Inspection Reports for Forest Farm Assisted Living
191 FOREST AVENUE, MIDDLETOWN, RI, 02842
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
62% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 8
May 14, 2025
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at Forest Farm Assisted Living on 05/14/2025.
Findings
Deficiencies were identified related to failure to provide care and services in accordance with community standards, including medication administration without proper physician orders, failure to review resident assessments timely, incomplete nurse reviews, improper medication storage, and inadequate documentation of emergency procedures and advance directives.
Complaint Details
The complaint/incident investigation was unannounced and conducted concurrently with the biennial State Licensure survey. Deficiencies were identified relative to the complaint/incident survey, including failure to follow emergency medical response policy and inadequate documentation of advance directives.
Deficiencies (8)
| Description |
|---|
| Failure to provide care and services in accordance with community standards relative to administering medications without physician's orders for Resident ID #1. |
| Failure to review resident assessments at intervals not to exceed twelve months and upon significant condition changes for 4 of 4 sample residents. |
| Failure to complete nurse reviews at least once every ninety days for 4 of 4 sample residents. |
| Failure to ensure medications were stored securely to prevent spoilage, dosage errors, administration errors, and inappropriate access. |
| Expired medications and medications without resident identifiers or directions were found in the medication cart. |
| Failure to maintain complete fire drill documentation including names of persons conducting drills. |
| Failure to have written policies and procedures for advance directives and emergency medical care for residents. |
| Failure to follow medical emergency response policy and delay in treatment for unresponsive resident. |
Report Facts
Dates of fire drills conducted: Fire drills were conducted on 3/23/2024, 4/25/2024, 6/10/2024, 7/26/2024, 10/10/2024, 12/20/2024, 1/25/2025, and 3/21/2025.
Frequency of audits: 3
Frequency of nurse reviews: 90
Number of sample residents reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Mello | Administrator | Signed the Plan of Correction document. |
| Staff A | Nursing Assistant (NA) | Interviewed during complaint investigation; provided information about resident's condition and response. |
| Staff B | Certified Medication Technician | Observed during medication cart inspection; acknowledged expired medications and improper labeling. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 29, 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 visit was triggered by complaint/incident investigation, ACTS reference numbers 97783. No deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 23, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the facility on 09/23/2024, referencing multiple ACTS numbers.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was based on complaint/incident reports with ACTS reference numbers 96442, 96782, 97434, 97474, and 97538. No deficiencies were found.
Inspection Report
Abbreviated Survey
Deficiencies: 2
Jun 25, 2024
Visit Reason
An unannounced abbreviated complaint/incident survey was conducted at Forest Farm Assisted Living to identify deficiencies related to resident assessments and safety requirements.
Findings
Deficiencies were found in the completion and signing of resident comprehensive assessment forms and in the documentation of fire drills, specifically the failure to include the amount of time taken to evacuate the building during drills.
Complaint Details
The survey was complaint/incident triggered as an unannounced abbreviated complaint/incident survey.
Deficiencies (2)
| Description |
|---|
| Resident comprehensive assessment forms failed to be completed in their entirety and were not signed by the Administrator as required. |
| Documentation of fire drills failed to include the amount of time taken to evacuate the building or unit. |
Report Facts
Sample residents reviewed: 4
Fire drills conducted: 6
Fire drill dates reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Mello | Administrator | Signed the Plan of Correction and was interviewed during the survey. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 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
The investigation was unannounced and complaint/incident related; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 5
Jul 27, 2023
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at Forest Farm Assisted Living on 07/27/2023.
Findings
Deficiencies were identified related to the State Licensure survey including failure to establish a quality improvement committee with required members, failure to review resident service plans at required intervals, failure to implement written policies to protect residents' rights, failure to comply with Rhode Island Food Code, and failure to conduct fire drills as required.
Complaint Details
The visit included a complaint/incident investigation survey (0PHY11) conducted on 07/27/2023.
