Inspection Reports for Cra-Mar Meadows
575 Seven Mile Rd, Hope, RI 02831, United States, RI, 02831
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
16.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
394% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
88% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 1, 2025
Visit Reason
A follow-up survey was conducted to verify correction of previous deficiencies at the facility.
Findings
All previous deficiencies were corrected and no new deficiencies were identified during this follow-up survey.
Inspection Report
Routine
Deficiencies: 15
Date: May 19, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, medication administration, infection control, and staff qualifications.
Findings
The facility was found deficient in multiple areas including failure to maintain residents' dignity during dining, protect resident identifying information, implement comprehensive care plans, provide appropriate treatment and medication management, ensure staff licensure and training, maintain infection prevention and control programs, and properly document vaccinations and medication administration.
Deficiencies (15)
Failed to care for residents in an environment that promotes dignity during dining for 3 of 6 residents requiring assistance with eating.
Failed to protect identifying information for a resident in the facility's survey results binder.
Failed to implement a comprehensive person-centered care plan for a resident with a suprapubic catheter.
Failed to provide appropriate treatment and services for a resident with a change in condition related to a rash and sweating.
Failed to ensure a resident's drug regimen was free from unnecessary drugs by administering blood pressure medication when it should have been held.
Failed to ensure medication error rates were below 5%, with an 8% error rate observed during medication administration.
Failed to ensure a resident's drug regimen was free from significant medication errors, including transcription errors leading to duplicate doses.
Employed a Certified Medication Technician with expired certifications.
Failed to safeguard resident-identifiable information and maintain accurate medical records related to medication administration.
Failed to develop and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program focused on medication errors.
Failed to provide and implement an infection prevention and control program, including failure to use Enhanced Barrier Precautions for residents with wounds and failure to clean CPAP equipment.
Failed to implement an antibiotic stewardship program including antibiotic use protocols and monitoring for residents receiving antibiotics.
Failed to designate a qualified infection preventionist who completed specialized training in infection prevention and control.
Failed to develop and implement policies and procedures for flu and pneumonia vaccinations, including documentation of vaccination status and updated policies.
Failed to develop, implement, and maintain an effective training program for all new and existing staff members consistent with their expected roles.
Report Facts
Residents observed requiring assistance with eating: 6
Residents affected by dignity deficiency: 3
Medication administration opportunities observed: 25
Medication errors observed: 2
Certified Medication Technician certifications expired: 1
Residents reviewed for pneumococcal vaccination documentation: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Nursing Assistant | Acknowledged standing while assisting residents with eating and not providing catheter care |
| Staff C | Speech Therapist | Acknowledged standing while assisting resident with eating |
| Staff D | Nursing Assistant | Acknowledged standing while assisting resident with eating |
| Director of Nursing Services | Director of Nursing Services | Acknowledged staff feeding preferences, medication errors, missing training, and lack of infection preventionist training |
| Staff F | Registered Nurse | Noted resident rash and sweating, did not notify provider, did not wear gown during wound care |
| Staff B | Certified Medication Technician | Observed medication administration errors and acknowledged errors |
| Staff H | Registered Nurse | Acknowledged medication transcription errors and failure to wear gown during wound care |
| Staff G | Nurse Practitioner | Ordered medications involved in transcription errors, unaware of medication errors |
| Staff A | Certified Medication Technician | Worked with expired certifications |
| Staff I | Minimum Data Set Nurse | Certified in infection control but does not assist with infection prevention currently |
| Staff J | Registered Nurse | Missing required training and competencies |
Inspection Report
Re-Inspection
Census: 36
Capacity: 41
Deficiencies: 14
Date: May 19, 2025
Visit Reason
A recertification and complaint survey was conducted from 5/19/2025 through 5/22/2025 to determine compliance with 42 C.F.R. Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Complaint Details
The survey included a complaint investigation as part of the recertification process, with findings related to resident rights, quality of care, medication errors, and infection control.
Findings
Deficiencies were identified related to resident rights, comprehensive care plans, quality of care, medication administration, infection control, staff qualifications, and emergency preparedness. The facility acknowledged the deficiencies and provided plans of correction including staff education, competency evaluations, and policy updates.
