Inspection Reports for Mount St Rita Health Centre
15 SUMNER BROWN ROAD, RI, 02864
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
144% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
79% occupied
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Nov 6, 2024
Visit Reason
An off-site desk audit was conducted on November 6, 2024, to review all previous deficiencies cited on September 26, 2024.
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: 77
Capacity: 98
Deficiencies: 5
Sep 26, 2024
Visit Reason
A recertification survey was conducted from 9/23/2024 through 9/26/2024 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 professional standards of care, comprehensive care plans, notification of changes in condition, pressure ulcer treatment, medication storage and labeling, and infection prevention and control. The facility failed to ensure residents received appropriate treatment and care consistent with professional standards.
Deficiencies (5)
| Description |
|---|
| Failure to ensure residents receive treatment and care in accordance with professional standards related to the use of a wanderguard bracelet for one resident. |
| Failure to notify physician and resident representative timely of changes in condition for a resident with edema. |
| Failure to ensure a resident with a pressure ulcer received necessary treatment and services to prevent new ulcers and promote healing. |
| Failure to store and label drugs and biologicals in accordance with professional standards, including expired medications and accumulation of ice in medication freezers. |
| Failure to establish an infection prevention and control program including antibiotic stewardship and monitoring antibiotic use for residents. |
Report Facts
Deficiencies cited: 5
Resident count: 77
Facility capacity: 98
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 6, 2023
Visit Reason
A revisit survey was conducted on December 6, 2023, for all previous deficiencies cited on October 24, 2023, related to the 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
Plan of Correction
Census: 72
Capacity: 98
Deficiencies: 14
Oct 25, 2023
Visit Reason
A Recertification survey and complaint investigation were conducted at Mount St Rita Health Centre from 10/23/2023 through 10/25/2023 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 personal privacy/confidentiality of records, services provided meeting professional standards, quality of care, tube feeding management, trauma informed care, pain management, infection prevention and control, food procurement and safety, and life safety code violations including emergency lighting, fire alarm system, sprinkler system, and electrical systems.
Deficiencies (14)
| Description |
|---|
| Failure to respect residents' right to personal privacy during wound dressing changes and insulin administration. |
| Failure to meet professional standards of quality related to use and monitoring of air mattresses for residents. |
| Failure to ensure residents receive wound care according to physician's orders. |
| Failure to ensure residents fed through feeding tubes receive appropriate treatment and services to prevent complications. |
| Failure to ensure pain management is provided consistent with professional standards and resident needs. |
| Failure to provide trauma informed care to residents with history of trauma and post-traumatic stress. |
| Failure to establish and maintain an infection prevention and control program including hand hygiene and transmission-based precautions. |
| Failure to ensure food safety requirements are met including proper storage, labeling, and sanitation. |
| Failure to maintain continuous emergency lighting in accordance with NFPA 101 Life Safety Code. |
| Failure to maintain fire alarm system and ensure proper notification and maintenance. |
| Failure to maintain automatic sprinkler system and perform required testing and maintenance. |
| Failure to maintain emergency power supply system and perform required testing and maintenance. |
| Failure to maintain exit signage and ensure illumination in event of power loss. |
| Failure to maintain and test fire alarm notification devices and visual alarms. |
Report Facts
Capacity: 98
Census: 72
Residents affected: 72
Residents affected: 72
Residents affected: 72
Residents affected: 72
Residents affected: 72
Deficiencies cited: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse | Observed performing dressing change compromising resident privacy |
| Staff C | Licensed Practical Nurse | Observed administering insulin and G-tube feedings without proper privacy or documentation |
| Staff D | Licensed Practical Nurse | Unable to explain air mattress settings and failed to perform hand hygiene and wound dressing properly |
| Staff E | Registered Nurse | Unaware of air mattress settings and unable to provide education or competency |
| Director of Nursing Services | Interviewed regarding privacy expectations, wound care, infection control, and competency monitoring | |
| Staff F | Nursing Assistant | Observed during resident behavioral incidents and care |
| Staff G | Reported resident behaviors and care plan awareness | |
| Staff H | Registered Nurse | Administered medications and reported on resident behaviors |
| Food Safety Director | FSD | Interviewed regarding food safety and kitchen observations |
| Maintenance Director | Interviewed regarding emergency lighting and air mattress maintenance |
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 24, 2022
Visit Reason
An off-site desk audit was conducted on August 24, 2022, to review all previous deficiencies cited on July 14, 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
Re-Inspection
Deficiencies: 7
Jul 14, 2022
Visit Reason
A Recertification Survey was conducted at Mount St Rita Health Centre from 07/11/2022 through 07/14/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
The facility was determined not to be in compliance with professional standards of quality for comprehensive care plans, medication administration, skin integrity, parenteral/IV fluids, laboratory services, food safety, infection control, and employee immunization and screening. Plans of correction were submitted addressing these deficiencies.
