Based on clinical record review and staff interview, the facility failed to ensure that residents with pressure ulcers (tissue damage or wounds caused by prolonged pressure to an area of the body) receive the necessary treatment and services, consistent with professional standards of practice, for 2 of 2 residents reviewed with sacral (the area just above the buttocks and at the base of the spine) pressure ulcers, Resident ID #s 39 and 3.Findings are as follows:1. Record review revealed Resident ID #39 was admitted to the facility in January of 2025 with diagnoses including, but not limited to, dementia and pain.Review of a care plan dated 1/26/2026 revealed the resident is at risk for skin alterations related to incontinence, cognitive impairment, and limited mobility, and the resident has a pressure ulcer to his/her sacrum.Record review revealed the following active physician's treatment order dated 6/10/2026, the resident's stage four pressure ulcer on his/her sacrum (the most severe classification of pressure ulcers; a wound that extends through the skin and subcutaneous tissue into underlying structures such as muscle, tendons, ligaments, cartilage, or bone):- Wash Sacral wound with Vashe (Hypochlorous acid; wound wash) solution: irrigate into wound with Vashe and 10 [milliliters] syringe; pack wound with Alginate calcium with silver (an absorbent wound dressing with antimicrobial properties) and [a] collagen sheet (a topically applied wound dressing without antimicrobial solution) and stomadhesive paste apply to skin.then adhere gauze island with borders.once daily.Review of documents titled [NAME] Specialty Physician Wound Evaluation & Management Summary revealed the following wound dressing treatment recommendations made on the following dates for the resident's stage four pressure ulcer to his/her sacrum:- 6/30/2026 - discontinue Alginate calcium with silver. Additional review revealed the wound dressing treatment recommendation was approved and signed by the provider on 7/1/2026. However, record review revealed the Alginate calcium with silver was not discontinued and the resident continued to receive the treatment. - 7/7/2026- continue with Vashe solution followed by a collagen sheet and a bordered island dressing. Additional record review revealed the wound dressing treatment recommendation had not been signed by the provider indicating it had not been reviewed.-7/17/2026- discontinue collagen sheet and to add collagen powder. Additional review revealed the wound dressing treatment recommendation was signed by the provider in 7/20/2026. However, record review revealed the collagen sheet was not discontinued and the collagen powder was not implemented. -7/24/2026- Silver Sulfadiazine 1% (an antibiotic topical cream) was added as a wound dressing treatment recommendation. Additional review revealed the wound dressing treatment recommendation was not signed by the provider. During a surveyor interview on 7/29/2026 at 10:22 AM with Licensed Practical Nurse (LPN), Staff O, he revealed that he had completed Resident ID #39's pressure ulcer dressing that morning with Vashe solution followed by a bordered island dressing. He further revealed that he did not follow the active order which included Alginate calcium with silver and stomadhesive. Additionally, he revealed that the [NAME] wound evaluations should be reviewed by the provider, and if the provider is in agreement, the dressing order should be updated in the resident's Treatment Administration Record (TAR). Furthermore, he acknowledged that the Alginate calcium with silver had not been discontinued, as ordered, on 7/1/2026, nor had any of the remaining above-mentioned recommendations been implemented. During a surveyor interview on 7/29/2026 at 10:41 AM with the Director of Nursing Services (DNS), she revealed that she prints the [NAME] evaluations and treatment plans once they are uploaded into the electronic medical record by Vohra, usually the day after the evaluation is completed. She further revealed that she is the only staff member who follows up with the [NAME] evaluations and once she prints them, she gives them to the unit nurse who then notifies the provider for review and new orders. Additionally, she revealed that she would expect the [NAME] wound treatment plans to be reviewed, orders transcribed, if approved by the provider, and dressing, to be completed as ordered. Record review of the July 2026 Treatment Administration Record (TAR) revealed the treatment order remained unchanged from 6/30/2026 until 7/29/2026, after it was brought to the facility's attention by the surveyor.2. Record review revealed Resident ID #3 was readmitted to the facility in January of 2026 with diagnoses including, but not limited to, protein-calorie malnutrition and a stage four pressure ulcer.Review of a care plan, last revised on 7/30/2026 revealed the resident has a stage four sacral pressure ulcer with interventions including, but not limited to, wound doctor consults. Review of the document titled [NAME] Specialty Physician Wound Evaluation & Management Summary dated 7/3/2026 revealed a dressing treatment plan which included, but was not limited to:- Add collagen sheet with silver (an advanced, topically applied wound dressing with antimicrobial solution intended to reduce and prevent bacterial colonization within the wound dressing).Review of the July 2026 TAR revealed the following order dated 7/4/2026:-Sacral Wound: Vashe soak, skin prep (a liquid applied to the skin to assist in adhering the dressing), collagen sheet (a topically applied wound dressing without antimicrobial solution), methylene blue (a foam dressing), followed by a silicone border dressing. Record review failed to reveal evidence that the treatment plan which included a collagen sheet with silver had been implemented from 7/3/2026 until 7/29/2026, approximately 25 days later. During a surveyor interview on 7/30/2026 at 11:30 AM with Registered Nurse, Staff P, she indicated that the sacral pressure ulcer dressing order should have been transcribed to include a collagen sheet with silver, as outlined in the [NAME] dressing treatment plan. During a surveyor interview on 7/30/2026 at 11:44 AM with the DNS, she revealed that she would expect the [NAME] dressing treatment plan to match the order transcribed into the TAR.During a surveyor interview on 7/31/2026 at 9:52 AM with the Medical Director, he revealed that he would expect [NAME] dressing orders to be implemented immediately once reviewed by the provider.
Every finding on record at Woonsocket Health Center
Woonsocket, Rhode Island · CCN 415041
25 findings across 7 inspections, in the inspector's own words, 5 of them at actual harm or above.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.
Inspection of July 31, 2026
9 findingsBased on surveyor observation, clinical record review, and staff interview, the facility failed to store drugs and biologicals in accordance with currently accepted professional principles for 2 of 5 medication carts observed. Findings are as follows:Record review of a facility policy titled Medication Administration Safety Program dated [DATE] states in part, .Storage: A supply of medications is maintained in the facility in locked medication carts stored under proper conditions with regards to.expiration date as directed by state and federal regulations and manufacturer's guidelines.1. During a surveyor observation of the third-floor Certified Medication Technician (CMT) medication cart on [DATE] at 1:14 PM, in the presence of CMT, Staff A, revealed the following:- Two Wixela 250-50 micrograms (mcg) inhalers (a medication prescribed to treat asthma and chronic obstructive pulmonary disease) opened and dated [DATE]. The manufacturer's instruction states to discard one month after opening.- One Wixela 250-50 mcg inhaler opened and dated [DATE].- Ondansetron 4 milligram (a medication prescribed to prevent nausea and vomiting) tablets with an expiration date of [DATE].During a surveyor interview immediately following the above-mentioned observation, Staff A acknowledged the inhalers were opened on the dates indicated and stated that she was unaware of the manufacture's discard date. Additionally, she acknowledged the Ondansetron had expired.2. During a surveyor observation of the third-floor nurse medication cart on [DATE] at 1:28 PM in the presence of Licensed Practical Nurse, Staff B revealed a Glucagon injectable kit (a medication prescribed to be used as an emergency situation to treat severely low blood sugar) with an expiration date of [DATE].During a surveyor interview immediately following the above-mentioned observation, Staff B acknowledged the Glucagon had expired.During a surveyor interview on [DATE] at 12:57 PM with the Director of Nursing Services, she was unable to provide evidence that medications were stored according to accepted professional principles.
Based on record review and staff interview, it has been determined that the facility failed to include Quality Assurance Performance Improvement (QAPI) mandatory training, which outlines and informs staff of the elements and goals of the facility's QAPI program, for 9 of 9 staff reviewed, Staff ID #s D, G, H, I, J, K, L, M, and N. Findings are as follows:Record review failed to reveal evidence that the mandatory QAPI training was completed for the following staff:-Licensed Practical Nurse (LPN), Staff D, with a hire date of 3/20/2014-Nursing Assistant (NA), Staff G, with a hire date of 4/7/1989-NA, Staff H, with a hire date of 8/6/2024-NA, Staff I, with a hire date of 10/3/2018-Certified Medication Technician, Staff J, with a hire date of 9/27/1985-Laundry Aide, Staff K, with hire date of 4/11/2024-LPN, Staff L, with a hire date of 4/29/2021-Registered Nurse, Staff M, with a hire date of 5/9/2024-Housekeeper, Staff N, with a hire date of 10/1/1997During a surveyor interview on 7/30/2026 at 2:50 PM with the Administrator of Clinical Services, she acknowledged that the above-mentioned staff had not been provide with QAPI education, as required.
