cms_RI
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1,896 rows
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | HATTIE IDE CHAFFEE HOME | 415002 | 200 WAMPANOAG TRAIL | EAST PROVIDENCE | RI | 2914 | 2019-01-04 | 755 | D | 0 | 1 | 2B5Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, surveyor observation, and staff interview, it has been determined that the facility failed to provide routine drugs relative to 1 of 8 residents reviewed for medication administration (ID# 42). Findings are as follows: Record review for Resident ID# 42 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed the following: 1. A 12/5/2018 physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. 2. A 12/20/2018 physician's orders [REDACTED]. Review of the MAR indicated [REDACTED]. 3. A 12/26/2018 physician's orders [REDACTED]. Review of the MAR indicated [REDACTED].Other for 3 of 9 opportunities. Surveyor observation during the Medication Administration Task on 1/3/2019 at 7:31 AM revealed that the current physician ordered B Complex 1 dose was not available to the resident. During an surveyor interview, immediately following this observation, Medication Aide (Staff A) revealed that the resident did not receive the B Complex and that the medication has not been available for a few days. During a subsequent interview on 1/3/2019 at 10:26 AM, the South Wing Charge Nurse was unable to provide evidence that the above physician ordered medications were available to Resident ID# 42. | 2020-09-01 |
| 2 | 2 | HATTIE IDE CHAFFEE HOME | 415002 | 200 WAMPANOAG TRAIL | EAST PROVIDENCE | RI | 2914 | 2019-01-04 | 761 | D | 0 | 1 | 2B5Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, surveyor observation, and staff interview, it has been determined that the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 residents reviewed for medication administration (ID# 45). Findings are as follows: Record review for Resident ID# 45 revealed the following: 1. A current physician's orders [REDACTED]. 2. A current physician's orders [REDACTED]. 3. A current physician's orders [REDACTED]. Surveyor observation during the Medication Administration Task on 1/3/2019 at 8:16 AM revealed the Unit Nurse (Staff B) leaving a medication cup with the [MEDICATION NAME] and [MEDICATION NAME] on the resident's bedside table while the resident was in the bathroom. During surveyor on 1/3/2019, immediately following the observation, Staff B revealed that the resident self-administers the medications and the [MEDICATION NAME] is stored in the bathroom, not in a locked compartment. Additionally, she has been leaving the resident's medications on the bedside table for a while and acknowledged that they were not secured. During a subsequent interview on 1/3/2019 at 9:35 AM, the Administrator was unable to provide evidence that the resident's drugs were stored in locked compartments. Additionally, during interview on 1/4/2019 at 8:19 AM, Resident ID# 45 confirmed that the [MEDICATION NAME] has been stored in the bathroom and that the nurses leave medications on the bedside table. | 2020-09-01 |
| 3 | 3 | HATTIE IDE CHAFFEE HOME | 415002 | 200 WAMPANOAG TRAIL | EAST PROVIDENCE | RI | 2914 | 2019-11-08 | 688 | D | 0 | 1 | KGGT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and resident and staff interviews, it has been determined that the facility failed to ensure a resident with limited mobility receives appropriate treatment to prevent further decrease in range of motion for 1 of 1 resident reviewed for limited range of motion (ID #45). Findings are as follows: Record review revealed that Resident ID #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further record review revealed a physician's orders [REDACTED]. Review of the care plan in place for Activities of Daily Living and Functional/Rehabilitation Potential revealed an intervention dated 11/22/2016 stating in part: .apply left hand palm protector q (every) daytime, as tolerated . Surveyor observation on the following dates and times revealed the resident without a left-hand palm protector on his/her hand: -11/7/2019 10:50 AM -11/7/2019 11:15 AM -11/7/2019 02:20 PM -11/8/2019 12:02 PM -11/8/2019 12:08 PM During a surveyor interview on 11/7/2019 at 11:34 AM with Certified Nursing Assistant (CNA), Staff A, she stated that the resident does not require anything on his/her hands during the day. During a surveyor interview on 11/8/2019 at 11:58 AM with the resident's assigned CNA for the day, Staff B, she stated the resident does not wear anything on his/her hands during the day and referenced a care card which is used for care instructions. Record review of the Resident's care card revealed in part, .left hand palm protector during the day as tolerated . During a surveyor interview with Resident ID #45 on 11/8/2019 at 12:02 PM, s/he stated that s/he sometimes wears something on his/her wrist during the day, but not always. During a surveyor interview on 11/8/2019 at 12:12 PM with the unit nurse, Staff C, she acknowledged that the resident should be wearing a left-hand palm protector during the day, however, she had not observed the resident wearing the palm protector for the last 2 days. | 2020-09-01 |
| 4 | 4 | HATTIE IDE CHAFFEE HOME | 415002 | 200 WAMPANOAG TRAIL | EAST PROVIDENCE | RI | 2914 | 2019-11-08 | 761 | D | 1 | 1 | KGGT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, staff interview and record review, it has been determined that the facility failed to ensure that expired medications were not available for administration and failed to date multi-dose vials when opened for 1 of 2 bottles of [MEDICATION NAME] Purified Protein Derivative (used intradermally to aid in [DIAGNOSES REDACTED]. Finding are as follows: Surveyor observation of the medication storage room refrigerator on 11/07/2019 at 11:35 AM with the Director of Nursing (DNS), revealed the following: 1) A 150 ml bottle of FirvanQ [MEDICATION NAME] (an antibiotic) 50 mg/ml for Resident ID #16. Instructions on the bottle state, contents must be used within 14 days discard if hazy. The bottle was received from the pharmacy on 9/5/2019. Additionally, there was a sticker on the bottle that stated Do Not use after 9/19/19. 2) A [MEDICATION NAME] 5 T units/ 0.1 ml vial in fridge opened and not dated when opened. Instructions on the bottle state,discard opened product after 30 days. During surveyor interview on 11/07/2019 at 11:40 AM with the DNS, she revealed that the [MEDICATION NAME] was expired and should have been discarded. She further revealed that the [MEDICATION NAME] should have been dated when opened. | 2020-09-01 |
| 5 | 5 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2018-02-08 | 689 | J | 1 | 0 | QYSV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, interview and record review, the facility failed to identify hazards and risks to ensure an environment that is free from accident hazards, and provides supervision to each resident to prevent avoidable accidents for 1 of 20 residents who reside on the secured Westerly Unit relative to supervision and exit door alarms. Findings are as follows: On 2/6/2018 resident ID# 1 exited the glass exit door to an outdoor patio which is adjacent to the common area of the secured Westerly Unit. The resident was noted to fall outside of the door onto the ground which went un-noticed by staff. Resident ID# 1 was on the ground outdoors for an unknown period which resulted in a hospital admission for hypothermia and a laceration above her eye. During surveyor observation of the secured Westerly Unit on 2/8/18 at approximately 9:20 AM, it was identified that there were two exit doors which open to the outside. Both doors have an alarm located adjacent to the top of door which when in the on position will sound an alarm if the door is open. This alerts staff that someone has opened the door. The alarms can be shut off to each exit door by manually pressing the on and off switch. The common room exit door has a glass front full view and a push bar which easily opened with very little resistance and was noted to close itself upon exit. During an interview with the Director of Nursing on 2/8/2018 at approximately 9:40 AM she stated elopement assessments are not the practice of Royal Healthcare and therefore one was never completed for resident ID# 1. Additionally, she stated this resident had no elopement history and has never attempted to leave the facility. She states the door alarms should be on always and could not explain why the alarm had been shut off or who may have shut the alarm off. She states, according to nursing staff it appeared the resident may have stood up from her chair, ambulated to door, pushed on the door hand… | 2020-09-01 |
| 6 | 6 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2019-08-08 | 623 | C | 1 | 1 | 02UK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it has been determined that the facility failed to send a copy of the notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman for 6 of 6 sample residents reviewed relative to discharge to the hospital or community. Resident ID #s 2, 26, 30, 49, 50, and 63. Findings are as follows: 1. Clinical record review for Resident ID #2 revealed s/he was transferred to the hospital on [DATE]. 2. Clinical record review for Resident ID #26 revealed s/he was transferred to the hospital on [DATE]. 3. Clinical record review for Resident ID #30 revealed s/he was transferred to the hospital on [DATE]. 4. Clinical record review for Resident ID #49 revealed s/he was transferred to the hospital on [DATE]. 5. Clinical record review for Resident ID #50 revealed s/he was transferred to the hospital on [DATE]. 6. Clinical record review for Resident ID #63 revealed s/he was discharged to the community on 5/23/2019. During an interview with the Administrator, on 8/8/2019 at 11:07 AM, he revealed that the facility does not notify the Office of the State Long-Term Care Ombudsman for routine transfers from the facility. | 2020-09-01 |
| 7 | 7 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2019-08-08 | 689 | D | 1 | 1 | 02UK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on water temperature readings and staff and resident interviews, it was determined that the facility failed to ensure the residents' environment remains free from accident hazards related to water temperatures above 120 degrees Fahrenheit (F), in areas used by residents on 1 of 3 units (Mystic). Findings are as follows: The surveyors obtained water temperatures on all units on 8/5/2019. The following temperatures were observed on Mystic Unit (non-dementia care unit), using digital thermometers: -10:40 AM, room [ROOM NUMBER], bathroom sink measured at 125.2 F -10:44 AM, Mystic Unit, common bathing room sink measured 125.1 F -10:48 AM, room [ROOM NUMBER], bathroom sink measured 128.2 F -10:52 AM, room [ROOM NUMBER], bathroom sink measured 125.2 F -11:35 AM, room [ROOM NUMBER], bathroom sink measured 126.0 F -11:35 AM, room [ROOM NUMBER], bathroom sink measured 126.7 F -11:35 AM, room [ROOM NUMBER], bathroom sink measured 125.2 F -11:35 AM, room [ROOM NUMBER], bathroom sink measured 121.3 F -11:37 AM, room [ROOM NUMBER], bathroom sink measured 120.4 F -11:39 AM, room [ROOM NUMBER], bathroom sink measured 122.2 F During a surveyor interview on 8/5/2019 at 11:55 AM, with the Maintenance Director, he revealed that he was unaware of the elevated water temperatures. Additionally, he revealed that he completes weekly water temperature monitoring and logs of 2 different rooms per unit and at the 2 mixing valves weekly, on Thursdays. He revealed that he has not had problems with high temperatures and expects the water temperatures to measure between 100.0 F to 110.0 F, plus or minus two degrees. Further, he expects the staff to inform maintenance if the water feels too hot. Additional measurements of the water temperatures by both the surveyor and the Maintenance Director on 8/5/2019, using separate thermometers, revealed the following: -12:05 PM, Mystic Unit, common bathing room sink measured 122.1 F -12:07 PM, room [ROOM NUMBER], bathroom sink… | 2020-09-01 |
| 8 | 8 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2019-08-08 | 692 | E | 1 | 1 | 02UK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor record review and staff interview, it has been determined that the facility failed to ensure that a resident is offered sufficient fluid intake to maintain proper hydration for 1 of 3 sample residents reviewed for a fluid restriction (ID# 49). Findings are as follows: The facility's policy titled, Fluid Restriction Policy and Procedure, states in part, .5. Nursing will allocate the fluid allotment over the 24-hour period and by shift. Record review revealed that Resident ID #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the following physician's orders [REDACTED]. - 3/15/2019 to 6/14/2019: 1000 ml / day fluid restriction . - 6/14/2019 to 7/8/2019: 1000 ml / day fluid restriction . -7/8/2019 to 7/18/2019: 1000 ml / day fluid restriction .No liquids except for water between meals . - 7/18/2019 to current: 1000 ml / day fluid restriction . No liquids except for water between meals . Review of the Medication Administration Record [REDACTED]. Review of the Vitals Reports from 5/1/2019 to 8/7/2019 revealed that the resident's fluid intake is not consistently monitored. There was no fluid intake documented on 48 out of the 92 days the resident was residing at the facility. Additionally, the days that fluid intake was documented ranged from 0 ml to 1030 ml in total and did not include documentation from each shift. During a surveyor interview on 8/8/2019 at 10:12 AM with Nursing Assistant, Staff B, she revealed that she does not document when she gives the resident fluids. During a surveyor interview on 8/8/2019 at 10:16 AM with the nurse, Staff D, she acknowledged that the total daily fluid intake was not being tracked. During a surveyor interviews with the Director of Nursing Services on 8/8/2019 at 10:33 AM and 11:54 AM, she acknowledged that the resident's fluid intake is not being documented consistently and that they do not have the resident's prescribed fluid restriction allocat… | 2020-09-01 |
| 9 | 9 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2019-08-08 | 759 | D | 1 | 1 | 02UK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observations, record reviews, and staff interviews, it has been determined that the facility has failed to ensure that each resident's medication regimen is free of medication error rates of 5% or greater. Based on 35 opportunities for error, there were five errors involving one resident (ID #6), resulting in an error rate of 14.29%. Findings are as follows: 1. Record review for Resident ID #6 revealed a [DATE] physician's orders [REDACTED]. During surveyor observation of the Medication Administration task on [DATE] at 7:38 AM, Staff Nurse C, prepared Aspirin chewable 81 mg instead of the delayed release/[MEDICATION NAME] coated Aspirin. 2. Record review for the resident revealed a [DATE] order with a stop date of [DATE] for [MEDICATION NAME] HFA aerosol inhaler (used to control and prevent symptoms of asthma). During surveyor observation on [DATE] at 7:38 AM, of the inhaler prior to administration, revealed an expiration date of (MONTH) (YEAR). Additionally, Staff C was observed administering the expired inhaler to the resident. 3. Record review for the resident revealed an [DATE] physician's orders [REDACTED]. Review of the Myrbetriq manufacturer's patient information states, in part, .Do not chew, break, or crush the tablet . During surveyor observation on [DATE] at 7:38 AM, revealed instructions on the pharmacy label stating, do not crush or chew. Additionally, Staff C was observed crushing the medication. 4. Record review for the resident revealed an [DATE] physician's orders [REDACTED]. Review of the Gericare [MEDICATION NAME] delayed-release manufacturer's directions on the original box state, in part, .swallow whole. Do not chew or crush capsule . During surveyor observation on [DATE] at 7:38 AM, Staff C cut open the [MEDICATION NAME] capsule, emptied the contents, and crushed the granules with the other medications. 5. Record review for the resident revealed a [DATE] physician's orders [REDACTED]. Review of the Va… | 2020-09-01 |
| 10 | 10 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2019-08-08 | 812 | F | 1 | 1 | 02UK11 | > Based on surveyor observations and staff interview, it has been determined that the facility failed to properly store, distribute, and serve food, in accordance with professional standards for food service safety, relative to the main kitchen and 2 of 2 kitchenettes. Findings are as follows: 1. Surveyor observation of the main kitchen on 8/5/2019 at 9:15 AM, in the presence of the Food Service Director (FSD), revealed the following: - 15 out of 15 blue, hard-plastic coffee cups were observed to have brown, scrapable matter on the inside of the cup. During a surveyor interview with the FSD, at the time of the above observation, he indicated that the coffee cups needed to be replaced. 2. Surveyor observation of the Mystic Wing Kitchenette on 8/6/2019 at 2:27 PM revealed the following: - The inside of the ice machine had an accumulation of pink matter, above where ice is dispensed. - A 1-quart container of[NAME]Ensure Plus (vanilla) was in the refrigerator, open and not dated. Manufacturer instructions indicate to use within 48 hours of opening. - Two containers of[NAME]nectar-thick apple juice, one container of[NAME]nectar-thick lemon water, and one container of[NAME]nectar-thick orange juice were in the refrigerator, open and not dated. Instructions on the container state to use within 7 days of opening. - The water dispenser had an accumulation of brown/black matter on the inside of both the room-temperature and cold-water spigots. 3. Surveyor observation of the Westerly Wing Kitchenette on 8/6/2019 at 2:47 PM revealed the following: - 9 out of 18 blue, hard-plastic coffee cups were observed in the cabinet with brown, scrapable matter on the inside of the cup. - There was one container of each of the following, open and not dated, in the refrigerator:[NAME]nectar-thick orange juice,[NAME]nectar-thick lemon water,[NAME]honey-thick lemon water,[NAME]honey-thick cranberry juice,[NAME]nectar-thick cranberry juice,[NAME]nectar-thick apple juice, and[NAME]honey-thick apple juice. Instructions on the container state t… | 2020-09-01 |
| 11 | 11 | ELDERWOOD AT RIVERSIDE | 415007 | 100 WAMPANOAG TRAIL | RIVERSIDE | RI | 2915 | 2019-01-04 | 758 | E | 1 | 1 | D5QX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary [MEDICAL CONDITION] drugs for 1 of 5 sampled residents who were reviewed for unnecessary medications (ID #45). Findings are as follows: Clinical record review for Resident ID #45 revealed a current physician's orders [REDACTED]. Further record review revealed a pharmacy recommendation report stating, The resident has an order for [REDACTED].PRN psychoactive medications may only be authorized for up to 14 days, then the resident must be re-evaluated for appropriateness and if continuation is necessary there must be a determined length of treatment. This recommendation was signed off by the Physician on 10/11/2018 indicating the Physician disagreed with the recommendation; however, he documented no rationale for extending the order or a length of treatment. A review of the Medication Administration Record [REDACTED]. During a surveyor interview with the Unit manager, Staff A, on 01/04/2019 at 10:13 AM, she was unable to provide evidence that the Physician documented a rationale or specified a duration. | 2020-09-01 |
