Inspection Report
Renewal
Deficiencies: 5
Nov 4, 2025
Visit Reason
An unannounced State licensure survey was conducted at Brookdale Centre of New England on 11/03/2025 through 11/04/2025 to determine compliance with state regulations.
Findings
Multiple deficiencies were identified related to smoking policy assessments, rights of residents postings, dietetic services and food safety, medication services, and limited health services license requirements. The facility failed to ensure timely smoking assessments, proper posting of survey results, compliance with food service sanitation, secure medication storage, and presence of licensed medical professionals at Quality Improvement Committee meetings.
Deficiencies (5)
| Description |
|---|
| Failure to ensure smoking assessments were completed upon admission, quarterly, and when a significant change in function occurs for residents who smoke. |
| Failure to prominently display the most recent State licensing survey results in the assisted living residence. |
| Failure to comply with Rhode Island Food Code related to sanitation and equipment maintenance in the main kitchen. |
| Failure to follow proper medication administration procedures including secure storage and proper sanitization protocols. |
| Failure to have a licensed physician, certified nurse practitioner, or licensed physician assistant as a member of the Quality Improvement Committee as required. |
Report Facts
Date survey completed: Nov 4, 2025
Resident IDs referenced: 2
Dates of smoking assessments: 3
Dates of Quality Improvement Committee meetings missing licensed professional: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Lascione | Executive Director | Signed the Plan of Correction and acknowledged survey findings |
| Staff A | Observed using dirty dish towel to wipe thermometer during food service observation | |
| Staff B | Licensed Practical Nurse | Acknowledged medication cart was left unlocked and unattended |
| Executive Director | Acknowledged survey results were not prominently displayed and was unable to provide evidence of licensed medical professional attendance at Quality Improvement Committee | |
| Assisted Living Director of Nursing | Acknowledged smoking assessments were not completed upon admission for Resident #6 and unable to provide evidence medications were stored securely | |
| Food Service Director | Acknowledged accumulation of debris on drinks/syrup dispenser and improper sanitation procedures | |
| Business Office Manager | Acknowledged survey results were not prominently displayed |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 12, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted on 08/12/2025 to determine compliance with state regulations following reported elopements of a resident.
Findings
The facility failed to ensure the Alzheimer Dementia Special Care Unit provided a secure distinct living environment appropriate for the resident population, as evidenced by multiple elopement incidents of Resident ID #1. The facility has implemented ongoing corrective actions including increased monitoring, staff training, and monthly committee reviews.
Complaint Details
The complaint investigation was triggered by multiple elopements of Resident ID #1, including incidents on 08/04/2025 and 08/05/2025. The resident was found outside the facility without alarms sounding. The resident was readmitted to a geriatric psychiatric unit and will not return to the community. The complaint was substantiated based on surveyor observations, record reviews, and staff interviews.
Severity Breakdown
L (Specific Requirements): 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The Alzheimer Dementia Special Care Unit/Program failed to provide a secure distinct living environment appropriate for the resident population, resulting in resident elopements. | L (Specific Requirements) |
Report Facts
Date of elopement incidents: Aug 4, 2025
Date of survey: Aug 12, 2025
Date of prior survey identifying issue: May 3, 2022
Time of surveyor observation: 1100
Time of resident last seen: 1615
Time of resident not found: 1620
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Autumn Bishop | Surveyor | Conducted survey and interviews related to elopement investigation |
| Annette Catalfano | Surveyor | Conducted survey and interviews related to elopement investigation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 16, 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 complaint reference numbers 100744 and 101036 and found no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 18, 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 100399, 100392, 100204, and 99544. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 10, 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 96956, 97640, and 97699. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 22, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at Brookdale Centre of New England on July 22, 2024, following a community-reported complaint.
Findings
The investigation found that the facility failed to provide care and services in accordance with prevailing community standards related to hospice recommendations for skin care for Resident #1. Specifically, staff did not apply barrier cream as recommended, and communication failures occurred regarding hospice recommendations.
Complaint Details
The complaint investigation was substantiated by findings that the resident had a reddened area and did not receive recommended barrier cream. Staff interviews revealed failures in communication and implementation of hospice care recommendations.
