cms_RI
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1,896 rows sorted by facility_id
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| Link | rowid | facility_name | facility_id ▼ | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | HATTIE IDE CHAFFEE HOME | 415002 | 200 WAMPANOAG TRAIL | EAST PROVIDENCE | RI | 2914 | 2019-01-04 | 755 | D | 0 | 1 | 2B5Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, surveyor observation, and staff interview, it has been determined that the facility failed to provide routine drugs relative to 1 of 8 residents reviewed for medication administration (ID# 42). Findings are as follows: Record review for Resident ID# 42 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed the following: 1. A 12/5/2018 physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. 2. A 12/20/2018 physician's orders [REDACTED]. Review of the MAR indicated [REDACTED]. 3. A 12/26/2018 physician's orders [REDACTED]. Review of the MAR indicated [REDACTED].Other for 3 of 9 opportunities. Surveyor observation during the Medication Administration Task on 1/3/2019 at 7:31 AM revealed that the current physician ordered B Complex 1 dose was not available to the resident. During an surveyor interview, immediately following this observation, Medication Aide (Staff A) revealed that the resident did not receive the B Complex and that the medication has not been available for a few days. During a subsequent interview on 1/3/2019 at 10:26 AM, the South Wing Charge Nurse was unable to provide evidence that the above physician ordered medications were available to Resident ID# 42. | 2020-09-01 |
| 2 | 2 | HATTIE IDE CHAFFEE HOME | 415002 | 200 WAMPANOAG TRAIL | EAST PROVIDENCE | RI | 2914 | 2019-01-04 | 761 | D | 0 | 1 | 2B5Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, surveyor observation, and staff interview, it has been determined that the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 residents reviewed for medication administration (ID# 45). Findings are as follows: Record review for Resident ID# 45 revealed the following: 1. A current physician's orders [REDACTED]. 2. A current physician's orders [REDACTED]. 3. A current physician's orders [REDACTED]. Surveyor observation during the Medication Administration Task on 1/3/2019 at 8:16 AM revealed the Unit Nurse (Staff B) leaving a medication cup with the [MEDICATION NAME] and [MEDICATION NAME] on the resident's bedside table while the resident was in the bathroom. During surveyor on 1/3/2019, immediately following the observation, Staff B revealed that the resident self-administers the medications and the [MEDICATION NAME] is stored in the bathroom, not in a locked compartment. Additionally, she has been leaving the resident's medications on the bedside table for a while and acknowledged that they were not secured. During a subsequent interview on 1/3/2019 at 9:35 AM, the Administrator was unable to provide evidence that the resident's drugs were stored in locked compartments. Additionally, during interview on 1/4/2019 at 8:19 AM, Resident ID# 45 confirmed that the [MEDICATION NAME] has been stored in the bathroom and that the nurses leave medications on the bedside table. | 2020-09-01 |
| 3 | 3 | HATTIE IDE CHAFFEE HOME | 415002 | 200 WAMPANOAG TRAIL | EAST PROVIDENCE | RI | 2914 | 2019-11-08 | 688 | D | 0 | 1 | KGGT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and resident and staff interviews, it has been determined that the facility failed to ensure a resident with limited mobility receives appropriate treatment to prevent further decrease in range of motion for 1 of 1 resident reviewed for limited range of motion (ID #45). Findings are as follows: Record review revealed that Resident ID #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further record review revealed a physician's orders [REDACTED]. Review of the care plan in place for Activities of Daily Living and Functional/Rehabilitation Potential revealed an intervention dated 11/22/2016 stating in part: .apply left hand palm protector q (every) daytime, as tolerated . Surveyor observation on the following dates and times revealed the resident without a left-hand palm protector on his/her hand: -11/7/2019 10:50 AM -11/7/2019 11:15 AM -11/7/2019 02:20 PM -11/8/2019 12:02 PM -11/8/2019 12:08 PM During a surveyor interview on 11/7/2019 at 11:34 AM with Certified Nursing Assistant (CNA), Staff A, she stated that the resident does not require anything on his/her hands during the day. During a surveyor interview on 11/8/2019 at 11:58 AM with the resident's assigned CNA for the day, Staff B, she stated the resident does not wear anything on his/her hands during the day and referenced a care card which is used for care instructions. Record review of the Resident's care card revealed in part, .left hand palm protector during the day as tolerated . During a surveyor interview with Resident ID #45 on 11/8/2019 at 12:02 PM, s/he stated that s/he sometimes wears something on his/her wrist during the day, but not always. During a surveyor interview on 11/8/2019 at 12:12 PM with the unit nurse, Staff C, she acknowledged that the resident should be wearing a left-hand palm protector during the day, however, she had not observed the resident wearing the palm protector for the last 2 days. | 2020-09-01 |
| 4 | 4 | HATTIE IDE CHAFFEE HOME | 415002 | 200 WAMPANOAG TRAIL | EAST PROVIDENCE | RI | 2914 | 2019-11-08 | 761 | D | 1 | 1 | KGGT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, staff interview and record review, it has been determined that the facility failed to ensure that expired medications were not available for administration and failed to date multi-dose vials when opened for 1 of 2 bottles of [MEDICATION NAME] Purified Protein Derivative (used intradermally to aid in [DIAGNOSES REDACTED]. Finding are as follows: Surveyor observation of the medication storage room refrigerator on 11/07/2019 at 11:35 AM with the Director of Nursing (DNS), revealed the following: 1) A 150 ml bottle of FirvanQ [MEDICATION NAME] (an antibiotic) 50 mg/ml for Resident ID #16. Instructions on the bottle state, contents must be used within 14 days discard if hazy. The bottle was received from the pharmacy on 9/5/2019. Additionally, there was a sticker on the bottle that stated Do Not use after 9/19/19. 2) A [MEDICATION NAME] 5 T units/ 0.1 ml vial in fridge opened and not dated when opened. Instructions on the bottle state,discard opened product after 30 days. During surveyor interview on 11/07/2019 at 11:40 AM with the DNS, she revealed that the [MEDICATION NAME] was expired and should have been discarded. She further revealed that the [MEDICATION NAME] should have been dated when opened. | 2020-09-01 |
| 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 |
| 1096 | 1096 | HATTIE IDE CHAFFEE HOME | 415002 | 200 WAMPANOAG TRAIL | EAST PROVIDENCE | RI | 2914 | 2015-02-23 | 253 | C | 0 | 1 | EC3811 | 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 environment relative to doors, baseboard and ceiling heating vents, and bathrooms on two of two nursing units (north and south). Findings are as follows: The following areas requiring maintenance services were observed: 1. Multiple resident room doors and shower/bathroom doors in both nursing units had stripped wood finish and staining,on the lower third of the doors. North nursing unit included doors for the soiled linen and custodian closets, room# 5, room# 7 bathroom doors and the ramp entrance. South nursing unit doors included room#'s 43, 45, 47, 49, 53 and 57, the soiled linen closet, family room and the ramp entrance. During the environmental tour on 2/23/15 at10:30 AM, the maintenance director acknowledged he was unaware of the above areas. 2. During surveyor observation on 2/18/2015 between 3:15 PM to 5:00 PM and 2/19/2015 between 8:30 AM to 9:30 AM revealed the followings; Heavy accumulation of dust in the following : 1. Vents in rooms # 8, 21, 23, 26, 27, 28, 33, 35, 37, 39, 43, 45, 53, 55, 57 2. Vents in bathrooms in rooms # 8, 21, 26, 28, 35, 37, 43 53 3. Vents in bathing area across from (south) nursing station 4. Vents above the doors from North and South nursing units to main dinning area 5. Mirror in bathroom between room # 37 and 39 with yellow stain (approximately 2 ft x 2 ft) and mirror in bathroom between room 33 and 35 with dark stain on lower part of it ( approximately 6 inches x 6 inches) 6.Several brown spots noted on the ceiling in room # 43 (approximately 4 ft x 4 ft) and room # 8 (approximately 4 ft x 3 ft). 7. Room # 39 with a stained closet door and radiator cover. 8. Pantry for North nursing unit, heavy accumulation of dust on the air conditioner 9. Broken tile (approximately 6 x 6 inc) in the bathing area north unit with heavy dust 12. Dark stained on lower part of door (soiled linen closet on Nor… | 2018-01-01 |
| 1097 | 1097 | HATTIE IDE CHAFFEE HOME | 415002 | 200 WAMPANOAG TRAIL | EAST PROVIDENCE | RI | 2914 | 2015-02-23 | 465 | C | 0 | 1 | EC3811 | Based on surveyor observations , it was determined that the facility failed to maintain a comfortable enviroment for the staff and the public in the North and South nursing stations and bathrooms. Findings are as follows: Observations were made on 2/18/2015 between 3:15PM to 5:00PM and 2/19/2015 and 2/19/2015 between 8:30AM to 9:30AM. 1. North nursing station. Staff bathroom with heavy accumulation of dust and brown stain on mirror, floor and wall; the plastic covering of a pipe had black matter (approximately 3.5 ft long) attached to it ; vents at nursing station as well as on the windows (sill and ledge) heavy accumulation of dust and the sink was loosely connected to the wall. 2. South nursing station. Staff bathroom with heavy accumulation of dust and brown stains on floor and wall; ceiling with paint peeling off as well as a heavy accumulation of dust on the window sill and ledge; heavy accumulation of dust noted on vents over the sink at the nursing. 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. | 2018-01-01 |
| 1369 | 1369 | HATTIE IDE CHAFFEE HOME | 415002 | 200 WAMPANOAG TRAIL | EAST PROVIDENCE | RI | 2914 | 2013-06-27 | 371 | F | 1 | 0 | ZJQD11 | 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 6/27/2013 at approximately 1:30 PM revealed the following: 1. The top of the mixer (which sits over the mixing bowl) was observed to be leaking grease. Following the observation, the mixer was observed with the maintenance director who revealed he had been unaware the mixer was leaking grease. During further interview, neither the maintenance director nor the person in charge of the kitchen, were able to provide evidence showing what this lubricant (the grease) was made of. 2. Surveyor observation of the can opener revealed an accumulation of black debris on the blade of the can opener. 3. A dietary employee was observed to enter the kitchen with a pair of gloves on. The employee failed to change his gloves. He then proceeded to unload clean dishes from the dishwasher. During an interview following the observation, the dietary employee acknowledged he had handled the clean dishware with the same gloves which he had worn while bringing a cart of dirty dishes to the kitchen. He further indicated it is his practice to not change his gloves upon returning to the kitchen. 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. | 2016-06-01 |
| 1486 | 1486 | HATTIE IDE CHAFFEE HOME | 415002 | 200 WAMPANOAG TRAIL | EAST PROVIDENCE | RI | 2914 | 2013-01-17 | 371 | F | 0 | 1 | JR4K11 | Based upon surveyor observation and staff interview, it was determined that the facility has failed to sanitize kitchen equipment correctly and failed to prepare food under sanitary conditions. Findings are as follows: During initial tour on 1/15/2013 at 8:52 AM and on 1/16/2013 at 1:00 PM, the following was observed: 1. A preparation table with a white resin cutting board on top measuring approximately 2 feet by 5 feet was observed to be yellow in color and had multiple gouged and chipped areas containing food debris. Additionally, dust and dried food was observed in the 2 large metal drawers of this table. 2. The standing commercial mixer had dried food debris. 3. A flour bin in the kitchen was not labeled. The sugar and flour bin had the handles of the scoops lying directly on top of the flour and sugar. 4. The large container of ice cream sprinkles was left open. 5. Three pipes under the 2-bay sink were open and protruding from the floor approximately 8 inches. The staff were unable to explain the purpose of those pipes. 6. The cold water faucet in the dish sink lacked a handle. 7. A set of large frying pans and mixing bowls were stored without being inverted. 8. Rodent droppings were observed in the dry storage room on the floor underneath shelving where food is stored. When interviewed on 1/15/2013 at 12:35 PM, the Food Service Director was unable to explain why the above areas were not addressed. | 2015-12-01 |
| 1487 | 1487 | HATTIE IDE CHAFFEE HOME | 415002 | 200 WAMPANOAG TRAIL | EAST PROVIDENCE | RI | 2914 | 2013-01-17 | 441 | D | 0 | 1 | JR4K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to maintain infection control practices/policies that ensure consistent adherence to infection control practices relative to dressing changes for 1 of 2 residents ID #7. Findings are as follows: On 1/16/2013 at 11:35 AM, a dressing change was observed on resident ID# 7, who is on contact precautions (gloves and gown) for Clostridium difficile (c-diff). The nursing assistant (NA) failed to put on a gown prior to entering the residents room, and proceeded to sit on the residents bed throughout the dressing change. The nurse failed to setup a clean field on the over the bed table where she placed her dressing supplies. She used 2 measuring strips to measure the wound, which came in contact with the resident. She then placed the measuring strips directly on the over the bed table next to the clean dressing supplies. At the completion of the dressing change, both the nurse and the NA removed their gloves and used the hand sanitizer to wash their hands. Additionally, the nurse failed to clean the over the bed table prior to leaving the room. Immediately following the dressing change, the nurse was interviewed and was unable to explain why she did not set up a clean field or why she did not discard the used measuring strips into the plastic bag. When interviewed on 1/16/2013 at 2:00 PM, the Director of Nursing stated that the facility's policy for[DIAGNOSES REDACTED] precautions include wearing a gown and washing hands with soap and water. | 2015-12-01 |
| 1669 | 1669 | HATTIE IDE CHAFFEE HOME | 415002 | 200 WAMPANOAG TRAIL | EAST PROVIDENCE | RI | 2914 | 2011-12-30 | 371 | E | 0 | 1 | CCG611 | Based upon surveyor observation and staff interview it was determined that the facility failed to prepare food under sanitary conditions, related to inadequate cooking of eggs, for 4 residents (IDs #1and 7 and non-sample IDs #17 and 18 ). Findings are as follow: Surveyor observation on 12/29/11 at 9:10 AM revealed a nursing assistant (NA) feeding resident ID #7 eggs. The egg yolks were observed to be runny (not congealed). During an interview at that time, the NA acknowledged that the yolks were runny. The NA stated the resident usually received eggs with runny yolks, as do other residents. During an interview on 12/29/11 at 10:05 AM, the food service director stated the shell eggs resident ID #7 were served were not pasteurized. He was unable to provide evidence that the eggs had been cooked at 145 degrees for 15 seconds till the whites were completely set and the yolks congealed. He further stated that resident ID #7 receives fried eggs with runny yolks daily, and that three other residents receive them on a regular basis ( sample ID # 1, non-sample #17 and #18). | 2015-04-01 |
| 1670 | 1670 | HATTIE IDE CHAFFEE HOME | 415002 | 200 WAMPANOAG TRAIL | EAST PROVIDENCE | RI | 2914 | 2011-12-30 | 365 | D | 0 | 1 | CCG611 | Based on surveyor observation, clinical record review and staff interview, it has been determined the facility failed to provide food prepared in a form designed to meet the individual needs of 1 of 4 sample residents (ID # 2), relative to thickened liquids. Findings are as follow: Review of this resident's clinical record revealed a current physicians order, (originally dated 7/5/2011) for pudding thick liquids. The current NA (nursing assistant) care card incorrectly specified "honey thick liquids". On 12/28/2011 at 1:00 PM, the surveyor observed Resident ID # 2 being fed by a Hospice NA. The resident's dietary slip indicated "Pudding thick liquids - honey thick milk." When the resident requested water instead of the milk, the surveyor observed the NA add 1 packet of honey consistency thickener to approximately 6 ounces of water. The NA proceeded to feed the resident approximately 60 ml of honey thick water instead of pudding thick. When the surveyor questioned the Hospice NA as to what consistency was to be provided, she conferred with a staff NA. The staff NA stated the resident received honey thick consistency. During an interview with the dietician on 12/28/11 at approximately 3:00 PM, she verified the diet slip was confusing for the staff. She went on to explain the honey thick milk on the slip meant this was to be thickened to a pudding consistency and that all liquids were to be pudding thick. | 2015-04-01 |
