Inspection Reports for Steere House Nursing & Rehabilitation Center
RI, 02903
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Inspection Report
Follow-Up
Deficiencies: 0
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
Complaint Investigation
Census: 111
Capacity: 120
Deficiencies: 7
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.
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.
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.
Severity Breakdown
Immediate Jeopardy: 1
Level 2: 2
Level 3: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| 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. | Immediate Jeopardy |
| Failure to store drugs and biologicals properly in locked compartments and maintain medication safety including expired medications found at bedside. | Level 2 |
| Failure to ensure medications were properly discarded and self-administration assessments completed. | Level 2 |
| 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. | Level 3 |
| 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. | Level 3 |
| Failure to ensure proper hand hygiene and food handling by staff during meal service. | Level 3 |
| 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
Follow-Up
Deficiencies: 0
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
Complaint Investigation
Deficiencies: 4
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.
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.
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.
Deficiencies (4)
| Description |
|---|
| 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
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
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.
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.
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.
Deficiencies (3)
| Description |
|---|
| 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
Plan of Correction
Deficiencies: 0
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
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.
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.
Complaint Details
Complaint investigation was part of the survey process as indicated by the reference number 80337. Specific substantiation status is not stated.
Deficiencies (9)
| Description |
|---|
| 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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