Deficiencies per Year
8
6
4
2
0
Unclassified
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 24, 2025
Visit Reason
An unannounced complaint/incident investigation survey and a biennial State licensure survey were conducted at the facility.
Findings
No deficiencies were identified during the complaint investigation and biennial licensure survey.
Complaint Details
The visit was triggered by complaint/incident investigation with ACTS reference numbers 99167 and a biennial State licensure survey (4G6M11). No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 24, 2025
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at this residence.
Findings
No deficiencies were identified relative to the State Licensure survey.
Complaint Details
The visit included a complaint/incident investigation survey (KOP111) conducted on 02/24/2025.
Inspection Report
Complaint Investigation
Deficiencies: 6
Oct 22, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the facility on 10/22/2024 to determine compliance with state regulations.
Findings
The facility failed to comply with Rhode Island Food Code standards related to dietetic services, including improper labeling, storage, and cleanliness issues in the kitchen and food service areas.
Complaint Details
The investigation was complaint/incident triggered with reference number 98076. A deficiency was identified during the survey.
Deficiencies (6)
| Description |
|---|
| A bag of salmon and fried chicken in the walk-in freezer were not labeled or dated and had openings. |
| Dry storage area contained rice, navy beans, and lentils not stored in sealed containers. |
| Reach-in refrigerator fan had a buildup of black matter; orange substance spilled on shelves; pitchers of lemonade and ice tea not properly labeled or discarded. |
| Ice cream freezer had accumulation of frost, no thermometer, spills of yellow matter, and a cover left on an ice cream container. |
| Food service area had a can opener and wall with buildup of debris and brown matter; shelving near stove had spills and accumulation of white matter and crumbs. |
| Multiple food items including waffles, tartar sauce, salsa, dressings, and sauces were not labeled or dated. |
Report Facts
Date of survey: Oct 22, 2024
Number of small individualized containers: 15
Number of small individualized containers: 2
Number of small individualized containers: 3
Number of small individualized containers: 12
Number of small individualized containers: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 1, 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: 6
Apr 25, 2023
Visit Reason
An unannounced State Licensure survey was conducted at Brookdale South Bay residence to identify deficiencies in compliance with regulatory requirements.
Findings
Multiple deficiencies were identified related to incomplete in-service training for employees, failure to update resident assessments and service plans timely, incomplete medication service evaluations, and inadequate fire drill documentation.
Deficiencies (6)
| Description |
|---|
| Employees failed to receive ongoing in-service training annually as required, including topics such as fire prevention, abuse recognition, infection control, and resident rights. |
| The residence failed to review resident assessments at intervals not to exceed twelve months and when resident conditions changed significantly for multiple residents. |
| The residence failed to update resident assessments within five working days of readmission from a health care facility. |
| Nurse reviews were not completed at least once every thirty days for residents, and quarterly medication aide evaluations were incomplete for some staff. |
| Fire drill documentation was incomplete, lacking required components such as type of drill, problems encountered, and employee observations. |
| The residence failed to send a variance request for a resident receiving palliative care and hospice services as required. |
Report Facts
Deficiencies cited: 6
Dates of fire drills reviewed: 12
Timeframe for in-service training: 12
Timeframe for resident assessment review: 12
Timeframe for nurse review: 30
Timeframe for quarterly medication aide evaluations: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Financial Services | Unable to provide evidence that employees had received all required in-service training annually. | |
| Executive Director | Unable to produce evidence that comprehensive assessments and fire drill documentation were updated and complete. | |
| Human Resources Manager | Completed audits and re-serviced department managers on in-service training requirements. | |
| Health & Wellness Director | Responsible for updating assessments, auditing residents' services, medication evaluations, and reporting results in Quality Assurance meetings. | |
| District Director of Clinical Services | Re-trained Health & Wellness Director on policies related to assessments and medication evaluations. | |
| Maintenance Director | Conducted fire drills and training for assisted living employees on fire drill procedures. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 28, 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 investigation was unannounced and no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 8, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at Brookdale South Bay Assisted Living to investigate medication services and storage practices.
Findings
The survey found that medications were not stored securely for one resident who self-administers medication, with baskets of medications found unsecured in the resident's apartment. The Director of Wellness acknowledged the issue, and corrective actions including secured medication storage units with keys and staff training were planned.
Complaint Details
The complaint investigation was substantiated by observation and staff interview revealing unsecured medication storage for one resident who self-administers medication.
Deficiencies (1)
| Description |
|---|
| Failure to ensure medications are stored securely for a resident who self-administers medication, with unsecured baskets of medications observed in the resident's apartment. |
Report Facts
Residents reviewed: 1
Medication storage unit keys: 1
Quality Improvement Committee review frequency: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Dufresne | Executive Director | Signed the Plan of Correction document |
| Director of Wellness | Acknowledged medications should be stored securely and was present during observation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 30, 2021
Visit Reason
An unannounced complaint/incident investigation survey was conducted at Brookdale South Bay to investigate deficiencies related to reporting requirements of incidents involving residents.
Findings
The facility failed to maintain evidence that all reportable incidents were thoroughly investigated and reported to the Department of Health within five business days for multiple residents. Several residents experienced falls and injuries, and the results of investigations were not reported timely as required.
Complaint Details
The complaint investigation found that the facility did not report incident investigations for residents #3, 5, 6, 7, and 9 within five business days as required. The Director of Wellness and a nurse were unable to provide evidence of timely reporting during interviews.
Deficiencies (1)
| Description |
|---|
| Failure to maintain evidence that all reportable incidents were thoroughly investigated and reported within five business days for multiple residents. |
Report Facts
Resident IDs with reporting deficiencies: 5
Date of survey completion: Jun 30, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Deguire | Executive Director | Signed the report and responsible for overseeing corrective action plan. |
Inspection Report
Plan of Correction
Deficiencies: 3
Apr 28, 2021
Visit Reason
An unannounced biennial State Licensure survey was conducted at Brookdale South Bay to assess compliance with licensure requirements and regulations.
Findings
Deficiencies were identified related to the Quality Assurance program, certification of food safety managers, and fire drill safety requirements. The facility failed to provide evidence of a compliant Quality Assurance program, lacked required food safety certifications, and did not ensure that 50% of fire drills were classified as obstructed as required.
Deficiencies (3)
| Description |
|---|
| Failure to provide evidence that the Quality Assurance Program met all regulatory requirements. |
| No person certified as a Food Safety Manager as required; expired certification and lack of scheduled training due to COVID-19 staffing shortages. |
| Failure to ensure that 50% of fire drills were classified as obstructed drills as required by fire safety regulations. |
Report Facts
Completion Date: Aug 1, 2021
Completion Date: Jul 1, 2021
Completion Date: Jun 1, 2021
Meetings documented: 2
Fire drills per year: 6
Fire drills per night: 2
Percentage of obstructed drills required: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Dapkunas | Executive Director | Acknowledged lack of documentation for Quality Assurance Program and inability to provide evidence that 50% of fire drills included a documented obstruction. |
| Unnamed Dining Services Director | Acknowledged expired food safety certification and lack of scheduled training due to COVID-19 staffing shortages. | |
| Unnamed Maintenance Director | Responsible for in-servicing environmental staff and department managers on fire drill regulations. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 5, 2021
Visit Reason
An unannounced focused infection control and complaint investigation survey was conducted related to COVID-19 infection control at the residence.
Findings
No deficiencies were identified during the infection control and complaint investigation survey.
Complaint Details
The visit was complaint-related and focused on COVID-19 infection control; no deficiencies were found.
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