Woonsocket Health Center

Inspectors wroteBased on surveyor observation 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.

Inspectors wroteBased on record review 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, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident reviewed for peritoneal dialysis (PD, a treatment for kidney failure that uses the lining of the abdomen to filter waste products from the blood), Resident ID #101 and for 2 of 3 residents reviewed for hemodialysis (a type of dialysis that filters blood to remove waste products and excess fluids), Resident ID #s 30 and 76.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 4 of 4 residents reviewed for antibiotic orders, Resident ID #s 2, 101, 114, and 374.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure the resident's medical record includes documentation that the resident either received the pneumococcal vaccination or did not receive the vaccination due to medical contraindications or refusal, for 4 of 5 residents reviewed, Residents ID #s 3, 4, 39, and 101.

Inspectors wroteBased on record review, surveyor observation, resident and staff interviews, it has been determined that the facility failed to ensure that residents with pressure ulcers receive the necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 3 residents reviewed with pressure ulcers, Resident ID #34.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that medications and biologicals were ordered by the prescriber for 1 of 3 residents reviewed for Lorazepam (a medication prescribed for anxiety) administration, Resident ID #30.

Inspectors wroteBased on record review and staff interview, it has been determined that the Medical Director failed to implement a resident care policy to coordinate care for residents related to the transcription and implementation of orders by providers.

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 4 of 4 kitchenettes observed.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to implement comprehensive person-centered care plans for 3 of 4 residents reviewed for anticoagulation therapy, relative to monitoring for bleeding (anticoagulant side effects), Resident ID #s 48, 62, and 118.

Inspectors wroteBased on surveyor observation, record review and staff interview it has been determined that the facility failed to meet professional standards of quality regarding not following the facility's emergency cart equipment procedure for 4 out of 4 emergency carts observed and for 1 of 1 resident reviewed relative to psychiatric consultant orders, Resident ID # 86.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that the irregularities identified by the Clinical Consultant Pharmacist during the monthly pharmacist Medication Regimen Review (RR) were acted upon for 1 of 1 resident reviewed related to phenytoin (a medication that is used to control seizures) , Resident ID #118.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to keep residents free from significant medication errors for 2 of 2 closed records reviewed, Resident ID #s 118 and 119.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to promptly identify and intervene for acute changes in a resident's condition for 1 of 1 resident reviewed, relative to a death in the facility, Resident ID #118.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 2 of 3 residents reviewed with a suprapubic catheter (a device inserted through the abdomen into the bladder to drain urine), Resident ID #s 78 and 115.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that residents who are fed by a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 3 residents reviewed relative to a gastrostomy tube (often called a G tube, which is a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) Resident ID #51.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety as identified in the plan of care for 1 of 1 resident reviewed for a change in condition, Resident ID #118.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure residents were free from misappropriation of property relative to narcotic medications for 4 of 4 units reviewed, including 13 of 24 residents reviewed, Resident ID #s: 2, 4, 8, 9, 11, 13, 16, 17, 19, 21, 22, 24, and 25.

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 1 of 3 medication storage rooms observed and 4 of 4 units observed.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan for 3 of 5 residents reviewed, relative to seizures, Resident ID #s 3, 4, and 5.

Inspectors wroteBased on surveyor observation, record review, staff and resident 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 a norovirus outbreak for 4 of 4 units and Extended spectrum beta-lactamases (ESBLs) for 1 of 1 residents reviewed, Resident ID #79.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that a resident received adequate supervision to prevent elopement from the facility for 1 of 4 closed records reviewed, Resident ID #127.