| 1671 | 1671 | HATTIE IDE CHAFFEE HOME | 415002 | 200 WAMPANOAG TRAIL | EAST PROVIDENCE | RI | 2914 | 2011-12-30 | 441 | D | 0 | 1 | CCG611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interview, it has been determined the facility failed to ensure the prevention of the spread of infection in 1 of 4 residents ( ID# 1 ) relative to staff following Contact Precautions. Findings are as follow: Resident ID # 1's current care plan indicates the staff will wear gloves and gowns when giving care per protocol for a [DIAGNOSES REDACTED]. The facility's protocol states"gowns and gloves should be worn when touching the resident, changing bed linens and when bathing or cleaning the resident". During a surveyor's observation on 12/28/11 at 9:00 AM, the resident was observed having the bed linens changed and personal care being given by 2 staff members. Neither staff member had a gown on.. During an interview with the Director of Nursing on 12/28/12 at 3:00 PM while discussing Contact Precautions , she stated gowns are to be worn by staff when providing ADL care (bathing and cleaning) to residents and having contact with their bed linens. "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 |
| 5 | 5 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2018-02-08 | 689 | J | 1 | 0 | QYSV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, interview and record review, the facility failed to identify hazards and risks to ensure an environment that is free from accident hazards, and provides supervision to each resident to prevent avoidable accidents for 1 of 20 residents who reside on the secured Westerly Unit relative to supervision and exit door alarms. Findings are as follows: On 2/6/2018 resident ID# 1 exited the glass exit door to an outdoor patio which is adjacent to the common area of the secured Westerly Unit. The resident was noted to fall outside of the door onto the ground which went un-noticed by staff. Resident ID# 1 was on the ground outdoors for an unknown period which resulted in a hospital admission for hypothermia and a laceration above her eye. During surveyor observation of the secured Westerly Unit on 2/8/18 at approximately 9:20 AM, it was identified that there were two exit doors which open to the outside. Both doors have an alarm located adjacent to the top of door which when in the on position will sound an alarm if the door is open. This alerts staff that someone has opened the door. The alarms can be shut off to each exit door by manually pressing the on and off switch. The common room exit door has a glass front full view and a push bar which easily opened with very little resistance and was noted to close itself upon exit. During an interview with the Director of Nursing on 2/8/2018 at approximately 9:40 AM she stated elopement assessments are not the practice of Royal Healthcare and therefore one was never completed for resident ID# 1. Additionally, she stated this resident had no elopement history and has never attempted to leave the facility. She states the door alarms should be on always and could not explain why the alarm had been shut off or who may have shut the alarm off. She states, according to nursing staff it appeared the resident may have stood up from her chair, ambulated to door, pushed on the door hand… | 2020-09-01 |
| 6 | 6 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2019-08-08 | 623 | C | 1 | 1 | 02UK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it has been determined that the facility failed to send a copy of the notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman for 6 of 6 sample residents reviewed relative to discharge to the hospital or community. Resident ID #s 2, 26, 30, 49, 50, and 63. Findings are as follows: 1. Clinical record review for Resident ID #2 revealed s/he was transferred to the hospital on [DATE]. 2. Clinical record review for Resident ID #26 revealed s/he was transferred to the hospital on [DATE]. 3. Clinical record review for Resident ID #30 revealed s/he was transferred to the hospital on [DATE]. 4. Clinical record review for Resident ID #49 revealed s/he was transferred to the hospital on [DATE]. 5. Clinical record review for Resident ID #50 revealed s/he was transferred to the hospital on [DATE]. 6. Clinical record review for Resident ID #63 revealed s/he was discharged to the community on 5/23/2019. During an interview with the Administrator, on 8/8/2019 at 11:07 AM, he revealed that the facility does not notify the Office of the State Long-Term Care Ombudsman for routine transfers from the facility. | 2020-09-01 |
| 7 | 7 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2019-08-08 | 689 | D | 1 | 1 | 02UK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on water temperature readings and staff and resident interviews, it was determined that the facility failed to ensure the residents' environment remains free from accident hazards related to water temperatures above 120 degrees Fahrenheit (F), in areas used by residents on 1 of 3 units (Mystic). Findings are as follows: The surveyors obtained water temperatures on all units on 8/5/2019. The following temperatures were observed on Mystic Unit (non-dementia care unit), using digital thermometers: -10:40 AM, room [ROOM NUMBER], bathroom sink measured at 125.2 F -10:44 AM, Mystic Unit, common bathing room sink measured 125.1 F -10:48 AM, room [ROOM NUMBER], bathroom sink measured 128.2 F -10:52 AM, room [ROOM NUMBER], bathroom sink measured 125.2 F -11:35 AM, room [ROOM NUMBER], bathroom sink measured 126.0 F -11:35 AM, room [ROOM NUMBER], bathroom sink measured 126.7 F -11:35 AM, room [ROOM NUMBER], bathroom sink measured 125.2 F -11:35 AM, room [ROOM NUMBER], bathroom sink measured 121.3 F -11:37 AM, room [ROOM NUMBER], bathroom sink measured 120.4 F -11:39 AM, room [ROOM NUMBER], bathroom sink measured 122.2 F During a surveyor interview on 8/5/2019 at 11:55 AM, with the Maintenance Director, he revealed that he was unaware of the elevated water temperatures. Additionally, he revealed that he completes weekly water temperature monitoring and logs of 2 different rooms per unit and at the 2 mixing valves weekly, on Thursdays. He revealed that he has not had problems with high temperatures and expects the water temperatures to measure between 100.0 F to 110.0 F, plus or minus two degrees. Further, he expects the staff to inform maintenance if the water feels too hot. Additional measurements of the water temperatures by both the surveyor and the Maintenance Director on 8/5/2019, using separate thermometers, revealed the following: -12:05 PM, Mystic Unit, common bathing room sink measured 122.1 F -12:07 PM, room [ROOM NUMBER], bathroom sink… | 2020-09-01 |
| 8 | 8 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2019-08-08 | 692 | E | 1 | 1 | 02UK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor record review and staff interview, it has been determined that the facility failed to ensure that a resident is offered sufficient fluid intake to maintain proper hydration for 1 of 3 sample residents reviewed for a fluid restriction (ID# 49). Findings are as follows: The facility's policy titled, Fluid Restriction Policy and Procedure, states in part, .5. Nursing will allocate the fluid allotment over the 24-hour period and by shift. Record review revealed that Resident ID #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the following physician's orders [REDACTED]. - 3/15/2019 to 6/14/2019: 1000 ml / day fluid restriction . - 6/14/2019 to 7/8/2019: 1000 ml / day fluid restriction . -7/8/2019 to 7/18/2019: 1000 ml / day fluid restriction .No liquids except for water between meals . - 7/18/2019 to current: 1000 ml / day fluid restriction . No liquids except for water between meals . Review of the Medication Administration Record [REDACTED]. Review of the Vitals Reports from 5/1/2019 to 8/7/2019 revealed that the resident's fluid intake is not consistently monitored. There was no fluid intake documented on 48 out of the 92 days the resident was residing at the facility. Additionally, the days that fluid intake was documented ranged from 0 ml to 1030 ml in total and did not include documentation from each shift. During a surveyor interview on 8/8/2019 at 10:12 AM with Nursing Assistant, Staff B, she revealed that she does not document when she gives the resident fluids. During a surveyor interview on 8/8/2019 at 10:16 AM with the nurse, Staff D, she acknowledged that the total daily fluid intake was not being tracked. During a surveyor interviews with the Director of Nursing Services on 8/8/2019 at 10:33 AM and 11:54 AM, she acknowledged that the resident's fluid intake is not being documented consistently and that they do not have the resident's prescribed fluid restriction allocat… | 2020-09-01 |
| 9 | 9 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2019-08-08 | 759 | D | 1 | 1 | 02UK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observations, record reviews, and staff interviews, it has been determined that the facility has failed to ensure that each resident's medication regimen is free of medication error rates of 5% or greater. Based on 35 opportunities for error, there were five errors involving one resident (ID #6), resulting in an error rate of 14.29%. Findings are as follows: 1. Record review for Resident ID #6 revealed a [DATE] physician's orders [REDACTED]. During surveyor observation of the Medication Administration task on [DATE] at 7:38 AM, Staff Nurse C, prepared Aspirin chewable 81 mg instead of the delayed release/[MEDICATION NAME] coated Aspirin. 2. Record review for the resident revealed a [DATE] order with a stop date of [DATE] for [MEDICATION NAME] HFA aerosol inhaler (used to control and prevent symptoms of asthma). During surveyor observation on [DATE] at 7:38 AM, of the inhaler prior to administration, revealed an expiration date of (MONTH) (YEAR). Additionally, Staff C was observed administering the expired inhaler to the resident. 3. Record review for the resident revealed an [DATE] physician's orders [REDACTED]. Review of the Myrbetriq manufacturer's patient information states, in part, .Do not chew, break, or crush the tablet . During surveyor observation on [DATE] at 7:38 AM, revealed instructions on the pharmacy label stating, do not crush or chew. Additionally, Staff C was observed crushing the medication. 4. Record review for the resident revealed an [DATE] physician's orders [REDACTED]. Review of the Gericare [MEDICATION NAME] delayed-release manufacturer's directions on the original box state, in part, .swallow whole. Do not chew or crush capsule . During surveyor observation on [DATE] at 7:38 AM, Staff C cut open the [MEDICATION NAME] capsule, emptied the contents, and crushed the granules with the other medications. 5. Record review for the resident revealed a [DATE] physician's orders [REDACTED]. Review of the Va… | 2020-09-01 |
| 10 | 10 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2019-08-08 | 812 | F | 1 | 1 | 02UK11 | > Based on surveyor observations and staff interview, it has been determined that the facility failed to properly store, distribute, and serve food, in accordance with professional standards for food service safety, relative to the main kitchen and 2 of 2 kitchenettes. Findings are as follows: 1. Surveyor observation of the main kitchen on 8/5/2019 at 9:15 AM, in the presence of the Food Service Director (FSD), revealed the following: - 15 out of 15 blue, hard-plastic coffee cups were observed to have brown, scrapable matter on the inside of the cup. During a surveyor interview with the FSD, at the time of the above observation, he indicated that the coffee cups needed to be replaced. 2. Surveyor observation of the Mystic Wing Kitchenette on 8/6/2019 at 2:27 PM revealed the following: - The inside of the ice machine had an accumulation of pink matter, above where ice is dispensed. - A 1-quart container of[NAME]Ensure Plus (vanilla) was in the refrigerator, open and not dated. Manufacturer instructions indicate to use within 48 hours of opening. - Two containers of[NAME]nectar-thick apple juice, one container of[NAME]nectar-thick lemon water, and one container of[NAME]nectar-thick orange juice were in the refrigerator, open and not dated. Instructions on the container state to use within 7 days of opening. - The water dispenser had an accumulation of brown/black matter on the inside of both the room-temperature and cold-water spigots. 3. Surveyor observation of the Westerly Wing Kitchenette on 8/6/2019 at 2:47 PM revealed the following: - 9 out of 18 blue, hard-plastic coffee cups were observed in the cabinet with brown, scrapable matter on the inside of the cup. - There was one container of each of the following, open and not dated, in the refrigerator:[NAME]nectar-thick orange juice,[NAME]nectar-thick lemon water,[NAME]honey-thick lemon water,[NAME]honey-thick cranberry juice,[NAME]nectar-thick cranberry juice,[NAME]nectar-thick apple juice, and[NAME]honey-thick apple juice. Instructions on the container state t… | 2020-09-01 |
| 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 |
| 749 | 749 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2016-09-01 | 167 | C | 0 | 1 | KYQ311 | Based on surveyor observations and staff interview, it was determined that the facility has failed to make the most recent survey results readily accessible to residents and visitors. Findings are as follows: Surveyor observations on 8/30 and 8/31/2016 failed to reveal the most recent survey results in a place readily accessible to residents and their families. A sign posted in the facility's lobby entrance specified that the survey results are available at each nurse's station and in the fireplace room. Surveyors observed that the survey results were not found at either of the two nurse's station or the fireplace room. During interview on 8/31/2016 at approximately 1:30 PM, the Director of Nurses acknowledged the survey results were not made readily available. | 2019-08-01 |
| 750 | 750 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2016-09-01 | 312 | D | 0 | 1 | KYQ311 | **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 a resident who is unable to carry out activities of daily living receives the necessary services to maintain good hygiene relative to nail care for 1 of 9 sample residents (ID# 1). Findings are as follows: Record review for resident ID #1 revealed [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] indicates the resident requires limited assistance of one staff with all activities of daily living (ADL's). Surveyor observation of the residents fingernails on 8/30/2016 at 10:45 AM revealed dried brown matter underneath the nails. At 12:46 PM and 5:20 PM, after ADL care was provided, the resident's fingernails were again observed to have dried brown matter underneath the nails. Subsequent surveyor observations on 8/31/2016 at 8:50 AM and 11:45 AM, the fingernails on both hands had dried brown matter underneath the nails. On 9/1/2016 at 8:55 AM, the resident's fingernails on both hands were again observed to have dried brown matter underneath the nails. The resident was asked how often they provide nail care. He/she stated that, due to limited eyesight, she/he cannot see the fingernails and rely's on staff to clean them and could not recall when they were last cleaned. The unit nurse (Staff A) was interviewed on 9/1/2016 at 9:25 AM and stated that the resident's nails are cleaned and clipped on shower days, however, they should clean them when soiled. 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. | 2019-08-01 |
| 938 | 938 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2015-07-23 | 323 | D | 0 | 1 | MZKI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it was determined that the facility failed to ensure the environment is as free of accident hazards as is possible relative to chemical storage on 2 of 3 units. Findings are as follows: 1. On 07/21/2015 at approximately 7:35 AM, and at 11:20 AM, the surveyor observed an unlocked utility room on the Mystic Unit, where there were 10 containers stored on a metal shelving unit (approximately 1 gallon each). The following were observed in the utility room: 1 gallon of disinfectant. 2 gallons of CEN-Kleen IV 3 gallons of CEN-Sol II 4 gallons of CEN Care II This utility room is located in the hallway, directly across from residents' rooms and the residents' dining room for the Mystic and Watch(NAME)Units. This room is accessible to residents who ambulate independently, residents who are independent with their wheelchairs and residents who have a [DIAGNOSES REDACTED]. On 07/21/2015 at approximately 7:35 AM, and 11:20 AM, the surveyor observed residents who are independent with ambulation, and residents who are independent with their wheelchairs, pass this utility room, when staff were not in the immediate area. When interviewed on 07/21/2015 at approximately 1:00 PM, with the Director of Maintenance, he could not provide an explanation as to why the chemicals were not secured. | 2018-10-01 |