Based on clinical record review and staff interview, the facility failed to ensure that the physician reviewed the total plan of care for each resident including signing and dating all of the physician's orders, for 10 of 12 residents reviewed, Resident ID #s 2, 3, 5, 8, 10, 14, 15, 21, 39, and 130.Findings are as follows:Record review of a facility policy titled, ATTENDING PHYSICIAN AGREEMENT states in part, I will supervise the medical care of my patients.I will date, write and sign a meaningful progress note after each patient visit.I will provide a yearly physical examination of health appraisal that addresses the overall plan of care. I will date and sign all orders.1) Record review revealed Resident ID #2 was readmitted to the facility in March of 2022 with a diagnosis including, but not limited to, atrial fibrillation (an irregular heart rhythm).Record review failed to reveal evidence that the resident's physician reviewed, signed and dated the following orders:-3/19/2025 -ondansetron-3/31/2025 -may straight Cath as needed for urine specimen-4/2/2026 -sit to stand transfer-1/27/2026 -trazadone-4/30/2026 -glucagon-5/14/2026 -puree diet supervised at meals-6/9/2026- omeprazole2) Record review revealed Resident ID #3 was readmitted to the facility in July of 2025 with a diagnosis including, but not limited to, an elevated white blood cell count.Record review failed to reveal evidence that the resident's physician reviewed, signed and dated the following orders:-7/12/2025 -fluticasone propionate-7/12/2025 -magnesium hydroxide-7/12/2025 -air mattress for comfort-7/12/2025 -full code status-7/12/2025 -diet order: HCC regular texture, thin liquids-9/1/2025 -monthly weights-10/1/2025 -monthly diabetic nail care-1/23/2026 -ipratropium-albuterol-1/23/2026 -acetaminophen-1/23/2026 -amlodipine-1/23/2026 -dapagliflozin propanediol-1/23/2026 -incruse ellipta-1/23/2026 -naloxone-1/23/2026 -prazosin-1/23/2026 -rivaroxaban-1/23/2026 -senna plus-3/18/2026 -house supplement 4oz-4/1/2026 -right 1/2 side rail to assist and facilitate bed mobility-7/14/2026 -weekly skin check: to be done on shower day3) Record review revealed Resident ID #5 was admitted to the facility in February of 2026 with a diagnosis including, but not limited to, polyneuropathy (a nerve disease caused by nerve damage).Record review failed to reveal evidence that the resident's physician reviewed, signed, and dated the following orders:-2/3/2026 -amlodipine-2/3/2026 -sertraline-2/5/2026 -miralax-2/5/2026 -fleet enema-2/5/2026 -omeprazole-3/9/2026 -milk of magnesia-4/1/2026 -bilateral 1/2 bed rail for bed mobility-4/10/2026 -code status: do not resuscitate, do not hospitalize-4/15/2026 -morphine concentrate-4/16/2026 -ondansetron-4/25/2026 -remove hearing aids at bedtime-4/29/2026 -Diet Order: House regular gluten free, thin liquids assist with meals-5/19/2026 -monthly weight4) Record review revealed Resident ID #8 was readmitted to the facility in May of 2026 with a diagnosis including, but not limited to, displaced left femur fracture.Record review failed to reveal evidence that the resident's physician reviewed, signed, and dated the following orders:-1/23/2026 -Code status: full code-5/26/2026 -albuterol-5/26/2026 -atorvastatin-5/26/2026 -baclofen-7/10/2026 -bumetanide-5/26/2026 -vitamin d3-5/26/2026 -Creon-5/26/2026 -farxiga-5/26/2026 -ferrous sulfate-5/26/2026 -ipratropium-albuterol-5/26/2026 -lantus insulin-5/26/2026 -ondansetron-5/26/2026 -plavix-5/26/2026 -suboxone-5/26/2026 -tramadol5) Record review revealed Resident ID #10 was admitted to the facility in November of 2025 with a diagnosis including, but not limited to, polyneuropathy.Record review failed to reveal evidence that the resident's physician reviewed, signed, and dated the following orders:-11/14/2025 -ammonium lactate-11/14/2025 -polyethylene glycol powder-11/14/2025 -latanoprost-11/14/2025 -fleet enema-11/18/2025 -weekly skin checks-12/2/22025 -house supplement-12/5/2025 -air mattress set to residents' comfort-12/5/2025 -senna plus-12/5/2025 -balmex to peri-area and right buttocks-12/5/2025 -skin prep to bilateral heels-1/8/2026 -hospice consult-1/10/2026 -monthly weight-1/22/2026 -timolol-1/22/2026 -acetaminophen-1/22/2026 -morphine-1/22/2026 -ammonium lactate-1/23/2026 -skin prep to bony prominences of feet/toes-3/22/2026 -narcan-3/27/2026 -code status: do not resuscitate and no tube feeding-4/1/2026 -two partial side rails-5/13/2026 -may crush medications-5/28/2026 -tramadol6) Record review revealed Resident ID #14 was admitted to the facility in April of 2026 with a diagnosis including, but not limited to, type 2 diabetes.Record review failed to reveal evidence that the resident's physician reviewed, signed, and dated the following orders:-4/4/2026 -eliquis-4/4/2026 -gabapentin-4/4/2026 -jardiance-4/4/2026 -lisinopril-4/4/2026 -lovastatin-4/4/2026 -metformin-4/4/2026 -metoprolol-4/4/2026 -polyethylene-4/4/2026 -senna-4/4/2026 -tradjenta-4/6/2026 -acetaminophen-4/6/2026 -diet as ordered, HCC regular texture, thin liquid-4/6/2026 -aspirin-4/6/2026 -duloxetine-4/7/2026 -dulcolax-5/28/2026 -weekly skin check7) Record review revealed Resident ID #15 was admitted to the facility in January of 2025 and readmitted in February of 2026 with a diagnosis including, but not limited to, hypertension.Record review failed to reveal evidence that the resident's physician reviewed, signed, and dated the following orders:-1/15/2025 -cholecalciferol-1/15/2025 -weekly skin check-1/15/2025 -psych, eye, dental, urology, podiatry consults prn-1/15/2025 -influenza virus vaccine annually and pneumonia vaccine may be given-1/15/2025 -fleet enema-1/15/2025 -house regular diet-8/2/2025 -monthly weight-9/8/2025 -loa as needed-11/10/2025 -miralax-2/27/2026 -bilateral half side rails-3/2/2026 -naloxone-3/2/2026 -oxycodone8) Record review revealed Resident ID #21 was admitted to the facility in May of 2025 and readmitted in May of 2025 with a diagnosis including, but not limited to, hypertension.Record review failed to reveal evidence that the resident's physician reviewed, signed, and dated the following orders:-6/2/2025 -weekly skin check-5/31/2025 -physical therapy x 4 weeks-9/13/2025 -air mattress set to resident's weight-10/11/2025 -enteral feeding-10/11/2025 -elevate head of bed 30 degrees-10/11/2025 -flush peg tube with 150 milliliters (ml) of water-10/14/2025 -maintain aspiration precautions at all times-10/20/2025 -diet order: Nothing by mouth-11/6/2025 -hospice admission order-11/8/2025 -monthly diabetic nail care-11/8/2025 -code status: Do not resistate/no hospitalization except for trauma-11/9/2025 -tylenol-12/6/2025 -monthly weight-1/2/2026 -apply calazime to peri-anal area-2/2/2026 -jevity 1.5 calorie tube feeding-2/2/2026 -lasix-2/9/2026 -valproic acid9) Record review revealed Resident ID #39 was admitted to the facility in January of 2025 and with a diagnosis including, but not limited to, unspecified dementia.Record review failed to reveal evidence that the resident's physician reviewed, signed, and dated the following orders:-1/14/2025 -pneumonia and influenza vaccine annually-1/14/2025 -psych, eye, dental, urology, podiatry consults as needed-1/14/2025 -generic equivalents permitted unless noted-1/14/2025 -hoyer for transfers-1/15/2025 -physical therapy clarification 5 x week for 4 weeks-2/28/2025 -code status: DNR, do not intubate (DNI), no artificial means of feeding-3/7/2025 -may crush medications in ice cream-5/1/2025 -senna-5/1/2025 -escitalopram-8/16/2025 -apply hearing aids in AM and place in med room on charger at nighttime-9/9/2025 -air mattress setting to comfort, check settings is at alternating pressure10) Record review revealed Resident ID #130 was admitted to the facility in March of 2026 and with a diagnosis including, but not limited to, heart failure.Record review failed to reveal evidence that the resident's physician reviewed, signed, and dated the following orders:-3/11/2026 -code status: full code DNI-3/11/2026 -eliquis-3/11/2026 -isosorbide-3/11/2026 -jardiance-3/13/2026 -atorvastatin-3/16/2026 -amiodarone-3/17/2026 -acetaminophen-3/17/2026 -bisacodyl-3/17/2026 -monitor for fluid volume overload, including edema, shortness of breath-3/29/2026 -miralax powder-4/2/2026 -wraps to bilateral lower extremityDuring a surveyor interview on 7/30/2026 at 2:54 PM with the Director of Nursing Services, she was unable to provide evidence that Resident ID #s 2, 3, 5, 8, 10, 14, 15, 21, 39, and 130's orders were reviewed and signed by the physician.During a surveyor interview on 7/31/2026 at 9:52 AM with the Medical Director, he indicated that he would expect that all physician's orders are signed per the facility policy. Additionally, he revealed his expectation of timely signatures would be within 30 days.
Based on clinical record review and staff interview, the facility failed to ensure that resident records are complete and accurately documented for 1 of 1 resident reviewed who was documented as receiving dialysis (a life-saving medical treatment that filters waste, extra salt, and fluid from the blood when the kidneys fail) and the assessment of an arteriovenous fistula (AVF; a surgically made access in the arm between an artery and a vein to clean the blood during dialysis), Resident ID #9. Findings are as follows:Record review revealed that Resident ID #9 was admitted to the facility in January of 2024 with a diagnosis including, but not limited to, peripheral vascular disease (a blood circulation disorder). Review of nursing progress notes revealed documentation regarding the resident receiving dialysis, to include the assessment for a bruit (a whooshing sound heard with a stethoscope) and a thrill (a vibration felt with the hand) on the following dates and times:-6/11/2026 at 11:49 PM, authored by Licensed Practical Nurse (LPN), Staff D.-6/20/2026 at 3:55 PM, authored by Registered Nurse, Staff E.-7/20/2026 at 7:47 AM, authored by LPN, Staff F. Record review failed to reveal evidence that the resident receives dialysis or that s/he has an AVF.During a surveyor interview on 7/29/2026 at 12:15 PM with Staff E, she acknowledged that the resident does not receive dialysis treatments. Additionally, she acknowledged that the above-mentioned documentation was inaccurate. Additionally, she revealed that she had copied and pasted the note that was intended for the resident's roommate. During a surveyor interview on 7/29/2026 at 12:31 PM with Staff D, he acknowledged that the resident does not receive dialysis treatments. Additionally, he acknowledged that the above-mentioned documentation was inaccurate. Additionally, he revealed that he had copied and pasted the note that was intended for the resident's roommate. During a surveyor interview on 7/29/2026 at 1:21 PM with the Director of Nursing Services, she acknowledged that the above-mentioned nursing notes were inaccurately documented in the resident's medical record.
Based on clinical record review and staff interview, the facility failed to ensure that residents who are trauma survivors, receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences, and preferences, in order to eliminate, or mitigate triggers that may cause re-traumatization of the resident for 1 of 1 resident reviewed with a diagnosis of Post Traumatic Stress Disorder (PTSD; a mental health condition that occurs when someone experiences or witnesses a frightening or life-threatening event and continues to feel its effects long afterwards), Resident ID #5.Findings are as follows:Review of an undated facility policy, titled, Trauma Informed Care Policy states in part, .All residents will receive person-centered care that acknowledges past and present traumatic experiences and seeks to avoid re-traumatization while promoting quality of life, emotional well-being, and resident choice.Record review revealed Resident ID #5 was admitted to the facility in February of 2026, with diagnoses including, but not limited to, anxiety and bipolar disorder (a mental health condition).Record review of a hospital Discharge summary dated [DATE] revealed an active diagnosis of PTSD.Record review failed to reveal evidence that the resident's PTSD diagnosis was transcribed upon admission to the facility.Record review of a Social Worker Assessment 2023 dated 2/5/2026 revealed the resident was assessed with a history of trauma related to the death of a parent and domestic violence.Review of the comprehensive care plan failed to identify triggers or include interventions to eliminate or mitigate triggers that may cause re-traumatization of the resident.During a surveyor interview on 7/29/2026 at approximately 3:15 PM with the Director of Social Services, she acknowledged the resident's PTSD and trauma history. Additionally, she acknowledged that the comprehensive care plan failed to identify triggers or include interventions to eliminate or mitigate triggers that may cause re-traumatization of the resident.During a surveyor interview on 7/30/2026 at approximately 1:14 PM, with the Administrator of Clinical Services, she revealed it would be her expectation that the comprehensive care plan would reflect the resident's history of trauma and include interventions to eliminate or mitigate triggers that may cause re-traumatization.
Based on clinical record review and staff interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice relative to following physician's orders for 1 of 2 residents reviewed who had an order for daily weights, Resident ID #130. 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 orders unless they believe the orders are in error or would harm the client.Review of the facility's undated policy titled Protocol for Addressing Weight Changes states, in part, .If applicable, the charge nurse may also notify the physician .Record review revealed the resident was admitted to the facility in March of 2026 with diagnoses including, but not limited to, congestive heart failure (a chronic condition in which the heart is unable to pump blood efficiently, resulting in fluid buildup in the lungs, legs, and other parts of the body) and edema (swelling caused by excess fluid).Record review revealed a physician's order dated 6/15/2026 to obtain daily weights and notify the provider of a weight gain of 3 pounds (lbs.) or more in one day or 5 lbs. or more in one week.Review of the July 2026 Treatment Administration Record (TAR) revealed the resident experienced weight gains of 3 lbs. or more in one day on the following dates:- 7/18: 248 lbs.-7/19: 252 lbs. (A 4 lb. weight gain)-7/20: 253 lbs.-7/21: 260.2 lbs. (A 7.2 lb. weight gain)-7/22: 248.5 lbs.-7/23: 252.2 lbs. (A 3.7 lb. weight gain)Review of the July 2026 TAR further revealed the resident experienced an 8.7 lb. weight gain within one week, from 7/16/2026 through 7/22/2026.Record review failed to reveal evidence that the provider was notified of the resident's weight gains of 3 lbs. or more in one day or 5 lbs. or more in one week, as required by the physician's order.During a surveyor interview on 7/30/2026 at 10:30 AM with the Director of Nursing Services, she stated that she would expect staff to notify the provider of the resident's weight gains in accordance with the physician's order.During a surveyor interview on 7/30/2026 at 11:18 AM with Nurse Practitioner, Staff C, she stated that she was not aware of the resident's daily or weekly weight gains. She further stated that she would expect staff to notify her of any weight gain that met the physician's notification parameters.
Based on clinical record review and staff interview, the facility failed to ensure that hospice services meet professional standards of principles that apply to individuals providing services in the facility for 1 of 1 residents reviewed, who is receiving hospice services, Resident ID #10. Findings are as follows:Record review revealed that Resident ID #10 was admitted to the facility in November of 2025 with a diagnosis including, but not limited to, chronic pain disorder. Record review revealed the resident was admitted to hospice services in January of 2026.Record review of a care plan, dated 1/22/2026, revealed the resident is receiving hospice services with interventions including, but not limited to, coordinate the plan of care with hospice.Review of the Resident's electronic and paper medical records failed to reveal evidence that the following hospice information was available in the medical record, per regulation: - The most recent hospice plan of care- Hospice election form- Physician certification and recertification of the terminal illness- Names and contact information for hospice personnel involved in hospice care- Hospice medication information-The Hospice physician's contact information During a surveyor interview on 7/30/2026 at 11:40 AM with the Director of Nursing Services, she was unable to provide evidence that the facility maintained the appropriate hospice information in the medical record, as required.
