Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 18, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations.
Findings
No deficiency was identified during the investigation.
Complaint Details
The investigation was based on ACTS reference numbers 102514, 102340, 102473, and 102492. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 3
Aug 14, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations following a complaint alleging neglect and other issues at the facility.
Findings
Deficiencies were identified related to failure to document physical therapy services, failure to ensure residents' rights were adhered to, and failure to provide timely podiatry services. The facility failed to notify responsible parties of refusals of care and did not maintain accurate service plans reflecting therapy services provided.
Complaint Details
The complaint was community reported on 7/23/2025 alleging neglect evidenced by severely overgrown toenails wrapped around toes of a resident. The complaint was substantiated by findings during the investigation.
Deficiencies (3)
| Description |
|---|
| Failure to document physical therapy services provided by an outside agency in the service plan for a resident. |
| Failure to ensure residents' rights were adhered to, including failure to notify responsible parties of refusals of care and failure to provide residents with copies of their rights. |
| Failure to provide timely podiatry services to a resident with overgrown toenails and failure to notify family of refusals of care. |
Report Facts
Dates related to therapy and service plans: Aug 29, 2024
Dates related to therapy orders: Jun 17, 2025
Date of fall: Jun 15, 2025
Date of complaint: Jul 23, 2025
Date of survey: Aug 14, 2025
Date plans put into effect: Aug 20, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Wellness | Acknowledged during survey interview that the service plan did not reflect physical therapy. | |
| Executive Director | Indicated during survey interview that podiatry services had not been received until brought to attention by outside agency. |
Inspection Report
Biennial
Deficiencies: 4
Jun 10, 2025
Visit Reason
An unannounced biennial State licensure survey was conducted at the residence from 06/09/2025 through 06/10/2025 to assess compliance with state licensure requirements.
Findings
Deficiencies were identified related to staff in-service training, dietary services compliance with Rhode Island Food Code, medication services, and fire safety requirements including obstructed fire drills.
Deficiencies (4)
| Description |
|---|
| Failure to ensure employees had ongoing in-service training at intervals not to exceed twelve months, including new employee orientation and training in required topics. |
| Failure to comply with Rhode Island Food Code requirements including lack of handwashing signage, improper storage and labeling of food items, and pest attraction in dietary dumpster area. |
| Failure to ensure medications were stored securely and properly, with expired and unlabeled medication supplies found in medication carts. |
| Failure to ensure fire drills met safety requirements, with at least 50% of drills being obstructed and inadequate documentation of evacuation procedures. |
Report Facts
Survey dates: 2
Number of staff missing required training: 9
Number of medication carts observed: 4
Number of fire drills reviewed: 10
Percentage of obstructed fire drills: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Stuck | Executive Director | Signed the statement of deficiencies and plan of correction |
| Staff K | Nurse who acknowledged expired and unlabeled medication supplies in medication cart | |
| Staff L | Certified Medication Technician | Present during medication cart observation |
| Staff J | Executive Chef | Present during dietary kitchen observations |
| Assistant Executive Director | Interviewed on 6/10/2025 regarding staff training | |
| Director of Wellness | Interviewed on 6/10/2025 regarding medication storage | |
| Executive Director | Interviewed on 6/9/2025 regarding fire drill documentation |
Inspection Report
Complaint Investigation
Deficiencies: 3
May 9, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted from 05/08/2025 through 05/09/2025 to determine compliance with state regulations related to resident care and management of services.
Findings
Deficiencies were identified related to failure to provide all care and services in accordance with the prevailing community standard of care, including inadequate incident documentation, failure to properly assess and treat a resident after falls, failure to maintain complete resident records, and failure to document necessary interventions in the service plan for residents at risk of falls.
Complaint Details
The investigation was complaint-driven with ACTS reference numbers 100708, 700696, 700626, 100609, 99980, and 99981. The complaint was substantiated by findings of deficient care and documentation related to a resident's falls and head injury management.
