Inspection Reports for Ethan Place Assisted Living

An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations.

No deficiency was identified during the investigation.

The investigation was based on ACTS reference numbers 100992, 101143, and 101943. No deficiencies were found.

An unannounced complaint/incident investigation survey was conducted from 05/27/2025 through 05/29/2025 to determine compliance with state regulations following complaints regarding medication administration for Resident ID #1.

The investigation found that the residence failed to provide care and services in accordance with the prevailing community standard of care related to administering medications per physician's orders for Resident ID #1. Multiple medication doses were missed or refused, and there was no evidence the physician was notified of these issues.

The complaint investigation was triggered by a community reported complaint sent to the Rhode Island Department of Health on 5/19/2025 alleging Resident ID #1 had trouble getting medications for days. The complaint was substantiated by record review and staff interview.

An unannounced complaint/incident investigation survey was conducted on 03/27/2025 at Ethan Place to determine compliance with state regulations following complaints regarding medication administration and resident care.

Deficiencies were identified related to failure to provide medications as ordered for Resident ID #1, incomplete and unsigned comprehensive assessments for Residents #1, 2, and 3, failure to update service plans to reflect current conditions, and failure to conduct required nurse reviews with proper documentation for Residents #1, 3, and 4.

The investigation was triggered by a community reported complaint sent to the Rhode Island Department of Health on 3/24/2025 alleging Resident ID #1 had trouble getting his/her medications. The complaint was substantiated by findings that Resident ID #1 did not receive medications as ordered.

An unannounced complaint/incident investigation survey was conducted at the residence on 04/03/2024 based on ACTS reference number 94747.

The facility failed to provide all care and services in accordance with the prevailing community standard of care for a singular resident reviewed for hospitalization. Specifically, the resident was discharged from the hospital with fluid restriction orders that were not transcribed or followed at the facility, and the resident's comprehensive assessment was not updated to reflect these changes.

The complaint investigation was unannounced and based on ACTS reference number 94747. It was substantiated that the facility failed to provide care consistent with hospital discharge orders and failed to update the resident's assessment accordingly.

An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility on 02/12/2024.

Deficiencies were identified related to residency requirements for resident assessments and service plans, and medication services. Specifically, the facility failed to update residents' comprehensive assessments at required intervals and did not ensure quarterly medication aide evaluations were completed for all staff.

The complaint/incident investigation was triggered by a psychiatric change in condition for Resident ID #1 resulting in emergency room visit, police involvement, and a facility incident report. The facility failed to update assessments as required and acknowledged this during the administrator interview.

An unannounced complaint/incident investigation survey was conducted at the residence to investigate identified deficiencies.

The facility failed to ensure resident comprehensive assessments were updated within required timeframes, failed to have a registered nurse visit the residence at least once every 30 days for some residents, and failed to review and update service plans when residents' conditions changed.

The investigation was triggered by a complaint/incident. Deficiencies were identified and substantiated based on record reviews and staff interviews.

An unannounced complaint/incident investigation survey was conducted at Ethan Place residence due to concerns about residency requirements and appropriateness of a resident for the community.

The facility failed to ensure that 1 out of 2 sampled residents met the definition of 'resident' as required by residency regulations. The resident exhibited severe cognitive impairment and behaviors warranting evaluation for memory care, with multiple documented incidents of wandering and elopement risk.

The complaint investigation found that the resident was not appropriate for the community based on cognitive and behavioral assessments, including a Mini-Mental State Exam score of 8 indicating severe impairment. Family was engaged regarding alternate placement and memory care evaluation was recommended.

An unannounced biennial State Licensure survey was conducted at this residence to assess compliance with state regulations and standards of care.

The facility was found deficient in multiple areas including management of services, resident assessments and service plans, medication services, nurse reviews, safety requirements, and variance procedures. Specific deficiencies involved failure to have physician orders for self-administration of medications, incomplete resident assessments, failure to ensure scheduled medications were administered by licensed personnel, incomplete nurse reviews, and inadequate fire drill documentation.

An unannounced complaint/incident investigation survey was conducted at Ethan Place to investigate deficiencies related to resident assessments, service plans, and reporting requirements.

The facility failed to update comprehensive assessments and service plans to reflect accurate start and discharge dates for outside therapy services for multiple residents. Additionally, the residence failed to maintain evidence of thorough investigations and timely reporting of reportable incidents to the Rhode Island Department of Health.

The investigation was complaint-driven and identified deficiencies in resident assessments, service plans, and reporting of incidents. The Administrator acknowledged these failures during interviews on 05/03/2021.