| 12 | 12 | ELDERWOOD AT RIVERSIDE | 415007 | 100 WAMPANOAG TRAIL | RIVERSIDE | RI | 2915 | 2019-01-04 | 812 | F | 1 | 1 | D5QX11 | > Based on surveyor observations and staff interview, it has been determined that the facility failed to properly store food under sanitary conditions relative to the main kitchen. Findings are as follows: During initial tour of the kitchen on 1/2/2019 at approximately 8:20 AM, the following items were found: 1.) There were 4 trays of pre-cooked Molly's Kitchen green stuffed peppers with beef in tomato sauce left out in the 3-bay sink to thaw. The instructions on the package state, food may be thawed up to 48 hours under refrigeration. 2.) There were 4 white, plastic coffee pitchers on the counter, stored upright with the lid on. One pitcher had a thin layer of coffee-colored liquid sitting in it and one pitcher had a thin layer of clear liquid sitting in it. During a surveyor interview with the Food Service Director on 1/2/2019 at approximately 8:50 AM, she acknowledged that the stuffed peppers should not have been left out to thaw. Additionally, she indicated that the coffee pitchers were stored away as clean and should have been stored inverted, without the covers on. | 2020-09-01 |
| 13 | 13 | ELDERWOOD AT RIVERSIDE | 415007 | 100 WAMPANOAG TRAIL | RIVERSIDE | RI | 2915 | 2019-11-01 | 757 | E | 1 | 1 | DE9111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it has been determined that the facility failed to ensure each resident's drug regimen is free of unnecessary drugs relative to blood pressure medications administered without adequate monitoring for 1 of 5 sample residents reviewed for unnecessary medication (ID# 16). The facility's policy titled, Medication Administration Methods states in part, 4. Medication administration must be documented on the Medication Administration Record/ EMAR immediately before going on to the next resident, documentation will include: .d) The nurse will take the pulse or blood pressure when a medication requires such. He/she will then record the results on the Medication Administration Record/ EMAR prior to medication administration . Findings are as follows: Clinical record review revealed a physician's orders [REDACTED]. Hold for systolic blood pressure (SBP) less than 110. Clinical record review revealed a physician's orders [REDACTED]. Give 1 tablet by mouth in the morning for Hypertension Hold for SBP less than 110 and heart rate (HR) of less than 60. Record review of the EMAR from 7/19/2019-10/31/2019 failed to reveal evidence of blood pressures being taken prior to medication administration on the following dates: 7/26, 7/27, 7/28, 7/29, 7/30, 7/31, 8/10, 8/11, 8/16, 8/17, 8/18, 8/23, 8/24, 8/25, 8/26, 9/18, 9/19, 9/20, 9/21, 9/22, 9/23, 9/25, 9/26, 9/27, 9/28, 9/29, 9/30, 10/16, 10/18, 10/19, 10/20, 10/21, 10/24, 10/25, 10/26, 10/27, 10/28 and 10/29/2019. During surveyor interview on 11/01/2019 at 2:14 PM with the Director of Nursing, she was unable to provide evidence that the blood pressures were taken prior to administering the above medications. | 2020-09-01 |
| 14 | 14 | GREENWOOD CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2019-11-26 | 635 | D | 0 | 1 | FCLN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to obtain complete admission orders [REDACTED]. Findings are as follows: Review of the facility policy entitled Skin Integrity Management revealed in part Practice Standards as follows; .3. Identify patient skin integrity status and need for prevention or treatment modalities . 7. Notify Physician/APP to obtain orders . Record review revealed Resident ID #43 was admitted on (MONTH) 27, 2019 with admitting [DIAGNOSES REDACTED]. Record review for Resident ID #43 revealed a continuity of care form dated 09/27/2019 which documented a stage II pressure sore on the coccyx, with a white wound bed, pink peri-wound and a scant amount of brown drainage. A left heel wound was determined to be unstageable. An additional wound was assessed as a black necrotic area on tip of toe. The record lacked evidence of physician orders for wound care for all areas until 09/30/2019. During a two-surveyor interview on 11/26/2019 at approximately 2:45 PM with the Director of Nurses, she was unable to provide evidence the orders for wound care were obtained from the primary care physican prior to 09/30/2019. | 2020-09-01 |
| 15 | 15 | GREENWOOD CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2019-11-26 | 812 | F | 0 | 1 | FCLN11 | Based on a two-surveyor observation and staff interview, it has been determined that the facility failed to store and prepare food in accordance with professional standards for food service safety relative to the ice machines in 2 of 2 kitchenettes. Findings are as follows: During a two-surveyor observation of the first floor kitchenette on 11/20/2019 at 2:52 PM and on 11/21/2019 at 9:47 AM, the ice machine did not have an air gap between the ice machine drain pipe and the floor drain. During a two-surveyor observation of the second floor kitchenette on 11/21/2019 at 9:50 AM, the ice machine did not have an air gap between the ice machine drain pipe and the floor drain. During a two-surveyor interview on 11/21/2019 at 9:55 AM with the Director of Food Service he observed and acknowledged there are no air gaps for the ice machines on both kitchenettes. | 2020-09-01 |
| 16 | 16 | GREENWOOD CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2019-11-26 | 880 | D | 0 | 1 | FCLN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a two-surveyor observations and staff interview, it has been determined that the facility failed to provide care to prevent the development of infection by performing hand hygiene procedures by staff involved in direct resident contact for 1 of 2 sample residents observed for wound care (Resident ID #43). Findings are as follows: Review of the facility's Wound Dressings Aseptic policy with a revision date of 11/01/2019 revealed in part, If gloves become contaminated, remove gloves, cleanse hands, and apply clean gloves . A two-surveyor observation of Resident ID #43's dressing change on 11/21/2019 starting at 10:33 AM by a unit nurse, Staff A, revealed the following: - Left stoma (an artificial opening that allows feces from the intestine to pass) was cleansed with normal saline, patted dry three times, gloves were removed and Staff A did not perform hand hygiene before applying clean gloves. - Left heel washed with normal saline twice, patted dry, Santyl wound ointment applied directly to wound bed with right fingertip, wearing the same gloves used to cleanse the wound, no hand hygiene performed after removing gloves and applying clean gloves. - Left top of great toe washed with normal saline, Iodosorb applied directly to wound with right fingertip, gloves removed with no hand hygiene performed prior to applying clean gloves. An addition one surveyor observation on 11/21/2019 at approximately 11:00 AM which was occured following the above wound treatments. The coccyx wound was cleansed with normal saline, Santyl wound ointment applied to wound bed, gloves removed with no hand hygiene performed prior to applying clean gloves. Staff A then applied [MEDICATION NAME] dressing, after she discardded the used supplies, Staff A removed her gloves and gown and walked back to the nurse's station and medication cart without performing hand hygiene. During an interview on 11/26/2019 at 11:25 AM, the two-surveyor informed the Director of Nurses … | 2020-09-01 |
| 17 | 17 | GREENWOOD CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2017-12-15 | 759 | D | 0 | 1 | 77YN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, staff interview and record review, it has been determined the facility has failed to ensure residents are free from a medication error rate of 5 percent or greater. Based on 26 opportunities, there were 2 errors involving 2 residents (ID#s 57 and 90) resulting in a 7.69 % medication error rate on 1 of 4 units observed during medication pass. These errors involved 1 employee. Findings are as follows: 1.) During surveyor observations of the morning medication pass on 12/12/2017 at 9:24 am with the unit nurse (Staff A), she administered [MEDICATION NAME] (Vitamin D) 1,000 units, 1 tablet to resident ID# 57. Record review for resident ID# 57 revealed a physician's orders [REDACTED]. 2.) Further surveyor observations of the morning medication pass on 12/12/2017, Staff A administered [MEDICATION NAME] (Vitamin B12) 1000 mcg to resident ID# 90. Record review for resident ID#90 revealed a physician's orders [REDACTED]. During an interview with Staff A on 12/12/2017 at approximately 12:00 pm, she was unable to provide an explanation as to why the medications were not administered as ordered by the physician. 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. | 2020-09-01 |
| 18 | 18 | SAINT ELIZABETH HOME EAST GREENWICH | 415010 | 1 SAINT ELIZABETH WAY | EAST GREENWICH | RI | 2818 | 2019-06-06 | 880 | D | 0 | 1 | 5TXS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interview, it has been determined the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents observed for wound care (Resident ID # 57). Findings are as follows: Record review of Resident #57 current physician's orders [REDACTED]. 1) Cleanse left heel with normal saline, apply [MEDICATION NAME] (a dressing used for wounds with drainage) to open area and cover with dry clean dressing every other day. 2) Cleanse left fourth toe with normal Saline, apply solosite (a wound dressing to create a moist wound environment) and gauze in between toes and secure at bedtime. Surveyor observation of dressing changes on 6/05/2019 at 10:47 AM with Nurse staff A, revealed the following; 1) Nurse staff A cleansed the left heel with normal saline and removed her gloves. She put on new gloves without performing hand hygiene and completed the wound dressing. She then removed her gloves. 2) Nurse staff A, without performing hand hygiene put on new gloves, washed the left toe wound with normal saline, and removed her gloves. She put on new gloves without performing hand hygiene and completed the wound dressing. During surveyor interview on 06/05/19 at 10:59 AM with Nurse staff A, she acknowledged that she did not perform hand hygiene with each glove change. | 2020-09-01 |
| 19 | 19 | SAINT ELIZABETH HOME EAST GREENWICH | 415010 | 1 SAINT ELIZABETH WAY | EAST GREENWICH | RI | 2818 | 2018-08-09 | 689 | D | 0 | 1 | GJE611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that the resident environment remains as free of accident hazards as is possible relative to 1 of 2 patios on the[NAME]unit. Findings are as follows: 1.) Resident ID #148 was admitted to the facility with a [DIAGNOSES REDACTED]. Surveyor observation of Resident ID #148 on 8/9/2018 at 12:16 PM revealed the resident walking inside with his/her walker from the outdoor patio (high room number side). The resident's walker became stuck on the rug as he/she was coming through the door and the resident had to lift the walker over the raised rug. Further observation by the surveyor at the above time revealed that the right corner of the rug in-between the doors (when coming inside from the patio) was frayed into a clump of string on top of the floor (~6 to 8 inches). Additionally, the rug was slightly raised across the length of the doorway. During a surveyor observation on 8/9/2018 at approximately 1:00 PM, in the presence of the Maintenance Director and the Unit Manager, Resident ID #148 proceeded to walk out to the patio with his/her walker, commenting on the condition of the rug. The Director of Maintenance and the Unit Manager acknowledged that the rug needed to be fixed. | 2020-09-01 |
| 20 | 20 | SAINT ELIZABETH HOME EAST GREENWICH | 415010 | 1 SAINT ELIZABETH WAY | EAST GREENWICH | RI | 2818 | 2018-08-09 | 692 | G | 0 | 1 | GJE611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to address the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition for 1 of 2 sample residents with significant weight loss (ID #135). Findings are as follows: The facility's policy titled Recording Dietary Intake states in part dietary intake will be recorded and monitored under the following circumstances for a two week period: loss of three lbs. (pounds) if weight is under 100 lbs. or five lbs. if weight is over 100 lbs. and weight loss was not intended Keep a clip board in the Dining Room with sheets to record intake percentage during this time. All interventions put on Care Plan. Record review revealed resident ID #135 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's record revealed a weight of 106.4 lbs. (pounds) on 6/5/2018, a weight of 98.6 lbs. on 7/26/2018. This indicates a 7.33% significant weight loss in 52 days. On 8/8/2018 an additional weight was recorded as 94.0 lbs. Record review revealed a significant change Minimum Data Set ((MDS) dated [DATE] that indicates that the resident had a weight loss of 5% or greater in the last month or 10% or greater in the last 6 months. Further record review revealed a care plan stating, Monitor intake and record. Record review revealed no evidence that the resident's intake was monitored and recorded per the care plan or facility policy. Review of the dietary progress notes on 7/16/2018 states Offer alternatives and shakes as needed for increased intake. Further record review failed to reveal evidence that shakes were ever ordered per the dietitian's recommendation. Record review revealed an additional dietary note on 7/26/2018 indicating that a weight was obtained on 7/25 and dietitian will continue to follow. There was no evidence of any interventions put into place on 7/26/2018, after … | 2020-09-01 |
| 21 | 21 | SAINT ELIZABETH HOME EAST GREENWICH | 415010 | 1 SAINT ELIZABETH WAY | EAST GREENWICH | RI | 2818 | 2018-08-09 | 758 | E | 0 | 1 | GJE611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined the facility failed to ensure a resident's drug regimen is free from unnecessary [MEDICAL CONDITION] drugs for 1 of 3 sampled residents (ID#13) who received as needed [MEDICAL CONDITION] medication orders extended beyond 14 days without a physician or prescribing practitioner's intended duration for the order. Findings are as follows: Record review for Resident ID #13 revealed a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED] - 6/4/2018, 9:59 PM - 6/20/2018, 10:17 AM - 6/24/2018, 10:27 PM - 6/25/2018, 8:13 PM - 6/28/2018, 10:29 PM - 7/2/2018, 9:10 PM - 7/4/2018, 7:06 PM - 7/5/2018, 7:29 PM - 7/7/2018, 9:13 PM - 7/9/2018, 6:17 PM - 7/19/2018, 9:13 PM - 8/3/2018, 3:12 PM Review of a pharmacy consultation report dated 11/24/2017 revealed that Resident ID#13 has an as needed order for an anxiolytic which has been in place for greater than 14 days without a stop date: [MEDICATION NAME]. The pharmacy recommendation states, If the medication cannot be discontinued at this time, current regulations require that the prescriber document the intended duration of therapy, and the rationale for the extended time period. The report is signed and dated by a prescribing practitioner on 12/11/2017. Additionally, handwriting on the bottom states, Pt (patient) is on Hospice-will not change any meds. During a surveyor interview with The Cove Unit Manager on 8/09/2018 at 2:52 PM, she was unable to provide evidence of the intended duration for the [MEDICATION NAME] order. | 2020-09-01 |
| 22 | 22 | SAINT ELIZABETH HOME EAST GREENWICH | 415010 | 1 SAINT ELIZABETH WAY | EAST GREENWICH | RI | 2818 | 2018-08-09 | 805 | D | 0 | 1 | GJE611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide food prepared in a form designed to meet individual needs for 1 of 8 sample residents reviewed for nutrition, ID #155. Findings are as follows: Record review revealed that the resident moved into the facility on [DATE] with [DIAGNOSES REDACTED]. Further record review revealed a current physician's orders [REDACTED]. Surveyor observations on the following dates and times revealed the resident's food not being cut up: 8/6/2018 at 12:49 PM 8/7/2018 at 12:15 PM 8/8/2018 at 12:30 PM Surveyor interview on 8/9/2018 at 1:00 PM with Staff Nurse B indicated the person that served the resident is responsible for cutting up the meal. Staff Nurse B acknowledged the meal was not cut up as ordered. | 2020-09-01 |
| 23 | 23 | SAINT ELIZABETH HOME EAST GREENWICH | 415010 | 1 SAINT ELIZABETH WAY | EAST GREENWICH | RI | 2818 | 2018-08-09 | 812 | F | 0 | 1 | GJE611 | Based on surveyor observations and staff interview, it has been determined that the facility failed to properly store, distribute, and serve food under sanitary conditions relative to the main kitchen, 2 of 3-unit kitchenettes in the main building and 3 of 4 kitchens in the Greenhouse Cottages. Findings are as follows: 1) During the initial tour of the kitchen on 8/06/2018 at 9:30 AM, the following items were observed by two surveyors: - The ice machine had small green and black colored matter going along the length of the white plastic material inside the machine, above where the ice is dispensed. At the time of the above observations the Food Services Director and Staff E, acknowledged that the ice machine needed to be cleaned. They could not provide evidence of a cleaning schedule for the ice machine. Surveyor observations on 8/7/2018 at 8:08 AM of the Cove Kitchenette in the main building revealed the following: - 1 package of hot dog rolls that had a green/black mold substance in the bag with an expiration date of 6/12/2018 - Interior ceiling, door and glass plate of the microwave oven had a heavy accumulation of food debris. During a surveyor interview on 08/07/2018 at 8:18 AM with Staff D, she acknowledged that the above item should have been discarded and the microwave needed to be cleaned. Surveyor observation on 8/7/2018 at 9:04 AM of the Bay Kitchenette in the main building revealed the following: - Freezer with heavy accumulation of frost on the interior of the drawer. The bottom of the freezer with heavy accumulation of black matter that could be wiped with fingers. Surveyor observation on 8/7/2018 at 10:15 AM of Greenhouse #17 with two surveyors revealed the following: - Staff F and G were not wearing hair nets while preparing food in the kitchen - Knife and utensil drawer with heavy accumulation of crumbs and food debris - Air conditioner vent above the kitchen island where food is prepared with heavy accumulation of dust The following items were found in the back of the refrigerator/freezer: - Bag… | 2020-09-01 |
| 24 | 24 | BRIARCLIFFE MANOR | 415012 | 49 OLD POCASSET ROAD | JOHNSTON | RI | 2919 | 2018-02-23 | 658 | E | 0 | 1 | ZK5E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interviews, the facility failed to meet professional standard of quality for 1 out of 5 residents observed during the medication pass (ID# 93). According to Basic Nursing, Mosby, 3rd, the registered nurse checks all transcribed orders against the original order for accuracy and thoroughness. If an order seems incorrect or inappropriate, the nurse consults the physician . Findings are as followed: Surveyor observation on 2/21/18 at approximately 8:15 AM, during the medication pass on Unit 2, revealed an order on the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The Medication Aide (MA) was then observed administering a [MEDICATION NAME] 100 mg extended release capsule and a 50 mg chewable tablet to ID# 93. During surveyor interview on 2/22/18 at 12:05 PM, the resident's physician revealed he was aware that [MEDICATION NAME] 150 mg did not come in an extended release form. The physician acknowledged that his expectation would be to have the order clarified with him and re-written to reflect the dosage/form of the medication on hand. | 2020-09-01 |
