Greenwood Operations Dba Greenwood Center

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to have sufficient nursing staff with the necessary competencies and skills to provide the required nursing and related services. This failure jeopardized resident safety and hindered the attainment or maintenance of the highest practicable physical, mental, and psychosocial wellbeing of each resident. This was particularly evident in the case of four nursing staff members: Staff B, C, D, and F, where a change in a resident's condition was not properly identified.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure medications were administered as ordered. Additionally, the facility failed to recognize a change in condition in a timely manner for 1 of 1 resident reviewed, who was transferred to the hospital by a non-medical transport company, after being found by facility staff to have experienced a change in mental status, a decrease in oxygen saturation levels, and who subsequently expired, Resident ID #1.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed who did not receive intravenous antibiotic therapy as ordered, Resident ID #1.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 1 resident reviewed who required oxygen therapy, Resident ID #1.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that resident records are complete and accurately documented, relative to medication administration for 1 of 1 resident reviewed who did not receive intravenous antibiotic therapy as ordered, Resident ID #1.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed who did not receive his/her Lispro (a medication prescribed to treat elevated blood sugar levels), as ordered, Resident ID #1. The failure to administer 17 out of 17 prescribed doses resulted in elevated blood glucose levels and contributed to the resident's clinical decline, including lethargy and critically elevated blood glucose levels, requiring transfer to an acute care hospital.

Inspectors wroteBased on record review, and resident and staff interviews, it has been determined that the facility failed to keep residents free from physical and verbal abuse for 2 of 4 residents reviewed, Resident ID #s 2 and 3.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to immediately put effective measures in place to prevent further potential abuse, neglect or mistreatment of residents from occurring, following incidents where staff members observed another staff member verbally and/or physically abuse residents for 2 of 2 residents reviewed who were subjects of abuse by a staff member, Resident ID #s 2 and 3.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to following a physician's order for 1 of 1 resident reviewed with orders to check blood sugars, Resident ID #2.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure that the resident's medical was accurate in accordance with accepted professional standards and practices, for 1 of 1 resident reviewed with an order for routine blood sugar monitoring, Resident ID #2.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary medication for 1 of 6 residents reviewed for medication administration, Resident ID #1.

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.

Inspectors wroteBased on surveyor observation, record review, staff and resident representative interviews, it has been determined that the facility failed to ensure that a resident's right to communication and access to persons and services inside and outside the facility to promote a dignified existence was promoted for 2 of 2 residents reviewed whose primary language is not English, Resident ID #s 16 and 52.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents' advance directives were consistent with the resident's electronic medical record (EMR) for 2 of 2 residents reviewed in which their advance directive copies did not match the EMR, Resident ID #s 16 and 154.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the residents' environment remains free from accident hazards relative to appropriately disposing of hazardous materials for 1 of 2 medication carts observed, One-North medication cart.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standard of practice for 2 of 3 residents reviewed for oxygen use, Resident ID #s 24 and 154.

Inspectors wroteBased on surveyor observation, record review, resident and staff interviews, it has been determined that the facility failed to ensure that residents who require dialysis (a life-sustaining treatment that is used to remove waste products and excess fluid from the blood when a person's kidneys are no longer functioning) receive such services, consistent with professional standards of practice for 1 of 1 resident reviewed for fluid restriction and on a renal diet (a dietary plan specifically designed for people with kidney disease), Resident ID #77.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for a medication with parameters, Resident ID #77.

Inspectors wroteBased on surveyor observation, resident, and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional standards for 2 of 4 medication carts observed, and 1 of 1 resident's room observed with medication at the bedside, Resident ID #99.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to prepare food and drink in a form designed to meet individual needs for 1 of 1 resident observed during the medication administration task that requires honey thickened liquids (liquid consistency that should flow like honey pouring off a spoon), Resident ID #69.

