Inspection Reports for The Dawn Hill Home for Rehab and Healthcare
ONE DAWN HILL ROAD, RI, 02809
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
165% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
89% occupied
Based on a January 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 30, 2024
Visit Reason
A complaint investigation survey was conducted at the facility to determine compliance with Federal and State Laws and Regulations.
Findings
No deficiencies were identified during the complaint investigation survey.
Complaint Details
The complaint investigation survey referenced ACTS numbers 95388 and 95156 and found no deficiencies.
Inspection Report
Follow-Up
Deficiencies: 0
Feb 14, 2024
Visit Reason
A follow-up to a previous Recertification survey was conducted on 02/14/2024 to verify correction of prior deficiencies. Additionally, a revisit survey was conducted on 02/16/2024 to verify correction of deficiencies cited on 01/19/2024 during the Re-certification/Licensure Life Safety Code survey.
Findings
All previous deficiencies were corrected and no new deficiencies or noncompliance were identified. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 118
Capacity: 133
Deficiencies: 15
Jan 22, 2024
Visit Reason
A Recertification and complaint survey was conducted from 1/16/2024 through 1/22/2024 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 due to failure to provide a safe and sanitary environment preventing infection transmission related to blood glucose monitoring. Multiple deficiencies were cited related to professional standards of care, food and nutrition services, infection control, resident records, and life safety code violations.
Complaint Details
The survey was a recertification and complaint survey triggered by concerns related to infection control and resident care practices. Immediate Jeopardy was identified due to infection control failures related to blood glucose monitoring.
Severity Breakdown
Immediate Jeopardy: 1
Level D: 6
Level J: 2
Level F: 6
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to provide a safe and sanitary environment to prevent transmission of infections related to blood glucose monitoring. | Immediate Jeopardy |
| Failure to meet professional standards of quality in services provided, including improper use of splints and offloading of heels for residents. | Level D |
| Failure to provide food prepared in a form designed to meet individual needs, including diet orders and adaptive equipment. | Level D |
| Failure to provide special adaptive eating equipment and utensils for residents who require them. | Level D |
| Failure to maintain food safety requirements including proper storage, sanitation, and equipment maintenance in the kitchen. | Level D |
| Failure to maintain accurate and confidential resident medical records. | Level D |
| Failure to establish and maintain an infection prevention and control program, including proper disinfection of glucometers and staff training. | Level J |
| Failure to follow diabetes-care of equipment policy related to glucometer cleaning and disinfection. | Level J |
| Failure to maintain emergency lighting systems in accordance with NFPA 101 standards. | Level F |
| Failure to maintain battery backup emergency lighting in the basement electrical room. | Level F |
| Failure to maintain proper exit signage and egress travel paths. | Level F |
| Failure to maintain minimum clearance between combustible storage and ceiling-mounted sprinkler heads. | Level F |
| Failure to maintain fire alarm system and sprinkler system in accordance with NFPA standards. | Level F |
| Failure to maintain automatic sprinkler system and conduct required inspections and testing. | Level F |
| Failure to maintain emergency power supply system and conduct required load testing. | Level F |
Report Facts
Residents reviewed for splint and offloading care: 5
Residents reviewed for food needs: 2
Residents reviewed for adaptive eating equipment: 5
Residents reviewed for infection control: 4
Facility capacity: 133
Facility census: 118
Inspection Report
Follow-Up
Deficiencies: 0
Dec 16, 2022
Visit Reason
An off-site desk audit was conducted on November 17, 2022, to review all previous deficiencies cited on October 17, 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.
Report Facts
Previous deficiencies cited: Deficiencies cited on October 17, 2022
Inspection Report
Complaint Investigation
Deficiencies: 2
Nov 17, 2022
Visit Reason
A Recertification Survey and allegation investigation survey were conducted at The Dawn Hill Home for Rehabilitation Nursing Home from 11/15/2022 through 11/17/2022 to determine compliance with 42 CFR Part 483.25 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were cited related to treatment and services to prevent and heal pressure ulcers and respiratory/tracheostomy care and suctioning. The facility failed to ensure appropriate skin prep and wound care for a resident with pressure ulcers and failed to provide respiratory care consistent with professional standards for three residents receiving oxygen therapy.
Complaint Details
The visit included an allegation investigation survey with ACTS Reference Numbers 87766 and 87826. The complaint was substantiated as deficiencies were cited related to pressure ulcer care and respiratory care.
Deficiencies (2)
| Description |
|---|
| Failure to ensure a resident with pressure ulcers received necessary treatment and services to prevent infection and new ulcers from developing. |
| Failure to provide respiratory care, including tracheostomy care and suctioning, consistent with professional standards for residents receiving oxygen therapy. |
Report Facts
Residents reviewed for oxygen therapy: 5
Residents mentioned: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Bauer | Administrator | Signed the Plan of Correction document |
Inspection Report
Annual Inspection
Census: 105
Capacity: 133
Deficiencies: 10
Aug 13, 2021
Visit Reason
A Recertification Survey was conducted from 08/10/2021 through 08/13/2021 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were identified related to professional standards of care, pressure ulcer treatment, medication administration, skin care protocols, nutrition and hydration, mobility, staffing levels, infection prevention and control, and hospice services. The facility failed to meet several regulatory requirements and submitted a Plan of Correction with a completion date of September 3, 2021.
Deficiencies (10)
| Description |
|---|
| Services provided did not meet professional standards of quality for 2 of 2 residents reviewed with thrombo-embolic deterrent (TED) stockings. |
| Facility failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing and prevent new ulcers. |
| Facility failed to maintain acceptable parameters of nutritional status and weight monitoring for 2 of 9 residents reviewed. |
| Facility failed to ensure a resident with limited range of motion received appropriate treatment to prevent further decrease. |
| Facility failed to provide sufficient nursing staff to ensure resident safety and well-being. |
| Facility failed to ensure residents were free of significant medication errors. |
| Facility failed to ensure medications and vaccines were properly labeled and stored with expiration dates monitored. |
| Facility failed to maintain medical records that were complete, accurate, and systematically organized for 5 of 23 residents reviewed. |
| Facility failed to ensure proper infection prevention and control program including hand hygiene and use of personal protective equipment. |
| Facility failed to meet hospice services requirements including documentation and coordination of care for hospice residents. |
Report Facts
Licensed capacity: 133
Average daily census: 105
Staffing ratio: 1
Staff vacancies: 5
Staff vacancies: 11
Deficiency count: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Brown | Administrator | Named in relation to Plan of Correction and exit conference. |
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