| 25 | 25 | BRIARCLIFFE MANOR | 415012 | 49 OLD POCASSET ROAD | JOHNSTON | RI | 2919 | 2018-02-23 | 756 | E | 0 | 1 | ZK5E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interviews, the pharmacy failed to report any irregularities to the attending physician, the facility's medical director, and the director of nursing for 1 non- sample resident observed during the medication pass (ID# 93). Findings are as follows: Record review of resident ID# 93's (MONTH) (YEAR) MAR indicated [REDACTED]. Surveyor observation on 2/21/18 at approximately 8:15 AM, during the medication pass on Unit 2, revealed an order on the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The Medication Aide (MA) was then observed administering a [MEDICATION NAME] 100 mg extended release capsule and a 50 mg chewable tablet to ID# 93. Surveyor record review of the pharmacy reports with the Registered Pharmacist (RPH) on 2/22/2018 at approximately 9:55 AM revealed that the pharmacy had failed to document the irregularity on a separate written report that is sent to the resident's physician, medical director and director of nursing. The report includes at a minimum the resident's name, drug and the irregularity identified by the pharmacist. In addition, the pharmacist stated the computer software system in place between the pharmacy and the facility did not highlight this irregularity and indicated this was a pharmacy system breakdown. 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. | 2020-09-01 |
| 26 | 26 | BRIARCLIFFE MANOR | 415012 | 49 OLD POCASSET ROAD | JOHNSTON | RI | 2919 | 2019-12-27 | 710 | E | 1 | 1 | IFE111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it has been determined that the facility failed to ensure the medical care of each resident is supervised by a physician for 1 of 5 sampled resident (ID #1) relative to diabetic monitoring. Findings are as follows: Closed record review for Resident ID #1 revealed a [DIAGNOSES REDACTED]. Record review revealed a drug regimen review dated 8/22/2019 with the pharmacist recommendation to monitor an A1C (bloodwork that tests your average blood glucose levels over the past 3 months) on the next convenient lab day and every 6 months if meeting treatment goals, or every 3 months if therapy has changed or goals are not being met. An A1C level was obtained on 8/26/2019 with results of 5.6 (less than 5.7 decreased risk for diabetes and greater than 6.4 is consistent with diabetes, according to the results range from the laboratory used by the facility). There was no evidence of a subsequent order for an A1C level. Record review revealed a drug regimen review dated 9/26/2019 with the pharmacist recommendation to discontinue Glimepiride (medication that manages blood sugar levels), if appropriate. Glucose monitoring should continue following any change in diabetic therapy. A telephone order dated 9/26/2019 was given to D/C (discontinue) glimepiride 2 mg daily, obtain blood sugar via fingerstick twice daily x 7 days, (1 week), to start 9/27/2019, and then D/C. Record review revealed blood sugars via fingerstick were obtained from 9/27/2019-10/3/2019 with results ranging from 68-223mg/dl (normal range for blood glucose levels according to the laboratory used by the facility is 70-99 mg/dl). There was no evidence that the resident's blood sugar results were reviewed by the physician. Further review of the resident's medical record revealed [REDACTED]. The result of the blood sugar reading was documented as Hi. The on-call provider was contacted by the nurse regarding the resident's assessment and subsequent order… | 2020-09-01 |
| 27 | 27 | BRIARCLIFFE MANOR | 415012 | 49 OLD POCASSET ROAD | JOHNSTON | RI | 2919 | 2019-12-27 | 759 | D | 1 | 1 | IFE111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each resident's medication regimen is free of medication error rates of 5% or greater. Based on 30 opportunities for error, there were two errors involving two residents (ID #s 77 and 58) resulting in an error rate of 6.67%. Findings are as follows: 1. Record review revealed Resident ID #77 has a physician's orders [REDACTED]. Instructions on the card from the pharmacy indicate not to crush the medication. During the medication administration task on 12/19/2019 at 8:41 AM, Medication Technician, Staff A, was observed preparing Resident ID #77's medications, including the [MEDICATION NAME] ER, which she crushed and put into applesauce. The surveyor intervened prior to the administration of the medication when Staff A revealed that she was ready to administer the medication. During a surveyor interview with Staff A on 12/19/2019 at 8:48 AM, she acknowledged that she crushed the [MEDICATION NAME] ER and that the pharmacy instruction states that the medication should not be crushed. 2. Record review revealed Resident ID #58 has a physician's orders [REDACTED]. Instructions on the card from the pharmacy indicate not to crush the medication. During the medication administration task on 12/19/2019 at 9:08 AM, Medication Technician, Staff B, was observed preparing Resident ID #58's medications, including the [MEDICATION NAME] ER, which she crushed and put into applesauce. The surveyor intervened prior to the administration of the medication when Staff B revealed that she was ready to administer the medication. During a surveyor interview with Staff B on 12/19/2019 at 9:13 AM, she acknowledged that she crushed the [MEDICATION NAME] ER and that the pharmacy instruction states that the medication should not be crushed. On 12/19/2019 at 10:22 AM, the Director of Nursing Services was notified of the medication errors and reve… | 2020-09-01 |
| 28 | 28 | GRACE BARKER NURSING CENTER | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2020-01-02 | 609 | D | 1 | 0 | Q0QB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse, are reported immediately, but not later than 2 hours after the allegation is made, for 1 of 4 residents reviewed for abuse. (ID #1). Finding are as follows: Review of the facility policy titled Abuse Prohibition states in part: D. Identification and Reporting .Any instance of actual or suspected abuse .must be reported timely to the DNS (Director of Nursing) / designee .supervisor on duty and an incident report is to be filled out. The Department of Health .will be contacted of allegations of abuse .within 2 hours of the allegation if the events that led to the allegation involve abuse . Record review revealed Resident ID #1 was admitted to the facility in (MONTH) of (YEAR). [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set Assessment was completed on 11/01/2019. This assessment revealed a Brief Interview for Mental Status score of 15 out of 15 indicating that the resident is cognitively intact. Further record review revealed a nursing note dated 12/14/2019 stating 6:30 am resident told med tech that CNA (certified nursing assistant)/ med tech (name) almost raped me . An interview was conducted with Staff A, on 01/02/2020 at approximately 2:20 PM, she was also the supervisor on duty at the time of the allegation. She was unable to provide evidence that this incident was reported to the state agency. An interview was conducted on 01/02/2020 at approximately 3:20 PM with the Director of Nursing. She stated that she would expect that an allegation of abuse be reported to the state agency immediately. | 2020-09-01 |
| 29 | 29 | GRACE BARKER NURSING CENTER | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2020-02-27 | 658 | D | 1 | 1 | 5Z7X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review and Staff interview, it has been determined that the facility failed to provide services that meet accepted standards of professional practice relative to physician orders [REDACTED].#s 22, 36, 53). Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, states in part that, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders [REDACTED]. 1.Review of Resident ID # 22's medical record revealed that s/he had an order dated 2/17/2020 which reads; No shoes or TEDS due to condition of Right Great Toe. Multiple observations of resident ID #22 on 2/26/2020 and 2/27/2020 revealed that s/he had both TEDS (stockings use to stop blood clot) stockings and shoes on. During an interview on 2/27/2020 at 1:35 PM with Certified Nursing Assistant, Staff A, revealed she was not aware of the above order. 2. Review of Resident ID #53's bowel movement (BM) log revealed that the resident had not had a BM since 2/22/2020. Further review of the Medication Administration Record (MAR) revealed the following orders for bowel regimen dated 12/19/2019. - Prune Juice 90 Milliliter (ML) by mouth if no BM in 2 days as needed. - Milk of Magnesia (medication use to treat constipation) 400 Milligram (MG)/5 ML once a day PRN (as needed): administered on day 2 if no BM. - [MEDICATION NAME] 10 MG (medication use to treat constipation) suppository once a day as PRN: Give for constipation on day 3 on 11-7. - Fleet Enema (Sodium [MEDICATION NAME]) 19-7gram/118ML once a day PRN (medication used to treat constipation): day 3 after 10-12 shifts since last BM. Record review revealed the resident did not receive any of the above bowel medications until it was brought to the facility attention by the surveyor on 2/27/2020. During a surveyor interview and review of the MAR and BM output on 2/27/2020 at 8:58 AM with Registered Nurse, Staff C, she could not provide evidence… | 2020-09-01 |
| 30 | 30 | GRACE BARKER NURSING CENTER | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2020-02-27 | 689 | E | 1 | 1 | 5Z7X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on water temperature readings, staff and resident interviews, it has been determined the facility failed to ensure the residents' environment remains free from accident hazards related to water temperatures above 120-degree Fahrenheit (F), in areas used by residents on 2 of 3 units (Moniz and North). Findings are as follows: The surveyors obtained water temperatures on all units on 2/24/2020. The following temperatures were obtained on Moniz Unit and North Unit using a digital thermometer. North Unit: -10:00 AM, room [ROOM NUMBER], bathroom sink measured at 121.6 F -10:18 AM, room [ROOM NUMBER], bathroom sink measured at 124.4 F -11:45 AM, sink in shower room measured at 129.7 F and shower stall measured at 122.4 F Moniz Unit: -11:56 AM, room [ROOM NUMBER], bathroom sink measured at 124.2 F -12:03 PM, room [ROOM NUMBER], bathroom sink measured at 126.9 F Record review of the facility weekly water temperature log on 2/24/2020 at approximately 2:15 PM revealed the water temperature ranging from 99-111 F. During an interview with the Maintenance Director on 2/24/2020 at approximately 2:30 PM, he revealed he checks the water temperature once a week at different locations and times. He further revealed that he does not calibrate the thermometer. At this time the survyors and Maintenance Director thermometers were calibrated, water temperatures were retaken and continue to remain high. Surveyor interviews conducted on 2/24/2020 with residents residing in rooms with high water temperatures, revealed the following: -11:54 AM, Resident ID #52 revealed s/he uses the bathroom daily and shower room on Moniz Unit. During a surveyor interview with the Director of Nursing Services on 2/24/2020 at approximately 1:37 PM, she revealed that she was not aware of the elevated water temperatures. | 2020-09-01 |
| 31 | 31 | GRACE BARKER NURSING CENTER | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2020-02-27 | 692 | D | 1 | 1 | 5Z7X11 | > Based on surveyor observation, staff interview and record review it has been determined that the facility failed to ensure that residents received necessary care to maintain acceptable parameters of nutritional status relative to body weight, unless the resident's clinical condition demonstrates that this is not possible, for 1 of 6 residents who require assistance with eating (ID #12). Findings are as follows: Record review for ID #12 revealed that s/he requires assistance with eating. The resident has a 2/20/2020 physicians order for 1-1 supervision for all meals due to difficulty feeding him/her-self and previous weight loss. Surveyor observed the resident on 2/24/2020 at 1:06 PM in bed in his/her room. The lunch meal tray had been delivered and placed on the bedside table and the resident was attempting to reach the food without success. The surveyor continued observation for approximately 45 minutes. No staff entered the room to check on the resident or to provide assistance. When staff removed the tray from the resident's room at approximately 1:52 PM, the food remained untouched. The surveyor observed the resident again on 2/26/2020 at 7:35 AM. The breakfast meal tray had been delivered and placed on the resident's bedside table. There was no staff present. The resident was attempting to eat scrambled eggs with his/her hands while in bed. At approximately 7:40 AM, staff entered the room and asked the resident how s/he was doing and then left the room at approximately 7:41 AM. The surveyor continue observation from 7:35 AM until 8:30 AM with no staff observed assisting the resident. Additional surveyor review of the resident's clinical record revealed that the Speech Language Pathologist (SLP) conducted a screen (a brief visual evaluation) on 2/19/2020, as requested by nursing. The SLP recommended a full speech therapy evaluation due to the resident's prior weight loss and cognitive decline. A care plan for: Imbalanced Nutrition: weight loss related to insufficient dietary intake was created on 2/20/2020.… | 2020-09-01 |
| 32 | 32 | GRACE BARKER NURSING CENTER | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2019-03-07 | 636 | B | 1 | 1 | Inf | > Based on clinical record reviews and staff interview, it has been determined that the facility failed to conduct a comprehensive assessment using the resident assessment instrument (RAI), for 5 of 19 residents reviewed for resident assessments (ID #s 10, 19, 20, 22, and 42). The comprehensive assessment must be completed within 14 calendar days after admission and not less than once every 12 months. Findings are as follows: 1. Record review for Resident ID #10 revealed an annual comprehensive assessment with a required completion date of 2/1/2019. Further review revealed, that as of 3/7/2019, the comprehensive assessment was not completed and was 34 days overdue. 2. Record review for Resident ID #19 revealed an annual comprehensive assessment with a required completion date of 1/30/2019. Further review revealed, that as of 3/7/2019, the comprehensive assessment was not completed and was 36 days overdue. 3. Record review for Resident ID #20 revealed an annual comprehensive assessment with a required completion date of 2/1/2019. Further review revealed, that as of 3/7/2019, the comprehensive assessment was not completed and was 34 days overdue. 4. Record review for Resident ID #22 revealed an annual comprehensive assessment with a required completion date of 2/1/2019. Further review revealed, that as of 3/7/2019, the comprehensive assessment was not completed and was 34 days overdue. 5. Record review for Resident ID #22 revealed an annual comprehensive assessment with a required completion date of 1/25/2019. Further review revealed, that as of 3/7/2019, the comprehensive assessment was not completed and was 41 days overdue. During a surveyor interview with the Minimum Data Set nurse, Staff A, on 3/7/2019 at 10:47 AM, she acknowledged that the comprehensive assessments were not completed on time. | 2020-09-01 |
| 33 | 33 | GRACE BARKER NURSING CENTER | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2019-03-07 | 637 | B | 1 | 1 | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it has been determined that the facility failed to complete a Significant Change in Status Assessment within 14 days after there has been a significant change in the resident's physical or mental condition for 2 of 3 sample residents who were admitted or discharged from Hospice services (ID#s 29 and 31). Findings are as follows: 1. Record review revealed that Resident ID #29 was admitted to the facility on [DATE]. The resident was admitted to Hospice services on 8/23/2018. Further record review revealed that a Significant Change in Status Assessment was not completed when the resident was admitted to Hospice services. 2. Record review revealed that Resident ID #31 was admitted to the facility on [DATE]. The resident was discharged from Hospice services on 1/11/2019. Further record review revealed that a Significant Change in Status Assessment was not completed when the resident was discharged from Hospice services. During a surveyor interview with the Minimum Data Set nurse, Staff A, on 3/7/2019 at 10:47 AM, she could not provide evidence that a Significant Change in Status Assessment was completed for either resident when they had a change in Hospice services. | 2020-09-01 |
| 34 | 34 | GRACE BARKER NURSING CENTER | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2019-03-07 | 638 | B | 1 | 1 | Inf | > Based on clinical record reviews and staff interview, it has been determined that the facility failed to assess residents using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for 9 out of 19 residents reviewed for resident assessments (ID #s 1, 4, 5, 7, 8, 11, 12, 13, and 14). Findings are as follows: 1. Record review for Resident ID #1 revealed a quarterly review assessment with a required completion date of 1/10/2019. Further review revealed, that as of 3/7/2019, the resident assessment was not completed and was 56 days overdue. 2. Record review for Resident ID #4 revealed a quarterly review assessment with a required completion date of 1/25/2019. Further review revealed, that as of 3/7/2019, the resident assessment was not completed and was 41 days overdue. 3. Record review for Resident ID #5 revealed a quarterly review assessment with a required completion date of 1/25/2019. Further review revealed, that as of 3/7/2019, the resident assessment was not completed and was 41 days overdue. 4. Record review for Resident ID #7 revealed a quarterly review assessment with a required completion date of 1/25/2019. Further review revealed, that as of 3/7/2019, the resident assessment was not completed and was 41 days overdue. 5. Record review for Resident ID #8 revealed a quarterly review assessment with a required completion date of 2/1/2019. Further review revealed, that as of 3/7/2019, the resident assessment was not completed and was 34 days overdue. 6. Record review for Resident ID #11 revealed a quarterly review assessment with a required completion date of 1/25/2019. Further review revealed, that as of 3/7/2019, the resident assessment was not completed and was 41 days overdue. 7. Record review for Resident ID #12 revealed a quarterly review assessment with a required completion date of 2/1/2019. Further review revealed, that as of 3/7/2019, the resident assessment was not completed and was 33 days overdue. 8. Record review for Resident ID… | 2020-09-01 |
| 35 | 35 | GRACE BARKER NURSING CENTER | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2019-03-07 | 695 | D | 1 | 1 | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 5 residents reviewed for oxygen therapy (ID #63). Findings are as follows: Surveyor observations on 3/3/2019 at 12:22 PM, 3/6/2019 at 7:30 AM, and 3/7/2019 at 10:24 AM revealed Resident ID #63 using oxygen via nasal cannula at 2 liters per minute. Review of the clinical record revealed this resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. There lacked evidence of the attending practitioner's order for oxygen therapy. During a surveyor interview with the Director of Nursing Services on 3/7/2019 at 12:23 PM, she revealed that the resident should have a practitioner's order for the oxygen. | 2020-09-01 |
