Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 1, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted on 10/1/2025 to determine compliance with state regulations based on complaint reference numbers 102160, 102079, and 101798.
Findings
The investigation found that the residence failed to ensure employees reported suspected abuse, neglect, or mistreatment of a resident within the required 24-hour timeframe. Specifically, a resident with a genital infection was not reported to the state agency as required. The Director of Wellness acknowledged the failure to report the incident.
Complaint Details
The complaint investigation was based on allegations submitted to the Rhode Island Department of Health on 9/22/2025 regarding a resident with a genital rash and infection. The resident was reportedly inappropriately touched. The facility failed to report this incident to the state agency within the required timeframe.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report suspected abuse, neglect, or mistreatment of a resident within 24 hours as required by licensure regulations. | Level D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Sanford | Executive Director | Signed the statement of deficiencies and plan of correction. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Jul 23, 2025
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility on 07/23/2025.
Findings
No deficiencies were identified relative to the State Licensure survey. However, deficiencies were found related to failure to ensure a Safe Resident Handling program, failure to provide care and services consistent with physician's orders for self-administration of insulin, failure to store medications securely, and failure to have menus developed or reviewed by a registered dietitian for the Alzheimer Dementia Special Care Unit.
Complaint Details
The complaint/incident investigation was part of the visit. The Administrator acknowledged the Safe Resident Handling program did not meet requirements. The Director of Wellness was unable to provide evidence of a physician's order for resident self-administration of insulin. Medication storage deficiencies were observed during surveyor observation and record review. The Administrator acknowledged menus had not been developed or reviewed by a registered dietitian for several years.
Deficiencies (4)
| Description |
|---|
| Failure to ensure there was a Safe Resident Handling program including committee meetings, training, and performance evaluations. |
| Failure to provide care and services in accordance with physician's orders for self-administration of insulin for a resident. |
| Failure to store medications securely and prevent spoilage, dosage errors, administration errors, and inappropriate access for three medication carts reviewed. |
| Failure to have menus for the Alzheimer Dementia Special Care Unit developed or reviewed by a registered dietitian as required. |
Report Facts
Date of survey completion: Jul 23, 2025
Survey observation time: 930
Survey interview time: 1115
Survey interview time: 1030
Survey interview time: 1315
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Sanford | Executive Director | Signed the plan of correction and acknowledged deficiencies |
| Director of Wellness | Interviewed during survey and unable to provide evidence of physician's order for insulin self-administration | |
| Administrator | Acknowledged Safe Resident Handling program deficiencies and menu review deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 24, 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 101324 and 101269 and found no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 12, 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 101156, 101175, 101192, and 100921. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 14, 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 100371, 100278, 100715, and 100740. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 12, 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 multiple ACTS reference numbers: 99441, 99434, 98433, 99672, 99767, 99766, and 99765. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 3, 2024
Visit Reason
An offsite 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 98530 covering the period 11/25/2024 to 12/3/2024. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 11, 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 complaint reference numbers 97923 and 97917 and found no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 19, 2024
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: 1
Aug 9, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted on 08/09/2024 due to a complaint related to nurse reviews at the facility.
Findings
The investigation found that the facility failed to ensure nurse reviews were completed at least once every ninety days for one of three sample residents reviewed (Resident ID #2). Record review and interview with the Executive Director confirmed the deficiency.
Complaint Details
An unannounced complaint/incident investigation survey was conducted. A deficiency was identified related to the complaint survey regarding nurse reviews not being completed timely for Resident ID #2.
Deficiencies (1)
| Description |
|---|
| Failure to complete nurse reviews at least once every ninety days for Resident ID #2 as required. |
Report Facts
Days for nurse review completion: 90
Date of comprehensive assessment: Oct 6, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Sanford | Executive Director | Interviewed during survey on 08/09/2024 regarding nurse review deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 3, 2024
Visit Reason
An unannounced complaint/incident investigation was conducted following an incident of successful elopement of two residents on 06/01/2024 at 4:11 PM.
Findings
The facility failed to provide a secure environment for two memory care residents, resulting in their elopement. The investigation revealed that an independent living resident opened an unlocked gate allowing the residents to leave the premises. Staff failed to locate the residents promptly, and there was a delay in notifying the police due to lack of immediate communication.
Complaint Details
The complaint was substantiated as the investigation confirmed the elopement incident and identified failures in securing the environment and timely staff response.