Deficiencies (3)
| Description |
|---|
| Failure to provide services with adequate professional and ancillary employees consistent with community standards, including proper incident documentation and medical intervention after falls. |
| Failure to maintain complete resident records including outside service notes and specific health problem information. |
| Failure to develop and document a resident assessment/service plan that includes necessary interventions to reduce fall risk and address resident needs. |
Report Facts
Dates of resident falls: Falls occurred on 1/22/2025, 1/25/2025, 2/1/2025, 2/8/2025, 3/1/2025, 3/12/2025, 3/18/2025, 4/2/2025, and 4/26/2025.
Date survey completed: 05/09/2025
Plan of correction completion dates: 6/3/2025, 6/30/2025, 7/1/2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Stock | Executive Director | Interviewed regarding facility protocol for head injury evaluation and discharge notices; named in findings related to failure to ensure proper resident care and documentation. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Feb 11, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted on 02/11/2025 to determine compliance with state regulations based on ACTS reference numbers 88848, 99456, and 99517.
Findings
Multiple deficiencies were identified including failure to ensure employees received required in-service training, incomplete policy and procedure manual updates, lack of adequate advance directives procedures, failure to perform comprehensive resident assessments, and failure to follow resident code status during an emergency medical event.
Complaint Details
The investigation was complaint/incident based with ACTS reference numbers 88848, 99456, and 99517. The complaint was substantiated as deficiencies were identified during the survey.
Deficiencies (5)
| Description |
|---|
| Failure to ensure employees had ongoing in-service training at intervals not to exceed twelve months. |
| Failure to have a policy and procedure manual that is reviewed and updated at intervals not to exceed twelve months. |
| Failure to have written policies and procedures addressing advance directives with sufficient instructions for employees. |
| Failure to perform a comprehensive resident assessment in its entirety for one out of three residents reviewed. |
| Failure to follow resident's Do Not Resuscitate (DNR) code status during an emergency medical event. |
Report Facts
Number of residents reviewed for assessment: 3
Number of residents with incomplete assessments: 1
Date of survey completion: Feb 11, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Stohl | Executive Director | Named in relation to findings and plan of correction; interviewed during survey. |
| Staff A | Certified Medication Technician (CMT)/Nursing Assistant (NA) | Named in relation to incomplete hire trainings and emergency event. |
| Staff B | Server | Named in relation to incomplete in-service trainings. |
| Staff C | Nursing Assistant (NA) | Named in relation to incomplete in-service trainings. |
| Staff D | Nursing Assistant (NA) | Named in relation to witnessing emergency event. |
| Director of Wellness | Director of Wellness | Interviewed regarding emergency event and resident assessments. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 11, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations based on ACTS reference numbers 98138, 98329, 98427, and 98475.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was triggered by multiple complaint/incident reports (ACTS reference numbers 98138, 98329, 98427, and 98475). No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 13, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted on 9/13/2024 at the residence following a community reported complaint to the Rhode Island Department of Health dated 8/5/2024 alleging reduced staff hours resulting in unsafe conditions.
Findings
The residence failed to provide qualified staff to administer medications for 5 of 5 residents reviewed, with no Certified Medication Technician (CMT) scheduled for certain shifts and inadequate staffing to meet residents' medication needs. The Executive Director confirmed staffing shortages and inability to provide evidence of appropriate licensed staff coverage.
Complaint Details
The complaint investigation was substantiated based on findings that the residence reduced staff hours leading to unsafe conditions, specifically inadequate medication administration coverage.
Deficiencies (1)
| Description |
|---|
| Failure to provide qualified staff to administer medications for 5 of 5 residents reviewed. |
Report Facts
Residents reviewed for medication administration: 5
Dates with no Certified Medication Technician (CMT) scheduled: 2
Date of complaint to Rhode Island Department of Health: Aug 5, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed regarding staffing and medication administration issues | |
| Care Nurse Manager | Discussed scheduling and staffing responsibilities for medication administration | |
| Director of Nursing | Works 9:00 AM - 9:00 PM three days/week and is on call at night; unable to provide evidence of appropriate staffing |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 9, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
An unannounced complaint/incident investigation survey was conducted; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 4, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence following allegations of a resident fall and related concerns.