| 939 | 939 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2015-07-23 | 463 | E | 0 | 1 | MZKI11 | Based on surveyor observations and staff interview, it was determined that the facility failed to provide a communication system in 1 unlocked bathroom across the conference room that is accessible to residents and the public. Findings are as follows: Surveyor observations on all 3 days of the survey revealed the absence of a communication system in the bathroom located across from the conference room. In addition, surveyor observations on all 3 days of the survey revealed some residents ambulating, either independently, using a walker, or self propelling via wheelchair, passing the bathroom. When interviewed on 7/23/2015 at approximately 2:30 PM, the Administrator was unable to explain why the bathroom had 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. | 2018-10-01 |
| 1310 | 1310 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2013-04-04 | 253 | C | 0 | 1 | 6Y3111 | Based on surveyor observation, review of Maintenance logs and staff interview, it was determined that the facility failed to provide necessary maintenance services relative to bedroom entry doors on 3 of 3 units and resident areas on 1 of 3 units. Findings are as follows: 1. Fourteen of fifteen entry doors (# ' s 1, 2, 3, 4, 9, 10, 11, 12, 13, 14, 18, 19, 20 and 21) to resident bedrooms on the Westerly Unit were observed on 4/2/2013 at 1:00 PM to be missing varnish and scratched on the bottom one third from one side to the other. 2. Nine of thirteen entry doors (#'s 22, 23, 28, 29, 30, 37, 38, 40 and 41) to resident bedrooms on the Watch Hill Unit were observed on 4/2/2013 at 1:15 PM to be missing varnish and scratched on the bottom one third from one side to the other. 3. One of fifteen entry doors (#25) to resident bedrooms on the Mystic Unit was observed on 4/2/2013 at 2:30 PM to be missing varnish and scratched on the bottom one third from one side to the other. In addition, four doors in resident areas on the Mystic Unit, including entry doors to the Shower Room, the Storage Room, the Hopper Room and the Laundry Room, were observed on 4/2/2013 at 10:00 AM to be missing varnish and scratched on the bottom one third from one side to the other. Record review on 4/3/2013 at 1:00 PM of the Maintenance Logs located on each of the units lacked evidence that the doors had been identified for repair. Interview with the Maintenance Director on 4/3/2013 at 1:45 PM revealed that he was unaware that the doors were in need of repair. | 2016-09-01 |
| 1311 | 1311 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2013-04-04 | 323 | D | 0 | 1 | 6Y3111 | Based on surveyor observation, it was determined that the facility failed to ensure that the environment remains as free of accident hazards as is possible relative to gouged bedroom entry doors on 1 of 3 Units. Findings are as follows: Observation of bedroom entry doors revealed that two of fifteen doors on the Watch Hill unit (#'s 26 and 42) had splintered and gouged surfaces with sharp edges measuring approximately 4-5 inches in size on the interior edge of the lower 1/3 of the doors. Clinical record review revealed the residents in room # 26 are able to ambulate with limited assistance and the resident in room # 42 uses a wheelchair for mobility. Upon passing the bedroom doors, the residents noted, as well as others entering and exiting these rooms, are at risk for contact with the sharp edges of the doors. | 2016-09-01 |
| 1312 | 1312 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2013-04-04 | 371 | F | 0 | 1 | 6Y3111 | Based on surveyor observation and staff interview, it was determined that the facility failed to sanitize dishware at the proper temperature, prepare food in a sanitary manner relative to the handling of raw eggs and sanitation of the thermometer. Findings are as follows: The U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code Requires that High Temperature Dish Washers (heat sanitization): that the final rinse must reach 180 degrees F. 1.) Review of the manufacturer's instructions relative to the dishwasher revealed that the rinse cycle should reach 180 degrees Fahrenheit (F) for 9 seconds. Surveyor observation on 4/2/2013 at approximately 1:15 PM revealed the dietary staff washing dishes. The dishwasher failed to reach 180 degrees F for two cycles (maximum temperatures reached only 161 degrees F and 177 degrees F). Interview with the dietary staff revealed that she does not verify that the dishwasher is operating at the required temperature prior to washing the dishes. In addition, she indicated that the observed dishware in the rinse cycle had been completed and theses dishes were ready to be put away. During an interview on 4/2/2013 following the observation, the Food Service Director (FSD) confirmed that the dietary staff should wait until the dishwasher rinse temperature reaches 180 degrees F before cleaning the dishware. The U.S. Department of Agriculture, Food Safety and Inspection Service, and the State of Rhode Island Department of Health Food Code (Chapter 3-501.16) requirements for refrigerated storage, for potentially hazardous foods (PHF) and foods that are Temperature Controlled for Safety (TCS) must be maintained at or below 41 degrees F. 2.) Interview with the food service director (FSD) on 4/2/2013 at approximately 8:30 AM revealed that breakfast is served on the Watch Hill/ Mystic unit kitchenette from 7:30 AM to approximately 9:30 AM. Surveyor observation on 4/3/2013 at 7:10 AM revealed a container containing whole eggs with ice below it… | 2016-09-01 |
| 1313 | 1313 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2013-04-04 | 425 | E | 0 | 1 | 6Y3111 | Based on record review and staff interview, it was determined that the facility failed to provide pharmaceutical services and procedures that ensure the proper labeling of multi -dose vials and the disposal of expired medications and biologicals on 2 of 2 units. Findings are as follows: 1. Observation on 4/4/2013 At 8:35 AM of the medication refrigerator on the Watch Hill/Mystic unit revealed 2 multi-dose vials of Vitamin B 12 that were labeled from the pharmacy with dates of 10/12/2012 and 10/29/2012 that were opened and not dated. During an interview with the Director of Nurses at the time of the observation she stated that the multi-dose vials should be dated when opened. During an interview with the Vitamin B 12's manufacturer's Clinical Pharmacist on 4/4/2013 at 1:50 PM she stated that the Vitamin B 12 must be discarded 28 days after opening. Observation of the medication room on the Watch Hill/Mystic unit on 4/4/2013 at 8:40 AM in the presence of the Director of Nurses revealed the following items with expired dates. 1. Betadine 4 ounce bottle expired 5/2012 2. Geri-Mox Antacid 12 ounce bottle expired 12/2012 Observation of the medication cabinet on the Westerly unit on 4/4/2012 at 8:40 AM in the presence of the staff nurse revealed the following items with expired dates: 1. Guardian Fiber Capsules 90 per bottle expired 12/2012 2. GeriCare aspirin enteric coated 100 tablet bottle expired 12/2012 3. Iron Supplement Elixir 16 ounce expired 6/2012 4. Iron Supplement Elixir 16 ounce expired 11/2011 During interview on 4/4/2013 at approximately 9 AM with the Director of Nurses she was unable to explain why these expired medications had not been disposed of. 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. | 2016-09-01 |
| 1803 | 1803 | WESTERLY NURSING HOME INC | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2011-03-11 | 249 | C | 0 | 1 | KJD111 | Based on record review and staff interview, it was determined that the facility failed to implement an activities program which is directed by a qualified professional relative to professional qualifications or experience. Findings are as follows: Review of the Activity Director's personnel record revealed that she has been employed at the facility since 8/16/10. In addition, the record revealed no evidence of the professional qualifications which include license or registration as a therapeutic recreation specialist or activities professional, eligibility for certification as an activities professional by a recognized body on or after 10/1/90 or 2 years of experience in a social or recreational program within the last 5 years with a minimum of 1 year of full-time in a patient activities program in a health care setting or qualifications as an Occupational Therapist or Occupational Therapy Assistant or completion of a training course approved by the state. When questioned on 3/11/11 at 10:30AM, the Administrator was unable to provide evidence that the Activity Director had been hired with previous experience in a health care setting or professional qualifications as an activity professional. "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 |
| 11 | 11 | ELDERWOOD AT RIVERSIDE | 415007 | 100 WAMPANOAG TRAIL | RIVERSIDE | RI | 2915 | 2019-01-04 | 758 | E | 1 | 1 | D5QX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary [MEDICAL CONDITION] drugs for 1 of 5 sampled residents who were reviewed for unnecessary medications (ID #45). Findings are as follows: Clinical record review for Resident ID #45 revealed a current physician's orders [REDACTED]. Further record review revealed a pharmacy recommendation report stating, The resident has an order for [REDACTED].PRN psychoactive medications may only be authorized for up to 14 days, then the resident must be re-evaluated for appropriateness and if continuation is necessary there must be a determined length of treatment. This recommendation was signed off by the Physician on 10/11/2018 indicating the Physician disagreed with the recommendation; however, he documented no rationale for extending the order or a length of treatment. A review of the Medication Administration Record [REDACTED]. During a surveyor interview with the Unit manager, Staff A, on 01/04/2019 at 10:13 AM, she was unable to provide evidence that the Physician documented a rationale or specified a duration. | 2020-09-01 |
| 12 | 12 | ELDERWOOD AT RIVERSIDE | 415007 | 100 WAMPANOAG TRAIL | RIVERSIDE | RI | 2915 | 2019-01-04 | 812 | F | 1 | 1 | D5QX11 | > Based on surveyor observations and staff interview, it has been determined that the facility failed to properly store food under sanitary conditions relative to the main kitchen. Findings are as follows: During initial tour of the kitchen on 1/2/2019 at approximately 8:20 AM, the following items were found: 1.) There were 4 trays of pre-cooked Molly's Kitchen green stuffed peppers with beef in tomato sauce left out in the 3-bay sink to thaw. The instructions on the package state, food may be thawed up to 48 hours under refrigeration. 2.) There were 4 white, plastic coffee pitchers on the counter, stored upright with the lid on. One pitcher had a thin layer of coffee-colored liquid sitting in it and one pitcher had a thin layer of clear liquid sitting in it. During a surveyor interview with the Food Service Director on 1/2/2019 at approximately 8:50 AM, she acknowledged that the stuffed peppers should not have been left out to thaw. Additionally, she indicated that the coffee pitchers were stored away as clean and should have been stored inverted, without the covers on. | 2020-09-01 |
| 13 | 13 | ELDERWOOD AT RIVERSIDE | 415007 | 100 WAMPANOAG TRAIL | RIVERSIDE | RI | 2915 | 2019-11-01 | 757 | E | 1 | 1 | DE9111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it has been determined that the facility failed to ensure each resident's drug regimen is free of unnecessary drugs relative to blood pressure medications administered without adequate monitoring for 1 of 5 sample residents reviewed for unnecessary medication (ID# 16). The facility's policy titled, Medication Administration Methods states in part, 4. Medication administration must be documented on the Medication Administration Record/ EMAR immediately before going on to the next resident, documentation will include: .d) The nurse will take the pulse or blood pressure when a medication requires such. He/she will then record the results on the Medication Administration Record/ EMAR prior to medication administration . Findings are as follows: Clinical record review revealed a physician's orders [REDACTED]. Hold for systolic blood pressure (SBP) less than 110. Clinical record review revealed a physician's orders [REDACTED]. Give 1 tablet by mouth in the morning for Hypertension Hold for SBP less than 110 and heart rate (HR) of less than 60. Record review of the EMAR from 7/19/2019-10/31/2019 failed to reveal evidence of blood pressures being taken prior to medication administration on the following dates: 7/26, 7/27, 7/28, 7/29, 7/30, 7/31, 8/10, 8/11, 8/16, 8/17, 8/18, 8/23, 8/24, 8/25, 8/26, 9/18, 9/19, 9/20, 9/21, 9/22, 9/23, 9/25, 9/26, 9/27, 9/28, 9/29, 9/30, 10/16, 10/18, 10/19, 10/20, 10/21, 10/24, 10/25, 10/26, 10/27, 10/28 and 10/29/2019. During surveyor interview on 11/01/2019 at 2:14 PM with the Director of Nursing, she was unable to provide evidence that the blood pressures were taken prior to administering the above medications. | 2020-09-01 |
| 1098 | 1098 | ELDERWOOD AT RIVERSIDE | 415007 | 100 WAMPANOAG TRAIL | RIVERSIDE | RI | 2915 | 2014-10-02 | 281 | D | 0 | 1 | QXFB11 | **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 for 1 of 3 sample residents with sliding scale insulin orders, ID # 9. 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 # 9's clinical record revealed a September 2014 physician order [REDACTED].>2 units if FS is 200-250; 4 units if FS is 251-300; 6 units if FS is 301-350; 8 units if FS is 351-400; 10 units if FS is 401-450; greater than 450 - Call MD Review of the September 2014 Sliding Scale Glucose Monitoring sheet revealed that on 9/6/2014 at 11:30 AM, the resident's blood sugar was 507. The resident was administered 10 units of insulin. On 9/15/2014 at 7:30 AM, the resident's blood sugar was 500 and the resident was administered 10 units of insulin. There is no evidence in the nurses notes that the physician was contacted relative to the high blood sugars. When interviewed on 10/1/2014 at 1:20 PM, the unit nurse manager could not provide evidence that the physician was called relative to the high blood sugars. 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. | 2018-01-01 |
| 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 |
| 1776 | 1776 | CHESTNUT TERRACE NURSING & REHABILITATION CENTER | 415007 | 100 WAMPANOAG TRAIL | RIVERSIDE | RI | 2915 | 2011-10-14 | 441 | D | 0 | 1 | NG1D11 | Based on record review and surveyor observations it was determined that facility staff (Nurse B) failed to wash her hands after administering eye drops to 1of 2 residents receiving eye drops, (ID# 13). Findings are as follows: Record review for resident ID# 13 reveals the resident is on contact precautions relative to colonized Methicillin Resistant Staff Aureus (MRSA) in both eyes. On 10/12/2011at 1:30 PM, surveyor observation of a medication pass on the upper level by Nurse B revealed Nurse B administered 1eye drop to each of the resident's eyes. Without washing her hands, Nurse B proceeded to administer medication to 7 additional residents. | 2014-10-01 |
| 1777 | 1777 | CHESTNUT TERRACE NURSING & REHABILITATION CENTER | 415007 | 100 WAMPANOAG TRAIL | RIVERSIDE | RI | 2915 | 2011-10-14 | 514 | D | 0 | 1 | NG1D11 | Based upon record review and staff interview, it has been determined that the facility has failed to accurately record the intake and output for 1 of 1 sample residents, ID# 3. Findings are as follows: Record review for resident ID# 3 revealed that staff was to record the resident's 24 hour intake and output. Review of the Comprehensive Intake-Output Record revealed that between 8/19/2011 and 10/11/2011, there was no recorded evidence of the resident's intake for 24 of 164 opportunities and no evidence of the resident's output for12 of 164 opportunities. Additionally, there is no evidence that the fluid intake during medication administration was recorded. When interviewed on 10/13/2011 at 8:15 AM, the unit charge nurse was unaware the resident's intake and output was to be recorded. "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." | 2014-10-01 |
| 14 | 14 | GREENWOOD CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2019-11-26 | 635 | D | 0 | 1 | FCLN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to obtain complete admission orders [REDACTED]. Findings are as follows: Review of the facility policy entitled Skin Integrity Management revealed in part Practice Standards as follows; .3. Identify patient skin integrity status and need for prevention or treatment modalities . 7. Notify Physician/APP to obtain orders . Record review revealed Resident ID #43 was admitted on (MONTH) 27, 2019 with admitting [DIAGNOSES REDACTED]. Record review for Resident ID #43 revealed a continuity of care form dated 09/27/2019 which documented a stage II pressure sore on the coccyx, with a white wound bed, pink peri-wound and a scant amount of brown drainage. A left heel wound was determined to be unstageable. An additional wound was assessed as a black necrotic area on tip of toe. The record lacked evidence of physician orders for wound care for all areas until 09/30/2019. During a two-surveyor interview on 11/26/2019 at approximately 2:45 PM with the Director of Nurses, she was unable to provide evidence the orders for wound care were obtained from the primary care physican prior to 09/30/2019. | 2020-09-01 |
