Adviniacare Waterview Villas, LLC

Inspectors wroteBased on clinical record review and staff interview, the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed with a foley catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag), Resident ID #1, and for 1 of 1 resident with a suprapubic catheter (SP tube, a medical device that drains urine from the bladder through a small incision in the abdomen), Resident ID #2.

Inspectors wroteBased on record review, surveyor observation, and staff interview, the facility failed to store drugs and biologicals in accordance with currently accepted professional principles for 3 of 6 medication carts observed during the medication storage task.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented and readily accessible for 2 of 2 residents reviewed for physician referral outpatient appointments, Resident ID #s 10 and 104.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight relative to 1 of 1 resident reviewed for severe weight loss who was not reweighed for verification, Resident ID #8.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility assessment failed to include active involvement/input received from resident representatives, and family members.

Inspectors wroteBased on clinical record review, resident, and staff interview the facility failed to provide pharmaceutical services that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident related to pramipexole (a medication prescribed to treat restless leg syndrome (RLS;) RLS is a neurological condition characterized by uncomfortable sensations described as crawling, tingling, or aching.) for 1 of 1 resident reviewed, Resident ID #1.

Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, the facility failed to ensure ordered diagnostic testing was obtained and failed to ensure significant laboratory results were reviewed and reported to the practitioner for 1 of 1 resident reviewed (Resident ID #1) who was treated for a herpes simplex outbreak (viral infection that can cause painful blisters or ulcers and is spread through skin to skin contact). The facility's failures in following practitioner orders, reviewing and reporting abnormal laboratory results, and ensuring timely communication with the resident's responsible party led to a delay in treatment and resulted in the need for a more invasive course of treatment.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that staff updated and implemented proper safety measures, including the use of bed rails, which resulted in the resident sustaining a significant fracture that required surgery and a significant decline from his/her prior level of function due to a preventable fall for 1 of 1 resident reviewed, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that garbage is properly disposed of in accordance with professional standards for food safety, relative to refuse being left outside the dumpster, potentially harboring and feeding pests.

Inspectors wroteBased on record review, staff and resident interview, it has been determined that the facility failed to ensure that each resident receives adequate care to prevent an accident for 1 of 1 resident reviewed. The resident required two staff members to assist during care, one staff member was providing care, resulting in the resident falling out of bed, injuring multiple areas, including a facial injury requiring immediate transfer to the hospital and hospitalization, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM for 2 of 2 residents reviewed with contractures (the shortening of muscles, tendons, skin, and nearby soft tissues that cause the joints to become very stiff, which prevents normal movement), Resident ID #s 67 and 79. Additionally, the facility failed to ensure a resident with limited mobility received appropriate services and equipment for 1 of 1 resident reviewed who was admitted to the facility for respite care, Resident ID #272.

Inspectors wroteBased on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice to prevent new ulcers from developing for 1 of 1 resident reviewed, who was admitted to the facility for respite care, Resident ID #272.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, relative to the main kitchen and the main dining room. 1. The Rhode Island Food Code 2018 Edition 4-601.11 states in part, .Nonfood contact surfaces shall be kept free of an accumulation of dirt, dust, food residue, and other debris . Surveyor observations of the main kitchen on 1/27/2025 at approximately 8:45 AM and on 1/28/2025 and 1/29/2025 at 9:40 AM revealed the following: [...]

Inspectors wroteBased on surveyor observations, record review and staff interviews, it has been determined that the facility failed to meet professional standards of quality relative to following physician's orders for 1 of 1 resident reviewed with refusals of medications, Resident ID #3, 1 of 1 resident reviewed with an order to not have straws with liquids, Resident ID #52, and 1 of 5 residents reviewed with an order for insulin parameters, Resident ID #93. Additionally, the facility failed to meet professional standards of quality relative to 1 of 2 wound dressings observed, Resident ID #272.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident who is diagnosed with a mental disorder or has a history of trauma, receives appropriate treatment and services to attain the highest practicable mental and psychosocial well-being relative to 1 of 1 resident reviewed for suicidal ideations, Resident ID #113.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide an ongoing activity program to support a resident in his/her choice of activities based on the comprehensive assessment, care plan, and preferences for 1 of 1 resident reviewed, Resident ID #90.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight for 2 of 4 resident reviewed for weight loss, Resident ID #s 52 and 272.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store drugs and biologicals in accordance with currently accepted professional principles relative to 1 of 1 secured unit observed.

Inspectors wroteBased on surveyor observation, record review, and staff interview it has been determined that the facility failed to maintain medical records on each resident that are accurately documented for 1 of 2 residents reviewed for heel boots, Resident ID #83, for 2 of 2 residents reviewed for off-loading heels, Resident ID #s 46 and 83 and for 1 of 2 residents observed for wound dressings, Resident ID #272 .

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment, and to help prevent the development and transmission of communicable diseases, relative to the disinfection of a glucometer that is used to obtain blood glucose readings for multiple residents, for 1 of 2 observations of blood sugar monitoring.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to notify each resident, or resident representative, that receives Medicaid benefits when the amount in the resident's account reaches $200 less than the Social Security Income (SSI) resource limit for 4 of 4 residents reviewed with over $4000 in personal needs funds handled by the facility, Resident ID #s 15, 18, 32 and 47.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality for 3 of 5 residents reviewed for physician's orders, Resident ID #s 3, 4, and 5.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to identify, implement, monitor, and modify interventions consistent with the residents' assessed needs to maintain nutritional status for 2 of 5 residents reviewed, Resident ID #s 1 and 3.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed, in accordance with professional standards for food safety relative to the main kitchen and 2 of 3 kitchenettes.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to the Multidrug-resistant Organism (MDRO) Clostridium difficile (C. Difficile), for 1 of 1 resident reviewed, Resident ID #264. Additionally, the facility also failed to protect a resident who was susceptible to infections due to being on Neutropenic Precautions, precautions implemented due to a low white blood cell count which in turn weakens your immune system, for Resident ID #40.

Inspectors wroteBased on surveyor observation and staff interview, it has been determined that the facility failed to ensure that the facility stores, distributes, and serves food in accordance with professional standards for food safety relative to observations of meal service on the third floor.