Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 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 related to complaint/incident references 100710, 101183, 100769, and 101882. No deficiencies were found.
Inspection Report
Biennial Inspection
Deficiencies: 3
Apr 29, 2025
Visit Reason
An unannounced biennial State licensure survey was conducted at the residence on 4/29/2025 through 4/30/2025 to assess compliance with the State licensure requirements.
Findings
Deficiencies were identified related to management of services, residents' rights, and dietetic services. Specific issues included failure to provide physician orders for residents to self-administer medications, failure to protect residents' privacy, and noncompliance with Rhode Island Food Code in the main kitchen.
Deficiencies (3)
| Description |
|---|
| Failure to provide physician orders for residents to self-administer medications for 2 of 3 residents reviewed. |
| Failure to ensure residents' privacy was protected, including lack of evidence of privacy protection during surveyor interview. |
| Failure to comply with Rhode Island Food Code in the main kitchen, including unlabeled and undated food items, scored cutting boards, and unclean storage areas. |
Report Facts
Deficiencies identified: 3
Survey dates: 2
Residents reviewed for self-administration: 3
Audit monitoring period: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Named in relation to findings on medication orders and kitchen food safety compliance. |
| Resident Care Director | Resident Care Director | Present during surveyor interview regarding medication orders and residents' privacy. |
| ED/Dining Service Director | ED/Dining Service Director | Responsible for re-education of kitchen staff and monitoring food safety compliance. |
Inspection Report
Biennial Inspection
Deficiencies: 3
Apr 29, 2025
Visit Reason
An unannounced biennial State licensure survey was conducted at the residence on 4/29/2025 through 4/30/2025 to assess compliance with State licensure requirements.
Findings
Deficiencies were identified related to management of services, residents' rights, and dietetic services. Specific issues included failure to provide physician orders for residents to self-administer medications, failure to protect residents' privacy, and noncompliance with Rhode Island Food Code standards in the kitchen.
Deficiencies (3)
| Description |
|---|
| Failure to provide physician orders for residents to self-administer medications as required by management of services regulations. |
| Failure to ensure residents' rights and privacy were protected, including lack of evidence of residents' privacy protection during surveyor interviews. |
| Noncompliance with Rhode Island Food Code including unlabeled and undated food items, scored cutting boards, and unclean storage areas in the kitchen. |
Report Facts
Date survey completed: Apr 30, 2025
Number of residents reviewed for self-administration: 3
Date of initial survey observation: Apr 29, 2025
Date of kitchen tour: Apr 29, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Named in relation to findings on medication orders and kitchen deficiencies |
| Resident Care Director | Resident Care Director | Present during resident interview regarding medication orders and privacy findings |
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 17, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted on 02/17/2025 to determine compliance with state regulations, triggered by multiple ACTS reference numbers.
Findings
A deficiency was identified related to the lack of qualified personnel to attend to food preparation for a resident requiring pureed textured food. The investigation included review of records and staff interviews, revealing failure to use recipes and provide evidence of competency in preparing pureed foods.
Complaint Details
The complaint involved an incident on 2/8/2025 where a server witnessed a resident choking and performed the Heimlich maneuver with assistance from the Dining Director. The resident was transported to the hospital by EMS. The resident had a diagnosis including dysphagia and was on a pureed texture diet with thin liquids. The facility failed to have qualified staff to prepare pureed foods and did not use recipes or provide evidence of competency for dietary staff.
Deficiencies (1)
| Description |
|---|
| Failure to have qualified personnel to attend to food preparation for a resident requiring pureed textured food. |
Report Facts
ACTS reference numbers: 6
Incident date: Feb 8, 2025
Record review date: Nov 5, 2024
Service plan date: Jan 30, 2025
Surveyor interview times: 130
Surveyor interview times: 315
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dining Director | Assisted with Heimlich maneuver during choking incident | |
| Staff A | dietary cook | Interviewed and revealed he does not use recipes to prepare pureed foods |
| Executive Director | Executive Director | Interviewed and unable to provide evidence of dietary staff competencies or recipes for pureed foods |
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 4, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted on 9/4/2024 at the facility following a community reported complaint dated 8/26/2024 alleging the residence did not have a Certified Medication Technician (CMT) overnight or a nurse to administer medications to residents.