| 15 | 15 | GREENWOOD CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2019-11-26 | 812 | F | 0 | 1 | FCLN11 | Based on a two-surveyor observation and staff interview, it has been determined that the facility failed to store and prepare food in accordance with professional standards for food service safety relative to the ice machines in 2 of 2 kitchenettes. Findings are as follows: During a two-surveyor observation of the first floor kitchenette on 11/20/2019 at 2:52 PM and on 11/21/2019 at 9:47 AM, the ice machine did not have an air gap between the ice machine drain pipe and the floor drain. During a two-surveyor observation of the second floor kitchenette on 11/21/2019 at 9:50 AM, the ice machine did not have an air gap between the ice machine drain pipe and the floor drain. During a two-surveyor interview on 11/21/2019 at 9:55 AM with the Director of Food Service he observed and acknowledged there are no air gaps for the ice machines on both kitchenettes. | 2020-09-01 |
| 16 | 16 | GREENWOOD CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2019-11-26 | 880 | D | 0 | 1 | FCLN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a two-surveyor observations and staff interview, it has been determined that the facility failed to provide care to prevent the development of infection by performing hand hygiene procedures by staff involved in direct resident contact for 1 of 2 sample residents observed for wound care (Resident ID #43). Findings are as follows: Review of the facility's Wound Dressings Aseptic policy with a revision date of 11/01/2019 revealed in part, If gloves become contaminated, remove gloves, cleanse hands, and apply clean gloves . A two-surveyor observation of Resident ID #43's dressing change on 11/21/2019 starting at 10:33 AM by a unit nurse, Staff A, revealed the following: - Left stoma (an artificial opening that allows feces from the intestine to pass) was cleansed with normal saline, patted dry three times, gloves were removed and Staff A did not perform hand hygiene before applying clean gloves. - Left heel washed with normal saline twice, patted dry, Santyl wound ointment applied directly to wound bed with right fingertip, wearing the same gloves used to cleanse the wound, no hand hygiene performed after removing gloves and applying clean gloves. - Left top of great toe washed with normal saline, Iodosorb applied directly to wound with right fingertip, gloves removed with no hand hygiene performed prior to applying clean gloves. An addition one surveyor observation on 11/21/2019 at approximately 11:00 AM which was occured following the above wound treatments. The coccyx wound was cleansed with normal saline, Santyl wound ointment applied to wound bed, gloves removed with no hand hygiene performed prior to applying clean gloves. Staff A then applied [MEDICATION NAME] dressing, after she discardded the used supplies, Staff A removed her gloves and gown and walked back to the nurse's station and medication cart without performing hand hygiene. During an interview on 11/26/2019 at 11:25 AM, the two-surveyor informed the Director of Nurses … | 2020-09-01 |
| 17 | 17 | GREENWOOD CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2017-12-15 | 759 | D | 0 | 1 | 77YN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, staff interview and record review, it has been determined the facility has failed to ensure residents are free from a medication error rate of 5 percent or greater. Based on 26 opportunities, there were 2 errors involving 2 residents (ID#s 57 and 90) resulting in a 7.69 % medication error rate on 1 of 4 units observed during medication pass. These errors involved 1 employee. Findings are as follows: 1.) During surveyor observations of the morning medication pass on 12/12/2017 at 9:24 am with the unit nurse (Staff A), she administered [MEDICATION NAME] (Vitamin D) 1,000 units, 1 tablet to resident ID# 57. Record review for resident ID# 57 revealed a physician's orders [REDACTED]. 2.) Further surveyor observations of the morning medication pass on 12/12/2017, Staff A administered [MEDICATION NAME] (Vitamin B12) 1000 mcg to resident ID# 90. Record review for resident ID#90 revealed a physician's orders [REDACTED]. During an interview with Staff A on 12/12/2017 at approximately 12:00 pm, she was unable to provide an explanation as to why the medications were not administered as ordered by the physician. You are hereby formally notified that where the above-listed deficiencies also constitute non-compliance with applicable provisions of the Rules and Regulations for Licensing of Nursing Facilities they are deficiencies under State regulations and grounds for licensure sanctions. | 2020-09-01 |
| 660 | 660 | GREENWOOD CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2016-12-09 | 329 | E | 0 | 1 | QG1C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined the facility has failed to ensure residents are free from unnecessary drugs due to inadequete monitoring for 3 of 11 sample residents (ID #13, 19 and 21) relative to medications with parameters. Findings are as follows: 1.) Record review for ID #13 revealed a current physician's orders [REDACTED]. The order has special instructions to hold for pulse less than 60 beats per minute and hold for systolic blood pressure less than 100. A review of the (MONTH) (YEAR) Medication Administration Record [REDACTED] 12/1/2016 AM and PM dose 12/2/2016 PM dose through 12/8/2016 AM dose Additionally, a review of the (MONTH) (YEAR) MAR indicated [REDACTED]. During surveyor interview and record review on 12/8/2016 at 2:55 PM with the 2 east unit nurse, she was unable to provide evidence that the resident's blood pressures were obtained prior to administration of the medication for the above mentioned. 2.) Record review for resident ID #19 revealed a current physician's orders [REDACTED]. mg by mouth once a day. This order has special instructions to hold for apical pulse less than 55. A review of the MAR indicated [REDACTED]. During surveyor interview on 12/9/2016 at 11:30 AM with the DNS, and the 1 East Unit Manager, both were unable to provide evidence that the apical pulse was obtained prior to the medication being administered. 3.) Record review revealed that resident ID#21 has a physician's orders [REDACTED]. Record review of the resident's (MONTH) (YEAR) MAR indicated [REDACTED]. During an interview with the 2nd floor East Unit Manager on 12/09/2016 at 11:00 am, she was unable to provide evidence that the BP was taken prior to administration of the [MEDICATION NAME]. 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 unde… | 2020-01-01 |
| 1248 | 1248 | GREENWOOD CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2014-01-10 | 154 | C | 0 | 1 | R18L11 | Based on record review and staff interview, it has been determined that the facility has a policy that failes to ensure that each resident is fully informed of his/her total health status including but not limited to his/her medical condition. Findings are as follows: The facility's Admission Packet includes under Information and Rights for Patients and Resident, page 14, # 5 that You have the right to be fully informed of your total health status including .your medical condition unless your physician has documented in your medical record that providing this information is medically contraindicated . This document is presented to residents on admission for their signature and does not give the resident a choice of being informed of their medical condition if the physician indicated it is medically contraindicated. This is in violation of the residents' right to know their medical condition. When interviewed on 1/9/2014 at 1:00 PM, the Administrator was unable to provide evidence that residents were fully informed of their medical condition. | 2017-01-01 |
| 1249 | 1249 | GREENWOOD CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2014-01-10 | 323 | E | 0 | 1 | R18L11 | Based on record review and staff and resident interviews, it was determined the facility failed to ensure that the environment remained free of accident hazards for 1 of 3 sample residents who smoke (ID# 13). Findings are as follows: Clinical record review of resident ID #13 revealed a 6/13/2013 Admission Nursing Assessment indicating the resident smoked a half a pack of cigarettes per day. The two subsequent Quarterly Nursing Assessments (September and December 2013) indicate the resident continues to smoke. There was no evidence of a safe smoking evaluation. When interviewed on 1/6/2014 at 2:45 PM, the unit charge nurse revealed the resident was a smoker who smoked outside of the building in the facility's parking lot with his/her friend or son. The nurse also indicated knowing the resident smoked in the designated smoking area outdoors. When asked where the resident kept his/her cigarettes and lighting materials, the nurse stated that the resident's friend or son would bring the cigarettes to him/her. The facility did not monitor or ensure the resident's smoking supplies, were maintained in a safe area. The charge nurse was unable to produce evidence of a safe smoking evaluation. When interviewed on 1/6/2013 at 3:00 PM the Director of Nursing Service (DNS) revealed the resident was informed upon admission that the facility did not allow smoking in the building or on the grounds. The DNS also stated that she was unaware the resident was smoking and therefore a safe smoking evaluation was not performed. When interviewed on 1/8/2013 at 1:00 PM the resident, who is alert and oriented, stated that in good weather s/he walks on the grounds and smokes as well as smokes in the designated outside smoking area. S/he also smokes with his/her friend or his/her son in their cars which are parked in the facility parking lot. Additionally, the resident stated that s/he keeps cigarettes and a lighter in his/her jacket pocket. Surveyor review of the facility's policy titled OPS137 Smoking revealed in section 2.3: The admitting… | 2017-01-01 |
| 1250 | 1250 | GREENWOOD CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2014-01-10 | 333 | D | 0 | 1 | R18L11 | **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 of significant medication errors for 1 of 23 sample residents (ID # 1). Findings are as follows: Clinical record review of resident ID # 1 revealed a current physician's orders [REDACTED]. Review of the January 2014 Medication Administration Record [REDACTED]. When interviewed on 1/9.2014 at 2:30 PM, the Unit Manager could not provide evidence that this medication was administered per physician order. 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. | 2017-01-01 |
| 1488 | 1488 | GREENWOOD CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2012-10-31 | 243 | B | 0 | 1 | IWFV11 | Based upon resident and staff interview, is has been determined that the facility failed to allow the residents to meet as a group without staff present. Findings are as follows: During the residents' group interview on 10/25/2012 at 10:30 AM, there were 14 residents present. The group stated that the facility does not allow resident council to meet privately without staff present. During an interview on 10/25/2012 at 1:50 PM, the Activities Director confirmed that residents were not able to meet without a staff member present. | 2015-12-01 |
| 1489 | 1489 | GREENWOOD CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2012-10-31 | 281 | B | 0 | 1 | IWFV11 | **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 relative to physician's orders [REDACTED].# 23) and two non-sample residents ID #28 and 29. 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. Resident ID# 23 has a 9/14/2012 physician's orders [REDACTED]. Record review failed to evidence of a skin check after 9/14/2012. During the interview on 10/31/2012 at 11:30 AM, the Director of Nursing Services (DNS) was unable to produce evidence the above physician's orders [REDACTED]. 2. Resident ID# 28 has a [DIAGNOSES REDACTED]. The surveyor observed a nurse administer 1 tablet of [MEDICATION NAME] to the resident on 10/26/2012 at 9:00 AM. Subsequent interviews with 3 nursing staff revealed the resident usually finishes her breakfast by 7:30 AM. When questioned later at 9:15 AM, the above nurse indicated she was not aware of the order to administer the [MEDICATION NAME] with meals and that she has been regularly administering the [MEDICATION NAME] after the resident finishes her breakfast. During an interview on 10/31/2012 at 10:00 AM, the DNS was unable to produce evidence the physicians' orders were followed for the above residents. 3. A 12/22/2011 revision by the Centers for Medicare and Medicaid Services for Appendix A, Section 482.239c0 Standard: Preparation and Administration of Drugs/A-0405 states in part: . In accordance with standard practice, a… | 2015-12-01 |
| 1490 | 1490 | GREENWOOD CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2012-10-31 | 332 | D | 0 | 1 | IWFV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and surveyor observation of medication pass, it was determined that the facility has failed to ensure that it is free of medication error rates of 5% or greater. Findings are as follows: 1. Non-sample resident ID # 26 has a current physician's orders [REDACTED]. During surveyor observation of the morning medication pass at 9:15 AM on 10/25/2012, the charge nurse ( East II unit) mistakenly administered [MEDICATION NAME] rather than [MEDICATION NAME]. During an interview on 10/25/2012 at 12:00 PM, the charge nurse and unit manager confirmed the resident received the wrong medication. 2. Non-Sample resident ID # 27 has a current physician's orders [REDACTED]. During surveyor observation of the morning medication pass at 10:45 AM on 10/25/2012, the charge nurse (East I unit) mistakenly administered Multivitamin rather than Multivitamin with Iron. 3. Resident ID # 28 has a current physician's orders [REDACTED]. During surveyor observation of the morning medication pass on 10/26/2012 at 9:00 AM, the charge nurse (North I unit) did not instruct the resident to take 2 separate inhalations. When questioned on 10/26/2012 at 9:15 AM, the charge nurse indicated she did not instruct the resident to take 2 separate inhalations because she was was not aware of the order. Based on 46 opportunities, there were 3 errors involving 3 residents and 3 nurses, resulting in a 6.5% medication error rate. 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. | 2015-12-01 |
| 1552 | 1552 | GREENWOOD CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2012-07-31 | 329 | E | 1 | 0 | R0U811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon clinical record review and staff interview it was determined that the facility failed to assure that residents were free from potentially unnecessary drugs. Specifically, the facility failed to assess and monitor the need for and/ or effectiveness of psychoactive and pain medications for 3 of 3 residents receiving medications as needed (ID #2, 3, &5). 1. Review of resident ID #5's clinical record revealed the [DIAGNOSES REDACTED]. Additionally, ID #5 had a 6/15/12 physicians order for 50 mg trazadone four times per day as needed for agitation. The resident also had a 7/6/12 order was for 1 mg [MEDICATION NAME] every 2 hours as needed for anxiety and restlessness. This order was changed to every 1 hour as needed on 7/25/12. Medication Administration Record [REDACTED].) Further record review revealed that staff should be documenting the residents pain every shift, before and after medication. Although the form indicates that each shift should document pain level (on a scale of 0-10) before and after medication administration, there is only one entry for each shift. These entries document no pain on all of the above days (except 7/13/12). The July 2012 MAR indicated [REDACTED]. Additionally, the resident received the PRN [MEDICATION NAME] 3 times without evidence of anxiety /restlessness and/ or effectiveness of the medication (7/12/12, 7/25/12 and 7/30/12 ). During an interview on 7/31/12 the Director of Nurses (DNS) was unable to say when the pain level on the above noted form had been recorded, (i.e. if it was pre or post medication administration.) She further indicated that staff should be assessing residents for the effectiveness of PRN medications, but was unable to provide evidence that this had been done. 2. Review of resident ID #3's clinical record revealed the resident has a July 2012 physicians order for 50 mg [MEDICATION NAME] HCL, 2 tabs, four times daily as needed (PRN). Additionally the resident has an order for [REDA… | 2015-08-01 |
| 1728 | 1728 | GREENWOOD CARE AND REHABILITATION CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2011-10-31 | 246 | D | 0 | 1 | DZ8611 | Based on surveyor observation and staff interview, it was determined the facility failed to provide reasonable accommodations of individual needs relative to comfort for 1 of 14 sample residents (ID #1). Findings are as follows: During surveyor observations on 10/26/2011 at 12:30 PM and on 10/27/2011 at 9:00 AM and 11:30 AM resident ID #1 was observed seated upright in a recliner chair at a table in the dining room with her feet dangling 4"-6" from the surface of the floor. An interview with the Unit Manager on 10/27/11 at 3:30 PM revealed that prior to the resident beginning Hospice care on 8/30/11, she was utilizing a wheelchair with foot rests. The Unit Manager indicated that Hospice had recommended that the resident use a recliner chair for comfort and positioning; and the resident should have been provided with support for her dangling feet while sitting upright in the recliner. Further surveyor observations on 10/31/11 at 10:30 AM revealed the resident seated in a high back wheelchair with a footrest. Additional interview with the Unit Manager at 11:00 AM revealed that the high back wheelchair with the footrest had been ordered for the resident after the the surveyor had brought the dangling feet to her attention. | 2014-12-01 |
