Inspection Reports for Steere House Nursing & Rehabilitation Center
RI, 02903
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
159% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
93% occupied
Based on a November 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 26, 2024
Visit Reason
A follow-up to a previous recertification survey was conducted at the facility on 11/26/2024.
Findings
All previous deficiencies were corrected and no new deficiencies were identified during this follow-up survey.
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Nov 4, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication storage, food preparation for residents with special diets, infection prevention and control, and overall resident safety and care at Steere House Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including improper medication storage with expired drugs not discarded, failure to provide food prepared according to individual dietary needs for residents on ground texture diets, inadequate infection prevention and control practices including failure to place a resident with MDRO on appropriate precautions and improper cleaning of BIPAP equipment, and failure to maintain proper hand hygiene during meal service.
Deficiencies (3)
Failure to store drugs and biologicals in accordance with professional principles; expired medications found in medication rooms and carts, and medications left unattended at resident bedside without proper orders or assessments.
Failure to provide and prepare food in a form designed to meet individual needs for residents with physician-ordered ground texture diets, including serving inappropriate foods such as garlic bread and whole toast, and failure to cut food into bite-sized pieces.
Failure to maintain an infection prevention and control program, including not placing a resident with ESBL infection on Enhanced Barrier Precautions, failure to properly clean BIPAP equipment per manufacturer's instructions, and failure to perform proper hand hygiene during meal service.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 3
Brief Interview of Mental Status (BIMS) score: 12
Brief Interview of Mental Status (BIMS) score: 9
Brief Interview of Mental Status (BIMS) score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Practical Nurse | Acknowledged expired Lorazepam and lack of precautions for Resident ID #27 |
| Staff M | Certified Medication Technician | Acknowledged expired eye drops on medication cart |
| Staff B | Certified Medication Technician | Unable to provide evidence of eye drop opening date |
| Staff N | Registered Nurse | Acknowledged medications left at resident bedside without orders |
| Staff D | Certified Medication Technician | Removed inappropriate food and acknowledged error in serving ground diet residents |
| Staff E | Dietary Aide | Unaware of proper food for ground diet residents |
| Staff F | Licensed Practical Nurse | Acknowledged ground diet residents should not be served garlic bread |
| Staff G | Cook | Acknowledged serving inappropriate foods to ground diet residents |
| Staff H | Nursing Assistant | Unaware of residents' diet orders |
| Staff I | Nursing Assistant | Unaware of menu requirements for ground diet residents |
| Staff J | Nursing Assistant | Acknowledged serving toasted bread to ground diet resident |
| Staff K | Nursing Assistant | Unaware if resident could have toast |
| Staff L | Registered Nurse | Acknowledged resident on ground diet was served toasted bread |
| Staff P | Dietary Aide | Observed failing to change gloves after phone use before handling food |
| Director of Nursing Services | Unable to explain medication and diet deficiencies; acknowledged no cleaning order for BIPAP | |
| Food Service Director | Acknowledged errors in food service and glove use | |
| Speech Language Pathologist | Provided input on diet texture and food preparation | |
| Medical Director | Provided expectations for diet and food service | |
| Infection Preventionist | Acknowledged lack of precautions for ESBL resident |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 120
Deficiencies: 7
Date: Nov 4, 2024
Visit Reason
A federal recertification survey and complaint investigation survey was conducted from 10/28/2024 through 11/4/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Complaint Details
The visit was complaint-related and included a federal recertification survey. Immediate Jeopardy was identified and a Partial Extended Survey was initiated. The Immediate Jeopardy was removed as of 11/1/2024 after the facility implemented corrective actions.
Findings
The survey identified Immediate Jeopardy related to failure to provide and prepare food in a form designed to meet individual needs for a resident with a physician's order for a ground texture diet. Additional deficiencies were found related to medication storage and labeling, medication administration, food preparation, infection control, and emergency preparedness. The facility implemented a plan of correction and the Immediate Jeopardy was removed as of 11/1/2024.
Deficiencies (7)
Failure to provide and prepare food in a form designed to meet individual needs relative to a physician's order for a ground texture diet for Resident #58.
