Deficiencies (last 3 years)
Deficiencies (over 3 years)
16.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
379% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 12, 2025
Visit Reason
The inspection was conducted following a community reported complaint submitted to the Rhode Island Department of Health on 12/9/2025, alleging that a resident was readmitted to the hospital due to the facility's failure to accurately check blood sugar levels and administer prescribed insulin.
Complaint Details
Complaint investigation based on a community reported complaint alleging failure to accurately check sugar levels and administer insulin, resulting in resident readmission to hospital with critically elevated blood glucose levels. Substantiated by record review and staff interviews.
Findings
The facility failed to ensure that one resident received 17 out of 17 prescribed doses of Insulin Lispro as ordered, resulting in elevated blood glucose levels, clinical decline including lethargy, and transfer to an acute care hospital. Staff interviews and record reviews confirmed the medication errors and lack of evidence of administration.
Deficiencies (1)
Failure to ensure residents are free from significant medication errors, specifically failure to administer Insulin Lispro as ordered to Resident ID #1.
Report Facts
Missed insulin doses: 17
Elevated blood glucose levels: 793
Blood glucose levels: 285
Blood glucose levels: 385
Blood glucose levels: 250
Blood glucose levels: 278
Blood glucose levels: 247
Blood glucose levels: 218
Blood glucose levels: 582
Blood glucose levels: 483
Blood glucose levels: 394
Blood glucose levels: 542
Blood glucose levels: 484
Critically elevated blood glucose level: 658
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Assigned nurse during the period of missed insulin doses; did not remember administering insulin |
| Director of Nursing Services | Unable to provide evidence that resident received insulin as ordered | |
| Nurse Practitioner | Indicated expectation that staff follow provider's orders |
Inspection Report
Complaint Investigation
Census: 2
Capacity: 4
Deficiencies: 2
Date: Sep 11, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of physical and verbal abuse by a staff member against residents at the facility.
Complaint Details
The complaint investigation found substantiated abuse by Certified Nursing Assistant Staff A against Residents #2 and #3, including verbal abuse and rough handling. Staff A appeared intoxicated and unfit for duty. The facility failed to immediately remove Staff A despite reports and observations of abuse and intoxication.
Findings
The facility failed to keep residents free from physical and verbal abuse by a Certified Nursing Assistant (Staff A) who appeared intoxicated and was witnessed being verbally abusive and rough with residents. The facility also failed to immediately remove the abusive staff member and implement effective measures to prevent further abuse.
Deficiencies (2)
Failure to protect residents from all types of abuse including physical, mental, sexual abuse, physical punishment, and neglect.
Failure to respond appropriately to all alleged violations of abuse.
Report Facts
Residents reviewed: 4
Residents affected: 2
BIMS score: 99
BIMS score: 15
Census: 2
Total capacity: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in findings for being intoxicated, verbally abusive, and physically rough with residents |
| Staff B | Certified Nursing Assistant (CNA) | Witnessed Staff A's abusive behavior and reported the incident |
| Staff C | Licensed Practical Nurse (LPN) | Witnessed Staff A's abusive behavior and reported the incident |
| Staff D | Registered Nurse (RN) | Received reports of Staff A's behavior and provided statements regarding the incidents |
| Director of Nursing Services (DNS) | Director of Nursing Services | Authored progress notes documenting resident complaints and acknowledged failure to provide evidence residents were kept free from abuse |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 4, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to follow a physician's order to check blood sugars four times daily for Resident ID #2.
Complaint Details
The complaint investigation found substantiated issues with failure to follow physician's orders and inaccurate medical record transcription related to blood sugar monitoring for Resident ID #2.
Findings
The facility failed to meet professional standards of quality by not following the physician's order to check blood sugars four times daily for Resident ID #2. Record review revealed that blood sugars were not checked for 137 out of 152 opportunities between 7/29/2025 and 9/4/2025. Staff interviews confirmed lack of awareness and transcription errors related to the physician's order.
Deficiencies (2)
Failure to follow a physician's order to check blood sugars four times daily for Resident ID #2.
Failure to ensure resident's medical records were accurate and in accordance with accepted professional standards for Resident ID #2.