| 1729 | 1729 | GREENWOOD CARE AND REHABILITATION CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2011-10-31 | 281 | B | 0 | 1 | DZ8611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to provide services that meet professional standards of quality for 2 of 14 sample residents, ID #2 relative to insulin administration and ID #8 relative to not following physician's orders [REDACTED]. Findings are as follows: 1. The American Diabetes Association website contains the following information: Injection site "...Rotation of the injection site is important to prevent lipohypertrophy or [DIAGNOSES REDACTED]... " Site Rotation The place on your body where you inject insulin affects your blood glucose level. Don't inject the insulin in exactly the same place each time, but move around the same area... If you inject insulin near the same place each time, hard lumps or extra fatty deposits may develop. Both of these problems are unsightly and make the insulin action less reliable." Resident ID #2 has been receiving insulin injections between 10/13-10/26/2011 according to a 10/12/2011 physician's orders [REDACTED]. When questioned on 10/31/2011 at 11:45 AM, the Director of Nursing Services was unable to provide evidence that on 20 of 20 opportunities, the insulin injection sites for this resident had been rotated. 2. 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." Resident ID #8 has a 10/18/2011 physician's orders [REDACTED]. Record review revealed no evidence that the above medication had been administered to the resident for 13 of 13 opportunities between 10/21-10/27/2011. When questioned on 10/31/2011 at 11:50 AM, the… | 2014-12-01 |
| 1730 | 1730 | GREENWOOD CARE AND REHABILITATION CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2011-10-31 | 242 | B | 0 | 1 | DZ8611 | Based on record review and staff interview it was determined the facility failed to ensure that residents have the right to make choices about aspects of his or her life in the facility significant to the resident for 1 of 24 sample residents relative to food choice (ID #15). Findings are as follows: Surveyor observation in the presence of resident ID #15 and the Unit Manager on 10/27/2011 at 12:40 PM revealed that the resident had not eaten her meal, which included a beef patty. When interviewed the resident revealed she does not like beef and will not eat it. Additionally she revealed that she has received food items she does not like on several previous occasions. The Unit Manager obtained an alternate meal without asking the resident what she wanted. The resident received a chopped ham sandwich on white bread and Cheetos. When the meal arrived the resident refused it because she does not like cold cuts or white bread. Additionally she stated she does not like Cheetos. A review of the resident's meal ticket revealed that wheat bread was listed under "special requests". Beef, ground beef and cold cuts were listed under "dislikes". Surveyor interview with the resident on 10/28/2011 at 7:34 PM revealed she had requested and received a grilled cheese and tomato sandwich for dinner. Although she ate the sandwich, she did not eat the Cheetos, which came with the meal. The Charge Nurse was interviewed immediately after and revealed that the resident had requested potato chips, not Cheetos, with her sandwich. Although the facility knows the likes and dislikes of this resident, her food preference choices were not honored. | 2014-12-01 |
| 1855 | 1855 | GREENWOOD CARE AND REHABILITATION CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2010-11-18 | 253 | C | XZ1S11 | Based on surveyor observations and staff interview, it was determined the facility failed to provide effective maintenance and housekeeping services as well as a clutter free environment on 6 of 6 living units as well as in the hallway leading to the Rehabilitation (Rehab) room. Findings are as follows: Surveyors' observations on all days of the survey (11/15/10 through 11/17/10) and during the tour with the Maintenance Director on 11/17/10 revealed the following: BASEMENT (Rehab Area) 1. The arm chair adjacent to the elevator door is heavily rusted and the wood finish on the armrests is completely worn. 2. The ceiling outside the elevator door has a 5' area showing orange foam caulking where the ceiling meets the wall. 3. There are 18 floor tiles outside the elevator door which have holes and are heavily marred by grey and black marks. 4. A bed frame, walker, recliner and two large vending machines are stored in the hallway across from the Rehab room. 5. There are 6 cracked floor tiles outside the Rehab entrance door and the entrance door frame is heavily marred with missing paint on the lower third. 6. The ceiling area outside the elevator door and extending 30 feet down the hallway to the Rehab room, has exposed multi-colored piping, multi-colored electrical wiring and a visible grey aluminum ventilation unit 1ST FLOOR NORTH 1. The baseboard heating vents in four locations (between room 11 and the exit door, between room 12 and the exit door, between room 14 and the utility closet and between room 16 and the shower room), have one or two end caps not securely attached to the unit. 2. The entrance door frames in room 10 and the resident lounge are heavily marred and missing paint on the lower third. 3. The wall between the bathroom door and the closet door in room 4 has a 3' x 1.5' area on the lower third which is gouged and missing paint. 4. The wall behind the resident's bed in room 8B has a 1.5' x 3" area that is gouged. 1ST FLOOR EAST 1. The baseboard heating vents in two locations (between room 2 and room … | 2014-02-01 | ||
| 1856 | 1856 | GREENWOOD CARE AND REHABILITATION CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2010-11-18 | 465 | C | XZ1S11 | Based on surveyor observation and staff interview, it was determined the facility failed to provide effective maintenance services to ensure a sanitary environment for residents, staff and the public in 4 exterior areas relative to smoking. Findings are as follows: During surveyor observation ,on survey days (11/15/10 through 11/17/10) in four exterior areas ( the main entrance door, the rear exit door adjacent to the fuel tank, the north wing exit door and the staff designated smoking area), a heavy accumulation of cigarette butts was noted on the ground. During an interview on 11/18/10 at 10:05AM, the Administrator was unable to provide evidence of an ongoing maintenance program to address these issues. "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 | ||
| 1865 | 1865 | GREENWOOD CARE AND REHABILITATION CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2010-09-21 | 323 | D | O18611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined the facility failed to provide safety devices to prevent accidents for 1 of 6 sample residents at risk for falls (ID#1). Findings are as follow: Resident ID #1 had a history of [REDACTED]. On 6/10/10, the resident attempted to get out of bed unassisted at approximately 11:15PM and fell to the floor. The resident called out for help and the charge nurse found her on the floor. A review of the 6/10/10 care plan for falls indicated interventions relative to getting up unassisted while sitting in her wheelchair or in her recliner. The resident's choice at bed time was noted to be a recliner on the care cards and the care plan.. A review of the Fall Investigation Worksheet for 6/10/10, noted that the resident had fallen out of bed. Although the resident had fallen from the bed, the only intervention added to the the care plan and care cards at that time was to use the recliner. During a telephone interview on 9/22/10 at 9:15AM, the Nursing Assistant, providing the resident with care on 6/10/10 at 10:45 PM, stated, on this particular evening , the resident requested to be assisted into her bed rather than her usual recliner. A review of the revised care plan for 6/10/10 failed to include interventions for the prevention of falls and injuries from bed.. During an interview with the Director of Nursing on 9/21/10 at approximately 10AM, she indicated the 6/10/10 care plan should have been revised to include safety interventions such as low bed and mats to the floor. "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 | ||
| 1866 | 1866 | GREENWOOD CARE AND REHABILITATION CENTER | 415008 | 1139 MAIN AVENUE | WARWICK | RI | 2886 | 2010-09-21 | 280 | D | O18611 | Based on record review and staff interview, it has been determined the facility failed to provide a comprehensive care plan revision for 1 of 6 sample residents (ID#1) relative to falls from bed. Findings are as follow: Resident ID #1 fell from bed on 6/10/10 at 11:15PM. A review of the 6/10/10 care plan provided no evidence the facility had revised the care plan after the incident to prevent and/or protect the resident from injury from a fall from bed. During an interview with the Director of Nursing on 9/21/10 at approximately 10AM, she indicated the care plan of 6/10/10 to the present time should have been revised to include safety interventions such as the provision of a low bed and mats to the floor. | 2014-01-01 | ||
| 675 | 675 | KENT REGENCY CENTER | 415009 | 660 COMMONWEALTH AVENUE | WARWICK | RI | 2886 | 2016-12-02 | 368 | C | 0 | 1 | 83PJ11 | Based on resident and staff interview, it has been determined that the facility failed to offer snacks daily at bedtime for 3 of 3 resident units. Finding are as follows: The resident group interview was conducted on 11/30/2016 at 10:30 AM with 10 residents in attendance. During this interview, 10 out of 10 residents (sample ID# 4 and 20, and non-sample ID #25 through 32) stated that they are not offered a snack daily at bedtime. In addition, during individual interviews conducted on 12/1/2016 with ID# 3 at 12:50 PM and ID# 7 at 10:00 AM, each resident stated that they are not offered snacks daily at bedtime. During an interview with the Director of Nursing Services on 12/1/2016 at 4:08 PM, she stated that snacks are available upon request but are not offered to residents daily at bedtime. | 2019-11-01 |
| 676 | 676 | KENT REGENCY CENTER | 415009 | 660 COMMONWEALTH AVENUE | WARWICK | RI | 2886 | 2016-12-02 | 371 | F | 0 | 1 | 83PJ11 | Based on surveyor observation and staff interview, it has been determined that the facility failed to store and prepare food under sanitary conditions for 1 of 1 main service kitchens. Findings are as follows: Surveyor observation during the initial kitchen tour on 11/29/2016 at 11:00 AM revealed the following: 1) Multiple items not clean to sight and touch including a large cutting board, two metal deep half pans, one metal mixing bowl, and a metal cheese grater. 2) Three small metal ladles in poor repair. One was observed with a hole measuring approximately a quarter of an inch through the food contact surface. The other two ladles were observed to have extensive pitting on the food contact surfaces. 3) A large plastic container filled with thickening agent which was not labeled. 4) Eight plastic pitchers were observed stored upright with covers on and water residue inside. During an interview with the Food Service Director at the time of these observations, he acknowledged that these items were not properly stored and maintained. | 2019-11-01 |
| 677 | 677 | KENT REGENCY CENTER | 415009 | 660 COMMONWEALTH AVENUE | WARWICK | RI | 2886 | 2016-12-02 | 458 | B | 0 | 1 | 83PJ11 | Based on surveyor observation during the initial tour and a review of the facility documentation, it was determined the facility failed to ensure that single resident rooms measured at least 100 square feet per resident room in 24 private rooms. Findings are as follows; The following single rooms each measure 87.39 square feet. Single rooms on the A-wing nursing unit of the facility, numbered 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24. Additionally, single rooms on the B-wing nursing unit, numbered 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24. 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 |
| 828 | 828 | KENT REGENCY CENTER | 415009 | 660 COMMONWEALTH AVENUE | WARWICK | RI | 2886 | 2015-10-26 | 281 | E | 0 | 1 | YNR811 | **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 physician's orders [REDACTED].#1, oxygen administration (ID # 5) and the application of support stockings and administration of [MEDICATION NAME] skin test (ID # 6). 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]. During an interview with staff (F) on 10/21/2015 at approximately 11:00 AM, she informed the surveyor that the [MEDICATION NAME] Syrup is provided from the house stock of medication. Surveyor observation of the stock medication revealed that only 44 mg of [MEDICATION NAME] Syrup is in stock medication. The surveyor questioned the discrepancy and was told that the stock bottle of [MEDICATION NAME], an iron supplement, is what is available and is what has been routinely given. Record review revealed that this medication was initially ordered on [DATE]. Review of the Medication Administration Record [REDACTED]. 2. Resident ID# 5 has a physician's orders [REDACTED]. During a surveyor observation on 10/20/2015 at 12:25 PM, 10/21/2015 at 10:30 AM and 12:20 PM and 10/22/2015 at 8:25 AM, 8:55 AM and 1:40 PM, the resident was found lying in bed in his/her room receiving oxygen via nasal cannula at 2 LPM. When interviewing in the presence of the Unit Manager (staff B) on 10/22/2015 at approximately 1:45 PM, the resident's nurse (staff C) was unaware the resident is to receive 3 li… | 2019-03-01 |
| 829 | 829 | KENT REGENCY CENTER | 415009 | 660 COMMONWEALTH AVENUE | WARWICK | RI | 2886 | 2015-10-26 | 367 | D | 0 | 1 | YNR811 | **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 beverages prepared in a form designed to meet the individual needs for 1 of 3 sample residents (ID #2) requiring thickened liquids. Findings are as follows: A review of resident ID #2's clinical record revealed an 8/6/2015 physician's diet order indicating nectar thick liquids, secondary to a [DIAGNOSES REDACTED]. During a surveyor observation on 10/21/2015 at 8:55 AM while eating breakfast in his/her room, the resident was observed drinking coffee that had not been thicken. Additionally, an unopened packet of Thick and Easy (powdered thickener) was observed on the tray. On the same date at 12:20 PM, the resident was observed with a mug containing a white powdered substance on the bottom. At this time, the resident requested tea. The nursing assistant (staff A) proceeded to fill the mug with hot water and a tea bag. At no time during this observation did the nursing assistant stir the white powder (Thick and Easy) to ensure the nectar thick consistency. When interviewed on 10/22/2015 at 10:00 AM, staff A was unable to explain why she did not thicken the resident's tea. | 2019-03-01 |
| 830 | 830 | KENT REGENCY CENTER | 415009 | 660 COMMONWEALTH AVENUE | WARWICK | RI | 2886 | 2015-10-26 | 458 | B | 0 | 1 | YNR811 | Based on surveyor observation during the initial tour and a review of the facility documentation, it was determined the facility failed to ensure that single resident rooms measured at least 100 square feet per resident room in 24 private rooms. Findings are as follows; The following single rooms each measure 87.39 square feet. Single rooms on the A-wing nursing unit of the facility, numbered 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24. Additionally, single rooms on the B-wing nursing unit, numbered 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24. | 2019-03-01 |
| 831 | 831 | KENT REGENCY CENTER | 415009 | 660 COMMONWEALTH AVENUE | WARWICK | RI | 2886 | 2015-10-26 | 465 | C | 0 | 1 | YNR811 | Based on surveyor observation and staff interview, it was determined that the facility failed to provide a sanitary environment in the 3 of 3 kitchenettes (A/B unit, C/D unit and E unit). Findings are as follows: During tour of the facility on 10/20/15 at approximately 10:00 AM, the following conditions were observed in the 3 of 3 kitchenettes: A/B Unit - Drawers containing baskets of coffee, tea bags, sugar, salt & pepper, jelly and hot chocolate had an accumulation of white grit on the bottom surface. C/D Unit - Drawers containing baskets of plastic eating utensils, salt & pepper, sugar packets, jelly and tea bags had an accumulation of grit and food crumbs on the bottom surface. - There were two bowls of cereal in the kitchenette cupboard, which were unlabeled and undated. E Unit - Drawers containing baskets of coffee, tea, salt & pepper had an accumulation of brown/gray grit along one edge and white grit on the bottom surface of the drawer. - Cupboard shelves were sticky and had an accumulation of dust and grit. The cupboards contained bins of Thick and Easy (powdered thickener), loaves of bread, individual containers of peanut butter and bottles of soda. Also observed, small plastic bags of cookies, pretzels and cheese crackers which were not sealed or dated. Additionally, loose cookies and crackers were observed in the bin. The areas were pointed out to the Food Service Director on 10/22/15 at 2:30 PM, as they remained in the same condition during the course of the survey. 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 |
