Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 13, 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 reference numbers 102373 and 102389. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 3, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations based on ACTS reference numbers 100707, 101998, and 102176.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was unannounced and based on multiple complaint reference numbers. No deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 13, 2025
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility on 03/12/2025 and 03/13/2025.
Findings
A deficiency was identified related to Residency Requirements 2.4.15(A) Resident Records, specifically the failure to include information about specific health problems of the resident receiving dialysis, as evidenced by missing dialysis communications and treatments documentation.
Complaint Details
The complaint investigation found that the residence failed to include, at a minimum, information about specific health problems of the resident receiving dialysis. Record review and staff interviews confirmed missing dialysis communications and treatments documentation for Resident ID #1.
Deficiencies (1)
| Description |
|---|
| Failure to maintain complete resident records including specific health problems and dialysis communications for a resident receiving dialysis. |
Report Facts
Date survey completed: Mar 13, 2025
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 13, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted along with a state licensure survey to determine compliance with state regulations.
Findings
A deficiency was identified relative to the state licensure survey during the investigation.
Complaint Details
The visit was triggered by complaint/incident investigation with ACTS reference numbers 99549 and 99917.
Deficiencies (1)
| Description |
|---|
| A deficiency was identified relative to the state licensure survey. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 7, 2024
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 related to a complaint or incident; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 6, 2024
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 based; no deficiencies were found.
Inspection Report
Renewal
Deficiencies: 3
May 22, 2023
Visit Reason
An unannounced biennial State Licensure survey was conducted at this residence to assess compliance with state licensure requirements.
Findings
The facility failed to provide care and services in accordance with prevailing community standards of care, including failure to supervise transfers and mobility for a high-risk resident, failure to review resident assessments timely, and failure to ensure medication safety for a resident retaining their own medications.
Deficiencies (3)
| Description |
|---|
| Failure to provide care and services in accordance with prevailing community standards of care, resulting in fall risks for resident #1. |
| Failure to review resident assessments at intervals not to exceed 12 months and when condition changes for residents #1 and #2. |
| Failure to ensure medication safety for resident #3 who retains their own medications, including lack of assessment for self-administration of oxygen. |
Report Facts
Dates of nurse reviews for resident #1: 01/05/2023, 04/06/2023, 10/26/2022, 11/19/2022, 03/26/2023, 03/27/2023, 03/28/2023, 04/12/2023
Dates of wound care entries for resident #1: 04/21/2023, 05/02/2023, 05/09/2023
Date of last comprehensive assessment for resident #1: 07/22/2022
Date of last comprehensive assessment for resident #2: 12/29/2022
Date hospice services began for resident #2: 01/25/2023
Date of comprehensive assessment for resident #3: 08/15/2021
Date of service plan for resident #3: 01/26/2023
Date of last self-administration assessment for resident #3: 03/15/2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Services Director | Acknowledged resident #1 had several falls with no documented care coordination for prevention; unable to provide evidence resident #1 and #2 assessments updated; named in retraining and compliance responsibility. | |
| Executive Director | Signed the report; responsible for auditing compliance weekly for 90 days. | |
| Regional Care Director | Assigned to retrain Resident Services Director and nursing staff on assessment requirements. |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 17, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the facility.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was unannounced and complaint/incident based; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 29, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at Atria Lincoln Place following an allegation of abuse involving two residents.
Findings
The residence failed to observe the standards related to residents' rights, specifically regarding prevention, detection, and reporting of abuse, neglect, and exploitation. The investigation found incidents involving two residents with dementia, including physical altercations and inadequate staff response and documentation.
Complaint Details
The complaint investigation was substantiated based on record review and staff interviews. Incidents included Resident #1 attempting to force Resident #2, physical altercations, and failure of staff to file incident reports timely. Resident #1 remained in the residence after the incident, and the facility failed to send Resident #1 for medical evaluation after the incident, placing Resident #2 at continued risk.
Deficiencies (1)
| Description |
|---|
| Failure to observe the standards stated in R.I. Gen. Laws § 23-17.4-16, 'Rights of Residents', for 1 of 2 residents reviewed relative to an allegation of abuse. |
Report Facts
Incident date: Sep 25, 2022
Incident report date: Sep 26, 2022
Plan of Correction completion date: Nov 13, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lynn-Marie Almeida | Executive Director | Signed the report and was interviewed regarding incident reporting and staff compliance |
| Resident Services Director | Responsible for retraining staff and reviewing communication logs and incident reports |
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 7, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at Atria Lincoln Place following a complaint filed regarding failure to notify family members about a resident's hospital transfer after a fall.
