Inspection Reports for Chapel Hill
10 Old Diamond Hill Rd, Cumberland, RI 02864, United States, RI, 02864
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Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 27, 2025
Visit Reason
A complaint investigation survey was conducted at the facility between 10/24/2025 and 10/27/2025 based on multiple ACTS reference numbers.
Findings
No deficiencies were identified during the complaint investigation survey.
Complaint Details
The complaint investigation was based on ACTS reference numbers 102330, 101035, 101813, 101999, 102054, 102182, and 102330. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 7, 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 reference numbers 101762 and was unannounced.
Inspection Report
Complaint Investigation
Deficiencies: 7
Mar 24, 2025
Visit Reason
An unannounced State Licensure survey and a complaint/incident investigation survey (ACTS M#1N11, 99965) were conducted at the residence on 3/20/2025 through 3/24/2025.
Findings
Deficiencies were identified relative to the State Licensure survey including failure to establish a written quality improvement plan with required components, failure to ensure all new employees received required training, failure to maintain complete personnel records, failure to document resident assessments and service plans accurately, failure to comply with food service and medication administration regulations, and failure to conduct required fire drills and safety procedures.
Complaint Details
The visit included a complaint/incident investigation survey as indicated by ACTS M#1N11, 99965. Specific complaint details or substantiation status are not explicitly stated in the report.
Deficiencies (7)
| Description |
|---|
| Failure to establish a written quality improvement plan that included all required components for the Dementia Special Care Unit. |
| Failure to ensure all new employees received required orientation and in-service training within specified timeframes. |
| Personnel records for newly hired staff lacked required documentation including BCI checks and training records. |
| Resident service plans failed to include required descriptions and interventions related to smoking status and other needs. |
| Food service violations including lack of hand soap in sinks, leaking sinks, discarded expired food, and improper food labeling and storage. |
| Medication administration deficiencies including failure to conduct BCI checks timely, improper medication storage, and failure to secure medications in resident apartments. |
| Failure to conduct required fire drills and maintain documentation as required by fire safety regulations. |
Report Facts
Date of survey: Mar 24, 2025
Number of residents affected by deficient practice: 110
Percentage of obstructed fire drills: 50
Percentage of drills documented: 26
Number of months for quality improvement documentation retention: 60
Audit frequency: 6
Audit frequency: 3
Audit frequency: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in findings related to personnel records and training deficiencies |
| Staff B | Certified Nursing Assistant (CNA) | Named in findings related to personnel records and training deficiencies |
| Staff C | Certified Medication Technician | Named in findings related to medication card discrepancies |
| Director of Wellness | Interviewed during survey; unable to provide evidence for staff training and medication storage | |
| Director of Dining Services | Responsible for food service corrective actions and audits | |
| Executive Director | Executive Director | Signed plan of correction and responsible for oversight |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 3, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence to determine compliance with state regulations.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was based on complaint reference numbers 98986, 98731, and 98803. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 3, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations based on ACTS reference numbers 98341, 98230, 98194, 98137, 98357, 98079, and 97984.
Findings
The facility failed to update comprehensive assessments for residents receiving outside services, specifically physical therapy and skilled nursing services, as required by Residency Requirements 2.4.16.D. Interviews with the Director of Wellness confirmed lack of evidence that assessments accurately reflected residents' receipt of these services.
Complaint Details
The investigation was complaint-driven, with multiple ACTS reference numbers cited. The deficiency related to failure to update resident assessments was identified and substantiated through record reviews and interviews.
Deficiencies (1)
| Description |
|---|
| Residency Requirements 2.4.16.D Resident Assessment/Service Plans not updated to document receipt of physical therapy and skilled nursing services for residents receiving outside services. |
Report Facts
ACTS reference numbers: 7
Residents with deficient assessments: 2
Dates of residents' comprehensive assessments: Resident #1 assessment dated 6/17/2024; Resident #2 assessment dated 6/10/2024.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 14, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
An unannounced complaint/incident investigation survey was conducted; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 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
An unannounced complaint/incident investigation survey was conducted; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 16, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The survey was triggered by a complaint or incident investigation; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 6, 2024
Visit Reason
An unannounced complaint/incident investigation was conducted at Chapel Hill on 03/04/2024 based on multiple ACTS reference numbers related to allegations.
Findings
Deficiencies were identified related to failure to ensure all new employees received at least ten hours of orientation and training within thirty days of hire and prior to working independently. Additionally, a reported incident involving a resident's death and failure to initiate CPR by certified staff was documented.
Complaint Details
The investigation was complaint/incident based, involving multiple ACTS reference numbers. A reported incident of a resident death was received by the Rhode Island Department of Health on 2/19/2024, involving failure to initiate CPR by certified staff. CPR was initiated by EMS upon arrival.