| 1067 | 1067 | KENT REGENCY CENTER | 415009 | 660 COMMONWEALTH AVENUE | WARWICK | RI | 2886 | 2014-12-12 | 328 | D | 0 | 1 | V78J11 | Based on surveyor observation, record review and staff interview, it has been determined the facility has failed to ensure that residents receive proper treatment and care relative to foot care for 3 of 15 residents, (resident ID #'s 3,14 & 19) Findings are as follows: 1. Observation of resident ID #14 on 12/11/2014 at 10:50 AM, in the presence of the unit manager, revealed the resident with elongated toe nails. Although, the podiatrist stated he saw the resident on 12/3/2014, the record review revealed the last podiatry visit for this resident was on 08/20/2014. 2. Observation of resident ID #3 on 12/11/2014 at 11:08 AM, in the presence of the unit manager, revealed the resident with elongated toe nails, a callus under his/her right foot, and thick white matter between his/her toes. Although, the podiatrist stated he saw the resident on 12/3/2014, the record review revealed the last podiatry visit for this resident was on 8/20/2014. 3. Observation of resident ID #19 on 12/12/2014 at 11:05 AM, in the presence of the unit manager and the Assistant Director of Nurses, revealed the resident with a redden area,(blanchable) on his/her left great toe, and elongated sharp nails of his/her 3rd and 4th toe on the right foot. Record review revealed the last podiatry visit for this resident was on 8/20/2014. During surveyor interview with the Unit Manager on 12/12/2014 at 11:22 AM, she was unable to produce evidence that the above residents were seen by podiatry since 8/20/2014. | 2018-03-01 |
| 1068 | 1068 | KENT REGENCY CENTER | 415009 | 660 COMMONWEALTH AVENUE | WARWICK | RI | 2886 | 2014-12-12 | 458 | B | 0 | 1 | V78J11 | Based on surveyor observation during the initial tour and a review of the facility documentation, it was determined the facility failed to ensure that single resident rooms measured at least 100 square feet per resident room in 24 private rooms. Findings are as follows: Single rooms on the A-wing nursing unit of the facility, numbered 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24, as well as single rooms on the B-wing nursing unit, numbered 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24 each measure 87.39 square feet. | 2018-03-01 |
| 1069 | 1069 | KENT REGENCY CENTER | 415009 | 660 COMMONWEALTH AVENUE | WARWICK | RI | 2886 | 2014-12-12 | 465 | C | 0 | 1 | V78J11 | Based on surveyor observation and staff interview, it was determined that the facility has failed to maintain a clean environment relative to kitchen and laundry room. The facility has also failed to replace a stained worn out carpeting in the hallway for 4 out of 5 resident units. Findings are as follows: 1. The kitchenette on the C/D unit was observed to have broken rotted wooden shelving beneath the cabinet of the sink with an approximate 1.5 foot hole through the wallboard exposing another area of broken and missing concrete and a thick accumulation of dirt. 2. The ice machine located in kitchenette on the C/D unit was raised off the floor. The area underneath the ice machine was observed with a thick accumulation of dust and debris as well as a rusted area noted on the left side. Additionally, on the front of the ice machine the air filter had a thick accumulation of dust. 3. Four of five nursing unit hallways were observed with carpeting which was stained and had areas which were frayed and worn out. During the environmental tour on 12/12/2014 at 9:30 AM, the Maintenance Director and Housekeeping Director both were unable to provide any evidence of a scheduled time for the above concerns to be addressed. 4. During surveyor observation of the laundry room on 12/12/2014 at approximately 11:00 AM in the presence of the Administrator and Maintenance Director, the laundry room was observed with a wet, thick accumulation of dirt and debris as well as a dirty wet mop head and wet towels on the floor around 2 of the 3 the washing machines. The flooring was noted to have several areas of deep gouges in the cement. Additionally, the surveyor observed a thick accumulation of dust and dirt on all tubing and connections to each of 3 washers. The sink located in the wash room was also observed with dried brown staining. During the above observation, the Administrator indicated that these areas are to be cleaned daily. 5. During an observation on the initial tour of the kitchen on 12/9/2014 at approximately 9:15 AM and 12… | 2018-03-01 |
| 1251 | 1251 | KENT REGENCY CENTER | 415009 | 660 COMMONWEALTH AVENUE | WARWICK | RI | 2886 | 2014-02-13 | 458 | B | 0 | 1 | XWXM11 | Based on surveyor observation during the initial tour and a review of the facility documentation, it was determined the facility failed to ensure that single resident rooms measured at least 100 square feet per resident room in 24 private rooms. Findings are as follows: Single rooms on the A-wing nursing unit of the facility, numbered 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24, as well as single rooms on the B-wing nursing unit, numbered 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24 each measure 87.39 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. | 2017-01-01 |
| 1491 | 1491 | KENT REGENCY CENTER | 415009 | 660 COMMONWEALTH AVENUE | WARWICK | RI | 2886 | 2012-12-14 | 458 | B | 0 | 1 | BF2R11 | Based on surveyor observation during the initial tour and a review of the facility documentation, it has been determined the facility has failed to ensure that single resident rooms measured at least 100 square feet per resident room in 24 private rooms. Findings are as follows: Single rooms on the A-wing nursing unit of the facility, numbered 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24, as well as single rooms on the B-wing nursing unit, numbered 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24 each measure 87.39 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. | 2015-12-01 |
| 1690 | 1690 | KENT REGENCY CENTER | 415009 | 660 COMMONWEALTH AVENUE | WARWICK | RI | 2886 | 2011-12-09 | 458 | B | 0 | 1 | JPS811 | Based on surveyor observation during the initial tour and a review of the facility documentation, it has been determined the facility failed to ensure that single resident rooms measured at least 100 square feet per resident room in 24 private rooms. Findings are as follows: Single rooms on the A-wing nursing unit of the facility, numbered 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24, as well as single rooms on the B-wing nursing unit, numbered 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24 each measure 87.39 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." | 2015-02-01 |
| 18 | 18 | SAINT ELIZABETH HOME EAST GREENWICH | 415010 | 1 SAINT ELIZABETH WAY | EAST GREENWICH | RI | 2818 | 2019-06-06 | 880 | D | 0 | 1 | 5TXS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interview, it has been determined the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents observed for wound care (Resident ID # 57). Findings are as follows: Record review of Resident #57 current physician's orders [REDACTED]. 1) Cleanse left heel with normal saline, apply [MEDICATION NAME] (a dressing used for wounds with drainage) to open area and cover with dry clean dressing every other day. 2) Cleanse left fourth toe with normal Saline, apply solosite (a wound dressing to create a moist wound environment) and gauze in between toes and secure at bedtime. Surveyor observation of dressing changes on 6/05/2019 at 10:47 AM with Nurse staff A, revealed the following; 1) Nurse staff A cleansed the left heel with normal saline and removed her gloves. She put on new gloves without performing hand hygiene and completed the wound dressing. She then removed her gloves. 2) Nurse staff A, without performing hand hygiene put on new gloves, washed the left toe wound with normal saline, and removed her gloves. She put on new gloves without performing hand hygiene and completed the wound dressing. During surveyor interview on 06/05/19 at 10:59 AM with Nurse staff A, she acknowledged that she did not perform hand hygiene with each glove change. | 2020-09-01 |
| 19 | 19 | SAINT ELIZABETH HOME EAST GREENWICH | 415010 | 1 SAINT ELIZABETH WAY | EAST GREENWICH | RI | 2818 | 2018-08-09 | 689 | D | 0 | 1 | GJE611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that the resident environment remains as free of accident hazards as is possible relative to 1 of 2 patios on the[NAME]unit. Findings are as follows: 1.) Resident ID #148 was admitted to the facility with a [DIAGNOSES REDACTED]. Surveyor observation of Resident ID #148 on 8/9/2018 at 12:16 PM revealed the resident walking inside with his/her walker from the outdoor patio (high room number side). The resident's walker became stuck on the rug as he/she was coming through the door and the resident had to lift the walker over the raised rug. Further observation by the surveyor at the above time revealed that the right corner of the rug in-between the doors (when coming inside from the patio) was frayed into a clump of string on top of the floor (~6 to 8 inches). Additionally, the rug was slightly raised across the length of the doorway. During a surveyor observation on 8/9/2018 at approximately 1:00 PM, in the presence of the Maintenance Director and the Unit Manager, Resident ID #148 proceeded to walk out to the patio with his/her walker, commenting on the condition of the rug. The Director of Maintenance and the Unit Manager acknowledged that the rug needed to be fixed. | 2020-09-01 |
| 20 | 20 | SAINT ELIZABETH HOME EAST GREENWICH | 415010 | 1 SAINT ELIZABETH WAY | EAST GREENWICH | RI | 2818 | 2018-08-09 | 692 | G | 0 | 1 | GJE611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to address the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition for 1 of 2 sample residents with significant weight loss (ID #135). Findings are as follows: The facility's policy titled Recording Dietary Intake states in part dietary intake will be recorded and monitored under the following circumstances for a two week period: loss of three lbs. (pounds) if weight is under 100 lbs. or five lbs. if weight is over 100 lbs. and weight loss was not intended Keep a clip board in the Dining Room with sheets to record intake percentage during this time. All interventions put on Care Plan. Record review revealed resident ID #135 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's record revealed a weight of 106.4 lbs. (pounds) on 6/5/2018, a weight of 98.6 lbs. on 7/26/2018. This indicates a 7.33% significant weight loss in 52 days. On 8/8/2018 an additional weight was recorded as 94.0 lbs. Record review revealed a significant change Minimum Data Set ((MDS) dated [DATE] that indicates that the resident had a weight loss of 5% or greater in the last month or 10% or greater in the last 6 months. Further record review revealed a care plan stating, Monitor intake and record. Record review revealed no evidence that the resident's intake was monitored and recorded per the care plan or facility policy. Review of the dietary progress notes on 7/16/2018 states Offer alternatives and shakes as needed for increased intake. Further record review failed to reveal evidence that shakes were ever ordered per the dietitian's recommendation. Record review revealed an additional dietary note on 7/26/2018 indicating that a weight was obtained on 7/25 and dietitian will continue to follow. There was no evidence of any interventions put into place on 7/26/2018, after … | 2020-09-01 |
| 21 | 21 | SAINT ELIZABETH HOME EAST GREENWICH | 415010 | 1 SAINT ELIZABETH WAY | EAST GREENWICH | RI | 2818 | 2018-08-09 | 758 | E | 0 | 1 | GJE611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined the facility failed to ensure a resident's drug regimen is free from unnecessary [MEDICAL CONDITION] drugs for 1 of 3 sampled residents (ID#13) who received as needed [MEDICAL CONDITION] medication orders extended beyond 14 days without a physician or prescribing practitioner's intended duration for the order. Findings are as follows: Record review for Resident ID #13 revealed a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED] - 6/4/2018, 9:59 PM - 6/20/2018, 10:17 AM - 6/24/2018, 10:27 PM - 6/25/2018, 8:13 PM - 6/28/2018, 10:29 PM - 7/2/2018, 9:10 PM - 7/4/2018, 7:06 PM - 7/5/2018, 7:29 PM - 7/7/2018, 9:13 PM - 7/9/2018, 6:17 PM - 7/19/2018, 9:13 PM - 8/3/2018, 3:12 PM Review of a pharmacy consultation report dated 11/24/2017 revealed that Resident ID#13 has an as needed order for an anxiolytic which has been in place for greater than 14 days without a stop date: [MEDICATION NAME]. The pharmacy recommendation states, If the medication cannot be discontinued at this time, current regulations require that the prescriber document the intended duration of therapy, and the rationale for the extended time period. The report is signed and dated by a prescribing practitioner on 12/11/2017. Additionally, handwriting on the bottom states, Pt (patient) is on Hospice-will not change any meds. During a surveyor interview with The Cove Unit Manager on 8/09/2018 at 2:52 PM, she was unable to provide evidence of the intended duration for the [MEDICATION NAME] order. | 2020-09-01 |
| 22 | 22 | SAINT ELIZABETH HOME EAST GREENWICH | 415010 | 1 SAINT ELIZABETH WAY | EAST GREENWICH | RI | 2818 | 2018-08-09 | 805 | D | 0 | 1 | GJE611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide food prepared in a form designed to meet individual needs for 1 of 8 sample residents reviewed for nutrition, ID #155. Findings are as follows: Record review revealed that the resident moved into the facility on [DATE] with [DIAGNOSES REDACTED]. Further record review revealed a current physician's orders [REDACTED]. Surveyor observations on the following dates and times revealed the resident's food not being cut up: 8/6/2018 at 12:49 PM 8/7/2018 at 12:15 PM 8/8/2018 at 12:30 PM Surveyor interview on 8/9/2018 at 1:00 PM with Staff Nurse B indicated the person that served the resident is responsible for cutting up the meal. Staff Nurse B acknowledged the meal was not cut up as ordered. | 2020-09-01 |
| 23 | 23 | SAINT ELIZABETH HOME EAST GREENWICH | 415010 | 1 SAINT ELIZABETH WAY | EAST GREENWICH | RI | 2818 | 2018-08-09 | 812 | F | 0 | 1 | GJE611 | Based on surveyor observations and staff interview, it has been determined that the facility failed to properly store, distribute, and serve food under sanitary conditions relative to the main kitchen, 2 of 3-unit kitchenettes in the main building and 3 of 4 kitchens in the Greenhouse Cottages. Findings are as follows: 1) During the initial tour of the kitchen on 8/06/2018 at 9:30 AM, the following items were observed by two surveyors: - The ice machine had small green and black colored matter going along the length of the white plastic material inside the machine, above where the ice is dispensed. At the time of the above observations the Food Services Director and Staff E, acknowledged that the ice machine needed to be cleaned. They could not provide evidence of a cleaning schedule for the ice machine. Surveyor observations on 8/7/2018 at 8:08 AM of the Cove Kitchenette in the main building revealed the following: - 1 package of hot dog rolls that had a green/black mold substance in the bag with an expiration date of 6/12/2018 - Interior ceiling, door and glass plate of the microwave oven had a heavy accumulation of food debris. During a surveyor interview on 08/07/2018 at 8:18 AM with Staff D, she acknowledged that the above item should have been discarded and the microwave needed to be cleaned. Surveyor observation on 8/7/2018 at 9:04 AM of the Bay Kitchenette in the main building revealed the following: - Freezer with heavy accumulation of frost on the interior of the drawer. The bottom of the freezer with heavy accumulation of black matter that could be wiped with fingers. Surveyor observation on 8/7/2018 at 10:15 AM of Greenhouse #17 with two surveyors revealed the following: - Staff F and G were not wearing hair nets while preparing food in the kitchen - Knife and utensil drawer with heavy accumulation of crumbs and food debris - Air conditioner vent above the kitchen island where food is prepared with heavy accumulation of dust The following items were found in the back of the refrigerator/freezer: - Bag… | 2020-09-01 |
