Inspection Reports for Elderwood of Scallop Shell at Wakefield
55 SCALLOP SHELL WAY, RI, 02879
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Deficiencies: 0
Dec 10, 2025
Visit Reason
A follow-up to a previous recertification survey and a Life Safety Code survey was conducted to verify correction of previous deficiencies.
Findings
All previous deficiencies were corrected, and no new deficiencies were identified during this follow-up survey.
Inspection Report
Plan of Correction
Census: 67
Capacity: 80
Deficiencies: 5
Nov 20, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction following a federal recertification survey, state licensure survey, and complaint investigation conducted from 11/17/2025 through 11/20/2025 at Elderwood of Scallop Shell at Wakefield.
Findings
The survey identified immediate jeopardy related to inadequate supervision leading to a resident choking incident, failure to provide proper notification to residents and representatives regarding Medicare coverage changes, failure to provide adequate care for residents with dysphagia, failure to ensure proper medication administration and documentation, and failure to maintain a safe environment with adequate emergency lighting. Corrective actions and education plans were implemented and monitored.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Immediate jeopardy due to inadequate supervision resulting in a resident choking incident and failure to implement interventions to prevent recurrence. | Immediate Jeopardy |
| Failure to properly notify residents and representatives of Medicare coverage changes as required by regulations. | — |
| Failure to provide adequate care and monitoring for residents with dysphagia, including failure to implement appropriate interventions to prevent choking. | — |
| Failure to ensure accurate medication administration and documentation, including failure to weigh residents daily as ordered and failure to administer medications as prescribed. | — |
| Failure to maintain a safe environment by ensuring emergency lighting was functional in the electrical room. | — |
Report Facts
Capacity: 80
Census: 67
Deficiencies cited: 5
Emergency lighting monitoring duration: 12
Audit monitoring duration: 12
Inspection Report
Complaint Investigation
Census: 67
Capacity: 80
Deficiencies: 6
Nov 20, 2025
Visit Reason
The inspection was conducted as a Federal recertification survey, State Licensure survey, and complaint investigation survey from 11/17/2025 through 11/20/2025, including review of complaint intake ID reference numbers 2666819, 2665913, and 2674257.
Findings
The facility was found to have multiple deficiencies including failure to provide adequate supervision to prevent choking incidents for Resident ID #9, failure to provide required Medicaid/Medicare notices to residents, failure to ensure quality of care related to fluid management for Resident ID #70, failure to ensure adequate nursing staff competency related to choking incidents, failure to ensure drug regimens were free from unnecessary drugs, and failure to maintain emergency lighting as per Life Safety Code. Immediate Jeopardy was identified related to choking incidents.
Complaint Details
The complaint investigation was initiated based on complaint intake IDs 2666819, 2665913, and 2674257. The facility was found to have Immediate Jeopardy related to choking incidents for Resident ID #9 and other deficiencies as noted. The IJ was removed as of 11/19/2025 after corrective actions were implemented.
Severity Breakdown
Immediate Jeopardy: 1
Severity Level C: 1
Severity Level G: 2
Severity Level E: 1
Severity Level F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision to prevent choking incidents for Resident ID #9, resulting in Immediate Jeopardy. | Immediate Jeopardy |
| Failure to provide required Medicaid/Medicare Advanced Beneficiary Notices (SNFABN) to residents #17, 22, and 30. | Severity Level C |
| Failure to ensure quality of care related to fluid management for Resident ID #70, including missed medication doses and failure to obtain daily weights. | Severity Level G |
| Failure to ensure adequate nursing staff competency and timely intervention related to choking incidents for Resident ID #9. | Severity Level G |
| Failure to ensure drug regimens were free from unnecessary drugs for residents #4, 79, 83. | Severity Level E |
| Failure to maintain emergency lighting in the basement electrical room as required by Life Safety Code. | Severity Level F |
Report Facts
Deficiencies cited: 6
Resident census: 67
Total capacity: 80
Dates of medication doses missed: 6
Dates of survey: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Registered Nurse | Named in findings related to failure to provide nursing services and documentation regarding choking incidents and medication administration. |
| Staff C | Nurse Practitioner | Named in findings related to presence during choking incident and assessment of resident. |
| Staff D | Unit Manager | Named in findings related to medication administration and resident care. |
| Administrator | Named in findings related to notification and corrective actions for choking incidents. | |
| Interim Director of Nursing Services | Named in findings related to nursing services and corrective actions. |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 80
Deficiencies: 7
Sep 6, 2024
Visit Reason
A recertification and complaint surveys were conducted from 09/03/2024 through 09/06/2024 to determine compliance with federal regulations for Long Term Care Facilities, including a complaint investigation.
Findings
Deficiencies were identified related to quality of care, treatment to prevent pressure ulcers, medication errors, hospice services, infection control, emergency preparedness, and life safety code compliance. Corrective actions and plans of correction were outlined for each deficiency with specific deadlines and monitoring plans.
