cms_RI
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 954 | 954 | HEBERT NURSING HOME | 415049 | 180 LOG ROAD | SMITHFIELD | RI | 2917 | 2018-07-18 | 760 | G | 1 | 0 | Deficiency Text Not Available | 2018-09-01 | |
| 1110 | 1110 | PAWTUCKET SKILLED NURSING & REHABILITATION | 415064 | 70 GILL AVENUE | PAWTUCKET | RI | 2861 | 2017-10-27 | 224 | D | 1 | 0 | Deficiency Text Not Available | 2017-12-01 | |
| 1111 | 1111 | PAWTUCKET SKILLED NURSING & REHABILITATION | 415064 | 70 GILL AVENUE | PAWTUCKET | RI | 2861 | 2017-10-27 | 225 | D | 1 | 0 | Deficiency Text Not Available | 2017-12-01 | |
| 1118 | 1118 | CHERRY HILL MANOR | 415053 | 2 CHERRY HILL ROAD | JOHNSTON | RI | 2919 | 2017-09-25 | 323 | E | 1 | 0 | Deficiency Text Not Available | 2017-11-01 | |
| 946 | 946 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2015-09-02 | 225 | D | 1 | 0 | 004Q11 | **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 report and thoroughly investigate abuse allegations and injuries of unknown origin in accordance with the requirements for 2 of 2 sample residents, resident's ID # 2 & 3. Findings are as follows: 1. Review of the complaint alleging resident to resident abuse, that was reported to the DOH by the facility on 7/21/2015, revealed that the incident occurred on 7/17/2015 involving resident's ID # 2 & 3. Review of the facilities investigation of the incident dated 7/24/2015, states that the staff did not witness resident ID # 2 push resident ID # 3, but states in part heard the sound of someone making physical contact with another. Interview with the Director of Nurses (DNS) on 8/26/2015 at approximately 10:30 AM, she was unable to explain what she meant by the sound of someone making physical contact with another, in her investigation report. Review of a nurse's note for resident ID # 3 dated 7/17/2015 States patient found on floor in television room on 3 West. Patient stating she cannot move, and is bleeding from the back of her head.Son called and will meet her at hospital. Review of the nurse's note for resident ID # 2 dated 7/17/2015 states reported by CNA (certified nursing assistant) that resident pushed another resident causing the other resident to fall and hit his/her head on the floor The surveyor interviewed the nursing assistant (Staff ID# B) on 8/31/2015 at 9:45 AM, regarding the allegation of resident ID # 2 pushing ID # 3 on 7/17/2015. She informed the surveyor that she was the only staff on the 3 West Dementia unit at the time of the incident. She stated that she did not witness the incident and only heard the residents talking in loud voices. She heard resident ID # 3 asking resident ID # 2 questions and that resident ID # 2 saying your in the way. She further stated that she did not hear resident ID # 3 fall but she observed her on the floor … | 2018-09-01 |
| 947 | 947 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2015-09-02 | 353 | J | 1 | 0 | 004Q11 | For findings see survey Event ID # *459S12, Fed - F - 0353 Sufficient 24 Hour Nursing Staff | 2018-09-01 |
| 1875 | 1875 | BAYBERRY COMMONS | 415080 | 181 DAVIS DRIVE | PASCOAG | RI | 2859 | 2010-10-28 | 365 | D | 021X11 | **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 failed to ensure that 1 of 6 residents with swallowing problems (ID# 9) received liquids in the form necessary to meet her individual needs. The facility failed to provide liquids thickened to nectar consistency. Findings are as follows: 1. Record review for resident ID# 9, indicated that the resident has a history of pneumonia, has difficulty chewing due to missing teeth, and difficulty swallowing. On 7/11/10 there was a physician's orders [REDACTED]. The resident eats lunch in the main dining room and can feed herself. During meal observations on 10/25/10 at 12:15 PM, on 10/26/10 at 12:40 PM, and on 10/27/10 at 12:20 PM, it was noted that the resident was served a dietary house supplement, which is a fortified vanilla shake. The supplement was poured directly from the carton into the resident's glass by activity staff, who served the lunch meal to the resident's. During these meals, surveyor observations revealed that the vanilla shake was not thickened by the staff. During an interview with the Food Service Director on 10/28/10 at 8:40 AM she stated that the vanilla shake is not a thickened liquid and that it is slightly thicker than water, but that it must be thickened. During an interview with the Activity Director on 10/28/10 at 8:50 AM, she indicated that she and her staff assumed that the vanilla shake was a nectar thickened product. "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." | 2014-01-01 | ||
| 1876 | 1876 | BAYBERRY COMMONS | 415080 | 181 DAVIS DRIVE | PASCOAG | RI | 2859 | 2010-10-28 | 242 | E | 021X11 | **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 1of 21 sample residents, ID # 14, was allowed to make choices about aspects of her life regarding the provision of care. The facility failed to make adjustments in the daily routine and to utilize strategies in an effort to support the resident in accepting care. Findings are as follows: Record review for resident ID # 14 revealed that she has [DIAGNOSES REDACTED]. The most recent Minimum Data Set (July 2010) indicated that the resident has impaired long and short term memory and impaired cognition for daily decision making. It further indicated that the resident resists care. During the initial tour of the facility on 10/25/10, the nurse identified the resident as one who is combative with care. During observation of care on 10/28/10 at 11:20 AM two Nursing Assistants (NA) approached the resident for a shower. The resident shouted "Leave me alone," became agitated and continued to verbally refuse care. The NA's continued to explain to the resident why she should take a shower. The resident was screaming and began to physically strike at the NA's. Although the NAs abandoned the shower, they continued to attempt to provide personal care despite the resident's physical and verbal protests. The nurse was summoned to the room and tried to soothe the resident but continued to explain to her that she required personal care. During an interview with the nurse on 10/28/10 at 11:30 AM, she reported that the resident "is like this everyday." She was unable to provide evidence that interventions, alternatives, or adaptations had been made in an effort to support the resident's choices and preferences related to care. Refer to F281 | 2014-01-01 | ||
| 1877 | 1877 | BAYBERRY COMMONS | 415080 | 181 DAVIS DRIVE | PASCOAG | RI | 2859 | 2010-10-28 | 281 | E | 021X11 | **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 services that meet professional standards for 2 of 21 sample residents, ID # 6 and 14. The facility failed to ensure that physicians orders were implemented relative to medication administration and nutritional supplementation. Findings are as follows: The State of Rhode Island Rules and Regulations for the Licensing of Nurses and Standards for the Approval of Basic Nursing Education Programs (R5-34-NUR/ED), Section 1.27, defines "Nursing", and states, in part: "It provides care and support of individuals and families during periods of wellness, illness, and injury and incorporates the appropriate medical plan of care as prescribed by a duly licensed physician, dentist, podiatrist, or other health care provider licensed to prescribe." 1. Record review for resident ID # 14 indicated that a psychiatric evaluation was done on 8/5/10 related to combative behaviors during care. In response to the psychiatric recommendations, the physician ordered (as of 8/13/2010 to the present) [MEDICATION NAME] 12.5 milligrams as needed before AM (morning) care and PM (evening ) care. Record review of the nurses' notes further indicated that the resident was described as usually combative with care or combative with NA's (nursing assistants) on 10/27/10 at 10:29 PM and 12:46 PM, 10/26/10 at 2:09 PM, 10/25/10 at 2:51 PM and 10/12/10 at 12: 48 PM. During an interview with a NA on 10/27/10 at approximately 1:30 PM, she described the resident as being combative with care. During surveyor observation of the resident's care on 10/28/10 at 11:20 AM, it was noted that the resident was very agitated at the suggestion of care and attempts at provision of care. The resident was shouting loudly, pushing and slapping care givers. During an interview with a nurse on 10/28/10 at 11:30 AM, she stated that the resident is "like this every day". Despite this, a r… | 2014-01-01 | ||
| 1878 | 1878 | BAYBERRY COMMONS | 415080 | 181 DAVIS DRIVE | PASCOAG | RI | 2859 | 2010-10-28 | 325 | E | 021X11 | **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, based on the comprehensive assessment, that a therapeutic nutritional intervention was provided when a nutritional problem had been identified for 1 of 21 sample residents ID # 6. The resident did not receive a supplement. Findings are as follows: Record review for resident ID # 6 revealed an assessment by a dietitian dated 10/7/10 that stated the resident was below ideal body weight and at risk for weight loss secondary to poor intake (0-50%) and has experienced nausea and vomiting. The dietitian recommended house shake or [MEDICATION NAME] (which ever is preferred) to promote weight gain or maintenance. On 10/8/10 an order was given for the resident to receive house shake or [MEDICATION NAME] 120 (cubic centimeters) cc, three times a day. During surveyor observations of the resident at meal times on 10/25/10 at 12:05 PM, on 10/27/10 at 8:35 AM on 10/26/10 at 12:00 PM and on 10/27/10 at 12:20 PM the resident was observed to have poor food consumption and little motivation to eat. Record review of the meal consumption record, under "Vitals", indicated that between 10/7/10 and 10/27/10 the resident consumed the following quantities of her meals: meals were not taken 4 times, the resident consumed 1-26 % 15 times, 26-50% 10 times and 51-75% 4 times. During an interview with a NA on 10/26/10 at 9:58 AM, she stated that on a routine basis all residents in the dinning room receive a supplement if they do not consume at least 50% of their meals. The facility produced documentation that the resident received supplements only 7 of 25 required times between 10/7/10 and 10/27/10. During an interview with the Director of Nurses on 10/28/10 at approximately 11:00 AM, she was unable to produce evidence that the resident had been provided with the supplement which was to address a nutritional problem. | 2014-01-01 | ||
| 1682 | 1682 | ALPINE NURSING HOME INC | 415089 | 557 WEAVER HILL ROAD | COVENTRY | RI | 2816 | 2011-12-21 | 281 | D | 0 | 1 | 02TF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview it was determined that the facility failed to follow physicians orders for 2 of 14 sample residents, ID # 2 relative to weights and ID #3 relative to a dietary supplement. Findings are as follows: The State of Rhode Island Rules and Regulations for the Licensing of Nurses and Standards for the Approval of Basic Nursing Education Programs (R5-34-NUR/ED), Section 1.27, defines "Nursing", and states, in part: "It provides care and support of individuals and families during periods of wellness, illness, and injury and incorporates the appropriate medical plan of care as prescribed by a duly licensed physician, dentist, podiatrist, or other health care provider licensed to prescribe." 1. Review of resident ID# 3's clinical record revealed that on 12/14/11 the dietitian documented the resident has lost 12.3 % body weight in 3 months. On 12/14/11 a physicians order was obtained to increase the resident's supplement (carnation instant breakfast), from 8 ounces twice a day, to 16 ounces twice a day. Review of the residents diet card and of the kitchen's beverage list revealed that the resident was receiving 8 ounces of supplement, instead of 16 ounces, at supper. During interview on 12/20/11 at approximately 1:00 PM, the dietary staff indicated the resident had not received 16 ounces at supper per the physicians order. 2. Review of resident ID# 2's clinical record revealed the resident's [DIAGNOSES REDACTED]. The resident had a physician order [REDACTED]. "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." | 2015-04-01 |
| 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 |
| 732 | 732 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2019-08-08 | 756 | E | 0 | 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 ensure a resident's drug regimen review was acted upon after irregularities were found for 1 of 8 sample residents reviewed for monthly pharmacy drug regimen reviews (ID #44). Findings are as follows: Clinical record review for Resident ID #44 revealed a current physician's orders [REDACTED]. Review of the monthly pharmacist medication regimen review revealed recommendations dated 11/3/2018 that state, in part, .This resident has been on the antipsychotic [MEDICATION NAME] 0.25 mg at bedtime since 12/2017. Please add dx (diagnosis) to ICD 10 (International Statistical Classification of Diseases and Related Health Problems) list to support use . Further review of the record revealed the following monthly pharmacy review progress notes: -11/4/2018 .dx for [MEDICATION NAME] . -12/10/2018 .dx for [MEDICATION NAME] . -1/3/2019 .[MEDICATION NAME] 0.25mg q hs (daily at bedtime) .see rec (recommendation) ICD10 .follow [MEDICATION NAME] dx . -2/14/2019 .[MEDICATION NAME] 0.25mg q hs .see rec ICD10 .dx [MEDICATION NAME] . -3/6/2019 .[MEDICATION NAME] 0.25mg q hs .see rec ICD10 .dx [MEDICATION NAME] . -4/10/2019 .[MEDICATION NAME] 0.25mg q hs .see rec ICD10 .dx [MEDICATION NAME] . -5/7/2019 .[MEDICATION NAME] 0.25mg q hs .see rec ICD10 . -6/9/2019 .[MEDICATION NAME] 0.25mg q hs .see rec ICD10 . -7/2/2019 .[MEDICATION NAME] 0.25mg q hs .see rec ICD10 . Record review from 11/4/2018 to 8/7/2019 lacked evidence that the recommendation to add a [DIAGNOSES REDACTED]. During a surveyor interview with the Director of Nursing Services on 8/7/2019 at 2:42 PM, she was unable to provide evidence that the drug regimen review was acted upon by the attending practitioner. | 2019-09-01 |
| 832 | 832 | BRIARCLIFFE MANOR | 415012 | 49 OLD POCASSET ROAD | JOHNSTON | RI | 2919 | 2016-02-19 | 253 | C | 0 | 1 | 02ZW11 | Based on surveyor observations and staff interviews, it was determined the facility has failed to provide housekeeping and maintenance services necessary to maintain an orderly and comfortable interior for 3 of 3 residential nursing units. Findings are as follows: 1. First Floor Nursing Unit a. The main dining room left entry door has extensive marring on the lower third. b. The boiler room door, across from the main dining/activity room, has extensive marring on the lower two-thirds. c. The elevator adjacent to the nursing station has heavily worn wooden flooring and an approximate 3'' x 2'' area of missing formica on the lower third of the door. 2. Second Floor Nursing Unit a. The wooden counter top at the nursing station is heavily worn in an approximate 12' x 1.5' area. b. Linoleum flooring at two areas adjacent to the nursing station, an area between room 32 and the common shower room, and an area between rooms 37 and 39, all approximately 8 feet x 1-2 inches, were heavily worn and cracked. c. Linoleum flooring in front of room 28, in an approximate area of 3 feet x 1-2 inches, were heavily worn and cracked. d. The door to room 32 has excessive marring on the lower third. e. The air conditioning unit in room 28 is heavily marred and stained. f. The baseboard heating covers /vents in rooms 19, 28, 34, 35 and 41 were heavily marred and the paint was peeling. g. There was an area of rust around the drain of the sink in room 28. h. The flooring at the entrance to room # 23 has a worn surface in an approximate 3.5' x 8 area. 3. Third Floor Nursing Unit a. The entry door and adjacent door frame to the restorative dining/activity room has excessive marring on the lower third. b. The biohazard room door has a 3' x 3 area of marring on the lower third. c. Doors to the med room, kitchenette and record rooms had extensive marring on the lower third. You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the 'Rules and Regulations for Licens… | 2019-03-01 |
