Inspection Reports for Anchor Bay at Greenwich
945 Main St, East Greenwich, RI 02818, United States, RI
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Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 12, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations.
Findings
No deficiency was identified during the investigation.
Complaint Details
The investigation was based on complaint/incident ACTS reference numbers 102348 and 102260. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 12, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations based on multiple ACTS reference numbers.
Findings
The facility failed to ensure adequate safeguards to prevent a resident at risk for elopement from exiting the building. The resident was found missing and was located by police approximately an hour later. The facility lacked a secure distinct living environment appropriate for a resident with a successful elopement history.
Complaint Details
The complaint investigation was substantiated by record review and interviews. The resident was found missing but unharmed, with no signs of injury. Staff interviews revealed the resident walked out unnoticed after the elevator closed. The resident was admitted the same day and had no prior history of elopement from a nursing facility.
Deficiencies (1)
| Description |
|---|
| Failure to ensure adequate safeguards to prevent resident elopement from exiting the building. |
Report Facts
ACTS reference numbers: 5
Date of incident: Sep 12, 2025
Date of corrective action assessment: Sep 3, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Isabelle L. Hara | Executive Director | Signed the statement of deficiencies and plan of correction. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 17, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The visit was triggered by complaint/incident investigation, ACTS reference numbers 100338. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 3
Apr 1, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted from 4/1/2025 through 4/3/2025 to determine compliance with state regulations related to residency requirements and limited health services at the assisted living residence.
Findings
Deficiencies were identified related to residency requirements, nurse reviews, and limited health services including failure to meet the definition of resident for one individual, incomplete nurse reviews every 90 days for two residents, and failure to obtain physician orders and resident consent for limited health services for a resident receiving wound care.
Complaint Details
The investigation was triggered by complaints referenced as ACTS numbers 99976 and 100121. The complaint was substantiated by findings of deficiencies in residency and limited health services compliance.
Deficiencies (3)
| Description |
|---|
| Residency Requirements 2.4.14.A: The residence retained a resident who did not meet the definition of a resident for the singular resident reviewed for wound care. |
| Residency Requirements 2.4.16.F Nurse Review: The residence failed to complete nurse reviews every 90 days as required for 2 of 3 residents reviewed. |
| Limited Health Services License Requirements 2.6.2.A/B: The residence failed to obtain a physician's order prior to delivering limited health services for a resident and failed to obtain written consent for limited health services from the resident or representative. |
Report Facts
Dates of survey: Survey conducted from 2025-04-01 through 2025-04-03
Stage III sacral ulcer size: 6
Stage III sacral ulcer depth: 2
Number of residents with incomplete nurse reviews: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Wellness | Interviewed during survey; unable to provide evidence of nurse reviews and physician orders | |
| Assessment Nurse | Named in corrective action plans for training on residency and limited health license requirements | |
| Executive Director | Named in corrective action plans and communications regarding deficiencies and training |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jan 24, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted on 01/24/2025 to determine compliance with state regulations following complaint/incident reference numbers 99268 and 99218.
Findings
Deficiencies were identified related to residency requirements and nurse review processes. Specifically, one resident did not meet the definition of a resident for continued residency, and nurse reviews for three residents failed to ensure required components such as physical assessments, physician order reviews, and medication reconciliation.
Complaint Details
The investigation was triggered by complaints/incident reports 99268 and 99218. The resident was found not suitable for continued residency due to physical limitations and increased care needs. The facility was unable to provide evidence of a 30-day notice to the resident when deemed not appropriate to reside. Nurse reviews were incomplete and inaccurate for residents #1, #2, and #3. The Interim Administrator was unable to provide evidence that all components of nurse reviews were completed.