Findings
The investigation found that the residence failed to provide qualified staff to administer PRN medications during the 11:00 PM to 7:00 AM shift on multiple dates for 12 of 20 residents on the secured memory unit. Interviews and record reviews confirmed the lack of licensed staff to administer medications overnight, and the facility was unable to provide evidence that it was staffed with appropriate licensed personnel to meet residents' needs.
Complaint Details
The complaint was substantiated based on findings that the residence did not have a Certified Medication Technician (CMT) or nurse available overnight to administer medications as required.
Deficiencies (1)
| Description |
|---|
| Failure to provide qualified staff to administer PRN medications during the 11:00 PM to 7:00 AM shift on multiple dates for 12 of 20 residents on the secured memory unit. |
Report Facts
Residents affected: 12
Dates reviewed: 8
PRN medications audit: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Resident Care Associate (RCA) | Interviewed on 9/4/2024 regarding medication administration and CMT on-call status. |
| Executive Director | Interviewed on 9/4/2024 and unable to provide evidence of appropriate licensed staffing. | |
| Resident Care Director (RCD) | Interviewed regarding awareness of missed medication administration on 8/21/2024. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 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
Plan of Correction
Deficiencies: 5
Jun 23, 2023
Visit Reason
An unannounced biennial State Licensure survey was conducted at this assisted living residence to assess compliance with state licensure regulations.
Findings
Deficiencies were identified related to administrative management, staffing for medication administration, resident assessments and service plans, and dietetic services including food safety practices. The facility failed to provide qualified staff to administer PRN medications during certain shifts and did not update resident assessments and service plans timely to reflect outside services. Food service staff were observed not wearing required hair restraints.
Deficiencies (5)
| Description |
|---|
| Failure to have an administrator certified by the Department and responsible for safe and proper operation of the residence. |
| Failure to staff the residence with adequate and qualified personnel to administer PRN medications during the 11:00 PM to 7:00 AM shift for residents requiring assistance. |
| Failure to review resident assessments at intervals not to exceed 12 months and update service plans when condition changes significantly for 4 of 6 residents reviewed. |
| Failure to review service plans at intervals not to exceed 12 months and update plans to accurately reflect outside services for 3 of 6 residents reviewed. |
| Failure to comply with Rhode Island Food Code requirements including food service staff not wearing hair restraints while preparing exposed food. |
Report Facts
Residents reviewed: 6
Audit frequency: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Acknowledged residents had PRN orders and staffing issues during interview on 6/23/2023 | |
| Nurse Designee, Staff A | Interviewed on 6/22/2023 regarding medication technician schedules and resident services | |
| Dining Service Director | Acknowledged staff were not wearing hair restraints while preparing exposed food |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 16, 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 visit was complaint-related as an unannounced complaint/incident investigation survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 8, 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
Nov 3, 2021
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: 6
Jul 7, 2021
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility on 07/07/2021.
Findings
Deficiencies were identified related to safe resident handling, administrative management, medication administration, and medication storage and documentation. The facility failed to produce evidence of a safe resident handling program, failed to ensure qualified staff administered medications properly, and failed to ensure medications were stored securely and administered according to physician orders.
Complaint Details
The visit included a complaint/incident investigation survey as part of the unannounced biennial licensure survey.