| 1862 | 1862 | HARRIS HEALTH CENTER, LLC | 415098 | 833 BROADWAY | EAST PROVIDENCE | RI | 2914 | 2010-10-08 | 250 | E | 05KX11 | Based on clinical record review, surveyor observation, staff and resident interview, it has been determined that the facility failed to provide medically-related social services to attain the highest practicable physical, mental and psychosocial well being for 2 non sample residents (ID#'s 11 and 12). Findings are as follows: Resident ID #11 was observed on 10/6/10 at approximately 1:30PM, lying in bed in his room. The volume of the television in his room was blaring. Interview with the charge nurse revealed that this resident is deaf in his right ear and the hearing aid for his left ear is missing. During a subsequent telephone interview with the resident's wife, she indicated that the resident had been without a hearing aid for several months. Clinical record review revealed a nurse's note dated 3/16/10 which states "...returned from consultation for left hearing aid...a request for new hearing aid was submitted...they will contact the facility in 3-4 weeks if the hearing aid is approved". During interview with the Director of Nurses on 10/7/10 at 11:15AM, she revealed that, although the facility was unaware of the status for the hearing aid, the audiologist had not been contacted to check on the approval of the hearing aid for the resident until prompted by the surveyor on this date. Review of Resident ID # 12's clinical record revealed a Social Service note dated 2/2/10 which stated "...informed by nursing that resident needs cataract surgery ...MD does not feel that resident is able to understand and sign for procedure...seeking guardianship..."A social service note dated 4/16/10 revealed "...spoke to ...regarding guardianship referral ...following up with further referral information...". Interview with the Social Service Designee on 10/7/10 at 11:15AM revealed that no subsequent call had been placed to check on the status of the guardianship until the matter was brought to her attention by the surveyor on this date. During interview with this resident on 10/8/10 at 7:40 AM , he stated "my left eye is blurr… | 2014-02-01 | ||
| 1863 | 1863 | HARRIS HEALTH CENTER, LLC | 415098 | 833 BROADWAY | EAST PROVIDENCE | RI | 2914 | 2010-10-08 | 313 | E | 05KX11 | Based on surveyor observation , clinical record review, staff, resident and family interview , it has been determined that the facility failed to ensure that each resident receives proper treatment and assistive devices to maintain vision and hearing for 2 non sample residents (ID#'s 11 and 12 ). Findings are as follows: On 10/6/10 at approximately 1:30 PM , Resident ID#11 was observed lying in bed . The volume of the television in his room was blaring. Interview with the charge nurse on 10/6/10 at 1:30PM revealed that the resident is deaf in his right ear and the hearing aid for his left ear has been missing for an undetermined length of time. During a subsequent telephone interview with the resident's wife, she indicated that the resident had been without a hearing aid for several months. Clinical record review revealed a nurses note dated 3/16/10 which states "...returned from consultation for left hearing aid...a request for new hearing aid was submitted ...they will contact the facility in 3-4 weeks if hearing aid is approved." Additional record review revealed the facility had not been contacted regarding the resident's hearing aid and no call had been placed to the audiologist to check on its status. During interview with the Director of Nurses on 10/7/10 at 11:15AM, she revealed that, although the facility was unaware of the status for the hearing aid, the audiologist had not been contacted to check on the approval of the hearing aid for the resident until prompted by the surveyor on this date. Review of Resident ID # 12's clinical record revealed a social service note dated 2-2-10 which stated "...informed by nursing that resident needs cataract surgery ...MD does not feel that resident is able to understand and sign for procedure...seeking guardianship ,,," A social service note dated 4-16-10 revealed "...spoke to ...regarding guardianship referral ...following up with further referral information..." During interview with the resident on 10/8/10 at 7:40 AM , he stated, "my left eye is blurred ". Interv… | 2014-02-01 | ||
| 1010 | 1010 | EASTGATE NURSING & REHABILITATION CENTER | 415083 | 198 WATERMAN AVENUE | EAST PROVIDENCE | RI | 2914 | 2015-02-19 | 157 | E | 0 | 1 | 07CV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it was determined the facility failed to promptly notify the physician when the resident continued to refuse a medication prescribed by their physician for 2 of 2 sample residents,ID # 7 and #10. Findings are as follows: 1. Resident ID #7 has a current physician's orders [REDACTED]. Review of the resident 's January and February 2015 Medication Administration Record [REDACTED]. During a telephone interview on 2/18/2015 at 1:35 PM with the resident 's physician, he was unable to recall being notified that the resident had been refusing the [MEDICATION NAME]. 2. Resident ID #10 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the resident 's February MAR indicated [REDACTED]. During a telephone interview on 2/18/2015 at 2:30 PM with the resident 's physician he was unable to recall being notified that the resident had been refusing the inhaler. Additionally, the charge nurse was interviewed on 2/18/2015 at approximately 9:10 AM and at 2:25 PM regarding the above stated residents, and was unable to provide evidence that the physician was notified of the medication refusals. | 2018-05-01 |
| 1011 | 1011 | EASTGATE NURSING & REHABILITATION CENTER | 415083 | 198 WATERMAN AVENUE | EAST PROVIDENCE | RI | 2914 | 2015-02-19 | 166 | E | 0 | 1 | 07CV11 | **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 resolve a resident's grievance(S) relative to wearing a personal safety alarm for 1 of 3 sample residents (ID #5) . Findings are as follows: Resident ID #5 was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. A brief Interview for Mental Status (BIMS) as conducted on 1/14/2015 resulting in a score of 13 out of 15 points. A comprehensive assessment completed on 1/22/2015 revealed that the resident scored a 10 out of 15 points on a BIMS. ID # 5 is alert, orientated and forgetful at times. During an interview on 2/17/2015 at 3:15 PM, the resident stated, The clip alarm on my back I undo I told staff I don't want it and was told I have to have it. The resident was given a mat alarm in place of the tab alarm and stated to the surveyor It hurts the sore on my bottom, and it goes off while I am in bed disturbing my sleep. I told the nurse, the aide and therapist and nothing was done. Review of the progress notes revealed: 2/11/15 resident continues to remove tab alarm 2/13/15- refusing mat alarm, despite education 2/15/15- call light used appropriately 2/17/15- resident refusing mat alarm at this time, complaint of discomfort to coccyx and noise bothers the resident. Interview with the unit charge nurse on 2/17/2015 at approximately 4:00 PM, revealed she was aware of the residents grievance regarding the alarm last week. The charge nurse was unable to provide evidence that the grievance was addressed or resolved. | 2018-05-01 |
| 1012 | 1012 | EASTGATE NURSING & REHABILITATION CENTER | 415083 | 198 WATERMAN AVENUE | EAST PROVIDENCE | RI | 2914 | 2015-02-19 | 281 | D | 0 | 1 | 07CV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interviews, it has been determined the facility failed to provide services in accordance with professional standards relative to following physician's orders [REDACTED].# 7. Findings are as follows: The State of Rhode Island Rules and Regulations for the Licensing of Nurses and Standards for the Approval of Basic Nursing Education Programs (R5-34-NUR/ED), Section 1.31, defines Nursing, and states, in part: It provides care and support of individuals and families during periods of wellness, illness, and injury and incorporates the appropriate medical plan of care as prescribed by a duly licensed physician, dentist, podiatrist, or other health care provider licensed to prescribe. Clinical record review for resident ID #7 revealed a current physician order [REDACTED]. Clinical documentation revealed the resident did not have a bowel movement from 1/28/2015 -1/31/2015. A review of the January 2015 Medical Administration Record revealed no documentation of a fleet enema given. During Interview with the unit charge nurse on 2/19/2015 at approximately 9:10 AM, she stated per the facility's bowel protocol, Milk of Magnesia (MOM) would be administered on the third day for constipation, and because of the resident's impaired renal status ([MEDICAL TREATMENT]) she could not have MOM and a fleet was ordered. The nurse was unable to provide evidence the physicians order was followed. | 2018-05-01 |
| 1013 | 1013 | EASTGATE NURSING & REHABILITATION CENTER | 415083 | 198 WATERMAN AVENUE | EAST PROVIDENCE | RI | 2914 | 2015-02-19 | 371 | F | 0 | 1 | 07CV11 | Based on surveyor observation and staff interview, it has been determined that the facility failed to store food under sanitary conditions relative to one of one milk storage refrigerators observed to be not clean to sight and touch. Findings are as follows: The initial kitchen tour was conducted on 2/16/2015 at 9:00 AM. At this time, the Food Service Director (FSD) was not present in the facility and therefore the tour was conducted in the presence of Staff F, the lead cook/staff supervisor. During the tour, a milk refrigerator was observed, with jugs of milk stored in crates. At this same time, upon opening the door, a strong, foul odor was immediately present and a large section in the center of the bottom panel was observed to be covered in a thick substance which was white in color with traces of black matter mixed with it. During an interview with staff F at the time of the observation, he acknowledged the odor and the substance and stated that it needed to be cleaned. 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. | 2018-05-01 |
| 1085 | 1085 | GRANDVIEW CENTER | 415020 | 100 CHAMBERS STREET | CUMBERLAND | RI | 2864 | 2015-03-23 | 441 | D | 0 | 1 | 08S511 | Based on surveyor observation, record review, and staff interviews, it was determined that the facility failed to ensure glucose meters are disinfected between resident use for 7 resident on 2 of 2 nursing units, (North and South), ID #'s 5, 16, 17, 18, 19, 20 and 21. Findings are as follows: A review of the facility's policy titled: Glucose Meter states, in part: 2. Disinfect meter before patient use. Surveyor observation on 3/19/2015 from 11:20 AM to 11:45 AM revealed a unit nurse (staff A) obtaining finger stick blood sugar (FSBS) with a glucose meter from residents ID #17, 5, 18, 19 and 20 respectively without cleaning the meter between residents. On 3/20/2015 at 11:35 AM, staff A was again observed obtaining an FSBS from resident ID #21 with a glucose meter. After completing the procedure, the surveyor observed the nurse put the glucose meter back into a storage container without cleaning it. At 11:40 AM, in the continued presence of the surveyor, this same nurse proceeded to obtain a FSBS from resident ID #16 without cleaning the glucose meter. After completing this procedure, the nurse again put the glucose meter back into the storage container without cleaning it. During an interview with staff A on 3/20/2015 at 11:45 AM, she stated that she was not aware that she needed to disinfect the glucose meter prior to patient use. During an interview with the Director of Nursing Services on 3/20/2015 at 12:20 PM, he stated that staff should be disinfecting glucose meters with Clorox wipes prior to each patient use. 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. | 2018-02-01 |
| 1768 | 1768 | GREENVILLE SKILLED NURSING & REHABILITATION | 415087 | 735 PUTNAM PIKE | GREENVILLE | RI | 2828 | 2011-10-21 | 502 | D | 0 | 1 | 09G411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews it was determined that the facility has failed to obtain laboratory services timely to meet the needs of its residents for 2 of 13 sample residents (ID #'s 13 and # 20). Findings are as follows: 1. Record review for resident ID #13 revealed physician orders [REDACTED]. During an interview with the unit charge nurse on 10/19/2011 at 10:50 AM, she was unable to provide evidence that the laboratory testing was completed as ordered. 2. Record review for resident ID # 20 revealed a 10/13/2011 physician order [REDACTED]. "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." | 2014-11-01 |
| 1769 | 1769 | GREENVILLE SKILLED NURSING & REHABILITATION | 415087 | 735 PUTNAM PIKE | GREENVILLE | RI | 2828 | 2011-10-21 | 281 | D | 0 | 1 | 09G411 | **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 meet professional standards of quality relative to following physician orders [REDACTED].# 2) relative to air an mattress, (ID #'s 2 and #6) relative to [MEDICATION NAME]es, (ID #6) relative to weights and (ID #16) relative to blood pressure monitoring. Findings are as follows: The State of Rhode Island Rules and Regulations for the Licensing of Nurses and Standards for the Approval of Basic Nursing Education Programs(R5-34-NUR/ED), Section 1.27, defines "Nursing", and states, in part: "It provides care and support of individuals and families during episodes of wellness, illness, and injury and incorporates the appropriate medical plan of care as prescribed by a duly licensed physician, dentist, podiatrist, or other health care provider licensed to prescribe." 1. Resident ID # 2 has a 10/1/2011 physician order [REDACTED]. Observations on 10/18/2011 at 8:05 AM, and at 10:06 AM revealed the air mattress was set at 300 lbs. Observations on 10/19/2011 at 11:00 AM, 10/20/2011 at 7:20 AM, 2:25 PM and on 10/21/2011 at 8:30 AM revealed that the air mattress was set at 150 lbs. When interviewed on 10/21/2011 at 8:35 AM, the Director of Nursing (DNS) was unable to provide evidence that the mattress was set as ordered. 2. Resident ID #2 has a 3/3/2011 physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. When questioned on 10/20/2011 at 9:10 AM, the unit charge nurse was unable to provide evidence that the number of patches administered and site of application were done. Resident ID #6 has a 9/6/2011, physician order [REDACTED]. Review of the MAR for this resident revealed that, although administered, there was no evidence of the number of patches administered in 9/2011 and 10/2011. Interview with the charge nurse on 10/20/2011, at 9:10 AM, was unable to provide evidence that the number administered and si… | 2014-11-01 |