Deficiencies (2)
| Description |
|---|
| Residency requirements not met for 1 of 3 sample residents reviewed, including failure to meet definition of resident and inadequate documentation of transfer notices. |
| Nurse reviews failed to include required physical assessments, physician order reviews, and medication reconciliation for three residents. |
Report Facts
Complaint/Incident Reference Numbers: 2
Residents reviewed: 3
Assist persons required: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 15, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was based on complaint reference numbers 99151, 99109, 98779, and 98778. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 6
Dec 13, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at Anchor Bay at Greenwich on 12/13/2024 to determine compliance with state regulations following complaint reference numbers 98697, 98696, and 98734.
Findings
Deficiencies were identified related to medication administration, including failure to provide qualified staff to administer medications, lack of documentation for medication technician evaluations, and failure to conduct required monthly and quarterly evaluations of Certified Medication Technicians (CMTs). Corrective actions and plans for ongoing training and audits were outlined.
Complaint Details
The complaint alleged that Staff A, a Certified Medication Technician (CMT), had impaired eyesight, was dropping medications on the floor, and was not cleared to pass medications. The facility was aware of safety risks but Staff A continued to pass medications on the memory care unit. The complaint was substantiated by findings during the investigation.
Deficiencies (6)
| Description |
|---|
| Failure to provide qualified staff to administer medications in the secure memory care unit on 8 of 18 days reviewed. |
| Failure to provide documentation of a Medication Technician Evaluation by a licensed nurse for Staff A. |
| Failure to evaluate Staff A monthly upon hire as required by regulation. |
| Failure to provide evidence of medication administration training for Staff A. |
| Failure to ensure in-service training was completed and documented for new staff within required timeframes. |
| Failure to ensure monthly evaluations of Certified Medication Technicians (CMTs) were conducted and documented for the first three months of hire and quarterly thereafter for Staff A, B, and D. |
Report Facts
Days medication administration failed: 8
Dates medication administration records reviewed: 9
Hours of training for Staff A: 5
Hours of training for Staff B: 4.5
Hours of training for Staff C: 8.75
Number of new hires reviewed for in-service training: 3
Number of medication aides lacking evaluations: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Technician (CMT) | Named in complaint and findings related to impaired eyesight, medication errors, and lack of evaluation and training documentation. |
| Staff B | Certified Medication Technician (CMT) | Named in findings related to lack of documented monthly and quarterly evaluations. |
| Staff C | Licensed Practical Nurse | Named in findings related to training hours and in-service training documentation. |
| Staff D | Certified Medication Technician (CMT) | Named in findings related to lack of documented monthly and quarterly evaluations. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 24, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the facility on 07/24/2024 due to an allegation of a resident hitting his/her significant other.
Findings
The facility failed to review and update the resident's service plan to reflect the new behavioral expression and failed to put interventions in place to protect the resident's significant other. The resident's service plan was later updated and staff were trained on recognizing and documenting behavioral changes.
Complaint Details
The complaint investigation was substantiated as the facility failed to reveal the resident's history of assaultive behaviors and failed to implement protective interventions. The Executive Director acknowledged the failure during the surveyor interview.
Deficiencies (1)
| Description |
|---|
| Failure to review the service plan each time a resident's condition changes significantly and failure to put interventions in place to protect a resident's significant other after an incident. |
Report Facts
Date of survey: Jul 24, 2024
Completion date for plan of correction: Aug 13, 2024
Quarterly audits duration: 1
Inspection Report
Complaint Investigation
Deficiencies: 3
Apr 29, 2024
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility on April 29, 2024.
Findings
Deficiencies were identified related to food service cleanliness, lack of licensed medical staff attendance at Quality Improvement Committee meetings, and failure to obtain required pre-employment and ongoing health screenings for staff.
Complaint Details
The visit was triggered by a complaint/incident investigation survey conducted concurrently with the biennial State Licensure survey.