Deficiencies (14)
Resident Rights: Facility failed to provide an environment that promotes maintenance of residents' dignity during dining for 3 of 6 residents requiring assistance.
Right to Survey Results: Facility failed to protect identifying information for a resident in the survey results binder.
Comprehensive Care Plan: Facility failed to develop and implement a person-centered care plan for a resident with an indwelling catheter.
Quality of Care: Facility failed to provide appropriate treatment and services for a resident with rash and diaphoresis related to medication.
Drug Regimen: Facility failed to ensure medication was held as ordered and medication errors occurred.
Medication Errors: Facility failed to ensure medication error rate was less than 5% for 1 of 3 residents reviewed.
Residents Free of Significant Med Errors: Facility failed to ensure a resident was free of significant medication errors related to transcription errors.
Staff Qualifications: Facility employed staff with expired NA and CMT licenses.
Resident Records - Identifiable Information: Facility failed to keep resident-identifiable information confidential.
Infection Prevention and Control: Facility failed to establish and maintain an infection prevention and control program.
Influenza and Pneumococcal Immunizations: Facility failed to ensure residents received or were offered immunizations.
Training Requirements: Facility failed to provide education and training to staff related to abuse, neglect, exploitation, catheter care, and other areas.
Resident Care Services - Administration of Drugs by Medication Tech: Facility failed to conduct and document quarterly evaluations for Certified Medication Technicians.
Life Safety Code: Facility failed to properly store, mark, and segregate full and empty oxygen cylinders.
Report Facts
Census: 36
Total Capacity: 41
Medication error rate: 8
Medication doses: 11
Certified Medication Technician evaluations: 2
Residents reviewed for immunization: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Nursing Assistant | Noted standing and assisting residents requiring 1:1 assistance during dining |
| Staff C | Speech Therapist | Noted standing and assisting residents requiring 1:1 assistance during dining |
| Staff D | Nursing Assistant | Noted standing and assisting residents requiring 1:1 assistance during dining |
| Staff F | Nursing Assistant | Revealed not providing catheter care and acknowledged medication administration observations |
| Staff G | Nurse Practitioner | Provided new medication orders and acknowledged medication errors |
| Staff H | Registered Nurse | Observed not wearing gown during wound care and acknowledged wound care observations |
| Staff A | Certified Medication Technician | Reviewed for staff qualifications and medication administration |
| Staff B | Certified Medication Technician | Observed administering medication and reviewed for staff qualifications |
| Staff J | Registered Nurse | Reviewed for training records and competency related to catheter care |
| Director of Nursing Services | Acknowledged staff training, medication administration, and infection control program status | |
| Assistant Administrator | Acknowledged failure to protect resident identifying information and oxygen cylinder storage deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 30, 2025
Visit Reason
The inspection was conducted in response to a community reported complaint alleging medication errors involving Resident ID #1, specifically incorrect administration of Ativan and Oxycodone medications.
Complaint Details
Complaint was submitted on 1/28/2025 alleging Resident ID #1 received Ativan in the morning along with as needed Oxycodone, and also received Oxycodone after it had been discontinued. The complaint was substantiated by record review and staff interviews.
Findings
The facility failed to ensure residents were free from significant medication errors, as Resident ID #1 received incorrect dosages of Ativan and Oxycodone on two occasions. Staff acknowledged the errors, and notifications were made to the provider, family, and Director of Nursing Services.
Deficiencies (2)
Resident was given 0.5 mg of Ativan at 6:45 AM instead of 5 mg of Oxycodone on 1/13/2025.
Resident received 5 mg of Oxycodone instead of 2.5 mg on 1/27/2025.
Report Facts
Medication dosage: 0.5
Medication dosage: 5
Medication dosage: 2.5
Medication dosage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Acknowledged medication errors involving Resident ID #1 on 1/13/2025 and 1/27/2025 |
| Director of Nursing Services | Acknowledged that Staff A administered medications in error to Resident ID #1 |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 9, 2024
Visit Reason
An off-site desk audit was conducted to review all previous deficiencies cited on May 23, 2024, and verify correction.
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: 11
Date: May 23, 2024
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with regulatory requirements for nursing home care and services.
