Inspection Reports for Brookdale Sakonnet Bay
1215 MAIN ROAD, TIVERTON, RI, 02878
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
115% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Follow-Up
Deficiencies: 0
Jun 24, 2025
Visit Reason
An off-site desk audit was conducted on June 24, 2025, to review all previous deficiencies cited on May 14, 2025.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 8
May 14, 2025
Visit Reason
A state licensure survey was conducted at Brookdale Sakonnet Bay from 5/12/2025 through 5/14/2025 to determine compliance with state law and regulations.
Findings
Deficiencies were cited related to the facility's failure to comply with all required components of the safe resident handling program, including hazard assessments, policy development, annual performance evaluations, and resident care policies. Additional deficiencies involved wound care and falls management practices.
Deficiencies (8)
| Description |
|---|
| Failure to conduct resident handling hazard assessments as part of the safe resident handling program. |
| Failure to develop a process to identify appropriate use of safe resident handling based on resident condition and equipment availability. |
| Failure to complete an annual performance evaluation of the safe resident handling program. |
| Failure to submit an annual report to the safe resident handling committee on activities related to injury risk control. |
| Failure to provide care and services in accordance with the prevailing community standard for wound care for 1 of 1 wound reviewed. |
| Failure to implement a falls management program including appropriate signage and interventions for residents at risk of falls. |
| Failure to implement a bladder toileting program and update care plans to prevent falls. |
| Failure to properly manage psychotropic medication use and re-evaluate orders as required. |
Report Facts
Dates of survey: Survey conducted from 2025-05-12 through 2025-05-14
Dates of plan completion: Corrective actions planned for completion on various dates including 2025-05-15, 2025-05-17, 2025-05-19, 2025-05-23, 2025-05-29, 2025-06-11
Fall Risk Data Collection score: 22
Number of wounds reviewed: 1
Number of residents reviewed for falls: 2
Number of residents reviewed for psychotropic medication: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marianne Wolcott | Administrator | Signed the plan of correction document |
| Staff A | Registered Nurse | Observed applying wound care and acknowledged improper technique |
| Director of Clinical Services | Interviewed during survey and involved in corrective actions and wound care oversight | |
| Executive Director | Present during surveyor interview with Director of Clinical Services |
Inspection Report
Plan of Correction
Deficiencies: 0
May 9, 2024
Visit Reason
An off-site desk audit was conducted on May 9, 2024, to review all previous deficiencies cited on March 22, 2024.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Deficiencies: 7
Mar 22, 2024
Visit Reason
The annual State licensure survey was conducted at Brookdale Sakonnet Bay from 3/20/2024 through 3/22/2024 to assess compliance with regulatory requirements.
Findings
Deficiencies were identified related primarily to COVID-19 practices and procedures, including failure to prevent transmission of COVID-19, inadequate use of PPE by staff, failure to screen visitors and staff for symptoms, and failure to complete required medical and physical assessments timely. Additional deficiencies involved medication administration and specialized rehabilitative services.
Deficiencies (7)
| Description |
|---|
| Failure to take proper actions to prevent transmission of COVID-19 in accordance with Rhode Island Department of Health guidance upon identification of residents who tested positive for COVID-19. |
| Staff failed to wear N95 masks and face shields or goggles as required when entering rooms of residents with COVID-19. |
| Failure to screen staff and visitors for COVID-19 symptoms upon entrance to the facility. |
| Failure to ensure medical care plans and physical examinations were completed within required timeframes for residents. |
| Failure to administer medications in accordance with physician orders for one resident. |
| Failure to provide rehabilitative services under a written plan of care for one resident. |
| Failure to follow policy related to nutritional care and weight monitoring for residents, including failure to notify appropriate staff of significant weight changes. |
Report Facts
Dates of survey: Survey conducted from 3/20/2024 through 3/22/2024
Number of residents positive for COVID-19: 7
Weight loss percentage: 4.2
Medication doses missed: Multiple medications not administered on specific dates in March 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Receptionist | Failed to screen surveyors for COVID-19 symptoms and did not wear N95 mask on unit with COVID-19 positive residents |
| Staff B | Receptionist | Did not screen surveyors or visitors for COVID-19 symptoms |
| Staff C | Occupational Therapist | Observed entering unit without wearing N95 mask; involved in evaluation of residents requiring AFOs |
| Staff D | Nursing Assistant | Observed entering COVID-19 positive resident room without face shield or eye protection |
| Staff F | Nursing Assistant | Revealed resident requires use of ankle-foot orthosis brace daily |
| Staff E | Registered Nurse | Unaware of resident's weight loss during survey interview |
| Staff G | Registered Nurse | Unaware of resident's weight loss during survey interview |
| Director of Clinical Services | Responsible for re-educating staff on COVID-19 infection control and monitoring compliance | |
| Director of Nursing Services | Interviewed regarding COVID-19 positive residents and staff PPE use | |
| Executive Director | Acknowledged screening visitors for COVID-19 symptoms was not conducted | |
| Assistant Director of Clinical Services | Conducted audits and monitoring of residents' history and physical completion | |
| Director of Rehabilitation | Acknowledged resident wearing ankle-foot orthosis brace |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 25, 2023
Visit Reason
An off-site desk audit was conducted on 4/25/2023 for all previous deficiencies cited on 4/5/2023 to verify correction.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected. The facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Deficiencies: 3
Apr 5, 2023
Visit Reason
The annual State licensure survey for Brookdale Sakonnet Bay was conducted from April 4, 2023 through April 5, 2023 to assess compliance with statutory and regulatory requirements.