Findings
Deficiencies were identified related to failure to adhere to the prevailing standard of care for a resident's fall, failure to complete a post-fall nursing assessment, and failure to report accidents, incidents, or medication errors resulting in hospital admission within the required timeframe. Additional deficiencies involved medication administration and storage practices.
Complaint Details
The investigation was triggered by a complaint alleging a resident had fallen on 10/22/2023. The nursing staff responded but did not follow up further. The resident was later hospitalized with rib fracture and hypoxia. The facility failed to report the incident to the Department of Health within the required timeframe. Additional complaints included medication administration errors involving two residents.
Deficiencies (3)
| Description |
|---|
| Failure to adhere to the prevailing standard of care for a resident's fall, including lack of documented nursing assessment post-fall. |
| Failure to report an accident, incident, or medication error resulting in hospital admission by the end of the next working day for one resident. |
| Failure to ensure medications were stored in a manner to prevent spoilage, dosage errors, administration errors, and/or inappropriate access for two residents. |
Report Facts
Date of Compliance: January 17, 2023
Date Survey Completed: 12/04/2023
Resident ID #1 admission date: 2021
Resident ID #2 admission date: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Stock | Executive Director | Signed the statement of deficiencies and plan of correction |
| Staff A | Registered Nurse | Named in documentation related to post-fall assessment and medication administration |
| Staff B | Certified Medication Technician | Named in complaint regarding medication administration error |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 19, 2023
Visit Reason
A complaint/incident investigation survey was conducted at the facility on 10/19/2023, referenced by ACTS number 92453.
Findings
No deficiencies were identified during the complaint/incident investigation survey.
Complaint Details
The complaint/incident investigation referenced ACTS number 92453 and was found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 4
Sep 21, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence to investigate deficiencies related to residency requirements and resident assessments.
Findings
The inspection found that the facility did not meet residency requirements for one of eight sampled residents, specifically regarding the definition of a resident and the need for a license endorsement to provide limited health services. Additionally, the facility failed to update resident assessments and service plans timely and did not have required signatures on service plans for multiple residents.
Complaint Details
The visit was complaint-related, investigating an unannounced complaint/incident. Deficiencies were identified related to residency requirements and resident assessments/service plans.
Deficiencies (4)
| Description |
|---|
| Residency Requirements 2.4.14.A - One resident did not meet the definition of a resident due to lack of license endorsement for providing limited health services. |
| Residency Requirements 2.4.16.D - Resident assessments were not reviewed and updated at required intervals for 2 of 8 sampled residents. |
| Residency Requirements 2.4.16.G.2 - Service plans were not signed, approved, and dated by required parties for 6 of 8 sampled residents. |
| Residency Requirements 2.4.16.G.3 - Service plans were not reviewed at required intervals or when resident conditions changed for 2 of 8 sampled residents. |
Report Facts
Sample residents reviewed: 8
Residents with deficient service plans: 6
Residents with deficient assessments: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Sale | Executive Director | Acknowledged resident was not appropriate for continued residence due to required assistance; signed the plan of correction |
| Director of Wellness | Acknowledged resident was not appropriate for continued residence due to required assistance; interviewed during survey; could not provide evidence of updated service plans | |
| Director of Nursing | Educated assessment nurse on assisted living regulations and mobility/functionality requirements |
Inspection Report
Complaint Investigation
Deficiencies: 4
Jun 28, 2023
Visit Reason
An unannounced complaint/incident investigation survey and a biennial State licensure survey were conducted at the facility on 06/28/2023.
Findings
Multiple deficiencies were identified including failure to maintain a documented quality assurance program, lack of a written safe resident handling policy and program, failure to provide ongoing in-service training for staff, and noncompliance with food service regulations related to food labeling and staff hair restraints.