Deficiencies (1)
| Description |
|---|
| The Alzheimer Dementia Special Care Unit failed to provide a secure distinct living environment appropriate for the resident population, resulting in elopement of two residents. |
Report Facts
Incident date: Jun 1, 2024
Report date: Jun 3, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Sanford | Director | Signed the report as provider representative |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 9, 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 visit was complaint-related and no deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 21, 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 based; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 12, 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 visit was complaint-related and no deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 4
Nov 28, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence following allegations reported to the Rhode Island Department of Health on 11/27/2023 regarding staff working outside their scope of practice and other regulatory concerns.
Findings
The investigation found multiple deficiencies including staff working without active licenses, failure to ensure proper qualifications for personal care staff, inadequate medication administration for a resident, and failure to report an incident within the required timeframe. The facility administration acknowledged these issues and outlined corrective actions including staff termination, hiring new qualified personnel, ongoing audits, and management meetings.
Complaint Details
The complaint was substantiated based on record reviews and staff interviews confirming staff working out of scope and failure to meet regulatory requirements. Specific incidents included unlicensed staff providing care and delayed medication administration leading to hospitalization.
Deficiencies (4)
| Description |
|---|
| Staff working without active licenses or certifications as required by regulations. |
| Failure to ensure that personal care staff meet required qualifications to perform assigned tasks. |
| Resident did not receive prescribed seizure medication timely, resulting in hospitalization. |
| Failure to report an incident of alleged resident abuse within the required 24-hour timeframe. |
Report Facts
Date of survey completion: Nov 28, 2023
Date of complaint report: Nov 27, 2023
Resident medication order date: Nov 21, 2023
Incident date: Nov 16, 2023
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 14, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the facility on 11/14/2023.
Findings
No deficiencies were identified during the complaint/incident investigation survey.
Complaint Details
The visit was triggered by a complaint/incident investigation with ACTS reference number 93084. No deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 31, 2023
Visit Reason
An complaint/incident investigation survey was conducted at the residence on 10/31/2023 referencing ACTS numbers 92552, 92560, and 92599.
Findings
No deficiencies were identified during the complaint/incident investigation survey.
Complaint Details
The visit was complaint-related, referencing ACTS numbers 92552, 92560, and 92599, with no deficiencies found.
Inspection Report
Plan of Correction
Deficiencies: 5
Sep 6, 2023
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility.
Findings
Multiple deficiencies were identified related to residency requirements, rights of residents, dietetic services, medication administration, and safety requirements including fire and law enforcement telephone postings. Corrective actions and plans of correction were documented for each deficiency.
Complaint Details
The visit included a complaint/incident investigation survey as part of the unannounced biennial licensure survey.
Deficiencies (5)
| Description |
|---|
| Residency requirements not met; resident was not an established resident prior to being admitted to hospice care as required. |
| Failure to prominently display a posting of the most recent state licensing survey results at the facility. |
| Food service deficiencies including expired food items and lack of hair restraints worn by kitchen personnel. |
| Medication administration deficiencies including expired medications and improper labeling/storage of medications. |
| Failure to post local fire department and law enforcement telephone numbers at each telephone in the facility. |
Report Facts
Dates of medication expiration: 6
Dates of survey observations: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Sanford | Executive Director | Signed the plan of correction document. |
| Staff B | Certified Medication Technician (CMT) | Observed during medication cart survey and acknowledged observations. |
| Director of Wellness | Interviewed by surveyor regarding residency and medication issues. | |
| Food Service Director (FSD) | Interviewed by surveyor regarding food service deficiencies. |
Inspection Report
Follow-Up
Deficiencies: 0
May 8, 2023
Visit Reason
A follow-up survey to a complaint investigation survey and a new complaint investigation survey was conducted at this residence on 05/08/2023.
Findings
The document does not provide specific findings or details of deficiencies beyond noting the follow-up and new complaint investigation surveys conducted.
Complaint Details
The visit was related to a complaint investigation and a follow-up to a prior complaint investigation survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 8, 2023
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 triggered by a complaint/incident investigation and included a follow-up to a previous survey. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 8, 2023
Visit Reason
A follow-up survey to a complaint investigation survey and a new complaint investigation survey (GQLG11, 05/08/2023) was conducted at this residence.