Findings
The investigation found that the residence failed to ensure all services were rendered in a safe and effective manner, specifically failing to notify the resident's power of attorneys (POAs) about the incident and hospital transfer. Documentation and communication efforts were insufficient, and the Regional Vice President acknowledged a lack of documentation regarding staff efforts to contact the POAs.
Complaint Details
The complaint was filed to the Rhode Island Department of Health on 01/26/2022 by POA #2, alleging failure to notify family about the resident's hospital transfer after a fall. The complaint was substantiated by findings of insufficient communication and documentation.
Deficiencies (1)
| Description |
|---|
| Failure to ensure all services were rendered in a safe and effective manner and failure to notify resident's POAs about emergency medical care and hospital transfer. |
Report Facts
Dates: Jan 7, 2022
Dates: Jan 8, 2022
Dates: Jan 14, 2022
Dates: Jan 26, 2022
Dates: Sep 7, 2022
Time: 1035
Time: 1200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lynn-Marie Almeida | Executive Director | Signed the plan of correction and responsible for retraining staff and reviewing communication logs |
Inspection Report
Complaint Investigation
Deficiencies: 3
Nov 5, 2021
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence due to identified deficiencies.
Findings
The facility failed to provide care and services in accordance with community standards and physician orders for two of six sampled residents, including failures in blood sugar monitoring and documentation, resident assessments, and timely updates of comprehensive assessments after changes in condition or readmission.
Complaint Details
The investigation was complaint/incident triggered. Deficiencies were identified related to medication administration and resident assessments. Substantiation status is not explicitly stated.
Deficiencies (3)
| Description |
|---|
| Failure to provide care and services in accordance with physician orders, including inadequate blood sugar monitoring and documentation. |
| Failure to review resident assessments at intervals not exceeding twelve months and after significant condition changes. |
| Failure to update comprehensive assessments to reflect changes in condition and readmission within required timeframes. |
Report Facts
Dates of missing blood sugar documentation: 13
Resident sample size: 6
Resident IDs with noted deficiencies: 3
Assessment review interval: 12
Readmission assessment timeframe: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Wellness | Interviewed on 11/05/2021 and unable to provide evidence for resident assessments and blood sugar monitoring. | |
| Executive Director | Responsible for reviewing assessments weekly and ensuring compliance with Appendix C requirements. | |
| Resident Services Director | Responsible for educating nurses on consistent documentation and conducting weekly audits until compliance is met. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 14, 2021
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the complaint/incident investigation survey.
Complaint Details
The visit was an unannounced complaint/incident investigation survey with no deficiencies identified.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 8, 2021
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 no deficiencies were found.
Inspection Report
Follow-Up
Deficiencies: 7
May 26, 2021
Visit Reason
A biennial State licensure survey and unannounced complaint/incident investigation survey were conducted at the facility to assess compliance with state regulations and investigate complaints.
Findings
Multiple deficiencies were identified related to safe resident handling, in-service training, resident assessments, medication services, and fire safety requirements. The facility failed to maintain a safe resident handling committee, conduct required resident assessments, provide required staff training, complete medication aide evaluations, and properly document fire drills.
Deficiencies (7)
| Description |
|---|
| Failed to maintain a safe resident handling committee chaired by a professional nurse or licensed health care professional. |
| Failed to conduct a safe resident handling hazard assessment on each resident as required. |
| Failed to provide ongoing in-service training for staff within required intervals. |
| Failed to complete safe resident handling assessments for residents admitted after September 2020. |
| Failed to use department-approved assessment forms for resident assessments. |
| Failed to ensure quarterly evaluations of registered medication aides administering drugs. |
| Failed to maintain proper documentation of fire drills including type of drill and resident evacuation ability. |
Report Facts
Dates of Safe Resident Handling Committee meetings: 5
Staff hire dates reviewed: 4
Fire drill dates reviewed: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Resident Service Assistant | Had a hire date of 12/17/2019 and was identified in in-service training deficiency |
| Staff B | Certified Nursing Assistant | Had a hire date of 04/12/2019 and was identified in in-service training deficiency |
| Staff C | Certified Medication Technician (CMT)/Certified Nursing Assistant (CNA) | Had a hire date of 10/12/2020 and was identified in medication services deficiency |
| Staff D | Certified Medication Technician (CMT)/Certified Nursing Assistant (CNA) | Had a hire date of 11/12/2020 and was identified in medication services deficiency |
| Staff E | Certified Medication Technician (CMT)/Certified Nursing Assistant (CNA) | Had a hire date of 11/02/2020 and was identified in medication services deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 21, 2021
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 no deficiencies were found, indicating no substantiated issues.
Inspection Report
Deficiencies: 0
Jan 5, 2021
Visit Reason
An administrative review/offsite investigation was conducted at this residence.
Findings
No deficiencies were identified during the administrative review/offsite investigation.
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