Inspection Reports for Greenville Operations Ri LLC DBA Greenville Skilled Nursing and Rehabilitation
735 PUTNAM PIKE, RI, 02828
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 9, 2025
Visit Reason
An off-site desk audit was conducted on January 9, 2025, to verify correction of all previous deficiencies cited on December 5, 2024. Additionally, a revisit survey was conducted on January 8, 2025, for all previous deficiencies cited on December 3, 2024, related to the Life Safety Code survey.
Findings
All deficiencies from previous inspections have been corrected, and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 6
Dec 5, 2024
Visit Reason
A recertification and complaint survey was conducted at Greenville Skilled Nursing and Rehabilitation from 12/2/2024 through 12/5/2024 to determine compliance with Long Term Care Facilities regulations and emergency preparedness requirements.
Findings
Deficiencies were identified related to dialysis care, fluid intake monitoring, unnecessary drug administration, food preferences accommodation, food safety and sanitation, antibiotic stewardship, and life safety code compliance. The facility failed to ensure proper monitoring and documentation of residents' dialysis and fluid restrictions, drug regimens, food preferences, and antibiotic time-outs. Life safety code deficiencies were also noted regarding smoke door separations.
Complaint Details
The survey was complaint-related as indicated by the recertification and complaint survey reference number 98627. Specific complaint details are not explicitly stated, but deficiencies relate to dialysis care, drug regimen, food preferences, and infection control.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure residents receiving dialysis received services consistent with professional standards, including monitoring AVF for bruit and thrill and fluid intake documentation. |
| Facility failed to ensure residents' drug regimens were free from unnecessary drugs, including administration of Midodrine outside prescribed parameters. |
| Facility failed to accommodate residents' food preferences, serving eggs instead of pancakes as preferred. |
| Facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards, including accumulation of dirt and debris in kitchen areas. |
| Facility failed to establish an antibiotic stewardship program including monitoring antibiotic use and completing antibiotic time-outs. |
| Life Safety Code deficiency: Smoke door separating Daisy unit and main core had a gap greater than allowable clearance. |
Report Facts
Deficiency count: 6
Fluid restriction order: 1500
Medication dosage: 5
Blood pressure parameters: 90
Blood pressure parameters: 120
Audit frequency: 4
Audit frequency: 2
Residents affected: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Director of Nursing Services | Acknowledged resident was DNR and discussed dialysis communication binder and fluid intake monitoring |
| Staff A | Registered Nurse | Unable to provide evidence of fluid intake monitoring for Resident #32 |
| Staff B | Registered Nurse | Acknowledged Resident #11 was on fluid restriction but failed to provide documentation of fluid intake |
| Staff C | Registered Nurse | Acknowledged Midodrine should not have been administered outside blood pressure parameters |
| Regional Executive Chef | Regional Executive Chef | Acknowledged Resident #28 failed to receive meal as per meal ticket |
| Maintenance Director | Maintenance Director | Acknowledged smoke door gap greater than allowable clearance |
| Director of Nursing | Director of Nursing | Will oversee process for dialysis care and medication audits |
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 1, 2024
Visit Reason
A revisit survey was conducted on February 1, 2024, for all previous deficiencies cited on December 21, 2023, related to Re-certification/Licensure Life Safety Code survey.
Findings
The deficiencies have been corrected and no new noncompliance was identified. The facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 8
Dec 21, 2023
Visit Reason
A Recertification Survey was conducted at Greenville Skilled Nursing and Rehabilitation from 12/18/2023 through 12/21/2023 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
Deficiencies were cited related to safe/clean/homelike environment, baseline care planning, quality of care, medication labeling and storage, food safety, facility assessment, infection prevention and control, and life safety code compliance. Specific issues included failure to maintain a safe environment, incomplete baseline care plans for residents with MRSA and vascular wounds, inadequate toileting assistance, expired medications, food safety violations, incomplete facility-wide assessments, and fire safety deficiencies.
