Inspection Reports for Brookdale South Bay
1959 KINGSTOWN ROAD, WAKEFIELD, RI, 02879
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
3% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Plan of Correction
Deficiencies: 0
May 10, 2024
Visit Reason
An off-site desk audit was conducted on May 10, 2024, to review all previous deficiencies cited on March 27, 2024.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Deficiencies: 5
Mar 27, 2024
Visit Reason
The inspection was conducted as the Annual State Licensure and a Complaint Investigation Survey at Brookdale South Bay from 03/25/2024 through 03/27/2024 to assess compliance with regulatory requirements.
Findings
Deficiencies were identified related to resident care services including dialysis care, infection control, nursing care procedures, administration of drugs, and dietetic services. The facility failed to provide care and services in accordance with community standards for some residents, and failed to implement adequate infection control practices and medication administration protocols.
Complaint Details
The survey included a complaint investigation referenced by ACTS number 94053. Deficiencies were identified as a result of the complaint investigation.
Deficiencies (5)
| Description |
|---|
| Failure to provide care and services to all residents in accordance with prevailing community standards, specifically related to hemodialysis and indwelling catheters. |
| Failure to ensure staff implemented infection control practices to prevent and control infections, including contact precautions for MRSA. |
| Failure to provide treatment and services to prevent pressure ulcers and contractures, including proper skin care and wound management. |
| Failure to administer medications in accordance with physician orders and proper documentation. |
| Failure to comply with Rhode Island Food Code standards in the nursing facility's food service operation. |
Report Facts
Dates of survey: Survey conducted from 2024-03-25 through 2024-03-27
Urinary output documentation opportunities: 75
Medication administration audit period: 3
Wound care audit period: 3
Dialysis audit frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Interviewed regarding assessment of resident AVF and dialysis communication. |
| Staff B | Nursing Assistant | Interviewed regarding PPE use and MRSA testing awareness. |
| Staff C | Licensed Practical Nurse | Authored nursing progress notes and interviewed regarding wound care. |
| Staff D | Registered Nurse | Interviewed regarding medication administration and resident care. |
| Director of Clinical Services | Interviewed regarding expectations for monitoring residents and responsible for plan of correction. | |
| Director of Dining Services | Conducted audits of food service and walk-in freezer. | |
| Registered Dietician | RD | Re-in serviced dining and maintenance staff on food service standards. |
Inspection Report
Plan of Correction
Deficiencies: 0
May 5, 2023
Visit Reason
An off-site desk audit was conducted on May 5, 2023 for all previous deficiencies cited on March 6, 2023.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected. The facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Deficiencies: 4
Apr 6, 2023
Visit Reason
The Annual State Licensure and a complaint investigation survey were conducted at Brookdale South Bay from 04/04/2023 through 04/06/2023 to assess compliance with regulatory requirements and investigate complaints.
Findings
Deficiencies were identified related to resident care services including failure to follow physician orders for monthly weights, failure to adhere to resident care plans for skin integrity and cardiovascular status, failure to administer medications as ordered, and failure to comply with food service standards. Corrective actions and audits were planned and initiated by the Director of Clinical Services and other staff.
Complaint Details
The survey included a complaint investigation with ACTS numbers 88903 and 88343. Deficiencies were identified as a result of the complaint investigation.
Deficiencies (4)
| Description |
|---|
| Failure to ensure services met professional standards related to following physician orders for monthly weights for 1 of 3 residents reviewed. |
| Failure to adhere to a resident's care plan specific to skin integrity interventions and cardiovascular status for 1 of 3 residents reviewed. |
| Failure to administer medications in accordance with physician orders for 1 of 3 residents reviewed. |
| Failure to comply with Rhode Island Food Code standards in the main kitchen, including accumulation of food debris and improper storage of water pitchers. |
Report Facts
Residents reviewed: 3
Dates of survey: Survey conducted from 2023-04-04 through 2023-04-06.
Audit frequency: 5
Audit frequency: 3
Audit frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Clinical Services | Responsible for auditing residents' monthly weights, care plans, medication administration, and overseeing corrective actions. | |
| Director of Nursing | Interviewed during survey; unable to provide evidence of monthly weights obtained for February and March 2023. | |
| Staff B | Nursing Assistant | Acknowledged resident was sitting without redistribution/reduction seat cushion and reported resident's sore bottom to charge nurse. |
| Staff C | Nursing Assistant | Revealed unawareness of resident's care plan for seat cushion. |
| Staff A | Registered Nurse | Unable to provide evidence of redistribution/reduction seat cushion. |
| Staff D | Hospice Nursing Assistant | Acknowledged providing morning care and observing resident's buttocks area but failed to report redness to unit nurse. |
| Director of Dining Services | Completed audit of all walk-in freezers and ice machines. | |
| Food Service Director | Acknowledged observations of food service deficiencies. | |
| Dietary worker | Observed not wearing hair restraint and removed water pitchers from floor. | |
| Cook Staff F | Observed dietary worker without hair restraint. |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 18, 2022
Visit Reason
An off-site desk audit was conducted on April 18, 2022 for all previous deficiencies cited on February 10, 2022.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected. The facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Deficiencies: 4
Feb 10, 2022
Visit Reason
The annual State licensure survey and complaint investigation survey (0U7Q11) were conducted at this facility to assess compliance with licensure requirements.
Findings
Deficiencies were identified related to the failure to maintain a Safe Resident Handling program, failure to establish a written Quality Improvement Plan including required components, failure to conduct in-service education for personnel, and failure to properly report and investigate resident abuse, accidents, and deaths.
Complaint Details
The complaint investigation was part of the annual survey and included review of abuse, neglect, and accident reporting. The investigation found insufficient evidence to substantiate abuse but identified failures in reporting and investigation procedures.
Deficiencies (4)
| Description |
|---|
| Failure to ensure a Safe Resident Handling program with required components including a committee chaired by a licensed professional and quarterly meetings. |
| Failure to establish a written Quality Improvement Plan containing all required components such as prevention and treatment of decubitus ulcers, dehydration, nutritional status, and changes in mental or psychological status. |
| Failure to conduct in-service education for personnel including orientation and ongoing training related to food services and sanitation. |
| Failure to properly report and investigate allegations of resident abuse, neglect, or mistreatment within required timeframes and to complete appropriate incident reports. |
Report Facts
Date survey completed: Feb 10, 2022
Plan of Correction Completion Date: Apr 15, 2022
Staff training completion timeframe: 45
Number of residents reviewed for Safe Resident Handling assessment: 5
Number of staff reviewed for in-service training: 6
Number of months for Quality Improvement Committee meetings: 12
Inspection Report
Deficiencies: 1
Aug 26, 2021
Visit Reason
An administrative review/off-site investigation was conducted due to the facility's failure to post monthly, on its website, a report containing detailed, aggregated data pertaining to the COVID-19 vaccination status of its health care workers.
Findings
The facility failed to post monthly COVID-19 vaccination data for health care workers on its website as required. Review of the facility's website confirmed the absence of this data.
Deficiencies (1)
| Description |
|---|
| Failure to post monthly, on its website, a report containing detailed, aggregated data pertaining to the COVID-19 vaccination status of its health care workers. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Dziewkowski | Exec. Dir. | Signed the Plan of Correction related to the deficiency. |
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