| 1770 | 1770 | GREENVILLE SKILLED NURSING & REHABILITATION | 415087 | 735 PUTNAM PIKE | GREENVILLE | RI | 2828 | 2011-10-21 | 253 | C | 0 | 1 | 09G411 | Based on surveyor observation and staff interview, it was determined the facility failed to provide the necessary housekeeping and maintenance services for 4 of 5 bathing suites in the facility. Findings are as follows: Surveyor observation of the bathing suites on the units of the facility known as Buttercup, Lilly of the Valley, Starflower and Sunflower on 10/19/11 at 10:00 AM revealed that shower stalls were covered with a thick black glue-like matter along the entire perimeter at the lower part of each wall. Subsequent interview with the Maintenance Director at 10:05 AM revealed that, although a log is provided on each unit to monitor needed repair and cleaning, he was unable to provide evidence that the shower stalls needing maintenance attention had been monitored or addressed. | 2014-11-01 |
| 1771 | 1771 | GREENVILLE SKILLED NURSING & REHABILITATION | 415087 | 735 PUTNAM PIKE | GREENVILLE | RI | 2828 | 2011-10-21 | 428 | D | 0 | 1 | 09G411 | **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 monthly medication reviews by the consulting pharmacist include identification of irregularities for 2 of 2 sample residents relative to transdermal patches (ID #'s 2 and # 6). Findings are as follows: 1. Record review for resident ID # 2 revealed a 4/20//2011 physician order [REDACTED]. A review of the clinical record revealed that, although monthly pharmacy reviews were conducted for 9/2011 and 10/2011, they had failed to inform the facility of the following irregularities: 0 indication of the number of patches used and 0 indication of the site rotation. 2. Record review for resident ID # 6 revealed a 9/6/2011 physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. | 2014-11-01 |
| 1772 | 1772 | GREENVILLE SKILLED NURSING & REHABILITATION | 415087 | 735 PUTNAM PIKE | GREENVILLE | RI | 2828 | 2011-10-21 | 315 | D | 0 | 1 | 09G411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and record review it was determined that the facility failed to ensure that 1 of 3 sample residents with a suprapubic or indwelling catheter received appropriate care and services to prevent infection relative to placement of the foley catheter tubing and drainage bag (ID # 17). Findings are as follows: Record review for resident ID # 17 indicated that the resident has a Supra Pubic Catheter secondary to a [DIAGNOSES REDACTED]. | 2014-11-01 |
| 1773 | 1773 | GREENVILLE SKILLED NURSING & REHABILITATION | 415087 | 735 PUTNAM PIKE | GREENVILLE | RI | 2828 | 2011-10-21 | 411 | E | 0 | 1 | 09G411 | Based on record review and staff interview, it was determined that the facility failed to provide dental services to meet the needs of the resident for 1 of 1 sample residents (ID #7) relative to a loose tooth. Findings are as follows: On 10/18/2011 at 11:30 AM , the resident was observed in the dining room eating lunch and that one of the resident's front tooth was loose (wiggling as resident chewed her food). Subsequent review of the clinical record for this resident revealed that on 8/23/2011, the family requested that the resident be seen by a dentist relative to the loose tooth. On 9/14/11, the resident was seen by a dental hygienist and the resident's teeth were cleaned. However, the resident's loose tooth had not been addressed. In addition, there is no evidence that a request was made for the dentist to assess the resident's loose tooth. Interview on 10/20/2011 at 11:30 AM with the facility's consulting dentist revealed that he had not been notified of a need for a dental consult relative to the resident's loose tooth. | 2014-11-01 |
| 1774 | 1774 | GREENVILLE SKILLED NURSING & REHABILITATION | 415087 | 735 PUTNAM PIKE | GREENVILLE | RI | 2828 | 2011-10-21 | 406 | E | 0 | 1 | 09G411 | **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 act on and obtain an outside resource for support relative to a Hospice Consult for 1 of 1 sample residents (ID# 13). Findings are as follows: Record review for resident ID # 13 revealed the resident was readmitted to the facility on [DATE]. On 9/23/2011 a Hospice Consult was ordered by the physician. Further review revealed no evidence of a Hospice Consult. Interview on 10/19/2011 at 2:20 PM with the unit charge nurse indicated that she was unaware of the consultation and that the Hospice nurse was not notified until brought to the facility's attention by the surveyor. When questioned on 10/19/2011 at 2:30 PM the evening supervisor revealed that the consult was not obtained and that "it looks like we dropped the ball". | 2014-11-01 |
| 1775 | 1775 | GREENVILLE SKILLED NURSING & REHABILITATION | 415087 | 735 PUTNAM PIKE | GREENVILLE | RI | 2828 | 2011-10-21 | 333 | E | 0 | 1 | 09G411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 2 of 24 sample residents (ID #'s 7 and 19). Findings are as follows: 1. Resident ID # 7 has a 8/1/2011 physician's orders [REDACTED]. Review of this resident's MAR for August 2011 revealed that it was not administered 8/1911 and 8/30/ . Review of this resident's MAR for September 2011 revealed that it was not administered on 9/8/2011 and 9/20/2011. Interview with the unit manager on 10/21/2011, at approximately 1:00 PM, revealed that the facility was unable to produce evidence that the insulin was administered as ordered. 2. Resident ID #19 has a 10/1/2011 physician order [REDACTED]. Interview with the unit manager on 10/21/2011 at approximately 1:00 PM revealed that the facility was unable to provide evidence that the insulin was given as ordered. | 2014-11-01 |
| 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 |
| 396 | 396 | BAYBERRY COMMONS | 415080 | 181 DAVIS DRIVE | PASCOAG | RI | 2859 | 2019-09-26 | 761 | D | 1 | 1 | 0I5Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review and staff interviews, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 1 of 2 medication storage rooms (West) and 1 of 4 medication carts (West Nurses Cart). Findings are as follows: 1) Surveyor observation of the West medication storage room on [DATE] at approximately 11:50 AM revealed 1 opened bottle of [MEDICATION NAME] (a medication used for anxiety) with an open date of [DATE], and 3 bottles of [MEDICATION NAME] opened and not dated. Manufacturer's instructions on the box state, discard open bottle after 90 days. During surveyor interview on [DATE] at approximately 11:50 AM, with Staff Nurse A, he acknowledged that the [MEDICATION NAME] that had an open date of [DATE] and was currently in use. Additionally, he acknowledged that the 3 [MEDICATION NAME] bottles were opened and undated. 2) Surveyor observation of the West nurse medication cart, on [DATE] at approximately 8:30 AM, revealed a bottle of [MEDICATION NAME] (medication used to treat constipation) which had an expiration date of ,[DATE]. During surveyor interview on [DATE] at approximately 8:15 AM with Staff Nurse B, she acknowledged that the [MEDICATION NAME] was expired. | 2020-09-01 |
| 515 | 515 | KINGSTON CENTER FOR REHABILITATION AND HEALTH CARE | 415107 | 415 GARDNER ROAD | WEST KINGSTON | RI | 2892 | 2019-01-25 | 609 | D | 1 | 0 | 0ISZ11 | **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 report an allegation of resident abuse within 2 hours to the licensing agency for 1 of 4 residents investigated for abuse, Resident ID#3. Findings are as follows: During an interview with the Administrator on 1/25/2019 at approximately 12:50PM he revealed that Resident ID#3 had complained about a night shift nurse (Staff A). During an interview with Resident ID#3 s/he revealed that was an incident with Staff A during the third shift (11:00PM-7:00AM) on 1/18/2019, during which Staff A called ID#3 an[***] . Review of a document titled Grievance Form dated 1/21/2019 revealed that the resident reported the incident to the Director of Nursing (DNS), the form states in part .The nurse in charge (Staff A) spoke to him/her (ID#3) about 'yelling in the hall'. He (Staff A) then told him/her s/he was an 'asshole' . During an interview with the DNS on 1/25/2019 at approximately 3:40 PM, she acknowledged that the resident had reported to her that Staff A allegedly called him/her an[***] and the incident of verbal abuse was not reported to the Department of Health as required. | 2020-09-01 |
| 673 | 673 | HATTIE IDE CHAFFEE HOME | 415002 | 200 WAMPANOAG TRAIL | EAST PROVIDENCE | RI | 2914 | 2016-11-22 | 323 | D | 0 | 1 | 0KZ511 | Based on surveyor observation, resident/staff interview, it has been determined that the facility failed to ensure that the resident environment remains free from accident hazards for 1 of 4 resident shower rooms relative to broken wall tiles. Findings are as follows: On 11/18/2016 at 10:00 AM, surveyor observation of the shower room on the North unit across from the nurse's station revealed several tiles noted to be broken or missing along the vertical edge of the lower left baseboard of the shower entry. This area measured approximately 12 by 6 inches and covered the three corners. These broken tiles were noted to be sharp and abrasive. During an interview on 11/18/2016 at approximately 11:50 AM with the housekeeper, she stated that the area had been broken for approximately 2 months' time. During an interview on 11/18/2016 at approximately 12:30 PM with the maintenance director, he stated that this area of tiles is frequently broken by being bumped by patient chairs on entry to the shower, he acknowledged the area should have been repaired. | 2019-11-01 |
| 674 | 674 | HATTIE IDE CHAFFEE HOME | 415002 | 200 WAMPANOAG TRAIL | EAST PROVIDENCE | RI | 2914 | 2016-11-22 | 431 | E | 0 | 1 | 0KZ511 | Based on surveyor observation and staff interview, it was determined that the facility failed to store all drugs in locked compartments which permit access only to authorized personnel. Findings are as follows: Observation on the North Unit by 2 surveyors on 11/18/16, at 1:45 PM, revealed 45 medication blister packs which were stored in an unlocked cabinet in an unlocked utility room. The medications included Remeron & trazodone (anti-depressants), warfarin (a blood thinner), glipizide (a diabetes medication), protonix (a stomach medication), Zofran (an anti-nausea medication), atorvastatin & pravastatin (anti-cholesterol medications), amoxicillin (an antibiotic) and others. During an interview on 11/18/2016 at approximately 1:50 PM with the director of nurses, she revealed that these discontinued, partially full medication blister packs were awaiting disposal and had been placed there by the night nurse. 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. | 2019-11-01 |
| 1827 | 1827 | ST ANTOINE RESIDENCE | 415106 | 10 RHODES AVENUE | NORTH SMITHFIELD | RI | 2896 | 2011-08-01 | 314 | E | 0 | 1 | 0L2R11 | **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 provide the necessary treatment and services to promote healing, prevent infection and new sores from developing for 1 of 9 residents (ID #8) with pressure ulcers. Findings are as follows: Resident ID# 8 was admitted to the facility on [DATE] from another long term care facility with a healing stage 3 pressure ulcer on the left buttock. A review of the Patient Care Referral Form dated 5/23/2011 from the discharging facility indicates the resident has a stage 3 pressure ulcer on the left buttock. A review of the wound evaluation record from the discharging facility notes the pressure ulcer measurements as 1cm x 1cm x <.25cm at the time of the discharge. A review of the facility's initial nursing assessment dated [DATE] reveals no evidence of any pressure ulcers. A 5/24/2011 nurse's note indicates the resident has a 1.9cm x 1cm open area with scant drainage, the note does not indicate the location of the open area. Additonal review of nursing notes and the treatment record from the time of admission reveals no evidence of any treatment to this pressure ulcer until 5/26/2011 when an order was obtained to treat the wound daily with a normal saline wash, followed by solosite and a coversite dressing. The initial 5/23/2011 care plan indicated impaired skin integrity. An approach to the problem includes wound measurements weekly. The care plan does not specify the location of the wound or note any description of the wound. Further review of the record reveals no evidence of any wound descriptions including weekly wound measurements and location of the pressure ulcer until 6/22/2011. On 6/22/2011 the left buttock ulcer was 1 cm in circumference with no drainage and pink granulating tissue. Review of the physician's progress notes dated 5/24/2011, indicate the resident has multiple skin isuues including a decubitis ulcer. The notes … | 2014-06-01 |
| 1828 | 1828 | ST ANTOINE RESIDENCE | 415106 | 10 RHODES AVENUE | NORTH SMITHFIELD | RI | 2896 | 2011-08-01 | 272 | D | 0 | 1 | 0L2R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, surveyor observation and staff interview, it was determined that the facility failed to accurately assess 1 of 9 residents (ID #8) relative to a stage 3 pressure ulcer. Findings are as follows: Resident ID #8 was admitted to the facility on [DATE] with a healing stage 3 pressure ulcer on the left buttock. Record review of the 5/30/2011 Admission Minimum Data Set and Care Assessment Area Problem Area: 16-Pressure Ulcer, for resident ID# 8, inaccurately identifies that the resident had a Stage 2 Pressure Ulcer on her coccyx. On 7/28/2011, at approximately 1:00 PM, surveyor observation revealed that this resident had a stage 3 pressure ulcer on the left butttock. | 2014-06-01 |
| 1829 | 1829 | ST ANTOINE RESIDENCE | 415106 | 10 RHODES AVENUE | NORTH SMITHFIELD | RI | 2896 | 2011-08-01 | 364 | B | 0 | 1 | 0L2R11 | Based on the group interview with residents, surveyor's observations and test tray food temperatures of meals, it was determined that the facility failed to serve food at customary temperatures on 3 of 5 units. Findings are as follows: During the group interview on Wednesday, 7/27/11 at 11:00 AM , four of twelve residents voiced concerns that food being served is not at the right temperature. The only food that is hot is the soup.One of the twelve residents in attendance, stated that temperature issues occur four out of seven days, at no one specific meal time and that this problem has been going on for a long time. The other three residents commented, were in agreement. On 7/28/11 the last tray to be served on each unit was sampled for temperatures. At 12:10 PM ,the food temperatures (in farenheit degrees) on Unit 2B for potatoes was 117, carrots 115 and gravy for pot roast at 114. In addition, the residents the tray sampled at 12:42 PM on Unit 1B revealed the temperatures (in Farenheit degrees) for the chicken salad at 62, mashed potatoes 112, carrots 114 and mighty shake at 52. At this time, the surveyor sampled the aforementioned food items and determined that all food and liquid temperatures to be lukewarm /tepid. | 2014-06-01 |
| 1830 | 1830 | ST ANTOINE RESIDENCE | 415106 | 10 RHODES AVENUE | NORTH SMITHFIELD | RI | 2896 | 2011-08-01 | 271 | D | 0 | 1 | 0L2R11 | **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 obtain initial physician orders for immediate care for 1 of 3 residents (ID#8)admitted with pressure ulcers. Findings are as follows: Resident ID #8 was admitted to the facility on [DATE] with a healing stage 3 pressure ulcer on left buttock. Record review for this resident revealed that there were no physician orders for the treatment of [REDACTED]. On 7/28/2011, surveyor interview with the two nurse's who provided care for this resident revealed that they could not produced any evidence of physician orders at the time of admission (5/23/2011) for treatment of [REDACTED]. Refer to F314 | 2014-06-01 |
