Inspection Reports for Golden Crest Nursing Centre
100 SMITHFIELD ROAD, RI, 02904
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Inspection Report
Plan of Correction
Deficiencies: 0
Feb 5, 2026
Visit Reason
An off-site desk audit was conducted to review all previous deficiencies cited on December 11, 2025, and verify correction based on an acceptable plan of correction and supporting documentation.
Findings
All previously cited deficiencies have been corrected, and the facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 0
Jan 12, 2026
Visit Reason
A follow-up to a previous Recertification and complaint investigation survey was conducted at this facility on 01/12/2026.
Findings
All previous deficiencies were corrected, and no new deficiencies were identified during this follow-up survey.
Inspection Report
Annual Inspection
Census: 147
Capacity: 152
Deficiencies: 6
Dec 11, 2025
Visit Reason
The inspection was conducted as an annual Federal Life Safety Code survey and compliance survey for Long Term Care Facilities, including recertification and complaint surveys, to determine compliance with 42 CFR Part 483 and state licensure requirements.
Findings
Deficiencies were identified in multiple areas including Freedom from Abuse and Neglect, ADL Care for Dependent Residents, Activities to Meet Resident Needs, Treatment and Services to Prevent Pressure Ulcers, Resident Records, and Fire Drills. The facility failed to meet several regulatory requirements as evidenced by observations, record reviews, and staff interviews.
Severity Breakdown
Level D: 3
Level G: 1
Level E: 1
Level F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Freedom from Abuse, Neglect, and Exploitation - Facility failed to ensure residents were free from neglect, evidenced by delay in personal care for Resident #40. | Level D |
| ADL Care Provided for Dependent Residents - Facility failed to provide necessary services for activities of daily living for Resident #118. | Level D |
| Activities Meet Interests/Needs of Each Resident - Facility failed to provide an ongoing activity program for Resident #118. | Level D |
| Treatment/Services to Prevent Pressure Ulcers - Facility failed to prevent pressure ulcers for Resident #7, including failure to implement physician-ordered offloading of heels. | Level G |
| Resident Records - Facility failed to maintain accurate medical records for residents including failure to reflect skin assessments accurately for Residents #21, #67, and #118. | Level E |
| Fire Drills - Facility failed to provide evidence that fire drills were conducted quarterly on all shifts as required by NFPA 101. | Level F |
Report Facts
Census: 147
Total Capacity: 152
Deficiencies cited: 6
Inspection Report
Annual Inspection
Census: 147
Capacity: 152
Deficiencies: 6
Dec 11, 2025
Visit Reason
Recertification and complaint surveys were conducted to determine compliance with 42 C.F.R. Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were identified in multiple areas including freedom from abuse and neglect, ADL care for dependent residents, activities to meet resident needs, prevention and treatment of pressure ulcers, and maintenance of resident medical records. Additionally, a Life Safety Code deficiency was found related to fire drills not being conducted quarterly on all shifts.
Complaint Details
The survey included complaint investigations with intake reference numbers 2637102, 2688992, and 2635642.
Severity Breakdown
SS = D: 3
SS = G: 1
SS = E: 1
SS = F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to ensure residents were free from neglect for 1 resident with delay in personal care. | SS = D |
| Facility failed to provide necessary ADL care to 1 of 3 residents reviewed. | SS = D |
| Facility failed to provide an ongoing activity program for 1 resident. | SS = D |
| Facility failed to prevent a new pressure ulcer for 1 resident and failed to consistently implement physician-ordered interventions. | SS = G |
| Facility failed to maintain accurate and confidential medical records for multiple residents. | SS = E |
| Facility failed to conduct fire drills quarterly on all shifts as required by NFPA 101 2012 edition. | SS = F |
Report Facts
Census: 147
Total Capacity: 152
Deficiencies cited: 6
Minimum Data Set assessment dates: Sep 12, 2025
Minimum Data Set assessment dates: Sep 17, 2025
Weekly skin assessment dates: Nov 9, 2025
Weekly skin assessment dates: Nov 23, 2025
Weekly skin assessment dates: Nov 30, 2025
Weekly skin assessment dates: Dec 7, 2025
Inspection Report
Follow-Up
Deficiencies: 0
Oct 23, 2024
Visit Reason
An off-site desk audit was conducted on October 23, 2024, to review all previous deficiencies cited on September 20, 2024.
