Pawtucket Falls Healthcare Center

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that the comprehensive care plan was revised by the interdisciplinary team after changes of condition for 5 of 6 residents reviewed, Resident ID #s 1, 3, 4, 5, and 6.

Inspectors wroteBased on record review and staff interview, the facility failed to meet professional standards of quality relative to not following physician's orders for behavior monitoring for 2 of 4 resident's reviewed, Resident ID #s 2 and 6.

Inspectors wroteBased on surveyor observation, clinical record review, and resident and staff interview, the facility failed to provide or obtain from an outside resource, emergency dental services for 2 of 2 residents reviewed, who were experiencing mouth pain, Resident ID #s 13 and 77.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that each resident was given a written accounting of his/her deposits, withdrawals, and balances, at least quarterly for 5 of 5 residents reviewed, Resident ID #s 21, 81, 85, 103, and 131.

Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, the facility failed to provide services that meet professional standards of quality relative to 1 of 1 resident reviewed with an arterial wound (a skin injury caused by poor blood flow), Resident ID #30. Additionally, the facility failed to follow the physician's orders for 1 of 1 resident reviewed with an order to obtain a T4 laboratory test (a blood test that measures the levels of the hormone produced by the thyroid gland) for Resident ID #74, and for 1 of 1 resident reviewed for Thrombo-Embolism Deterrent (TED) stockings (a compression sock used to prevent blood clots in immobile, bedridden, or post-surgical patients), Resident ID #142.

Inspectors wroteBased on surveyor observation, clinical record review, and resident and staff interviews, the facility failed to provide necessary services to residents who are unable to carry out activities of daily living (ADLs) relative to scheduled showers for 2 of 2 residents reviewed who did not receive their scheduled weekly showers on 5/8/2026, Resident ID #s 3 and 122, and for 1 of 1 resident reviewed for nail care, Resident ID #8.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that irregularities identified by the Consultant Pharmacist during the monthly Medication Regimen Review (MRR) were acted upon for 3 of 3 residents reviewed with outstanding pharmacy recommendations related to medication monitoring, Resident ID #s 10, 43, and 48.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 2 of 2 residents reviewed with medication recommendations identified by the Consultant Pharmacist during the monthly Medication Regimen Review (MRR), Resident ID #s 75 and 111.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that residents are free from any significant medication errors for 3 of 3 residents reviewed for significant medication irregularities identified by the Consultant Pharmacist during the Medication Regimen Review (MRR), including the omission of an antibiotic and the failure to discontinue insulin for Resident ID #48, for a change in medication to manage excess fluids for Resident ID #70, and for an inhaler to manage a chronic lung disease for Resident ID #111. Additionally, the facility failed to ensure that residents are kept free from any significant medication errors for 1 of 1 resident reviewed for vascepa (a medication prescribed for cardiovascular health) and stiolto respimat (an inhaled medication prescribed to treat chronic obstructive pulmonary disease, COPD), Resident ID #73.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure the resident's record is accurate, complete, and readily accessible for 1 of 1 resident reviewed with an order for a permacath (a type of central venous catheter that is inserted into a large vein, typically in the chest, to provide long-term vascular access) Resident ID #8.

Inspectors wroteBased on record review and staff interview, 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 2 of 2 residents reviewed who required notification, Resident ID #s 21 and 103. Additionally, the facility failed, upon a resident's death, to convey within 30 days the resident's funds and a final accounting of those funds to the individual or probate jurisdiction administering the resident's estate, in accordance with state law for 1 of 1 resident reviewed for personal needs funds handled by the facility that had expired, Resident ID #148.

Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, the facility failed to ensure residents were free from misappropriation of property for 2 of 2 residents reviewed during the medication administration task, when medications intended for Residents ID #18 and #115 were administered to Resident ID #90.

Inspectors wroteBased on surveyor observation, clinical record review, and staff and resident interviews, the facility failed to ensure that each resident receives treatment and care in accordance with professional standards of practice. This included failure to ensure staff completed and documented required weekly skin assessments, reported changes in skin condition to the provider, and initiating timely treatment interventions for 1 of 1 resident observed with a skin impairment, Resident ID #8.

Inspectors wroteBased on clinical record review, and resident and staff interview, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight, for 3 of 3 residents reviewed, who experienced actual weight loss, Resident ID #s 1, 11, and 111.

Inspectors wroteBased on clinical record review, and staff and resident interview, the facility failed to ensure that residents who requires dialysis (a treatment that removes excess fluid, waste, and toxins from the blood when the kidneys are no longer functioning properly) receive such services consistent with professional standards of practice for 1 of 1 resident reviewed, Resident ID #8.

Inspectors wroteBased on surveyor observation, clinical record review, and resident and staff interview, the facility failed to have sufficient nursing staff to assure resident safety and attain the highest practicable, physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 2 of 2 residents reviewed who failed to receive their scheduled shower due to staffing shortages, Residents ID #s 3 and 122.