| 1831 | 1831 | ST ANTOINE RESIDENCE | 415106 | 10 RHODES AVENUE | NORTH SMITHFIELD | RI | 2896 | 2011-08-01 | 441 | E | 0 | 1 | 0L2R11 | Based on surveyor observations and staff interview, it was determined the facility failed to maintain an effective Infection Control program relative to Contact Precautions and their Dry-Clean Technique for resident, ID # 8 with a known organism, clostridium difficile (C-Diff) . Findings are as follows: A. The facility's policy on DRESSING-CLEAN TECHNIQUE PROCEDURE state "to prepare clean, dry work area and wash hands before and after procedure." B. The facility's procedure on CONTACT PRECAUTIONS are "after gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other residents or environments." Additionally the policy states, "In addition to wearing gloves utilizing standard precautions, wash hands immediately with soap and water" On 7/28/2011, at approximately 12:30 PM the surveyor observed the nurse preparing the treatment dressing in direct contact with the bedside table. In addition, the surveyor observed that the nurse did not wash her hands before and after the treatment to a pressure ulcer. Additionally, at the same time as above, the surveyor observed the nurse place the soiled dressing into a plastic bag, then removed the plastic bag from the room and carried it down the hallway in direct contact with her clothing. On 7/28/2011, at approximately 1:00 PM, the surveyor interviewed the nurse who changed the dressing, and she stated she failed to prepare a clean, dry work area and wash her hands prior to and after the treatment according to the facility's policies. On 7/29/2011 at 10:00 AM, the surveyor interviewed the Infection Control Nurse regarding contact precautions and she stated, "the nurse should not hold the bag (with the discarded dressing supplies) next to her clothing and that all items should be considered contaminated." | 2014-06-01 |
| 1832 | 1832 | ST ANTOINE RESIDENCE | 415106 | 10 RHODES AVENUE | NORTH SMITHFIELD | RI | 2896 | 2011-08-01 | 463 | F | 0 | 1 | 0L2R11 | Based on surveyor observations and interviews, it was determined that the facility failed to provide a communication system in 4 unlocked bathrooms used by the residents/public that are located on the first and second levels of the facility. Surveyor observations on all days of the survey revealed the absence of a communication system in the male and female bathrooms located on the first level adjacent to the lobby ( C-Core1) and the second level adjacent to lobby balcony ( C-Core 2). In addition, surrveyor observations on 4 of 6 survey days revealed some residents utilizing the aforementioned bathrooms. Interviews with the Director of Maintenance and the Administrator on 8/1/2011at approximately 10 AM and 11AM respectively, disclosed that residents due utilize the bathrooms being discussed and that the bathrooms have never been equipped with a call system. "You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with the applicable provisions of the Rules and Regulations for Licensing of Nursing Facilities, they are deficiencies under State regulations and grounds for licensure sanctions." | 2014-06-01 |
| 1308 | 1308 | GREENVILLE SKILLED NURSING & REHABILITATION | 415087 | 735 PUTNAM PIKE | GREENVILLE | RI | 2828 | 2013-10-30 | 253 | B | 0 | 1 | 0LI511 | Based on surveyor observation and staff interview it was determined the facility failed to provide maintenance services necessary to maintain the resident's environment in good condition and repair on 2 of 5 units. Findings are as follows: 1. Surveyor observations on 10/21/2013 at 9:00 AM on the Daisy Unit revealed the vinyl covering on two shower chairs in the two shower stalls were observed to be cracked with black matter in the seams of the chairs. Additionally, the surveyor observed two vents in the shower room, two vents in the linen storage area and two vents at the end of the hall with a thick accumulation of dust. 2. During the tour on 10/21/2013 at 9:00 AM on the Lilly Unit, the surveyor observed a shower chair with cracked vinyl and black matter in the seam of the chair. Surveyor observations with the Maintenance Director on 10/22/2013 at 2:30 PM revealed he was unaware of the dusty vents and damaged shower seats. When interviewed on 10/23/2013 at 1:50 PM, the Administrator was unable to provide evidence that the above maintenance issues had been identified or there was a plan to make the necessary repairs. | 2016-10-01 |
| 1309 | 1309 | GREENVILLE SKILLED NURSING & REHABILITATION | 415087 | 735 PUTNAM PIKE | GREENVILLE | RI | 2828 | 2013-10-30 | 323 | E | 0 | 1 | 0LI511 | Based on surveyor observations and staff interviews, it was determined that the facility failed to ensure that the environment remained free of accident hazards on 2 of 5 units, Daisy and the Sun Unit, relative to a splintered doorway and radiator cover. Findings are as follows: 1. Surveyor observations on the Sun Unit on 10/21/2013 at 11:30 AM revealed that the entry door to room #6 had an approximate 3 foot long by 3 inches wide raised layer of laminate over the wood towards the hinge side. Splintering was noted at the midpoint of the raised laminate. During the Life Safety Code inspection on 10/22/2013 at 11:00 AM, the surveyor interviewed the Maintenance Director who revealed that he was unaware of the problems with the splintered door. 2. Surveyor observation on 10/21/2013 at approximately 9:00 AM, in 1 of 2 shower rooms on the Daisy Unit revealed a radiator located adjacent to a shower stall having a protruding corner of the metal housing which formed a sharp and rusted edge extending roughly 3 inches outward. This sharp protrusion was located directly next to the entry of the shower stall. During an interview with the Maintenance Director on 10/21/2013 at 10:30 AM revealed he was unaware of the protruding metal edge on the radiator unit. 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. | 2016-10-01 |
| 251 | 251 | CHARLESGATE NURSING CENTER | 415052 | 100 RANDALL STREET | PROVIDENCE | RI | 2904 | 2017-01-10 | 281 | D | 0 | 1 | 0LQS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it was determined the facility failed to ensure that services provided by the facility meet professional standards of quality for 1 of 3 sample residents (ID #3) relative to physicians' orders for oxygen. Findings are as follows: 1. The State of Rhode Island Rules and Regulations for the Licensing of Nurses and Standards for the Approval of Basic Nursing Education Programs (R5-34-NUR/ED), Section 1.31, defines Nursing, and states, in part: It provides care and support of individuals and families during periods of wellness, illness, and injury and incorporates the appropriate medical plan of care as prescribed by a duly licensed physician, . Surveyor observations on 01/04/2017 at 12:00 PM and 12:25 PM; on 01/05/2017 at 8:30 AM and 11:55 AM; and on 01/06/2017 at 10:40 AM, revealed the resident in his/her room receiving oxygen at 2.5 liters per minute via nasal cannula. During an interview, the resident who is alert and oriented stated she has been receiving oxygen for the last few weeks. Record review for resident ID #3 failed to reveal a physician's orders [REDACTED]. During surveyor interview with the Clinical Nurse Manager (staff A) on 01/06/2017 at 11:00 AM, she revealed the resident has been receiving oxygen for the last few weeks. 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 |
| 793 | 793 | GRACE BARKER NURSING CENTER | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2016-04-07 | 309 | E | 0 | 1 | 0MXC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interview, it has been determined that the facility has failed to ensure that each resident receive and the facility provide the necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 1 sample residents, (ID#1) relative to fluid restrictions. Findings are as follows: Resident ID# 1 was admitted to the facility on [DATE] with primary [DIAGNOSES REDACTED]. Record review reveals that on 3/25/2016 blood work was obtained revealing that the resident had an abnormal low sodium level of 125 (normal range 135 - 145). When reported to the physician, new orders were received to limit the resident's fluid by restricting to 1000 milliliter (ml) daily with 720 ml's of fluid to be allotted during meal times and 280 ml's to be used by nursing for medication administration. Repeat blood work drawn on 3/29/2016 revealed no change in the resident's sodium level (125) despite the ordered fluid restriction intervention in place. When reported to the Nurse Practitioner (NP), on this same date, she ordered, to Continue fluid restrictions 1000 ml a day. On 4/4/2016 at 12:20 PM surveyor observation revealed the resident eating lunch in his/her room with a mug filled with black coffee (240 ml) and 2 small plastic glasses filled with milk (120 ml) and juice (120 ml) totaling 480 ml's of fluid served for this meal. On 4/5/2016 at 7:25 AM surveyor observation revealed the resident eating in his/her room with the breakfast tray containing a mug filled with black coffee (240 ml) and 2 small plastic glasses filled with milk (120 ml) and juice (120 ml) totaling 480 ml's of fluid served for this meal. Immediately following this observation, the surveyor read the resident's diet card which was located on top of the food truck, indicating, Fluid Restrictions 240 ml's per meal for this resident. Additionally, when interviewing the nursing assistant (NA) (staff A) at 7:35 AM, w… | 2019-04-01 |
| 157 | 157 | BANNISTER CTR FOR REHABILITATION AND HEALTH CARE | 415038 | 135 DODGE STREET | PROVIDENCE | RI | 2907 | 2018-04-05 | 755 | D | 1 | 0 | 0O5J11 | **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 routine drugs to its residents relative to 1 of 4 residents reviewed for administration of pain medication (ID #79). Findings are as follows: Record review for Resident ID# 79 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident ID# 79's record has a current physician's orders [REDACTED]. Review of the resident's Medication Administration Record [REDACTED]. Progress notes documented that the [MEDICATION NAME] was not administered because it was unavailable. Dates and times are as follows: 4/1/2018, 10:33 PM [MEDICATION NAME] .Awaiting PHA (pharmacy); 4/2/2018, 5:21 AM, [MEDICATION NAME] .med not available awaiting pharmacy delivery; 4/2/2018, 3:20 PM, [MEDICATION NAME] .med is not available; and 4/2/2018, 9:59 PM, [MEDICATION NAME] .waiting for pharmacy delivery. During a surveyor interview with the Regional Nurse on 4/5/2018, at approximately 8:00 AM, she revealed that the resident did not receive the [MEDICATION NAME] on the above-mentioned dates as ordered by the physician and the medication should have been ordered by the nurse when the supply was low. A subsequent interview was conducted with the 2nd floor unit manager on 4/5/2018 at 10:30 AM. She revealed that she noticed that there was no remaining [MEDICATION NAME] after administering the 2:00 PM dose on 4/1/2018, however she was unable to provide evidence that she notified the pharmacy of the need for a refill until the afternoon of 4/2/2018 which resulted in the resdient missing four consecutive scheduled doses of the medicaton. 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 |
| 881 | 881 | WOODPECKER HILL HEALTH CENTER | 415105 | 2052 PLAINFIELD PIKE | GREENE | RI | 2827 | 2015-11-13 | 412 | B | 0 | 1 | 0ODH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, it was determined the facility has failed to provide or obtain from an outside resource, dental services for 1 of 9 sample residents (ID#1). Findings are as follows: Review of resident ID#1's clinical record revealed an admission Minimum Data Set ((MDS) dated [DATE], in the dental section, that the resident has obvious or likely cavity and or broken teeth. Further review of the record did not reveal any information regarding dental services. Review of the residents care plan dated 12/21/2014 for ADL Function states provide dentures as tolerated. Review of the residents dental record lacked evidence of an authorization for dental services. The surveyor interviewed the staff nurse (staff A) on 11/12/2015 at approximately 9:20 AM, she stated that the facility had a contract for Dental Care. When questioned about the care plan, she stated the resident has some of his/her own teeth and a partial that he/she takes out and has not used it in a while. The surveyor asked Staff A, about the notation for the dental status and she was unaware of the documentation in the MDS relative to broken teeth or cavity. She reviewed her list from the Dental Service and resident ID #1 was not seen by the dental service when they came to the facility. The Surveyor interviewed the Director of Nurses on 11/13/2015 at approximately 9:30 AM and she provided the surveyor with copies of the authorization for Dental Services that was signed by the resident's daughter on 11/24/2014 and located in the business office. However, she was not able to produce evidence that the resident had been seen by dental to evaluate her teeth. The surveyor contacted the Dental Service on 11/13/2015 at approximately 11:50 AM, and they stated that they had just received the authorization forms for resident ID# 1 early that morning, and that they had never seen or provided dental service to the resident. The facility failed to provide dental services f… | 2019-01-01 |
| 952 | 952 | HEBERT NURSING HOME | 415049 | 180 LOG ROAD | SMITHFIELD | RI | 2917 | 2015-05-07 | 323 | E | 0 | 1 | 0P6V11 | Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure the environment is as free of accident hazards as is possible relative to lab specimen storage on 3 of 4 units. Findings are as follows: On 05/04/2015, at approximately 6:30 PM, the surveyor observed an unlocked lab specimen refrigerator in the shower room on the South Unit, which contained an unlabeled lab specimen cup containing a dark yellow liquid. On 05/05/2015, at approximately 8:10 AM, the same specimen cup was observed in the same unlocked lab specimen refrigerator. This shower room is located at the end of the South Unit hallway, which is on the way to the resident's smoking room, on the way to the North A Unit, and is accessible to ambulatory residents. Several ambulatory residents who reside on the units are also cognitively impaired. Additionally, many of the residents who reside on the units have behavioral issues. The surveyor observed several residents going past this room when staff were not in the immediate vicinity. An interview with the nurse on the South Unit, on 05/07/2015 at approximately 10:05 AM, revealed the lab specimen storage area is used by the whole facility. She added the specimens are left in the refrigerator and not picked up by the lab until the next morning. A subsequent interview with the Administrator and the Director of Nurses, on 05/07/2015, at 1:00 PM, revealed they were unaware that lab specimens were left in an unlocked refrigerator in the South Unit main shower room. | 2018-09-01 |
| 953 | 953 | HEBERT NURSING HOME | 415049 | 180 LOG ROAD | SMITHFIELD | RI | 2917 | 2015-05-07 | 371 | F | 0 | 1 | 0P6V11 | Based upon surveyor observation and staff interview, it was determined that the facility failed to prepare and distribute food in a sanitary manner relative to food service equipment and glove use. Findings are as follows: Surveyor observation on 5/4/2015 at approximately 6:22 PM revealed the following: 1. A dietary aide was observed unloading soiled dinner trays from a food truck, scraping the plates and removing the soiled debris from the trays. With the same gloved hands, he then proceeded to handle clean dinnerware coming out of the dishwasher. This activity was observed for over 10 minutes. During an interview following the observation, the dietary employee acknowledged he had handled the clean dishware with the same gloves. 2. A hand mixer had an accumulation of dried brown matter on the mixer and cord. The mixer was in a drawer with clean kitchen equipment. 3. The can opener had an accumulation of dried red debris on the blade and mechanism of the can opener. 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. | 2018-09-01 |
