the right lateral heel and right lateral foot. Additionally, the summaries revealed that s/he has an unstageable DTI to the left lateral heel, left lateral foot and left plantar foot with a recommendation to off-load wound, float heels in bed and elevate legs. Review of the physician's orders…

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 appropriate treatment and services for care of a resident for 3 of 7 residents reviewed with an indwelling catheter, Resident ID #s 41, 32 and 5. Findings are as follows: 1. The Center for Disease Control and Prevention (CDC) document titled, Guideline for Prevention of Catheter Associated Urinary Tract Infections 2009, states in part, .Proper techniques for Urinary Catheter Maintenance .Do not rest the bag on the floor . Record review for Resident ID #41 revealed that s/he was readmitted to the facility in April of 2020 and has diagnoses including, but not limited to, hydronephrosis with renal and ureteral calculous obstruction (swelling of the kidney due to build up of urine), urinary tract infections, and retention of urine. During surveyor observations revealed the resident's urinary drainage bag was resting on the floor on the side of the bed on 2/23/2023 at 9:01 AM, 1:09 PM, 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 record review and staff interview, it has been determined that the facility failed to ensure that medical records on each resident are accurately documented for 1 of 26 residents reviewed relative to medication administration, Resident ID #5. Findings are as follow: Record review revealed the resident was admitted to the facility in December of 2022 with diagnoses including, but not limited to, generalized anxiety and weakness. Record review revealed a physician's order dated 1/2/2023 for Fluticasone Propionate Nasal Suspension 50 MCG [micrograms]/ACT (fluticasone Propionate Nasal) 1 spray in each nostril in the morning for nasal congestion . During a surveyor interview with Licensed Practical Nurse, Staff L, on 2/27/2023 at 9:33 AM, she revealed that the resident did not receive the medication due to it not being available but she documented it as being administered. During a surveyor interview with Licensed Practical Nurse, Staff I, on 2/27/2023 at 9:57 AM, she revealed the Fluticasone Propionate has not been administered since it was ordered on 1/2/2023 because it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, staff and resident 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 2 of 26 residents reviewed, Resident ID #s 107 and 94. Findings are as follows: Record review of the facility's policy titled Call Light Policy states in part .The purpose of this procedure is to respond to the resident's request and needs .when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . 1. Record review for Resident ID #107 revealed s/he was originally admitted to the facility in November of 2020 and has diagnoses including, but not limited to, hemiplegia (paralysis of one side one the body), muscle weakness and chronic respiratory failure. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a…

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

Based on record review and staff interview, it has been determined that the facility failed to properly provide notice to residents and/or representatives informing where changes in coverage are made to items and services covered by Medicare and/or the medical state plan related to the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) for 2 of 3 residents discharged from Medicare Part A Services, Resident ID#s 87 and 123. Findings are as follows: Review of the Center for Medicare and Medicaid Services (CMS) document (Form CMS-10055), titled, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN), states in part: Medicare requires SNFs [Skilled Nursing Facilities] to issue the SNFABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is: - not medically reasonable and necessary; - or considered custodial. The SNFABN provides information to the beneficiary so that s/he can decide whether 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 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 2 of 3 residents reviewed for abuse and injury of unknown origin, Residents ID #s 100 and 21. Findings are as follows The facility policy and procedure titled, Abuse Prohibition revised on 10/31/2022, states in part; .All allegations of violations defined in this policy must be reported immediately to the Department of Health, Division of Facility Regulation .This means as soon as possible not to exceed 2 hours after the discovery . 1. Record review for Resident ID #100 revealed the resident was admitted to the facility in June of 2022 with diagnoses including, but…

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 residents who are unable to carry out activities of daily living, relative to nail care for 1 of 3 residents observed, Residents ID #70. Findings are as follows: Record review of Resident ID #70 revealed s/he was admitted to the facility in March of 2022 with diagnoses including, but not limited to, muscle weakness, altered mental status and cerebral infarction (stroke). Record review of a quarterly Minimum Data Set assessment dated [DATE] revealed s/he is coded as requiring Total dependence for personal hygiene and requires one person physical assistance. During a surveyor observation on 2/22/2023 at approximately 10:00 AM, the resident was observed with all fingernails approximately 1 centimeter long. There was brown and black matter underneath all of the fingernails. During a surveyor interview immediately following the observation, the 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.