Findings
The facility was found deficient in multiple areas including failure to revise care plans after assessments, inadequate activity programs reflecting resident preferences, insufficient supervision during meals, lack of appropriate follow-up care for a resident with a suprapubic catheter, incomplete dialysis care documentation and agreements, inadequate infection control practices during a COVID-19 outbreak, failure to document pneumococcal vaccinations, and lack of mandatory staff training in effective communication, QAPI, behavioral health, and nurse aide in-service training.
Deficiencies (11)
Failure to revise each resident's care plan by the interdisciplinary team after assessments for residents with falls and oxygen therapy.
Failure to provide an ongoing activity program reflecting resident preferences for 6 of 12 residents reviewed.
Failure to ensure adequate supervision during meals for a resident requiring supervision.
Failure to provide appropriate follow-up care and urology appointments for a resident with a suprapubic catheter.
Failure to ensure dialysis care orders included required information and lack of a contractual dialysis service agreement until survey prompted.
Failure to provide infection prevention and control program with proper PPE use during COVID-19 outbreak for 2 nursing units.
Failure to document pneumococcal vaccination status or refusal for 3 of 7 residents reviewed.
Failure to ensure mandatory effective communication training for 3 staff employed over a year.
Failure to provide mandatory QAPI training for 3 staff employed over a year.
Failure to provide minimum 12 hours per year of nurse aide in-service training for 2 nurse aides employed over a year.
Failure to provide behavioral health training consistent with requirements for 3 staff employed over a year.
Report Facts
Unwitnessed falls: 8
Residents reviewed for activities: 12
Residents affected by activity deficiency: 6
Residents affected by infection control deficiency: 5
Staff reviewed for training deficiencies: 3
Nurse aides reviewed for in-service training deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Interviewed regarding fall interventions and care plan updates. |
| Staff B | Registered Nurse | Interviewed regarding oxygen therapy and training deficiencies. |
| Staff E | Nursing Assistant | Observed not wearing proper PPE during COVID-19 precautions. |
| Staff F | Nursing Assistant | Observed not wearing eye protection during COVID-19 precautions. |
| Director of Nursing Services | Director of Nursing Services | Acknowledged care plan deficiencies, training deficiencies, and infection control issues. |
| Activity Director | Activity Director | Interviewed regarding activity care plans and program deficiencies. |
| MDS Coordinator | MDS Coordinator | Unable to provide evidence of updated care plans for activities and oxygen therapy. |
| Director of Therapy | Director of Therapy | Interviewed regarding meal supervision and therapy notes. |
| Administrator | Administrator | Unable to provide evidence of activity program based on assessments and preferences. |
Inspection Report
Annual Inspection
Census: 34
Capacity: 41
Deficiencies: 8
Date: May 23, 2024
Visit Reason
A recertification survey was conducted from 5/20/2024 through 5/23/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a state licensure and emergency preparedness survey.
Findings
Deficiencies were identified at the substandard quality of care level, including issues with care plan timing and revision, activities and interaction, free of accident hazards, incontinence care, infection prevention and control, communication training, QAPI training, and behavioral health training. No Life Safety Code deficiencies were identified.
Deficiencies (8)
Care plan timing and revision deficiencies related to fall prevention and oxygen therapy interventions not updated timely.
Activities and interaction program failed to meet residents' interests and support well-being.
Facility failed to ensure resident environment free of accident hazards related to supervision during meals for resident with dysphagia.
Incontinence care deficiencies including failure to provide appropriate treatment and services for residents with urinary and fecal incontinence.
Infection prevention and control program deficiencies including failure to prevent transmission of communicable diseases and ensure proper PPE use.
Communication training not completed by all direct care staff as required.
QAPI training not completed by all required staff.
Behavioral health training not completed by all required staff.
Report Facts
Census: 34
Total Capacity: 41
Deficiencies cited: 8
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 23, 2023
Visit Reason
An off-site desk audit was conducted on May 23, 2023 for all previous deficiencies cited on April 27, 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
Deficiencies: 6
Date: Apr 27, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and ensure the facility meets professional standards of care for residents.