| 497 | 497 | HARRIS HEALTH CENTER LLC | 415098 | 833 BROADWAY | EAST PROVIDENCE | RI | 2914 | 2019-12-31 | 609 | D | 1 | 0 | 0S4Q11 | > 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 2 reportable allegations of abuse (Resident ID #1). Findings are as follows: Record review of a Complaint Inquiry revealed that Resident ID# 1 made an allegation of resident to resident abuse on 12/27/2019. Further record review revealed the facility failed to report the allegation to the State Survey Agency. During a surveyor interview on 12/31/2019 at approximately 12:15 PM, with the Administrator and Director of Nursing, they could not produce evidence the allegation of abuse was reported in accordance with state law. | 2020-09-01 |
| 498 | 498 | HARRIS HEALTH CENTER LLC | 415098 | 833 BROADWAY | EAST PROVIDENCE | RI | 2914 | 2019-12-31 | 610 | D | 1 | 0 | 0S4Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, surveyor observation, resident and staff interview, it has been determined the facility failed to thoroughly investigate an allegation of abuse and prevent further potential abuse for 1 of 4 residents reviewed (Resident ID #2). Findings are as follows: Record review revealed Resident ID #2 was sent to the hospital on [DATE] after a behavioral disturbance. The Continuity of Care (C[NAME]) form dated 12/29/2019, provided to the facility from the hospital, indicates that the resident reports that s/he was upset at the way the CNA was treating his/her roommate. After the resident complained to the CNA and to the nursing staff, the CNA grabbed his/her arm and threw him/her against the chair. During an interview and observation on 12/31/2019 at approximately 9:00 AM, Resident ID #2 indicated s/he had bruising to the upper left arm as a result of the CNA pushing him/her into a chair on 12/28/2019. During an interview on 12/31/2019 at approximately 12:05 PM, the Director of Nursing indicated an investigation had not occurred, nor had interventions been put in place to prevent further abuse, as the information on the C[NAME] was overlooked and she had just become aware of the allegation of abuse. | 2020-09-01 |
| 499 | 499 | HARRIS HEALTH CENTER LLC | 415098 | 833 BROADWAY | EAST PROVIDENCE | RI | 2914 | 2019-12-31 | 655 | D | 1 | 0 | 0S4Q11 | > Based on record review and staff interview, it has been determined that the facility failed to develop and implement a baseline care plan within 48 hours of admission, that includes the instructions needed to provide effective and person-centered care, for 1 of 4 residents reviewed for baseline care plans (Resident ID #4). Findings are as follows: Resident ID #4 was admitted to the facility in (MONTH) of 2019. Record review revealed that the facility failed to complete and implement a baseline care plan. During a surveyor interview on 12/31/2019 at approximately 12:05 PM, the Director of Nursing was unable to produce evidence that a baseline care plan was completed for Resident ID #4. | 2020-09-01 |
| 500 | 500 | HARRIS HEALTH CENTER LLC | 415098 | 833 BROADWAY | EAST PROVIDENCE | RI | 2914 | 2019-12-31 | 658 | E | 1 | 0 | 0S4Q11 | **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 services provided by the facility meet professional standards of quality for 3 of 4 residents reviewed for physician's orders [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]. 1.Review of the clinical record for Resident ID #1 revealed an active physician's orders [REDACTED]. Review of the resident's weekly skin observation record revealed skin observations were not completed on 10/23, 10/30, 11/6, 11/20, 11/27, 12/4 and 12/11/2019. 2.Review of the clinical record for Resident ID #2 revealed an active physician's orders [REDACTED]. Review of the resident's weekly skin observation record revealed skin observations were not completed on 7/14, 7/21, 8/11, 8/18, 9/1, 9/8, 9/15, 9/29, 10/13, 10/27, 11/3, 11/24, 12/8, 12/15, 12/22 and 12/29/2019. 3.Review of the clinical record for Resident ID #3 revealed an active physician's orders [REDACTED]. Review of the resident's weekly skin observation record revealed skin observations were not completed on 9/19, 10/3, 10/17, 10/31, 11/14, 11/28 and 12/12/2019. During a surveyor interview on 12/31/2019 at approximately 12:00 PM, the Director of Nursing, was unable to produce evidence that weekly skin observations were completed for Resident ID #s 1, 2, and 3. | 2020-09-01 |
| 1860 | 1860 | STEERE HOUSE NURSING & REHABILITATION CENTER | 415091 | 100 BORDEN STREET | PROVIDENCE | RI | 2903 | 2011-03-11 | 333 | D | 0XQT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure that residents are free of any significant medication errors for 1 of 13 sample residents (ID#7) and 1 non-sample resident (ID#38). Findings are as follows: 1. Clinical record review of resident ID#7 revealed a 2/22/2011 physician's orders [REDACTED]. After positive results were obtained for a urinary tract infection, a 2/24/2011 physician's orders [REDACTED]. Review of the February 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 2. Clinical record review of resident ID#38 revealed a 2/11/2011 physician's orders [REDACTED]. After positive results were obtained for a urinary tract infection, a 2/13/2011 physician's orders [REDACTED]. Review of the February 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. When interviewed on 3/11/2011 at 11:00 AM, the Assistant Director of Nursing Services was unable to provide evidence that the above antibiotics were administered as ordered. "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." | 2014-02-01 | ||
| 1861 | 1861 | STEERE HOUSE NURSING & REHABILITATION CENTER | 415091 | 100 BORDEN STREET | PROVIDENCE | RI | 2903 | 2011-03-11 | 309 | D | 0XQT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interview, it was determined the facility failed to ensure that pain medications were administered according to the comprehensive assessment and plan of care for 1 of 22 sample residents (ID#3). A review of resident ID#3's clinical record revealed a 2/24/2011 Care Area Assessment (CAA) indicating the resident has an unstagable pressure area over the coccyx and has been exhibiting signs and symptoms of worsening pain relative to this wound. The CAA also indicates the resident is at risk for unrelieved pain resulting in a revised care plan. Review of the 2/24/2011 revised nursing care plan revealed an intervention to: "medicate prior to wound care and as needed." Further review revealed the resident has a 3/4/2011 standing physician's orders [REDACTED]. On 3/8/2011 at 11:00 AM, the surveyor observed the resident's wound care nurse in the presence of a nursing assistant (NA). When the nurse removed the old dressing the resident grimaced. Upon irrigating the wound the resident cried out, "Ow, ow." The NA asked the resident "Are you in pain? " to which the resident replied "Yes." The nurse then asked the resident "Does it hurt when I squirt the liquid in? " to which the resident replied "Yes". The surveyor asked the nurse if the resident had been medicated for pain. The nurse replied, "I'm not sure. I think she received her standing dose." The nurse then proceeded to complete the treatment and the resident continued to moan. Review of the resident's March 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. When interviewed at 2:55 PM on 3/8/2011, the nurse indicated that she was aware of physician's orders [REDACTED]. | 2014-02-01 | ||
| 1398 | 1398 | EPOCH SENIOR HEALTH CARE ON BLACKSTONE BOULEVARD | 415126 | 353 BLACKSTONE BOULEVARD | PROVIDENCE | RI | 2906 | 2013-06-18 | 163 | C | 1 | 0 | 0Y8Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review and review of a complaint received by the DOH, it has been determined that the facility failed to ensure that residents are given a choice of a personal attending physician for 1 of 1 sample resident, resident (ID # 5 ). During a review of resident ID # 5's record, it was revealed that the resident was admitted to the facility on [DATE] from an acute care hospital. Review of the Admission notification and Consent forms, reveal that the section titled Physician Services, the resident's daughter documented that the resident was not given a choice of physician. Interview with the Director of Nurses (DON) on 6/18/2013 at approximately 11:15 AM, when questioned regarding resident's choice of physician she stated that, the admissions department assigns the physician when the resident is accepted. When questioned further, as to if there was a list of physicians for residents to chose from, she stated no. However if a resident does not like the physician they are assigned they can ask to change physician to one of the other physicians credentialed by the facility. Interview with the Director of Admissions on 6/18/2013 at approximately 12:30 PM, she stated that physician's are assigned to residents by the admissions department when the resident is accepted. The Admission Notification and Consent forms are filled out, including the name of the physician assigned and the physician's phone number prior to the resident's admission to the facility. When questioned by the surveyor as to how they give the resident a choice of physician as it is stated in the admission packet under physician services, that I have designated the physician of my choice, she was unable to produce evidence that the residents are given a choice of physicians. She further stated that if a residents are not pleased with the physician assigned, they can make a change after admission. You are hereby formally notified that where the above listed… | 2016-06-01 |
| 1804 | 1804 | SILVER CREEK MANOR | 415031 | 7 CREEK LANE | BRISTOL | RI | 2809 | 2011-05-13 | 458 | B | 0 | 1 | 0YSU11 | Based on surveyor observation and facility documentation, it was determined the facility failed to provide at least 80 square feet per resident in multiple resident rooms in 12 bedrooms in the facility. Findings are as follows: The following semi-private resident rooms measure less than the required 160 square feet (sq.ft.) of space in multiple resident bedrooms. Rooms 103, 105, 107, 109, 116, 119, 121 & 122 with 158.8 sq.ft. per room. Room 110 with 153.6 sq.ft. per resident room. Room 115 with 149.9 sq.ft. per resident room. Room 117 with 157.5 sq.ft. per resident room. Room 123 with 152 sq.ft. per resident room. "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." | 2014-06-01 |
| 1805 | 1805 | SILVER CREEK MANOR | 415031 | 7 CREEK LANE | BRISTOL | RI | 2809 | 2011-05-13 | 225 | D | 0 | 1 | 0YSU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to report and investigate an injury of unknown origin to the administrator of the facility or to other officials in accordance with state law for 1 of 10 sample residents (ID #8). Findings are as follows: 1. Review of resident ID #8's clinical record revealed a 1/29/2011 nurse's note 3:00-11:00 PM shift, indicating the resident sustained [REDACTED]. Further record review failed to reveal the bruise was reported to the facility's administrator, or investigated. During an interview on 5/11/2011 at 11:45 AM, the Director of Nurses indicated that she was unaware of the bruise and was unable to provide evidence that this injury of unknown origin had been reported to the administrator of the facility or to other officials in accordance with state law. Additionally, she was unable to provide evidence of any investigation relative to the right thigh bruise. | 2014-06-01 |
| 1806 | 1806 | SILVER CREEK MANOR | 415031 | 7 CREEK LANE | BRISTOL | RI | 2809 | 2011-05-13 | 428 | E | 0 | 1 | 0YSU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure that any irregularity was reported to the attending physician and the Director of Nurses (DON) for 1 of 14 sample residents (ID #8) relative to administration of medication. Findings are as follows: 1. Resident ID #8 has January - May 2011 physician's orders [REDACTED]. A review of the Medication Administration Records for January - May 2011 revealed the resident has been refusing the above medication daily between 1/18 - 5/12/2011. A review of the Medication Regimen Review dated 2/2, 3/4, 4/5 and 5/3/2011 failed to reveal a report of this irregularity to the resident's physician and the DON by the facility ' s pharmacist. During an interview on 5/13/2011 at 11:00 AM, the DON indicated she was unaware the resident has been refusing the medication. Additionally, the DON was unable to provide evidence that the pharmacist reported this irregularity to the resident's physician. | 2014-06-01 |
| 1807 | 1807 | SILVER CREEK MANOR | 415031 | 7 CREEK LANE | BRISTOL | RI | 2809 | 2011-08-04 | 360 | D | 0 | 1 | 0YSU12 | **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 provide a special diet to meet the needs of 1 of 14 sample residents (ID#11). Findings are as follows: On 8/4/2011, at 10:35 AM, the surveyor observed ID#11 had approximately 2 ounces of orange juice with a straw, left at his bedside table over his bed. Surveyor record review revealed that the resident was admitted from the hospital on [DATE] with a [DIAGNOSES REDACTED]. Review of the Continuity of Care Form, dated 8/2/2011 from the hospital, specifies that the resident was to receive a cardiac/renal diet. Further review of the record revealed no evidence of a renal diet. Surveyor interview on 8/4/2011, at approximately 12:15 PM, with the resident's nurse stated that she forgot to write the diet order. At 12:20 PM, surveyor interview with dietary staff stated that the resident is not on a renal diet. Additionally, after brought to the nurse's attention by the surveyor, the nurse ordered a renal diet for this resident Additionally, surveyor review of the diet manual indicates no orange juice allowed on renal diets. "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." | 2014-06-01 |
| 1276 | 1276 | BALLOU HOME FOR THE AGED | 415094 | 60 MENDON ROAD | WOONSOCKET | RI | 2895 | 2014-02-12 | 159 | C | 0 | 1 | 11UD11 | Based on a review of the resident funds account and interviews with facility staff, it was determined that the facility failed to obtain written authorizations for the holding and safeguarding of monies that may be periodically held by the facility for 25 of 28 residents. In addition, these funds were not deposited into an interest bearing account when they exceed $50 nor were quarterly status reports maintained. Findings are as follows: Interviews with the Business Office Manager on 2/11/2014 at approximately 4:15 PM and on 2/12/2014 at approximately12:45 PM, revealed that she could not provide evidence of written authorizations for the monies that are being periodically held, evidence that said monies were deposited into an interest bearing account, and evidence of quarterly reports on the status of the monies. As of 2/11/14, monies in the amount of $1,543.11 were being held by the facility for these 25 residents. | 2016-12-01 |