Based on clinical record review and staff interview, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the transfer or discharge to the hospital for 2 of 2 residents reviewed for hospitalization, Resident ID #s 13 and 143. Findings are as follows:1. Record review revealed Resident ID #13 was discharged from the facility to the hospital on 5/13/2026 and on 5/23/2026. Additional review failed to reveal evidence that written notification was sent to the Office of the State Long-Term Care Ombudsman regarding either of the hospital transfers in May. 2. Record review revealed Resident ID #143 was discharged from the facility to the hospital on 5/20/2026. Additional review failed to reveal evidence that written notification was sent to the Office of the State Long-Term Care Ombudsman.During a surveyor interview on 7/28/2026 at 12:14 PM with the Social Services Manager, she revealed that the facility does not provide notification to the Office of the State Long-Term Care Ombudsman when a resident is transferred to the hospital.During a surveyor interview on 7/30/2026 at approximately 3:15 PM with the Administrator of Clinical Services, she was unable to provide evidence that the Office of the State Long-Term Care Ombudsman was notified of Resident ID #s 13 and 143's discharges to the hospital.
Inspection of April 3, 2025
6 findingsBased on surveyor observation and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, relative to the main kitchen. Findings are as follows: 1. The Rhode Island Food Code 2018 Edition 2-402.11, states in part, .food employees shall wear .beard restraints .that are designed and worn to effectively keep their hair from contacting exposed food . During surveyor observations of the main kitchen on the following dates and times revealed Dietary Aide, Staff F, who has full facial hair, preparing food without a beard restraint: - 3/31/2025 at approximately 9:45 AM - 4/2/2025 at 10:12 AM During a surveyor interview immediately following the above observation on 4/2/2025 with the Food Service Director (FSD), he acknowledged that Staff F was not wearing a beard restraint and indicated that one is required. 2. Review of the Rhode Island Food Code 2018 Edition 5-202.13 states in part, An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE .may not be less than 25mm [millimeter] (1 inch) . During a surveyor observation on 3/31/2025 at approximately 9:30 AM, of the main kitchen during the initial walk through in the presence of the FSD, the pipe from the ice machine was noted to be inserted into the plumbing fixture (drain) in the floor, and did not have, at a minimum, a one-inch air gap, as required. During a surveyor interview immediately following the above observation with the FSD, he acknowledged that the ice machine pipe was inserted into the floor drain and did not have the required minimum air gap clearance as outlined in the Rhode Island Food Code. 3. Review of the Rhode Island Food Code 2018 Edition 3.202.15 states in part, Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to .potential contaminants. During a surveyor observation on 3/31/2025 at approximately 9:30 AM, of the main kitchen during the initial walk through in the presence of the FSD, the walk-in freezer fan blades located within the freezer, was noted to have dripped and formed an accumulation of ice build-up approximately two inches high onto an unsealed box containing an opened package of cheddar cheese omelets, which was directly below the unit. During a surveyor interview immediately following the above observation with the FSD, he acknowledged the leaking fan unit and buildup of ice on the unsealed box of cheddar cheese omelets and revealed that the food should be discarded.
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a treatment that removes excess fluid, waste, and toxins from the blood when the kidneys are no longer functioning properly) receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident reviewed for peritoneal dialysis (PD, a treatment for kidney failure that uses the lining of the abdomen to filter waste products from the blood), Resident ID #101 and for 2 of 3 residents reviewed for hemodialysis (a type of dialysis that filters blood to remove waste products and excess fluids), Resident ID #s 30 and 76. Findings are as follows: 1. Record review revealed Resident ID #101 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, end stage renal disease and dependence on renal dialysis. Record review revealed a care plan initiated on 8/27/2024 for PD. Interventions include, but are not limited to, administer dialysis solution based off vital signs, as ordered - see chart in room provided by dialysis nurse, monitor for post dialysis complications such as dizziness, fatigue, nausea, hypotension (low blood pressure), discomfort, distress, peritonitis (inflammation of the tissue that lines the inside of the abdominal cavity), monitor PD site for signs or symptoms of infection, tunneling, patency (blockage), leaks and or bleeding at the site, increased edema (swelling), complaints of abdominal pain or signs of dehydration, and to report any complications noted to the provider and dialysis care team. 1a. Review of a policy titled PERITONEAL DIALYSIS POLICY & PROCEDURE states in part, .For the resident receiving PD the Practitioner orders for each individualized prescription must include at least the number of exchanges or cycles to be done during each dialysis session, the volume of fluid for each exchange, duration of fluid in the peritoneal cavity, the concentration of glucose of other osmotic agent [a substance that causes fluid retention and fluid secretion into the lumen] to be used for fluid removal, and the use of an automated, manual or combined technique . Record review revealed the following physician orders with a start date of 8/7/2024: - connect PD at hour of sleep - disconnect PD when completed Record review failed to reveal evidence of an individualized physician order that includes at least the number of exchanges or cycles to be completed during each dialysis session, the volume of fluid for each exchange, duration of fluid in the peritoneal cavity, the concentration of glucose of other osmotic agent to be used for fluid removal, and the use of an automated, manual or combined technique, per the facility policy. During a surveyor interview on 4/1/2025 at 1:51 PM, with the Offsite Dialysis Nurse, she revealed that the resident's current PD prescription includes six cycles with an 1800 fill volume, a run time of 10.5 hours and last fill of 500 cubic centimeters. She further revealed that she will input the prescription into the PD machine remotely and if there are any changes, she will call and inform a nurse at the facility. During a surveyor interview on 4/2/2025 at 11:08 AM, with Registered Nurse (RN), Staff B, she acknowledged that there is not a physician order in the resident's record indicating what the dialysis prescription is and revealed that the PD prescription is monitored by the Offsite Dialysis Nurse. During a surveyor interview on 4/3/2025 at 9:42 AM, with Nurse Practitioner, Staff C, she revealed that the resident's dialysis prescription should be in the resident's medical record, as it is a physician order. 1b. Further review of the policy titled PERITONEAL DIALYSIS POLICY & PROCEDURE states in part, .Before, during and after receiving the PD, the nursing staff must, based on the practitioners' orders and professional standards of practice, obtain VS [vital signs, which include blood pressure, pulse, temperature, heart rate, respiratory rate, and pain], weights, assess the resident's stability level of consciousness, comfort or distress. Monitor for post-dialysis complication and symptoms such as but not limited to dizziness, nausea, fatigue or hypotension. The staff must report identified or suspected complications immediately to the PCP/NP [Primary Care Physician/Nurse Practitioner] and the dialysis staff to enable timely interventions. The resident record must include documentation of ongoing evaluation of the peritoneal catheter, including assessment of catheter related infections and tunnel for condition, monitoring for patency, leaks, infection and bleeding at the site. In addition, staff should monitor for complications such as peritonitis .PROCEDURE .Record resident weight & BP [blood pressure] in appropriate binder located in the resident bedside stand, Review chart to see what solutions will be used .Conduct initial assessment of resident, Note any s/s [signs or symptoms] of increased edema or dehydration and monitor for complaints of abdominal pain or discomfort . Record review revealed the following physician orders: - connect PD at hour of sleep, with instructions to obtain blood pressure, with a start date of 8/7/2024 - disconnect PD when completed, with instructions to obtain blood pressure, with a start date of 8/7/2024 - obtain daily weight at bedtime with a start date of 8/19/2024 Record review failed to reveal evidence that a full set of vital signs were obtained before, during, and after the resident's PD treatment. Record review failed to reveal evidence of completed documentation relative to the resident's stability, level of consciousness, comfort or distress, increased edema, increased dehydration or any complaints of abdominal pain or discomfort prior to his/her PD treatment. Additionally, record review failed to reveal evidence of complete documentation that includes post dialysis complications or symptoms, such as, dizziness, nausea, fatigue or hypotension, per the facility policy. Further record review failed to reveal documentation of an ongoing evaluation of the peritoneal catheter, including assessment of catheter related infections and tunnel for condition, monitoring for patency, leaks, infection, bleeding at the site, or other complications such as peritonitis, per the facility policy. During a surveyor interview on 4/1/2025 at 1:51 PM, with the Offsite Dialysis Nurse, she revealed that staff are obtaining and entering the resident's blood pressure and weight into the PD machine prior to his/her PD treatment and obtaining the resident's blood pressure following his/her PD treatment. She indicated that at times, staff have not obtained vitals, but revealed the machine will work without the vital sign information. During a surveyor interview on 4/1/2025 at 3:59 PM, with RN, Staff D, he revealed that he obtains the resident's blood pressure and weight prior to the resident's PD treatment, indicating he does not obtain a full set of vital signs. During a surveyor interview on 4/2/2025 at 11:08 AM, with Staff B, she revealed that nursing will input the resident's blood pressure and weight in the PD machine before each treatment but revealed that there is no resident binder located in his/her room to document the resident's vital signs, at his/her bedside, per the facility policy. 1c. Further review of the policy titled, PERITONEAL DIALYSIS POLICY & PROCEDURE states in part, .END OF THERAPY .record initial drain volume in resident binder .record total UF [ultrafiltration, the amount of fluid drained] in resident binder .record average dwell time in resident binder . Record review failed to reveal evidence of documentation including the initial drain volume, total UF, or the average dwell time, per the facility policy. During a surveyor interview on 4/2/2025 at 11:08 AM, with RN, Staff B, she revealed that there is not a resident binder located in the resident's room to document the initial drain volume, total UF, or the average dwell time, per the facility policy. 1d. Additional review of the policy titled, PERITONEAL DIALYSIS POLICY & PROCEDURE states in part, .Beginning the Therapy .Attach drain extension line. Remove pull tab from end of drain line, and attach to drain bag . During a surveyor interview on 4/1/2025 at 3:18 PM, with Resident ID #101 and his/her representative, they revealed that staff place a drainage tube into the toilet every night to drain the fluid from the PD machine and indicated that at times, the tubing has touched the fluid in the toilet. During a surveyor interview on 4/1/2025 at 3:59 PM, with RN, Staff D, he revealed that a tube is placed into the toilet, to drain the fluid from the PD machine. He further revealed that they only attach a drain bag when there are concerns, such as high white blood counts (indicates an infection). During a surveyor interview on 4/2/2025 at 8:46 AM, with Staff B, she revealed that the fluid is drained into a bag only if the Offsite Dialysis Nurse needs the fluid for a sample and indicated that it is usually drained directly into the toilet via tubing. She further revealed that once every two weeks the fluid is drained into a bag for collection. During a surveyor interview on 4/3/2025 at 10:29 AM, with the Director of Nursing Services (DNS), she revealed that she did not know what the resident's PD prescription was and indicated that she does not administer the treatment. She revealed that fluid is only drained into a collection bag when it is needed for a sample, although the policy states to drain it into a bag. Moreover, she was unable to provide evidence of an individualized physician order for the PD treatment, completed documentation relative to the resident's stability, level of consciousness, comfort or distress, increased edema, increased dehydration or any complaints of abdominal pain or discomfort prior to his/her PD treatment, a full set of vital signs were obtained before, during, and after the resident's PD treatment, completed documentation of any post dialysis complications or symptoms, such as, dizziness, nausea, fatigue or hypotension post dialysis treatment, evidence of documentation including ongoing evaluation of the peritoneal catheter, including assessment of catheter related infections and tunnel for condition, monitoring for patency, leaks, infection, bleeding at the site, or other complications such as peritonitis, or documentation including the initial drain volume, total UF, or the average dwell time, per the facility policy. 