Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 10, 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 ACTS reference numbers 100784, 101881, and 101735. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 18, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations based on ACTS reference numbers 100394, 100373, and 100063.
Findings
The facility failed to update the service plan and implement interventions for residents assessed as fall risks, specifically for Resident ID #1 and Resident ID #11. Evidence showed lack of customized interventions to reduce fall risks in service plans and staff notification.
Complaint Details
The investigation was complaint-related with substantiation implied by identification of deficiencies in service plan updates and fall risk interventions for residents.
Deficiencies (1)
| Description |
|---|
| Failure to update the service plan and implement interventions for residents assessed as fall risks, including lack of customized interventions to reduce fall risks. |
Report Facts
Residents reviewed: 3
Fall incidents: 2
Dates of service plan review: Mar 19, 2025
Date of surveyor interview: Apr 18, 2025
Plan of correction completion date: Apr 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Wellness | Interviewed by surveyor on 4/18/2025; unable to provide evidence of customized interventions | |
| Regional Care Director | Retrained Resident Service Director and designee to ensure compliance with service plan requirements | |
| Resident Service Director | Responsible for including custom interventions in service plans and auditing service plans for 90 days | |
| Executive Director | Will audit service plans for 90 days to ensure compliance |
Inspection Report
Original Licensing
Deficiencies: 1
Mar 4, 2025
Visit Reason
The inspection was conducted to review compliance with regulations regarding the licensure of nursing assistants and medication aides, specifically assessing whether staff providing personal care hold the required Rhode Island CNA license.
Findings
The inspection found that two staff members providing personal care to residents did not hold a Rhode Island CNA license, which is required by state regulations. The facility acknowledged that Resident Service Assistants providing personal care do not hold active CNA licenses.
Deficiencies (1)
| Description |
|---|
| Staff providing personal care to residents do not hold a Rhode Island CNA license as required by state regulations. |
Report Facts
Date of survey completion: Mar 4, 2025
Plan of correction completion date: Jun 30, 2025
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 7, 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 complaint reference numbers 97860, 97613, and 97805 and found no deficiencies.
Inspection Report
Plan of Correction
Deficiencies: 2
Dec 19, 2023
Visit Reason
The document is a plan of correction submitted in response to deficiencies identified during a State Complaint Investigation Survey conducted on December 19, 2023, at Atria Aquidneck Place.
Findings
Deficiencies were identified related to failure to review and update resident assessments and service plans at required intervals, including failure to document outside services and physical therapy received by a resident. The facility failed to update assessments and service plans to reflect significant condition changes and outside services provided.
Complaint Details
This was an unannounced complaint/incident investigation survey with ACTS reference numbers 92575 and 93161. Deficiencies were identified during this complaint investigation.
Deficiencies (2)
| Description |
|---|
| Failure to review the resident's comprehensive assessment at intervals not to exceed twelve months and when condition changes significantly. |
| Failure to review and update the resident's service plan at required intervals and to accurately reflect outside services provided. |
Report Facts
ACTS reference numbers: 92575 and 93161 related to the complaint investigation
Dates of physical therapy visits: 10/24/2023, 10/27/2023, 11/1/2023, 10/26/2023 through 11/16/2023
Dates of un-witnessed falls: 10/6/2023, 10/8/2023, 11/6/2023, 11/21/2023
Assessment review interval: 12
Number of sample residents reviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason M. Grifka | Administrator | Signed the plan of correction letter |
| Diane T. Pelletier | Chief, Center for Health Facilities Regulation | Signed the letter transmitting the plan of correction |
Inspection Report
Plan of Correction
Deficiencies: 9
May 10, 2023
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the residence on 05/10/2023.
Findings
Multiple deficiencies were identified related to safe resident handling, management of services including care and service provision, residency requirements, resident assessments, smoking policy, dietetic services, physical plant safety requirements, and fire drills. The facility submitted a Plan of Correction to address these deficiencies and ensure compliance with applicable laws and regulations.