Report Facts
Missed blood sugar checks: 137
Total blood sugar check opportunities: 152
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Interviewed on 9/4/2025; unaware of physician's order and acknowledged no record of blood sugar checks. |
| Staff B | Nurse Practitioner | Interviewed on 9/4/2025; stated expectation that physician's order would have been followed. |
| Director of Nursing Services | Interviewed on 9/4/2025; unable to provide evidence that physician's order was followed and indicated transcription error in EMR. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 14, 2025
Visit Reason
The inspection was conducted in response to a community complaint alleging that a Medication Technician administered medications prescribed to a resident's roommate to the wrong resident.
Complaint Details
The complaint was submitted to the Rhode Island Department of Health on 2025-08-13 alleging that a Medication Technician administered Resident ID #1 medications prescribed to Resident ID #2. The complaint was substantiated by record review and staff interviews.
Findings
The facility failed to ensure that Resident ID #1's drug regimen was free from unnecessary medications when a Medication Technician administered medications intended for Resident ID #2 to Resident ID #1. The incident was confirmed through record review and staff interviews.
Deficiencies (1)
Facility failed to ensure that the resident's drug regimen is free from unnecessary medication for 1 of 6 residents reviewed for medication administration.
Report Facts
Residents reviewed for medication administration: 6
Residents affected: 1
Monitoring timeframe: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse | Authored progress note and provided interview confirming medication error |
| Staff A | Medication Technician | Administered medications intended for Resident ID #2 to Resident ID #1 |
| Director of Nurses | Acknowledged that Resident ID #1 received unnecessary medications |
Inspection Report
Routine
Deficiencies: 11
Date: Mar 6, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements related to resident rights, advance directives, medication management, respiratory care, dialysis care, infection control, food safety, and environmental safety.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' communication rights for non-English speakers, inconsistencies in advance directives documentation, improper disposal of hazardous materials, respiratory care not consistent with orders, failure to monitor fluid restrictions for dialysis patients, administration of unnecessary medications, improper medication storage and labeling, failure to provide food and liquids in prescribed forms, food safety violations, infection prevention lapses related to enhanced barrier precautions, and maintenance issues affecting resident comfort and safety.
Deficiencies (11)
Failed to ensure residents' right to communication and access to services for residents whose primary language is not English.
Failed to ensure residents' advance directives were consistent with the electronic medical record for 2 residents.
Failed to ensure residents' environment was free from accident hazards related to improper disposal of hazardous materials on medication carts.
Failed to provide respiratory care consistent with professional standards for oxygen use for 2 residents.
Failed to provide safe and appropriate dialysis care including monitoring and documenting fluid restriction for a resident on renal diet.
Failed to ensure resident's drug regimen was free from unnecessary drugs; medication given despite parameters to hold.
Failed to store and label drugs and biologicals in accordance with accepted professional standards; medications left unlabeled and at bedside.
Failed to prepare food and drink in a form designed to meet individual needs; resident requiring honey thickened liquids was given thin liquids.
Failed to store, prepare, distribute, and serve food in accordance with professional standards; including unclean surfaces, improper food temperatures, unlabeled food containers, and expired food items.
Failed to maintain an infection prevention and control program; lapses in enhanced barrier precautions including improper handling of suprapubic tube and PICC line care.
Failed to maintain a safe, functional, and comfortable environment; resident rooms and furnishings in disrepair including torn recliner upholstery, unpainted walls, missing weather stripping on windows.
Report Facts
Medication administration errors: 20
Fluid restriction: 1000
Oxygen liters: 8
Oxygen liters: 3
Food temperature: 48
Food temperature: 45
Medication administration dates: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Interviewed regarding newsletter distribution and PICC line care without gown. |
| Staff B | Registered Nurse | Acknowledged inconsistency in advance directives documentation. |
| Staff C | Registered Nurse | Interviewed regarding oxygen administration and fluid restriction monitoring. |
| Staff D | Registered Nurse | Observed improper disposal of sharps and medication administration practices. |
| Staff E | Licensed Practical Nurse | Unable to provide evidence of proper oxygen administration. |
| Staff F | Registered Nurse | Acknowledged opened Lidoderm patch left on resident's nightstand. |
| Staff G | Nursing Assistant | Observed providing care without gown for resident on Enhanced Barrier Precautions. |
| Staff H | Maintenance Assistant | Acknowledged recliner and wall disrepair; unaware of conditions. |
| Staff I | Hospice Aide | Reported resident's concern about unpainted wall. |
| Director of Nursing Services | Director of Nursing Services | Multiple interviews regarding deficiencies in care and compliance. |
| Food Service Director | Food Service Director | Acknowledged food safety violations. |
| Nurse Practitioner | Nurse Practitioner | Expected medication to be held per parameters. |
| Registered Dietitian | Registered Dietitian | Acknowledged renal diet violations. |
Inspection Report
Routine
Deficiencies: 11
Date: Mar 6, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, advance directives, medication management, infection control, dietary services, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' communication rights, inconsistencies in advance directives, improper disposal of hazardous materials, inadequate respiratory care, failure to provide dialysis-related care, medication administration errors, improper drug storage and labeling, failure to provide food in appropriate form, food safety violations, infection control breaches, and maintenance issues affecting resident comfort and safety.