| 1195 | 1195 | SAINT ELIZABETH HOME EAST GREENWICH | 415010 | 1 SAINT ELIZABETH WAY | EAST GREENWICH | RI | 2818 | 2014-08-22 | 323 | D | 0 | 1 | N5LS11 | Based on surveyor observation, record review and staff interviews, it was determined that the facility failed to ensure that the environment remained as free of accident hazards as is possible for 1 of 3 sample residents (ID # 1) who is transferred using a mechanical lift to wheelchair. Findings are as follows: The Manufacturer's Instructions for the Invcare Reliant 450 (mechanical lift) Section 8.3- Transferring to Wheelchair states : 3. Engage the rear wheel locks of the wheelchair to prevent movement of the chair A Warningbox states the wheelchair locks must be in a locked position before lowering the patient into the wheelchair for transport. A review of ID #1's current care plan dated 6/25/2014 revealed the resident requires total assist with care and is to be transferred by mechanical lift with assist of two staff. Surveyor observation on 8/20/2014 at 12:08 PM revealed resident ID # 1 being transferred from bed to wheelchair by mechanical (Hoyer) lift with assist of 2 Nurse assistants. One Nursing Assistant (NA #1) did not lock the wheelchair and proceeded to tilt the wheelchair back on its rear wheels, then guided the resident down into the chair. When questioned at this time, (NA#1) disclosed that tiliting the wheelchair back helps position the resident further back in the wheelchair. Interview on 8/21/2014 at 9:20 AM with the Unit Manager revealed chairs should be locked during transfers and it is not the facility's policy or practice to tilt wheelchairs. 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. | 2017-05-01 |
| 1794 | 1794 | SAINT ELIZABETH HOME, EAST GREENWICH | 415010 | 1 SAINT ELIZABETH WAY | EAST GREENWICH | RI | 2818 | 2011-04-15 | 371 | F | 0 | 1 | XDLK11 | Based on surveyor observations and staff interview, it was determined the facility failed to ensure that food contact surfaces were protected from cross-contamination during the dishwashing process. Findings are as follows: Surveyor observation of the kitchen on 4/14/2011 at 3:20 PM, revealed a dishwasher wearing gloves, load dirty salad bowls and dishes into the holding racks and guide the racks into the dishwashing machine. After the contents of the racks were washed, the dishwasher touched some of the clean salad bowls and dishes without changing his gloves or washing his hands. At the surveyor's request and in the presence of the Food Services Director (FSD) the dishwasher ran another set of dirty salad bowls and dishes through the dishwashing machine neither changing his gloves nor washing his hands. Following the observation, the FSD directed the dishwasher to change his gloves and run the washed salad bowls and dishes through the dishwashing machine one more time. "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." | 2014-09-01 |
| 24 | 24 | BRIARCLIFFE MANOR | 415012 | 49 OLD POCASSET ROAD | JOHNSTON | RI | 2919 | 2018-02-23 | 658 | E | 0 | 1 | ZK5E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interviews, the facility failed to meet professional standard of quality for 1 out of 5 residents observed during the medication pass (ID# 93). According to Basic Nursing, Mosby, 3rd, the registered nurse checks all transcribed orders against the original order for accuracy and thoroughness. If an order seems incorrect or inappropriate, the nurse consults the physician . Findings are as followed: Surveyor observation on 2/21/18 at approximately 8:15 AM, during the medication pass on Unit 2, revealed an order on the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The Medication Aide (MA) was then observed administering a [MEDICATION NAME] 100 mg extended release capsule and a 50 mg chewable tablet to ID# 93. During surveyor interview on 2/22/18 at 12:05 PM, the resident's physician revealed he was aware that [MEDICATION NAME] 150 mg did not come in an extended release form. The physician acknowledged that his expectation would be to have the order clarified with him and re-written to reflect the dosage/form of the medication on hand. | 2020-09-01 |
| 25 | 25 | BRIARCLIFFE MANOR | 415012 | 49 OLD POCASSET ROAD | JOHNSTON | RI | 2919 | 2018-02-23 | 756 | E | 0 | 1 | ZK5E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interviews, the pharmacy failed to report any irregularities to the attending physician, the facility's medical director, and the director of nursing for 1 non- sample resident observed during the medication pass (ID# 93). Findings are as follows: Record review of resident ID# 93's (MONTH) (YEAR) MAR indicated [REDACTED]. Surveyor observation on 2/21/18 at approximately 8:15 AM, during the medication pass on Unit 2, revealed an order on the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The Medication Aide (MA) was then observed administering a [MEDICATION NAME] 100 mg extended release capsule and a 50 mg chewable tablet to ID# 93. Surveyor record review of the pharmacy reports with the Registered Pharmacist (RPH) on 2/22/2018 at approximately 9:55 AM revealed that the pharmacy had failed to document the irregularity on a separate written report that is sent to the resident's physician, medical director and director of nursing. The report includes at a minimum the resident's name, drug and the irregularity identified by the pharmacist. In addition, the pharmacist stated the computer software system in place between the pharmacy and the facility did not highlight this irregularity and indicated this was a pharmacy system breakdown. You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the 'Rules and Regulations for Licensing of Nursing Facilities' they are deficiencies under State Regulations and grounds for licensure sanctions. | 2020-09-01 |
| 26 | 26 | BRIARCLIFFE MANOR | 415012 | 49 OLD POCASSET ROAD | JOHNSTON | RI | 2919 | 2019-12-27 | 710 | E | 1 | 1 | IFE111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it has been determined that the facility failed to ensure the medical care of each resident is supervised by a physician for 1 of 5 sampled resident (ID #1) relative to diabetic monitoring. Findings are as follows: Closed record review for Resident ID #1 revealed a [DIAGNOSES REDACTED]. Record review revealed a drug regimen review dated 8/22/2019 with the pharmacist recommendation to monitor an A1C (bloodwork that tests your average blood glucose levels over the past 3 months) on the next convenient lab day and every 6 months if meeting treatment goals, or every 3 months if therapy has changed or goals are not being met. An A1C level was obtained on 8/26/2019 with results of 5.6 (less than 5.7 decreased risk for diabetes and greater than 6.4 is consistent with diabetes, according to the results range from the laboratory used by the facility). There was no evidence of a subsequent order for an A1C level. Record review revealed a drug regimen review dated 9/26/2019 with the pharmacist recommendation to discontinue Glimepiride (medication that manages blood sugar levels), if appropriate. Glucose monitoring should continue following any change in diabetic therapy. A telephone order dated 9/26/2019 was given to D/C (discontinue) glimepiride 2 mg daily, obtain blood sugar via fingerstick twice daily x 7 days, (1 week), to start 9/27/2019, and then D/C. Record review revealed blood sugars via fingerstick were obtained from 9/27/2019-10/3/2019 with results ranging from 68-223mg/dl (normal range for blood glucose levels according to the laboratory used by the facility is 70-99 mg/dl). There was no evidence that the resident's blood sugar results were reviewed by the physician. Further review of the resident's medical record revealed [REDACTED]. The result of the blood sugar reading was documented as Hi. The on-call provider was contacted by the nurse regarding the resident's assessment and subsequent order… | 2020-09-01 |
| 27 | 27 | BRIARCLIFFE MANOR | 415012 | 49 OLD POCASSET ROAD | JOHNSTON | RI | 2919 | 2019-12-27 | 759 | D | 1 | 1 | IFE111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each resident's medication regimen is free of medication error rates of 5% or greater. Based on 30 opportunities for error, there were two errors involving two residents (ID #s 77 and 58) resulting in an error rate of 6.67%. Findings are as follows: 1. Record review revealed Resident ID #77 has a physician's orders [REDACTED]. Instructions on the card from the pharmacy indicate not to crush the medication. During the medication administration task on 12/19/2019 at 8:41 AM, Medication Technician, Staff A, was observed preparing Resident ID #77's medications, including the [MEDICATION NAME] ER, which she crushed and put into applesauce. The surveyor intervened prior to the administration of the medication when Staff A revealed that she was ready to administer the medication. During a surveyor interview with Staff A on 12/19/2019 at 8:48 AM, she acknowledged that she crushed the [MEDICATION NAME] ER and that the pharmacy instruction states that the medication should not be crushed. 2. Record review revealed Resident ID #58 has a physician's orders [REDACTED]. Instructions on the card from the pharmacy indicate not to crush the medication. During the medication administration task on 12/19/2019 at 9:08 AM, Medication Technician, Staff B, was observed preparing Resident ID #58's medications, including the [MEDICATION NAME] ER, which she crushed and put into applesauce. The surveyor intervened prior to the administration of the medication when Staff B revealed that she was ready to administer the medication. During a surveyor interview with Staff B on 12/19/2019 at 9:13 AM, she acknowledged that she crushed the [MEDICATION NAME] ER and that the pharmacy instruction states that the medication should not be crushed. On 12/19/2019 at 10:22 AM, the Director of Nursing Services was notified of the medication errors and reve… | 2020-09-01 |
| 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 |
| 28 | 28 | GRACE BARKER NURSING CENTER | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2020-01-02 | 609 | D | 1 | 0 | Q0QB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse, are reported immediately, but not later than 2 hours after the allegation is made, for 1 of 4 residents reviewed for abuse. (ID #1). Finding are as follows: Review of the facility policy titled Abuse Prohibition states in part: D. Identification and Reporting .Any instance of actual or suspected abuse .must be reported timely to the DNS (Director of Nursing) / designee .supervisor on duty and an incident report is to be filled out. The Department of Health .will be contacted of allegations of abuse .within 2 hours of the allegation if the events that led to the allegation involve abuse . Record review revealed Resident ID #1 was admitted to the facility in (MONTH) of (YEAR). [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set Assessment was completed on 11/01/2019. This assessment revealed a Brief Interview for Mental Status score of 15 out of 15 indicating that the resident is cognitively intact. Further record review revealed a nursing note dated 12/14/2019 stating 6:30 am resident told med tech that CNA (certified nursing assistant)/ med tech (name) almost raped me . An interview was conducted with Staff A, on 01/02/2020 at approximately 2:20 PM, she was also the supervisor on duty at the time of the allegation. She was unable to provide evidence that this incident was reported to the state agency. An interview was conducted on 01/02/2020 at approximately 3:20 PM with the Director of Nursing. She stated that she would expect that an allegation of abuse be reported to the state agency immediately. | 2020-09-01 |
| 29 | 29 | GRACE BARKER NURSING CENTER | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2020-02-27 | 658 | D | 1 | 1 | 5Z7X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review and Staff interview, it has been determined that the facility failed to provide services that meet accepted standards of professional practice relative to physician orders [REDACTED].#s 22, 36, 53). Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, states in part that, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders [REDACTED]. 1.Review of Resident ID # 22's medical record revealed that s/he had an order dated 2/17/2020 which reads; No shoes or TEDS due to condition of Right Great Toe. Multiple observations of resident ID #22 on 2/26/2020 and 2/27/2020 revealed that s/he had both TEDS (stockings use to stop blood clot) stockings and shoes on. During an interview on 2/27/2020 at 1:35 PM with Certified Nursing Assistant, Staff A, revealed she was not aware of the above order. 2. Review of Resident ID #53's bowel movement (BM) log revealed that the resident had not had a BM since 2/22/2020. Further review of the Medication Administration Record (MAR) revealed the following orders for bowel regimen dated 12/19/2019. - Prune Juice 90 Milliliter (ML) by mouth if no BM in 2 days as needed. - Milk of Magnesia (medication use to treat constipation) 400 Milligram (MG)/5 ML once a day PRN (as needed): administered on day 2 if no BM. - [MEDICATION NAME] 10 MG (medication use to treat constipation) suppository once a day as PRN: Give for constipation on day 3 on 11-7. - Fleet Enema (Sodium [MEDICATION NAME]) 19-7gram/118ML once a day PRN (medication used to treat constipation): day 3 after 10-12 shifts since last BM. Record review revealed the resident did not receive any of the above bowel medications until it was brought to the facility attention by the surveyor on 2/27/2020. During a surveyor interview and review of the MAR and BM output on 2/27/2020 at 8:58 AM with Registered Nurse, Staff C, she could not provide evidence… | 2020-09-01 |
| 30 | 30 | GRACE BARKER NURSING CENTER | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2020-02-27 | 689 | E | 1 | 1 | 5Z7X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on water temperature readings, staff and resident interviews, it has been determined the facility failed to ensure the residents' environment remains free from accident hazards related to water temperatures above 120-degree Fahrenheit (F), in areas used by residents on 2 of 3 units (Moniz and North). Findings are as follows: The surveyors obtained water temperatures on all units on 2/24/2020. The following temperatures were obtained on Moniz Unit and North Unit using a digital thermometer. North Unit: -10:00 AM, room [ROOM NUMBER], bathroom sink measured at 121.6 F -10:18 AM, room [ROOM NUMBER], bathroom sink measured at 124.4 F -11:45 AM, sink in shower room measured at 129.7 F and shower stall measured at 122.4 F Moniz Unit: -11:56 AM, room [ROOM NUMBER], bathroom sink measured at 124.2 F -12:03 PM, room [ROOM NUMBER], bathroom sink measured at 126.9 F Record review of the facility weekly water temperature log on 2/24/2020 at approximately 2:15 PM revealed the water temperature ranging from 99-111 F. During an interview with the Maintenance Director on 2/24/2020 at approximately 2:30 PM, he revealed he checks the water temperature once a week at different locations and times. He further revealed that he does not calibrate the thermometer. At this time the survyors and Maintenance Director thermometers were calibrated, water temperatures were retaken and continue to remain high. Surveyor interviews conducted on 2/24/2020 with residents residing in rooms with high water temperatures, revealed the following: -11:54 AM, Resident ID #52 revealed s/he uses the bathroom daily and shower room on Moniz Unit. During a surveyor interview with the Director of Nursing Services on 2/24/2020 at approximately 1:37 PM, she revealed that she was not aware of the elevated water temperatures. | 2020-09-01 |
| 31 | 31 | GRACE BARKER NURSING CENTER | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2020-02-27 | 692 | D | 1 | 1 | 5Z7X11 | > Based on surveyor observation, staff interview and record review it has been determined that the facility failed to ensure that residents received necessary care to maintain acceptable parameters of nutritional status relative to body weight, unless the resident's clinical condition demonstrates that this is not possible, for 1 of 6 residents who require assistance with eating (ID #12). Findings are as follows: Record review for ID #12 revealed that s/he requires assistance with eating. The resident has a 2/20/2020 physicians order for 1-1 supervision for all meals due to difficulty feeding him/her-self and previous weight loss. Surveyor observed the resident on 2/24/2020 at 1:06 PM in bed in his/her room. The lunch meal tray had been delivered and placed on the bedside table and the resident was attempting to reach the food without success. The surveyor continued observation for approximately 45 minutes. No staff entered the room to check on the resident or to provide assistance. When staff removed the tray from the resident's room at approximately 1:52 PM, the food remained untouched. The surveyor observed the resident again on 2/26/2020 at 7:35 AM. The breakfast meal tray had been delivered and placed on the resident's bedside table. There was no staff present. The resident was attempting to eat scrambled eggs with his/her hands while in bed. At approximately 7:40 AM, staff entered the room and asked the resident how s/he was doing and then left the room at approximately 7:41 AM. The surveyor continue observation from 7:35 AM until 8:30 AM with no staff observed assisting the resident. Additional surveyor review of the resident's clinical record revealed that the Speech Language Pathologist (SLP) conducted a screen (a brief visual evaluation) on 2/19/2020, as requested by nursing. The SLP recommended a full speech therapy evaluation due to the resident's prior weight loss and cognitive decline. A care plan for: Imbalanced Nutrition: weight loss related to insufficient dietary intake was created on 2/20/2020.… | 2020-09-01 |