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
Plan of Correction
Deficiencies: 0
Oct 23, 2024
Visit Reason
An off-site desk audit was conducted on October 23, 2024, to review all previous deficiencies cited on September 20, 2024.
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
Follow-Up
Deficiencies: 0
Oct 31, 2023
Visit Reason
A follow-up to a recertification investigation survey was conducted at the facility on 10/31/2023 to verify correction of previous deficiencies.
Findings
All previous deficiencies were corrected and no new deficiencies were identified during this follow-up inspection.
Inspection Report
Complaint Investigation
Census: 142
Capacity: 152
Deficiencies: 9
Oct 13, 2023
Visit Reason
Recertification and Complaint Surveys were conducted from 10/10/2023 through 10/13/2023 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 cited at a scope and severity level H, constituting substandard quality of care. Key issues included failure to protect residents from abuse, failure to complete timely MDS assessments, failure to meet professional standards in care, inadequate treatment of pressure ulcers, failure to provide necessary ADL services, and failure to maintain accurate and confidential resident records.
Complaint Details
The complaint investigation was substantiated with findings of abuse and neglect related to a resident's behavioral contract restricting coffee and activities, which was not properly implemented or agreed upon by all parties. Multiple interviews and observations confirmed failure to protect the resident from abuse and neglect.
Severity Breakdown
Level H: 1
Level D: 8
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to protect resident from abuse, neglect, misappropriation of resident property, and exploitation. | Level H |
| Failure to complete Minimum Data Set (MDS) assessments within required timeframes for discharged residents. | Level D |
| Failure to meet professional standards of quality related to abdominal girth measurements. | Level D |
| Failure to provide necessary services for dependent residents to carry out activities of daily living (ADLs). | Level D |
| Failure to provide treatment and services for pressure ulcers consistent with professional standards. | Level D |
| Failure to ensure residents are free of accident hazards and receive adequate supervision. | Level D |
| Failure to provide appropriate colostomy, urostomy, or ileostomy care consistent with professional standards. | Level D |
| Failure to maintain accurate, complete, and confidential resident medical records. | Level D |
| Failure to establish and maintain an effective infection prevention and control program. | Level D |
Report Facts
Census: 142
Total Capacity: 152
Residents reviewed: 3
Residents reviewed: 8
Residents reviewed: 7
Residents reviewed: 5
Residents reviewed: 8
Residents reviewed: 1
Residents reviewed: 1
Inspection Report
Follow-Up
Deficiencies: 0
Aug 30, 2022
Visit Reason
An off-site desk audit was conducted on August 30, 2022, to review all previous deficiencies cited on August 4, 2022.
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
Plan of Correction
Deficiencies: 0
Aug 25, 2022
Visit Reason
An off-site desk audit was conducted on August 25, 2022 for all previous deficiencies cited on August 5, 2022.
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
Plan of Correction
Census: 142
Capacity: 152
Deficiencies: 2
Aug 5, 2022
Visit Reason
A Recertification, Complaint, and COVID-19 Vaccine Compliance Surveys were conducted from 08/01/2022 through 08/05/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities. A State licensure and emergency preparedness surveys were also conducted.
Findings
The facility was determined not to be in compliance with requirements related to professional standards of care and treatment, including failure to ensure nursing staff followed physician's orders for pain medication and failure to provide necessary treatment and services to prevent and heal pressure ulcers for several residents.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i) - Facility failed to ensure services met professional standards of quality for 1 of 8 residents reviewed relative to physician's order for pain medication. | SS=D |
| Treatment/Services to Prevent/Heal Pressure Ulcer CFR(s): 483.25(b)(1)(i)(ii) - Facility failed to ensure residents at risk for pressure ulcers received necessary treatment and services to promote healing and prevent new ulcers for 4 of 10 residents reviewed. | SS=E |
Report Facts
Census: 142
Total Capacity: 152
Deficiencies cited: 2
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