Severity Breakdown
D: 2
E: 5
F: 1
M: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to maintain a safe, clean, comfortable, and homelike environment including extension cords attached to air conditioners and peeling paint in common bathroom. | D |
| Failure to develop and implement baseline care plans within 48 hours of admission for residents with MRSA, vascular wounds, and condom catheter. | D |
| Failure to ensure residents receive necessary care and services to maintain highest practicable physical well-being related to toileting and incontinence care. | E |
| Failure to ensure medications are properly labeled, stored, and expired medications discarded. | E |
| Failure to ensure food safety requirements including cleanliness of kitchen equipment and proper food storage. | E |
| Failure to conduct and document facility-wide assessment to determine resources necessary to care for residents. | F |
| Failure to report promptly to the Rhode Island Department of Health cases of communicable diseases including RSV outbreak. | M |
| Life Safety Code deficiencies including inadequate exit signage, sprinkler system deficiencies, fire drills not conducted quarterly, and electrical system maintenance issues. | E |
Report Facts
Residents observed for quality of care: 7
Residents affected by sprinkler system deficiency: 82
Expired medication carts observed: 2
Expired medication rooms observed: 3
Residents identified with cough and congestion: 11
Residents on droplet precautions: 8
Residents observed with infection prevention issues: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Maintenance Director | Named in relation to monitoring exit signage, sprinkler system, and oxygen storage compliance |
| Director of Nursing | Director of Nursing | Acknowledged resident care plan issues and oversaw corrective actions for care and infection control |
| Interim Administrator | Interim Administrator | Acknowledged findings related to facility environment and sprinkler system |
| Infection Preventionist | Infection Preventionist | Reported unawareness of respiratory illness outbreak and testing deficiencies |
Inspection Report
Follow-Up
Deficiencies: 0
Dec 6, 2022
Visit Reason
A follow-up to a previous complaint investigation survey was conducted at this facility.
Findings
All previous deficiencies were corrected and no new deficiencies were identified.
Inspection Report
Annual Inspection
Census: 94
Deficiencies: 15
Oct 27, 2022
Visit Reason
The annual Federal Life Safety Code survey was conducted by the State Survey Agency pursuant to the National Fire Protection Association 101 Life Safety Code, 2012 Edition, and a Recertification and Complaints Investigation Survey was conducted from 10/24/2022 to 10/28/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
Deficiencies were identified related to Life Safety Code including failure to maintain HVAC fire dampers, conduct fire drills, and maintain emergency power systems. The complaint investigation found immediate jeopardy related to infection control measures during a COVID-19 outbreak, and multiple deficiencies in care plans, quality of care, accident prevention, medication administration, infection control, and other regulatory requirements.
Complaint Details
The complaint investigation found immediate jeopardy related to failure to implement infection control measures to prevent spread of COVID-19 during an outbreak starting 10/20/2022, involving 7 residents, 2 staff, and 1 visitor. The facility submitted a Removal Plan and corrective action plan including staff education. Additional deficiencies were cited related to care plans, medication administration, accident prevention, and infection control.