Deficiencies (6)
| Description |
|---|
| Failure to ensure a safe resident handling program was established and maintained, including quarterly meetings and assessments. |
| Failure to have an administrator certified by the Department in charge of maintenance and services, and failure to provide qualified staff to administer medications properly. |
| Failure to administer medications according to physician orders and failure to have qualified staff available to administer PRN medications and oxygen therapy during the 11 PM-7 AM shift. |
| Failure to ensure medications were stored securely, properly labeled, and administered according to policy, including failure to dispose of hypodermic needles properly. |
| Failure to ensure expired medications were removed from the medication cart and failure to maintain proper medication records. |
| Failure to provide physician orders for oxygen therapy and failure to document oxygen administration properly. |
Report Facts
Dates of meetings reviewed: 3
Number of sample residents reviewed: 12
Number of residents with PRN medications reviewed: 9
Dates of medication orders expiration: 7
Dates of oxygen therapy record review: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Interviewed on 07/07/2021 regarding safe resident handling program and medication administration. | |
| Staff A | Registered Nurse | Interviewed on 07/07/2021 regarding oxygen therapy administration for Resident ID #10. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 7, 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/incident investigation survey.
Complaint Details
The complaint/incident investigation was unannounced and no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 3
Mar 11, 2021
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence due to a complaint filed by a resident's family member alleging neglect related to poor nutritional status and lack of food and water intake.
Findings
The investigation found deficiencies in the comprehensive assessment and service plans for Resident ID #1, including failure to update assessments to reflect changes in condition, inadequate monitoring of weight and nutritional status, and failure to provide care consistent with community standards for residents with dementia. The family's claim of neglect was determined to be unsubstantiated.
Complaint Details
Complaint filed on 3/5/2021 by Resident ID #1's family member alleging neglect due to poor nutritional status and lack of food and water intake. The Rhode Island Department of Health investigation concluded the family's claim was 'unfounded'.
Deficiencies (3)
| Description |
|---|
| Failure to ensure comprehensive assessment reflected changes in condition or annual updates for Resident ID #1. |
| Failure to uphold residents' rights related to neglect of significant changes in nutritional status for Resident ID #1. |
| Failure to provide care and services in accordance with community standards for residents with dementia, including monitoring weight and nutritional status for Resident ID #1. |
Report Facts
Weight loss: 9
Resident weight: 50.4
Resident weight: 100.1
Inspection date: Mar 11, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director and Interim Director of Wellness | Acknowledged that Resident ID #1's comprehensive assessment had not been updated to reflect changes in condition. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Feb 15, 2021
Visit Reason
An unannounced complaint/incident investigation survey and a follow-up to a previous survey (SRVJ11, 02/15/2021) was conducted at this residence to investigate deficiencies related to resident care and service plans.
Findings
Deficiencies were identified related to failure to update and review service plans for residents with significant changes in condition, inadequate supervision and safety measures for a resident with dementia and wandering behaviors, and failure to uphold residents' rights in a safe environment. The facility acknowledged these issues and planned corrective actions including updated care plans, staff re-education, and audits.
Complaint Details
The visit was triggered by an unannounced complaint/incident investigation and was a follow-up to a previous survey. The complaint involved Resident ID #1 who exhibited wandering, confusion, hallucinations, and unsafe behaviors. The facility was found to have failed in updating service plans and ensuring safety and rights of the resident. The Executive Director and Administrator acknowledged the behaviors and deficiencies during interviews.
Deficiencies (3)
| Description |
|---|
| Failure to ensure the resident's service plan was updated to reflect changes of condition for one of five sample residents. |
| Resident residing in the Alzheimer Dementia Special Care Unit did not have adequate tracking and safety measures to ensure a safe environment. |
| Failure to ensure residents' rights were upheld relative to a safe environment for one of five sample residents. |
Report Facts
Deficiencies cited: 3
Timeframe for tracking audits: 4
Timeframe for tracking audits: 2
Months since resident moved to Alzheimer Dementia Special Care Unit: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Acknowledged Resident ID #1's change in condition and behaviors during interviews. | |
| Administrator | Acknowledged that the secure unit was not at licensed capacity at the time of Resident ID #1's wandering behavior. |
Inspection Report
Follow-Up
Deficiencies: 0
Feb 15, 2021
Visit Reason
A follow-up survey to a complaint investigation survey and a new complaint investigation survey was conducted at this residence.
Findings
All former deficiencies were corrected. New deficiencies were identified and are listed on the complaint investigation survey.
Complaint Details
The visit was related to a complaint investigation survey and a new complaint investigation survey.
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