Findings
The report contains a summary statement indicating that the visit was a follow-up and new complaint investigation survey. No specific deficiencies or findings are detailed in the document.
Complaint Details
The visit was related to a follow-up and new complaint investigation survey as indicated by the initial comments.
Inspection Report
Complaint Investigation
Deficiencies: 3
Mar 2, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at Darlington Memory Lane to assess compliance with residency requirements and resident assessment/service plans.
Findings
The facility failed to ensure resident assessments and service plans were reviewed and updated as required, including nurse reviews every 90 days and proper documentation of outside services such as hospice care. Deficiencies were identified in resident chart audits, nurse reviews, and service plan updates.
Complaint Details
The investigation was triggered by an unannounced complaint/incident. The findings indicated non-compliance with residency requirements related to resident assessments, nurse reviews, and service plan documentation. The complaint was substantiated by record reviews and staff interviews.
Deficiencies (3)
| Description |
|---|
| Failure to review resident assessments annually or when condition changes significantly for 1 of 2 sample residents. |
| Failure to complete nurse reviews every 90 days as required. |
| Failure to review and update service plans to reflect significant changes and outside services. |
Report Facts
Deficiencies cited: 3
Dates: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Margaret Burke | Administrator | Signed the statement of deficiencies and plan of correction |
| Director of Wellness | Interviewed during survey on 3/2/2023 regarding resident assessments and nurse reviews | |
| Assistant Director of Wellness | Present during survey interview on 3/2/2023 and acknowledged deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 5
Feb 16, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at Darlington Memory Lane following a complaint related to quality of care involving a resident with a wound requiring hospitalization.
Findings
The investigation found deficiencies in wound care management, including failure to perform weekly wound assessments, inadequate documentation, lack of proper wound care license, and failure to conduct hourly safety rounds on the special care unit. Staff acknowledged these failures during interviews.
Complaint Details
The complaint investigation was triggered by a report on 1/19/2023 that a resident was hospitalized due to a deep wound. The complaint was substantiated by findings of inadequate wound care and safety practices.
Deficiencies (5)
| Description |
|---|
| Failure to monitor and document wound assessments weekly for residents with wounds. |
| Failure to maintain proper residency requirements for residents who do not meet the definition of resident. |
| Failure to maintain detailed resident records including wound care documentation and physician orders. |
| Failure to operate and provide services to all residents of the Special Care Unit according to community standards, including safety rounds. |
| Staff sleeping on duty during overnight shifts, failing to perform required hourly safety rounds. |
Report Facts
Residents on Special Care Unit: 23
Dates of safety rounds missed: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Sanford | Executive Director | Named in wound care and documentation findings; acknowledged failures during interviews |
| Director of Wellness | Acknowledged failure to perform weekly skin assessments and maintain wound documentation | |
| Director of Human Resources | Reported staff sleeping on duty during overnight shifts |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 10, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the facility.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was unannounced and complaint/incident related; no deficiencies were found.
Inspection Report
Deficiencies: 0
Nov 10, 2022
Visit Reason
An administrative review/offsite investigation was conducted at this residence.
Findings
No deficiencies were identified during the administrative review/offsite investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 21, 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: 2
Aug 12, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the assisted living residence following allegations of sexual activity between residents and concerns about supervision and safety.
Findings
The investigation found that the residence failed to provide a safe and secure environment for three memory care residents, with incidents of sexual activity between residents and inadequate supervision. The facility did not ensure all residents were free from abuse, and some residents were hospitalized following the incidents.
Complaint Details
The complaint investigation was substantiated based on record reviews and staff interviews revealing incidents of sexual activity between residents and inadequate supervision. The Administrator acknowledged the incidents during interviews.
Deficiencies (2)
| Description |
|---|
| Failure to provide a safe and secure environment for memory care residents, including inadequate supervision and failure to prevent sexual activity between residents. |
| Failure to ensure all residents were free from abuse as required by the 'Rights of Residents' regulations. |
Report Facts
Number of residents reviewed: 3
Dates of incidents: Incidents occurred around 5/27/2022 and reported on 7/28/2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Sanford | Executive Director | Signed the report and involved in the investigation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 14, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
Unannounced complaint/incident investigation survey with no deficiencies identified.
Inspection Report
Plan of Correction
Deficiencies: 6
Sep 16, 2021
Visit Reason
An unannounced biennial modified State Licensure survey was conducted at the residence to assess compliance with residency requirements, infection control, dietetic services, medication services, and other regulatory standards.