| 36 | 36 | GRACE BARKER NURSING CENTER | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2019-03-07 | 791 | D | 1 | 1 | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review and staff interview, it was determined that the facility has failed to assist residents in obtaining routine dental services for 1 of 3 residents reviewed for dental (ID #59). Findings are as follows: Surveyor observation on 3/4/2019 at 1:38 PM revealed that Resident ID #59 has his/her own natural teeth. Review of the clinical record revealed this resident was admitted to the facility on [DATE]. Further review revealed a 9/8/2018 annual Minimum Data Set assessment stating that the resident has obvious or likely cavity or broken natural teeth. There lacked evidence that the resident had obtained routine dental services. During a surveyor interview with the Charge Nurse on 3/7/2019 at 9:14 AM, she was unable to provide evidence that the resident or responsible party declined routine dental services. During a subsequent interview with Resident ID #59's responsible party on 3/7/2019 at 10:56 AM she revealed that she would like the resident to be seen by a dentist. | 2020-09-01 |
| 37 | 37 | GRACE BARKER NURSING CENTER | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2018-03-30 | 761 | E | 1 | 1 | N83B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observations and staff interview, it has been determined that the facility failed to ensure that medication bottles were dated when opened for 6 of 9 [MEDICATION NAME] Concentrate. Findings are as follows: Surveyor observation of the refrigerator in the medication room, on 3/28/2018 at 10:51 AM, noted nine bottles of open [MEDICATION NAME] Liquid, 6 were undated when opened. Manufacturer's instructions written on the box state, discard opened bottle after 90 days. During an interview immediately after the above observation with the Unit Manager, she was unable to explain why the [MEDICATION NAME] Concentrate were open and not dated. 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. | 2020-09-01 |
| 38 | 38 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2020-02-12 | 689 | G | 1 | 0 | T0R811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review, and staff interview, it is determined the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 residents reviewed (ID #1). Findings are as follows: Resident ID #1 was originally admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Of note is that the resident's medical regimen included the administration of [MEDICATION NAME] (a blood thinner) due to the [DIAGNOSES REDACTED]. The resident's functional ability was assessed as requiring extensive or total assistance for all activities of daily living and personal hygiene. A review of the resident's clinical record revealed she/he sustained a witnessed fall out of bed on 12/26/2019 at 7:35 AM. The resident was attended by a certified nurse assistant (Staff A), who had rolled the resident onto his/her side to provide incontinence care. Staff A supported the resident's position with her hand on the resident's back and reached for a clean brief. She then observed the resident rolling off the edge of the bed and landing on both knees. The resident's knees and head hit the bedside table and the resident's left elbow went into the wastebasket. Staff A called out for help and was assisted by a nurse (Staff B) to remove the resident's elbow from the wastebasket and to roll him/her onto his/her back. Emergency service (911) was called and the resident was transported to a hospital emergency room (ER) for assessment. In the ER, the resident was examined for a possible head injury and pain of the left leg. An x-ray of his/her left knee was obtained and revealed a minimally displaced, closed [MEDICAL CONDITION] femur of the left leg. The x-ray also revealed a prior total knee replacement, which remained in alignment. A CT scan was then obtained, which showed the fracture, the total knee hardware, and a complex appearing mass in the back of the knee described as most likely… | 2020-09-01 |
| 39 | 39 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2020-02-12 | 700 | D | 1 | 0 | T0R812 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to assess the resident for risk of entrapment from bed rails prior to installation for 1 of 3 residents reviewed for use of bed rails (ID #3). Findings are as follows: Record review for Resident ID #3 revealed an admitted [DATE]. [DIAGNOSES REDACTED]. Review of a comprehensive Minimum Data Set ((MDS) dated [DATE] revealed the resident has moderately impaired cognition and requires extensive assist of two or more persons for bed mobility. Record review lacked evidence that a siderail evaluation was completed since admission. Review of the Individualized Resident Assignment Card (Kardex) revealed the section titled, Siderails, is blank. A surveyor observation on 3/10/2020 at 12:15 PM, revealed two siderails on the resident's bed. During an interview on 3/10/2020 at 2:10 PM with the Director of Nursing Services, she acknowledged that the resident has side rails on her bed, was unable to explain why the resident was not assessed prior to siderail installation, or why the Kardex was blank. | 2020-09-01 |
| 40 | 40 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2019-10-04 | 567 | B | 1 | 1 | II8Y11 | > Based on record review and staff interview, it has been determined that the facility failed to obtain written authorization for residents whom the facility is holding personal funds relative to 3 of 7 residents reviewed (ID#s 4, 5, and 28). Findings are as follows: Review of the facility's records related to personal needs funds on 10/3/2019 at 9:00 AM revealed the facility was holding funds for Resident ID#s 4, 5, and 28. 1. Record review for Resident ID #4 revealed a Trust Statement with an ending balance of $125.17 on 9/20/2019. A Resident Personal Needs Authorization form dated 3/8/2017 revealed that the resident did not authorize the facility to hold their funds. 2. Record review for Resident ID #5 revealed a Trust Statement with an ending balance of $40.24 on 8/31/2019. A Resident Personal Needs Authorization form dated 6/27/2018 indicated that the resident declined to deposit personal funds with the facility. 3. Record review for Resident ID #28 revealed a Trust Statement with an ending balance of $1,164.68 on 9/20/2019. A Resident Personal Needs Authorization form dated 1/24/2016 revealed that the resident did not authorize the facility to hold their funds. During a surveyor interview with the Business Office Manager on 10/3/2019 at approximately 9:30 AM, she could not provide evidence that the Resident Personal Needs Authorization forms were accurately completed. | 2020-09-01 |
| 41 | 41 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2019-10-04 | 570 | B | 1 | 1 | II8Y11 | > Based on record review and staff interview, it has been determined that the facility failed to assure the security of all personal funds of residents deposited within the facility relative to purchasing a surety bond which adequately protects resident funds against loss. Findings are as follows: Record review revealed the facility had a surety bond for $15,000.00 effective 12/21/2018 to 12/21/2019. Further record review of the Resident Trust Fund bank statements revealed: -Account balance on (MONTH) 31, 2019 was $20,534.65 -Account balance on (MONTH) 30, 2019 was $17,614.09. During a surveyor interview with the Business Office Manager on 10/3/2019 at 9:05 AM, she could not provide evidence that the current surety bond covered the resident's funds deposited in the facility for (MONTH) and (MONTH) 2019. | 2020-09-01 |
| 42 | 42 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2019-10-04 | 658 | E | 1 | 1 | II8Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it has been determined that the facility failed to provide services that meet professional standards of quality relative to physician's orders [REDACTED].#s 7, 17, and 19) reviewed for weight orders and 1 of 2 residents reviewed for blood sugar monitoring (ID #19). Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders [REDACTED]. 1. Record review for Resident ID #7 revealed a current physician's orders [REDACTED]. Review of the record from 9/1/2019 to 9/30/2019 revealed that the resident was not weighed on 2 of 13 opportunities (9/13/2019 and 9/23/2019) as ordered by the physician. 2. Record review for Resident ID #17 revealed a current physician's orders [REDACTED]. Review of the record from 7/1/2019 to 9/30/2019 revealed the following: -7/1/2019 to 7/31/2019, the resident was not weighed on 4 of 14 opportunities (7/3/2019, 7/17/2019, 7/19/2019, and 7/22/2019) -8/1/2019 to 8/31/2019, the resident was not weighed on 4 of 13 opportunities (8/5/2019, 8/12/2019, 8/14/2019, and 8/19/2019) -9/1/2019 to 9/30/2019, the resident was not weighed on 3 of 13 opportunities (9/4/2019, 9/13/2019, and 9/30/2019) 3. Record review for Resident ID #19 revealed a 5/16/2019 physician's orders [REDACTED]. Review of the record from 9/1/2019 to 10/4/2019 revealed that the resident was not weighed on 3 of 5 opportunities (9/8/2019, 9/15/2019, and 9/22/2019) as ordered by the physician. 4. Additional record review for Resident ID #19 revealed a 3/27/2019 physician's orders [REDACTED]. Review of the record from 9/1/2019 to 10/4/2019 revealed that the resident's blood sugar was not monitored on 2 of 5 opportunities (9/11/2019 and 9/18/2019) as ordered by the physician. During surveyor interviews with the Director of Nursing Services on 10/4/2019 at 8:30 AM, 10:30 AM, and 11:30 AM,… | 2020-09-01 |
| 43 | 43 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2019-10-04 | 677 | E | 1 | 1 | II8Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, resident interview, and staff interview, it has been determined that the facility failed to provide the necessary services to maintain good personal hygiene, for residents who are unable to carry out activities of daily living, relative to showers for 5 of 15 residents who participated in the Resident Council meeting (ID#s 4, 7, 13, 25, and 32). Findings are as follows: During the Resident Council meeting with the surveyor on 10/2/2019 at approximately 1:30 PM, ID#s 4, 7, 13, 25, and 32 revealed that they do not get showers regularly. Furthermore, they indicated that they are supposed to receive a shower weekly; however, they sometimes need to wait two to three weeks. Review of the Resident Council Meeting minutes from (MONTH) 29, 2019 and (MONTH) 19, 2019 revealed the following: - July: Residents are concerned they are not being cared for properly. They are not getting showered regularly - August: Residents are concerned they are not getting their scheduled showers During a surveyor interview with the Activities Director on 10/4/2019 at 1:02 PM, she revealed that residents have been complaining for months about not getting showers regularly. Review of the residents' records revealed the following: 1. Record review revealed that Resident ID #4 was admitted to the facility on [DATE]. The resident's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident has a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating that they are cognitively intact. Further review revealed that the resident requires physical help of one person for bathing. The resident's annual MDS, dated [DATE], revealed that it is very important to him/her to choose between a tub bath, shower, bed bath or sponge bath. Review of the care plan, initiated on 10/6/2016, revealed that s/he prefers a shower over a bath. Review of the Nursing Assistant's documentation related to shower/baths from 9/3/2019 to 10/3/2019 reveale… | 2020-09-01 |
| 44 | 44 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2019-10-04 | 725 | E | 1 | 1 | II8Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, resident interview, and staff interview, it has been determined that the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care related to 5 of 5 residents (ID#s 4, 7, 13, 25, 32) reviewed for showers, 3 of 4 residents (ID#s 7, 17, and 19) reviewed for weights, and 4 of 4 substantiated complaints involving staffing. Findings are as follows: During the Resident Council meeting with the surveyor on 10/2/2019 at approximately 1:30 PM, ID#s 4, 7, 13, 25, and 32 revealed concerns relative to staffing. Furthermore, they indicated that they are supposed to receive a shower weekly; however, they sometimes need to wait two to three weeks. Review of the Resident Council Meeting minutes from (MONTH) 24, 2019, (MONTH) 29, 2019 and (MONTH) 19, 2019 revealed the following: - June: .Residents are concerned that there is only one to two CNAs (Certified Nursing Assistants) on evening/night time shifts and only one nurse, as this is not safe staffing for the amount of residents per care taker . - July: .Residents are concerned about the staffing .Residents are concerned they are not being cared for properly. They are not getting showered regularly . - August: .Residents are concerned they are not getting their scheduled showers . During a surveyor interview with the Activities Director on 10/4/2019 at 1:02 PM, she revealed that residents have been complaining for months about not getting showers regularly. The Administration will address the residents about the concerns and tell them they are doing the best they can. Review of the residents' records revealed the following: 1. Resident ID #4 was admitted to the facility on [DATE]. The resident's quarterly Minimum Data Set (MDS), dated [DATE], revealed the reside… | 2020-09-01 |
| 45 | 45 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2019-10-04 | 757 | D | 1 | 1 | II8Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview it was determined that the facility failed to assure each resident's drug regimen was free from unnecessary drugs for 1 of 6 sample residents reviewed for unneccessary medications (ID # 41) related to a community reported complaint. Findings are as follows: Record review of a 9/11/2018 discharge summary from the Hospital, revealed an order under Discharge Medications for .[MEDICATION NAME] ([MEDICATION NAME])(a medication to treat high blood pressure) 20 mg tablet take 40 mg by mouth daily Record review of the (MONTH) (YEAR) Medication Administration Record, [REDACTED]. This resulted in the resident receiving double the dosage of [MEDICATION NAME] on these days. During a surveyor interview on 10/4/2019 at 10:34 AM with the Director of Nursing Services, she acknowledged that the [MEDICATION NAME] was not administered as instructed on the discharge summary. | 2020-09-01 |
| 46 | 46 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2019-10-04 | 812 | F | 1 | 1 | II8Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation and staff interview, it has been determined that the facility failed to properly store, distribute, and serve food, in accordance with professional standards for food service safety, relative to the main kitchen. Findings are as follows: During the initial tour of the main kitchen by two surveyors on [DATE] at 8:55 AM, the following was observed in the main refrigerator: -One 46-ounce container of[NAME]ReadyCare Thickened Lemon Flavored Water with a manufacturer's expiration date of [DATE]. The container was open and not dated when opened. -[NAME]to sauce in a large plastic pitcher, covered with plastic wrap and not dated. -Creamy Italian dressing in a large plastic measuring cup, covered with plastic wrap and not dated or labeled. -Red colored sauce in a large plastic pitcher, covered with plastic wrap and not dated or labeled. -Ketchup in a plastic condiment bottle without a lid, covered with plastic wrap and not dated or labeled. -4 single-serving condiment cups of sour cream not dated or labeled. During a surveyor interview with the Head Cook at the time of the observation, she acknowledged that the above items were not dated and/or labeled, that the[NAME]ReadyCare beverage was expired, and she was unable to identify the red colored sauce. She additionally acknowledged that all items stored in the refrigerator should be dated and labeled. During a surveyor interview with Dietary Manager on [DATE] at 9:40 AM, she acknowledged that all items stored in the refrigerator should be dated and labeled. | 2020-09-01 |
| 47 | 47 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2019-10-04 | 880 | D | 1 | 1 | II8Y11 | > Based on surveyor observation and staff interview it has been determined that the facility failed to adhere to standard precautions to prevent the spread of infections for 1 of 1 sample residents observed for wound care (ID # 11). Findings are as follows: Record review of Resident ID# 11's treatment record for (MONTH) 2019, revealed an order to cleanse coccyx wound with normal saline followed by allevyn foam, change every 3 days and as needed. Surveyor observation of Resident ID# 11's dressing change on 10/3/2019 at 11:17 AM by Staff Nurse B, revealed upon completion of the treatment the nurse removed her gloves and exited the room without performing hand hygiene. She then failed to perform hand hygiene prior to entering the nurse's station to document in a resident record. During surveyor interview on 10/3/2019 at 11:23 AM with Staff B, she acknowledged that she did not perform hand hygiene after completing the dressing change. | 2020-09-01 |
| 48 | 48 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2019-10-04 | 943 | C | 1 | 1 | II8Y11 | > Based on record review and staff interview it was determined that the facility failed to provide training to their staff, that at a minimum includes abuse, neglect, exploitation, and misappropriation of resident property and dementia management. Findings are as follows: Record review of a listing of current staff revealed that the facility has 76 staff members. Record review of a sign in sheet for a dementia care in-service training dated 6/25/2019 revealed 12 signatures of staff members who attended the in-service, for a total of 15 percent of staff educated. Record review of a sign in sheet for a Resident Abuse and Neglect in-service training dated 6/20/2019 revealed 52 signatures of staff members who attended the in-service, for a total of 68 percent of staff educated. During a surveyor interview on 10/4/2019 at 2:34 PM with the Director of Nursing Services and the Corporate Nurse, they could not provide evidence that in-service training on abuse and dementia were provided to all staff members. | 2020-09-01 |
| 49 | 49 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2019-10-04 | 947 | C | 1 | 1 | II8Y11 | > Based on record review and staff interview, it has been determined that the facility failed to provide at least 12 hours of in-service training annually for nurse aides, which includes dementia management and resident abuse prevention training. Findings are as follows: Record review of a listing of current staff revealed that the facility has 17 nurse aides. During a surveyor interview on 10/4/2019 at 2:34 PM with the Director of Nursing Services and the Corporate Nurse, they could not provide evidence of at least 12 hours of in-service training annually, including dementia and abuse training, for the employed nurse aides. | 2020-09-01 |
| 50 | 50 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2017-10-05 | 161 | C | 0 | 1 | 0DHM11 | Based on record review and staff interview, it has been determined that the facility failed to assure the security of all personal funds of residents deposited with the facility relative to purchasing a surety bond which adequately protects resident funds against loss. Findings are as follows: Record review revealed that the facility had a surety bond in the amount of $7500.00. Review of the bank statements for the resident trust account for the last three months (July-September (YEAR)) revealed that on 33 of 92 days, the balance of the resident funds account exceeded the $7500.00 covered by the surety bond. During an interview on 10/3/2017 at approximately 3:00 PM, the manager responsible for handling resident personal needs funds was unaware that the surety bond did not meet the requirement. 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. | 2020-09-01 |