Deficiencies (9)
| Description |
|---|
| Failed to ensure at least half of the safe resident handling committee members are hourly, non-managerial employees who provide direct resident care. |
| Failed to provide care and services in accordance with prevailing community standards of care relative to skin assessment and wound care for residents. |
| Failed to complete a quarterly smoking assessment for a resident who smokes. |
| Retained residents who did not meet the definition of a resident for wound care. |
| Failed to complete discharge summaries for 5 of 5 closed resident records reviewed. |
| Failed to ensure nurse reviews were completed at least once every 90 days for two of four sample residents reviewed. |
| Failed to ensure resident assessments and service plans were completed and reviewed as required, including use of approved forms and documentation of outside services. |
| Failed to employ managers certified in food safety as required for licensed capacity and food preparation. |
| Failed to conduct required fire drills with at least 50% completion rate and documented resident ability to carry out evacuation procedures. |
Report Facts
Dates of safe resident handling committee attendance sheets lacking hourly members: 3
Dates of safe resident handling committee attendance sheets lacking hourly members: 1
Number of residents reviewed for wound care: 3
Number of residents reviewed for discharge summaries: 5
Number of residents reviewed for nurse reviews: 4
Number of residents reviewed for assessments and service plans: 12
Licensed capacity threshold for food safety manager requirements: 26
Number of fire drills conducted: 16
Percentage of obstructed fire drills: 12.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Service Director | Named in multiple findings related to wound care, resident assessments, smoking assessments, medication management, and audits. | |
| Executive Director | Named in interviews and responsible for oversight of compliance and audits. | |
| Regional Director of Care | Retained Resident Service Director and provided retraining according to facility work instructions. | |
| Director of Culinary Services | Completed Rhode Island Food Manager Certification and responsible for food safety compliance. | |
| Maintenance Director | Responsible for fire drill procedures and compliance. |
Inspection Report
Routine
Deficiencies: 0
Jan 11, 2022
Visit Reason
An administrative review/offsite investigation was conducted at this residence to assess compliance.
Findings
No deficiencies were identified during this deficiency free survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 1, 2021
Visit Reason
An unannounced focused survey was conducted at this residence related to COVID-19 infection control.
Findings
No deficiencies were identified during the COVID-19 infection control focused survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 13, 2021
Visit Reason
A biennial State licensure survey and a complaint/incident investigation survey were conducted at this residence on 05/13/2021.
Findings
No deficiencies were identified relative to the State licensure survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 13, 2021
Visit Reason
A complaint/incident investigation survey and a biannual State licensure survey were conducted at this residence on 05/13/2021.
Findings
No deficiencies were identified relative to the State licensure survey.
Complaint Details
The visit was complaint-related as it included a complaint/incident investigation survey.
Inspection Report
Complaint Investigation
Deficiencies: 4
Dec 9, 2020
Visit Reason
An unannounced complaint investigation survey and a focused COVID-19 infection control survey were conducted at the residence.
Findings
Deficiencies were identified related to infection control, including failure to establish infection control provisions for the mutual protection of residents, employees, and the public relative to COVID-19 standards. Specific issues included lack of required gowns for staff caring for quarantined residents, inadequate signage, and failure of staff to follow disinfectant contact time instructions.
Complaint Details
The visit was triggered by an unannounced complaint investigation survey focused on COVID-19 infection control. Deficiencies were identified relative to infection control practices and failure to comply with CDC and Rhode Island Department of Health COVID-19 guidance.
Deficiencies (4)
| Description |
|---|
| Failure to establish infection control provisions for mutual protection of residents, employees, and the public relative to COVID-19 standards. |
| Staff failed to wear gowns when caring for residents on quarantine. |
| Signage at the door of quarantined residents' rooms failed to require a gown for care. |
| Maintenance and housekeeping staff failed to provide accurate information or follow manufacturer directions regarding disinfectant contact time needed to kill viruses. |
Report Facts
Date of survey: Dec 9, 2020
Training completion deadline: Jan 25, 2021
Audit period: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrew L M Santo | FD | Provider/Supplier Representative who signed the plan of correction |
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