Deficiencies (11)
Failed to ensure residents whose primary language is not English received communication materials in a language they understand.
Residents' advance directives were inconsistent with their electronic medical records.
Failed to properly dispose of hazardous materials on medication carts, leaving sharps accessible to residents.
Failed to provide respiratory care consistent with professional standards, including incorrect oxygen flow rates and lack of physician orders.
Failed to ensure dialysis resident's fluid intake was monitored and restricted according to physician orders.
Administered medication despite parameters indicating it should be held based on blood pressure readings.
Failed to store and label drugs and biologicals properly; medications were left at bedside and unlabeled medication cups were found in medication carts.
Failed to provide food and drink in a form designed to meet individual needs; resident requiring honey thickened liquids was given thin liquids causing coughing.
Failed to store, prepare, distribute, and serve food in accordance with professional standards; issues included grease accumulation, improper food temperatures, unlabeled and expired food items, and unclean surfaces.
Failed to maintain infection prevention and control program; breaches in Enhanced Barrier Precautions including improper handling of suprapubic tube and PICC line.
Failed to maintain a safe, functional, and comfortable environment; resident rooms had torn recliner upholstery, missing weather stripping on windows, unpainted walls, and wall gouges.
Report Facts
Medication administration errors: 22
Fluid restriction: 1000
Oxygen flow rate: 8
Oxygen flow rate: 3
Food temperature: 48
Food temperature: 45
Medication dosage: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Acknowledged failure to wear gown during PICC line antibiotic administration and improper newsletter distribution. |
| Staff B | Registered Nurse | Acknowledged inconsistency in advance directives and EMR for Resident ID #16. |
| Staff C | Registered Nurse | Acknowledged oxygen administration without physician order and fluid restriction documentation issues. |
| Staff D | Registered Nurse | Acknowledged improper disposal of sharps and administering thin liquids to resident requiring thickened liquids. |
| Staff E | Licensed Practical Nurse | Unable to provide evidence of correct oxygen administration and humidifier use. |
| Staff F | Registered Nurse | Acknowledged opened Lidoderm patch left on resident's nightstand. |
| Staff G | Nursing Assistant | Observed providing hygiene care without gown for resident on Enhanced Barrier Precautions. |
| Staff H | Maintenance Assistant | Acknowledged recliner and wall disrepair; unaware of conditions. |
| Staff I | Hospice Aide | Reported resident's concern about unpainted wall. |
| Director of Nursing Services | Provided multiple interviews acknowledging expectations and deficiencies in care and compliance. | |
| Food Service Director | Acknowledged food safety violations and unclean kitchen conditions. | |
| Nurse Practitioner | Expected medication to be held per parameters; acknowledged medication errors. | |
| Registered Dietitian | Acknowledged renal diet violations and lack of diet slip indication. |
Inspection Report
Routine
Deficiencies: 13
Date: Mar 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident assessments, care planning, medication administration, infection control, environment safety, and other quality of care standards.
Findings
The facility was found deficient in multiple areas including inaccurate resident behavioral assessments, failure to develop baseline care plans within 48 hours of admission, inadequate management of a baclofen pump, medication administration errors, failure to provide necessary assistance with activities of daily living, inadequate pressure ulcer care, unsafe water temperatures, improper catheter care, dialysis care deficiencies, improper psychotropic medication use, medication storage and labeling issues, failure to provide routine dental care, infection prevention and control lapses, and environmental maintenance issues.
Deficiencies (13)
Failed to ensure accurate behavioral assessments for residents #109 and #113.