2a. Record review revealed Resident ID #30 was readmitted to the facility in August of 2023 with diagnoses including, but not limited to, end stage renal disease and the dependence of renal dialysis. Record review revealed the resident receives hemodialysis three times a week. Review of the resident's care plan with a problem start date of 9/11/2024 revealed, the resident requires dialysis three times per week with an intervention including, but not limited to, administer medications as ordered. Record review revealed the following physician orders: - cyclobenzaprine (muscle relaxant) 5 milligrams (mg), three times a day, with a start date of dated 2/10/2025 - acetaminophen (pain reliever) 500 mg, three times a day, with a start date of dated 2/10/2025 - sevelamer carbonate (a medication prescribed to lower blood phosphate levels) 2400 mg three time a day, with a start date of dated 2/10/2025 - albuterol sulfate inhaler (a medication prescribed to treat shortness of breath) every four hours, with a start date of dated 2/10/2025 - escitalopram oxalate (antidepressant medication) 10 mg one time a day, with a start date of dated 2/10/2025 - Eliquis (anticoagulant medication) 5 mg twice a day with a start date of 2/10/2025 - linzess (a medication prescribed to treat irritable bowel syndrome) 145 micrograms one time a day, with a start date of 3/13/2025 - Keppra XR (anticonvulsant medication) 500 mg one time a day, with a start date of 2/10/2025 - MiraLAX (a medication prescribed to treat constipation) 17-gram one time a day, with a start date of 2/10/2025 - Nephro Vitamins (a medication prescribed to provide extra water-soluble vitamins needed for kidney health) 0.8 mg one time a day, with a start date of 3/14/2025 - probiotic 60 billion one time a day, with a start date of 2/10/2025 - senna plus (stool softener) 8.6-50 mg one time a day, with a start date of 3/14/2025 - simethicone (a medication prescribed to relive excess gas in the stomach) 80 mg one time a day, with a start date of 2/10/2025 - Symbicort inhaler (a medication prescribed to treat asthma) twice a day, with a start date of 2/10/2025 - Nepro (nutritional supplement), 120 milliliters, to be given to resident if s/he does not eat after coming back from dialysis on Monday, Wednesday, and Friday, with a start date of 2/10/2025 Record review of the Medication Administration Records (MAR) for March of 2025 revealed on the following dates, the cyclobenzaprine, acetaminophen, sevelamer carbonate, and albuterol sulfate were not offered or administered due to the resident being at dialysis: - 3/3/2025 - 3/7/2025 - 3/10/2025 - 3/12/2025 - 3/14/2025 - 3/17/2025 - 3/19/2025 - 3/21/2025 - 3/24/2025 - 3/26/2025 - 3/28/2025 - 3/31/2025 Record review of the MAR for March of 2025 revealed on the following dates, the Nepro was not offered or administered to the resident as ordered, due to the resident being at dialysis: - 3/28/2025 - 3/31/2025 Record review of the MAR for March of 2025 revealed on the following dates, the escitalopram oxalate, Eliquis, linzess, Keppra XR, MiraLAX, Nephro Vitamins, probiotic, senna plus, simethicone, and Symbicort inhaler were not offered or administered to the resident as ordered, due to the resident being at dialysis: - 3/19/2025 - 3/28/2025 - 3/31/2025 Record review failed to reveal evidence that the physician or dialysis center were notified regarding the above missed medications. During a surveyor interview on 4/2/2025 at 10:00 AM, with RN, Staff B, she acknowledged that Resident ID #30 missed the above-mentioned medications and that the providers were not notified of the missed medications. During a surveyor interview on 4/2/2025 at 2:56 PM, with NP, Staff C, she revealed that she was not made aware the resident was missing his/her medications on dialysis days. Additionally, she revealed that she would expect the staff to notify her of missed medications so she could adjust the timing of the medications. 2b. Record review revealed Resident ID #76 was admitted to the facility in May of 2023 with a diagnosis including, but not limited to, end stage renal disease. Record review revealed the resident receives hemodialysis three times a week. Review of the resident's care plan with a problem start date of 5/1/2024 revealed the resident requires dialysis three times per week with an intervention including, but not limited to, administer medications as ordered. Record review revealed a physician order dated 3/3/2025 for velphoro (a medication prescribed to lower high blood phosphate levels) 500 mg, three times a day. Review of the March 2025 MAR revealed on 3/4/2025 at 7:00 AM and 11:30 AM, the resident was not offered or administered the velphoro as ordered, due to the resident being out at dialysis. Record review revealed a physician order dated 3/1/2025 for terranics probiotic capsule (a medication prescribed for digestive support), 60 billion, twice daily. Review of the March 2025 MAR revealed on the following dates, the resident was not offered or administered the terranics probiotic capsule as ordered, due to the resident being out at dialysis: - 3/4/2025 - 3/6/2025 - 3/8/2025 - 3/11/2025 - 3/13/2025 - 3/15/2025 Record review revealed a physician order dated 3/4/2025 for sevelamer carbonate 800 mg, three times a day before meals. Review of the March 2025 MAR revealed on the following dates and times, the resident was not offered or administered the sevelamer carbonate as ordered, due to the resident being out at dialysis: - 3/6/2025 at 7:00 AM and 11:30 AM - 3/8/2025 at 7:00 AM - 3/11/2025 at 7:00 AM Record review revealed a physician order dated 11/12/2024 for Rena Vite tablet (a dietary supplement for individuals on dialysis) 0.8 mg, once daily. Review of the March 2025 MAR revealed on the following dates, the resident was not offered or administered the renal-vitae tablet as ordered, due to the resident being out at dialysis: - 3/1/2025 - 3/4/2025 - 3/6/2025 - 3/8/2025 - 3/13/2025 - 3/15/2025 - 3/18/2025 - 3/27/2025 Record review revealed a physician order dated 3/17/2025 for [NAME], 8 ounces, once daily. Review of the March 2025 MAR revealed on 3/18/2025, 3/20/2025 and 3/26/2025, the resident was not offered or administered the [NAME] as ordered, due to the resident being out at dialysis. Record review revealed a physician order dated 3/12/2025 for lanthanum tablet (a medication prescribed to reduce blood levels of phosphate) 750 mg, three times a day. Review of the March 2025 MAR revealed on the following dates and times, the resident was not offered or administered the lanthanum as ordered, due to the resident being out at dialysis: - 3/13/2025 at 7:15 AM and 11:30 AM - 3/15/2025 at 7:15 AM and 11:30 AM - 3/18/2025 at 7:15 AM and 11:30 AM - 3/20/2025 at 11:30 AM - 3/27/2025 at 7:15 AM - 3/29/2025 at 7:15 AM Record review revealed a physician order dated 11/15/2024 for brimonidine eye drops, twice daily. Review of the March 2025 MAR revealed on the following dates, the resident was not offered or administered the brimonidine eye drops as ordered, due to the resident being out at dialysis: - 3/1/2025 - 3/4/2025 - 3/6/2025 - 3/8/2025 - 3/11/2025 - 3/13/2025 - 3/15/2025 - 3/18/2025 - 3/20/2025 - 3/27/2025 Record review failed to reveal evidence that the physician or dialysis center were notified regarding the above missed medications. During a surveyor interview on 4/2/2025 at 10:00 AM, with Staff B, she acknowledged that Resident ID #76 missed the above-mentioned medications, as s/he was at dialysis and that the providers were not notified of the missed medications. During a surveyor interview on 4/3/2025 at 11:50 AM with Nurse Practitioner, Staff E, she revealed that she was not made aware that Resident ID #76 had missed the above-mentioned medications, while the resident was at dialysis. She further revealed that she would expect the facility to administer the resident's medication around his/her dialysis appointments. During a surveyor interview on 4/3/2025 at 1:09 PM with the DNS, she was unable to provide evidence that the facility effectively communicated with the dialysis center or the resident's provider that the above mentioned medications were not being administered to Resident ID #s 30 and 76, per the physician orders. Surveyor: [NAME], Moulikato 46338
Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 4 of 4 residents reviewed for antibiotic orders, Resident ID #s 2, 101, 114, and 374. Findings are as follows: According to the Centers for Disease Control and Prevention (CDC) document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes states in part, Standardize the practices which should be applied during the care of any resident suspected of an infection or started on an antibiotic. These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed in your facility. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information is available .Track the amount of antibiotic used in your nursing home to review patterns of use and determine the impact of new stewardship interventions .Interventions designed to shorten the duration of antibiotic courses, or discontinue antibiotics based on post-prescription review (i.e., antibiotic time-out), may not necessarily change the rate of antibiotic starts, but would decrease the antibiotic DOT [days of therapy] . Review of a facility policy titled ANTIBIOTIC STEWARDSHIP PROGRAM states in part, .Antibiotic therapy should be reassessed in 2-3 days after treatment was initiated by a clinician and answer key questions: does the patient have an infection that will respond to the antibiotic, is it the right antibiotic, is it the right dose, the right route, can a more targeted antibiotic be used and how long should they be on the antibiotic . 1. Record review revealed that Resident ID #2 was readmitted to the facility in August of 2023 with a diagnosis including, but not limited to, cellulitis (infection in the skin) of the left lower limb. Record review revealed a physician order for doxycycline (an antibiotic) tablet 100 milligrams (mg) give 1 tablet by mouth one time a day for cellulitis with a start date of 3/20/2025 and an end date of 4/3/2025. Record review failed to reveal evidence of an antibiotic review or an antibiotic time out. 2. Record review revealed that Resident ID #101 was readmitted to the facility in March of 2025 with a diagnosis including, but not limited to, dependence on renal dialysis (a treatment that removes excess fluid, waste, and toxins from the blood when the kidneys are no longer functioning properly). Record review revealed a physician order for amoxicillin-pot clavulanate (an antibiotic), give 250-125 mg by mouth two times a day for an infection of [site redacted] surgical wound with a start date of 3/3/2025 and an end date of 4/3/2025. Record review failed to reveal evidence of an antibiotic review or an antibiotic time out. 3. Record review revealed that Resident ID #114 was admitted to the facility in March of 2025 with a diagnosis including, but not limited to, elevated white blood cell count. Record review revealed a physician order for doxycycline tablet 100 mg give 1 tablet by mouth one time a day for cellulitis with a start date of 3/11/2025 and an end date of 3/21/2025. Record review failed to reveal evidence of an antibiotic review or an antibiotic time out. 4. Record review revealed that Resident ID #374 was admitted to the facility in March of 2025 with a diagnosis including, but not limited to, acute and subacute endocarditis (an inflammation of the inner lining of the heart chambers and valves, usually caused by a bacterial infection). Record review revealed a physician order for ampicillin sodium (an antibiotic) 2 grams intravenous every 4 hours for acute and subacute endocarditis with a start date of 3/26/2025 and an end date of 5/14/2025. Record review failed to reveal evidence of an antibiotic review or an antibiotic time out. During surveyor interviews with the Infection Preventionist on 4/2/2025 at 10:40 AM and 1:41 PM, she revealed that she does not complete antibiotic time outs. Additionally, she was unable to provide evidence of antibiotic time outs being completed for the above-mentioned residents. During a surveyor interview on 4/2/2025 at approximately 1:59 PM with the Director of Nursing Services, she was unable to provide evidence that antibiotic time outs had been completed for the above-mentioned residents receiving antibiotics.