| 51 | 51 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2018-10-09 | 567 | B | 0 | 1 | XNYN11 | Based on record review and staff interview, it has been determined that the facility failed to obtain written authorization of residents for whom the facility is holding personal funds for 3 of 5 residents reviewed, ID#s 3, 16, 34. Findings are as follows: Review of the facility's records relative to resident personal needs funds on 10/5/2018 at approximately 3:00PM revealed that the facility was holding funds for resident ID#s 3, 16, 34. Further record review failed to reveal evidence that written authorization had been obtained from the residents or their representatives to hold the funds. During an interview with the person responsible for handling resident personal needs funds at the time of the review, he could not provide evidence that written authorization had been obtained. | 2020-09-01 |
| 52 | 52 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2018-10-09 | 658 | D | 0 | 1 | XNYN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, staff and resident interview, it has been determined that services provided by the facility failed to meet professional standards of quality relative to physician's orders [REDACTED].#12, 43 and 44. Findings are as follows: 1)Potter and Perry, Fundamentals of Nursing, Eighth Edition, page 305 states in part nurses follow health care providers' orders unless they believe the orders are in error or harm patients. Review of Resident ID#12's clinical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Further record review revealed a current physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. During a surveyor interview on 10/9/18 at approximately 11:00 AM with Staff A she was not able to provide evidence that daily weights were obtained per physician order. During an additional surveyor interview on 10/9/18 at approximately 1:45 PM with the Director of Nurses, she was acnowledged the weights were not obtained as ordered. 2) The Standards for Nursing Skills & Techniques, Perry/Potter, 6th edition, Chapter 21, page 719, Box 21-4: Review provider's MEDICATION ORDERS FOR [REDACTED]. Surveyor observation of resident ID # 43 on 10/3/2018 at approximately 11:15AM revealed he/she had oxygen in place via nasal canula running at 2 Liters per minute. Record review revealed resident ID # 43 had a physician's orders [REDACTED]. The order omitted the Liter flow. Surveyor observation of resident ID # 44 on 10/3/2018 at approximately 11:30AM revealed he/she had oxygen in place via nasal canula running at 2 Liters per minute. Record review revealed resident ID#44 had a physician order [REDACTED]. The order omitted the Liter flow. An interview was conducted with the Director of Nursing Services on 10/9/2018 at approximately 12:00PM. She acknowledged there should be a liter flow per the physician in the orders for oxygen. | 2020-09-01 |
| 53 | 53 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2018-10-09 | 761 | F | 0 | 1 | XNYN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations and staff interview, it has been determined that the facility failed to ensure that expired medications were discarded per the manufacturer's instructions and failed to label medications in accordance with currently accepted professional principles for 1 of 1 medication storage room and 2 of 2 medications carts. Findings are as follows: Facility policy entitled General Dose Preparation and Medication Administration states in part . facility should enter the date opened on the label of medications with shortened expiration dates (e.g., insulin's, irrigation solutions etc.) .facility staff may record the expiration date based on date opened on the label of medications with shortened expiration dates .prior to the administration of medication, facility staff should check the expiration date on the medication . 1. Surveyor observation of the refrigerator in the medication storage room, in the presence of the Corporate Registered Nurse on 10/04/2018 at approximately 10:35 AM, revealed 2 of 3, multidose vials of [MEDICATION NAME] Purified Protein ([MEDICATION NAME]), opened and dated 8/20/2018. Manufacturer's instructions written on the box state, once entered vial should be discarded after 30 days. Additional observation of the refrigerator revealed 1 of 3 bottles of [MEDICATION NAME] Liquid not dated when opened. Manufacturer's instructions written on the box state, discard opened bottle after 90 days. 2. Surveyor observation of the medication storage cart side 2, in the presence of the Corporate Registered Nurse on 10/4/2018 at approximately 10:50 AM, revealed the following: Calcium 500 MG with D3 400 IU with an expiration date of 8/2018 Calcium [MEDICATION NAME] 500 mg with an expiration date of 9/2018 [MEDICATION NAME] 0.125 mg with an expiration date of 9/2018 One vial of [MEDICATION NAME] opened and not dated Two vials of Humalog insulin opened and not dated One vial of [MEDICATION NAME]opened and not dated One… | 2020-09-01 |
| 54 | 54 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2018-10-09 | 812 | F | 1 | 1 | XNYN11 | > Based on surveyor observation and interview, it was determined that the facility failed to provide a sanitary environment for residents relative to an ice machine on the main floor of the facility. Findings are as follows: Surveyor observation on 10/3/2018 at 9:30 AM revealed the end of the approximately 3/4-inch drain pipe from the ice machine on the main floor of the facility directly entering the floor drain with no air gap between the end of the ice-machine drain pipe and the floor drain. In an interview with the Food Service Director (FSD) on 10/3/2018 at 9:35 AM she acknowledged there was no air gap between the end of the ice machine drain pipe and the floor drain. She confirmed that the ice machine was used to provide ice for the entire facility. | 2020-09-01 |
| 55 | 55 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2018-10-09 | 880 | F | 0 | 1 | XNYN11 | Based on record review and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment relative to implementation of water system management control measures to mitigate the development of Legionella and other opportunistic waterborne pathogens. Findings are as follows: On 10/4/2018, review of the facility's water system management plan dated 7/31/2017 revealed the facility had identified control measures/monitoring procedures to implement for the mitigation of bacterial growth in the water system. These measures included but are not limited to the following: -Hot Water Storage: Water temperature inside the hot water storage tanks should be maintained at or above 140F and should be verified daily. The circulation pump installed on the water lines should be verified for operation as well. These practices should be documented and kept in the service records section of this plan . -Hot and Cold-water taps, shower heads, and tubs should be periodically flushed to help mitigate the potential for stagnation. Shower sprayers, Tubs, and Faucet taps should be disinfected with a EPA registered disinfectant on a scheduled cleaning program, to reduce the buildup of bacteria. Daily testing of the water temperatures delivered at taps and recorded should be conducted.Uncommonly used tubs/showers/faucets should be flushed for 3-5 minutes on hot and cold lines and disinfected monthly. This process should be documented and kept in the services records section of this program. -Eyewash stations should be checked weekly for visual inspection per manufacturer and ANSI requirements. Plumbed Eyewash stations should also be flushed monthly. Flushing of the station should be done for 3 minutes. These stations should also be disinfected regularly to reduce bacteria growth. This practice should be documented and kept in the service section of this plan. Review of the service section of the plan revealed multiple worksheets desig… | 2020-09-01 |
| 56 | 56 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2019-11-17 | 689 | D | 1 | 0 | PFX511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff and resident interview, it has been determined that the facility failed to ensure a resident received adequate supervision and assistance to prevent a fall during transfer care for 1 of 1 resident reviewed for accidents, Resident ID #1. Findings are as follows: Record review for Resident ID #1 revealed s/he was admitted to the facility in 8/2019 with [DIAGNOSES REDACTED]. An admission Minimum Data Set ((MDS) dated [DATE] indicates a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating the resident is cognitively intact and that the resident requires extensive assistance by two staff members for transfers. Additional record review reveals a Physical Therapy Clarification Order dated 9/10/2019 that states 2 person OOB (out of bed)transfer. Further record review reveals an Individualized Resident Assignment that indicates the resident is an assist of two for transfers. During an interview on 11/07/2019 with Resident ID #1 s/he indicated that s/he had a fall on 11/15/2019. S/he further indicated that the Certified Nursing Assistant (CNA), Staff A transferred him/her independently and did not apply the prosthesis to the left extremity. During an interview on 11/19/2019 at approximately 10:00 AM with Staff A she acknowledged that she attempted to transfer the resident from bed to chair independently without his/her prosthesis on resulting in a fall. | 2020-09-01 |
| 57 | 57 | SUNNY VIEW NURSING HOME INC | 415023 | 83 CORONA STREET | WARWICK | RI | 2886 | 2017-05-11 | 371 | E | 0 | 1 | MCC011 | Based on surveyor observation and staff interview, it has been determined that the facility failed to distribute and serve food under sanitary conditions in the main and the small dining rooms. Findings are as follows: Surveyor observation on 5/8/17 at 1:00 PM in the small dining room, revealed 1 bottle of nectar pre-thickened orange juice opened and not dated. The bottle indicates to use within 10 days of opening. There was no evidence as to when the bottle was opened. Surveyor observation on 5/8/17 at 1:05 PM in the main dining room kitchenette, revealed 1 bottle of nectar thickened cranberry juice, 1 bottle of nectar thickened water and 1 bottle of nectar thickened milk. The bottles indicate use within 10 days of opening. There was no evidence as to when the bottles were opened. Further observations in the main dining area revealed 25 plastic coffee cups stored in a cabinet in the inverted position ready to use. Observation of all 25 cups revealed a white film residue on the inside that was able to be wiped off the food contact surface. Five of the 25 cups were found with heavy accumulation of dark brown coffee colored residue on the inside bottom of the cups that was able to be scraped off. Seven of the 25 coffee cups were observed to have condensation of water on the food contact surface. An interview was conducted with the food service director on 5/8/17 at 1:25 PM, he stated he was not aware that nectar thickened liquids must be dated after opening. He further stated that he recognized the ready to use coffee cups were dirty and wet. 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. | 2020-09-01 |
| 58 | 58 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2020-02-10 | 658 | D | 1 | 0 | PGHX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review and staff interview, it has been determined the facility failed to assure that services being provided meet professional standards of quality related to administering oxygen without a physician order [REDACTED]. Findings are as follows: According to Brunner and Sudarth's textbook, Medical and Surgical Nursing, 7th Edition, 1992, page 524, as with other medications, oxygen is administered with care, and its effects on each patient are carefully assessed. Oxygen is a drug, except in emergency situations is prescribed by a physician. Review of the closed medical record for Resident ID #3 indicates s/he was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the progress notes for (MONTH) 2019 and (MONTH) 2020 revealed the resident was on continuous oxygen ranging from 2-4 liters per minute. The record failed to reveal evidence of a physician's orders [REDACTED]. During an interview with the Assistant Director of Nursing on 2/10/2020 at approximately 11:50 AM, she acknowledged there was no order for the use of [REDACTED] | 2020-09-01 |
| 59 | 59 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2018-02-19 | 658 | E | 1 | 0 | 1BEJ11 | Deficiency Text Not Available | 2020-09-01 |
| 60 | 60 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2018-02-19 | 695 | E | 1 | 0 | 1BEJ11 | Deficiency Text Not Available | 2020-09-01 |
| 61 | 61 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2019-06-12 | 635 | D | 1 | 0 | EEZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it has been determined that facility failed to obtain complete admission orders [REDACTED]. Findings are as follows: Review of Resident ID #3's closed clinical record revealed an admission date of [DATE], discharge date of [DATE], and [DIAGNOSES REDACTED]. Further review revealed a 6/6/2019 Admission Evaluation indicating the resident was admitted to the facility with pressure ulcers and blisters including 5 pressure ulcers, 3 blisters, and 1 suspected deep tissue injury. Review of the physician's admission orders [REDACTED] -[MEDICATION NAME] Skin Protectant, apply to affected area topically every 12 hours as needed for skin protectant -[MEDICATION NAME] Ointment, apply to affected area topically one time a day for skin protectant -[MEDICATION NAME] Wound/Burn Dressing Paste, apply to affected area topically one time a day for wound The record lacked orders specific to the 5 pressure ulcers, 3 blisters, and suspected deep tissue injury. During a surveyor interview with the Director of Nursing Services on 6/12/2019 at 10:00 AM, she could not provide evidence that complete admission orders [REDACTED]. | 2020-09-01 |
| 62 | 62 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2018-06-18 | 550 | B | 0 | 1 | NPS511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, record review, and staff interview, it was determined that the facility has failed to ensure residents' dignity was maintained relative to posting personal information and being left exposed for 2 of 3 sample residents ID # 90 & ID # 215. Findings are as follows: 1. A surveyor observation of Resident ID#90 on 6/13/2018 at approximately 9:15 AM, in the presence of the nurse unit manager, revealed a sign with the resident's name, the name of a medication ([MEDICATION NAME]) and directions to apply the medication. It was signed by the respiratory therapist and posted on the outside of the resident's door which was visible from the hallway. When the surveyor asked the nurse manager about the sign, she was unable explain why the note was posted on the resident's door. On 06/14/2018 at 1:37 PM, the surveyor interviewed the Corporate Nurse, staff C, and spoke with the respiratory therapist on the phone who placed the sign on the door. She stated she wanted the nurses to know about the medication and to change the site every three days. She acknowledged she should not have placed it on the door of the resident's room. 2. Surveyor observation of Resident ID #215 on the following days and times revealed the resident lying in bed, uncovered with his/her legs and brief exposed, and visible from the hallway. - 06/14/18 09:24 AM observation of resident in bed, uncovered, with brief exposed and legs up in the air - 06/14/18 01:31 PM observation of resident in bed, uncovered, with his/her legs hanging off the bed and the brief exposed - 06/15/18 09:33 AM observation of resident in bed, uncovered, legs elevated, knees up, and brief exposed - 06/15/18 09:48 AM observation of the resident still in the same position as above, uncovered and exposed - 06/15/18 10:56 AM observation of the resident, by two surveyors, exposed with legs up, no covers and brief exposed. Staff observed in the area walking into the room across the hall and… | 2020-09-01 |
| 63 | 63 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2018-06-18 | 578 | D | 0 | 1 | NPS511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's formulated advance directive would be followed as there was inconsistency between the paper medical record and the Electronic Medical Record (EMR) for 1 of 22 sample residents (ID #29). Findings are as follows: Review of the paper medical record for resident ID #29 revealed an advance directive dated 9/25/2017, indicating full code with limited additional interventions - do not intubate (DNI). Review of the resident's EMR revealed a physician's orders [REDACTED]. During a surveyor interview with the 1st floor Unit Manager on 6/15/2018 at approximately 1:30 PM, she was unable to explain why the advance directive in the paper medical record and the EMR did not match. | 2020-09-01 |
| 64 | 64 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2018-06-18 | 584 | C | 0 | 1 | NPS511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to maintain a safe and clean environment relative to rough edges and/or missing paint on the lower third of doors and worn/stripped wood finishing on handrails. Findings are as follows: 1. The lower third of doors with rough edges and/or missing paint included: First Floor A) Resident rooms 109, 111, 115, 116 and 117. B) Both separate entrance doors to the main dining room. C) The entrance door to the main shower room adjacent to room [ROOM NUMBER]. Second Floor A) Resident rooms 204, 205, 219, 221, 222, 223, 224. B) The soiled utility closet adjacent to room [ROOM NUMBER]. Third Floor A) Resident rooms 302, 305, 306, 308, 310, 311, 313, 314, 316 and 317. B) The common shower room adjacent to room [ROOM NUMBER]. 2. Handrails with worn/stripped wood finishing included: First Floor: A) The left hand rail adjacent to the elevator (5' x 7 area). B.) The left and right corner edges opposite nursing station (2) (1' x 6 areas). Second Floor: A) The left and right hand rails adjacent to the elevator (2) (2' x 8 areas). B) The handrail adjacent to room [ROOM NUMBER] (10' x 8 area). C) The handrail adjacent to room [ROOM NUMBER] (1.5' x 8 area). During an interview on 6/18/2018 at 11:30 AM, both the Administrator and Maintenance Director acknowledged the above listed doors and handrails were in need of repair. | 2020-09-01 |
| 65 | 65 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2018-06-18 | 656 | D | 0 | 1 | NPS511 | Based on surveyor observations, record review and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives to meet a resident's needs, relative to dignity for 1 of 22 sample residents (ID# 215). Findings are as follows: During multiple surveyor observations on 6/14/2018 and 6/18/2018, the resident was observed with his/her brief and lower half of body exposed. Clinical record review for resident ID #215 revealed a care plan dated 6/11/2018, which lacked evidence of any behaviors or interventionsto address the resident being exposed. During an interview with the DNS on 6/18/2018 at 1:20 PM, she acknowledged that the resident's care plan was not person-centered as it lacked evidence of the behaviors or interventions to address the resident's right of the facility to ensure his/her dignity. | 2020-09-01 |