Findings
The facility was found deficient in several areas including failure to develop a comprehensive care plan for a resident with a baclofen pump, failure to ensure services met professional standards for baclofen pump management, failure to maintain acceptable nutritional status for a resident with significant weight loss, failure to provide appropriate dialysis care including monitoring pre- and post-dialysis weights, failure to update and review menus periodically, and failure to conduct a comprehensive facility-wide assessment to determine necessary resources for resident care.
Deficiencies (6)
Failed to develop a comprehensive person-centered care plan including measurable objectives and timeframes for a resident with a baclofen pump.
Failed to ensure services provided meet professional standards of quality relative to baclofen pump use for a resident.
Failed to ensure residents maintain acceptable parameters of nutritional status; significant unaddressed weight loss for a resident.
Failed to provide safe, appropriate dialysis care/services including failure to document pre- and post-dialysis weights for a resident.
Failed to update menus periodically and have them reviewed annually by a clinically qualified professional.
Failed to conduct and document a facility-wide assessment identifying necessary resources to care for residents competently during day-to-day operations and emergencies.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: Many
Weight loss percentage: 5.1
Weight loss pounds: 9.8
Weight variance pounds: 5.2
Weekly weights recorded: 7
Dialysis frequency per week: 3
Menu cycle date: Aug 17, 2017
Menu last reviewed: Oct 1, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Director of Nursing Services | Acknowledged no orders or care plan for baclofen pump and lack of facility assessment details |
| Registered Nurse Staff A | Registered Nurse | Revealed resident had a baclofen pump |
| Registered Nurse Staff B | Registered Nurse | Was unaware resident had a baclofen pump |
| Physician Assistant | Physician Assistant | Revealed resident did not have a baclofen pump that he could recall |
| Dietitian | Dietitian | Notified of resident weight loss, acknowledged not being informed timely, and acknowledged menus not reviewed or revised |
| Cook Staff C | Cook | Revealed no seasonal menus |
| Food Service Director | Food Service Director | Unable to provide evidence menus were updated periodically |
Inspection Report
Renewal
Deficiencies: 5
Date: Apr 27, 2023
Visit Reason
A recertification survey was conducted at Cra-Mar Meadows from 04/24/2023 through 04/27/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were cited related to the development and implementation of comprehensive care plans, nutrition and hydration status maintenance, dialysis services, menus and nutritional adequacy, and facility assessment. A plan of correction was submitted addressing these deficiencies.
Deficiencies (5)
Failure to develop and implement a comprehensive person-centered care plan for a resident with an implanted baclofen pump.
Failure to ensure residents maintain acceptable parameters of nutritional status, including weight monitoring for residents with weight loss.
Failure to ensure residents who require dialysis receive services consistent with professional standards, including documentation of pre- and post-dialysis weights.
Failure to update menus periodically and have them reviewed annually by a clinically qualified nutrition professional.
Failure to conduct and document a facility-wide assessment addressing resident population, staffing, physical environment, and other resources.
Report Facts
Dates of survey: 4
Resident weight records reviewed: 7
Weight loss percentage: 5.1
Dialysis frequency: 3
Menu review frequency: 1
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 2, 2022
Visit Reason
An off-site desk audit was conducted on May 2, 2022 for all previous deficiencies cited on April 6, 2022 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: 6
Date: Apr 6, 2022
Visit Reason
A recertification off hours survey was conducted from 04/03/2022 to 04/06/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were identified related to protection of resident identifying information, development and revision of comprehensive care plans, medication administration, infection prevention and control, and abuse, neglect, and exploitation training.
Deficiencies (6)
Facility failed to protect identifying information for 12 residents listed in the survey results binder.
Facility failed to develop a comprehensive person-centered care plan for residents receiving hospice services and those with skin impairment.
Facility failed to revise resident care plans following identification of new skin impairments and falls.
Facility failed to meet professional standards of quality in medication administration for 1 of 12 residents reviewed.
Facility failed to establish and maintain an effective infection prevention and control program, including failure to conduct an annual review and maintain education and competency assessments.
Facility failed to provide required training to staff on abuse, neglect, exploitation, and dementia management.
Report Facts
Residents with identifying information not protected: 12
Residents reviewed for care plans: 11
Residents reviewed for medication administration: 12
Employees listed in infection control education review: 49
Staff members for dementia training review: 42
Staff members not trained in abuse, neglect, and dementia management: 12
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