Inspection Report
Plan of Correction
Deficiencies: 0
Jan 14, 2025
Visit Reason
An off-site desk audit was conducted on January 14, 2025, to review all previous deficiencies cited on December 10 and 12, 2024, and to verify the facility's compliance based on the submitted plan of correction and supporting documentation.
Findings
All previously cited deficiencies have been corrected, and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 89
Capacity: 154
Deficiencies: 5
Dec 12, 2024
Visit Reason
An off-hour recertification and complaint survey was conducted to determine compliance with 42 C.F.R. Part 483 requirements for Long Term Care Facilities, including a state licensure and emergency preparedness survey.
Findings
Deficiencies were identified related to accuracy of assessments, professional standards of care, increase/prevent decrease in range of motion/mobility, dialysis care, and life safety code compliance including fire drills and electrical systems. The facility failed to accurately reflect a resident's fall injury in assessments, ensure orthostatic blood pressure monitoring, prevent contractures, monitor fluid restrictions, and maintain emergency power and fire safety systems.
Complaint Details
The survey was an off-hour recertification and complaint survey (ACTS reference number 93898) conducted to investigate allegations related to resident falls, treatment standards, and care practices. Findings included inaccurate assessments of a resident's fall injury and failure to meet professional standards in care.
Severity Breakdown
SS=D: 2
SS=E: 2
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure assessments accurately reflected resident status related to a fall with injury. | SS=D |
| Facility failed to ensure residents received treatment and care in accordance with professional standards for orthostatic blood pressure monitoring. | SS=D |
| Facility failed to ensure residents with limited range of motion received appropriate treatment and services to prevent further decrease in ROM. | SS=E |
| Facility failed to ensure residents requiring dialysis received care consistent with professional standards. | SS=E |
| Facility failed to provide evidence of compliance with emergency preparedness and life safety code requirements including fire drills and electrical system maintenance. | SS=F |
Report Facts
Capacity: 154
Census: 89
Deficiencies cited: 5
Fire drills conducted: 8
Resident MDS Assessment Scores: 14
Resident MDS Assessment Scores: 10
Resident MDS Assessment Scores: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Interviewed regarding resident fall and MDS assessment |
| Staff B | Nurse Practitioner | Interviewed regarding orthostatic blood pressure orders |
| Staff C | Licensed Practical Nurse | Interviewed regarding application of treatment devices |
| Staff D | Activities Aide | Observed providing coffee to resident with fluid restriction |
| Staff F | Unit Manager | Interviewed regarding monitoring of resident fluid intake |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding care standards and treatment compliance |
| Administrator | Administrator | Interviewed regarding fire drills and facility compliance |
| Director of Maintenance | Director of Maintenance | Interviewed regarding fire drills and emergency power system maintenance |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 5, 2024
Visit Reason
An off-site desk audit was conducted on January 5, 2024, to review all previous deficiencies cited in December 2023 and verify correction.
Findings
Based on an acceptable plan of correction and supporting documentation, all previously cited deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 11
Dec 12, 2023
Visit Reason
A Recertification Survey and Complaint/Incident Investigation Survey was conducted at Pawtucket Falls Healthcare Center from 12/11/2023 through 12/13/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness surveys.
Findings
Deficiencies were cited related to failure to protect identifying information of residents, failure to revise comprehensive care plans timely, failure to provide necessary treatment and services to prevent pressure ulcers, failure to provide appropriate bowel/bladder incontinence care and catheter care, failure to provide respiratory care consistent with professional standards, failure to provide trauma-informed care, failure to ensure drug regimen free from unnecessary drugs, failure to maintain fire alarm and sprinkler systems, failure to conduct fire drills properly, and failure to properly label and store drugs and biologics.
Complaint Details
The visit was a complaint/incident investigation survey combined with recertification and emergency preparedness surveys. Deficiencies were cited as a result of the complaint investigation and survey findings.
Deficiencies (11)
| Description |
|---|
| Facility failed to protect identifying information for 13 residents listed in the survey results binder. |
| Facility failed to ensure comprehensive care plans were revised by the interdisciplinary team for 3 of 6 residents reviewed. |
| Facility failed to provide necessary treatment and services to prevent pressure ulcers for 1 resident with an actual pressure injury. |
| Facility failed to provide appropriate treatment and services for bowel/bladder incontinence and catheter care for 4 of 4 residents reviewed with catheters. |
| Facility failed to provide respiratory care consistent with professional standards for 1 of 3 residents reviewed for oxygen therapy. |
| Facility failed to ensure residents who are trauma survivors receive culturally competent, trauma-informed care for 10 of 15 residents reviewed. |
| Facility failed to ensure drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for blood pressure medications. |
| Facility failed to maintain fire alarm system in accordance with NFPA 101 Life Safety Code 2012 Edition. |
| Facility failed to maintain sprinkler system in accordance with NFPA 101 Life Safety Code 2012 Edition. |
| Facility failed to conduct fire drills in accordance with NFPA 101 Life Safety Code 2012 Edition. |
| Facility failed to properly label and store drugs and biologics in accordance with professional standards and regulations. |
Report Facts
Residents with identifying information not protected: 13
Residents with care plan revision deficiencies: 3
Residents with pressure ulcer treatment deficiency: 1
Residents with catheter care deficiencies: 4
Residents with respiratory care deficiency: 1
Residents with trauma-informed care deficiency: 10
Residents with unnecessary drug regimen: 1
Residents affected by fire alarm system deficiency: 61
Residents affected by sprinkler system deficiency: 61
Residents affected by fire drill deficiency: 61
Inspection Report
Follow-Up
Deficiencies: 0
Mar 21, 2023
Visit Reason
A follow-up to a previous re-certification/State Licensure survey was conducted at this facility to verify correction of prior deficiencies.