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 Enhanced Barrier Precautions (EBP; involves using a gown and gloves during high-contact resident care activities) 1 of 1 resident reviewed with a suprapubic tube (SPT; a tube that drains urine from your bladder through a small incision in your abdomen), Resident ID #37 and for 1 of 1 resident observed for medication administration via a peripherally inserted central catheter (PICC; a long, thin tube inserted through a vein in your arm that extends to your heart), Resident ID #51.

Inspectors wroteBased on surveyor observation, resident and staff interviews, it has been determined that the facility failed to maintain a safe, functional, and comfortable environment for residents, staff, and the public relative to resident rooms and furnishings in disrepair on 2 of 6 units observed, affecting Resident ID #s 14, 70, 73, and 79.

Inspectors wroteBased on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure that the residents' environment remained as free of accident hazards as possible, relative to maintaining safe water temperatures on 5 of 6 units.

Inspectors wroteBased on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure that residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 2 residents reviewed with facility acquired pressure ulcers (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) Resident ID #33.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to the use of a baclofen pump for 1 of 1 resident reviewed, Resident ID #317 and 1 of 7 residents medication reviewed during the medication administration task, Resident ID #103.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 4 of 6 residents reviewed with an indwelling catheter (a flexible tube that collects urine from the bladder and leads to a drainage bag), Resident ID #s 1, 25, 69, and 104.

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 for 5 of 5 residents reviewed relative to Multidrug Resistant Organisms (MDRO), Resident ID #'s 1, 77, 105, 318 and 372.

Inspectors wroteBased on surveyor observations and staff interview, it has been determined that the facility failed to maintain a sanitary and comfortable environment relative to 2 of 2 kitchenettes observed and 2 of 6 units reviewed relative to residents rooms.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that the assessment accurately reflected the resident's status for 2 of 2 residents reviewed for behavioral assessments, Resident ID #'s 109 and 113.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to develop and implement a baseline care plan for each resident within 48 hours of a resident's admission, that includes the instructions needed to provide effective and person-centered care for 3 of 3 newly admitted residents reviewed, Resident ID #s 109, 366, and 317.

Inspectors wroteBased on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to provide the necessary services to a resident who is unable to carry out activities of daily living (ADLs), for 1 of 1 resident reviewed relative to transfers, Resident ID #366 and 1 of 3 residents reviewed relative to assistance with meals, Resident ID #88.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, for 1 of 1 resident reviewed receiving dialysis, Resident ID #164.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary psychotropic drugs for 1 of 3 residents reviewed for psychotropic medications, Resident ID #43.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 1 of 3 medication rooms and 2 of 4 medication carts observed.

Inspectors wroteBased on surveyor observation, record review, staff, resident and family interview, it has been determined that the facility failed to provide or obtain from an outside resource, dental services for 1 of 1 resident reviewed for dental services, Resident ID #55.

Inspectors wroteBased on record review and staff interview if has been determined that the facility failed to promptly identify and intervene for an acute change in condition of a resident's for 1 of 1 resident reviewed for new seizure activity and physician notification, Resident ID #1. Record review of a facility reported incident submitted to the Rhode Island Department of Health on 11/17/2023 revealed in part, that Resident ID #1 experienced two seizures on 11/15/2023. Record review of a facility policy titled seizure precautions states that after full return to baseline of consciousness .notify physician/advanced practice provider (APP) and family .document: [...]

Inspectors wroteBased on surveyor observation, record review, and staff and resident interviews, it has been determined that the facility failed to ensure that each resident receive adequate supervision and assistive devices to prevent accidents for 1 of 1 resident reviewed for smoking, Resident ID #15.

Inspectors wroteBased on surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is served in accordance with professional standards for food service safety, relative to the main kitchen and 1 of 2 kitchenettes.

Inspectors wroteBased on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections relative to the disposal of used/contaminated non-retractable lancets (small needle used to pierce skin) for 1 of 1 residents reviewed, Resident ID #43.

Inspectors wroteBased on surveyor observation and staff interview, it has been determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 of 2 kitchenettes observed.