| 66 | 66 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2018-06-18 | 812 | F | 0 | 1 | NPS511 | Based on surveyor observation and staff interview, it has been determined that the facility failed to store food in accordance with professional standards for food service safety relative to the main kitchen. Findings are as follows: During a surveyor observation, in the presence of the Food Service Director (FSD), on 6/12/2018 at 12:30 PM, the following items were found: 1.) The ice machine had pink colored matter going along the length of the white plastic material inside the machine, above where the ice is dispensed. 2.) The white-painted wooden shelf, to the right of the ice machine, was covered in dust and coffee stains. Three white, plastic coffee pitchers were stored inverted on the dusty shelf and the three covers were stored with the inside of the cover on the dusty shelf. Two stainless steel coffee/hot water pitchers were also stored on the shelf, with one of the pitchers stored inverted. 3.) There were 17 out of 20 hard, plastic coffee cups with brown, scrapable matter accumulated on the inside of the cup. 4.) There was an accumulation of dust and debris covering the dish caddy where the porcelain plates were stacked. During a surveyor interview with the FSD at the time of the above observations, he acknowledged that the above items needed to be cleaned. | 2020-09-01 |
| 67 | 67 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2018-06-18 | 842 | D | 0 | 1 | NPS511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to maintain medical records on each resident that are complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 2 non-sample residents selected for a medication review (ID #11) and 1 of 22 sample residents (ID #49). Findings are as follows: 1. Resident ID # 11's record revealed that the resident was seen by the Wound Clinic on 5/18/2018 with the following recommendations: a.) Right, Lateral Ankle Wound: wash wound with vashe solution, apply santyl oint nickel thick to wound bed, follow by Algisite M, and dressing. Change dressing daily. b.) Left, Proximal, Anterior Leg Wound: wash wound with vashe solution, apply santyl oint nickel thick to wound bed, follow by Algisite M, and dressing. Change dressing daily. c.) Left, Distal, Anterior Leg Wound: wash wound with vashe solution, apply santyl oint nickel thick to wound bed, follow by Algisite M, and dressing. Change dressing daily. d.) Right Leg Circumference Wound: wash wound with vashe solution, apply durafiber Ag, and dressing. Change dressing daily. Review of the physician's orders [REDACTED].>Review of the Medication Administration Record [REDACTED]. Additionally, the (MONTH) TAR revealed 3 out of 13 opportunities and the (MONTH) TAR revealed 5 out of 15 opportunities where the treatment to the left distal anterior leg was not documented as complete. During a surveyor interview with the Corporate Nurse, staff B, on 6/15/2018 at 10:39 AM, she was unable to explain why one of the four wound clinic recommendations were not ordered nor why two of the wound treatments ordered on [DATE] were not on the TAR. Additionally, she was unable to provide documentation that the treatment to the left proximal anterior leg wound was done on the days it was not signed off. 2. Resident ID #49's record revealed a physician's orders [REDACTED]. An additional order dat… | 2020-09-01 |
| 68 | 68 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2017-06-30 | 167 | C | 1 | 0 | 1II511 | > Based on surveyor observation and staff interview, it has been determined that the facility failed to make the results of the most recent survey of the facility conducted by Federal or State surveyors available for examination in a place readily accessible to residents or post a notice of their availability for 3 of 3 floors. Findings are as follows: On 6/28/2017 at 12:30 PM, surveyor observation of the first floor failed to reveal evidence of the most recent survey results posted in a public area. During interview with the director of maintenance at this time, he could not locate a posted notice of availability and indicated that the survey results were stored behind the reception desk (where residents do not have free access). Further observation of the second and third floor revealed that survey results were readily accessible, however, the results available were not from the most recent survey. During interview with the Administrator on 6/30/2017, she could not provide evidence of survey results being readily accessible to residents on the first floor or that a notice of their availability was posted. She further acknowledged that the survey results on the second and third floor were not of the most recent survey. | 2020-09-01 |
| 69 | 69 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2017-06-30 | 281 | E | 1 | 0 | 1II511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, surveyor observations, and staff interviews, it has been determined that the facility failed to provide services which meet professional standards of quality for 4 of 16 sample residents (ID#s 3, 5, 13, and 15) relative to clarifying physician's orders [REDACTED]. Findings are as follows: According to Basic Nursing, Mosby, 3rd Edition, The registered nurse checks all transcribed orders against the original order for accuracy and thoroughness. If an order seems incorrect or inappropriate, the nurse consults the physician . The following orders were found to be incomplete and requiring clarification from the physician: 1.) Record review for resident ID #3 revealed the following physician orders: -Current order dated 2/23/2017 for [MEDICATION NAME] Tablet 325 mg, give 2 tablets by mouth every 4 hours as needed for pain. -Current order dated 4/18/2017 for [MEDICATION NAME] (Concentrate) Solution 20 mg/ml, give 5 mg by mouth every 4 hours as needed for pain. The above orders do not include parameters stating the conditions under which each medication should be administered, leaving it unclear as to which to administer when the resident is experiencing pain. Further record review for resident ID #3 revealed the following physician orders: -Current order dated 2/28/2017 for [MEDICATION NAME] Solution 1%, give 2 drops by mouth every 2 hours as needed for secretions. -Current order dated 2/28/2017 for [MEDICATION NAME] Solution 1%, give 4 drops by mouth every 2 hours as needed for secretions. The above orders do not include directions indicating which to administer when the resident is experiencing secretions. 2.) Record review for resident ID #5 revealed the following physician orders: -Current order dated 5/14/2017 for Tylenol, give 2 tabs by mouth (PO) every six hours as needed for pain. -Current order dated 6/2/2017 for [MEDICATION NAME], give 0.25 mg every four hours as needed for pain or dyspnea. The above orders do not… | 2020-09-01 |
| 70 | 70 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2017-06-30 | 329 | E | 1 | 0 | 1II511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident's drug regimen is free from unnecessary drugs for 1 of 3 sample residents with a physician's orders [REDACTED].#5) relative to medication dosage and adequate indication for its use. Findings are as follows: Resident ID #5 has a physician's orders [REDACTED]. Observation of the resident on all days of the survey revealed the resident wearing oxygen via nasal cannula. Surveyor observation during initial tour on 6/27/2017 at 6:40 PM revealed ID #5 receiving oxygen at 4 liters via nasal cannula. Further observation of ID #5 on 6/28/2017 at 8:20 AM and 12:45 PM revealed the resident receiving 4 liters of oxygen via nasal cannula. Review of the oxygen saturation summary revealed that the resident had been receiving oxygen daily from 6/26/2017 to 6/30/2017. Record review revealed no documentation indicating the resident was SOB. An interview was conducted with the DNS on 6/29/2017 at 1:00 PM. She was unable to explain why the resident was receiving 4 liters of oxygen instead of 2 liters as ordered. She was also unable to explain why the resident had been receiving oxygen with no indication for use. | 2020-09-01 |
| 71 | 71 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2017-06-30 | 371 | F | 1 | 0 | 1II511 | > Based on surveyor observations and staff interview, it has been determined that the facility failed to properly store, distribute, and serve food under sanitary conditions relative to the main kitchen and 3 of 4 unit kitchenettes. Findings are as follows: During initial tour of the kitchen on 6/27/2017 at 6:05 PM, the following items were found: - Raw salmon stored above ready-to-eat foods in the walk-in refrigerator. - Approximately 25 stainless-steel pans which were not properly dried and found stacked with trapped water between each pan. - Eleven 46 fluid-ounce cartons of[NAME]pre-thickened liquids. Directions on the carton state to use within 7 days of opening. During surveyor observation of the second-floor kitchenette on 6/28/2017 at 8:45 AM, there were five 46 fluid-ounce cartons of[NAME]pre-thickened liquids found in the refrigerator, all open with no date of opening. Directions on the carton state to use within 7 days of opening. During surveyor observation of the third-floor kitchenette on 6/28/2017 at 10:55 AM, there were four 46 fluid- ounce cartons of[NAME]pre-thickened liquids found in the refrigerator, all open with no date of opening. Directions on the carton state to use within 7 days of opening. During surveyor observation of the first-floor kitchenette on 6/28/2017 at 11:00 AM, there were four 46 fluid-ounce cartons of[NAME]pre-thickened liquids found in the refrigerator, all open with no date of opening. Directions on the carton state to use within 7 days of opening. During surveyor interview with the Night Cook on 6/27/2017at 6:20 PM, he acknowledged that the raw salmon was stored above ready-to-eat foods. During surveyor interview with the Day Cook on 6/29/2017 at 11:05 AM, he acknowledged that the stainless-steel pans were stored wet and that the thickened liquids should have been dated when opened. 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 Facili… | 2020-09-01 |
| 72 | 72 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2018-10-11 | 554 | D | 1 | 0 | SL3R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review, and staff interview, it has been determined that the facility has failed to ensure that residents may self-administer medications after the interdisciplinary team (IDT) has determined which medications may be self-administered and that the medication is stored safely and securely for 1 of 2 residents (ID #7). Findings are as follows: The facility's policy, titled, Self-Administration of Medications, states in part, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. 1. As part of their overall evaluation the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the nurse will perform a more specific skill assessment, including (but not limited to) the resident's: a. Ability to read and understand medication labels; b. Comprehension of the purpose and proper dosage and administration time for his or her medications; c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and d. Ability to recognize risks and major consequences of his or her medications . 4. The staff and practitioner will ask residents who are identified as being able to self-administer medications whether they wish to do so and written consent must be obtained. 5. The staff and practitioner will document their findings and choices of residents who are able to self-administer medications . 13. The staff and practitioner will periodically (for example, during quarterly MDS (Minimum Data Set- an assessment of the resident) reviews) reevaluate a resident's ability to continue to self-administer medications. Record review for Resident ID #7 revealed a 10/9/2018 physician… | 2020-09-01 |
| 73 | 73 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2018-10-11 | 600 | D | 1 | 0 | SL3R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview it has been determined that the facility failed to ensure that residents are free from abuse for 3 of 6 residents reviewed for abuse, ID#s 3, 5 and 8. Findings are as follows: 1. Record review revealed that Resident ID#4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed an unscored Brief Interview of Mental Status (BIMS) score, indicating that the resident is rarely or never understood. Further record review for ID #4 revealed a current care plan for behavior symptoms such as socially inappropriate, verbally aggressive/abusive, physically aggressive/abusive, delusions, and wandering behaviors related to cognitive impairment. Record review for Resident ID #3 revealed that s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] revealed a BIMS score of 7 out of 15, indicating severe cognitive impairment. Review of the facility reported incident revealed that on 9/17/2018, Resident ID#4 pushed Resident ID#3 causing him/her to fall. Per the facility's investigation report, ID#4 admitted to pushing ID#3 and ID#3 was witnessed falling by staff. ID#4 was went to the hospital for a psychiatric evaluation. ID #3 was assessed and found to have no injury. 2. Record review revealed that Resident ID#8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] revealed a BIMS score of 10 out of 15, indicating moderate cognitive impairment. Review of the facility reported incident revealed that on 8/21/2018, Resident ID #4 pushed Resident ID #8 and punched him/her in the stomach. The incident was witnessed by staff. ID #8 was assessed and found to have no injury. 3. Closed record review reveled that Resident ID #6 was admitted to the facility on [DATE] wit [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] revealed an unscored BIMS, indicating that the r… | 2020-09-01 |
| 74 | 74 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2018-10-11 | 609 | D | 1 | 0 | SL3R11 | > Based on record review and staff interview, it has been determined that the facility has failed to ensure that all alleged violations involving abuse are reported immediately (but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse) to the Administrator of the facility and to the State Survey Agency in accordance with State law for 1 out of 7 reportable allegations of abuse (ID #4). Findings are as follows: Review of resident ID #4's record revealed a progress note dated 8/22/2018 indicating the following: This evening (Resident ID #4) had multiple verbal behaviors and outbursts and was highly unredirectable. Prior to dinner (s/he) was arguing with another resident and made the statement towards them 'I am going to cut you throat with a knife' . During a surveyor interview with the Administrator on 10/11/2018 at 11:10 AM, she was unaware of the incident and could not provide evidence that the incident was reported to the State Survey Agency. | 2020-09-01 |
| 75 | 75 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2018-10-11 | 658 | D | 1 | 0 | SL3R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it has been determined that the facility failed to ensure the services provided by the facility meet professional standards of quality relative to medication administration charting for 1 of 2 residents (Resident ID# 10). Findings are as follows: According to Basic Nursing, Mosby, 3rd: after administering a drug, the nurse records it immediately on the appropriate record form. Recording the drug includes the name of the drug, dosage, route of administration and exact time of administration. The facility's policy, titled, Administering Medications, states in part, .3.2 The nurse who pours or prepares the medications is solely responsible for safeguarding, administering, and recording each medication . 12. Never pour a medication from one container to another or back into a container from a medicine cup. Drugs from a bottle, box or container which are not labeled should not be used. All meds to be removed from blister pack in descending order. Never give medications from memory. Always refer to Medication Administration Record [REDACTED] 19. The individual administering the medication must initial the resident's MAR indicated [REDACTED]. Record review for Resident ID #10 revealed the following: 1. A 5/29/2018 physician's orders [REDACTED]. 2. A 2/3/2018 physician's orders [REDACTED]. 3. A 6/25/2018 physician's orders [REDACTED]. 4. A 6/25/2018 physician's orders [REDACTED]. Review of the MAR indicated [REDACTED]. Further review of the record revealed a progress note dated 9/15/2018 at 11:02 PM, written by Nurse, Staff C, which states, Resident extremely upset and yelling, stating that (s/he) did not receive (his/her) 'bedtime' meds. (S/he) specifically named which meds (s/he) did not receive and stated that if (s/he) did not receive them, (s/he) wanted to be sent to the hospital. Resident is alert and oriented .Writer administered scheduled [MEDICATION NAME], Asenapine, [MEDICATION NAME] and [MEDICA… | 2020-09-01 |
| 76 | 76 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2018-10-11 | 686 | D | 1 | 0 | SL3R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 1 residents who have actual pressure ulcers (Resident ID# 13). Findings are as follows: Record review for Resident ID #13 revealed that s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Additionally, the resident has a 10/2/2017 care plan for alteration in skin integrity-resident has a resolving stage 4 (pressure ulcer) on coccyx. Interventions include: treatment as ordered and wound consult. Further review revealed a 9/13/2018 physician's orders [REDACTED]. Review of a 10/10/2018 Continuity of Care form from an outside wound clinic revealed a recommendation to continue with the same treatment as ordered above. Surveyor observation on 10/11/2018 at approximately 12:00 PM revealed the resident's wound treatment, completed by Nurse Manager, Staff D. The nurse soaked the wound with Vashe, used [MEDICATION NAME] packing strips (gauze strips are impregnated with [MEDICATION NAME], an antiseptic agent) and covered the wound with a bordered foam dressing. During an interview on 10/11/2018 at 2:23 PM, Staff D acknowledged she used [MEDICATION NAME] packing instead of the physician ordered Iodosorb gel for the wound treatment. 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. | 2020-09-01 |
| 77 | 77 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2018-11-03 | 584 | F | 1 | 0 | KKNN11 | > Based on surveyor observations and staff interviews, it has been determined that the facility has failed to provide the resident with a safe, clean, comfortable and homelike environment relative to 3 of 3 shower rooms and 2 of 3 unit bathrooms. Findings are as follows: An anonymous complaint was reported to the Department of Health on 10/29/2018 alleging various environmental issues including clogged toilets and an unsanitary environment. 1) Surveyor observation of the Third Floor Subacute shower room on 11/3/2018 at 4:10 PM revealed resident ID # 1 attempting to get into the area where the toilet was located. The resident could not use this toilet as it was clogged and was unable to be flushed. Resident ID # 1 indicated s/he uses this bathroom when his/her's is occupied. Additionally, there was a wheelchair in the shower room that had a heavy accumulation of food debris noted on the seat. Surveyor observation of the Third Floor Subacute shower room on 11/14/2018 at 1:30 PM revealed a shower chair with dried yellow matter with a strong foul odor. During an interview on 11/15/2018 at 1:35 PM with the Administrator, he acknowledged that the shower chair should have been cleaned. Surveyor observation on the Third Floor unit bathroom on 11/3/2018 at 4:13 PM revealed several spots of a red liquid substance on the floor in front of the toilet. During an interview with the Unit Manager, Staff A on 11/3/2018 at 4:20 PM she acknowledged that the toilet was clogged and she would have expected that the wheelchair would have been cleaned. She also indicated that the red liquid substance on the floor was blood and she could not determine how long it had been there. 2) Surveyor observation of the Second Floor Transitional unit shower room on 11/3/2018 at 4:37 PM revealed that the toilet was clogged and was unable to be flushed. During an interview on 11/3/2018 at 4:39 PM with the certified nursing assistant, Staff B she acknowledged the toilet was clogged. 3) Surveyor observation of the Second Floor Harbor unit bathroom on 1… | 2020-09-01 |