Based on record review and staff interview, it has been determined that the facility failed to ensure the resident's medical record includes documentation that the resident either received the pneumococcal vaccination or did not receive the vaccination due to medical contraindications or refusal, for 4 of 5 residents reviewed, Residents ID #s 3, 4, 39, and 101. Findings are follows: According to the Centers for Disease Control and Prevention (CDC), pneumococcal vaccination for all adults 19 through [AGE] years old who have certain chronic medical conditions or [AGE] years or older who have only received PPSV23 [type of pneumococcal conjugate vaccination], the PCV15 [type of pneumococcal conjugate vaccine] or PCV20 [type of pneumococcal conjugate vaccine] dose should be administered at least one year after the most recent PPSV23 vaccination. For adults 19 through [AGE] years old who have certain chronic medical indications who have only received PCV13 [type of pneumococcal conjugate vaccine], give 1 dose of the PCV20 at least 1 year after PCV13 or give 1 dose of PPSV23 at least 8 weeks after PCV13. For adults [AGE] years or older who have only received PCV13, give PPSV23 or PCV20 as previously recommended. 1. Record review revealed that Resident ID #3 was admitted to the facility in July of 2024. Record review of the resident's immunization records failed to reveal evidence that the PCV15, PCV13, PPSV23, or PCV20 was offered, received, or declined. 2. Record review revealed that Resident ID #4 was admitted to the facility in July of 2024. Record review of the resident's immunization records failed to reveal evidence that the PCV15, PCV13, PPSV23, or PCV20 was offered, received, or declined. 3. Record review revealed that Resident ID #39 was readmitted to the facility in October of 2023. Record review of the resident's immunization records failed to reveal evidence that the PCV15, PCV13, or PCV20 was offered, received, or declined. 4. Record review revealed that Resident ID #101 was admitted to the facility in August of 2024. Record review of the resident's immunization records failed to reveal evidence that the PCV13, PCV15, or PCV20 was offered, received, or declined. During a surveyor interview with the Infection Preventionist (IP) on 4/2/2025 at 10:47 AM, she revealed that she usually gives the pneumococcal vaccination as soon as possible or within a few weeks of gaining consent. She indicated that consent is received at time of the admission. Additionally, the IP was unable to provide evidence that Resident ID #s 3, 4, 39, and 101, received the pneumococcal immunization or documentation that they did not receive the pneumococcal immunization due to a medical contraindication or refusal. During a surveyor interview on 4/2/2025 at 1:59 PM, with the Director of Nursing Services, she was unable to provide evidence that Resident ID #s 3, 4, 39, and 101's medical records included documentation that indicates, at a minimum, the residents either received the pneumococcal immunization or did not receive the pneumococcal immunization due to a medical contraindication or refusal, until brought to the attention of the facility by the surveyor.
Based on record review, surveyor observation, resident and staff interviews, 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 for 1 of 3 residents reviewed with pressure ulcers, Resident ID #34. Findings are as follows: Review of a facility policy titled, Low Air Loss System Policy and Procedure states in part, The purpose of the Low Air mattress is to provide therapeutic benefits to the resident at risk for or suffering from pressure ulcers while optimizing comfort . Record review revealed that the resident was readmitted to the facility in November of 2023 with diagnoses including, but not limited to, pressure ulcer of the sacral (the large, triangular bone at the base of the spine) region and pain. Review of a Wound Evaluation and Summary report dated 4/1/2025 revealed, the resident has a stage III pressure ulcer (full-thickness skin loss potentially extending into the subcutaneous tissue layer) to his/her coccyx (tailbone) measuring 0.3 centimeters (cm) by 0.2 cm by 0.4 cm. Record review revealed that the resident's most recent weight on 3/18/2025 was 98.5 pounds (lbs). During surveyor observations on the following dates and times, the resident was observed laying on an air mattress set to firm or 350 lbs and max inflate: - 3/31/2025 at 9:32 AM - 4/1/2025 at 10:30 AM - 4/3/2025 at 8:20 AM During a surveyor interview on 4/3/2025 at 8:25 AM with the resident, s/he revealed that the air mattress s/he was laying on was uncomfortable. Additionally, s/he revealed that the bed is hard and lumpy and that s/he has to constantly reposition him/herself because the wound on his/her back side is painful. Record review failed to reveal evidence of a physician order or care plan in place for the air mattress. During a surveyor interview on 4/3/2025 at 8:45 AM, with Licensed Practical Nurse (LPN), Staff A, he acknowledged that the resident's air mattress was set to max inflate and not to his/her weight. Additionally, he acknowledged that there was no care plan or physician order in place for use of the air mattress. During a surveyor interview on 4/3/2025 at 9:03 AM, with the Director of Nursing Services (DNS) she acknowledged that the resident's air mattress was set to firm or 350 lbs. Additionally, the DNS acknowledged that the resident did not have a care plan or physician order for use of the air mattress, until after it was brought to the facility's attention by the surveyor.
Based on record review and staff interview, it has been determined that the facility failed to ensure that medications and biologicals were ordered by the prescriber for 1 of 3 residents reviewed for Lorazepam (a medication prescribed for anxiety) administration, Resident ID #30. Findings are as follows: Record review revealed that the resident was admitted to the facility in February of 2025 with diagnoses including, but not limited to, dependence on renal dialysis (a treatment to remove extra fluid and waste when kidneys fail to function effectively), end stage renal disease, and anemia (lack of enough healthy red blood cells to carry oxygen to the body's tissues). Review of a physician order revealed Lorazepam 1 milligram (MG) once a day on Monday, Wednesday, and Friday, prior to dialysis. Review of the March 2025 Medication Administration Record failed to reveal evidence that the Lorazepam was administered, on the following dates: - 3/7/2025 - 3/10/2025 - 3/12/2025 - 3/14/2025 During a surveyor interview on 4/2/2025 at approximately 11:00 AM, with Registered Nurse, Staff B, she revealed that the Lorazepam was ordered due to the resident's increased anxiety related to dialysis. Additionally, Staff B acknowledged that the resident did not receive the medication on the above-mentioned dates before dialysis, as ordered. During a surveyor interview on 4/3/2025 at 10:02 AM, with the Pharmacy Manager, he indicated that the pharmacy was unable to deliver the Lorazepam because a new prescription was not received until 3/14/2025. During a surveyor interview on 4/3/2025 at 1:09 PM with the Director of Nursing Services, she revealed that the resident did not receive the Lorazepam as ordered because the Medication Aide, who administers it, failed to communicate the need for a new prescription to the charge nurse. Additionally, she revealed that she would expect the provider to be notified for a new prescription as soon as possible, and would expect better communication between staff.
Inspection of April 30, 2024
5 findings39496 Based on record review and staff interview, it has been determined that the Medical Director failed to implement a resident care policy to coordinate care for residents related to the transcription and implementation of orders by providers. Findings are as follows: Record review of the facility provided document titled Medical Director Agreement revealed in part, .The Medical Director's responsibilities include .Directing and coordinating medical care in the organization .participating in establishing policies, procedures, and guidelines to ensure adequate,comprehensive services .participating in training programs as needed .Consulting with the administrator and Education Director about the organization's ability to meet the resident's needs . This document was signed by the Medical Director on 7/1/2023. Record review of the facility policy titled, Obtaining Physician Orders-Policy and Procedure revealed in part, To ensure orders are accurately completed and put in Matrix for completion .The nurse will receive verbal order from MD [Medical Doctor] or NP [Nurse Practitioner] and will transcribe it in the notepad indicating physician orders. Or .The MD or NP will transcribe the order in the book .The nurse will promptly transcribe the order upon receiving it, then place it on shift report, and in the Progress notes .The oncoming nurse will double check the order and ensure that the order was correctly transcribed and followed through . Record review of the facility policy titled, Transcription of new orders for Non-controlled Substances Policy and Procedure revealed the following, To ensure that all resident information is complete and accurate, has been reconciled and is verified by physician/prescriber before transmitting order to pharmacy .Authorized facility staff should enter new EMAR [Electronic Medication Administration Record] orders as soon as they are received . Record review of the facility assessment states in part, .The Purpose of the facility assessment is to determine what resources are necessary to care for its residents competently during both day-to day operations and emergencies .WORKING WITH MEDICAL PRACTITIONERS .recruits and maintains enough medical practitioners who are adequately trained and knowledgeable in the care of our residents to meet the needs and scope of our population .Medical practitioners are given written guidance with regard to current regulations pertaining to care, as well as any protocols developed by our medical director . During a surveyor interview on 4/25/2024 at 11:50 AM, with Licensed Practical Nurse (LPN), Staff C, he revealed that the practitioner usually writes orders on lab slips, and the Nurse Practitioners from Optum use the verbal/telephone order book to write orders. He further revealed that when verbal orders are given, they are put into the verbal/telephone order book. During a surveyor interview on 4/25/2024 at 11:55 AM with LPN, Staff B, she revealed that if there is a lab slip, the providers write the orders on the lab slip and the nurses transcribe the orders into the EMAR. If the NP comes to the unit and sees the patient, they will verbally tell the nurse the orders or write them in the verbal/telephone orders book. If the doctors come in, they will verbally tell the nurse the orders and the nurse will enter the orders in the EMAR. During a surveyor interview on 4/25/2024 at 12:09 PM with Registered Nurse, Staff D, she revealed that she receives verbal orders from the providers, and she enters the orders into the EMAR. During a surveyor interview on 4/26/2024 at 8:53 AM with Nurse Practitioner (NP), Staff L, she revealed that she gives verbal orders to the nurse, the nurse repeats it back then puts it in the computer. If there is a lab, she revealed that she writes the order on a lab slip. She further revealed that she thinks the nurses have a book where they write down the orders, but she is not exactly sure how they do it. During a surveyor interview on 4/26/2024 at 9:12 AM with the Medical Director, he revealed that the process for communication of orders is that the provider would give a verbal order and the nurse enters the order into the computer. If it is a verbal order, the nurse also writes it down on a piece of paper. During a surveyor interview on 4/26/2024 at 9:59 AM with Physician, Staff H, he indicated that he thinks the Nurse Practitioner communicates orders to the nurse and the nurse enters the orders into the EMAR. During a surveyor interview on 4/26/2024 at 4:20 PM with NP, Staff G, she revealed that if she is at the facility, she will write her orders in the verbal/telephone order book or on a lab slip, if reviewing labs. She will read the order with the nurse or have the nurse read back the orders. She further revealed that occasionally she will give verbal orders that are not transcribed into the verbal/telephone order book. During surveyor interviews on 4/26/2024 at 11:35 AM, and on 4/29/2024 at 2:23 PM, with the Director of Nursing Services, she revealed the provider will communicate the order verbally to the nurse and the nurse should write the order into the verbal/telephone order book, or the provider will write the orders down themselves. She further revealed that the book is the system that the facility utilizes for obtaining orders. Additionally, she was unable to provide evidence that all nurses were educated regarding the use of the verbal/telephone orders book. During a surveyor interview on 4/26/2024 at 11:03 AM with NP, Staff M, she revealed that she verbally communicates orders with the nurses or writes them on lab slips. Additionally, she revealed that she will sometimes write the orders down on a piece of paper. She further revealed that she hasn't seen the verbal/telephone order book lately. During a surveyor interview on 4/26/2024 at 12:43 PM with the Administrator, Staff N, when asked about the Medical Director's oversight of the facility, she revealed that it was his NP, Staff M, that implemented the verbal/telephone orders book, as a good tool for the facility to use. She further revealed that she would expect the Medical Director to have knowledge of the verbal/telephone order book protocol. Additionally, she was unable to provide evidence that the Medical Director effectively implemented the policy related to protocols and ensured education and training's regarding the use of the verbal/telephone order book.
47939 Based on surveyor observations and staff interview, it has been determined that the facility failed to maintain a sanitary and comfortable environment relative to 4 of 4 kitchenettes observed. Findings are as follows: During a surveyor observation on 4/22/2024 at 9:28 AM of the 1st floor, [NAME] Point unit kitchenette, revealed a toaster oven with a buildup of food debris in the bottom of the toaster oven. During a surveyor observation on 4/22/2024 at 9:37 AM of the 2nd floor, Cold Spring Place kitchenette, revealed the following: - a freezer with an accumulation of brown debris and a pooling of a dry sticky red substance - a refrigerator with a pooling of a red colored sticky substance in the bottom - a toaster oven with a buildup of food debris in the bottom During a surveyor observation on 4/22/2024 at 9:59 AM of the 2nd floor, Park Square unit kitchenette, revealed the following: - a countertop with an accumulation of a brown sticky substance - a microwave with the top of the inside with an accumulation of brown food debris - flooring with an accumulation of a brown and gray substance - a freezer with an accumulation of brown debris and a pooling of a dry sticky brown substance - a refrigerator with a dry white substance observed along the left bottom drawer and a pooling of a sticky yellow and red substance in the bottom - a toaster oven with a buildup of food debris in the bottom During a surveyor observation on 4/22/2024 at 10:05 AM of the 3rd floor, [NAME] Hill unit kitchenette, revealed the following: - a freezer with a pooling of a dry sticky brown substance - a refrigerator with a clear sticky substance observed along the bottom drawers, shelving, and drawer handle - a toaster oven with a buildup of food debris in the bottom During a surveyor interview on 4/22/2024 at 11:01 AM with the Director of Environmental Services, he acknowledged the above-mentioned observations and indicated that they needed to be cleaned.
