Inspection Reports for Royal of Westerly Nursing Center
79 BEACH STREET, RI, 02891
Back to Facility Profile
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 31, 2024
Visit Reason
An off-site desk audit was conducted to review all previous deficiencies cited on December 5, 2024.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 59
Capacity: 66
Deficiencies: 3
Dec 5, 2024
Visit Reason
A recertification and complaint survey was conducted from 12/1/2024 through 12/5/2024 to determine compliance with 42 C.F.R. Part 483 and other requirements for Long Term Care Facilities. Additionally, an Emergency Preparedness Survey was conducted on 12/2/2024.
Findings
Deficiencies were identified related to quality of care, medication administration, infection prevention and control, and drug regimen management. Plans of correction were submitted addressing notification of physicians, staff education, audits, and infection control procedures. The facility was found in compliance with Emergency Preparedness requirements.
Complaint Details
The survey included a complaint investigation under ACTS reference number 98144. Deficiencies were substantiated as a result of the complaint survey.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure a resident received treatment and care in accordance with professional standards, specifically regarding edema management and physician notification. | SS=D |
| Failure to ensure residents are free from any significant medication errors, including incorrect dosing of atorvastatin. | SS=D |
| Failure to establish and maintain an infection prevention and control program, including proper use of enhanced barrier precautions for residents with MDROs. | SS=D |
Report Facts
Deficiencies cited: 3
Resident pain levels: 8
Medication doses: 30
Survey dates: 5
Capacity: 66
Census: 59
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Counseled regarding contact precautions and observed wound dressing change |
| Staff B | Licensed Practical Nurse | Observed edema and unable to provide evidence physician was notified |
| Staff E | Director of Nursing Services | Acknowledged medication error and reviewed discharge paperwork |
| Staff F | Nursing Assistant | Revealed resident incontinence and need for assistance with ADL |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 4, 2024
Visit Reason
An off-site desk audit was conducted on March 4, 2024, to review all previous deficiencies cited on January 12 and January 17, 2024, based on acceptable plans of correction and supporting documentation.
Findings
The facility was found to be in compliance with all regulations surveyed, and the previously cited deficiencies have been corrected.
Inspection Report
Annual Inspection
Census: 66
Capacity: 66
Deficiencies: 7
Jan 12, 2024
Visit Reason
A Recertification Survey and complaint survey were conducted at Royal of Westerly Nursing Home from 01/09/2024 through 01/12/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey. Additionally, an annual Federal Life Safety Code survey was conducted on 01/17/2024.
Findings
Deficiencies were cited related to accounting and records of personal funds, pharmacy services including medication administration errors, labeling and storage of drugs and biologicals, and life safety code violations including exit signage, fire alarm system testing, and emergency power supply system maintenance. Plans of Correction (POCs) were provided for all deficiencies with specific corrective actions and completion dates.
Severity Breakdown
Level B: 1
Level D: 1
Level E: 2
Level F: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to provide quarterly statements for residents' personal funds for 5 of 5 residents reviewed. | Level B |
| Facility failed to provide routine medications to residents for 5 of 15 residents reviewed. | Level E |
| Facility failed to ensure residents are free of significant medication errors for 3 of 15 residents reviewed. | Level D |
| Facility failed to store and label drugs and biologicals properly in medication storage rooms and carts. | Level E |
| Exit signage was inadequate; facility lacked adequate exit signage in accordance with NFPA 101. | Level F |
| Fire alarm system testing and maintenance documentation was incomplete; annual battery discharge test not documented. | Level F |
| Emergency Power Supply System (EPSS) generator was not exercised under load as required; documentation incomplete. | Level F |
Report Facts
Residents reviewed for personal funds statements: 5
Residents reviewed for medication administration: 15
Residents reviewed for significant medication errors: 15
Facility capacity: 66
Residents census: 66
Medication audit frequency: 4
Fire alarm system inspection frequency: 12
Inspection Report
Renewal
Deficiencies: 0
Nov 30, 2022
Visit Reason
An off site desk review was conducted on November 30, 2022, for the deficiency identified during the November 3, 2022, Recertification/Licensure survey.
Findings
Based on an acceptable plan of correction with supporting documentation, the deficiency was determined to be corrected. The facility is in compliance with the 2012 Edition of NFPA 101 Federal Life Safety Code.
Inspection Report
Re-Inspection
Deficiencies: 5
Nov 2, 2022
Visit Reason
A Recertification Survey and complaint investigation were conducted at Royal of Westerly Nursing Center from 11/1/2022 through 11/3/2022 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 to be out of compliance with deficiencies cited related to accident hazards, respiratory care, life safety code violations including means of egress, emergency lighting, and fire drills. Corrective actions and plans of correction were detailed for each deficiency.
Complaint Details
The visit included a complaint investigation under ACTS Reference Number 87390.
Severity Breakdown
Level D: 4
Level F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure the resident environment remains free of accident hazards related to securing hazardous chemicals (Ajax Powder Cleanser). | Level D |
| Facility failed to provide respiratory care consistent with professional standards for 1 of 1 residents receiving oxygen therapy (Resident #28). | Level D |
| Facility failed to maintain means of egress free of all obstructions to full use in case of emergency. | Level D |
| Facility failed to maintain emergency lighting systems in accordance with NFPA 99 2012 Edition and NFPA 101 2012 Edition. | Level D |
| Facility failed to provide evidence that fire drills were conducted at varied times on each shift as required. | Level F |
Report Facts
Deficiencies cited: 5
Resident count affected: 1
Resident count affected: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Revealed Ajax is a cleaning product and cleaning products should be kept in a locked closet. |
| Director of Housekeeping | Stated that leaving Ajax Powder Cleanser in residents' bathroom could be dangerous and cleaning chemicals should be secured. | |
| Director of Nursing Services | Acknowledged Ajax Powder Cleanser should not be in residents' bathroom and oxygen orders reviewed and verified. | |
| Registered Nurse Staff B | Registered Nurse | Acknowledged physician's order failed to include oxygen flow rate. |
| Maintenance Director | Acknowledged combustible items stored in exit stairwell, emergency lighting repair, and fire drills not conducted at varied times. |
Loading inspection reports...