| 1277 | 1277 | BALLOU HOME FOR THE AGED | 415094 | 60 MENDON ROAD | WOONSOCKET | RI | 2895 | 2014-02-12 | 458 | B | 0 | 1 | 11UD11 | Based on surveyor observation and facility measurements of 5 residents rooms, it was determined that the facility has failed to ensure that five (5) semi-private bedrooms measure at least 160 square feet in area. Room 106 = 155 square feet Room 108 = 155 square feet Room 109 = 154 square feet Room 111 = 154 square feet Room 113 = 154 square feet 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. | 2016-12-01 |
| 1572 | 1572 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2012-03-29 | 281 | D | 1 | 0 | 18OF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record reviews and staff interviews, it was determined the facility failed to ensure that services provided or arranged by the facility meet professional standards of quality for 3 of 5 sample residents (ID #'s 1, 2 and 5) relative to physicians' orders. Findings are as follows: The State of Rhode Island Rules and Regulations for the Licensing of Nurses and Standards for the Approval of Basic Nursing Education Programs (R5-34-NUR/ED), Section 1.31, defines "Nursing", and states, in part: "It provides care and support of individuals and families during periods of wellness, illness, and injury and incorporates the appropriate medical plan of care as prescribed by a duly licensed physician, dentist, podiatrist, or other health care provider licensed to prescribe." 1. Record review for resident ID #1 revealed a physician's orders [REDACTED]. A review of the Braden Scale - Predicting Pressure Sore Risk assessment for September 2011 lacked evidence that the assessments were conducted weekly for 2 of 3 weeks. When interviewed on 3/28/2012 at 12:20 PM, the Director of Nursing was unable to provide evidence that the resident was assessed weekly in accordance with the physician's orders [REDACTED]. 2. Record review for resident ID #2 revealed the resident has a physician's orders [REDACTED]. A review of the Braden Scale - Predicting Pressure Sore Risk assessment from 3/1/2012 through 3/28/2012 lacked evidence that the assessments were conducted weekly for 2 of 3 weeks. When interviewed on 3/28/2012 at 12:30 PM, the Assistant Director of Nursing was unable to provide evidence that the resident was assessed weekly in accordance with the physician's orders [REDACTED]. 3. Record review for resident ID #4 revealed the resident has a Foley catheter in place secondary to [MEDICAL CONDITION]. A physician's orders [REDACTED].#20 FR (french) with 30 ML (millimeter) balloon-change every week if possible". A review of the progress no… | 2015-07-01 |
| 1324 | 1324 | ST ANTOINE RESIDENCE | 415106 | 10 RHODES AVENUE | NORTH SMITHFIELD | RI | 2896 | 2013-07-08 | 253 | C | 0 | 1 | 195F11 | Based on surveyor observation and staff interviews, it has been determined the facility failed to maintain a clean environment on all units, relative to 7 of 7 EZ stands and 2 of 6 mechanical lifts on 5 of 5 units. Findings are as follows: 1. Surveyor observation on 7/2/2013 at 10:00 am and 7/8/2013 at 1:00 PM on unit 1 A revealed an EZ stand foot base covered with dust, dirt particles and debris. Surveyor observation on 7/8/2013 at 8:30 am revealed 2 EZ stand devices with foot bases covered with white and brown flaky material and debris. In addition the second device revealed a soiled belt which would be placed against the resident's body. Surveyor observation on 7/2/2013 at 10:00 am and 7/8/2013 at 10:30 am on unit 2 A revealed an EZ stand foot base covered with dust, dirt particles and debris. In addition the EZ stand right pad was ripped revealing an opening approximately 3 X 6 inches of the foam. During interview with the charge nurse on 7/8/2013 at approximately 12:45 PM on unit 2 A, she acknowledged the soiled foot base and that it should have been cleaned. Surveyor observation on 7/8/2013 at 9:15AM on unit 2 B revealed an EZ stand foot base with brown and white debris. During interview with the charge nurse on 7/8/2013 at approximatley 9:30 AM on unit 2B, the nurse stated she was not sure who cleaned the stands and mechanical lifts, and belived it was the night shift. Surveyor observation on 7/8/2013 at 1:30 PM on the special care unit (SCU) revealed an EZ stand foot base with brown and white debris. Interview with the charge nurse on the SCU on 7/8/2013 at 1:30 PM revealed that the nursing staff who work nights are responsible for cleaning EZ stands and mechanical lifts. 2. Surveyor observation on 7/8/2013 at 1:00 PM on unit 1 A revealed a mechanical lift with a heavy build up of dust particles on the legs Surveyor observation on 7/8/2013 at 9:15 am on unit 2 B revealed a mechanical lift with heavy build up of dust particles on the legs. Interview with the Director of Housekeeping Services on 7/8/2013 at… | 2016-09-01 |
| 1325 | 1325 | ST ANTOINE RESIDENCE | 415106 | 10 RHODES AVENUE | NORTH SMITHFIELD | RI | 2896 | 2013-07-08 | 281 | F | 0 | 1 | 195F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record reviews and staff interviews, it was determined the facility failed to ensure that services provided or arranged by the facility meet professional standards of quality for 7 of 10 sample residents (ID #'s 2,4,5,6,7,8, and 16) relative to physicians orders for (O2) Oxygen administration and 1 of 1 sample resident ID #22 relative to nebulizer treatments. Findings are as follows: The State of Rhode Island Rules and Regulations for the Licensing of Nurses and Standards for the Approval of Basic Nursing Education Programs (R5-34-NUR/ED), Section 1.33, defines Nursing, and states, in part: It provides care and support of individuals and families during periods of wellness, illness, and injury and incorporates the appropriate medical plan of care as prescribed by a duly licensed physician, dentist, podiatrist, or other health care provider licensed to prescribe. 1. Resident ID # 2 who resides on the 2 B unit, has a physician order [REDACTED]. Review of the resident's record failed to reveal that the residents pulse oximetry was being monitored. Surveyor interview with the unit manager on 7/8/2013 at approximately 11:15 AM she was unable to produce evidence that the resident's pulse oximetry had been monitored to determine if the resident needed O2. 2. Resident ID # 4, who resides on the 2 B unit, has a physician order [REDACTED]. Review of the resident's record reveals that on the resident' s (TAR) Treatment Administration Record the resident is receiving O2 continuously. Surveyor interview with the unite manager on 7/8/2013 at approximately 11:20 AM, when questioned regarding the two orders for O2, she acknowledge that O2 orders should have been clarified, as the resident has both a PRN order for Oxygen dated 1/16/2013 and a order for continuous O2 dated 4/28/2013. The two different O2 orders remain on the current July physicians orders. 3. Resident ID # 5 who resides on the 2 A unit, has a physician order [RED… | 2016-09-01 |
| 1326 | 1326 | ST ANTOINE RESIDENCE | 415106 | 10 RHODES AVENUE | NORTH SMITHFIELD | RI | 2896 | 2013-07-08 | 425 | C | 0 | 1 | 195F11 | Based on surveyor observation and staff interviews it was determined that the facility failed to maintain an accurate method of replacing medications when used in the emergency kits for antibiotics on 6 of 6 units, and the emergency injectable kits on 4 of 6 units. The facility also failed to discard outdated medications and biological's on 3 of 6 units. Surveyor observations: 2 B Unit 7/2/2013 at 8:40 AM, the emergency injectable kit had an expiration date of 6/13/2013. The emergency antibiotic kit that had been used, the drugs that had been used had not been replaced by the pharmacy. Interview with the charge nurse, immediately following the above observation she was unsure as to when the medications were used and why they were not replaced by the pharmacy after they were used, she was also unaware that the emergency injectable kit had expired. 2 A Unit 7/2/2013 at 8:55 AM, the emergency injectable kit had been opened and drugs had been used and not replaced by the pharmacy. Interview with the charge nurse immediately following the observation, she was unaware of the expired medications and was unable to explain why the pharmacy had not replaced the used injectable's in the emergency kit. 1 A Unit 7/2/2013 at 9:02 AM the emergency antibiotic and emergency injectable kits were both opened and the drugs that had been used had not been replaced. Interview with the charge nurse immediately following the above observation, she was unaware of when the medications were used and that the used medications had not been replaced in the emergency kits by the pharmacy. 1 B Unit 7/2/2013 at 9:10 AM, the emergency antibiotic and the injectable kits had been used and the drugs that had been used had not been replaced. Additionally there were 16 Heparin Flush 3 cc (syringes) that had expirations dates of 6/20/2013, 19 Heparin flush 5 cc (syringes) with expiration date of 5/20/2013 and 10 ed top blood collection tubes with expiration dates of 5/13/2013. Interview with the charge nurse immediately following the observation, she w… | 2016-09-01 |
| 1327 | 1327 | ST ANTOINE RESIDENCE | 415106 | 10 RHODES AVENUE | NORTH SMITHFIELD | RI | 2896 | 2013-07-08 | 441 | D | 0 | 1 | 195F11 | Based on surveyor observations and staff interview, it was determined the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection for resident ID # 5 with known organisms in the wound containing Methicillin Resistant Staph Aureus (MRSA) and Extended Spectrum Beta Lactamase (ESBL). Findings are as follows: Review of the facility ' s GUIDELINES FOR THE MANAGEMENT OF METHICILLIN RESISTANT Staphylococcus Aureus (MRSA) require CONTACT PRECAUTIONS. Contact precautions require: Gloves are to be worn when: ? entering the room of a resident on Contact Precautions. ? handling items potentially contaminated by MRSA such as over bed tables, bed rails, bedside furniture, bed controls, television controls, bathroom fixtures, medical equipment (IV poles, suction machine, etc.). ? Gloves are to be changed after contact with material that may contain high concentrations of MRSA, gloves should be removed, hands cleansed and new gloves applied before proceeding with other aspects of care or contact with the environment (avoid touching items in the room with contaminated gloves). Gloves and long sleeved gowns should be worn when changing the beds of residents on Contact Precautions 1. On 7/3/2013 at approximately 10:35 AM the surveyor observed the nurse who was wearing gloves and a long sleeved gown perform the resident's daily wound care to an infected heel wound. Upon completing the wound care, a new dressing was applied by the nurse who then maneuvered the protective gown allowing him to reach into his pocket beneath and pulled out a pen. While still wearing the gloves used to change the dressing he used his pen to date the gauze dressing and then replaced it back into his pocket without removing the gloves. 2. On 7/3/2013 at approximately 11:15 AM two nursing assistant ' s (NA) went into the resident's room to transfer her from the bed to the wheelchair using the Sit-to-Stand equipment. One of the NA's wore gloves and the other did not. When interviewing the NA… | 2016-09-01 |
| 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 |
| 957 | 957 | ELMHURST REHABILITATION & HEALTHCARE CENTER | 415084 | 50 MAUDE STREET | PROVIDENCE | RI | 2908 | 2015-09-01 | 164 | B | 1 | 0 | 1DEQ11 | Based on review of facility records and staff interview, it was determined that the facility has failed to maintain privacy of resident clinical records. Findings are as follows: A binder containing the 2567 survey report, for the survey ending 5/16/14, was observed in the main lobby of the facility. The binder is placed to allow review by the general public, as required by regulation. Although deficiencies identify residents by an identification number in order to maintain resident privacy, the facility had placed the resident roster, with identifying names and ID numbers, in the binder along with the deficiencies. Because of this, information such as dementia diagnoses, incontinence status and pressure sores in private areas of the body were disclosed to anyone who reviewed the binder. Facility staff acknowledged that the identifying roster should not have been included in the binder. 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. | 2018-09-01 |
| 678 | 678 | CRA-MAR MEADOWS | 415066 | 575 SEVEN MILE ROAD | CRANSTON | RI | 2920 | 2016-11-04 | 412 | E | 0 | 1 | 1GOU11 | **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 provide or obtain from an outside resource, dental services for 4 of 10 sample residents (ID #'s 3, 5, 9, and 10). Findings are as follows: 1. Record review for resident ID #3 revealed this resident was admitted to the facility on [DATE] and lacked evidence of routine dental service. 2. Record review for resident ID #5 revealed this resident has no routine dental services since 8/11/2014. 3. Record review for resident ID #9 revealed this resident was admitted to the facility on [DATE] and lacked evidence of routine dental services since admission. 4. Record review for resident ID #10 revealed this resident was admitted to the facility on [DATE] and lacked evidence of routine dental since admission. The Director of Nursing Service (DNS) was interviewed on 11/4/2016 at approximately 11:00 AM and was unable to produce evidence that the above residents have had routine dental services. | 2019-11-01 |
| 679 | 679 | CRA-MAR MEADOWS | 415066 | 575 SEVEN MILE ROAD | CRANSTON | RI | 2920 | 2016-11-04 | 502 | E | 0 | 1 | 1GOU11 | **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 provide or obtain laboratory services to meet the needs of 1 of 10 sample residents (ID # 2). Findings are as follows: Record review for resident ID #2 revealed the resident has been taking vitamin D 2 (50,000 units) 1 capsule by mouth, twice a month. The resident has a physician's orders [REDACTED]. Review of the resident's clinical record failed to reveal evidence that the vitamin D level was obtained since 8/14/2014. During an interview with the Director of Nursing Services on 11/3/2016 at 11:30 AM, she was unable to produce evidence that vitamin D level was obtained as ordered by the physician. | 2019-11-01 |
| 680 | 680 | CRA-MAR MEADOWS | 415066 | 575 SEVEN MILE ROAD | CRANSTON | RI | 2920 | 2016-11-04 | 504 | E | 0 | 1 | 1GOU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it has been determined that the facility failed to provide laboratory services only when ordered by the physician for 5 of 10 sample residents (ID#'s 1, 3, 5, 7, and 9). Findings are as follows: 1. Record review for resident ID #1 revealed two laboratory test results dated 7/7/2016 for Chem 7 (blood tests that provides information about metabolism) and CBC (complete blood count) and 12/17/2015 for CMP (comprehensive metabolic panel) and CBC. Further review failed to reveal a physician's orders [REDACTED]. When interviewed on 11/3/2016 at 2:45 PM, the Director of Nursing Services (DNS) was unable to produce evidence of a physician's orders [REDACTED]. 2. Record review for resident ID #3 revealed a laboratory test results dated 9/15/2016, for a WBC (white blood cell). Further review failed to reveal a physician's orders [REDACTED]. When interviewed on 11/3/2016 at 2:10 PM, the DNS was unable to produce evidence of a physician's orders [REDACTED]. 3. Record review for resident ID #5 revealed a laboratory test result dated 12/22/2015 for liver function tests. Further review failed to reveal a physician's orders [REDACTED]. When interviewed on 11/4/2016 at 10:00 AM, the DNS was unable to produce evidence of a physician's orders [REDACTED]. 4. Record review for resident ID #7 revealed two laboratory test results dated 12/22/2015 and 5/5/2016, for a CBC and CMP. Further review failed to reveal a physician's orders [REDACTED]. When interviewed on 11/4/2016 at 8:20 AM, the DNS was unable to produce evidence of a physician's orders [REDACTED]. 5. Record review for resident ID #9 revealed a laboratory test result dated 10/6/2016 for glucose and glycosylated hemoglobin (blood test used to measure the average level of glucose). Further review failed to reveal a physician's orders [REDACTED]. When interviewed on 11/4/2016 at approximately 9:00 AM, the DNS was unable to produce evidence of a physician's orders [R… | 2019-11-01 |