Based on record review and staff interview, it has been determined that the facility failed to ensure that the irregularities identified by the Clinical Consultant Pharmacist during the monthly pharmacist Medication Regimen Review (RR) were acted upon for 1 of 1 resident reviewed related to phenytoin (a medication that is used to control seizures) , Resident ID #118. Findings are as follows: Record review revealed Resident ID #118 was readmitted to the facility in April of 2015 with diagnoses including, but not limited to, vascular dementia and epilepsy. Record review of the document titled [Pharmacy] Consultation Report dated 2/27/2024, revealed a recommendation to monitor phenytoin trough concentration (indicates drug levels in an individual's body) on the next convenient lab day. Further review of this document revealed the resident .does not have a trough concentration documented in the medical record within the previous 6 months. Phenytoin has a narrow therapeutic index and requires close monitoring to help prevent adverse events. Further record review revealed the nurse practitioner accepted and authorized the above laboratory test recommendation on 2/28/2024. Record review of the document titled [Pharmacy] Consultation Report dated 3/27/2024, states in part, .prescriber accepted a pharmacy recommendation to obtain phenytoin concentration on 2/28, but the order has not yet been processed . Record review failed to reveal evidence that the above-mentioned pharmacy recommendation was obtained until 4/1/2024. Additionally, the phenytoin concentration result on 4/1/2024 was 25 micrograms (ug)/milliliter(ml) (normal range 10-20), indicating a high concentration of the medication. During a surveyor interview on 4/24/2024 with Nurse Practitioner, Staff G, she indicated that she would have expected the phenytoin trough level to have been obtained after the order was given on 2/28/2024. During a surveyor interview on 4/26/2024 at 11:35 AM with the Director of Nursing Services, she acknowledged that the ordered phenytoin trough level was not obtained until 4/1/2024 and had revealed a high result. She further indicated that she would expect that the phenytoin trough level would have been obtained the following day after it was ordered on 2/28/2024.
47939 Based on surveyor observation, record review and staff interview it has been determined that the facility failed to meet professional standards of quality regarding not following the facility's emergency cart equipment procedure for 4 out of 4 emergency carts observed and for 1 of 1 resident reviewed relative to psychiatric consultant orders, Resident ID # 86. Findings are as follows: 1) Record review of the facility's policy titled, Emergency Cart Equipment revealed in part, .Every unit is equipped with an emergency (crash cart). It is located behind the nurse's station. The emergency cart contains the following: Suction machine 2 oxygen connection tubing's 2 suction catheters 1 bottle of normal saline 1 medium airway Gloves 1 each oxygen cannula, mask and non-rebreather 1 ambu bag [self-inflating bag, is a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately] Gowns Infection Control Pack Carry-all containing gloves, 4x4's in zip lock bag, ice pack, and blood spill kit It is the responsibility of the 11-7 nurse to check the emergency cart nightly to ensure all equipment is available and that suction machine is in working order . During a surveyor observation on 4/25/2024 at 1:54 PM in the presence of Licensed Practical Nurse (LPN), Staff B, of the [NAME] Point unit, revealed the emergency cart failed to have a blood spill kit or normal saline. During a surveyrour interview immediately following the abocve observation, Staff B acknowledged that the above findings. During a surveyor observation on 4/25/2024 at 1:44 PM in the presence of LPN, Staff C, of the Park Square unit, revealed the emergency cart failed to have an ambu bag, or a canister for the suction machine. It also revealed the oxygen tank that was kept with the cart was empty. During a surveyrour interview immediately following the abocve observation, Staff C acknowledged that the above findings. During a surveyor observation on 4/25/2024 at 1:41 PM in the presence of Registered Nurse (RN) Staff D, of the Cold Spring unit, revealed the emergency cart failed to have a non-rebreather mask. It also revealed that there were 2 oxygen tanks that were kept with the emergency cart, one was empty and the other was nearly empty. During a surveyrour interview immediately following the abocve observation, Staff D acknowledged that the above findings During a surveyor observation on 4/25/2024 at 1:38 PM in the presence of RN, Staff E, of the [NAME] Hill unit, revealed the emergency cart failed to have a non-rebreather mask. During a surveyrour interview immediately following the abocve observation, Staff E acknowledged that the above findings During a surveyor interview on 4/26/2024 at 11:35 AM with the Director of Nursing Services, she revealed that she would expect the emergency carts to be fully always stocked. Additionally, she was unable to provide evidence that the 11:00 PM to 7:00 PM nurse checks the emergency cart nightly to ensure all equipment is available. 2) Record review revealed Resident ID #86 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, anxiety and depression. Record review of a geriatric psychiatry recommendation dated 3/20/2024 revealed a recommendation to check valproic acid level (VPA- lab work to test the level of valproate in the blood used primarily for patients with epilepsy or bipolar disorder) and liver function tests (LFTs- lab work to test the functioning of the liver) with next blood draw for monitoring. Record review of a progress note dated 3/21/2024 reveals in part, .NP [Nurse Practitioner] .also reviewed psych [psychiatric] report .okay with her recom [recommendation] .VPA level, LFT's Labs booked for tomorrow . During a surveyor interview on 4/26/2024 at 2:09 PM with Licensed Practical Nurse, Staff B, she was unable to provide evidence that the orders for the labs were transcribed, or that the labs were completed. Record review failed to reveal evidence that the VPA level and LFTs were obtained as ordered until it was brought to the attention of the facility on 4/26/2024 by the surveyor. During a surveyor interview on 4/29/2024 at 10:56 AM with the Director of Nursing Services (DNS), she acknowledged that the orders for the labs were missed, and they weren't completed. Record review of a lab report printed on 4/29/2024 at 4:59 PM revealed a valproic acid level of 31 microgram/milliliter (reference values 50-100 microgram/milliliter). Of note the lab slip states the therapeutic range for patients receiving valproic acid for bipolar disorder is 50-125 microgram/milliliter indicating the resident's valproic acid level is not within the therapeutic range. During an additional surveyor interview on 4/30/2024 at 1:58 PM with the DNS, she was unable to provide evidence that the low valproic acid level was reported to the Nurse Practitioner prior to the surveyor brining it to their attention.
47939 43987 Based on record review and staff interview, it has been determined that the facility failed to implement comprehensive person-centered care plans for 3 of 4 residents reviewed for anticoagulation therapy, relative to monitoring for bleeding (anticoagulant side effects), Resident ID #s 48, 62, and 118. Findings are as follows: Record review of the facility policy titled, ANTICOAGULATION/ANTITHROMBOTIC THERAPY MONITORING reveals in part, .Purpose To ensure appropriate anticoagulant/antithrombotic dosing and to reduce the likelihood of resident harm associated with the use of anticoagulant/antithrombotic therapy .PROCEDURE .15. Continue to monitor resident for overt/covert signs of bleeding. The most serious risks associated with oral anticoagulant therapy is hemorrhage in any tissue or organ. Suspected or overt abnormal bleeding ( .appearance of blood in stools, urine .petechiae [non-blanchable small spot that indicated bleeding under the skin], excessive bruising or persistent oozing from superficial injuries), new or excessive vaginal bleeding [or bleeding] from nose or gums, spitting of blood are early manifestations of anticoagulation beyond a safe and satisfactory level . 1. Record review revealed Resident ID #48 was admitted to the facility in February of 2023 and readmitted in April of 2024 with diagnoses including, but not limited to, fracture of shaft of left tibia and hypertension. Record review of a care plan initiated on [DATE] includes a focus area for potential for abnormal bleeding related to the use of anticoagulation therapy. Additionally, it revealed interventions to observe for signs of abnormal bleeding such as unexplained bleeding, nose bleeds and bleeding gums. Record review revealed a physician's order dated [DATE] for heparin (blood thinner) solution 5000 unit/M L(milliliter) 1 ML subcutaneous (injection under the skin) every 8 hours. Record review failed to reveal evidence that the care plan for Resident ID #48 was being implemented relative to observing for signs and symptoms of abnormal bleeding. During a surveyor interview on [DATE] at 3:17 PM with Registered Nurse (RN), Staff A, she was unable to provide evidence that the care plan for Resident ID #48 was being implemented relative to observing for signs and symptoms of abnormal bleeding. 2. Record review revealed Resident ID #62 was admitted to the facility in January of 2024 with diagnoses including, but not limited to, intertrochanteric fracture of right femur, pulmonary embolism (PE- a blood clot that forms inside a deep vein in your leg, arm or pelvis), phlebitis (a condition of inflammation of veins causing pain, discomfort and swelling) and thrombophlebitis (a condition where an inflammation in a vein is caused by a blood clot, affecting normal blood flow) of lower extremities. Record review of a care plan initiated on [DATE] revealed a focus area for potential for abnormal bleeding related to history of a PE with interventions to observe for signs of abnormal bleeding such as, unexplained bruising, nose bleeds, gastrointestinal, genitourinary bleeding, bleeding gums and to report concerns. Record review revealed a physician's order dated [DATE] for Eliquis (blood thinner) 5 mg (milligrams) 1 tablet twice a day. Record review failed to reveal evidence that the care plan for Resident ID #62 was being implemented relative to observing for signs and symptoms of abnormal bleeding. During a surveyor interview on [DATE] at 10:24 AM with Staff A, she was unable to provide evidence that the care plan for Resident ID #62 was being implemented relative to observing for signs and symptoms of abnormal bleeding. 3. Record review of a closed record revealed Resident ID #118 was readmitted to the facility in April of 2015 with diagnoses including, but not limited to, venous thrombosis and embolism (referring to the development and risk of lodging blood clots in the veins), long term use of anticoagulant and gastrointestinal hemorrhage. Resident ID #118 expired in April of 2024. Record review of the care plan initiated on [DATE] included a focus area for deep vein thrombosis (DVT). Additionally, it revealed interventions including, but not limited to, monitor for signs of abnormal bleeding , observe for redness, swelling or pain to left lower extremity, signs, and symptoms of DVT, monitor labs and to report concerns to Medical Doctor or Nurse Practitioner. Record review revealed a physician's order dated [DATE] for Eliquis 2.5 mg 1 tablet twice a day. Record review failed to reveal evidence that the care plan for Resident ID #118 was being implemented relative to observing for signs and symptoms of abnormal bleeding. During a surveyor interview on [DATE] at 10:58 AM with the Director of Nursing Services (DNS), she acknowledged the above-mentioned residents received anticoagulant medications as well as have comprehensive care plans which include interventions to monitor for signs of abnormal bleeding. Additionally, she was unable to provide evidence that the care plans for Resident ID #s 48, 62, and 118 were being implemented relative to observing for signs and symptoms of abnormal bleeding.