Deficiencies (1)
| Description |
|---|
| Failure to ensure all new employees received at least ten hours of orientation and training within thirty days of hire and prior to working independently in the residence. |
Report Facts
ACTS reference numbers: 9
Hours of orientation and training required: 10
Dates of hire for staff: 2
Date of resident death report: Feb 19, 2024
Date of code status informed consent form: Dec 4, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Technician (CMT) | Hired 8/22/2023; CPR certified; called to respond to medical emergency. |
| Staff B | Certified Nursing Assistant (CNA) | Hired 5/31/2023; assisted resident when became unresponsive. |
| Staff C | Business Office Manager | Acknowledged staff did not receive required training within timeframe. |
| Director of Wellness | Could not provide evidence staff received required training; acknowledged CPR was not initiated by Staff A. |
Inspection Report
Complaint Investigation
Deficiencies: 6
May 25, 2023
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the assisted living residence to assess compliance with state licensure requirements.
Findings
The facility was found deficient in multiple areas including failure to establish a Safe Resident Handling program, incomplete resident records regarding wound care, inadequate nurse reviews, failure to update service plans after significant resident condition changes, noncompliance with residents' rights regulations, and violations of food service safety codes.
Complaint Details
The visit included a complaint/incident investigation survey (HHCL11) conducted from 05/24/2023 through 05/25/2023. Deficiencies were identified relative to the State Licensure survey.
Deficiencies (6)
| Description |
|---|
| Failure to establish a Safe Resident Handling program including committee meetings, policy implementation, hazard assessments, and staff training. |
| Failure to provide detailed descriptions of all pressure ulcers or skin lesions in resident records, specifically for Resident ID #7. |
| Failure to complete nurse reviews with all required components for multiple residents. |
| Failure to update service plans to reflect significant changes in resident conditions, including bowel incontinence and hospitalizations. |
| Failure to comply with residents' rights regulations including access to records, notification of rights, and proper documentation. |
| Failure to comply with Rhode Island Food Code including staff hair restraints, food storage, temperature controls, and sanitation. |
Report Facts
Dates of wound care record review: 4/13/2023, 4/17/2023, 4/20/2023, 4/28/2023, 5/1/2023, 5/4/2023, 5/10/2023
Number of residents with incomplete nurse reviews: 5
Audit frequency: 10
Audit review frequency: 3
Dates of staff in-service: Safe Resident Handling in-service to be completed by 6/30/2023; Residents' Rights in-service held 6/14; Food service audits weekly for four weeks then monthly for six months
Inspection Report
Complaint Investigation
Deficiencies: 0
May 3, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
An unannounced complaint/incident investigation survey was conducted. No deficiencies were identified.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 1, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
An unannounced complaint/incident investigation survey was conducted; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 25, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at Chapel Hill Senior Living to investigate a deficiency identified related to management of services and care.
Findings
The facility failed to provide care and services in accordance with community standards relative to physician's orders for one resident. Specifically, the resident's weights were not consistently obtained as ordered, and medication refusals were not properly documented or communicated to the nurse practitioner and family members.
Complaint Details
The visit was complaint-related, triggered by an unannounced complaint/incident investigation. The deficiency was substantiated based on record review, resident and staff interviews.
Deficiencies (1)
| Description |
|---|
| Failure to provide care and services in accordance with physician's orders, including missing resident weights and missed medication doses without proper notification. |
Report Facts
Missed medication doses: 7
Dates weights not obtained: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Aquintia Reyes | Regional Director of Operations | Signed the plan of correction document. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 7, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence due to a deficiency identified related to the failure to maintain back-up or contingency equipment for hot water supply.
Findings
The residence failed to maintain operational back-up boiler equipment, resulting in no hot water due to the main boiler failure. The contingency boiler was not operational and missing parts, and there was no evidence of repair to ensure functionality in case of system failure.
Complaint Details
The complaint investigation found that the residence did not have operational contingency equipment for hot water after the main boiler failed. The National Director of Facilities Management was unaware that the contingency equipment was non-operational prior to the main equipment failure.
Deficiencies (1)
| Description |
|---|
| Failure to develop and maintain back-up or contingency plans and equipment to address possible internal system and/or equipment failures, specifically the failure to maintain an operational contingency boiler for hot water supply. |
Report Facts
Repair timeframe: 12
Invoice date: Feb 8, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christine McAndrews | Executive Director | Signed the report |
| National Director of Facilities Management | Interviewed regarding contingency equipment status |
Inspection Report
Complaint Investigation
Deficiencies: 3
Aug 30, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the Chapel Hill assisted living residence to assess compliance with residency requirements and service plans.