Deficiencies (1)
| Description |
|---|
| Failure to provide care and services in accordance with hospice recommendations for skin care for Resident #1, including failure to apply barrier cream as recommended and failure to communicate hospice recommendations to the physician. |
Report Facts
Date survey completed: Jul 22, 2024
Plan of Correction completion dates: Aug 9, 2024
Plan of Correction completion dates: Jul 31, 2024
Plan of Correction completion dates: Aug 7, 2024
Plan of Correction completion dates: Aug 9, 2024
Plan of Correction completion dates: Oct 8, 2024
Inspection Report
Complaint Investigation
Deficiencies: 0
May 29, 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 no deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 15, 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 related; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 4
Jan 3, 2024
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility to assess compliance with state licensure requirements.
Findings
Deficiencies were identified related to medication administration, including expired medications and improper storage, as well as inadequate staff training on limited health services. The facility failed to ensure medications were stored securely and that staff received required orientation and ongoing training.
Complaint Details
The visit included a complaint/incident investigation survey as part of the unannounced biennial licensure survey.
Deficiencies (4)
| Description |
|---|
| Failure to ensure medications were stored securely and in a manner to prevent spoilage, dosage errors, administration errors, and inappropriate access for 1 of 4 medication carts observed. |
| Expired medications found on medication carts without resident identifiers or directions for use. |
| Failure to discard Lorazepam opened for greater than 90 days as required. |
| Failure to provide evidence that all employees received at least four hours of orientation and training prior to working with residents receiving limited health services and ongoing training at intervals not to exceed 12 months. |
Report Facts
Medication carts observed: 4
Hours of orientation and training required: 4
Training interval months: 12
Number of employees reviewed for training: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Gaccione | Executive Director | Signed as provider representative on the Statement of Deficiencies and Plan of Correction. |
| Staff A | Certified Medication Technician present during medication cart observation revealing expired medications. | |
| Staff B | Registered Nurse | Observed during medication cart narcotics drawer review and acknowledged expired medication. |
| Director of Wellness | Interviewed and unable to provide evidence of proper medication storage and staff training compliance. | |
| Staff C | Certified Nursing Assistant | Employee record reviewed for hire date and training compliance. |
| Staff D | Certified Nursing Assistant | Employee record reviewed for hire date and training compliance. |
| Staff E | Certified Nursing Assistant | Employee record reviewed for hire date and training compliance. |
| Staff F | Registered Nurse | Employee record reviewed for hire date and training compliance. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 23, 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 complaint-related and no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 9, 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 and no deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 4
Mar 24, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at Brookdale Centre of New England on March 24, 2022, following medication errors related to Resident ID #1.
Findings
The investigation found that the facility failed to ensure all services were rendered safely and effectively, specifically regarding medication administration errors for Resident ID #1. Multiple medication errors occurred between 02/21/2022 and 02/24/2022, resulting in the resident being sent to the hospital for critically high blood pressure. Staff interviews and record reviews confirmed errors in medication orders, administration, and reconciliation.
Complaint Details
The complaint investigation was substantiated as medication errors were confirmed through record review and staff interviews. Resident ID #1 experienced multiple medication errors from 02/21/2022 to 02/24/2022, leading to hospitalization for hypertensive crisis.
Deficiencies (4)
| Description |
|---|
| Failure to ensure all services are rendered in a safe and effective manner consistent with community standards, specifically medication administration errors for Resident ID #1. |
| Failure to complete medication reconciliation after resident admission on 02/23/2022. |
| Incorrect entry of medication orders and administration of wrong medication doses by staff. |
| Medication administration record inaccuracies and failure to document medication administration properly. |
Report Facts
Date of survey completion: Mar 24, 2022
Medication errors timeframe: 4
Resident admission date: Feb 23, 2022
Blood pressure reading: 22494
Number of medications due: 10
Number of medications with no documentation: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse | Noted medication errors, failed to administer medications on 02/23/2022, and acknowledged placing medications in med room without administering |
| Staff A | Licensed Practical Nurse (LPN) | Acknowledged entering the bumetanide order incorrectly |
| Staff C | Registered Nurse | Acknowledged administering the wrong dose of bumetanide on 02/24/2022 and not checking medication accuracy |
| Health and Wellness Director | Responsible for completing medication record review and retraining clinical staff | |
| Executive Director | Responsible for quarterly quality assurance review and verifying compliance |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 7, 2022
Visit Reason
An unannounced complaint/incident investigation survey and a biennial State licensure survey were conducted at this residence.
