Inspection Report
Annual Inspection
Deficiencies: 4
Nov 4, 2025
Visit Reason
An unannounced State licensure survey was conducted from 11/03/2025 through 11/04/2025 to determine compliance with state regulations.
Findings
The facility failed to comply with Rhode Island Food Code standards related to dietetic services, including issues with an ice machine accumulation, staff not wearing beard coverings, unlabeled and undated food items, and expired prunes in storage.
Deficiencies (4)
| Description |
|---|
| Ice machine with an accumulation of light orange and brown substance along the top inside white flap. |
| Cook, Staff A, without a beard covering while prepping soup. |
| Four clear bags of cereal with no label and no date. |
| Seven-pound cans of prunes with a best by date of April 2025 found expired in dry storage. |
Report Facts
Weight of expired prunes: 7
Number of clear bags of cereal: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 7, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations based on multiple ACTS reference numbers.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was based on complaint/incident reference numbers 101890, 100742, 100314, 101116, 101407, and 102181. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 22, 2024
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 ACTS reference numbers 98364, 98367, 98343, and 97937. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 1, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted on 10/1/2024 at Arbor Hill residence due to an allegation of violation of residents' rights.
Findings
The investigation found that the residence failed to issue a 30-day notice to a resident (Resident ID #1) before discharge despite escalating behaviors and warnings. The resident left the facility without proper notice after being threatened with psychiatric admission and was not given the required written notice as per regulations.
Complaint Details
The complaint alleged violation of residents' rights related to discharge procedures. It was substantiated that Resident ID #1 was not given a 30-day notice as required when behaviors continued, and the resident was threatened with psychiatric admission and hospital evaluation.
Deficiencies (1)
| Description |
|---|
| Failure to issue a 30-day notice to a resident before discharge despite escalating behaviors and warnings. |
Report Facts
Date of survey completion: Oct 1, 2024
Date resident left: Sep 11, 2024
Date resident returned: Oct 12, 2024
Date of facility letter: Feb 2, 2024
Date of surveyor interview: 822
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Wellness | Interviewed by surveyor regarding resident behaviors and notice procedures | |
| Chief Operating Officer (COO) | Discussed resident's escalating behaviors and hospital evaluation with resident |
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 7, 2024
Visit Reason
An administrative review/offsite investigation was conducted at this residence as part of the annual inspection process.
Findings
No deficiencies were identified during the survey; the facility was found to be deficiency free.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 29, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
An unannounced complaint/incident investigation survey was conducted. No deficiencies were identified.
Inspection Report
Routine
Deficiencies: 1
Dec 27, 2023
Visit Reason
An unannounced biennial State Licensure survey was conducted at this residence to assess compliance with State Licensure requirements.
Findings
The residence failed to ensure medications were stored securely and properly, specifically noting opened and undated inhalers on medication carts. Observations and interviews confirmed noncompliance with medication storage and labeling requirements.
Deficiencies (1)
| Description |
|---|
| Failure to ensure medications were stored securely and in a manner to prevent spoilage, dosage errors, administration errors, and/or inappropriate access for 2 of 3 medication carts observed. |
Report Facts
Medication carts observed: 3
Medication carts with deficiencies: 2
Inhaler discard timeframe: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sherry Vieira | Wellness Director | Named in plan of correction and interview regarding medication storage deficiencies |
| Staff A | Certified Medication Technician | Observed with opened and undated inhaler during medication cart survey |
| Staff B | Certified Medication Technician | Observed with opened and undated inhalers during medication cart survey |
Inspection Report
Complaint Investigation
Deficiencies: 2
Nov 28, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at Atria Harborhill on 11/28/2023 to investigate deficiencies related to resident service plans and incident reporting.
Findings
The investigation found that Resident ID #1's service plan did not accurately reflect behavioral needs or required interventions after a physical altercation and psychiatric evaluation. Resident ID #2's record failed to document a thorough investigation and follow-up of a resident-to-resident abuse incident. Both deficiencies were based on record reviews and staff interviews.
Complaint Details
The visit was complaint-related, investigating incidents involving Resident ID #1 and Resident ID #2, including physical altercation and resident-to-resident abuse. Substantiation status is not explicitly stated.