Findings
Deficiencies were identified related to failure to develop a timely written service plan for a resident, lack of a secure distinct living environment in the Alzheimer Dementia Special Care Unit, and inadequate elopement policies and supervision for a resident with behavioral disturbances.
Complaint Details
The investigation was triggered by a complaint/incident involving a resident with diagnoses including dementia and behavioral disturbances who had multiple state reportable incidents of elopement from a secure memory care unit and resident-to-resident altercations. The resident's service plan was lacking, and staff were unable to determine how the resident exited the secure unit on multiple occasions.
Deficiencies (3)
| Description |
|---|
| Failure to develop a written service plan within seven days after move-in for one of three sample residents. |
| Failure to provide a secure distinct living environment in the Alzheimer Dementia Special Care Unit to ensure resident safety and quality of life. |
| Inadequate elopement policies and supervision for a cognitively impaired resident with multiple prior elopements and behavioral issues. |
Report Facts
Deficiencies cited: 3
Days to develop service plan: 7
Resident incidents: 3
Elopement drills and checks: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristie M. Andrews | Executive Director | Signed the plan of correction and was involved in interviews regarding resident elopement incidents. |
| Care Director | Interviewed regarding lack of service plan and resident elopement; name not fully provided. |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 18, 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 complaint/incident related; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 18, 2021
Visit Reason
An unannounced complaint/incident investigation survey was conducted at Chapel Hill Senior Living to investigate allegations related to elopement from the Alzheimer Dementia Special Care Unit.
Findings
The facility failed to provide a secure distinct living environment to prevent elopement of Resident ID #1, who was observed leaving the secure unit undetected and required police assistance to be returned. Staff were re-educated on elopement policy and corrective actions were initiated including securing windows and conducting audits.
Complaint Details
The complaint investigation was substantiated as Resident ID #1 was observed eloping from the secure unit multiple times, requiring police intervention. Staff interviews and record reviews confirmed the failure to maintain a secure environment.
Deficiencies (1)
| Description |
|---|
| Failure to provide a secure distinct living environment in the Alzheimer Dementia Special Care Unit to ensure resident safety and prevent elopement. |
Report Facts
Date of initial report to RIDOH: Jul 28, 2021
Date of investigation by RIDOH: Aug 3, 2021
Date of second observation: Aug 16, 2021
Date of survey completion: Aug 18, 2021
Audit duration: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Courtney A. Fisher | Executive Director | Named as Executive Director who provided interview and signed the document |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 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
The investigation was unannounced and related to a complaint or incident; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 3
Jun 17, 2021
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at Chapel Hill Senior Living on 06/17/2021.
Findings
Deficiencies were identified related to Safe Resident Handling, Resident Assessment/Service Plans, and Dietetic Services. The facility failed to produce evidence of an established Safe Resident Handling program and failed to update resident assessments timely following changes in condition or readmission from healthcare facilities. The community dishwasher sanitizer levels were also found to be inadequate.
Complaint Details
The visit included a complaint/incident investigation component as part of the unannounced survey. Specific findings related to failure to update resident assessments and service plans for multiple residents were documented.
Deficiencies (3)
| Description |
|---|
| Failure to establish a Safe Resident Handling program including committee, policies, training, and evaluations. |
| Failure to review and update resident assessments and service plans at required intervals and after significant changes in condition or readmission. |
| Failure to comply with Rhode Island Food Code regarding sanitizer levels in the dishwashing process. |
Report Facts
Deficiencies cited: 3
Completion dates for corrective actions: Jul 30, 2021
Completion dates for corrective actions: Jun 30, 2021
Completion dates for corrective actions: Jul 16, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Courtney A. Fisher | Executive Director | Named in relation to findings and corrective actions for Safe Resident Handling and Resident Assessment deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 17, 2021
Visit Reason
An unannounced complaint/incident investigation survey and a biennial State licensure survey were conducted at this residence.
Findings
No deficiencies were identified relative to this complaint/incident investigation survey.
Complaint Details
The visit was triggered by a complaint/incident investigation; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 20, 2021
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence.
Findings
No deficiencies were identified during the investigation survey.
Complaint Details
The visit was complaint-related and no deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 4, 2021
Visit Reason
An unannounced complaint/incident investigation survey and a follow-up to a previous survey were conducted at the facility.
Findings
No deficiencies were identified during the investigation and follow-up survey.
Complaint Details
The visit was complaint-related and included an incident investigation; no deficiencies were found.
Inspection Report
Follow-Up
Deficiencies: 0
Feb 4, 2021
Visit Reason
A follow-up survey to a complaint investigation survey and a new complaint investigation survey were conducted at this residence on 02/04/2021.
Findings
No deficiencies were identified during the follow-up and complaint investigation surveys.
Complaint Details
The visit was related to a complaint investigation and a follow-up to a previous complaint investigation survey.
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