Failure to store drugs and biologicals properly in locked compartments and maintain medication safety including expired medications found at bedside.
Failure to ensure medications were properly discarded and self-administration assessments completed.
Failure to provide and prepare food to meet individual needs for residents on ground texture diets, including serving inappropriate foods such as garlic bread and uncut pieces.
Failure to maintain infection prevention and control program, including failure to follow Enhanced Barrier Precautions for residents with MDRO infections and failure to clean BIPAP machines properly.
Failure to ensure proper hand hygiene and food handling by staff during meal service.
No Life Safety Code deficiencies identified; facility in compliance with all regulations surveyed.
Report Facts
Deficiencies cited: 6
Capacity: 120
Census: 111
BIMS score: 12
BIMS score: 9
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 30, 2024
Visit Reason
The inspection was conducted following complaints and incidents involving resident-to-resident physical abuse, failure to develop a comprehensive care plan for a urinary tract infection, and inadequate supervision leading to an elopement and injury of a resident.
Complaint Details
The complaint investigation was substantiated for resident-to-resident abuse where Resident ID #3 admitted to hitting Resident ID #2 with a trash can causing injury. Additionally, a complaint regarding inadequate supervision was substantiated when Resident ID #1 wheeled out of the facility unsupervised, fell, and sustained injuries.
Findings
The facility failed to protect residents from physical abuse, as substantiated by an incident where Resident ID #3 hit Resident ID #2 with a trash can causing injury. The facility also failed to develop and implement a care plan for a resident's urinary tract infection and failed to provide adequate supervision to prevent an elopement and injury of another resident.
Deficiencies (3)
Failed to protect residents from physical abuse resulting in actual harm to Resident ID #2.
Failed to develop and implement a comprehensive care plan for a urinary tract infection for Resident ID #1.
Failed to ensure adequate supervision to prevent an accident resulting in actual harm to Resident ID #1 due to elopement and fall.
Report Facts
Wound size: 1.7
Wound size: 1.4
Duration of wound treatment: 31
Room changes: 7
BIMS score: 9
BIMS score: 14
BIMS score: 4
Blood pressure: 210
Blood pressure: 94
Medication dosage: 500
Medication duration: 7
Tylenol dosage: 1000
Tylenol as needed dosage: 1000
Wheelchair mobility distance: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Authored progress note documenting Resident ID #2's injury and interview during survey |
| Staff B | Nursing Assistant | Witnessed Resident ID #1 wheel out of the facility and fall from wheelchair |
| Staff C | Registered Nurse | Authored Elopement Risk Evaluation for Resident ID #1 |
| Staff D | Minimum Data Set Coordinator | Acknowledged failure to update care plan for Resident ID #1's UTI |
| Director of Nursing Services | Interviewed regarding failure to provide evidence of protection from abuse and adequate supervision |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 5, 2024
Visit Reason
An off-site desk audit was conducted on January 5, 2024, to review all previous deficiencies cited on November 30, 2023.
Findings
Based on an acceptable plan of correction and supporting documentation, all previously cited deficiencies have been corrected. The facility is in compliance with all regulations surveyed.
Inspection Report
Routine
Deficiencies: 2
Date: Nov 30, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with nursing competencies related to hydrocollator use, infection prevention and control practices, and safe and sanitary environment standards.
Findings
The facility failed to ensure nurses had appropriate competencies for hydrocollator use, resulting in a resident burn. Additionally, infection control deficiencies were found related to improper disinfection of glucometers and inadequate hand hygiene during wound dressing changes.
Deficiencies (2)
Failure to ensure licensed nurses have the specific skill sets necessary to safely use hydrocollator treatments, resulting in a burn to one resident.
Failure to provide and implement an infection prevention and control program, including improper disinfection of glucometers and inadequate hand hygiene during wound dressing changes.
