Inspection Report
Annual Inspection
Census: 89
Capacity: 210
Deficiencies: 11
Mar 21, 2025
Visit Reason
A recertification survey and complaint survey were conducted at the Respiratory and Rehabilitation Center of Rhode Island Nursing Home on 3/18/2025 through 3/21/2025 to determine compliance with 42 CFR Part 483, requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were identified in multiple areas including informed consent for antipsychotic medication, accounting and records of personal funds, Medicaid/Medicare coverage notices, freedom from abuse and neglect, accuracy of assessments, care plan timing and revision, drug regimen review, infection prevention and control, and life safety code compliance. The facility failed to ensure timely kitchen hood suppression system servicing and automatic sprinkler system maintenance.
Complaint Details
Complaint investigation was triggered by a community reported complaint submitted to the Rhode Island Department of Health on 3/17/2025 alleging failure to obtain consent for antipsychotic medication for Resident #101. The complaint was substantiated as the facility failed to inform the resident's representative about the addition of Rexulti and associated risks.
Deficiencies (11)
| Description |
|---|
| Facility failed to inform resident's representative about risks and benefits of antipsychotic medication. |
| Facility failed to provide written accounting of personal funds for 5 of 7 residents reviewed. |
| Facility failed to provide timely Medicaid Non-Coverage Notices to residents. |
| Facility failed to keep resident free from neglect for 1 resident related to activities of daily living. |
| Facility failed to ensure accurate assessments for 1 resident with schizophrenia. |
| Facility failed to properly notify residents of changes in Medicare coverage and services. |
| Facility failed to implement and revise care plan after assessments for 1 of 2 residents reviewed. |
| Facility failed to ensure drug regimen review was conducted monthly and irregularities reported for 1 of 2 residents reviewed. |
| Facility failed to maintain infection prevention and control program including antibiotic stewardship and staff compliance with gown use. |
| Facility failed to ensure residents receiving dialysis had effective communication and care plans. |
| Facility failed to maintain kitchen hood suppression system and automatic sprinkler system in compliance with NFPA standards. |
Report Facts
Deficiencies cited: 11
Resident census: 89
Total capacity: 210
Dates of medication administration: 141
Dates of medication administration: 71
Inspection Report
Follow-Up
Census: 34
Capacity: 124
Deficiencies: 2
May 14, 2024
Visit Reason
A follow-up to a previous recertification and complaint investigation survey was conducted to verify correction of previous deficiencies and to assess continued compliance.
Findings
Most previous deficiencies were corrected; however, a new deficiency related to insufficient nursing staff was identified and recited due to continued noncompliance. Additionally, a life safety code deficiency regarding sprinkler coverage at the main entrance was found but has been resolved.
Complaint Details
The continued noncompliance citation was issued due to failure to ensure resident safety and provide adequate staffing, including an unlicensed person conducting assessments, treatments, and medications to five residents without proper supervision.
Deficiencies (2)
| Description |
|---|
| Insufficient nursing staff to assure resident safety and provide the highest practicable physical, mental, and psychosocial well-being of each resident. |
| Sprinkler system installation at the main entrance lacked sprinkler coverage between two sliding doors, failing to meet NFPA 101 Life Safety Code 2012 requirements. |
Report Facts
Residents affected by staffing deficiency: 34
Residents potentially impacted by sprinkler deficiency: 124
Hours worked by registered nurse in 24-hour period: 20
Date of survey completion: May 14, 2024
Date of sprinkler system survey: May 10, 2024
Inspection Report
Annual Inspection
Census: 124
Capacity: 210
Deficiencies: 5
Apr 8, 2024
Visit Reason
A Recertification Survey and complaint investigation survey was conducted from 4/2/2024 through 4/8/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were cited related to tube feeding management, physician supervision, sufficient nursing staff, food safety, and life safety code violations including fire exit door and emergency lighting issues. The facility provided plans of correction including staff education, audits, and corrective actions.
Complaint Details
Complaint investigation was part of the survey to address concerns related to feeding tube management and resident care.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure residents fed through feeding tubes received appropriate treatment and services to prevent complications, including failure to verify G-tube placement and failure to provide nutrition, hydration, and medications for approximately 36 hours. |
| Facility failed to ensure medical care of resident was supervised by a physician, including failure to ensure medication orders and lab results were properly managed. |
| Facility failed to provide sufficient nursing staff with appropriate competencies and skills to assure resident safety and care for ADL needs. |
| Facility failed to properly store, distribute, and serve food in accordance with professional standards for food service safety, including unlabeled and undated food items in kitchenettes and resident refrigerators. |
| Life Safety Code deficiencies including fire exit door failing to open within 15 seconds, delayed-egress door-locking system not compliant, emergency lighting system not maintained, sprinkler system deficiencies, portable space heaters improperly used, and electrical equipment power cords and extension cords improperly used. |
Report Facts
Resident census: 124
Total capacity: 210
Duration of survey: 7
Days resident did not receive medication: 15
Time for fire exit door to open: 15
Audit frequency: 4
Inspection Report
Follow-Up
Deficiencies: 0
Feb 16, 2023
Visit Reason
An off-site desk audit was conducted on February 16, 2023 for all previous deficiencies cited on January 26, 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
Census: 128
Capacity: 164
Deficiencies: 5
Jan 26, 2023
Visit Reason
A Recertification Survey and complaint investigation were conducted to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey.
Findings
Deficiencies were cited related to drug regimen errors, medication error rates exceeding 5%, improper storage and labeling of drugs and biologicals, food safety violations, and failure to ensure infection preventionist completed specialized training. No Life Safety Code deficiencies were identified.
Complaint Details
Complaint investigation was part of the survey, referenced by ACTS Reference Number 88568.
Deficiencies (5)
| Description |
|---|
| Drug regimen was not free from unnecessary drugs for 1 of 5 residents reviewed (Resident ID #5). |
| Resident's medication regimen had error rates of 6.67%, exceeding the 5% threshold (Resident ID #119). |
| Failure to store drugs and biologicals in accordance with accepted professional principles in 1 of 2 medication storage rooms and 1 of 4 medication carts. |
| Failure to ensure food is stored, served, and distributed in accordance with professional standards for food service safety, including unclean equipment and improper employee hygiene. |
| Failure to designate infection preventionist(s) who completed specialized training in infection prevention and control. |
Report Facts
Residents reviewed for drug regimen: 5
Medication error opportunities: 30
Medication errors observed: 2
Medication storage rooms observed: 2
Medication carts observed: 4
Dietary staff re-education frequency: 90
Inspection Report
Life Safety
Deficiencies: 0
Feb 7, 2022
Visit Reason
The annual Federal Life Safety Code survey was conducted by the State Survey Agency to assess compliance with the National Fire Protection Association 101 Life Safety Code, 2012 Edition, as referenced in 42 CFR 483.90 (a - d) Physical Environment.
Findings
No Life Safety Code deficiencies were identified during the annual survey conducted on 02/07/2022.
Inspection Report
Annual Inspection
Deficiencies: 11
Nov 8, 2021
Visit Reason
A Recertification Survey was conducted at Respiratory And Rehabilitation Center of RI from 11/08/2021 through 11/12/2021 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities. A State licensure and emergency preparedness surveys were also conducted at this facility.
Findings
The facility was determined not to be in compliance with several requirements, resulting in multiple deficiencies cited related to resident self-administration of medications, advance directives, comprehensive care plans, bowel/bladder incontinence, nutrition/hydration status, respiratory care, physician visits, medication errors, food procurement and safety, smoking policies, and quality assurance performance improvement.
Deficiencies (11)
| Description |
|---|
| Resident Self-Admin Meds-Clinically Appropriate - Facility failed to ensure residents are assessed to self-administer medications for 1 resident. |
| Right to request, refuse, and/or discontinue treatment, participate in experimental research, and formulate an advance directive - Facility failed to ensure a resident's code status was consistent with their wishes. |
| Develop/Implement Comprehensive Care Plan - Facility failed to develop and implement comprehensive person-centered care plans with measurable objectives for multiple residents. |
| Bowel/bladder incontinence, catheter, UTI - Facility failed to provide appropriate treatment and services for a resident with an indwelling catheter. |
| Nutrition/Hydration Status Maintenance - Facility failed to ensure sufficient fluid intake for 1 resident. |
| Respiratory/Tracheostomy Care and Suctioning - Facility failed to ensure respiratory care consistent with professional standards for 1 resident. |
| Physician Visits - Facility failed to ensure physician reviewed resident's total program of care and progress notes for 4 residents. |
| Free of Medication Errors Rate 5 Percent or More - Facility failed to ensure medication error rate was below 5 percent; error rate was 18.75 percent. |
| Food Procurement - Facility failed to store and serve food in accordance with professional standards for food service safety. |
| Smoking Policies - Facility failed to follow established policies relative to smoking/smoking safety for 2 residents. |
| Quality assessment and assurance - Facility failed to maintain a quality assessment and assurance committee and failed to implement an effective QAPI program. |
Report Facts
Medication error rate: 18.75
Medication error threshold: 5
Residents reviewed for physician visits: 4
Residents reviewed for care plans: 6
Residents reviewed for smoking assessment: 2
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