Failed to develop and implement baseline care plans within 48 hours of admission for residents #109, #366, and #317.
Failed to ensure services met professional standards related to the use of a baclofen pump for resident #317 and medication administration errors for resident #103.
Failed to provide necessary assistance with transfers and meals for residents #366 and #88.
Failed to provide appropriate pressure ulcer care for resident #33.
Failed to maintain safe water temperatures exceeding 120°F on multiple units posing immediate jeopardy to resident health or safety.
Failed to provide appropriate catheter care and monitoring for residents #1, #25, #69, and #104.
Failed to provide safe and appropriate dialysis care for resident #164 including failure to follow physician orders and communication of dialysis recommendations.
Failed to implement gradual dose reductions and non-pharmacological interventions prior to psychotropic medication use for resident #43.
Failed to store and label drugs and biologicals properly in medication rooms and carts.
Failed to provide routine and emergency dental care for resident #55.
Failed to maintain an infection prevention and control program to prevent transmission of communicable diseases for residents with MDROs including failure to follow PPE and hand hygiene protocols.
Failed to maintain a sanitary and comfortable environment including issues with kitchenettes and resident rooms with exposed nails and damaged walls.
Report Facts
Medication doses: 97
Medication doses: 27
Water temperature: 129
Water temperature: 135.1
Water temperature: 126.5
Water temperature: 124.1
Water temperature: 122.1
Water temperature: 122.6
Water temperature: 123.6
Water temperature: 125.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Unaware of resident's baclofen pump. |
| Staff B | Registered Nurse | Administered diphenhydramine as scheduled instead of PRN; unable to provide evidence of urine monitoring for Resident #1; acknowledged expired insulin pens. |
| Staff C | Nursing Assistant | Unaware of resident #366's transfer assistance needs. |
| Staff D | Nursing Assistant | Unaware of resident #366's transfer assistance needs. |
| Staff E | Nursing Assistant | Unaware of resident #366's transfer assistance needs. |
| Staff F | Licensed Practical Nurse | Unaware of resident #366's transfer assistance needs; acknowledged meal tray left untouched. |
| Staff G | Nursing Assistant | Failed to assist resident #88 with meals; failed to perform hand hygiene and PPE removal properly. |
| Staff H | Registered Nurse | Stated expectation for staff to assist resident #88 with meals. |
| Staff I | Nursing Assistant | Had not repositioned resident #33 since start of shift. |
| Staff J | Wound Nurse | Acknowledged new pressure ulcer on resident #33 and applied dressing. |
| Staff K | Nursing Assistant | Failed to reposition resident #33 when requested and did not notify nurse of pain or wound. |
| Staff L | Nursing Assistant | Acknowledged hot water temperatures and lack of thermometer use. |
| Staff M | Licensed Practical Nurse | Unable to provide evidence of urine monitoring for Resident #25; acknowledged undated insulin pens. |
| Staff P | Registered Nurse | Unable to explain why blood pressure was taken on wrong arm for Resident #164; unable to provide evidence of urine monitoring for Resident #69; unable to decipher insulin vial dates. |
| Staff Q | Registered Nurse | Changed sterile dressing without physician order for Resident #164. |
| Staff R | Registered Nurse | Failed to wash hands with soap and water after contact with Resident #318 on C-Diff precautions. |
| Staff S | Housekeeper | Acknowledged unsanitary conditions in resident bathroom. |
| Physical Therapist Assistant | Removed PPE outside resident #372's room. | |
| Administrator | Acknowledged past issues with chair rail moldings and expected rooms to be maintained. | |
| Director of Nursing Services | Acknowledged multiple deficiencies including inaccurate assessments, care planning failures, medication errors, infection control lapses, and environmental issues. | |
| Director of Rehabilitation | Unaware if transfer information was communicated to nursing for resident #366. | |
| Infection Preventionist | Stated residents with MDROs should be on enhanced barrier precautions. | |
| Acting Maintenance Director | Acknowledged environmental concerns including exposed nails and damaged walls. | |
| District Manager | Acknowledged need to clean kitchenettes. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 21, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to promptly identify and intervene for an acute change in condition of a resident who experienced new seizure activity and to verify physician notification.
Complaint Details
The complaint investigation revealed that the facility did not notify the physician about the resident's new seizure activity or increased blood pressure on 11/15/2023. The resident had no prior history of seizures. Staff interviews confirmed the failure to notify the provider. The physician was unaware of the seizure and stated she would have ordered hospital evaluation if informed.