| 78 | 78 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2018-12-14 | 600 | D | 1 | 1 | BZ8811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observations, staff interviews, and record reviews, it has been determined that the facility failed to ensure that residents are free from abuse for 4 of 11 residents reviewed, ID#s 56, 76, 86, & 92. Findings are as follows: 1. Record review revealed that resident ID# 56 had [DIAGNOSES REDACTED].# 1 had [DIAGNOSES REDACTED]. The record review revealed that on 11/23/2018 at 7:35 AM on the patio, resident ID# 56 was witnessed by Staff Activity Aide C, to have been kicked in the knee by resident ID# 1. No injuries were identified during an assessment. 2. Record review revealed that resident ID# 74 had a [DIAGNOSES REDACTED].#76 had a [DIAGNOSES REDACTED]. The record review revealed that on 9/17/2018 resident ID #74 was witnessed to have struck Resident ID #76 on his/her right hand. An x-ray of resident ID# 76's hand was ordered and no injuries were identified. 3. Record review revealed that resident ID# 86 has a [DIAGNOSES REDACTED].# 2 has a [DIAGNOSES REDACTED]. The record review revealed that on 10/21/2018, Staff Aide D witnessed resident ID# 2 pulling the hair of resident ID# 86 and hitting his/her right shoulder. There were no assessed injuries and the residents were immediately separated. 4. Record review revealed that resident ID# 92 had [DIAGNOSES REDACTED].# 51 had a [DIAGNOSES REDACTED]. The record revealed that on 11/21/2018 at 10:45 AM resident ID# 51 was witnessed by Staff Aide [NAME] flinging liquid toward resident ID #92 and splashing the resident. The residents were separated and no injuries were noted. During a surveyor interview conducted with the Director of Nursing Services on 12/14/2018 at approximately 2:00 PM, she was unable to provide evidence that the residents were free from abuse. | 2020-09-01 |
| 79 | 79 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2018-12-14 | 623 | C | 1 | 1 | BZ8811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it has been determined that the facility failed to send a copy of the notice of discharge to a representative of the Office of the State Long-Term Care Ombudsman for 5 of 5 sample residents reviewed relative to discharges to the hospital, Resident ID#s 26, 35, 48, 76, 219. Findings are as follows: 1. Record review of a hospital continuity of care form dated 11/10/2018 for Resident ID# 26 revealed, s/he was sent to the hospital for a fall. 2. Record review of a nursing progress note for Resident ID# 35 revealed, s/he was sent to the hospital for right foot [MEDICAL CONDITION] on 8/17/2018. 3. Record review of a nursing progress note dated 10/3/2018 for Resident ID# 48 revealed, s/he was sent to the hospital for an infection. 4. Record review of a nursing progress note dated 11/7/2018 for Resident ID# 76 revealed, s/he was sent to the the hospital for a fall. 5. Record review of a social worker progress note dated 11/15/2018 for Resident ID# 219 revealed, s/he was sent to the hospital for unstable gait, slurring words and lethargy. During an interview with the Director of Nursing Services on 12/13/2018 at 2:30 PM, she was unable to provide evidence that the facility sent a notice of discharge to the ombudsman following these hospitalization s. | 2020-09-01 |
| 80 | 80 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2018-12-14 | 760 | E | 1 | 1 | BZ8811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation, and staff interview, it has been determined that the facility has failed to ensure that residents are free of any significant medication errors for 1 of 5 sample residents receiving insulin for resident ID# 94. Findings are as follows: Record review for resident ID# 94 revealed a 11/18/2018 physician's orders [REDACTED]. Surveyor observation during the medication administration task on 12/13/2018 at approximately 8:35 AM revealed Staff Nurse B administered the Humalog to Resident ID# 94, despite a recorded blood sugar of 134 in the Medication Administration Record [REDACTED] Further review of the record revealed the following MAR indicated [REDACTED] -11/29/2018, 11:00 AM, blood sugar 130 -12/7/2018, 11:00 AM, blood sugar 93 -12/8/2018, 6:00 AM, blood sugar 149 -12/12/2018, 4:00 PM, blood sugar 129 During a surveyor interview immediately after the observation with Staff B, he was unable to explain why the insulin was administered when the blood sugar was below the parameters. The above medication errors involved 5 different nurses. During a subsequent interview with the Director of Nursing Services on 12/14/2018 at approximately 2:00 PM she was also was unable to explain why the insulin was administered when the blood sugar was below the parameters. | 2020-09-01 |
| 81 | 81 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2018-12-14 | 761 | D | 1 | 1 | BZ8811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observations and staff interview, it has been determined that the facility failed to label and store medications in accordance with currently accepted professional principles for 2 of 4 units observed (1st floor nurse's medication cart and 3rd floor medication room). Findings are as follows: The facility's policy, titled, Storage of Medications states, in part, Drugs and biological's shall be stored in the packaging, containers or other dispensing systems in which they are received. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Additionally, the facility's policy, titled, Administering Medications states, in part, The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multidose container, the date shall be recorded on the container. 1. Surveyor observation of the 1st floor nurse's medication cart, in the presence of Staff Nurse A on 12/13/2018 at 9:26 AM, revealed 6 of 12 opened and undated insulin pens, which include the following: -(1) [MEDICATION NAME] FlexTouch Pen (manufacturer's instructions reveal it can be stored after opened for 42 days). -(1) Toujeo [MEDICATION NAME] Pen (manufacturer's instructions reveal that it can be stored after opened for 56 days). -(2) Humalog KwikPen (manufacturer's instructions reveal that it can be stored after opened for 28 days). -(2) [MEDICATION NAME] Pen (manufacturer's instructions reveal that it can be stored after opened for 28 days). The facility failed to record the date the pens were opened, therefore the discard date could not be determined. Additionally, the following was observed in the same medication cart: -(1) [MEDICATION NAME] Pen with a pharmacy label for Resident ID# 57 inside a plastic bag which was labeled with another resident's name. -(1) [MEDICATION NAME] Pen with a pharmacy label for Resident ID# 65 inside a … | 2020-09-01 |
| 82 | 82 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2017-12-20 | 600 | J | 1 | 0 | MUG111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review and staff interview it has been determined that the facility failed to provide services to avoid physical harm and emotional distress, defined as neglect for 1 of 44 sample residents, Resident ID # 84. Findings are as follows: 1. Surveyor observation on 12/14/2017 at 5:55 AM of the second floor nursing unit revealed Staff A, the unit nurse, in a dark area adjacent to the nursing station, stretched out on a small couch, eyes closed, not responding to verbal cues made by the surveyor. Surveyor interviewed nursing assistant, Staff B, at the time of the observation, who was present on the unit. Staff B approached the nurse on the couch, turned the light on and called his name. Staff A got up off the couch and proceeded to the bathroom. When he was questioned after the time of the observation, the nurse stated he was on his break. He stated he did not leave the unit because there was no one who could cover his break. He could not explain why he did not respond to verbal cues when laying on the couch with his eyes closed. Subsequent surveyor observation during medication pass with Staff A on 12/14/2017 at 6:40 AM revealed Resident ID # 84, sitting on the edge of the bed, short of breath, gasping for air with abnormal audible breath sounds, anxious and in respiratory distress. The nurse took a pulse oximetry reading which measures the blood oxygen level and it was 88% on 5 Liters (L) of oxygen via nasal cannula. Lippincott Manual of Nursing Practice, eighth edition, 2006, defines Respiratory Assessment as, assessment of respiratory status when administering inhalation medications. It states in part . Auscultate (listen to) the chest after administration of aerosol [MEDICATION NAME] to assess improvement in aeration and reduction in adventitious (abnormal) breath sounds. Review of the Medication Administration Record [REDACTED]. Staff A proceeded to administer the breathing treatment at 6:40 AM, but he d… | 2020-09-01 |
| 83 | 83 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2017-12-20 | 656 | E | 1 | 0 | MUG111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observations, record reviews, and staff interviews it was determined that the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 23 sample residents, ID#s 7, 78, 85, and 332. Findings are as follows: 1. Review of Resident ID # 7's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Further record review revealed a care plan initiated on 10/25/2017 indicating the resident is a smoker. Interventions include, staff observation will be provided while smoking and to remove cigarettes, lighters and matches and keep in secure location. Review of a quarterly assessment note written by social services on 10/25/2017 revealed that the social worker was aware that the resident goes outside frequently throughout the day to smoke, he/she will smoke cigarettes from other residents, as well as hoard cigarette butts. Review of the plan of care revealed no revision made at this time to re-evaluate the residents needs. Surveyor observation on 12/11/2017 at 1:20 PM, 12/12/2017 at 9:09 AM, 12/12/2017 at 10:16 AM, and 12/15/2017 at 10:39 AM revealed the resident outside smoking unsupervised. The resident was utilizing smoking materials that s/he took out of his/her pocket, which were not removed by staff and kept in a secure location as indicated in the plan of care. An interview was conducted with the Administrator on 12/19/2017 at approximately 1:00 PM, she was unaware that the resident was outside smoking unsupervised, using smoking materials kept on his/her person and acknowledged that the plan of care should have been implemented and revised for this resident. 2. Review of Resident ID # 78's clinical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review of the recor… | 2020-09-01 |
| 84 | 84 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2017-12-20 | 676 | D | 1 | 0 | MUG111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to give the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living for 1 of 8 sampled residents triggered for an investigation related to activities of daily living (ADLs) (ID #2). Findings are as follows: Resident ID #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed a physician's orders [REDACTED]. 1/4 side rails to both sides of bed which is medically appropriate to increase bed mobility and positioning. Additionally, record review revealed a Physical Therapy progress note dated 11/24/2017 stating, patient requires bed 1/4 siderails for bed mobility and transfers in and out of bed. Observations on the following dates revealed side rails were not present on the residents bed: - 12/13/17 10:20 AM - 12/14/17 08:36 AM - 12/15/17 02:50 PM - 12/18/17 10:16 AM - 12/18/17 01:21 PM During a surveyor interview with the Administrator on 12/18/2017 at 2:08 PM, she acknowledged that the resident should have had 1/4 side rails on his/her bed. | 2020-09-01 |
| 85 | 85 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2017-12-20 | 686 | J | 1 | 0 | MUG111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for 2 of 7 residents who triggered an investigation for the risk of developing pressure ulcers or who have actual pressure ulcers (ID #s 2 and 85). Findings are as follows: 1. Resident ID #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review revealed a Braden Scale for Predicting Pressure Ulcers on 12/06/2017 which assessed the resident as at high risk for pressure. Record review for resident ID #2 revealed an admission assessment dated [DATE] which revealed that the resident has a pressure ulcer to the coccyx. There was no documentation of the size, exudate (wound drainage), pain, and description of wound bed and wound edges. Review of the resident's progress notes revealed a physician admission note dated 11/24/2017 which indicates the resident had a Stage 2 pressure ulcer (partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red/pink wound bed, without slough) to the coccyx. Additional record review revealed a physician's orders [REDACTED]. 1/4 side rails to both sides of bed which is medically appropriate to increase bed mobility and positioning. Further record review revealed a Physical Therapy progress note dated 11/24/2017 stating, patient requires bed 1/4 siderails for bed mobility and transfers in and out of bed. Observations on the following dates and times revealed no evidence of 1/4 side rails on the resident's bed: - 12/13/17 10:20 AM - 12/14/17 08:36 AM - 12/15/17 02:50 PM - 12/18/17 10:16 AM - 12/18/17 01:21 PM During a surveyor interview with the Physical Therapist, Staff G, on 12/18/2017 at 10:17 AM he stated that 1/4 side rails may help to reduce skin breakdown as it can help to shift pressure when used for positioni… | 2020-09-01 |
| 86 | 86 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2017-12-20 | 692 | J | 1 | 0 | MUG111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to address the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition for 1 of 2 sample residents with significant weight loss (ID #2). Findings are as follows: Resident ID #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review for resident ID #2 revealed a physician's orders [REDACTED]. Review of the resident's record revealed a weight of 111.2 lbs (pounds) on 11/23/2017, a weight of 100.4 lbs on 12/12/2017, and a re-weight of 99.8 lbs on 12/13/2017. This indicates a 10.3% significant weight loss in 20 days. Further record review revealed that the resident's Power of Attorney (POA) signed a Medical Orders for Life Sustaining Treatment (MOLST) on 11/30/2017 identifying the resident as a Full Code, with indications of long-term artificial nutrition (feeding tube), if needed. Review of the dietary progress notes revealed a note by the Registered Dietitian on 12/13/2017 noting a 10.3% change in weight and a response will monitor and remain available PRN. During a surveyor interview with the 3rd floor Unit Manager on 12/13/2017 at 10:20 AM, she acknowledged that the resident should have been weighed twice a week. During a surveyor interview with the Registered Dietitian on 12/15/2017 at 1:45 PM, she acknowledged that the resident was not being weighed twice a week. Additionally, she revealed that she was aware of the resident's Full Code status; however, could not explain why new interventions were not added until brought to the attention of the facility on 12/14/2017. | 2020-09-01 |
| 87 | 87 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2017-12-20 | 693 | D | 1 | 0 | MUG111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that residents who are fed by a feeding tube receive the appropriate treatment and services to prevent complications for 2 of 2 sample residents reviewed receiving nutrition via feedin[DEVICE], ID #'s 46 and 78. Findings are as follows: 1. Resident ID # 46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the following physician's orders [REDACTED]. Review of the facility's policy, provided by the Director of Nursing Service (DON), titled, Administering Medications through an Enteral Tube (feeding tube), states, in part, .when correct tube placement and acceptable GRV (gastric residual volume) have been verified flush tubing .administer medication by gravity flow . Surveyor observation on 12/14/2017 at 6:30 AM revealed Staff Nurse A during medication pass. Staff A proceeded to administer the medication without checking tube placement by checking for gastric residual volume. An interview was conducted with Staff A following the onservation. He was unable to explain why he did not check feeding tube placement. 2. Review of Resident ID#78's clinical record revealed [DIAGNOSES REDACTED]. Further review of the record revealed a physician's orders [REDACTED]. Additionally, the resident has a current care plan dated 10/16/2017 indicating that the resident has potential for fluid deficit related to feeding tube with an intervention to provide tube feed and flushes as ordered. Review of the facility's policy, provided by the Director of Nursing Service (DNS), titled, Administering Medications through an Enteral Tube (feeding tube), states, in part, .when correct tube placement and acceptable GRV (gastric residual volume) have been verified flush tubing with 15-30 ml warm sterile water (or prescribed amount) .dilute the crushed or split medication with 15-30 ml sterile or purified water (or… | 2020-09-01 |
| 88 | 88 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2017-12-20 | 695 | J | 1 | 0 | MUG111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, staff interview and record review it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 1 residents reviewed for respiratory care, ID # 84 who was observed to be in respiratory distress. Lippincott Manual of Nursing Practice, eighth edition, 2006, defines Respiratory Assessment as, Assessment of respiratory status when administering inhalation medications. It states in part . Auscultate (listen to) the chest after administration of aerosol [MEDICATION NAME][MEDICATION NAME] to assess improvement in aeration and reduction in adventitious (abnormal) breath sounds. Record review revealed that ID # 84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's physician orders [REDACTED]. 1. An order dated 11/13/2017 for [MEDICATION NAME] Nebulizer Solution (a [MEDICATION NAME] for inhilation) 2.5 milligrams (mg) in 3 milliliters (ml) every 4 hours (4 AM, 8 AM, 12 PM, 4 PM, 8 PM and 12 AM). 2. An order dated 11/14/2017 which reads, Respiratory Assessment with nebulizer treatment. 3. An order dated 12/01/2017 for Oxygen 1-3 liters (L) via nasal cannula (NC) continuous 4. An order dated 12/04/2017 stating O2 (oxygen) sats (saturation) greater than or equal to 92%. Surveyor observation during medication pass with Staff Nurse A on 12/14/2017 at 6:40 AM revealed resident ID # 84, sitting on the edge of the bed, anxious, short of breath, gasping for air with abnormal audible breath sounds, in respiratory distress. The resident's respirations were shallow and were counted at 33 per minute (normal adult range is 12-22 per minute). The resident stated I need the bag, get me the bag, holding the nebulizer mask to his/her face attempting to get air from the mask. Surveyor observed oxygen infusing at 5 L via nasal cannula. Staff A placed the medication, [MEDICATION NAME], into the administration set up, then left t… | 2020-09-01 |