Deficiencies (5)
| Description |
|---|
| Failed to establish a quality improvement committee including administrator, registered nurse, and dietary services representative. |
| Failed to review resident service plans at intervals not to exceed 12 months and upon significant condition changes. |
| Failed to implement written policies and procedures to ensure employees protect residents' rights. |
| Failed to comply with Rhode Island Food Code including accumulation of black substance on kitchen equipment and failure to wear hair restraints. |
| Failed to conduct required fire drills six times per year with proper documentation and compliance. |
Report Facts
Dates quality assurance meeting minutes missing dietary services representative: 3
Number of sample residents reviewed for service plans: 7
Fire drills required per year: 6
Fire drills conducted: 2
Fire drills documented: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Mello | Administrator | Administrator interviewed during survey and acknowledged deficiencies. |
| Staff A | Cook | Observed with accumulation of black substance on kitchen equipment and acknowledged observations. |
| Staff B | Dietary Aide | Observed preparing food without wearing hair restraint. |
| Food Service Director | Acknowledged accumulation of black substance on stove hood. | |
| Maintenance Director | Cleaned kitchen hood upon notification. | |
| Dietary Manager | Ensured quarterly hood cleaning and hair restraint audits. |
Inspection Report
Complaint Investigation
Deficiencies: 2
May 3, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at Forest Farm Assisted Living following an allegation of resident abuse involving a staff member.
Findings
The investigation found that personnel records were not reviewed and updated as required for one of five personnel records. The facility failed to maintain evidence that all reportable incidents were thoroughly investigated and actions taken to prevent further incidents. A specific allegation of resident abuse was investigated but evidence of a thorough investigation was not found, and the investigation was still in progress at the time of the survey.
Complaint Details
The complaint involved a staff-to-resident allegation submitted to the Rhode Island Department of Health on 4/20/2023 alleging that a nurse was yanking a resident's arm out of bed in a forceful manner causing pain. The resident reported increased feelings of anxiety, discomfort, and insecurity. The investigation was ongoing at the time of the survey.
Deficiencies (2)
| Description |
|---|
| Personnel records were not reviewed and updated at intervals not to exceed twelve months for 1 of 5 personnel records reviewed. |
| The residence failed to maintain evidence that all reportable incidents have been thoroughly investigated and that actions have been taken to prevent further incidents while the investigation is in progress for 1 of 1 reportable incidents. |
Report Facts
Personnel records reviewed: 5
Reportable incidents investigated: 1
Date of complaint submission: Apr 20, 2023
Inspection Report
Complaint Investigation
Deficiencies: 5
Aug 17, 2021
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at Forest Farm Assisted Living to assess compliance with state regulations.
Findings
Deficiencies were identified related to resident assessments, service plans, and medication services. The facility failed to review resident assessments timely, document required service plan details, and ensure safe possession and control of medications for residents self-administering medications.
Complaint Details
The visit included a complaint/incident investigation survey as part of the unannounced biennial licensure survey.
Deficiencies (5)
| Description |
|---|
| Failure to review resident assessments at intervals not to exceed 12 months and upon significant condition changes for two of three sample residents. |
| Failure to document a description of services and interventions needed, including all services provided by outside healthcare agencies, in service plans for two of three sample residents. |
| Failure to have service plans signed, approved, and dated by a registered nurse and/or certified assisted living residence administrator for three of three sample residents. |
| Failure to ensure a resident with possession and control of medications was deemed safe by the resident, guardian if appropriate, and administrator or designee for two residents self-administering medications. |
| Failure to send a variance request for hospice services for a resident receiving hospice care. |
Report Facts
Dates of resident assessments: Resident ID #1 had assessments on 07/30/2020, 10/15/2020, 01/06/2021, 03/02/2021, 06/01/2021, and 07/27/2021.
Dates of resident assessments: Resident ID #2 had assessments on 02/15/2021, 05/05/2021, and 08/06/2021.
Corrective action completion date: Corrective action date will be October 8, 2021.
Variance procedure review date: Variance request for hospice services to be reviewed at quarterly CQI meetings.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Mello | Administrator | Signed as the provider/supplier representative on the plan of correction. |
| Director of Nursing | Provided lists of outside services and was interviewed regarding resident assessments and service plans. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 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 the complaint investigation.
Complaint Details
The complaint investigation was unannounced and no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 2, 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 complaint/incident related; no deficiencies were found.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 11, 2021
Visit Reason
An unannounced focused survey was conducted at this residence related to COVID-19 infection control.
Findings
No deficiencies were identified during the COVID-19 infection control survey.
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