| 841 | 841 | CORTLAND PLACE | 415123 | 20 AUSTIN AVENUE | GREENVILLE | RI | 2828 | 2015-10-16 | 253 | B | 0 | 1 | 1HII11 | Based on surveyor observation and staff interview, it has been determined that the facility has failed to provide housekeeping and maintenance services necessary to maintain a comfortable interior, relative to dresser drawer handles, on 1 of 2 Units (Second Floor Rehabilitation Unit). Findings are as follows: On 10/14/2015 at approximately 8:30 AM, during the initial tour, and at 11:30 AM, the surveyor observed the following rooms with broken or missing handles on the dresser drawers. 202 B - both handles missing. 208 A - bottom handle missing. 215 B - bottom handle missing. 216 B - top handle is broken. 218 B - top handle is broken. On 10/16/2015 at 8:15 AM, an interview with the Maintenance Director revealed he could not produce evidence that he was aware the dresser drawer handles were broken. | 2019-03-01 |
| 842 | 842 | CORTLAND PLACE | 415123 | 20 AUSTIN AVENUE | GREENVILLE | RI | 2828 | 2015-10-16 | 323 | E | 0 | 1 | 1HII11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon surveyor observation, record review and staff interview, it has been determined that the facility has failed to provide adequate supervision and assistance devices to prevent accidents for 2 of 8 sample residents at risk for falls, (ID 3 & 7). Findings are as follows: 1) Record review of resident ID# 3 reveals a quarterly Minimum Data Set ((MDS) dated [DATE] which reveals that since readmission on 5/8/2015, the resident has had 3 falls, 1 with injury. A falls Care Area Summary (CAA) dated 5/20/2015 indicates the resident is at risk for falls due to an unsteady gait, impulsive acts, poor safety awareness and cognitive loss. A falls care plan updated 8/26/2015 has approaches to include: Keep walker in front of resident at all times when sitting. If attempts to stand without assist, will encourage her/him to use walker. Do not leave alone in room while awake. Non-skid socks when in bed. The resident was observed on 10/15/2015 intermittently between 7:36 AM to 8:30 AM lying in bed on her/his right side, awake, feet dangling outside the bed,wearing plain white socks only. Surveyor observation on 10/16/2015 at 7:00 AM revealed the door to the resdient's room closed. Intermittently between 7:50 - 8:40 AM, the surveyor knocked on the resident' s door to enter. The resident was awake, alone in the room, and without non skid socks. Upon entering the room at 8:42 am the surveyor and DNS observered the resdeint awake,alone, and without nonskid socks. Additionally, at 10:40 AM, the resident was observed sitting in a high backed chair in the common area. The walker was not placed in front of the resident and the resident was observed attempting to stand. 2) Record review of resident ID# 7 reveals a quarterly MDS dated [DATE] which reveals that, since the last MDS, the resident has had 3 falls, 2 with injury. A falls Care assessment dated [DATE] indicates the resident is at risk for falls due to balance deficits and the daily use of antidepressan… | 2019-03-01 |
| 843 | 843 | CORTLAND PLACE | 415123 | 20 AUSTIN AVENUE | GREENVILLE | RI | 2828 | 2015-10-16 | 371 | F | 0 | 1 | 1HII11 | Based upon surveyor observation and staff interview, it has been determined that the facility failed to prepare and distribute food in a sanitary manner relative to food service equipment and glove use. During initial tour of the kitchen on 10/14/2015 between 8:15 and 8:34 AM, the following was observed: The dishwasher (staff C) was observed handling both soiled and clean dishes without washing her hands. When interviewed, she acknowledged that she did not wash her hands after handling soiled dishes and before handling clean dishes. The cook' s utensil drawer, which holds measuring utensils and scoops, was found to have dried food debris on the inside of the drawer and some measuring utensils were visibly soiled. The drawer handle was sticky with dried food debris. 2 metal racks that hold sheet pans were observed with dried food matter on the railings and sides of the racks. All shelving in the walk-in refrigerator had dried food matter on the top of the shelves and dark matter on the underside of the shelves. Additionally, at 11:30 AM, a dietary aide delivered an empty plastic truck that would be used to place the empty lunch trays. The truck was visibly soiled both inside and outside with dried food matter. When interviewed on 10/15/2015 at 9:45 AM, the interim Dietary Manager was unable to produce evidence that an effective cleaning schedule was in place. | 2019-03-01 |
| 844 | 844 | CORTLAND PLACE | 415123 | 20 AUSTIN AVENUE | GREENVILLE | RI | 2828 | 2015-10-16 | 465 | B | 0 | 1 | 1HII11 | Based on surveyor observation, it was determined that the facility failed to maintain a clean, sanitary kitchen located in the dinning room on the third floor. Findings are as follows: During observation of the 3rd floor kitchen/pantry on 10/14/2015 at 10:15 AM, the following was observed: Ice scoop, including the handle, sitting directly on the ice in the ice machine. Dried food crumbs in the top gasket of the ice machine. Kitchen cabinet doors sticky to touch with dried food matter visible. Refrigerator and freezer handles sticky to the touch. When interviewed on 10/15/2015 at 9:45 AM, the interim Dietary Manager was unable to produce evidence that an effective cleaning schedule was in place. 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. | 2019-03-01 |
| 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 |
| 662 | 662 | PAWTUCKET SKILLED NURSING & REHABILITATION | 415064 | 70 GILL AVENUE | PAWTUCKET | RI | 2861 | 2016-11-16 | 281 | E | 0 | 1 | 1LX511 | **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 in accordance with professional standards relative to physician's orders [REDACTED].#'s 8 & 13). 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. Resident ID# 13 is a risk for impaired swallowing. There is a physician's orders [REDACTED]. Additionally, there is an order dated 5/17/2016 to current to continue to monitor daily weights. Observations on 11/10/2016 at 8:10 AM and 12:20 PM and again on 11/15/2016 at 8:20 AM revealed the resident eating a meal. There were no staff present observing the resident at these times. During an interview with the nursing assistant (staff A) on 11/15/2016 at approximately 8:35 AM, she stated that they occasionally check in on the resident during mealtime. Additionally, review of the resident's medical record failed to reveal daily weights were obtained. During an interview with the unit nurse (staff B) on 11/16/2016 at 11:05 AM, she failed to produce evidence that the resident was weighed daily. 2. Resident ID #8 has a physician's orders [REDACTED]. A review of the Treatment Administration Record revealed no evidence the above order has been followed. During an interview with the unit nurse (staff B) on 11/10/2016 at 11:05 AM, she was unable to provide evidence that the the physician's orders [REDACTED]. | 2020-01-01 |
| 663 | 663 | PAWTUCKET SKILLED NURSING & REHABILITATION | 415064 | 70 GILL AVENUE | PAWTUCKET | RI | 2861 | 2016-11-16 | 282 | D | 0 | 1 | 1LX511 | Based on surveyor observations, record review and staff interview, it has been determined that the facility failed to provide services in accordance with the resident's plan of care for 1 of 2 sample residents (ID# 13) relative to guidance with meals. Findings are as follows: Resident ID# 13 has a care plan, initiated on 1/14/2016 and revised on 5/31/2016 relative to risk for impaired swallowing. Interventions include: provide nectar thick liquids via teaspoon, encourage small sips/bites and cue as needed, encourage resident to chew and swallow each bite, and encourage resident to alternate liquids and solids. Observations on 11/10/2016 at 8:10 AM and 12:20 PM and again on 11/15/2016 at 8:20 AM revealed the resident eating a meal with no staff present. During an interview with the nursing assistant (staff A) on 11/15/2016 at approximately 8:35 AM, she stated that they occasionally check in on the resident during mealtime and that the resident drinks her liquids independently via cup. | 2020-01-01 |
| 664 | 664 | PAWTUCKET SKILLED NURSING & REHABILITATION | 415064 | 70 GILL AVENUE | PAWTUCKET | RI | 2861 | 2016-11-16 | 329 | D | 0 | 1 | 1LX511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility has failed to ensure residents are free from unnecessary drugs for 2 of 14 sample residents (ID#'s 5 & 6). Findings are as follows: 1) Record review for ID# 5 revealed a current physician's orders [REDACTED]. Review of resident's Medication Administration Record [REDACTED]. 2) Record review for ID # 6 revealed a current physician's orders [REDACTED]. Review of the MAR indicated [REDACTED]. Further review of the resident's bowel record revealed the resident had large bowel movements on 11/13/2016 and 11/14/2016. An interview was conducted on 11/15/2016 at 11:45 AM with the unit nurse (staff D). She was unable to explain why the resident had received a laxative even though he/she had a bowel movement on 11/13/2016 and 11/14/2016. | 2020-01-01 |
| 665 | 665 | PAWTUCKET SKILLED NURSING & REHABILITATION | 415064 | 70 GILL AVENUE | PAWTUCKET | RI | 2861 | 2016-11-16 | 371 | F | 0 | 1 | 1LX511 | Based on surveyor observation and staff interview, it has been determined that the facility failed to store, prepare, distribute and serve food under sanitary conditions and within temperature control. Findings are as follows: During the initial tour of the kitchen on 11/9/2016 at 8:30 AM, the surveyor observed the following: 1) A stainless steel plate heater unit with dried food debris on the outside and inside of the unit. 2) A stainless steel shelf containing large pots placed over dried food matter. 3) The convection oven had dried food matter on all inside surfaces of the unit. 4) There were three saute pans with dried on food matter, dented, and not stored inverted. 5) The walk-in refrigerator contained 2 trays of small dessert dishes and one additional tray of ketchup that were uncovered. 6) A rectangular pan containing a meat/tomato sauce that was not labeled or dated. This regulation, under tray line and alternative meal preparation and service area states, in part: * Holding foods in danger zone temperatures which are between 41 degrees Fahrenheit (F) and 135 degrees F. On 11/10/2016 at 11:15 AM, the lunch service line was observed to contain tunafish sandwiches and 2 different pasta salads, ready for service. The temperatures were taken at this time and revealed the following: Tuna sandwiches at 63.3 degrees F Regular pasta salad at 50 degrees F Modified diet pasta salad at 51.1 degrees F At this time, the Food Service Director (FSD) was unable to explain why the items were not held at the temperature control of 41 degrees or below as required. Additionally, at 11:35 AM, a dietary aide was observed with coffee cups setup and ready to be used. Out of 25 cups, 14 were observed with dried brown matter that could be easily scraped off. Six out of 8 soup cups were observed to have dried matter on the inside of the cups. When interviewed on 11/10/2016 at 2:30 PM, the FSD was unable to explain why the above referenced items were soiled. You are hereby formally notified that where the above listed deficiencies… | 2020-01-01 |
| 1237 | 1237 | PAWTUCKET SKILLED NURSING & REHABILITATION | 415064 | 70 GILL AVENUE | PAWTUCKET | RI | 2861 | 2016-11-16 | 313 | E | 0 | 1 | 1LX511 | Deficiency Text Not Available | 2017-03-01 |
| 1238 | 1238 | PAWTUCKET SKILLED NURSING & REHABILITATION | 415064 | 70 GILL AVENUE | PAWTUCKET | RI | 2861 | 2016-11-16 | 323 | D | 0 | 1 | 1LX511 | Deficiency Text Not Available | 2017-03-01 |
| 1247 | 1247 | CORTLAND PLACE | 415123 | 20 AUSTIN AVENUE | GREENVILLE | RI | 2828 | 2014-02-26 | 281 | D | 1 | 0 | 1N7M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The State of Rhode Island Rules and Regulations for the Licensing of Nurses and Standards for the Approval of Basic Nursing Education Programs (R5-34-NUR/ED), Section 1.31, defines Nursing, and states, in part: It provides care and support of individuals and families during periods of wellness, illness and injury and incorporates the appropriate medical plan of care as prescribed by a duly licensed physician, dentist, podiatrist, or other health care provider licensed to prescribe. Based on clinical record review and staff interviews, it was determined that the facility failed to meet professional standards of quality for 2 of 5 sample residents, ID#'s 1 and 3, relative to not following physician's orders [REDACTED]. Findings are as follows: Resident ID #1 has a February 2014 physician's orders [REDACTED]. Review of ID #1's Medication Administration Record [REDACTED]. Resident ID# 3 has a February 2014 physician's orders [REDACTED]. Review of ID #3's MAR indicated [REDACTED]. An interview with an RN, on 2/26/2014 at approximately 3:45 PM, revealed that she was responsible for administering the above medications on 2/21/2014. This nurse stated that she administered the medications. However, there was no evidence on the MARs that these medications were administered. 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. | 2017-02-01 |
| 1511 | 1511 | CHESTNUT TERRACE NURSING & REHABILITATION CENTER | 415007 | 100 WAMPANOAG TRAIL | RIVERSIDE | RI | 2915 | 2012-12-20 | 281 | E | 0 | 1 | 1O4T11 | **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 meet professional standards of quality for 3 of 5 sample residents, (ID #'s7,9 and 12) relative to oxygen . Findings are as follows: The State of Rhode Island Rules and Regulations for the Licensing of Nurses and Standards for the Approval of Basic Nursing Education Programs (R5-34-NUR/ED), Section 1.31, defines Nursing, and states, in part: It provides care and support of individuals and families during periods of wellness, illness, and injury and incorporates the appropriate medical plan of care as prescribed by a duly licensed physician, dentist, podiatrist, or other health care provider licensed to prescribe. 1. Record review for resident ID # 7 revealed a physician's orders [REDACTED]. Surveyor observations on 12/18/2012 at 2:20 PM and 3:10 PM revealed the oxygen concentrator was set at a rate of less than 2 liters per minute via nasal cannula. Additional observations on 12/19/2012 at approximately 8:35 AM, 10:35 AM and 12:10 PM revealed the resident was again administered oxygen at a rate of less than 2 liters per minute via nasal cannula. At 1:10 PM and 2:25 PM on the same day the resident was observed observation sitting in her chair with her nasal canula in place and the oxygen concentrator's control knob was in the off position. At 2:25 PM, the surveyor requested the nurse in charge to measure the residents' blood oxygen level. The nurse proceeded to measure the resident's blood oxygen level which revealed it to be at 88 (minimum oxygen level should be 90). The nurse was unable to explain why the oxygen was not administered as ordered. 2. Record review for resident ID # 9 revealed a 4/18/2012 to present physician's orders [REDACTED]. Surveyor observations on 12/20/2012 at 9:30 AM and 11:30 AM revealed the resident sitting in his room with no oxygen administered and his concentrator in the off position beside his bed. When … | 2015-11-01 |