Deficiencies (7)
| Description |
|---|
| Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i) - Facility failed to ensure services met professional standards of quality for 1 of 2 residents reviewed for wounds and 1 of 5 residents reviewed for medication administration. |
| Treatment/Services to Prevent/Heal Pressure Ulcers CFR(s): 483.25(b)(1)(i)(ii) - Facility failed to ensure a resident received care to prevent new pressure ulcers and promote healing for 1 of 6 residents reviewed for pressure ulcers. |
| Parenteral/IV Fluids CFR(s): 483.25(h) - Facility failed to ensure parenteral fluids were administered consistent with professional standards of practice for 1 of 1 resident observed receiving parenteral medication. |
| Laboratory Services CFR(s): 483.50(a)(1)(i) - Facility failed to obtain laboratory services to meet the needs of 1 of 1 resident reviewed for Warfarin therapy. |
| Food Safety Requirements CFR(s): 483.60(i)(1)(2) - Facility failed to store food in the main kitchen in accordance with professional standards for food service safety. |
| Infection Control CFR(s): 483.80(a)(1)(2)(4)(e)(f) - Facility failed to ensure infection prevention and control program was effective to prevent transmission of communicable diseases for 2 of 2 residents observed relative to blood glucose monitoring. |
| Personnel Immunization & Screening - Facility failed to obtain evidence of immunity for all health care workers in accordance with rules and regulations for 4 of 9 sample staff reviewed. |
Report Facts
Deficiencies cited: 7
Survey dates: 4
Inspection Report
Complaint Investigation
Deficiencies: 7
May 6, 2021
Visit Reason
A Recertification and Complaints Investigation Survey was conducted from 05/02/2021 through 05/06/2021 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
The survey identified an Immediate Jeopardy related to failure to ensure appropriate treatment and services for a resident with suicidal ideation. The facility submitted an immediate plan of correction and removed the Immediate Jeopardy by 05/06/2021. Additional deficiencies were cited related to financial security, notification of changes, baseline care plans, accident hazards, behavioral health services, and treatment of mental/psychosocial concerns.
Complaint Details
The visit was complaint-related, triggered by concerns about a resident with suicidal ideation who was not properly supervised or provided appropriate care. The Immediate Jeopardy was removed after the facility implemented corrective actions including staff education and care plan revisions.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure a resident with suicidal ideation received appropriate treatment and services, constituting Immediate Jeopardy under 42 CFR 483.40 F742. | Immediate Jeopardy |
| Failure to purchase a surety bond or provide assurance for security of all personal funds of residents. | — |
| Failure to notify resident's physician and representative of significant change in mental status. | — |
| Failure to develop and revise baseline care plan for resident with suicidal ideation. | — |
| Failure to ensure adequate supervision to prevent accidents for resident with suicidal ideation. | — |
| Failure to ensure each resident receives necessary behavioral health services. | — |
| Failure to provide appropriate treatment and services to resident with mental disorder or psychosocial adjustment difficulty. | — |
Report Facts
Surety bond amount: 30000
Account balance: 63291.03
Account balance: 34574.11
Account balance: 33795.58
Dates of survey: Survey conducted from 05/02/2021 through 05/06/2021.
Loading inspection reports...