Findings
All previous deficiencies were corrected on this second revisit and no new deficiencies were identified.
Inspection Report
Follow-Up
Deficiencies: 1
Mar 10, 2023
Visit Reason
A follow-up to a previous recertification and complaint investigation survey was conducted to verify correction of prior deficiencies related to food procurement, storage, preparation, and sanitary practices.
Findings
The facility was found to have previously failed to ensure food was stored covered or tightly wrapped to prevent contamination. Immediate corrective actions were taken, including removal of uncovered food items, staff education, and implementation of audits to ensure compliance with food safety standards.
Complaint Details
This visit was a follow-up to a complaint investigation. The complaint was substantiated as deficiencies were found and corrected during the follow-up survey.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Food procurement, store, prepare, serve-sanitary practices were not met, including uncovered food items in the refrigerator. | F |
Report Facts
Date of survey completion: Mar 10, 2023
Plan of Correction completion date: Mar 15, 2023
Number of uncovered dishes observed: 14
Distance to dining room: 150
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Named in education and audit process related to food safety deficiency | |
| Administrator | Acknowledged food storage issues during surveyor interview | |
| Regional Nurse | Acknowledged food storage issues during surveyor interview |
Inspection Report
Life Safety
Deficiencies: 0
Dec 22, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction related to a life safety code survey conducted at Pawtucket Falls Healthcare Center.
Findings
Based on an acceptable Plan of Correction with supporting documentation, it was determined that compliance with NFPA 101, 2012 Edition of the Federal Life Safety Code has been achieved.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 9, 2021
Visit Reason
An off-site desk audit was conducted on December 9, 2021, to review all previous deficiencies cited on November 18, 2021.
Findings
Based on an acceptable plan of correction, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 11
Nov 18, 2021
Visit Reason
A Recertification Survey and Complaint/Incident Investigation Survey were conducted at Pawtucket Falls Healthcare Center from 11/15/2021 through 11/18/2021 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey.
Findings
The facility was found not in compliance with requirements related to advance directives, comprehensive care plans, nutrition and hydration, respiratory care, nursing services, medication management, food safety, resident records, and life safety code deficiencies. Corrective actions and plans of correction were provided for multiple deficiencies.
Complaint Details
The visit included a complaint/incident investigation with reference numbers 82328, 81890, 82435, and 82413. The facility was found not in compliance with advance directives and other care standards as a result of the complaint investigation.
Severity Breakdown
SS=E: 5
SS=D: 3
SS=F: 3
Deficiencies (11)
| Description | Severity |
|---|---|
| Facility failed to ensure that a resident's code status was consistent with medical record and physician's orders for 6 of 24 residents reviewed. | SS=E |
| Facility failed to provide services meeting professional standards of quality for 1 of 5 residents relative to hypoglycemic protocol. | SS=D |
| Facility failed to maintain acceptable parameters of nutritional status for 2 of 5 residents reviewed. | SS=E |
| Facility failed to provide respiratory care consistent with professional standards for 2 of 7 residents receiving respiratory care. | SS=D |
| Facility failed to ensure sufficient nursing staff competencies and skills sets to provide nursing and related services. | SS=F |
| Facility failed to complete regular in-service education for nurse aides. | SS=F |
| Facility failed to ensure drug regimen free from unnecessary drugs for 1 of 11 residents reviewed. | SS=E |
| Facility failed to properly store medications with expired and undated items in medication carts. | SS=E |
| Facility failed to ensure food safety requirements related to storage, preparation, and serving of food. | SS=F |
| Facility failed to maintain resident records complete, accurate, and systematically organized for 3 of 18 residents reviewed. | SS=E |
| Facility failed to maintain emergency lighting and battery-powered emergency lighting in generator room. | SS=D |
Report Facts
Residents reviewed for advance directives: 24
Residents reviewed for hypoglycemic protocol: 5
Residents reviewed for nutritional status: 5
Residents reviewed for respiratory care: 7
Residents reviewed for drug regimen: 11
Residents reviewed for medication storage: 2
Residents reviewed for resident records: 18
Residents reviewed for weight monitoring: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Catherine Donnelly | Administrator | Signed multiple pages of the plan of correction and corrective actions |
| Staff Nurse B | Mentioned in physician note regarding resident hypoglycemia | |
| Director of Nursing Services | Interviewed regarding advance directives and oxygen administration | |
| Staff Nurse C | Acknowledged medication storage issues during surveyor interview | |
| Staff Nurse D | Acknowledged medication storage issues during surveyor interview | |
| Staff Nurse E | Observed medication storage issues during surveyor interview | |
| Education Coordinator | Interviewed regarding nurse aide competency and in-service education | |
| Dietitian | Interviewed regarding weight monitoring and nutritional assessments | |
| Maintenance Director | Interviewed regarding emergency lighting and portable space heaters | |
| Food Service Director | Interviewed regarding food safety and storage deficiencies | |
| Staff F | Observed not wearing left hand palm protector during survey | |
| Staff G | Acknowledged lack of competency/skill checks for special treatments |
Report
File
PAWTUCKET FALLS HEALTHCARE CENTER POC, EXIT DATE 01-23-2023.pdf
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