Inspection Reports for Heatherwood Rehabilitation and Health Care Center
398 BELLEVUE AVENUE, RI, 02840
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Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 19, 2025
Visit Reason
A complaint survey was conducted at the Nursing Home on 03/19/2025 to determine compliance with 42 C.F.R. Part 483, requirements for Long Term Care Facilities.
Findings
No deficiencies were identified during the complaint survey.
Complaint Details
Complaint survey with ACTS reference numbers 99848 and 99930 was conducted; no deficiencies were found.
Inspection Report
Life Safety
Deficiencies: 0
Nov 28, 2023
Visit Reason
An off-site desk audit was conducted for the Life Safety Code Survey to verify correction of previously cited deficiencies.
Findings
The facility was found to be in compliance with all regulations surveyed for the Life Safety Code Survey after correction of sprinkler head replacement deficiencies.
Inspection Report
Renewal
Deficiencies: 0
Oct 16, 2023
Visit Reason
An off-site desk audit was conducted on October 16, 2023, for the Recertification Survey to verify correction of deficiencies cited on September 13, 2023.
Findings
Based on an acceptable plan of correction and supporting documentation, the Recertification Survey deficiencies have been corrected. The facility is in compliance with all regulations surveyed for the Recertification Survey.
Inspection Report
Complaint Investigation
Deficiencies: 10
Sep 13, 2023
Visit Reason
A recertification survey was conducted from 9/11/2023 through 9/13/2023 at Heatherwood Rehabilitation Health Care Center to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including investigation of alleged abuse, neglect, exploitation, or mistreatment.
Findings
The facility was found to have failed to ensure thorough investigation of alleged abuse involving a resident with bruising to the genital area attributed to a fall. Additional deficiencies were cited related to professional standards of care, pressure ulcer treatment, foot care, respiratory care, medication labeling and storage, food safety, and life safety code compliance.
Complaint Details
The visit was complaint-related involving allegations of abuse, neglect, exploitation, or mistreatment. The investigation found the facility failed to thoroughly investigate alleged abuse involving a resident with bruising to the genital area attributed to a fall.
Deficiencies (10)
| Description |
|---|
| Failed to ensure that all alleged violations of abuse were thoroughly investigated for 1 of 1 residents reviewed with bruising to genital area. |
| Failed to ensure services provided met professional standards of quality for 2 of 7 residents reviewed relative to physician orders. |
| Failed to provide necessary treatment and services to prevent pressure ulcers from developing or worsening for 2 of 5 residents reviewed. |
| Failed to provide proper foot care treatment for 2 of 8 residents reviewed. |
| Failed to ensure residents received necessary respiratory care and services for 1 of 5 residents reviewed. |
| Failed to ensure medication carts and rooms were properly labeled and stored according to accepted professional principles. |
| Failed to ensure dentures were obtained or provided for 1 of 1 residents reviewed for dental pain. |
| Failed to ensure food items were dated and discarded timely in kitchen and nourishment refrigerators. |
| Failed to maintain fire drills, fire extinguishers, and emergency power supply system in accordance with NFPA standards. |
| Failed to ensure oxygen cylinders were stored properly and oxygen medication rooms were audited for compliance. |
Report Facts
Residents reviewed for professional standards: 7
Residents reviewed for pressure ulcer treatment: 5
Residents reviewed for foot care: 8
Residents reviewed for respiratory care: 5
Residents reviewed for dental services: 1
Residents affected by sprinkler system deficiency: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Director of Nursing Services (DNS) | Named in relation to investigation of resident bruising and oversight of compliance |
Inspection Report
Follow-Up
Deficiencies: 0
Jun 30, 2022
Visit Reason
An off-site desk audit was conducted on June 30, 2022 for all previous deficiencies cited on June 8, 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
Complaint Investigation
Deficiencies: 6
Jun 8, 2022
Visit Reason
The inspection was a Recertification Survey, vaccination compliance, and complaint investigation survey conducted from 06/06/2022 through 06/08/2022 at Heatherwood Rehabilitation Health Care Center 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 employee immunization and screening, medication administration errors for residents, inadequate supervision related to smoking hazards, failure to maintain acceptable nutritional parameters, improper food safety practices, and infection control issues including failure to ensure staff COVID-19 vaccination and testing compliance.
Complaint Details
The survey included a complaint investigation related to vaccination compliance and medication administration. The complaint was substantiated as deficiencies were found in these areas.
Deficiencies (6)
| Description |
|---|
| Failure to obtain evidence of immunity for all health care workers related to immunization, testing, and health screening. |
| Facility failed to assure that services met professional standards of quality related to medication administration for 2 of 7 residents reviewed. |
| Facility failed to ensure adequate supervision to prevent smoking hazards for 5 of 6 residents reviewed. |
| Facility failed to maintain acceptable parameters of nutritional status for 1 of 6 residents reviewed. |
| Facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. |
| Facility failed to establish and maintain an infection prevention and control program including failure to ensure staff received COVID-19 booster vaccination and comply with testing requirements. |
Report Facts
Date survey completed: Jun 8, 2022
Residents reviewed for medication administration: 7
Residents with medication errors: 2
Residents reviewed for smoking supervision: 6
Residents with inadequate supervision for smoking: 5
Resident weight records reviewed: 6
Temperature of dishwasher sanitizing cycle: 150
Temperature of dishwasher rinse cycle: 180
Weight of Resident ID #33 for June: 188
COVID-19 total new cases per 100,000 in last 7 days: 253.2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Nurse Assistant | Named in immunization deficiency and COVID-19 testing and vaccination deficiencies |
| Staff N | Named in immunization deficiency | |
| Staff O | Per diem employee | Named in immunization deficiency |
| Staff P | Nurse Assistant | Named in COVID-19 testing deficiency |
| Staff A | Nurse Staff | Named in infection control and COVID-19 vaccination deficiency |
| Staff F | Food Service Director | Named in food safety deficiency |
| Director of Nursing | Director of Nursing | Responsible for ensuring ongoing compliance with medication administration, smoking supervision, weight audits, and infection control |
| Administrator | Administrator | Responsible for ensuring ongoing compliance with immunization, smoking supervision, and food safety |
| Infection Preventionist | Infection Preventionist | Interviewed regarding immunization and infection control deficiencies |
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