| 1583 | 1583 | EVERGREEN HOUSE HEALTH CENTER | 415056 | 1 EVERGREEN DRIVE | EAST PROVIDENCE | RI | 2914 | 2012-03-26 | 329 | F | 0 | 1 | 1QNJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility has failed to ensure that each resident's drug regimen was free from unnecessary drugs for 3 of 24 sample residents (ID #'s 1, 16, 21) and 1 non sample resident (ID #25); ID # 1 for the administration of an antidepressive medication and ID #'s 16, 21 and 25 for sliding scale insulin administration involving 2 of 3 nursing units. Findings are as follows: 1. Clinical record review of resident ID # 1 revealed he was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 1/25/2012 physician order [REDACTED]. Review of the February 2012 and March 2012 Medication Administration Records revealed that the resident continued to receive the medication from 2/1/2012 through 2/29/2012 and 3/1/2012 through 3/22/2012 until brought to the attention of the facility. When interviewed on 3/23/2012 at 8:50 AM, the unit nurse manager could not provide evidence that this medication was necessary for this resident. 2. Clinical record review of resident ID # 16 revealed he was readmitted to the facility with [DIAGNOSES REDACTED]. 111-130 = 2 units 131-150 = 4 units 151-170 = 6 units 171-190 = 8 units 191-210 = 10 units 211-230 = 12 units 231-240 = 14 units Call physician for a FSBS less than 60 or greater than 240. A review of the March 2012 Sliding Scale Insulin Sheet revealed the following: On 3/18/2012 at 11:30 AM, the resident's FSBS was recorded as 130 and was adminitered 6 units instead of the ordered 4 units. When interviewed on 3/23/2012 at 11:00 AM, the unit manager acknolwedged that the resident received insulin in excess of the physician's orders [REDACTED]. 3. Clinical record review of resident ID # 25 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 2/13/2012 physician's orders [REDACTED]. 200-250 = 2 units 251-300 = 4 units 301-350 = 6 units 351 and above = 8 units call the physician for a FSBS of greater than 450. R… | 2015-07-01 |
| 1584 | 1584 | EVERGREEN HOUSE HEALTH CENTER | 415056 | 1 EVERGREEN DRIVE | EAST PROVIDENCE | RI | 2914 | 2012-03-26 | 514 | D | 0 | 1 | 1QNJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to maintain clinical records in accordance with accepted professional standards for 2 of 28 sample residents (ID# 16, and 21). Findings are as follows: 1. A review of resident ID # 21's clinical record revealed a 3/5/2012 physician's telephone order for finger sticks blood sugars three times per day with regular insulin sliding scale coverage as follows: ....250 - 300 give 2 units. The resident's March 2012 Sliding Scale Insulin Sheet revealed the sliding scale coverage as follows: 251 - 300 give 2 units. 2. Clinical record review of resident ID # 16 revealed a 3/19/2012 physician order [REDACTED]. 111-130 = 4 units 131-150 = 6 units 151-170 = 8 units 171-190 = 10 units 191-210 = 12 units 211-230 = 14 units 231-240 = 16 units Call physician if less than 60 or greater than 240. Review of the Sliding Scale Insulin Sheet indicated the following sliding scale: 111-130 = 2 units 131-150 = 4 units 151-170 = 6 units 171-190 = 8 units 191-210 = 10 units 211-230 = 12 units 231-245 = 14 units Call physician if less than 60 or greater than 240. In separate interviews on 3/23/2012 with the unit nurse at approximately 12:30 PM, and the Director of Nurses at approximately 1:30 PM, both indicated that they were unaware that the physician's telephone order was inaccurately documented onto the Sliding Scale Insulin Sheet for March 2012. "You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the 'Rules for Licensing of Nursing Facilities' they are deficiencies under State Regulations and grounds for licensure sanctions." | 2015-07-01 |
| 1585 | 1585 | EVERGREEN HOUSE HEALTH CENTER | 415056 | 1 EVERGREEN DRIVE | EAST PROVIDENCE | RI | 2914 | 2012-03-26 | 333 | F | 0 | 1 | 1QNJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, it was determined the facility failed to ensure that residents are free of any significant medication errors for 5 of 12 residents receiving sliding scale insulin coverage (sample ID #'s 14 and 16; and non-sample (NS) ID #'s 25, 27, and 28). The medication errors involved nurses from 2 of 3 nursing units (first floor and third floor). Findings are as follows: First Floor Unit 1. Review of resident ID# 16's clinical record revealed a physician's orders [REDACTED]. For BS less than 60 - call MD For BS less than 89 - hold insulin 90 - 110 = 2 units 111- 130 = 4 units 131 - 150 = 6 units 151 - 170 = 8 units 171- 190 = 10 units 191 - 210 = 12 units 211- 230 = 14 units 231- 245 = 16 units For BS greater than 250 - call MD Review of the January 2012 Sliding Scale Insulin Sheet revealed the following: On 1/3/2012 at 11:30 AM, the resident's FSBS was recorded as 176 and 8 units was administered instead of the required 10 units. On 1/11/2012 at 9:00 PM , the resident's FSBS was recorded as 111 and 2 units was administered instead of the required 4 units. On 1/13/2012 at 11:30 AM, the resident's FSBS was recorded as 197 and 8 units was administered instead of the required 12 units. On 1/17/2012 at 11:30 AM , the resident's FSBS was recorded as 96 and no insulin was administered instead of the required 2 units. On 1/19/2012 at 9:00 PM, the resident's FSBS was recorded at 235 and 14 units was administered instead of the required 16 units. On 1/30/2012 at 11:30 AM , the resident's FSBS was recorded at 256 and no insulin was administered. Additionally, there is no evidence in the record that the physician was notified. Review of the February 2012 Sliding Scale Insulin Sheet revealed the following: On 2/2/2012 at 9:00 PM , the resident's FSBS was recorded as 197 and 2 units was administered instead of the required 12 units. On 2/6/2012 at 4:30 PM , the resident's FSBS was recorded as 149 and no insulin was admini… | 2015-07-01 |
| 1586 | 1586 | EVERGREEN HOUSE HEALTH CENTER | 415056 | 1 EVERGREEN DRIVE | EAST PROVIDENCE | RI | 2914 | 2012-03-26 | 281 | D | 0 | 1 | 1QNJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of practice relative to sliding scale insulin administration and fingerstick blood sugars for 1 non sample resident, ID # 25. Findings as as follows: The State of Rhode Island Rules and Regulations for the Licensing of Nurses and Standards for the Approval of Basic Nursing Education Programs (R5-34-NUR/ED), Section 1.31, defines "Nursing", and states, in part: "It provides care and support of individuals and families during periods of wellness, illness and injury and incorporates the appropriate medical plan of care as prescribed by a duly licensed physician, dentist, podiatrist, or other health care provider licensed to prescribe." Review of ID # 25's clinical record revealed a February 2012 physician order [REDACTED]. 200-250 = 2 units; 251-300 = 4 units; 301-350 = 6 units; 351 and above = 8 units of insulin; greater than 450 - Call the physician Insulin to be given after meals if resident ate greater than 75%. Review of the February 2012 Sliding Scale Insulin Sheet and nursing notes revealed no evidence that a FSBS was obtained at 11:30 AM on 2/14/2012. When interviewed on 3/23/2012 at 11:00 AM, the unit nurse manager could not provide evidence that the FSBS was taken as ordered. The unit manager also stated that the resident always eats greater than 75% of her meals. | 2015-07-01 |
| 1587 | 1587 | EVERGREEN HOUSE HEALTH CENTER | 415056 | 1 EVERGREEN DRIVE | EAST PROVIDENCE | RI | 2914 | 2012-03-26 | 428 | D | 0 | 1 | 1QNJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it was determined the facility failed to ensure that monthly medication reviews by the consulting pharmacist include identification of irregularities for 2 of 28 sample residents; ID # 1 relative to the administration of an antidepressant medication and ID #16 relative to sliding scale insulin administration. Findings are as foll 1. Clinical record review of resident ID # 1 revealed a 1/25/2012 physician order [REDACTED]. Review of the resident's February 2012 Medication Administration Record [REDACTED]. 2. Clinical record review of resident ID # 16 revealed a physician order [REDACTED]. For BS less than 60 - call MD For BS less than 89 - hold insulin 90 - 110 = 2 units 111- 130 = 4 units 131 - 150 = 6 units 151 - 170 = 8 units 171- 190 = 10 units 191 - 210 = 12 units 211- 230 = 14 units 231- 245 = 16 units For BS greater than 250 - call MD The resident was administered the wrong dose of Novolog Insulin per sliding scale on 1/3/2012 at 11:30 AM, 1/11/2012 at 9:00 PM, 1/13/2012 at 11:30 AM, 1/17/2012 at 11:30 AM, and 1/19/2012 at 9:00 PM. Review of the Pharmacy Medication Regimen Review for 2/23/2012 for these 2 residents failed to reveal evidence that the pharmacy consultant identifed that the antidepressant continued to be administered to ID # 1, as well as the sliding scale insulin errors for resident ID # 16. When interviewed on 3/23/2012 at 11:00 AM, the pharmacy consultant could not provide evidence that these irregulaties were reported to either the physician or the Director of Nursing. | 2015-07-01 |
| 1431 | 1431 | HERITAGE HILLS NURSING & REHABILITATION CENTER | 415039 | 80 DOUGLAS PIKE | SMITHFIELD | RI | 2917 | 2013-08-30 | 248 | E | 0 | 1 | 1UMS11 | **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 provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and physical, mental and psychosocial well-being for 3 of 15 sample residents (ID's #1, 4 and 8). Findings are as follows: 1. Resident ID # 1 has a [DIAGNOSES REDACTED]. Surveyor observation on 8/27/2013 at approximately 12:30 PM, the resident was seated at the dinning room with her doll in her arms. Surveyor observation on 8/28/2013 at 8:10 AM the resident was observed sitting in the dinning room where he/she remained until after lunch when he/ she was returned to bed. The resident was not observed participating or attending any of the activities that were listed in his/her MDS. Review of the resident's Actives Participation Record for May, June, July & August failed to reveal that the resident is participating in activities. Interview with the Director of Activities on 8/29/2013 at approximately 10 AM, she was unable to produce evidence that the resident was participating or being offered the opportunity to participate in actives. 2. Resident ID # 4 has [DIAGNOSES REDACTED]. An annual Minimum Data Set ((MDS) dated [DATE] indicates it is important to the resident to do the following activities: listen to music s/he likes, participate in programs involving pets, and participate in news and religious programs. Review of the resident's activity progress note dated 11/20/2012 revealed the resident was no longer able to communicate but is wheeled to the dining room to observe musical events. In addition, the notes indicated that the activity goal was to continue daily visits with the resident to promote socialization. A review of the Activities Participation Record for June, July and August 2013 revealed no evidence that the resident had been provided with activities or had participated in daily visits according to t… | 2016-04-01 |
| 1432 | 1432 | HERITAGE HILLS NURSING & REHABILITATION CENTER | 415039 | 80 DOUGLAS PIKE | SMITHFIELD | RI | 2917 | 2013-08-30 | 281 | E | 0 | 1 | 1UMS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interviews it was determined the facility failed to provide services in accordance to physician's orders [REDACTED].#5) who utilizes a Gastrostomy tube ([DEVICE]). Finding are as follows: The State of Rhode Island Rules and Regulations for the Licensing of Nurses and Standards for the Approval of Basic Nursing Education Programs (R5-34-NUR/ED), Section 1.31, defines Nursing, and states, in part: It provides care and support of individuals and families during periods of wellness, illness and injury and incorporates the appropriate medical plan of care as prescribed by a duly licensed physician, dentist, podiatrist, or other health care provider licensed to prescribe. 1. Record review for resident ID #5 revealed a physician's orders [REDACTED]. During surveyor observation on 8/27/2013 at 12:15 PM revealed nurse B rinsed the [DEVICE] extension with water (no soap) after she used it to administer the medication to the resident. The nurse then put the extension tube in an uncovered plastic box which was kept in the bottom drawer of the medication cart. When question during the observation, nurse B indicated she has been administering medication on a regular basis via [DEVICE], and that she only rinses the extension tube with water. Additional observations on 8/28/2013 at approximately 8:30 AM and 12:00 PM failed to reveal nurse B followed the physician's orders [REDACTED]. During an interview on 8/29/2013 at 10:15 AM, the Director of Nurses was unable to produce evidence as to why the nurse did not follow the physician's orders [REDACTED].> | 2016-04-01 |
| 1433 | 1433 | HERITAGE HILLS NURSING & REHABILITATION CENTER | 415039 | 80 DOUGLAS PIKE | SMITHFIELD | RI | 2917 | 2013-08-30 | 441 | D | 0 | 1 | 1UMS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interviews, it was determined the facility failed to maintain infection control practices/policies on 1 of 3 nursing Units for 1 of 4 sample resident's ID # 5 relative to the [DEVICE] and precaustions. The facility's policy titled Infection Control Basics states, in part: Hand washing: Washing your hands is the simplest, most effective thing you can do to reduce the spread of infectious diseases . You should wash your hands before and after touching blood, body fluids, or any articles or equipment that could be contaminated with blood or body fluids .Wash hands before you apply gloves and after removing. Contact precaution: Before you leave the patient's room, remove your gown and gloves, and then wash your hands with antimicrobial soap or waterless antiseptic . Infectious agents transmitted by contact include Clostridium difficile (C-Diff) . 1. Resident ID # 5 Record review for resident ID #5 revealed laboratory results dated [DATE] and 8/27/2013 indicate s/he is positive for[DIAGNOSES REDACTED] and is on contact precautions. The resident has a physician's orders [REDACTED]. During surveyor observation of medication administration via [DEVICE] on 8/27/2013 at 12:00 PM revealed nurse B applied her gloves and placed a disposable pad over the resident's abdomen. The nurse connected the extension tube to the [DEVICE], and the gastric contents (yellow and orange color) poured out onto the disposable pad and the floor. The nurse's gloves were visibly soiled with gastric content. The nurse then administered medications via [DEVICE] without changing her gloves. She then placed the soiled supplies ([DEVICE] extension, syringe, medication cups, a plastic cups and bottles and disposables pad) directly on the medication cart. Without removing the soiled gloves, the nurse then pushed the medication cart back to the nursing station. She proceded to remove a set of keys from her pocket and open the med… | 2016-04-01 |
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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 );