Deficiencies (2)
| Description |
|---|
| Failure to document a description of the services and interventions needed on the service plan for Resident ID #1. |
| Failure to thoroughly investigate and document an incident related to injury for Resident ID #2. |
Report Facts
Dates related to corrective actions: Corrective action dates include 9/14/2023, 1/10/2024, 2/1/2024, and 3/31/2024 for various compliance steps.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Wellness | Acknowledged that Resident ID #1's and Resident ID #2's service plans and incident documentation did not accurately reflect behavioral needs and incident investigations during interviews on 11/28/2023. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 18, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
Unannounced complaint/incident investigation survey with no deficiencies identified.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 23, 2023
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 based on complaint reference numbers 91648 and 91552 and found no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 17, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was unannounced and complaint/incident related; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 14, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was unannounced and complaint/incident related; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 29, 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
Mar 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 investigation was unannounced and complaint/incident related; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 3
Jan 4, 2022
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the residence on 01/04/2022.
Findings
Deficiencies were identified related to dietetic services, medication services, and physical plant safety requirements. Issues included improper food labeling and storage, lack of sanitizer in dishwasher, expired and unlabeled medications, and failure to conduct fire drills as required.
Complaint Details
The visit included a complaint/incident investigation component as part of the unannounced biennial survey.
Deficiencies (3)
| Description |
|---|
| Food service failed to comply with Rhode Island Food Code requirements including improper labeling and storage of food items and lack of sanitizer in dishwasher. |
| Medication services failed to ensure medications were properly labeled, stored securely, and administered according to physician orders; expired and unlabeled medications were found. |
| Physical plant safety requirements were not met as fire drills were not conducted effectively, with 50% of drills obstructed and incomplete documentation. |
Report Facts
Dates of fire drills conducted: Fire drills were conducted on 12/21/2020, 01/07/2021, 02/04/2021, 02/05/2021, 03/30/2021, 04/08/2021, 05/09/2021, 06/30/2021, 07/26/2021, 08/25/2021, 09/25/2021, 10/10/2021, 11/02/2021, and 12/06/2021.
Percentage of obstructed fire drills: 50
Number of kitchen storage bins with unlabeled food ingredients: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 8, 2021
Visit Reason
An unannounced complaint/incident investigation survey and a biennial State licensure survey were conducted at the facility on 04/08/2021.
Findings
No deficiencies were identified relative to the complaint survey.
Complaint Details
The complaint investigation was unannounced and no deficiencies were found related to the complaint.
Inspection Report
Complaint Investigation
Deficiencies: 7
Apr 8, 2021
Visit Reason
A biennial State licensure survey and a complaint investigation survey were conducted at Atria Harborhill on 04/08/2021 to assess compliance with state licensure regulations and investigate complaint allegations.
Findings
Deficiencies were identified related to safe resident handling committee composition, in-service training documentation, resident assessments and service plans, medication storage and administration, safety requirements including fire drills, and staff health screening documentation. The facility submitted plans of correction for these deficiencies.
Complaint Details
The complaint investigation was conducted concurrently with the biennial licensure survey on 04/08/2021. Deficiencies were substantiated as evidenced by record reviews, staff interviews, and surveyor observations.
Deficiencies (7)
| Description |
|---|
| Safe resident handling committee did not include at least half of its members as hourly, non-managerial employees who provide direct resident care. |
| Three out of seven staff sampled failed to have documented ongoing in-service training within required intervals. |
| Comprehensive resident assessments and service plans were not updated to reflect changes in condition for four of five sampled residents. |
| Medications were not stored securely and seven of nine sampled residents had medication discrepancies including expired medications and missing administration directions. |
| Facility failed to ensure 50% of fire drills were not obstructed and documentation of drill types was incomplete. |
| Facility failed to provide proof of influenza vaccination or declination forms for four of seven sampled staff. |
| Facility failed to send a variance request for physical therapy services for one resident. |
Report Facts
Number of staff sampled for in-service training: 7
Number of residents sampled for assessment review: 5
Number of residents with medication discrepancies: 7
Number of fire drills reviewed: 50
Number of staff missing flu vaccine or declination form: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Named in findings related to in-service training, medication discrepancies, and exit interviews. |
| Staff F | Personal Care Assistant | Named in findings related to in-service training deficiencies. |
| Staff G | Certified Medication Technician | Named in findings related to in-service training deficiencies and medication administration observations. |
| Staff H | Certified Nursing Assistant | Named in findings related to missing flu vaccine documentation. |
| Staff I | Certified Nursing Assistant | Named in findings related to missing flu vaccine documentation. |
| Staff J | Certified Medication Technician | Named in findings related to missing flu vaccine documentation. |
| Executive Director | Participated in exit interviews and acknowledged deficiencies. | |
| Senior Community Business Director | Participated in exit interviews and acknowledged deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 12, 2021
Visit Reason
An offsite review/complaint investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the complaint investigation survey.
Complaint Details
Complaint investigation survey conducted offsite; no deficiencies found.
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