Deficiencies (15)
| Description |
|---|
| Facility failed to provide evidence that HVAC fire dampers were maintained as required. |
| Facility failed to provide evidence that fire drills were conducted quarterly as required. |
| Facility failed to provide proper documentation for Emergency Power Supply System generator maintenance and testing. |
| Facility failed to meet professional standards of quality related to comprehensive care plans and services provided. |
| Facility failed to ensure residents received treatment and care in accordance with professional standards. |
| Facility failed to ensure a resident's skin integrity and wound management were properly addressed. |
| Facility failed to ensure residents environment remained free from accident hazards in secured memory care unit. |
| Facility failed to ensure proper disposal of disposable razors in secured memory unit. |
| Facility failed to ensure residents received appropriate enteral nutrition and medication administration via feeding tube. |
| Facility failed to ensure residents received dialysis services consistent with professional standards. |
| Facility failed to ensure residents with medication orders received medications as prescribed and medication administration was properly performed. |
| Facility failed to ensure proper storage and labeling of drugs and biologicals. |
| Facility failed to ensure residents' medication carts were properly maintained and labeled. |
| Facility failed to ensure infection prevention and control program was established and maintained, including COVID-19 precautions. |
| Facility failed to ensure antibiotic stewardship program was established and maintained. |
Report Facts
Residents affected by HVAC fire damper deficiency: 94
Fire drills documented: 3
Residents in facility: 94
COVID-19 cases: 7
Staff COVID-19 cases: 2
Visitor COVID-19 cases: 1
Residents affected by accident hazards: 3
Residents reviewed for quality of care: 1
Residents reviewed for accident hazards: 31
Residents reviewed for medication administration: 6
Residents reviewed for dialysis: 1
Residents reviewed for food and drink: 2
Residents reviewed for infection control: 94
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kile Claire J. Tamburri Moran | NHA | Signed the plan of correction documents |
| Senior Maintenance Director | Acknowledged deficiencies and responsible for oversight of corrections related to fire safety and HVAC maintenance | |
| Staff A | Nursing Assistant | Observed applying ointment to resident rash and interviewed regarding care |
| Staff B | Licensed Practical Nurse | Observed administering medications and interviewed regarding medication administration |
| Staff C | Nurse Practitioner | Authored progress notes and interviewed regarding resident care |
| Staff D | Regional Nurse | Interviewed regarding physician orders and treatment expectations |
| Staff E | Nursing Assistant | Interviewed regarding resident feeding and care |
| Staff F | Licensed Practical Nurse | Interviewed regarding medication storage and administration |
| Staff J | Infection Control Nurse | Observed infection control practices and interviewed regarding COVID-19 protocols |
| Staff K | Licensed Practical Nurse | Observed infection control and medication administration practices |
| Administrator | Interviewed regarding infection control and facility compliance | |
| Unit Manager (UM) | Responsible for auditing and re-education related to multiple deficiencies | |
| Director of Nursing (DON) | Responsible for auditing and re-education related to multiple deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 8
Jul 29, 2021
Visit Reason
The annual Federal Life Safety Code survey was conducted by the State Survey Agency to determine compliance with the National Fire Protection Association 101 Life Safety Code, 2012 Edition, and a Recertification Survey was conducted to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness.
Findings
Life safety code deficiencies related to utilities - gas and electric were identified, including failure to maintain natural gas fueled boilers in accordance with NFPA codes. Additional deficiencies were found related to residents' rights to refuse treatment, safe environment, comprehensive care plans, labeling and storage of drugs, and smoking policy enforcement. Corrective actions and system changes were planned or implemented for all deficiencies.
Deficiencies (8)
| Description |
|---|
| Facility failed to maintain natural gas fueled boilers in accordance with NFPA 1, NFPA 101 and NFPA 54. |
| Facility failed to ensure all residents have an opportunity to formulate an advanced directive and ensure consistency between medical records and advance directives. |
| Facility failed to provide a safe, clean, comfortable, homelike environment relative to two of four shower rooms. |
| Facility failed to meet professional standards of quality related to weights for 2 of 8 sample residents. |
| Facility failed to provide necessary services to dependent residents unable to carry out activities of daily living relative to nail care. |
| Facility failed to ensure adequate supervision and assistance devices to prevent accidents for one resident. |
| Facility failed to ensure adequate supervision to prevent accidents related to smoking for one resident. |
| Facility failed to ensure proper labeling and storage of drugs and biologicals in locked compartments with authorized access. |
Report Facts
Deficiencies cited: 8
Sample residents reviewed: 33
Sample residents reviewed: 8
Sample residents reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Toni A. Pendleton | CED | Signed as Laboratory Director or Provider/Supplier Representative on multiple pages |
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