Findings
Deficiencies were identified relative to the complaint survey and are listed on the biennial State licensure survey.
Complaint Details
The visit was triggered by a complaint/incident investigation as stated in the initial comments.
Inspection Report
Complaint Investigation
Deficiencies: 16
Jan 7, 2022
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility on January 7, 2022.
Findings
Multiple deficiencies were identified related to safe resident handling, administrative management, resident assessments and service plans, infection control, dietary services, medication services, safety requirements, and health screening. The facility failed to meet several regulatory requirements including establishing a safe resident handling program, scheduling nurses for medication administration, completing resident assessments and service plans timely, infection control protocols, and proper documentation of staff health screenings and vaccinations.
Complaint Details
The inspection included a complaint/incident investigation survey as indicated in the initial comments on page 1.
Deficiencies (16)
| Description |
|---|
| Failed to produce evidence of an established Safe Resident Handling program including committee, policies, hazard assessments, and evaluations. |
| Failed to have a scheduled nurse to administer controlled substances as ordered for a resident. |
| Failed to review resident assessments at required intervals and update service plans for residents with significant condition changes. |
| Failed to complete nurse reviews including physical assessments identifying symptoms of illness or changes in health status for six residents. |
| Failed to complete service plans timely and ensure they were reviewed and acknowledged by both parties for residents with condition changes. |
| Failed to establish infection control provisions including screening, temperature documentation, PPE monitoring, and signage related to COVID-19 precautions. |
| Failed to comply with Rhode Island Food Code requirements including proper sanitizing, chemical usage, and food service staff certification. |
| Failed to employ managers certified in food safety as required for licensed capacity. |
| Failed to properly store medications securely and maintain medication administration records for residents. |
| Failed to ensure medication disposal procedures and documentation were followed for hypodermic needles and syringes. |
| Failed to ensure residents received medications as ordered and maintain accurate medication administration records. |
| Failed to develop and maintain a written fire safety plan and conduct required fire drills with adequate resident participation. |
| Failed to maintain documentation of fire drills and ensure exits and means of escape were unobstructed. |
| Failed to submit required variance for hospice services provided to a resident and failed to operate the Alzheimer's Dementia Special Care Unit according to regulations. |
| Failed to ensure residents' rights to access licensed home nursing care or hospice services were documented and communicated. |
| Failed to obtain proper health screenings and immunization documentation for staff providing limited health services. |
Report Facts
Dates of fire drills conducted: 12
Number of screening tools failed to document temperature: 97
Number of screening tools failed to document temperature: 19
Number of screening tools failed to document temperature: 25
Number of visitors/vendors failed to document temperature: 726
Number of fire drills obstructed: 6
Number of residents reviewed for assessment deficiencies: 6
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
Jun 4, 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
Complaint Investigation
Deficiencies: 1
Jan 25, 2021
Visit Reason
An unannounced complaint/incident investigation survey was conducted at Brookdale Centre of New England on January 25, 2021, following community reported complaints.
Findings
The investigation found deficiencies in the resident assessment and service plans, specifically failure to report residents' needs and gather appropriate information for individualized service plans. Documentation of incidents involving inappropriate touching between residents was incomplete, and there were no interventions to prevent future incidents.
Complaint Details
The complaint investigation was substantiated by record reviews and staff interviews revealing incidents of inappropriate touching between residents and inadequate documentation and interventions. Resident #1 no longer resides in the community; Resident #2's service plan was updated to reflect notification and interventions.
Deficiencies (1)
| Description |
|---|
| Failure to report resident's needs and gather information for individualized service plans for two of five residents reviewed. |
Report Facts
Residents reviewed: 5
Incident dates: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Thomas C. Alarcon | Executive Director | Signed the Plan of Correction and acknowledged deficiencies |
| Health and Wellness Director | Acknowledged comprehensive assessments and service plan deficiencies during interview |
Report
File
BROOKDALE CENTRE OF NEW ENGLAND POC EXIT DATE 5.3.2022.pdf
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