Report Facts
Resident burn wound size: 5
Resident burn wound size: 3
Blood sugar monitoring frequency: 4
Blood sugar monitoring frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Physical Therapist | Interviewed regarding hydrocollator treatment procedures and nurse training |
| Staff B | Licensed Practical Nurse | Applied hydrocollator HotPac multiple times; acknowledged not disinfecting glucometer between uses; admitted not monitoring resident during hydrocollator treatment |
| Staff C | Registered Nurse | Applied hydrocollator HotPac multiple times; acknowledged lack of formal education on hydrocollator use and not monitoring resident during treatment |
| Staff D | Licensed Practical Nurse | Educated some nurses on hydrocollator use; observed failing to perform hand hygiene during wound dressing change |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding hydrocollator use, nursing competencies, and infection control practices; unable to provide evidence of proper training or policy compliance |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Nov 30, 2023
Visit Reason
A Recertification and Complaint Investigation Survey was conducted from 11/27/2023 through 11/30/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a state licensure and emergency preparedness survey.
Complaint Details
The visit was complaint-related as part of a Recertification and Complaint Investigation Survey with ACTS Reference Numbers 92929, 93196, 93218, 93226. The complaint involved concerns about nursing staff competency and resident safety related to the use of hydrocollator heating packs.
Findings
Deficiencies were cited related to nursing staff competencies in the use of hydrocollator heating packs resulting in a resident burn, and infection control failures related to cleaning and disinfecting glucometers and dressing change procedures. Additionally, life safety code deficiencies were identified involving emergency lighting and fire alarm system maintenance.
Deficiencies (4)
The facility failed to ensure all licensed nurses had the specific competencies necessary to care for residents, evidenced by a burn injury to Resident #21 due to improper use of hydrocollator heating packs.
The facility failed to establish and maintain an infection prevention and control program, including failure to properly clean and disinfect glucometers and maintain sanitary conditions during dressing changes for residents.
The facility failed to maintain emergency lighting systems in accordance with NFPA 101 Life Safety Code, including failure to install a battery backup emergency lighting unit in the basement electrical room.
The facility failed to ensure the fire alarm system was maintained and tested, including failure to complete an annual battery discharge test for the Fire Alarm Control Panel.
Report Facts
Deficiencies cited: 4
Resident ID: 21
Survey dates: 11/27/2023 through 11/30/2023
Blood sugar monitoring frequency: 4
Battery backup emergency lighting units missing: 1
Residents observed for infection control: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Physical Therapist | Revealed nurses complete hydrocollator treatment but unaware of training. |
| Staff B | Licensed Practical Nurse (LPN) | Observed during medication administration and glucometer use; did not clean glucometer properly. |
| Staff C | Registered Nurse | Revealed wrapping HotPac in towels but no formal education on hydrocollator use. |
| Staff D | Licensed Practical Nurse | Observed during wound dressing change; failed to perform hand hygiene. |
| Director of Nursing Services | Director of Nursing | Responsible for executing plans of correction for nursing competencies and infection control. |
| Maintenance Director | Maintenance Director | Acknowledged missing battery backup emergency lighting unit and fire alarm system maintenance issues. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 12, 2022
Visit Reason
An off-site desk audit was conducted on October 12, 2022, to review all previous deficiencies cited on November 19, 2022.
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
Complaint Investigation
Census: 106
Capacity: 120
Deficiencies: 3
Date: Sep 19, 2022
Visit Reason
A Recertification and Complaints Investigation Survey was conducted from 09/14/2022 through 09/19/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey and a Covid-19 Staff Vaccination survey.
Complaint Details
This was a Recertification and Complaints Investigation Survey with reference numbers 86270, 86271, 86142, 85949. Deficiencies were cited as a result of this complaint investigation.
Findings
Deficiencies were cited related to the improper labeling and storage of drugs and biologicals, including failure to date opened medications and lack of proper locking mechanisms for controlled substances. The facility failed to store all drugs and biologicals according to accepted professional principles and regulatory requirements.
Deficiencies (3)
Failure to properly label and date medications including Milk of Magnesia and Morphine Sulfate solution.
Failure to store controlled medications in locked compartments with restricted access.
Medication refrigerators not locked and controlled substances not stored securely with double locks as required.