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 has failed to ensure that each resident receives adequate supervision and assistive devices to prevent accidents for 2 of 5 residents reviewed for falls, Resident ID #s 127 and 89. Findings are as follows: 1. Review of a facility policy titled, Falls Prevention Program states in part, Procedure: .6. Any and all immediate fall prevention interventions are to be added to the resident's care plan at that time . Record review revealed that Resident ID #127 was admitted to the facility in January of 2023 with diagnoses including, but not limited to, unsteadiness on feet and lack of coordination. Review of a Morse Fall Scale dated 2/5/2023 revealed s/he is a high fall risk. Review of the resident's care plan revealed s/he is a high risk for falls related to confusion and poor comprehension. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed the resident utilized a walker and required 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.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional and hydration status, such as usual body weight and failed to follow their policy relative to weight loss and weight gain for 2 of 9 residents reviewed, Resident ID #s 123 and 32. Findings are as follows: 1. Review of a facility policy titled, Weight Monitoring Policy dated 2/24/2017, states in part, All residents are to be weighed at least monthly so as to monitor for weight loss, to assess for underlying causes of weight loss and to intervene accordingly in a timely manner to allow for an optimal level for well-being .if the weight is +/-3 pounds from previous month, the resident is to be removed from scale and reweighed immediately .If the re-weight is accurate and there has been a significant weight loss, nursing must notify the following: physician, dietician .After the unit manager reviews the report and a weight loss has been confirmed, the resident will be placed on weekly weights. The dietician…

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 therapy, Resident ID #43. Findings are as follows: Record review of a facility policy titled Oxygen Administration states in part, .Procedure .Check the physician's order for liter flow and method of administration .Documentation .Ensure that a physician's order has been obtained . Record review revealed the resident was admitted to the facility in April 2022 with a diagnosis including, but not limited to, chronic obstructive pulmonary disease (COPD, chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review revealed a care plan dated 4/20/2022 which states in part, .has oxygen therapy r/t [related to] COPD .Give medications as ordered by physician . During surveyor observations on 2/22/2023 at 9:04 AM, 2/23/2023 at 8:21 AM, and 2/24/2023 at approximately 8:20 AM revealed the resident receiving oxygen therapy at 2…

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

Based on record review and staff interview, it has been determined that the facility failed to provide routine medication to its residents for 1 of 26 residents reviewed, Resident ID #5. Findings are as follows: Record review revealed the resident was admitted to the facility in December of 2022 with diagnoses including, but not limited to, generalized anxiety and weakness. Record review revealed a physician's order dated 1/2/2023 for Fluticasone Propionate Nasal Suspension 50 MCG [micrograms]/ACT (fluticasone Propionate Nasal) 1 spray in each nostril in the morning for nasal congestion . Record review for January and February 2023 revealed the medication was not administered per the physician's order. During a surveyor interview with Licensed Practical Nurse, Staff F on 2/27/2023 at 9:57 AM, she revealed the above medication has not been administered since it was ordered on 1/2/2023. During a surveyor interview with the Director of Nursing on 2/27/2023 at 12:17 PM, she acknowledged that the medication was unavailable and it was not administered as ordered. 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 and staff interview, it has been determined that the facility failed to obtain laboratory services to meet the needs of its residents relative to the timeliness of the services for 1 of 5 residents reviewed, Resident ID #98. Findings are as follows: Record review revealed the resident was admitted to the facility in November of 2022 with diagnoses including, but not limited to, dementia and major depressive disorder. Review of a pharmacy consultation report dated 12/23/2022 revealed a recommendation to obtain a Fasting A1C (a blood test to obtain the three-month average of blood sugar) on the next convenient lab day and then annually following that result. Additionally, the recommendation was signed by the physician on 12/31/2022 to be implemented with added instruction to check the A1C every six months following the initial test. Review of a physician's order dated 1/17/2023 revealed an order to obtain a fasting A1C on 2/1/2023. Record review failed to reveal evidence that the fasting A1C was obtained as ordered. During a surveyor interview on 2/27/2023 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 record review and staff interview, it has been determined the facility failed to promptly notify the practitioner of results that fall outside of clinical reference ranges for 1 of 1 residents reviewed relative to abnormal X-ray results, Resident ID #100. Findings are as follows: Record review revealed the resident was admitted to the facility in June 2022 with diagnoses including, but not limited to, paraplegia (paralysis of all or part of your trunk, legs, and pelvic organs) and Cauda Equina Syndrome (when a bundle of nerves below the end of the spinal cord is damaged). Record review revealed a progress note dated 2/16/2023 at 10:47 PM that states in part, .resident showed nurse a fist size bruise to right upper ribs. With gentle palpation, [s/he] could feel some pain. Spoke with on call MD [physician] at .office who approved x-ray to ribs on 2-17-23 . Record review of x-ray results dated 2/17/2023 revealed in part, .Right rib bruising .Old fracture of the right eighth rib . Additional record review failed to reveal evidence that the x-ray results dated 2/17/2023 were…

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.