Findings
The survey identified deficiencies related to medication technician evaluations, dietetic services compliance with Rhode Island Food Code, and pharmaceutical services including proper labeling and storage of medications. The facility submitted plans of correction for each deficiency with timelines for completion.
Deficiencies (3)
| Description |
|---|
| Failure to ensure quarterly evaluations for medication technicians were completed and documented. |
| Failure to comply with Rhode Island Food Code standards for food labeling and dating in the main kitchen and kitchenettes. |
| Failure to ensure proper labeling of drugs and biologicals including resident name, physician name, drug dosage, cautionary instructions, and expiration dates. |
Report Facts
Containers of food observed: 50
Expired supplies: 100
Expired urine cups: 5
Expired antiseptic wipes: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Technician | Named in deficiency related to failure to complete quarterly medication technician evaluations and medication labeling issues. |
| Director of Clinical Services | Interviewed regarding medication technician evaluations and medication labeling deficiencies. | |
| Staff B | Dietary Aide | Interviewed regarding food items without dates in the kitchenettes. |
| Director of Dining Services | Interviewed regarding food labeling and dating deficiencies. | |
| Assistant Director of Clinical Services | ADCS | Interviewed regarding expired medication supplies and labeling issues. |
Inspection Report
Plan of Correction
Deficiencies: 0
May 6, 2022
Visit Reason
An off-site desk audit was conducted on 5/6/2022 to review all previous deficiencies cited on 3/17/2022.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Capacity: 30
Deficiencies: 11
Mar 17, 2022
Visit Reason
The annual State licensure and a complaint investigation (L29611) survey were conducted at Brookdale Sakonnet Bay on 03/17/2022.
Findings
Deficiencies were identified including failure to have a written quality improvement plan with all required components, failure to evaluate all resident care services including contracted services, failure to obtain evidence of immunity for all health care workers, failure to maintain bed linens, failure to properly document remedial actions, failure to secure medication carts, failure to properly document wound care and skin integrity, failure to administer medication according to physician orders, and failure to comply with Rhode Island Food Code standards in the food service operation.
Complaint Details
Complaint investigation (L29611) was conducted concurrently with the annual licensure survey.
Deficiencies (11)
| Description |
|---|
| Facility failed to have a written quality improvement plan which included all required components. |
| Quality improvement committee failed to evaluate all resident care services including contracted services such as physical therapy, occupational therapy, speech therapy, hospice care, psychiatric services, and dietitian services. |
| Facility failed to obtain evidence of immunity for all health care workers in accordance with immunization, testing, and health screening rules. |
| Facility failed to maintain an adequate quantity of bed linens and failed to provide bed linens in accordance with policy. |
| Facility failed to document appropriate remedial action to address problems identified through the quality improvement program. |
| Medication carts were not secured during medication passes and medication administration was not properly documented according to physician orders. |
| Resident care records failed to document detailed descriptions of pressure ulcers and skin lesions, and wound care documentation was incomplete or missing. |
| Facility failed to administer medication in accordance with physician orders including oxygen administration and medication dosage. |
| Food service operation failed to comply with Rhode Island Food Code including non-food contact surfaces, handwashing sinks, temperature control, and cleaning schedules. |
| Facility failed to maintain a quantity of linen equivalent to three times the number of beds as required. |
| Facility failed to conduct full-scale emergency preparedness drills annually and failed to maintain documentation of such drills. |
Report Facts
Licensed beds: 30
Weekly bed linens available: 19
Temperature readings: 9
Pressure ulcer stage: 3
Weight loss percentage: 5.71
Oxygen liters: 4
Weekly wound audits: 3
Emergency preparedness drills: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant Staff B failed to reveal evidence of up-to-date Tdap or influenza vaccination. | |
| Staff E | Certified Nursing Assistant Staff E failed to reveal evidence of vaccination for influenza or declination. | |
| Staff F | Registered Nurse | Observed preparing blood glucose test and medication administration; unable to provide evidence of weekly wound data collection completion. |
| Director of Clinical Services | Unable to produce evidence of a written quality improvement plan; acknowledged quality improvement committee did not document remedial action; verified medication cart was locked; reviewed resident charts and wound documentation; responsible for audits and corrective actions. | |
| Assistant Director of Clinical Services | Unable to provide evidence of detailed wound descriptions; re-educated nurses on wound documentation and medication cart policy. | |
| Director of Dining Services | Updated cleaning schedule and re-educated kitchen staff on cleaning and sanitizing procedures. | |
| Maintenance Technician | Resolved hot water supply issue by opening diversion valve. | |
| Administrator | Acknowledged no bed linens on invoices and total bed linens available did not meet requirements. | |
| Lead Housekeeper | Will monitor weekly bed linen counts and provide results to QAPI committee. |
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