| 89 | 89 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2017-12-20 | 759 | D | 1 | 0 | MUG111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review and staff interview, it was determined that the facility has failed to ensure that each resident's medication regimen is free of medication error rates of 5% or greater. Based on 30 opportunities for error, there were 2 errors involving 2 residents (ID #'s 71 and 84) resulting in an error rate of 6.67%. Findings are as follows: 1. Resident ID # 84 has a physician's orders [REDACTED]. During observation of the medication pass on 12/14/2017 at 6:40 AM, the nurse administered the breathing treatment 2 hours and 40 minutes after the scheduled time. 2. Resident ID # 71 has a physicians order dated 11/28/2017 for [MEDICATION NAME] 25 mg, give 50 mg by mouth three times a day .hold for systolic (blood pressure) less than 100 and heart rate less than 60. During observation of the medication pass on 12/14/2017 at 7:11 AM, the nurse administered the [MEDICATION NAME] without taking a blood pressure reading or obtaining a heart rate. Although a blood pressure reading was documented on the medication administration record, the surveyor was in the presence of the nurse from 5:55 AM until 7:38 AM and did not witness the nurse obtain a blood pressure or heart rate prior to administering the [MEDICATION NAME]. During an interview with the medication nurse immediately following these observations he was unable to explain why he had not taken the blood pressure or pulse prior to administration of the medication. | 2020-09-01 |
| 90 | 90 | WEST SHORE HEALTH CENTER | 415028 | 109 WEST SHORE ROAD | WARWICK | RI | 2889 | 2017-04-07 | 202 | B | 0 | 1 | 68GN11 | Based on closed record review and staff interviews it was determined that the facility failed to provide documentation of physicians' discharge orders for 3 of 4 residents (IDs #23, 24, and 29). 1. A closed record review for resident ID #23 revealed the resident was discharged from the facility on 12/6/2016 with no evidence of a physician's discharge order. 2. A closed record review for resident ID #24 revealed the resident was discharged from the facility on 1/4/2017 with no evidence of a physician's discharge order. 3. A closed record review for resident ID #29 revealed the resident was discharged from the facility on 7/16/2015 with no evidence of a physician's discharge order. During surveyor interview on 4/7/2017 at 12:30 PM the Director of Nurses unable to provide evidence of a physician's discharge order for resident IDs #23 and 24. During surveyor interview on 4/7/2017 at 10:05 AM the Assistant Director of Nurses was unable to provide evidence of a physician's discharge order for resident ID #29. 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. | 2020-09-01 |
| 91 | 91 | WEST SHORE HEALTH CENTER | 415028 | 109 WEST SHORE ROAD | WARWICK | RI | 2889 | 2018-07-09 | 656 | E | 0 | 1 | DOH811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, record review and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives to meet a resident's needs, relative to dignity 1 of 1 sample residents, resident ID # 66. Findings are as follows: During multiple surveyor observations on 6/28/2018 through 7/6/2018, the resident was observed with his/her brief exposed and the lower half of his/her body exposed. Surveyor observation of Resident ID #66, on all days of the survey was seen pacing in the hallway and or in his/her room with his/her brief down to the knees, with his/her privates, back and buttocks exposed. The resident was also observed lying on his bed with his knees up in the air uncovered with privates exposed. The resident has an extremely large scrotum that extends down to the knees and is not covered with the brief. Review of the resident's care plan dated 8/9/2017 and revised on 5/17/2018, there is no indication that the facility has addressed this problem of maintaining the residents right to dignity by implementing any interventions that would provide for the resident to be clothed in a dignified manner. During a surveyor interview with the Assistant Director of Nursing Services (ADNS) on 07/2/2018 at approximately 1:20 PM, he acknowledged that the resident's clothing does not provide the resident with personal privacy due to the [MEDICAL CONDITION] scrotum. He stated the staff has give the resident suspenders in an effort to hold up his trousers, however when the resident tried to use these his pants are so low that the residents back and buttocks are exposed. The ADNS was unable to provide evidence that the facility had develop and implement a comprehensive person-centered care relative to dignity for resident ID # 66. | 2020-09-01 |
| 92 | 92 | WEST SHORE HEALTH CENTER | 415028 | 109 WEST SHORE ROAD | WARWICK | RI | 2889 | 2018-07-09 | 658 | D | 0 | 1 | DOH811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interview, it has been determined the facility failed to assure that services being provided meet professional standards of quality relative to following physicians MEDICATION ORDERS FOR [REDACTED]. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders [REDACTED]. Clinical record review for resident ID#71 reveals a physician's orders [REDACTED]. Further record review of the Medication Administration Record [REDACTED] The 7:30 AM dose was administered late on 14 out of 59 dates; 05/16/2018, 05/20/2018, 05/21/2018, 05/22/2018, 05/24/2018, 05/30/2018, 05/31/2018, 06/13/2018, 06/14/2018, 06/15/2018, 06/16/2018, 06/18/2018, 06/20/2018, and 06/21/2018. The 11:30 AM dose was administered late on 3 out of 59 dates; 05/20/2018, 06/11/2018 and 06/12/2018. The 4:30 PM dose was administered late on 8 out of 59 dates; 05/07/2018, 05/08/2018, 05/09/2018, 05/13/2018, 05/14/2018, 06/08/2018, 06/11/2018 and 06/20/2018. During surveyor interview on 07/05/18 at 03:06 PM with Staff nurse B, he acknowledged that the medication was being given late and revealed that [MEDICATION NAME]-[MEDICATION NAME] should be given before meals per the physician's orders [REDACTED].> | 2020-09-01 |
| 93 | 93 | WEST SHORE HEALTH CENTER | 415028 | 109 WEST SHORE ROAD | WARWICK | RI | 2889 | 2018-07-09 | 689 | F | 0 | 1 | DOH811 | Based on surveyor observation and staff interview, it was determined that the facility failed to ensure that the resident environment remains as free of accident hazards as possible related to chemicals stored unsecured in the linen closet for 4 of 6 closets on the following units; First Floor South, Second floor South, West and North units. Findings are as follows: During a surveyor observation of the 1st floor south linen closet on 7/03/2018 at 12:25 PM, there were the following chemicals stored unsecured: - 2 containers of Clorox Bleach Germicidal Wipes - 4 containers of Clorox Hydrogen Peroxide Disinfecting Wipes - 3 bottles of barrier skin cream - 1 bottle of no rinse skin cleanser During a surveyor observation of the 2nd floor (south) on 7/3/2018 at 12:30 PM, there were the following chemicals stored unsecured in the linen closet: - 1 container of Clorox Bleach Germicidal Wipes - 4 containers of Clorox Hydrogen Peroxide Disinfecting Wipes - 2 unopened Fleet enemas - 6 spray bottles of medline ready cleaning body lotions - 1 container PDI sani-hands - 1 4 ounce bottle of mouth wash - 1 bottle of sunscreen - 4 bottles of no rinse cleanser - 5 packages of ReadyFlush Biodegradable Flushable Wipes - 1 4 ounce bottle of hand sanitizer During a surveyor observation of the 2nd floor (north) on 7/3/2018 at 12:35 PM, there were the following chemicals stored unsecured in the linen closet: - 1 container of Clorox Bleach Germicidal Wipes - 4 containers of Clorox Hydrogen Peroxide Disinfecting Wipes - 1 box of denture cleaning tablets - 4 bottles of hand sanitizer During a surveyor observation of the 2nd floor (west) on 7/3/2018 at 12:40 PM, there were the following chemicals stored unsecured in the linen closet: - 2 containers of Clorox Bleach Germicidal Wipes - 1 container of Clorox Hydrogen Peroxide Disinfecting Wipes During a surveyor interview with the, Staff, ( Staff H) on 7/5/2018 at approximately 2:30 PM she indicated that the linen closets should always be locked. In a subsequent interview with the Director of … | 2020-09-01 |
| 94 | 94 | WEST SHORE HEALTH CENTER | 415028 | 109 WEST SHORE ROAD | WARWICK | RI | 2889 | 2018-07-09 | 698 | D | 0 | 1 | DOH811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interview, it was determined that the facility failed to ensure that the residents who require [MEDICAL TREATMENT] receive services, consistent with professional standards of practices for 1 of 1 sample residents, resident ID # 61, relative to the access site. Findings are as follows: Record review revealed resident ID #61 was admitted on [DATE] with a [DIAGNOSES REDACTED]. He/she is dependent on [MEDICAL TREATMENT]. Further record review failed to reveal evidence that the facility was assessing, observing and documenting the care of access site, such as auscultation/palpation of the AV fistula (connection of a vein and an artery, usually in the forearm, to allow access to the vascular system for [MEDICAL TREATMENT]) to assure adequate blood flow. During a surveyor interview on 7/5/2018 at approximately 2:45 PM with Staff F she was unable to provide evidence that the facility was assessing, observing and documenting the care of AV fistula. During an interview with the Director of Nurses on 7/6/2018 at approximately 10:00 AM she was unable to provide evidence that the facility is assessing and documenting the care of the access site. | 2020-09-01 |
| 95 | 95 | WEST SHORE HEALTH CENTER | 415028 | 109 WEST SHORE ROAD | WARWICK | RI | 2889 | 2018-07-09 | 761 | E | 0 | 1 | DOH811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, staff interview and record review, it was determined that the facility failed to ensure that medications were dated when opened in accordance with current accepted professional principles, and that expired medications are not administered for 1of 1 residents with expired eye drops, ( resident ID# 114) Finding are as follows: 1. Surveyor observation of the first floor north medication cart on 7/5/2018 at 1:00 PM, in the presence of the Medication Technician, revealed one bottle of [MEDICATION NAME] 0.1% eye drops for resident ID # 114, that were dated as opened on 5/16/2018, had a discard date of 6/15/2018 written on the label. Record review of the (MONTH) and (MONTH) Medication Administration Record [REDACTED]. During an interview with the Medication Aide (Staff G) on 7/05/2018 at 1:00 PM she acknowledged that these eyes drops continued to be administered after the discard date ( (MONTH) 15,2018) and that the eye drops should have been removed from the medicine cart. 2. Surveyor observation of the first floor medication cart on 7/5/2018 at 12:50 PM revealed one [MEDICATION NAME] 1 ml vial opened with no date indicating when it was opened. The [MEDICATION NAME] was issued from the pharmacy on 2/09/2018. During an interview with Staff nurse F on 7/05/2018 at 12:50, she acknowledged that the [MEDICATION NAME] was not dated when opened, per facility policy/ protocol. 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. | 2020-09-01 |
| 96 | 96 | WEST SHORE HEALTH CENTER | 415028 | 109 WEST SHORE ROAD | WARWICK | RI | 2889 | 2017-10-25 | 225 | D | 1 | 0 | REJ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and staff interviews, it has been determined that the facility failed to ensure that all alleged violations of abuse, including injuries of unknown source, are thoroughly investigated and reported to the state agency for 2 of 10 sample residents (Resident ID#s 1 and 10). Findings are as follows: 1. On 10/23/2017 a community complaint was filed to the State Agency regarding bruising discovered by staff on or about 10/11/2017 on Resident ID#1's pubic bone which the facility told the complainant was caused by a diaper. The complainant revealed that s/he requested an investigation by the facility and discovered that the facility never reported the incident to the State Agency. Review of Resident ID#1's 10/10/2017 11:52 PM progress note written by Staff Nurse B states, in part, During HS (hour of sleep) care CNA (certified nursing assistant) reports ecchymotic (bruise) that was not there when she worked last night. assessed with [REDACTED]. Ecchymotic area noted to from pubis mons (tissue over the pubic bone) to right hip Reported to Director of Nursing Service (DNS) via telephone. Will continue to monitor . Surveyor observation of the resident on 10/23/2017 at 3:15 PM in the presence of Supervisor Nurse C and the Nurse Practitioner revealed only fading right hip bruising and the area over the mons pubis resolved. Surveyor interviews were conducted with multiple facility staff and revealed descriptions of the injury and the following speculations on possible causes of the ecchymosis: -10/23/2017 3:20 PM Supervisor Nurse C revealed it could have been caused by a gait belt (a device used for assisting resident with ambulation). -10/23/2017 3:21 PM Nurse Practitioner revealed that her first observation of the wound was on this date in the presence of the surveyor and that it could possibly have been caused by rolling onto an item, like a bed control, during repositioning in bed. -10/24/2017 7:36 AM Staff Nurse D revealed tha… | 2020-09-01 |
| 97 | 97 | WEST SHORE HEALTH CENTER | 415028 | 109 WEST SHORE ROAD | WARWICK | RI | 2889 | 2017-10-25 | 226 | D | 1 | 0 | REJ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it was determined that the facility failed to ensure that the Abuse Prohibition Policy and Procedure was implemented related to investigation and reporting to the state agency for an injury of unknown origin and potential abuse in 2 of 8 facility incidents reviewed affecting sample residents (ID#1 and 10). Findings are as follows: The facility's policy titled, Abuse Prohibition, revised 3/31/2017, states, in part, Abuse .Sexual-includes sexual harassment, coercion or assault . .Injuries of unknown origin-an injury that satisfies both of the following conditions: The source or cause of the injury was not observed by any person or the source of the injury can not be explained by the resident AND the injury is suspicious because of the extent of the injury OR the location of the injury OR the number of injuries observed at one particular point of time OR the incidence of injuries over time . Investigation- It is the DNS/designee's responsibility to act immediately to: .Obtain statements from witnesses . It is also the responsibility of the Director of Nursing to ensure that: .personnel and witness statements are obtained timely .the investigation is comprehensive and timely documented appropriately. It is the responsibility of the Nursing Home Administrator to: Notify the appropriate agencies in writing. Submit the report of the allegations and the results of the internal investigation to the Department of Health within 5 working days of the original filing . 1. Review of a community reported complaint received by the State Agency on 10/23/2017 revealed on or about 10/11/2017 staff discovered bruising on Resident ID #1's pubic bone which the facility told the complainant was caused by a diaper. The complainant revealed that s/he requested an investigation by the facility and took photographs of the injury. Record review for Resident ID#1 revealed an admitted [DATE] with [DIAGNOSES REDACTED]. A 10/10/… | 2020-09-01 |
| 98 | 98 | GOLDEN CREST NURSING CENTRE | 415029 | 100 SMITHFIELD ROAD | NORTH PROVIDENCE | RI | 2904 | 2020-02-04 | 692 | E | 1 | 1 | XRKT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 of 6 residents reviewed for nutrition, ID # 86. Findings are as follows: Review of the facility policy titled: Obtaining Height and Weights reads in part: Procedure: 3 .If the resident weight reflects a five pound fluctuations obtain a re-weigh. Record review revealed Resident ID #86 was admitted to the facility in July of 2019 with [DIAGNOSES REDACTED]. Further review revealed a physician's order dated 09/02/2019 for weekly weight, once a day on Wednesday's. Review of a progress note written by the Registered Dietitian (RD) dated 01/03/2020 revealed the Resident's weight was 120 pounds (lbs.) Review of Resident ID # 86's weight record for January 2020 revealed the following weights: 01/01/2020 120 lbs. 01/08/2020 114.2 lbs. 01/15/2020 113 lbs. 01/22/2020 114.2 lbs. 01/29/2020 114 lbs. This indicates a significant weight loss of 5% in 1 week. There was no evidence of a re-weigh. Record review failed to reveal evidence that the significant weight loss was reviewed or reported to the RD and/or Physician. An interview was conducted on 01/30/2020 at 11:56 AM with the RD. She revealed she was unaware of the 5% weight loss. | 2020-09-01 |
| 99 | 99 | GOLDEN CREST NURSING CENTRE | 415029 | 100 SMITHFIELD ROAD | NORTH PROVIDENCE | RI | 2904 | 2020-02-04 | 761 | E | 1 | 1 | XRKT11 | > Based on Surveyor observation, record review and staff interview, it has been determined that the facility failed to provide for accurate labeling to facilitate consideration of precautions and safe administration and storage of medications on one of four medication carts reviewed for ID #95. Findings are as follows: Medication storage observation on 1/30/2020 at approximately 7:45 AM revealed the following: 1.) Breo Ellipta inhaler 100-25 micrograms, current order dated 06/17/2019; one puff; inhalation once daily. The medication was opened and dated 12/15/2019. Manufacturer's instructions indicate to discard 6 weeks after opening. Medication expired on 01/26/2020. 2.) Latanoprost 0.005% eye drops, current order dated 12/17/2018; one drop once daily before bed. The medication was opened and dated 11/23/2019. Manufacturer's instructions indicate to discard 6 weeks after opening. Medication expired on 01/04/2020. During Surveyor interview with the Certified Medication Technician, Staff D, immediatley following the observation, she confirmed that both the above medications were expired and should have been discarded. | 2020-09-01 |
| 100 | 100 | GOLDEN CREST NURSING CENTRE | 415029 | 100 SMITHFIELD ROAD | NORTH PROVIDENCE | RI | 2904 | 2019-02-07 | 550 | D | 0 | 1 | D0BG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, record review, and staff interviews, it was determined that the facility has failed to ensure a resident's dignity was maintained relative to administering insulin in a common area for 1 of 2 sample residents observed (Resident ID#101). Findings are as follows: Surveyor observations on 2/5/2019 at 8:28 AM and 2/7/2019 at 8:03 AM revealed Staff Nurse A administer an insulin injection to Resident ID#101 who was sitting in the common area with approximately 18 residents present in the room. The nurse lifted the resident's clothing and administered the injection into Resident ID#101's thigh on both occasions. Record review for Resident ID#101 revealed [DIAGNOSES REDACTED]. A 1/25/2019 quarterly Brief Interview for Mental Status score of 3 out of 15, indicating severe cognitive impairment. The Medication Administration Record [REDACTED]. During surveyor interviews with Staff Nurse A on 2/5/2019 at 8:50 AM and 2/7/2019 at 8:29 AM, she revealed she administers insulin to Resident ID#101 in the common area. During a surveyor interview with the Assistant Director of Nursing Services on 2/7/2019 at 9:25 AM, she revealed that privacy should be provided when administering injections and that the resident's dignity must be maintained. | 2020-09-01 |
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CREATE TABLE [cms_RI] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );