Inspection Reports for Cra-Mar Meadows
575 Seven Mile Rd, Hope, RI 02831, United States, RI, 02831
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Inspection Report
Follow-Up
Deficiencies: 0
Jul 1, 2025
Visit Reason
A follow-up survey was conducted to verify correction of previous deficiencies at the facility.
Findings
All previous deficiencies were corrected and no new deficiencies were identified during this follow-up survey.
Inspection Report
Re-Inspection
Census: 36
Capacity: 41
Deficiencies: 14
May 19, 2025
Visit Reason
A recertification and complaint survey was conducted from 5/19/2025 through 5/22/2025 to determine compliance with 42 C.F.R. Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were identified related to resident rights, comprehensive care plans, quality of care, medication administration, infection control, staff qualifications, and emergency preparedness. The facility acknowledged the deficiencies and provided plans of correction including staff education, competency evaluations, and policy updates.
Complaint Details
The survey included a complaint investigation as part of the recertification process, with findings related to resident rights, quality of care, medication errors, and infection control.
Severity Breakdown
SS=D: 10
SS=E: 4
Deficiencies (14)
| Description | Severity |
|---|---|
| Resident Rights: Facility failed to provide an environment that promotes maintenance of residents' dignity during dining for 3 of 6 residents requiring assistance. | SS=D |
| Right to Survey Results: Facility failed to protect identifying information for a resident in the survey results binder. | SS=D |
| Comprehensive Care Plan: Facility failed to develop and implement a person-centered care plan for a resident with an indwelling catheter. | SS=D |
| Quality of Care: Facility failed to provide appropriate treatment and services for a resident with rash and diaphoresis related to medication. | SS=D |
| Drug Regimen: Facility failed to ensure medication was held as ordered and medication errors occurred. | SS=D |
| Medication Errors: Facility failed to ensure medication error rate was less than 5% for 1 of 3 residents reviewed. | SS=D |
| Residents Free of Significant Med Errors: Facility failed to ensure a resident was free of significant medication errors related to transcription errors. | SS=D |
| Staff Qualifications: Facility employed staff with expired NA and CMT licenses. | SS=D |
| Resident Records - Identifiable Information: Facility failed to keep resident-identifiable information confidential. | SS=D |
| Infection Prevention and Control: Facility failed to establish and maintain an infection prevention and control program. | SS=E |
| Influenza and Pneumococcal Immunizations: Facility failed to ensure residents received or were offered immunizations. | SS=E |
| Training Requirements: Facility failed to provide education and training to staff related to abuse, neglect, exploitation, catheter care, and other areas. | SS=E |
| Resident Care Services - Administration of Drugs by Medication Tech: Facility failed to conduct and document quarterly evaluations for Certified Medication Technicians. | — |
| Life Safety Code: Facility failed to properly store, mark, and segregate full and empty oxygen cylinders. | — |
Report Facts
Census: 36
Total Capacity: 41
Medication error rate: 8
Medication doses: 11
Certified Medication Technician evaluations: 2
Residents reviewed for immunization: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Nursing Assistant | Noted standing and assisting residents requiring 1:1 assistance during dining |
| Staff C | Speech Therapist | Noted standing and assisting residents requiring 1:1 assistance during dining |
| Staff D | Nursing Assistant | Noted standing and assisting residents requiring 1:1 assistance during dining |
| Staff F | Nursing Assistant | Revealed not providing catheter care and acknowledged medication administration observations |
| Staff G | Nurse Practitioner | Provided new medication orders and acknowledged medication errors |
| Staff H | Registered Nurse | Observed not wearing gown during wound care and acknowledged wound care observations |
| Staff A | Certified Medication Technician | Reviewed for staff qualifications and medication administration |
| Staff B | Certified Medication Technician | Observed administering medication and reviewed for staff qualifications |
| Staff J | Registered Nurse | Reviewed for training records and competency related to catheter care |
| Director of Nursing Services | Acknowledged staff training, medication administration, and infection control program status | |
| Assistant Administrator | Acknowledged failure to protect resident identifying information and oxygen cylinder storage deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 9, 2024
Visit Reason
An off-site desk audit was conducted to review all previous deficiencies cited on May 23, 2024, and verify correction.