Inspectors wroteBased on record review, and staff and resident interview, the facility failed to ensure a resident was free from verbal abuse for 1 of 5 residents reviewed, Resident ID #1.

Inspectors wroteBased on record review, staff, and resident interview, it has been determined that the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 2 residents reviewed who alleged staff to resident abuse, Resident ID #2.

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) receives appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM for 1 of 2 residents reviewed with contractures, Resident ID #13.

Inspectors wroteBased on record review, resident, and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a treatment that removes excess fluid, waste, and toxins from the blood when the kidneys are no longer functioning properly) receive such services, consistent with professional standards of practice for 1 of 2 residents reviewed for fluid restrictions, Resident ID #30.

Inspectors wroteBased on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure that assessments accurately reflect the residents' status for 1 of 1 resident reviewed relative to a fall with injury, Resident ID #75.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following physician's order for obtaining orthostatic blood pressure (a form of low blood pressure that happens when standing up from a sitting or lying down position) for 1 of 1 resident reviewed, Resident ID #76.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility was not being administered in a manner that enabled it to utilize resources effectively and efficiently to maintain the highest practicable physical, mental and psychosocial well-being of each resident related to infection control. This failure resulted in immediate jeopardy for F 880. Additionally, the Administrator directed an employee, who did not have a Food Safety Manager Certification, to work as the only cook in the main kitchen for all of the facility's residents.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by allowing a staff member who tested positive for COVID-19 on 7/31/2024, to work as the cook in the kitchen during the evening shift on 8/3/2024 and during the morning and evening shifts on 8/4/2024.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure licensed nurses have specific competencies and skill sets necessary to care for residents' needs, relative to indwelling urinary catheters (a thin hollow tube that is inserted through the urethra into the bladder to drain urine, which is held in place by a water filled balloon), Staff B, C and D.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to prepare, serve and distribute food in accordance with professional standards for food service safety as the facility failed to have any certified food protection managers available during the preparation of evening meals on 7/1, 7/7, 7/15, 7/20 and 8/3/2024 or during the preparation of all the meals on 8/4/2024.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed for medication administration, Resident ID #5.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to develop, implement, and maintain an effective training program for all newly hired employees and annual training for existing employees consistent with their expected roles, relative to education involving abuse, infection control, dementia behavioral health management, trauma informed care and QAPI (Quality Assurance and Performance Improvement) per the facility assessment, for 9 of 9 newly hired or existing employees, Staff A, B, C, D, F, G, H, I and J. .

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide written notice of bed-hold policy to the resident or resident representative, prior to the transfer of the resident to the hospital, for 1 of 5 residents reviewed, Resident ID #2.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to develop and implement a baseline care plan within 48 hours of the resident's admission that includes instructions needed to provide effective and person-centered care that meets professional standards of quality care, the resident's immediate health and safety needs, physician and dietary orders as well as therapy and social services for 1 of 2 residents reviewed, Resident ID # 2.

Inspectors wroteBased on record review and staff interview, it has been determined that the that the facility failed to ensure that the resident's Advanced Directive requesting to refuse lifesaving treatment was followed for 1 of 5 residents reviewed, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that the comprehensive care plan was revised by the interdisciplinary team for 3 of 6 residents reviewed for advanced directives, Resident ID #s 2, 23, and 45.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for care of a resident for 4 of 4 residents reviewed with catheters, Resident ID #s 2, 4, 35 and 54.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors, receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents experiences, and preferences, in order to eliminate, or mitigate triggers that may cause re-traumatization of the resident for 10 of 15 residents reviewed for Trauma Informed Care, Resident ID #s 2, 9, 23, 24, 35, 45, 49, 54, 58, and 59.

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

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing for 1 of 1 resident reviewed who has an actual pressure injury, Resident ID #4.

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 standards of practice for 1 of 3 residents reviewed for oxygen therapy, Resident ID #19.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that a resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for a blood pressure medications with parameters, Resident ID #4.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to protect identifying information for 13 residents listed in the facility's survey results binder, Resident ID #s 4, 6, 26, 27, 30, 31, 43, 49, 52, 463, 464, 465, and 466.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to keep a resident free from sexual abuse for 1 of 6 residents reviewed, Resident ID #2. The facility also failed to screen newly admitted residents upon admission for their sex offender status (as required by the facility assessment) for 2 of 2 newly admitted residents from June 2023 through September of 2023, Resident ID #s 1 and 7, resulting in Resident ID #1 touching a vulnerable resident in a sexual manner, Resident ID #2.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure that each resident receives adequate supervision based on the risks and current professional standards of practice relative to preventing an incident by a known sex offender, Resident #1.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 2 out of 2 residents related to determining if a resident was a registered sex offender prior to admission from June of 2023 until September of 2023, Resident ID #s 1 and 7.