Inspection Report
Complaint Investigation
Deficiencies: 5
Oct 24, 2025
Visit Reason
An unannounced complaint and biennial State Licensure survey was conducted at the residence from 10/22/2025 through 10/24/2025 to assess compliance with state regulations and investigate complaint allegations.
Findings
Deficiencies were identified related to quality assurance, residents' rights, dietetic services, physical plant fire safety, and special care license requirements. No deficiencies were found relative to the complaint survey. Corrective actions were planned or implemented for all deficiencies.
Complaint Details
No deficiencies were identified relative to the complaint survey portion of the visit.
Deficiencies (5)
| Description |
|---|
| Failure to establish a written quality improvement plan including required components for dementia care and limited health services licenses. |
| Failure to post the most recent state licensing survey results as required. |
| Failure to comply with Rhode Island Food Code requirements including cleanliness and labeling of food items. |
| Failure to have an annual State Fire Marshal inspection indicating compliance with the Fire Safety Code. |
| Menus for the Alzheimer Dementia Special Care Unit/Program were not developed under the direction of a licensed dietitian as required. |
Report Facts
Inspection dates: Inspection conducted from 10/22/2025 through 10/24/2025
Corrective action completion dates: Corrective actions have completion dates ranging from 10/27/2025 to 12/31/2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rosa Dufault | Administrator | Signed the plan of correction on 11/14/2025 |
| Executive Director | Interviewed during survey on 10/23/2025 and 10/24/2025 regarding quality improvement plan, survey results posting, and menu development | |
| Director of Culinary | Interviewed regarding kitchen cleanliness and food storage deficiencies | |
| National Director of Culinary Experience | Interviewed on 10/24/2025 regarding menu development for Alzheimer Dementia Special Care Unit |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 26, 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 with ACTS reference numbers 101993 and 99809. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 8, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was unannounced and no deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 12, 2023
Visit Reason
An unannounced complaint/incident investigation survey and a biennial State licensure survey were conducted at the residence on 12/12/2023.
Findings
Deficiencies were identified related to medication administration, fire safety drills, and failure to obtain required variances for hospice services. Specific issues included expired medications, improperly stored medications, obstructed fire drills, and lack of approved variances for hospice care for certain residents.
Complaint Details
The visit was triggered by a complaint/incident investigation survey combined with a biennial licensure survey. Deficiencies were identified relative to the complaint and licensure requirements.
Deficiencies (3)
| Description |
|---|
| Medications were not stored securely to prevent spoilage, dosage errors, administration errors, and/or inappropriate access; expired and improperly dated medications were found. |
| Fire drills were not conducted as required; at least 50% of monthly fire drills were obstructed and documentation was incomplete. |
| The residence failed to obtain required variances for hospice services for 3 of 3 sampled residents receiving hospice care. |
Report Facts
Dates of fire drills conducted in 2023: 11
Percentage of obstructed fire drills in 2023: 18.18
Dates of fire drills conducted in 2022: 11
Percentage of obstructed fire drills in 2022: 8.3
Number of residents receiving hospice services without approved variance: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician (CMT) | Present during medication cart observation where expired medication was found. | |
| Licensed Practical Nurse (LPN) | Present during medication cart observation where improperly dated medications were found. | |
| Director of Wellness | Interviewed regarding medication storage and hospice services; acknowledged expired medications and lack of variance approval. | |
| Executive Director | In-serviced Director of Maintenance regarding fire drills; reviewed corrective actions. | |
| Director of Maintenance | In-serviced on fire drill compliance and responsible for conducting fire drills. | |
| Administrator | Interviewed regarding fire drill documentation; could not provide evidence drills were conducted as required. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 29, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The survey was complaint/incident investigation related and no deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 24, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The visit was complaint-related and no deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 22, 2021
Visit Reason
An unannounced complaint/incident investigation survey and a biennial State licensure survey were conducted at the facility.
Findings
No deficiencies were identified relative to the complaint survey.
Complaint Details
The complaint investigation was unannounced and no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 7
Dec 21, 2021
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the residence on 12/21/2021.
Findings
Deficiencies were identified related to management of services, smoking policy, resident assessments and service plans, dietetic services, medication services, and health screening for health care workers. Corrective actions and audits were planned or completed for each deficiency.
Complaint Details
The visit included a complaint/incident investigation survey (EQGV11) conducted on 12/21/2021. Deficiencies related to medication self-administration, smoking assessments, resident assessments, food safety, medication management, and staff health screenings were identified and addressed.
Deficiencies (7)
| Description |
|---|
| Failure to provide care and services in accordance with prevailing community standards of care relative to physician's orders for oxygen self-administration for Resident ID #1. |
| Failure to complete quarterly smoking assessments for Resident ID #2. |
| Failure to review resident assessments at intervals not to exceed 12 months and update service plans to reflect skilled nursing services for Resident ID #3. |
| Failure to comply with Rhode Island Food Code including dishwasher temperature and kitchen cleanliness. |
| Failure to assess a resident to ensure possession and control of medications was safe for Resident ID #1. |
| Failure to ensure medications were administered in accordance with written orders and proper labeling, storage, and documentation for multiple residents. |
| Failure to obtain proper employment health screenings for Staff D and E. |
Report Facts
Date of survey completion: Dec 22, 2021
Audit completion dates: Feb 10, 2022
Audit completion dates: Feb 7, 2022
Audit completion dates: Jan 26, 2022
Audit completion dates: Jan 31, 2022
Audit frequency: 10
Staff hire dates: Dec 13, 2020
Staff hire dates: Oct 7, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nursing Assistant (CNA) | Files reviewed for health screening and immunization documentation; deficiencies found |
| Staff E | Certified Nursing Assistant (CNA) | Files reviewed for health screening and immunization documentation; deficiencies found |
| Staff C | Certified Medication Technician (CMT)/Certified Nursing Assistant (CNA) | Observed administering medications on 12/22/2021 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 12, 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 found.
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