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
Census: 34
Capacity: 41
Deficiencies: 8
May 23, 2024
Visit Reason
A recertification survey was conducted from 5/20/2024 through 5/23/2024 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 identified at the substandard quality of care level, including issues with care plan timing and revision, activities and interaction, free of accident hazards, incontinence care, infection prevention and control, communication training, QAPI training, and behavioral health training. No Life Safety Code deficiencies were identified.
Deficiencies (8)
| Description |
|---|
| Care plan timing and revision deficiencies related to fall prevention and oxygen therapy interventions not updated timely. |
| Activities and interaction program failed to meet residents' interests and support well-being. |
| Facility failed to ensure resident environment free of accident hazards related to supervision during meals for resident with dysphagia. |
| Incontinence care deficiencies including failure to provide appropriate treatment and services for residents with urinary and fecal incontinence. |
| Infection prevention and control program deficiencies including failure to prevent transmission of communicable diseases and ensure proper PPE use. |
| Communication training not completed by all direct care staff as required. |
| QAPI training not completed by all required staff. |
| Behavioral health training not completed by all required staff. |
Report Facts
Census: 34
Total Capacity: 41
Deficiencies cited: 8
Inspection Report
Plan of Correction
Deficiencies: 0
May 23, 2023
Visit Reason
An off-site desk audit was conducted on May 23, 2023 for all previous deficiencies cited on April 27, 2022.
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
Renewal
Deficiencies: 5
Apr 27, 2023
Visit Reason
A recertification survey was conducted at Cra-Mar Meadows from 04/24/2023 through 04/27/2023 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 the development and implementation of comprehensive care plans, nutrition and hydration status maintenance, dialysis services, menus and nutritional adequacy, and facility assessment. A plan of correction was submitted addressing these deficiencies.
Deficiencies (5)
| Description |
|---|
| Failure to develop and implement a comprehensive person-centered care plan for a resident with an implanted baclofen pump. |
| Failure to ensure residents maintain acceptable parameters of nutritional status, including weight monitoring for residents with weight loss. |
| Failure to ensure residents who require dialysis receive services consistent with professional standards, including documentation of pre- and post-dialysis weights. |
| Failure to update menus periodically and have them reviewed annually by a clinically qualified nutrition professional. |
| Failure to conduct and document a facility-wide assessment addressing resident population, staffing, physical environment, and other resources. |
Report Facts
Dates of survey: 4
Resident weight records reviewed: 7
Weight loss percentage: 5.1
Dialysis frequency: 3
Menu review frequency: 1
Inspection Report
Plan of Correction
Deficiencies: 0
May 2, 2022
Visit Reason
An off-site desk audit was conducted on May 2, 2022 for all previous deficiencies cited on April 6, 2022 to verify correction.
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: 6
Apr 6, 2022
Visit Reason
A recertification off hours survey was conducted from 04/03/2022 to 04/06/2022 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 related to protection of resident identifying information, development and revision of comprehensive care plans, medication administration, infection prevention and control, and abuse, neglect, and exploitation training.
Deficiencies (6)
| Description |
|---|
| Facility failed to protect identifying information for 12 residents listed in the survey results binder. |
| Facility failed to develop a comprehensive person-centered care plan for residents receiving hospice services and those with skin impairment. |
| Facility failed to revise resident care plans following identification of new skin impairments and falls. |
| Facility failed to meet professional standards of quality in medication administration for 1 of 12 residents reviewed. |
| Facility failed to establish and maintain an effective infection prevention and control program, including failure to conduct an annual review and maintain education and competency assessments. |
| Facility failed to provide required training to staff on abuse, neglect, exploitation, and dementia management. |
Report Facts
Residents with identifying information not protected: 12
Residents reviewed for care plans: 11
Residents reviewed for medication administration: 12
Employees listed in infection control education review: 49
Staff members for dementia training review: 42
Staff members not trained in abuse, neglect, and dementia management: 12
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