Inspection of March 27, 2023
2 findings46539 Based on surveyor observation, record review, staff and resident 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 a norovirus outbreak for 4 of 4 units and Extended spectrum beta-lactamases (ESBLs) for 1 of 1 residents reviewed, Resident ID #79. Findings are as follows: During surveyor observations on 3/20/2023 through 3/23/2023 failed to reveal any signage posted indicating that the facility was experiencing a Gastrointestinal Illness Outbreak. 1. Review of a facility provided document titled Norovirus in Healthcare Facilities Fact Sheet revealed that noroviruses are highly contagious and are transmitted by direct person-to-person spread. Additionally, noroviruses can also spread via a droplet route from vomitus. Review of an additional document provided by the facility titled Key Infection Control Recommendations for Control of Norovirus Outbreak in Healthcare Settings states in part, .Place patients with norovirus gastroenteritis on Contact Precautions for a minimum of 48 hours after the resolution of symptoms . Additionally the document revealed, If norovirus infection is suspected, adherence to Personal Protective Equipment (PPE) use according to Contact Precautions for individuals entering the patient care area (i.e., gowns and gloves upon entry). During multiple surveyor tours on 3/20/2023 at approximately 9:10 AM of all 4 units revealed no resident were on contact precautions and one resident on droplet precautions. During a surveyor interview on 3/20/2023 at 9:21 AM on unit [NAME] Hill with Resident ID #128 s/he revealed s/he was not feeling well and was experiencing vomiting today. Record review of Resident ID #128 revealed a progress note dated 3/20/2023 at 5:49 PM which states in part, Resident c/o [complaint of] not feeling well, vomited x [times] 2 this morning with a low grade temp . Additional record review failed to reveal evidence that Resident ID #128 was placed on contact precautions. During a surveyor interview on 3/20/2023 at 10:22 AM on unit Cold Spring Place with Resident ID #71 s/he revealed that s/he had been vomiting and having episode of diarrhea for 2 days. Record review of Resident ID #71 revealed, s/he vomited on 3/18/2023. Further review failed to reveal the resident was placed on contact precautions. During multiple surveyor tours on 3/21/2023 at approximately 8:00 AM of all 4 units, failed to reveal evidence that residents were placed on contact precautions. One resident was on droplet precautions for COVID-19. During a surveyor interview with the Infection Preventionist she revealed that she has been in contact with the Rhode Island Department of Health related to a norovirus outbreak which had started on 3/7/2023 and has received guidance related to what to do to prevent the spread of the virus. Additionally, she revealed that the facility has had 3 stool samples test positive for norovirus on 3/14/2023. Furthermore, she revealed that the facility is not placing the residents on contact precautions. Record review of a facility provided document titled Gastrointestinal Illness Outbreak: Cumulative* Line List for RESIDENTS dated 3/10/2023 revealed the original illness started on 3/7/2023 and had 15 residents on the Park Square Unit with symptoms of norovirus with 3 confirmed positive stool samples for norovirus. Additional review revealed 9 residents on the Cold Spring Unit with norovirus symptoms as of 3/18/2023 and 3 residents on [NAME] Hill unit with norovirus symptoms as of 3/20/2023. During a surveyor tour of all 4 units on 3/22/2023 from approximately 7:55 AM through 8:10 AM failed to reveal resident's on contact precautions. During a surveyor interview on 3/22/2023 at 7:55 AM with Registered Nurse, Staff E, she revealed that she would not use a gown and gloves when caring for resident experiencing nausea, vomiting, and diarrhea. Additionally, she revealed that two residents on the Cold Spring Unit are having additional symptoms of norovirus. Furthermore, she revealed that the two residents with symptoms were not placed on contact precautions. During a surveyor interview on 3/22/2023 at 7:58 AM with Staff F and Staff B they revealed that on [NAME] Hill Unit, they had a resident with nausea today and was vomiting over the weekend and that s/he missed the appointment on Monday related to vomiting. Additionally, they revealed no residents were on contact precautions at this time. During a surveyor interview on 3/22/2023 at 8:10 AM with Licensed Practical Nurse, Staff G, she revealed that on the [NAME] Point Unit, there were two residents complaining of norovirus symptoms and that there were not any residents on contact precautions at this time. Additionally, she states if there was vomit on the ground, I would use gloves. During a surveyor interview at 3/22/2023 at 9:29 AM with the Infection Preventionist she revealed that residents are not placed on Contact Precautions. If a resident was on contact precautions the resident would have an isolation cart and signage outside of the room. Additionally, she revealed that there would be carts everywhere. Furthermore, she revealed the facility was still in a Gastroenteritis outbreak. During a surveyor interview on 3/22/2023 at 12:38 PM with the Administrator of Clinical Services, she was unable to provide evidence the facility implemented contact precautions to help prevent the transmission of the norovirus resulting in facility wide outbreak. 2. Review of a facility policy titled, ISOLATION AND INFECTION PRECAUTIONS CONTACT PRECAUTIONS, states in part, .The purpose of contact Precautions is to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact. Contact precautions apply to specified residents known or suspected to be infected or colonized with epidemiologically important microorganisms which are transmitted by direct or indirect contact, including, but not limited to .Extended Spectrum Beta Lactamase [ESBL] . Record review revealed Resident ID #79 was readmitted to the facility in January of 2023 with diagnoses including, but not limited to, metabolic encephalopathy (abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function) and altered mental status. Additional record review revealed a urine culture, obtained on 1/21/2023, which states in part, .CONFIRMATORY TESTING POSITIVE FOR ESBL . Review of a care plan, last revised on 3/8/2023, states in part, ALTERATION IN URINARY ELIMINATION .REQUIRES EXTENSIVE ASSIST WITH INCONTINENCE CARE .ESBL . Review of the February 2023 Medication Administration Record revealed an order for ESBL precautions, with a start date of 1/22/2023 and an end date of 2/2/2023. Surveyor observations on the following dates and times of the resident revealed: - 3/20/2023 at 9:14 AM, no signage or isolation cart outside of the resident's room to indicate the resident is on contact precautions. -3/21/2023 at 11:10 AM, no signage or isolation cart outside of the resident's room to indicate the resident is on contact precautions. -3/23/2023 at 12:12 PM, no signage or isolation cart outside of the resident's room to indicate the resident is on contact precautions. During a surveyor interview on 3/23/2023 at 12:03 PM, with Licensed Practical Nurse, Staff H, he acknowledged that Resident ID #79 was not on contact precautions. During a surveyor interview on 3/23/2023 at 12:15 PM, with the Infection Preventionist, she revealed that residents with ESBL are on contact precautions only for a week and are monitored for symptoms after. Additionally, she was unable to provide evidence that Resident ID #79 was on contact precautions, per the facility policy. During a surveyor interview on 3/23/2023 at 1:08 PM, with the Administrator of Clinical Services, she was unable to provide evidence that Resident ID #79 was on contact precautions, per facility policy.
Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident received adequate supervision to prevent elopement from the facility for 1 of 4 closed records reviewed, Resident ID #127. Findings are as follows: Review of a facility policy titled, Elopement Policy and Procedure states in part, Policy: To determine and safely return residents whom cannot be accounted for .Notify Authorities .call police. Provide picture, description of resident of clothing, advisory such as specific medical conditions, possible destination (i.e. relatives, former residence) .If the resident has not been located within two hours: a. copy resident photograph and prepare for mass distribution b. Call all off-duty supervisory staff to assist in search c. [NAME] search area. Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities last revised 10/21/2022, states in part, .A situation in which a resident with decision-making capacity leaves the facility intentionally would generally not be considered an elopement unless the facility is unaware of the resident's departure and/or whereabouts . Record review revealed the resident was admitted to the facility in February of 2023 with diagnoses including, but not limited to, endocarditis (inflammation of the inner lining of the heart chambers and valves. Usually caused by bacterial infection) and opioid abuse. Review of a care plan dated 2/22/2023 revealed the resident has a Peripherally Inserted Central Catheter (PICC) line to his/her right upper extremity due to endocarditis and s/he has polysubstance abuse (abuse of 2 or more drugs that cause impairment or distress) with methadone use for addiction. Review of a progress note dated 3/9/2023 at 4:11 AM, revealed that the resident was unable to be found in the facility or on the grounds as of 12 AM. It further revealed that the resident was discharged AMA (against medical advice). During a surveyor interview on 3/21/2023 at 1:54 PM with Registered Nurse (RN), Staff A, he revealed that he was the nurse working on 3/8/2023 when the resident was unable to be located. He revealed that the resident had not been seen at all during his shift that began at 3 PM and he was unsure when the resident left the building or where s/he had gone. Additionally, he revealed that the resident left with an operational PICC line in his/her arm because s/he was receiving antibiotics for endocarditis and that he was aware the resident had a history of IV (intravenous) drug usage prior to admission. He further revealed that he did not call the police or follow the facility's elopement policy. Staff A also revealed that the resident did not request to leave AMA and s/he did not sign the appropriate AMA paperwork. During a surveyor interview on 3/21/2023 at 2:16 PM with RN, Staff B, she revealed that the last time she saw the resident was approximately 3:00 PM on 3/8/2023 and that the resident did not ask to leave AMA and did not say s/he was leaving the facility. Review of a note dated 2/14/2023 written by the Nurse Practitioner (NP), Staff C, revealed that she was aware of the resident's previous drug use and that the resident was educated regarding not administering any forms of drugs in his/her PICC line. Further record review revealed a physician orders for Cefazolin (antibiotic) 2 grams to be administered intravenous every 8 hours. Review of the Medication Administration Record for March 2023 revealed the resident missed 3 doses of the antibiotic being used to treat endocarditis during the time the facility was unaware of his/her whereabouts. During a surveyor interview on 3/21/2023 at 2:23 PM with the Director of Nursing Services (DNS) she acknowledged that the resident left the faciity on [DATE] without the staff being aware. She further revealed that the resident's whereabouts were not known to the facility until the following day at approximately 2:45 PM, which is almost 24 hours since the facility had last seen him/her. She was unable to provide evidence that the staff followed the elopement policy. She further revealed that the resident did not sign out of the facility or request to leave AMA. During a surveyor interview on 3/21/2023 at 2:28 PM with the Social Worker, Staff D, she revealed that she was notified the following day of the resident leaving the facility. She revealed that she had attempted to call the phone number listed in the chart for the resident and his/her emergency contact without success. Additionally, she revealed that Resident ID #127 left on 3/8/2023 with another resident's debit card, Resident ID #95. Resident ID #95 called the police to report his/her card stolen on 3/9/2023. When the police arrived, they were notified of the resident leaving the previous evening and having a PICC line in place. It was at this time that the police revealed they were aware of the resident's whereabouts. During a surveyor interview with the Administrator of Clinical Services, she acknowledged that she was concerned the resident left the facility with a PICC line and a history of IV drug use. She revealed that she was not notified with in two hours of the resident leaving the facility per the policy. She further revealed that the resident left the facility and they were not aware of his/her whereabouts. Additionally, she revealed the police were notified by Resident ID #95 on 3/9/2023, when s/he called to report his/her bank card missing. She indicated that when they police came to speak with Resident ID #95 the DNS spoke with the police for the first time regarding Resident ID #127's whereabouts. Furthermore, she was unable to provide evidence that the facility provided the resident with adequate supervision to prevent elopement.