Complaint Details
The visit was triggered by an unannounced complaint/incident investigation. The report does not explicitly state the substantiation status of the complaint.
Deficiencies (4)
| Description |
|---|
| Failure to maintain a documented quality assurance program with required components including Alzheimer’s Dementia Special Care Unit criteria and quality improvement documentation. |
| Failure to have a written safe resident handling policy and program including training, hazard assessment, and performance evaluation as required by licensure. |
| Failure to provide evidence of ongoing in-service training for employees on required topics including fire prevention, abuse recognition, resident rights, infection control, and others. |
| Failure to comply with Rhode Island Food Code requirements for food packaging dates and staff hair restraints in food preparation areas. |
Report Facts
Deficiencies cited: 4
Dates of staff hire: 3
Dates of survey and observations: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 25, 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 no deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 2
Apr 4, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence to investigate deficiencies related to medication administration and staffing.
Findings
The investigation found that the administrator failed to staff the residence with qualified personnel to administer insulin and follow physician orders for 4 of 5 sampled residents. There was insufficient licensed nursing staff to administer medications, resulting in residents not receiving their insulin and pain medications as ordered on specific dates.
Complaint Details
The complaint investigation found substantiated deficiencies related to medication administration and staffing shortages causing residents to miss insulin and pain medication doses on specified dates.
Deficiencies (2)
| Description |
|---|
| Failure to staff the residence with qualified staff to administer medication (insulin) and follow physician orders for 4 of 5 residents reviewed. |
| Failure to provide a scheduled nurse to administer a schedule II-controlled substance medication to a resident requiring assistance on the 11 PM-7 AM shift. |
Report Facts
Residents reviewed: 5
Dates insulin not administered: 3
Dates pain medication not administered: 8
Date of compliance: Jun 1, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Acknowledged residents did not receive insulin and pain medication as ordered due to insufficient staffing. |
| Staffing Coordinator | Acknowledged no nurse was available on 3/26/2023 during the 7:00 AM-3:00 PM shift. | |
| Administrator | Acknowledged residents did not receive insulin on 3/26/2023 due to insufficient licensed staff. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 24, 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 complaint-related and no deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 3
Feb 16, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence to investigate identified state deficiencies.
Findings
The facility failed to provide scheduled nurse coverage for medication administration for one resident, failed to update comprehensive assessments annually for one resident, and failed to ensure secure medication storage preventing inappropriate access for one resident. Multiple deficiencies related to administrative management, resident assessments, and medication services were cited.
Complaint Details
The investigation was complaint/incident triggered. The Administrator acknowledged the lack of qualified staff to administer medication and the failure to store medications securely. Resident ID #1 was on hospice with a PRN morphine order and no nurse coverage at night. Resident ID #3 had a missing medication bottle and medication administration failures.
Deficiencies (3)
| Description |
|---|
| Failure to provide a scheduled nurse to administer controlled substance medications during the night shift for one resident. |
| Failure to update the comprehensive assessment annually and for condition changes for one resident. |
| Failure to ensure all medications were stored securely to prevent spoilage, dosage errors, administration errors, or inappropriate access for one resident. |
Report Facts
Dates of medication administration failures: Medication not administered on 1/31/2023 at 7:00 AM, 12:00 PM, 7:00 PM and on 2/1/2023 at 8:23 AM and 1:22 PM for Resident ID #3.
Staffing schedule coverage period: Night nurse staffing schedule (11 PM - 7 AM) was staffed from 12/2022 through 01/2023.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 19, 2022
Visit Reason
An unannounced complaint investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the complaint investigation survey.
Complaint Details
The complaint investigation was unannounced and no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 7, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The visit was triggered by a complaint or incident investigation; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 2
May 2, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence to investigate identified deficiencies.
Findings
The residence failed to ensure all services were rendered in a safe and effective manner, specifically regarding medication administration and resident service plans. Deficiencies included improper medication management for Resident ID #1 and failure to develop a timely written service plan for Resident ID #2.