Deficiencies (3)
| Description |
|---|
| Food service surfaces had heavy accumulation of dark brown substance and brownish liquid dripping from the hood above the stove. |
| Failure to have a licensed physician, certified nurse practitioner, or licensed physician assistant attend the Quality Improvement Committee meetings as required. |
| Failure to obtain pre-employment health screenings for staff with direct resident contact, including evidence of immunizations and tuberculosis screening. |
Report Facts
Date of survey completion: Apr 29, 2024
Dates of Quality Improvement Committee meetings reviewed: 3
Number of staff health screenings missing: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Courtney A Fisher | ALRA | Signed the report as provider/supplier representative |
| Staff A | Dietary Staff | Acknowledged accumulation of substances on kitchen hood during survey |
| Food Service Director | FSD | Acknowledged hood accumulation during observation and interview |
| Executive Director | Could not provide evidence of licensed medical staff attendance or required health screenings during interviews | |
| Staff B | Registered Nurse/Director of Wellness | Failed to provide evidence of required immunizations and health screenings |
| Staff E | Certified Nursing Assistant/Certified Medication Technician | Failed to provide evidence of tuberculosis screening |
| Staff F | Certified Nursing Assistant | Failed to provide evidence of TDAP screening |
Inspection Report
Complaint Investigation
Deficiencies: 8
Oct 5, 2021
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility on 10/05/2021.
Findings
Multiple deficiencies were identified related to safe resident handling, staff in-service training, resident assessments and service plans, staff training on dementia care, and limited health services licensure requirements. Corrective actions including hazard assessments, staff training, audits, and variance submissions were planned or completed.
Complaint Details
The visit included a complaint/incident investigation survey as part of the unannounced biennial licensure survey.
Deficiencies (8)
| Description |
|---|
| Failure to produce evidence of an established Safe Resident Handling program including committee maintenance, hazard assessments, and staff training. |
| Failure to ensure new staff received all required in-service training within 10 days of hire and prior to working alone. |
| Failure to utilize Department-approved resident assessment forms and complete required assessments for sample residents. |
| Failure to ensure nurse reviews accurately reflected changes in condition and services provided for residents receiving outside nursing services. |
| Failure to document and update service plans to reflect services and interventions needed for residents receiving outside healthcare services. |
| Failure to file variance requests for residents receiving hospice and skilled nursing services as required. |
| Failure to ensure all new employees assisting residents with personal care at the dementia care level received at least four hours of orientation and training prior to working alone and ongoing education. |
| Failure to provide limited health services licensure required staff training and Quality Improvement Committee participation by licensed practitioners. |
Report Facts
Percentage of resident records to be audited: 10
Number of sample residents with failed quarterly assessments: 3
Number of sample employees lacking required in-service training: 5
Number of sample residents with incomplete assessments: 6
Number of sample residents with incomplete service plans: 3
Number of sample residents requiring variance requests: 2
Hours of orientation required for dementia care staff: 4
Hours of continued education required for dementia care staff: 12
Number of Quality Improvement Committee meetings missed by licensed practitioners: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela B. Robertson | Executive Director | Named as Executive Director responsible for review of findings and corrective actions. |
| Staff A | Registered Nurse/Health and Wellness Director | Identified as Registered Nurse/Health and Wellness Director; involved in findings related to staff training and resident care. |
| Staff B | Certified Medication Technician (CMT)/Certified Nursing Assistant (CNA) | Sample employee with hire date and training deficiencies noted. |
| Staff C | Certified Medication Technician (CMT)/Certified Nursing Assistant (CNA) | Sample employee with hire date and training deficiencies noted; terminated. |
| Staff D | Certified Medication Technician (CMT)/Certified Nursing Assistant (CNA) | Sample employee with hire date and training deficiencies noted; terminated. |
| Staff E | Certified Nursing Assistant (CNA) | Sample employee with hire date and training deficiencies noted; terminated. |
| Staff F | Certified Nursing Assistant (CNA) | Sample employee with hire date and training deficiencies noted; terminated. |
| Staff G | Certified Nursing Assistant (CNA) | Sample employee with hire date and training deficiencies noted. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 4, 2021
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
An unannounced complaint/incident investigation survey was conducted. No deficiencies were identified.
Report
File
ANCHOR BAY AT GREENWICH POC EXIT DATE 4.7.2022.pdf
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