Findings
The facility failed to notify the physician or follow its own seizure precaution policy after a resident experienced two seizures on 11/15/2023. The resident became unresponsive during the second seizure, requiring CPR and hospital transfer. Staff acknowledged not informing the provider, and the physician stated she would have ordered hospital evaluation if notified.
Deficiencies (1)
Failure to promptly identify and intervene for an acute change in condition of a resident with new seizure activity and failure to notify the physician as per facility policy.
Report Facts
Residents affected: 1
Seizure events: 2
Blood pressure: 177
Blood pressure diastolic: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Administering medications when resident experienced second seizure |
| Staff B | Registered Nurse | Acknowledged not calling provider about resident's seizure and increased blood pressure |
| Physician | Interviewed and stated she was not informed of seizure activity and would have ordered hospital evaluation if notified |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 4, 2023
Visit Reason
The inspection was conducted in response to a community reported complaint submitted on 2023-08-03 alleging the facility failed to repair a resident's broken foot board on his/her bed and the tiles around his/her toilet.
Complaint Details
Complaint investigation based on a community reported complaint submitted on 2023-08-03 alleging failure to repair resident's broken foot board and bathroom tiles.
Findings
The facility failed to maintain a safe, clean, and homelike environment in one of three units observed. Observations included a resident's bed foot board detached and placed aside, multiple loose tiles and unclean bathroom conditions in several rooms, and a hole in a bathroom ceiling with exposed wires. The facility acknowledged these issues and noted the absence of a Maintenance Director or Assistant Maintenance Director.
Deficiencies (3)
Failed to maintain a safe, clean, comfortable and homelike environment including unrepaired broken foot board on resident's bed and loose tiles around the toilet.
Bathroom floor had loose tiles and accumulation of black matter next to and behind the toilet.
Bathroom had a hole in the ceiling approximately 12 inches x 12 inches with exposed wires hanging down.
Report Facts
Loose tiles: 10
Hole size: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse | Staff A interviewed and unaware that resident's foot board was not attached | |
| Housekeeper | Staff B acknowledged bathroom needed cleaning | |
| Administrator | Acknowledged observations and noted lack of Maintenance Director or Assistant Maintenance Director |
Inspection Report
Routine
Deficiencies: 4
Date: Jan 30, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident supervision, food safety, infection control, and facility environment safety.
Findings
The facility was found deficient in ensuring adequate supervision of a resident who smoked unsupervised in a non-smoking facility, failure to follow food safety standards in the main kitchen and kitchenettes, improper disposal of contaminated lancets by a diabetic resident, and unsanitary conditions in kitchenettes including ice machine drain contamination.
Deficiencies (4)
Failed to ensure adequate supervision and assistive devices to prevent accidents for a resident smoking unsupervised in a non-smoking facility.
Failed to ensure food is served in accordance with professional standards; issues included grease accumulation in exhaust hood, wet sheet pans stored stacked, dirty coffee mugs, improper storage of corn flakes, opened jelly left unrefrigerated, debris in toaster, dented can in refrigerator.
Failed to establish and maintain an infection prevention and control program related to improper disposal of used non-retractable lancets by a resident.
Failed to provide a safe, functional, sanitary, and comfortable environment; observed thick buildup of brownish-black matter with hairlike strands in ice machine drain pipes and floor drains in two kitchenettes.
Report Facts
Discarded cigarette butts: 50
Coffee mugs with brown film: 19
Coffee mugs with brown matter: 9
Non-retractable lancets: 2
Blood sugar checks per day: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Interviewed regarding resident smoking and lack of supervision | |
| Licensed Practical Nurse Staff C | Interviewed about resident smoking and supervision | |
| Assistant Director of Nursing Services | Present during interview with Licensed Practical Nurse Staff C | |
| Dietary Aide Staff E | Acknowledged wet sheet pans and brown film in coffee mugs | |
| Assistant Food Service Director | Acknowledged improper storage of corn flakes scoop | |
| Registered Nurse Staff F | Acknowledged food safety observations | |
| Food Service Director | Acknowledged food safety issues including jelly storage | |
| Maintenance Director | Acknowledged unsanitary conditions in ice machine drain pipes |
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