Findings
Deficiencies were identified related to resident assessments, service plans, infection control policies, dietetic services including kitchen cleanliness and food safety certifications, and medication management including expired medications and improper storage.
Deficiencies (6)
| Description |
|---|
| Failure to review resident assessments at intervals not to exceed 12 months and when condition changes, including failure to document active smoking status and physical therapy services. |
| Failure to update service plans to reflect outside services and changes in resident condition. |
| Failure to establish infection control provisions consistent with COVID-19 standards, including staff mask compliance and monitoring. |
| Failure to maintain kitchen ventilation hood cleanliness and proper operation, leading to accumulation of grease and smoke. |
| Failure to employ certified food safety managers as required by licensed capacity regulations. |
| Failure to ensure medication services comply with regulations, including expired medications, improper labeling, and inadequate medication storage security. |
Report Facts
Deficiencies cited: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Sargent | Laboratory Director or Provider/Supplier Representative | Signed the plan of correction document. |
| Staff A | Maintenance | Observed not wearing mask properly during survey. |
| Staff B | Activities Director | Observed with mask beneath nose during survey. |
| Staff C | Kitchen Staff | Observed preparing meals without current food safety certification. |
| Staff D | Certified Medication Technician (CMT) | Observed during medication cart audit. |
| Staff E | Certified Medication Technician (CMT) | Observed during medication cart audit. |
| Wellness Director | Interviewed regarding resident assessments and medication management. | |
| Administrator | Interviewed regarding staff mask compliance and kitchen ventilation issues. | |
| Director of Nursing | Confirmed physical therapy service dates for residents. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Aug 5, 2021
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence following a 5-day investigation by the Rhode Island Department of Health regarding staff conduct and resident falls.
Findings
The investigation revealed that a Certified Nursing Assistant was found sleeping during her shift at the time of a resident's fall and was subsequently terminated. The facility failed to ensure responsible staffing and adequate supervision, and failed to provide all care and services in a safe and effective manner, resulting in multiple resident falls and injuries.
Complaint Details
The complaint investigation was substantiated by findings that Staff B, a Certified Nursing Assistant, was sleeping during her shift at the time of Resident ID #2's fall. The staff member was terminated. The facility failed to ensure safe care and adequate supervision, contributing to resident injuries including fractures and contusions. Resident ID #1 passed away following injuries sustained.
Deficiencies (4)
| Description |
|---|
| Failure to provide sufficient staffing with responsible adults awake and on premises at all times. |
| Staff found sleeping during shift leading to resident fall and injury. |
| Failure to ensure all services were rendered in a safe and effective manner consistent with community standards of care. |
| Failure to update comprehensive resident assessments annually and upon condition changes. |
Report Facts
Investigation duration: 5
Resident falls resulting in injury: 2
Number of residents reviewed: 3
Assessment date: Nov 15, 2019
Resident death date: Jul 15, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant | Named in finding for sleeping during shift leading to resident fall |
| Staff A | Certified Medication Technician | Interviewed regarding Staff B sleeping during shift |
| Director of Nursing | Interviewed regarding Staff B sleeping and resident care |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 10, 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.
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 21, 2021
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence to investigate visitation restrictions and compliance with residents' rights.
Findings
The facility failed to observe the standards related to residents' rights to visitation without unreasonable restrictions. Visitation was limited to five days a week, Monday through Friday, with visits allowed for only 20 minutes, contrary to state and CMS guidance requiring at least 45 minutes and weekend visitation. The administrator was unable to provide evidence that weekend visitation was offered, and residents were allowed only one visit every six days during set weekday time blocks.
Complaint Details
The investigation was prompted by a community-reported complaint dated 3/24/2021 stating that when a resident receives a visit from family for 20 minutes, a family member cannot return to visit again until every resident in the building has received a visit. The complaint was substantiated by surveyor observations and interviews.
Deficiencies (1)
| Description |
|---|
| Failure to observe residents' rights regarding visitation, including limiting visitation to five days a week and restricting visit duration contrary to state and federal guidance. |
Report Facts
Visitation days per week: 5
Visit duration minutes: 20
Required visitation duration minutes: 45
Required visitation days per week: 6
Visit frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Sanford | Executive Director | Signed the report and mentioned in the plan of correction regarding visitation monitoring. |
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