Inspection Report
Renewal
Deficiencies: 5
Aug 20, 2025
Visit Reason
An unannounced biennial State Licensure survey was conducted at the assisted living residence from 08/19/2025 through 08/20/2025 to assess compliance with state licensure requirements.
Findings
Deficiencies were identified related to the quality assurance program and dietetic services, including failure to establish a written quality improvement plan with required objectives and methods, and noncompliance with food safety and sanitation standards in the kitchen and Harbor unit kitchenette.
Deficiencies (5)
| Description |
|---|
| Failure to establish a written quality improvement plan with program objectives and methods to identify, evaluate, and correct identified problems. |
| Noncompliance with Rhode Island Food Code related to kitchen sanitation, including dishwashers not reaching appropriate sanitizing temperature, sticky refrigerator shelving, accumulation of food debris on worktable shelving, and improper cold food storage temperatures. |
| Food items not properly labeled with date for consumption or discard within 7 days. |
| Ice cube trays stored improperly in Harbor freezer and uncovered ice cubes. |
| Food employees observed working without beard nets and failure of dishwasher staff to wash hands after handling soiled dishes. |
Report Facts
Survey dates: 2
Dishwasher temperature: 157
Rinse temperature: 195
Wash temperature: 165
Cold beverage temperature: 41
Milk cold holding temperatures: 43
Milk cold holding temperatures: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Dining Services | Named in findings related to quality assurance meeting attendance and food safety interviews | |
| Dietary Cook Staff A | Observed working in main kitchen without beard net | |
| Dietary Cook Staff B | Observed working in main kitchen without beard net | |
| Dishwasher Staff C | Failed to wash hands after handling soiled dishes and glasses | |
| Executive Director | Executive Director | Interviewed during survey and acknowledged cleaning deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 27, 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 visit was triggered by complaint/incident investigation, ACTS reference numbers 99945. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 13, 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 98667, 98692, 98677, 98892, and 99232. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 26, 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 multiple ACTS reference numbers: 98453, 98386, 98358, 98292, 98288, 98195, 98180, and 98013. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 1, 2024
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 related to a complaint or incident; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 8, 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 complaint-related and no deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 3
Aug 29, 2023
Visit Reason
An unannounced complaint/incident investigation survey and a State licensure survey were conducted at the facility from 8/28/2023 through 8/29/2023.
Findings
The facility failed to comply with Rhode Island Food Code requirements related to dietetic services, including failure of food service staff to wear hair restraints, food items without dates and labels, and accumulation of black substance on the hood over the stove. Corrective actions and education were planned and ongoing.
Complaint Details
The visit was triggered by an unannounced complaint/incident investigation survey, ACTS reference number 91573.
Deficiencies (3)
| Description |
|---|
| Food employees were observed plating food without wearing hair restraints as required by Rhode Island Food Code. |
| Food items in a standup refrigerator were observed without dates indicating when the food shall be consumed or discarded. |
| The hood compartments above the stove had an accumulation of a black substance and were not cleaned as required. |
Report Facts
Date of survey: Aug 29, 2023
Number of food items without dates: 5
Time observations: 840
Time observations: 855
Time observations: 843
Time observations: 845
Time observations: 1125
Time observation: 1130
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 5, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the 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: 0
Nov 29, 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
Complaint Investigation
Deficiencies: 0
Dec 7, 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, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 5
Sep 3, 2021
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey (NBQ711) were conducted at the facility on 09/03/2021.
Findings
Deficiencies were identified related to residency requirements for resident assessments and service plans, and medication services including improper medication storage and labeling. The facility failed to ensure medication assessments and service plans were updated and accurate, and medications were stored securely with proper labeling and directions.
Complaint Details
The visit included a complaint/incident investigation survey (NBQ711) conducted on 09/03/2021.
Deficiencies (5)
| Description |
|---|
| Failure to review resident assessments at intervals not to exceed 12 months and when condition changes significantly for two of five sample residents. |
| Failure to ensure Resident ID #1's clinical record reflected self-administration of oxygen therapy. |
| Failure to ensure service plans reflected skilled nursing services provided by outside agencies for Resident ID #2. |
| Failure to store medications securely to prevent spoilage, dosage errors, administration errors, and/or inappropriate access in two of three medication storage areas reviewed. |
| Medications for Residents #3, #4, #5, and #6 were found with no resident identifiers or directions for use. |
Report Facts
Deficiency sample residents: 5
Medication storage areas reviewed: 3
Residents with medication labeling issues: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 3, 2021
Visit Reason
An unannounced complaint/incident investigation survey and a biennial State licensure survey were conducted at the facility.
Findings
No deficiencies were identified relative to this complaint investigation survey.
Complaint Details
The complaint investigation survey found no deficiencies and no substantiated issues.
Loading inspection reports...