Complaint Details
The investigation was complaint-driven, focusing on medication administration and service plan deficiencies. Substantiation status is not explicitly stated.
Deficiencies (2)
| Description |
|---|
| Failure to ensure all services are rendered in a safe and effective manner, including medication administration errors and improper self-administration of medication for Resident ID #1. |
| Failure to develop a written service plan within seven days after move-in for Resident ID #2. |
Report Facts
Date of admission for Resident ID #1: Mar 3, 2021
Date of admission for Resident ID #2: Jan 4, 2022
Timeframe for service plan development: 7
Number of sample residents referenced: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Authored notes regarding medication refusal for Resident ID #1 | |
| Staff B | Involved in attempted medication administration for Resident ID #1 | |
| Staff C | Involved in attempted medication administration for Resident ID #1 | |
| Staff D | Documented medication administration records and indicated medication was not available | |
| Director of Nursing | Director of Nursing | Interviewed and indicated Resident ID #1 should not self-administer medications |
| Executive Director | Executive Director | Interviewed and unable to provide evidence of medication administration per physician's orders |
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 21, 2021
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence to investigate deficiencies related to residency requirements.
Findings
The investigation found that the facility retained a resident who did not meet the definition of a resident as per assisted living residency requirements, due to inability to ambulate and need for skilled nursing services. Observations and interviews confirmed the resident had not ambulated for several months despite therapy services.
Complaint Details
The complaint investigation was substantiated as deficiencies were identified regarding residency requirements and resident status.
Deficiencies (1)
| Description |
|---|
| Residency Requirements 2.4.14(A) not met as a resident was retained who does not meet the definition of a resident due to inability to ambulate and need for skilled nursing services. |
Report Facts
Date of last ambulation documented: Jun 25, 2021
Date of survey completion: Sep 21, 2021
Date of compliance: Dec 1, 2021
Resident falls dates: 3
Inspection Report
Complaint Investigation
Deficiencies: 11
Aug 11, 2021
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at this assisted living residence with an Alzheimer's Dementia Special Care Unit license.
Findings
The residence failed to establish and maintain a Safe Resident Handling program, failed to display the current license and required postings, and did not complete required resident assessments and nurse reviews within regulatory timeframes. Medication management deficiencies were also identified, including expired medications and incomplete medication aide evaluations.
Complaint Details
The inspection included a complaint/incident investigation survey as part of the unannounced biennial licensure survey.
Deficiencies (11)
| Description |
|---|
| Failed to produce evidence of an established Safe Resident Handling program including committee, policies, hazard assessments, and performance evaluations. |
| Failed to display the current license issued by the State of Rhode Island in a conspicuous place on the premises. |
| Failed to display required postings related to reporting requirements, resident rights, grievance procedures, and state licensing survey results in common areas. |
| Failed to complete resident assessments and service plans at intervals not to exceed twelve months and upon significant condition changes for sample residents. |
| Failed to complete nurse reviews at least every thirty days for sample residents, including medication regimen monitoring and documentation. |
| Failed to complete quarterly evaluations of nurse aide medication administration for sample residents within required timeframes. |
| Failed to document services and interventions needed in service plans for sample residents, including those provided by outside healthcare agencies. |
| Failed to ensure safe possession and control of medications by residents and proper storage and documentation of medications and medication administration. |
| Expired medications were found on the medication cart and were not removed timely. |
| Failed to conduct and document quarterly evaluations of registered medication aides by licensed personnel. |
| Failed to maintain and post accurate COVID-19 vaccination status reports for personnel and failed to post monthly COVID-19 vaccination data in a public location and on the residence's website. |
Report Facts
Date of Compliance: Sep 30, 2021
Date of Compliance: Aug 18, 2021
Date of Compliance: Sep 22, 2021
Date of Compliance: Sep 30, 2021
Date of Compliance: Oct 21, 2021
Number of residents reviewed: 8
Number of residents with assessment deficiencies: 3
Number of residents with nurse review deficiencies: 2
Number of expired medications found: 4
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