| 32 | 32 | GRACE BARKER NURSING CENTER | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2019-03-07 | 636 | B | 1 | 1 | Inf | > Based on clinical record reviews and staff interview, it has been determined that the facility failed to conduct a comprehensive assessment using the resident assessment instrument (RAI), for 5 of 19 residents reviewed for resident assessments (ID #s 10, 19, 20, 22, and 42). The comprehensive assessment must be completed within 14 calendar days after admission and not less than once every 12 months. Findings are as follows: 1. Record review for Resident ID #10 revealed an annual comprehensive assessment with a required completion date of 2/1/2019. Further review revealed, that as of 3/7/2019, the comprehensive assessment was not completed and was 34 days overdue. 2. Record review for Resident ID #19 revealed an annual comprehensive assessment with a required completion date of 1/30/2019. Further review revealed, that as of 3/7/2019, the comprehensive assessment was not completed and was 36 days overdue. 3. Record review for Resident ID #20 revealed an annual comprehensive assessment with a required completion date of 2/1/2019. Further review revealed, that as of 3/7/2019, the comprehensive assessment was not completed and was 34 days overdue. 4. Record review for Resident ID #22 revealed an annual comprehensive assessment with a required completion date of 2/1/2019. Further review revealed, that as of 3/7/2019, the comprehensive assessment was not completed and was 34 days overdue. 5. Record review for Resident ID #22 revealed an annual comprehensive assessment with a required completion date of 1/25/2019. Further review revealed, that as of 3/7/2019, the comprehensive assessment was not completed and was 41 days overdue. During a surveyor interview with the Minimum Data Set nurse, Staff A, on 3/7/2019 at 10:47 AM, she acknowledged that the comprehensive assessments were not completed on time. | 2020-09-01 |
| 33 | 33 | GRACE BARKER NURSING CENTER | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2019-03-07 | 637 | B | 1 | 1 | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it has been determined that the facility failed to complete a Significant Change in Status Assessment within 14 days after there has been a significant change in the resident's physical or mental condition for 2 of 3 sample residents who were admitted or discharged from Hospice services (ID#s 29 and 31). Findings are as follows: 1. Record review revealed that Resident ID #29 was admitted to the facility on [DATE]. The resident was admitted to Hospice services on 8/23/2018. Further record review revealed that a Significant Change in Status Assessment was not completed when the resident was admitted to Hospice services. 2. Record review revealed that Resident ID #31 was admitted to the facility on [DATE]. The resident was discharged from Hospice services on 1/11/2019. Further record review revealed that a Significant Change in Status Assessment was not completed when the resident was discharged from Hospice services. During a surveyor interview with the Minimum Data Set nurse, Staff A, on 3/7/2019 at 10:47 AM, she could not provide evidence that a Significant Change in Status Assessment was completed for either resident when they had a change in Hospice services. | 2020-09-01 |
| 34 | 34 | GRACE BARKER NURSING CENTER | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2019-03-07 | 638 | B | 1 | 1 | Inf | > Based on clinical record reviews and staff interview, it has been determined that the facility failed to assess residents using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for 9 out of 19 residents reviewed for resident assessments (ID #s 1, 4, 5, 7, 8, 11, 12, 13, and 14). Findings are as follows: 1. Record review for Resident ID #1 revealed a quarterly review assessment with a required completion date of 1/10/2019. Further review revealed, that as of 3/7/2019, the resident assessment was not completed and was 56 days overdue. 2. Record review for Resident ID #4 revealed a quarterly review assessment with a required completion date of 1/25/2019. Further review revealed, that as of 3/7/2019, the resident assessment was not completed and was 41 days overdue. 3. Record review for Resident ID #5 revealed a quarterly review assessment with a required completion date of 1/25/2019. Further review revealed, that as of 3/7/2019, the resident assessment was not completed and was 41 days overdue. 4. Record review for Resident ID #7 revealed a quarterly review assessment with a required completion date of 1/25/2019. Further review revealed, that as of 3/7/2019, the resident assessment was not completed and was 41 days overdue. 5. Record review for Resident ID #8 revealed a quarterly review assessment with a required completion date of 2/1/2019. Further review revealed, that as of 3/7/2019, the resident assessment was not completed and was 34 days overdue. 6. Record review for Resident ID #11 revealed a quarterly review assessment with a required completion date of 1/25/2019. Further review revealed, that as of 3/7/2019, the resident assessment was not completed and was 41 days overdue. 7. Record review for Resident ID #12 revealed a quarterly review assessment with a required completion date of 2/1/2019. Further review revealed, that as of 3/7/2019, the resident assessment was not completed and was 33 days overdue. 8. Record review for Resident ID… | 2020-09-01 |
| 35 | 35 | GRACE BARKER NURSING CENTER | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2019-03-07 | 695 | D | 1 | 1 | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 5 residents reviewed for oxygen therapy (ID #63). Findings are as follows: Surveyor observations on 3/3/2019 at 12:22 PM, 3/6/2019 at 7:30 AM, and 3/7/2019 at 10:24 AM revealed Resident ID #63 using oxygen via nasal cannula at 2 liters per minute. Review of the clinical record revealed this resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. There lacked evidence of the attending practitioner's order for oxygen therapy. During a surveyor interview with the Director of Nursing Services on 3/7/2019 at 12:23 PM, she revealed that the resident should have a practitioner's order for the oxygen. | 2020-09-01 |
| 36 | 36 | GRACE BARKER NURSING CENTER | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2019-03-07 | 791 | D | 1 | 1 | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review and staff interview, it was determined that the facility has failed to assist residents in obtaining routine dental services for 1 of 3 residents reviewed for dental (ID #59). Findings are as follows: Surveyor observation on 3/4/2019 at 1:38 PM revealed that Resident ID #59 has his/her own natural teeth. Review of the clinical record revealed this resident was admitted to the facility on [DATE]. Further review revealed a 9/8/2018 annual Minimum Data Set assessment stating that the resident has obvious or likely cavity or broken natural teeth. There lacked evidence that the resident had obtained routine dental services. During a surveyor interview with the Charge Nurse on 3/7/2019 at 9:14 AM, she was unable to provide evidence that the resident or responsible party declined routine dental services. During a subsequent interview with Resident ID #59's responsible party on 3/7/2019 at 10:56 AM she revealed that she would like the resident to be seen by a dentist. | 2020-09-01 |
| 37 | 37 | GRACE BARKER NURSING CENTER | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2018-03-30 | 761 | E | 1 | 1 | N83B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observations and staff interview, it has been determined that the facility failed to ensure that medication bottles were dated when opened for 6 of 9 [MEDICATION NAME] Concentrate. Findings are as follows: Surveyor observation of the refrigerator in the medication room, on 3/28/2018 at 10:51 AM, noted nine bottles of open [MEDICATION NAME] Liquid, 6 were undated when opened. Manufacturer's instructions written on the box state, discard opened bottle after 90 days. During an interview immediately after the above observation with the Unit Manager, she was unable to explain why the [MEDICATION NAME] Concentrate were open and not dated. You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the Rules and Regulations for Licensing of Nursing Facilities they are deficiencies under State Regulations and grounds for licensure sanctions. | 2020-09-01 |
| 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 |
| 1641 | 1641 | GRACE BARKER NURSING CENTER INC. | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2012-03-09 | 502 | D | 0 | 1 | 8XPP11 | **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 laboratory services to meet the needs of its residents for 1 of 16 residents (ID # 5). Findings are as follows: Resident ID # 5 has a physician's orders [REDACTED]. There lacked evidence that LFT's have been done in the past year, i.e. from March 2011 to March 2012. During interview on 3/9/12, staff were unable to produce evidence that these tests have been done. Upon bringing this to the attention of the resident's nurse practitioner on 3/9/12, LFT's were ordered to be done immediately. "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." | 2015-05-01 |
| 1642 | 1642 | GRACE BARKER NURSING CENTER INC. | 415014 | 54 BARKER AVENUE | WARREN | RI | 2885 | 2012-03-09 | 428 | D | 0 | 1 | 8XPP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that the consultant pharmacist reported any irregularities to the physician and director of nursing for 1 of 16 residents reviewed (ID # 5). Findings are as follows: Record review for resident ID # 5 revealed that the resident has an order for [REDACTED]. Per interview with nursing staff on 3/9/12, the LFT's are ordered secondary to the resident's use of a statin medication. There lacked evidence that the consultant pharmacist noted the omission of these tests or ever reported the omission to either the attending physician or director of nursng. | 2015-05-01 |
| 38 | 38 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2020-02-12 | 689 | G | 1 | 0 | T0R811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review, and staff interview, it is determined the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 residents reviewed (ID #1). Findings are as follows: Resident ID #1 was originally admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Of note is that the resident's medical regimen included the administration of [MEDICATION NAME] (a blood thinner) due to the [DIAGNOSES REDACTED]. The resident's functional ability was assessed as requiring extensive or total assistance for all activities of daily living and personal hygiene. A review of the resident's clinical record revealed she/he sustained a witnessed fall out of bed on 12/26/2019 at 7:35 AM. The resident was attended by a certified nurse assistant (Staff A), who had rolled the resident onto his/her side to provide incontinence care. Staff A supported the resident's position with her hand on the resident's back and reached for a clean brief. She then observed the resident rolling off the edge of the bed and landing on both knees. The resident's knees and head hit the bedside table and the resident's left elbow went into the wastebasket. Staff A called out for help and was assisted by a nurse (Staff B) to remove the resident's elbow from the wastebasket and to roll him/her onto his/her back. Emergency service (911) was called and the resident was transported to a hospital emergency room (ER) for assessment. In the ER, the resident was examined for a possible head injury and pain of the left leg. An x-ray of his/her left knee was obtained and revealed a minimally displaced, closed [MEDICAL CONDITION] femur of the left leg. The x-ray also revealed a prior total knee replacement, which remained in alignment. A CT scan was then obtained, which showed the fracture, the total knee hardware, and a complex appearing mass in the back of the knee described as most likely… | 2020-09-01 |
| 39 | 39 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2020-02-12 | 700 | D | 1 | 0 | T0R812 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to assess the resident for risk of entrapment from bed rails prior to installation for 1 of 3 residents reviewed for use of bed rails (ID #3). Findings are as follows: Record review for Resident ID #3 revealed an admitted [DATE]. [DIAGNOSES REDACTED]. Review of a comprehensive Minimum Data Set ((MDS) dated [DATE] revealed the resident has moderately impaired cognition and requires extensive assist of two or more persons for bed mobility. Record review lacked evidence that a siderail evaluation was completed since admission. Review of the Individualized Resident Assignment Card (Kardex) revealed the section titled, Siderails, is blank. A surveyor observation on 3/10/2020 at 12:15 PM, revealed two siderails on the resident's bed. During an interview on 3/10/2020 at 2:10 PM with the Director of Nursing Services, she acknowledged that the resident has side rails on her bed, was unable to explain why the resident was not assessed prior to siderail installation, or why the Kardex was blank. | 2020-09-01 |
| 40 | 40 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2019-10-04 | 567 | B | 1 | 1 | II8Y11 | > Based on record review and staff interview, it has been determined that the facility failed to obtain written authorization for residents whom the facility is holding personal funds relative to 3 of 7 residents reviewed (ID#s 4, 5, and 28). Findings are as follows: Review of the facility's records related to personal needs funds on 10/3/2019 at 9:00 AM revealed the facility was holding funds for Resident ID#s 4, 5, and 28. 1. Record review for Resident ID #4 revealed a Trust Statement with an ending balance of $125.17 on 9/20/2019. A Resident Personal Needs Authorization form dated 3/8/2017 revealed that the resident did not authorize the facility to hold their funds. 2. Record review for Resident ID #5 revealed a Trust Statement with an ending balance of $40.24 on 8/31/2019. A Resident Personal Needs Authorization form dated 6/27/2018 indicated that the resident declined to deposit personal funds with the facility. 3. Record review for Resident ID #28 revealed a Trust Statement with an ending balance of $1,164.68 on 9/20/2019. A Resident Personal Needs Authorization form dated 1/24/2016 revealed that the resident did not authorize the facility to hold their funds. During a surveyor interview with the Business Office Manager on 10/3/2019 at approximately 9:30 AM, she could not provide evidence that the Resident Personal Needs Authorization forms were accurately completed. | 2020-09-01 |
| 41 | 41 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2019-10-04 | 570 | B | 1 | 1 | II8Y11 | > Based on record review and staff interview, it has been determined that the facility failed to assure the security of all personal funds of residents deposited within the facility relative to purchasing a surety bond which adequately protects resident funds against loss. Findings are as follows: Record review revealed the facility had a surety bond for $15,000.00 effective 12/21/2018 to 12/21/2019. Further record review of the Resident Trust Fund bank statements revealed: -Account balance on (MONTH) 31, 2019 was $20,534.65 -Account balance on (MONTH) 30, 2019 was $17,614.09. During a surveyor interview with the Business Office Manager on 10/3/2019 at 9:05 AM, she could not provide evidence that the current surety bond covered the resident's funds deposited in the facility for (MONTH) and (MONTH) 2019. | 2020-09-01 |
| 42 | 42 | APPLE REHAB WATCH HILL | 415015 | 79 WATCH HILL ROAD | WESTERLY | RI | 2891 | 2019-10-04 | 658 | E | 1 | 1 | II8Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it has been determined that the facility failed to provide services that meet professional standards of quality relative to physician's orders [REDACTED].#s 7, 17, and 19) reviewed for weight orders and 1 of 2 residents reviewed for blood sugar monitoring (ID #19). Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders [REDACTED]. 1. Record review for Resident ID #7 revealed a current physician's orders [REDACTED]. Review of the record from 9/1/2019 to 9/30/2019 revealed that the resident was not weighed on 2 of 13 opportunities (9/13/2019 and 9/23/2019) as ordered by the physician. 2. Record review for Resident ID #17 revealed a current physician's orders [REDACTED]. Review of the record from 7/1/2019 to 9/30/2019 revealed the following: -7/1/2019 to 7/31/2019, the resident was not weighed on 4 of 14 opportunities (7/3/2019, 7/17/2019, 7/19/2019, and 7/22/2019) -8/1/2019 to 8/31/2019, the resident was not weighed on 4 of 13 opportunities (8/5/2019, 8/12/2019, 8/14/2019, and 8/19/2019) -9/1/2019 to 9/30/2019, the resident was not weighed on 3 of 13 opportunities (9/4/2019, 9/13/2019, and 9/30/2019) 3. Record review for Resident ID #19 revealed a 5/16/2019 physician's orders [REDACTED]. Review of the record from 9/1/2019 to 10/4/2019 revealed that the resident was not weighed on 3 of 5 opportunities (9/8/2019, 9/15/2019, and 9/22/2019) as ordered by the physician. 4. Additional record review for Resident ID #19 revealed a 3/27/2019 physician's orders [REDACTED]. Review of the record from 9/1/2019 to 10/4/2019 revealed that the resident's blood sugar was not monitored on 2 of 5 opportunities (9/11/2019 and 9/18/2019) as ordered by the physician. During surveyor interviews with the Director of Nursing Services on 10/4/2019 at 8:30 AM, 10:30 AM, and 11:30 AM,… | 2020-09-01 |
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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 );