Report Facts
Census: 106
Total Capacity: 120
Survey Dates: Survey conducted from 2022-09-14 through 2022-09-19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Technician | Observed medication cart and medication handling |
| Staff B | Certified Medication Technician | Observed medication cart and medication handling |
| Staff C | Licensed Practical Nurse | Observed medication cart and medication handling |
| Staff D | Licensed Practical Nurse | Interviewed regarding medication refrigerator and storage |
| Staff E | Registered Nurse | Interviewed regarding medication refrigerator and storage |
| Staff F | Licensed Practical Nurse | Observed medication storage in Transitional Care Unit |
| Assistant Director of Nursing Services | ADNS | Interviewed regarding medication storage policies and deficiencies |
| Administrator | Interviewed regarding medication storage deficiencies and corrective actions |
Inspection Report
Routine
Deficiencies: 4
Date: Sep 16, 2022
Visit Reason
The inspection was conducted to assess compliance with medication storage and labeling regulations in the facility, focusing on proper storage of drugs and biologicals, including controlled substances.
Findings
The facility failed to store all drugs and biologicals according to accepted professional principles, including failure to date opened medications such as Milk of Magnesia and Morphine Sulfate, and failure to secure controlled substances with double locks in medication refrigerators and storage rooms.
Deficiencies (4)
Failure to date opened Milk of Magnesia bottles on multiple medication carts.
Failure to date opened Morphine Sulfate solution bottles labeled with resident information.
Medication refrigerators in multiple medication storage rooms were not locked, and controlled substances such as Ativan Intensol were not stored under double lock.
Loose pills found in medication cart without resident name on packaging.
Report Facts
Medication carts observed: 4
Medication storage rooms observed: 4
Controlled Substances Audit date: Aug 12, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Technician | Observed with medication cart containing undated Milk of Magnesia and loose pills |
| Staff B | Certified Medication Technician | Observed with medication cart containing undated Milk of Magnesia |
| Staff C | Licensed Practical Nurse | Observed with medication cart containing undated Morphine Sulfate bottles and medication storage room with unlocked refrigerator |
| Staff D | Licensed Practical Nurse | Observed medication storage room with unlocked refrigerator containing controlled substances |
| Staff E | Registered Nurse | Observed medication storage room with unlocked refrigerator containing controlled substances |
| Staff F | Licensed Practical Nurse | Observed medication storage room with unlocked refrigerator containing narcotic emergency kit |
| Assistant Director of Nursing Services | ADNS | Interviewed regarding medication storage policies and awareness of deficiencies |
| Administrator | Interviewed acknowledging lack of double lock installation for controlled substances |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 28, 2021
Visit Reason
An off-site desk audit was conducted on July 28, 2021 for all previous deficiencies cited on June 24, 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
Recertification Survey
Census: 95
Capacity: 120
Deficiencies: 9
Date: Jun 24, 2021
Visit Reason
A Recertification Survey and complaint investigation survey was conducted from 6/21/2021 through 6/24/2021 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Complaint Details
Complaint investigation was part of the survey process as indicated by the reference number 80337. Specific substantiation status is not stated.
Findings
Deficiencies were cited related to accuracy of assessments, comprehensive care planning, professional standards of care, activities, treatment and prevention of pressure ulcers, respiratory care, medication errors, resident records, and infection prevention and control. Plans of correction were submitted for each deficiency.
Deficiencies (9)
Accuracy of assessments failed to accurately reflect resident status for 3 of 26 sample residents.
Facility failed to develop a comprehensive person-centered care plan for oxygen use for 2 of 4 sample residents.
Facility failed to assure services met professional standards of quality for 2 of 26 sample residents.
Facility failed to provide a program to support resident choice of activities for 1 of 1 resident whose primary language is Spanish.
Facility failed to provide treatment and services to prevent pressure ulcers for 1 of 3 sample residents at risk.
Facility failed to provide respiratory care consistent with professional standards for 2 of 6 residents reviewed.
Facility failed to ensure medication error rate was less than 5% for 1 resident with an 8% error rate.
Facility failed to maintain accurate and complete resident records for 1 of 4 sample residents reviewed for oxygen use.
Facility failed to establish and maintain an infection prevention and control program consistent with professional standards.
Report Facts
Capacity: 120
Census: 95
Medication error rate: 8
Medication error opportunities: 25
Medication error residents: 1
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