Inspection of January 27, 2022
1 findingBased on record review and staff interview, it has been determined that the facility failed to ensure that each resident receives treatment and care in accordance with professional standards of practice for 1 of 5 sample resident's relative to weight change and respiratory status, Resident ID #51. Findings are as follows: The facility's PROTOCOL FOR ADDRESSING WEIGHT CHANGES state in part; . If the weight change is extreme and appeared inaccurate. Notify the charge nurse and reweigh perhaps on a different scale . If there is a #5 weight change let the charge nurse know . Once notified the charge nurse should -Notify the dietitian and document in the chart. -Address in the resident care plan. If applicable the Charge nurse may also; Notify physician . If #5 [pounds] or greater weight gain has occurred, check for possible reasons such as [CONDITION(S)] [swelling, puffiness], ascites [fluids builds up in abdomen] .Follow up with appropriate disciplines as needed. Record review for this resident revealed s/he was originally admitted to the facility in November 2020. The resident has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional record review revealed the following progress notes: -1/5/2022 at 5:30 PM .wgt [weight] today 187.6 lbs [pounds], [15.2 lbs weight gain from 12/10/2021 (172.4 lbs), 8.82 % in less than a month] . -1/6/2022 at 4:23 PM, .Today weight is 189 lbs [weight gain 1.4 lbs from 1/5/2022, and 16.6 lbs from 12/10/2021, 9.63 % in less than a month], reported to [dietitian] who order to repeat it tomorrow and if accurate to check TSH ([CONDITION(S)] stimulating hormone) level . -1/11/2022 at 6:01 PM, .Wgt today 187 lbs (14.6 lbs weight gain from 12/10/2022, 8.47 % in a month). Further record review failed to reveal evidence that the dietitian was notified of the reweigh on 1/11/2022. Additionally, there is no evidence that the physician or nurse practitioner were notified of the weight gain. Record review failed to reveal evidence that the care plan was updated to address the weight change or that the resident was monitored for [CONDITION(S)] and/or ascites. Additional record review revealed the following progress notes regarding his/her respiratory status/oxygen use: -1/7/2022 at 4:16 PM, .on o2 [oxygen] at 2 liters, .denies SOB [shortness of breath] at this time, ls [lung sounds]: clear . -1/8/2022 at 12:07 AM, .on 2L [liters] Oxygen . -1/10/2022 at 11:30 PM, .at 2L continuous Oxygen . -1/11/2022 at 6:01 PM, . O2 2L .[oxygen 2 liters] . -1/12/2022 at 4:22 PM, .on 2 L. [liters] . -1/13/2022 at 12:55 AM, .at 2 L Oxygen . Further record review failed to reveal evidence of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further record review revealed that this resident went to his/her cardiology clinic on 1/13/2022 at 1:00 PM. Review of a progress note dated 1/13/2022 at 4:06 PM revealed the resident was sent to the hospital from the cardiology clinic and the resident was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital discharge summary dated 1/19/2022 revealed: .Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Cardiology: Patient presented with progressive [CONDITION(S)] and dyspnea on exertion [shortness of breath/air hunger/difficulty with breathing] .BNP (brain natriuretic peptide; small amounts are found in the blood stream) greater than 17,000 [normal level less than 125 pg/ml (picograms per milliliter), if levels were higher than normal, it usually means is indicative heart failure] .on a [MEDICATION(S)] drip [medication that reduces fluid in body] with optimal respond .and leg [CONDITION(S)] has improved . Renal: It appears patient has had worsening creatinine in the setting of CHF exacerbation .likely cardiorenal syndrome [abnormal heart function that is associated with abnormal kidney function] . During an interview with the Director of Nursing Services (DNS) on 1/26/2022 at 9:02 AM, she revealed that if a resident has a weight gain of 3 lbs or more that the dietitian and physician should be notified. The DNS stated, although the policy and procedure for addressing the weight change indicates 5 lbs weight change for a notification, she stated that the dietitian likes it this way. The DNS stated that if staff notify the dietician or the physician, they should document in the record. The DNS further stated she is aware of the 15.2 lbs weight gain and that staff should have reweighed the resident next day. She was unable to provide evidence that the resident's physician and/or nurse practitioner were notified relative to the resident's weight gain. The DNS was also unable to provide evidence that a care plan had been updated to address the weight change or that the resident was monitored for [CONDITION(S)] or ascites after 1/5/2022. During an interview on 1/27/2022 at 9:50 AM, with the dietitian she revealed she was notified on 1/6/2022 relative to the 15.2 lbs weight gain. She revealed her recommendations, were to recheck the weight and notify the physician to obtain an order to check TSH level. She indicated a reweigh should be obtained within 24-48 hours. She revealed she was not notified relative to the reweigh on 1/11/2022. During an interview with the Nurse Practioner, Staff E on 1/27/2022 at 10:04 AM, she revealed she was not aware of the weight gain. Staff E stated No one told me I would go in and see [him/her] right away. I'm there almost every day. Staff E further revealed the resident goes to the cardiologist and they manage his/her medications and staff should notify the cardiologist as well. Additionally, Staff E revealed that the resident is very compromised and if staff had told her that the resident gained 15 pounds, she would have seen the resident and prescribed [MEDICATION(S)] (a medication that reduces fluid in body). Staff E further revealed she was not aware that the resident received oxygen on 1/7, 1/8, 1/10, 1/12 and 1/13/2022. Staff E stated that would have prompted me to see (him/her) right away .(S/he) was going into CHF (congestive heart failure) . During a phone interview with the resident's cardiologist on 1/27/2022 at 10:37 AM, he revealed he saw the resident on 1/13/2022 at approximately 1:30 PM and the resident was coughing, huffing and could not finish [his/her] sentence .[S/he] was short of breath .and had 3 plus [CONDITION(S)] [severe swelling] . The cardiologist further stated when he saw the resident, he knew that the resident needed to go to the hospital right away. The cardiologist further revealed the resident was sent from the nursing home and utilizing oxygen during his/her appointment. During an interview on 1/27/2022 at 12:35 PM, the Administrator was unable to provide evidence that the resident received appropriate care and treatment in accordance with professional standards of practice.
Inspection of September 23, 2021
1 findingBased on record review and staff interview it has been determined that the facility failed to provide sufficient supervision of a resident to prevent an accident for 1 of 4 residents reviewed for falls resulting in an injury, Resident ID #1. Findings are as follows: Record review revealed that the resident was admitted to the facility in November of 2012 and has diagnoses including, but not limited to, Alzheimer's disease, [CONDITION(S)], and dementia with behavioral disturbance. Review of a document titled, Department of Health, Office of Facilities Regulation Nursing Facility Required Reporting dated 9/17/2021, indicates that on 9/15/2021 at 10:00 AM CNA [certified nursing assistant] was performing AM care and was turning [resident] on [his/her] side to change [his/her] brief when [s/he] had a sudden jerky movement and rolled off the bed falling to the floor. No injury noted @ [at] that time. On 9-16-21 R [right] leg appeared swollen c [with] pain. Resident sent to ER [emergency room ] + [and] admitted c [with] R femur fx [fracture] . Record review of the facility's investigation file revealed a written statement from Staff A, CNA, which states, [Resident's name redacted] 9-15-21 I was doing patient care and I turned [him/her] over on [his/her] side to was [sic.] [his/her] bottom and [s/he] made a sudden move and rolled off the bed. [S/he] fell on the mat on [his/her] right side. Record review of a quarterly Minimum Data Set assessment dated [DATE] revealed that for bed mobility, toilet use, and bathing the resident was coded as total dependence and Two+ which indicates that the resident required full assistance of 2 or more staff members for the activity at the time of the assessment. Review of a progress note from social services dated 9/6/2021 revealed that the resident is alert and oriented to his/her name only and has severe memory impairment. Further review of this note revealed that the resident has his/her bed positioned low to the ground due to being at risk for falls and transfers with the use of a Hoyer lift. Record review of a quarterly Risk of Falls assessment completed on 9/2/2021 revealed that for Activities of Daily Living including bathing, dressing, and grooming, the resident requires total assistance of two staff members. Additionally, this document indicated that the resident was a moderate risk for falls. Record review of nursing progress notes revealed the following: - 9/15/2021 at 2:08 PM .RESIDENT ROLLED ON TO MAT ON THE FLOOR WHILE BEING TURNED DURING AM CARE IN [his/her] BED. PA [physician assistant] NOTIFIED. NNO [no new orders] AT THIS TIME . - 9/16/2021 at 2:54 PM, .CNA [certified nursing assistant] REPORTED RIGHT LEG SWELLING DURING AM CARE. PA .NOTIFIED AND ORDERED STAT [immediate] RADIOLOGY EXAM . Further review of the nursing progress notes revealed that the ordered radiology exam was not obtained due to the resident's leg contractures and s/he was transported to the hospital on 9/16/2021 at 2:15 PM. S/he was admitted to the hospital on 9/17/2021 with a fracture of the right femur (thigh bone) and returned to the facility on [DATE]. Review of the hospital's discharge summary states in part, .had x-rays done of the right leg which showed 'Displaced, angulated and comminuted [more than two fragments] fracture of the mid shaft of the femur' .orthopedics were consulted and they declined to accept the patient for any surgical intervention because of [his/her] age dementia and contractures .the patient was admitted for pain control .patient should be evaluated by hospice care . Additional record review revealed that the resident was admitted to hospice services at the facility on 9/19/2021. During a surveyor interview on 9/22/2021 at 1:13 PM and at 2:24 PM with Staff A, she indicated that on 9/15/2021 she was providing the resident with a bath while in bed, as well as incontinence care, and was alone, without other staff present. She stated that during care, she rolled the resident on his/her side and s/he rolled off the bed. During a surveyor interview on 9/23/2021 at 3:11 PM with the Director of Nursing Services and the MDS Nurse, they were unable to provide evidence that Staff A used the assistance of an additional staff member for bed mobility support, toileting support, and bathing support during the resident's care on the morning of 9/15/2021, which resulted in the resident falling off the bed onto the floor subsequently sustaining a right femur fracture.
Inspection of September 17, 2018
1 findingBased on record review and staff interviews, it has been determined that the that the facility has failed to ensure that the resident's right to refuse treatment, including CPR (cardio-pulmonary resuscitation), has been upheld for 1 of 1 sampled residents (Resident ID#132). Findings are as follows: Review of the facility policy: Code Status, states, in part, To ensure that all residents are provided with the right to accept or refuse medical/surgical treatment and to formulate an advance directive .Once resident, family member, responsible party or DPOA (durable power of attorney) for Health Care has formulated an advance directive and signed the code status form, physician will be called to obtain order . Review of the facility policy: Cardiopulmonary Resuscitation Policy and Procedure, states, in part, Objective: To ventilate the resident until adequate circulation to the brain is re-established .Do not start CPR if: pupils are dilated, there are signs of rigor mortis, or resident is a DNR (do not resuscitate) status . Closed record review for Resident ID#132 revealed [DIAGNOSES REDACTED]. Further review revealed the resident was admitted to the facility initially on [DATE], hospitalized from [DATE] to [DATE], and readmitted to the facility on [DATE]. Review of the resident's Code Status signed by the resident's mother and physician on [DATE] indicated that s/he was a DNR-No CPR (Cardiopulmonary Resuscitation), No Intubation (Ventilator Assisted Breathing), No Defibrillation (electric Shock to restore heartbeat). A physician's order on [DATE] revealed that the resident's code status: DNR. The current plan of care, dated [DATE] , directs that staff will honor the resident's advanced directives: DNR, elected by the resident and/or resident representative. Review of the resident's [DATE] quarterly Minimum Data Set revealed a pain assessment interview stating no presence of pain. A progress note dated [DATE] stated, . (Resident ID#132) was having trouble breathing .Color became blue and nonresponsive .No AP/BP (apical pulse/blood pressure) .CPR initiated .Within one minute BP=,[DATE]. Pulse=90 (indicating successful resuscitation) .CPR stopped. 2nd nurse had gone to check code status and returned stating (s/he) was a DNR but by this point CPR had been stopped .To (hospital) via rescue at 8:45 am . Review of the hospital record revealed a discharge [DIAGNOSES REDACTED]. Additional hospital documentation states, .The nursing home reported that the patient was found unresponsive with no pulse and started CPR this morning. The patient has been documented as a DNR code status in the past including previous admissions to this hospital and to this ICU last year. There is . a signed DNR sheet in her nursing home records from (MONTH) 1, (YEAR). So apparently CPR was stopped but by that time the patient seemed to have responded .The pain is most concerning thing for (him/her). The problem continues to be chest wall pain around the area where (s/he had CPR) . Review of the resident's progress notes upon readmission to the facility revealed the following: [DATE] 2:52 AM, Returned from (hospital) at 4:00 .Complaining of left and right flank pain . [DATE] 4:10 PM, .c/o (complaints of) bilateral rib pain . [DATE] 7:09 AM, .c/o left side rib pain . [DATE] 3:18 PM, .c/o left ribcage pain . [DATE] 2:36 PM, .c/o left ribcage pain . [DATE] 10:39 PM, .Resident complains of pain to her left side (ribs) . [DATE] 5:06 AM, .c/o left side rib pain . [DATE] 7:04 AM, .c/o 'some left side pain' . [DATE] 3:45 PM, .continues to c/o pain to left ribcage area . [DATE] 7:20 AM, .c/o pain 'left side' with fair effect . [DATE] 2:59 PM, .c/o pain to left ribcage .Continues to state can't take the pain .At 2:10 PM respirations ceased. No BP .Dr .made aware. (MONTH) release body to funeral home . During surveyor interview with Staff Nurse A on [DATE] at 2:38 PM she revealed that she was in the room at the time of the resident's unresponsive episode, the nurse felt confident that resident was a full code, an emergency code was called, CPR lasted less than one minute, another nurse came in and said the resident was a DNR but CPR had already stopped and resident was resuscitated. Additionally, Staff Nurse A revealed the resident sustained [REDACTED]. During surveyor interview with the Director of Nursing Service (DNS) on [DATE] at 1:45 PM she revealed that staff should check the resident's code status prior to initiation of CPR and confirmed that the resident's advanced directive at the time of the incident was listed as a DNR. You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the Rules and Regulations for Licensing of Nursing Facilities they are deficiencies under State Regulations and grounds for licensure sanctions.
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