Deficiencies (last 3 years)
Deficiencies (over 3 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
26% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Nov 21, 2024
Visit Reason
The inspection was conducted based on complaint allegations regarding failure to implement comprehensive care plans, improper use of mechanical lifts, inadequate range of motion treatment, respiratory care deficiencies, food safety violations, and infection control issues.
Complaint Details
The visit was complaint-related due to allegations of failure to follow care plans, improper resident transfers, inadequate treatment for limited range of motion, failure to post oxygen safety signs, food safety violations, and infection control lapses. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to implement person-centered care plans for residents, failure to assist residents with repositioning and toileting, improper use of Hoyer lifts, failure to provide appropriate range of motion care, failure to post oxygen caution signs, improper food handling practices, inadequate ice machine installation, and failure to disinfect a multiuse glucometer properly.
Deficiencies (6)
Failed to implement a comprehensive person-centered care plan related to skin integrity and mechanical lift transfer for residents.
Failed to assist resident with repositioning, incontinence care, and toileting during continuous observations.
Failed to provide appropriate care for limited range of motion using a hand roll device.
Failed to provide safe and appropriate respiratory care by not posting cautionary and safety signs indicating oxygen use for residents.
Failed to ensure food is stored and distributed in accordance with professional standards, including improper glove use and inadequate ice machine air gap.
Failed to maintain an infection prevention and control program by not disinfecting a multiuse glucometer properly.
Report Facts
Observation duration: 245
Observation duration: 260
BIMS score: 4
BIMS score: 15
BIMS score: 15
Oxygen flow rate: 2
Ice machine air gap: 0.25
Hand roll usage time: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Nursing Assistant | Named in failure to assist resident with repositioning and toileting |
| Staff C | Nursing Assistant | Acknowledged transferring resident alone with Hoyer lift |
| Staff D | Licensed Practical Nurse | Acknowledged resident did not have left-hand roll in place |
| Staff E | Registered Nurse | Acknowledged failure to post oxygen caution signs |
| Staff F | Cook | Acknowledged failure to change gloves during food handling |
| Staff G | Licensed Practical Nurse | Acknowledged failure to disinfect glucometer properly |
| Staff H | Occupational Therapist | Provided information on hand roll device use |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding care plan compliance, Hoyer lift transfers, hand roll application, oxygen safety signs, and infection control |
| Food Service Director | Food Service Director | Acknowledged food safety violations and ice machine air gap issue |
| Infection Control Nurse | Infection Control Nurse | Interviewed regarding glucometer disinfection protocol |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 1, 2024
Visit Reason
The inspection was conducted in response to a community reported complaint alleging that a Medication Technician administered medications prescribed for one resident to another resident in error.
Complaint Details
The complaint was substantiated. It was reported on 2/28/2024 that Staff A gave Resident ID #1 medications prescribed for Resident ID #2. Staff A and Licensed Practical Nurse Staff B confirmed the error during interviews. The Director of Nursing acknowledged the error and the expectation for proper resident identification.
Findings
The facility failed to ensure residents were free from significant medication errors when Resident ID #1 was given medications prescribed for Resident ID #2 on 1/19/2024. Interviews with staff and the resident confirmed the medication error occurred due to failure to properly identify the resident prior to administration.
Deficiencies (1)
Failure to ensure residents are free from significant medication errors, specifically Resident ID #1 receiving Resident ID #2's medications on 1/19/2024.
Report Facts
Residents reviewed: 3
Residents affected: 1
Medication error date: Jan 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Technician | Named in medication error finding for administering wrong medications |
| Staff B | Licensed Practical Nurse | Reported the medication error by Staff A |
| Director of Nursing Services | Director of Nursing | Acknowledged the medication error and expectation for proper resident identification |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 1, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding significant medication errors and the safety and sanitation of facility equipment.
Complaint Details
The complaint investigation found substantiated medication errors involving Resident ID #24, with medications administered despite diastolic blood pressure being below 60 mm Hg on multiple dates. The facility also failed to maintain microwave cleanliness and safety, with rust and food buildup observed.
Findings
The facility failed to ensure a resident's drug regimen was free from significant medication errors, as medications were administered outside prescribed blood pressure parameters. Additionally, the facility failed to maintain a safe, sanitary, and comfortable environment, evidenced by rust and food buildup in microwaves.
Deficiencies (2)
Failure to ensure residents are free from significant medication errors; medications administered when diastolic blood pressure was below ordered parameters.
Failure to provide a safe, sanitary, and comfortable environment; rust and food buildup observed in 2 of 3 microwaves.
Report Facts
Dates medications administered below DBP parameter: 22
Number of microwaves observed: 3
Number of microwaves with deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Technician | Acknowledged administering medications outside ordered parameters |
| Staff B | Licensed Practical Nurse | Acknowledged rust areas in microwave |
| Director of Nursing Services | Unable to provide evidence resident was free from medication errors; acknowledged microwave deficiencies and replacement |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 13, 2023
Visit Reason
The inspection was conducted following a complaint related to a resident fall incident reported to the Rhode Island Department of Health on 3/22/2023.
Complaint Details
The visit was complaint-related due to a reported resident fall incident on 3/22/2023. The complaint was substantiated by findings that the resident's bed was not locked and could not be locked, contributing to the fall.
Findings
The facility failed to identify and mitigate accident hazards, specifically a resident's bed that could not be locked, contributing to a fall incident involving Resident ID #2 who has a history of falls and cognitive impairment.
Deficiencies (1)
Facility failed to ensure the nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents, specifically related to a bed that could not be locked.
Report Facts
Residents reviewed: 3
Residents affected: 1
Incident time: 1230
Incident date: Mar 22, 2023
MDS Mental Status Score: 7
Progress note date: Mar 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nursing Assistant | Interviewed regarding the resident's bed not being locked |
| Administrator | Interviewed and unable to provide evidence that the bed could be locked; revealed bed was taken out of service |
Inspection Report
Routine
Deficiencies: 3
Date: Oct 7, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to pressure ulcer care, medication storage and labeling, infection prevention and control, and proper use of personal protective equipment in the facility.
Findings
The facility was found deficient in providing appropriate pressure ulcer care for a resident with a stage 4 pressure ulcer, failed to properly store and label medications including insulin, and did not consistently follow infection prevention protocols including proper PPE use and blood glucose monitoring procedures.
Deficiencies (3)
Failed to ensure residents at risk for pressure ulcers receive necessary treatment and services to promote healing and prevent new ulcers, specifically for Resident ID #27.
Failed to store and label drugs and biologicals in accordance with professional principles, including leaving medication carts unlocked and insulin vials undated.
Failed to establish and maintain an infection prevention and control program, including improper glove use during blood glucose monitoring and improper PPE use by staff.
Report Facts
Residents reviewed for pressure ulcers: 3
Medication storage rooms reviewed: 2
Medication carts reviewed: 3
Units observed for PPE usage: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Acknowledged leaving medication cart unattended and unlocked, and improper glove use during blood glucose monitoring. |
| Staff C | Registered Nurse | Observed leaving medication cart unlocked and acknowledged improper mask use during dressing change. |
| Staff D | Housekeeper | Observed exiting COVID-19 positive resident's room wearing only a surgical mask and acknowledged removing PPE prematurely. |
| Corporate Compliance Officer | Provided expectations regarding weekly skin assessments, medication storage, and PPE use. |
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