Complaint Details
The visit included complaint surveys with reference numbers 97328 and 97343. Deficiencies were substantiated as evidenced by findings related to quality of care, medication errors, infection control, and other areas.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure residents received treatment and care in accordance with professional standards, including weekly skin assessments for residents with skin grafts and impairments. |
| Facility failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing and prevent infection. |
| Facility failed to ensure residents were free of significant medication errors, including incorrect heparin dosing. |
| Facility failed to ensure hospice services met regulatory requirements including documentation and communication. |
| Facility failed to establish and maintain an infection prevention and control program to prevent transmission of communicable diseases. |
| Facility failed to conduct emergency preparedness exercises and maintain compliance with emergency preparedness regulations. |
| Facility failed to provide evidence of required fire drills and compliance with life safety code requirements. |
Report Facts
Capacity: 80
Census: 62
Deficiencies cited: 7
Medication dosage units: 5000
Medication dosage units: 7500
Audit completion date: Oct 6, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amber Gravers | Licensed Nurse Administrator (LNA) | Signed the statement of deficiencies and plan of correction |
Inspection Report
Follow-Up
Deficiencies: 0
Oct 25, 2023
Visit Reason
A follow-up to a previous recertification survey was conducted at this facility.
Findings
All previous deficiencies were corrected and no new deficiencies were identified.
Inspection Report
Complaint Investigation
Deficiencies: 10
Sep 19, 2023
Visit Reason
A Recertification Survey and Complaints Investigation Survey was conducted at Elderwood of Scallop Shell at Wakefield from 9/18/2023 through 9/22/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities. The visit included a complaint investigation triggered by a community report alleging mistreatment and medication issues.
Findings
Deficiencies were cited related to failure to develop and implement comprehensive care plans, failure to meet professional standards in wound care and skin assessments, failure to provide treatment and care in accordance with professional standards, failure to ensure pain management, failure to maintain infection prevention and control, and failure to ensure proper medication management including antibiotic stewardship. The facility also failed to maintain proper documentation and timely interventions for residents' care needs.
Complaint Details
The complaint investigation was triggered by a community report received by the Rhode Island Department of Health on 9/21/2023 alleging that Resident ID #36 was treated with an antibiotic, Invanz (Ertapenem Sodium), for a urinary tract infection from 9/2/2023 to 9/6/2023 and experienced confusion and hallucinations. The allegation included that the antibiotic had not been added to the resident's allergy list to alert the provider or pharmacy of the adverse reaction. The complaint was substantiated as deficiencies were cited related to medication management and allergy documentation.
Deficiencies (10)
| Description |
|---|
| Failure to develop and implement a comprehensive person-centered care plan for residents, including measurable objectives and timelines. |
| Failure to meet professional standards of quality for wound assessments and following physician orders for skin checks. |
| Failure to provide treatment and care in accordance with professional standards for residents with adverse medication reactions and hospice care. |
| Failure to ensure pain management services consistent with professional standards for residents requiring such services. |
| Failure to establish and maintain an infection prevention and control program to prevent communicable diseases and infections. |
| Failure to ensure residents receive food and drink that is palatable, attractive, and at a safe and appetizing temperature. |
| Failure to ensure feeding assistants provide dining assistance only to residents without complicated feeding problems. |
| Failure to maintain resident-identifiable medical records that are complete, accurate, accessible, and systematically organized. |
| Failure to provide adequate antibiotic stewardship program including monitoring and documentation of antibiotic use. |
| Failure to provide influenza and pneumococcal immunizations or document refusals for residents. |
Report Facts
Residents reviewed for pain management: 3
Residents reviewed for wound care: 4
Residents reviewed for antibiotic use: 3
Residents reviewed for immunizations: 8
Residents reviewed for feeding assistance: 2
Inspection Report
Follow-Up
Deficiencies: 0
Jul 14, 2022
Visit Reason
An off-site desk audit was conducted on July 14, 2022, to review all previous deficiencies cited on June 22, 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: 3
Jun 22, 2022
Visit Reason
A Recertification Survey was conducted at Elderwood Of Scallop Shell At Wakefield from 06/20/2022 through 06/22/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were cited related to Respiratory/Tracheostomy Care and Suctioning, Infection Prevention & Control, and Resident Call Systems. The facility failed to provide respiratory care consistent with professional standards, failed to implement adequate infection control measures, and failed to adequately equip residents to call for staff assistance.
Deficiencies (3)
| Description |
|---|
| Failure to provide respiratory care consistent with professional standards for oxygen therapy, including lack of orders for oxygen therapy and weekly tubing changes. |
| Failure to establish and maintain an infection prevention and control program, including improper disinfection of equipment and improper hand hygiene. |
| Failure to adequately equip residents to call for staff assistance through a communication system, including call light placement and accessibility. |
Report Facts
Survey duration: 3
Oxygen therapy flow rate: 3
Residents reviewed for call system: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Unit nurse interviewed regarding oxygen therapy orders and infection control practices | |
| Director of Nursing Services | Interviewed regarding infection control and call light policies | |
| Staff B | Nursing Assistant observed during hand hygiene and linen handling | |
| Staff C | Nursing Assistant interviewed regarding call light placement and use |
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