Inspection Report
Complaint Investigation
Deficiencies: 6
Aug 18, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted from 08/08/2025 to 08/18/2025 to determine compliance with state regulations following allegations of neglect and improper staffing.
Findings
Deficiencies were identified related to administrative management, use of an unlicensed nursing service agency, failure to provide care according to physician orders, residency requirements, and resident records. The facility failed to ensure proper staffing, care services, and documentation for Resident ID #1, who is no longer living in the community.
Complaint Details
The investigation was triggered by a complaint alleging neglect of Resident ID #1 by Staff A, an employee of an unlicensed nursing service agency. The complaint was substantiated by video and audio evidence showing neglect and failure to respond to the resident's difficulty with eating.
Deficiencies (6)
| Description |
|---|
| Failure to employ or contract with adequate and qualified personnel to attend to food preparation, housekeeping, personal care, medication administration, and other services relative to a certified nursing assistant (CNA) providing care to Resident ID #1. |
| Use of an unlicensed nursing service agency to provide staff to the facility, resulting in neglect of Resident ID #1. |
| Failure to provide care and services in accordance with prevailing community standards of care relative to physician's orders for diet for Resident ID #1. |
| Retention of a resident who did not meet the definition of a 'resident' under licensing regulations. |
| Failure to maintain a Limited Health Service license and inability to accommodate residents requiring certain health services. |
| Failure to maintain required resident records including specific health problems, physician orders, and documentation related to dementia diagnosis and care for Resident ID #1. |
Report Facts
Dates of survey: 08/08/2025 to 08/18/2025
Date complaint incident form sent: 07/28/2025
Date resident was fed by Staff A: 07/27/2025
Expected completion dates for corrective actions: Ranges from 09/05/2025 to 09/10/2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named as an employee of an unlicensed nursing service agency involved in neglect of Resident ID #1 | |
| Pamela Letourneau | Assistant Executive Director | Signed the plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 21, 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 reference numbers 99606. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 5
Jan 30, 2025
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted from 01/29/2025 through 01/30/2025 at Highlands on the East Side to assess compliance with state licensure requirements and investigate a complaint.
Findings
Deficiencies were identified related to residency requirements, resident records, rights of residents, and dietetic services. Specific issues included a resident who did not meet the definition of a resident due to wound care needs, failure to maintain complete resident records, removal of the resident and staff roster during the survey, failure to protect residents' privacy, and multiple food safety violations in the dietary service.
Complaint Details
The complaint investigation focused on residency requirements and documentation for a resident receiving skilled nursing wound care outside the facility. The investigation found the resident did not meet the definition of a resident and documentation issues related to PACE residents. The resident and staff roster was also removed during the survey, and residents' privacy was not protected.
Deficiencies (5)
| Description |
|---|
| The residence retained a resident who did not meet the definition of a resident due to wound care needs. |
| Failure to maintain complete resident records including specific health problems and documentation for PACE residents. |
| The resident and staff roster was removed immediately during the survey process, limiting access for review. |
| Failure to protect residents' privacy during the survey. |
| Multiple violations of Rhode Island Food Code including improper labeling, storage, and sanitation in the dietary service. |
Report Facts
Survey dates: 2
Dates of food items: 5
Slough on wound: 25
Cleaning schedule duration: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Van Norden | Executive Director | Signed the plan of correction and referenced in meetings regarding PACE resident documentation and corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 5, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the facility from 8/5/2024 through 8/6/2024 due to an allegation that a resident eloped during a medical appointment.
Findings
The investigation found that the facility failed to complete and update the comprehensive assessment each time a resident's condition changed significantly, specifically for Resident ID #1 who eloped. The behavioral information section of the resident's assessment was incomplete and had not been updated to reflect the elopement.
Complaint Details
The complaint investigation was substantiated as the resident eloped and the facility failed to update the resident's comprehensive assessment accordingly.
Deficiencies (1)
| Description |
|---|
| Failure to complete and update the comprehensive assessment each time a resident's condition changed significantly, including incomplete behavioral information related to wandering, assaultive/destructive behavior, danger to self, and self-preservation. |
Report Facts
Dates of survey: Survey conducted from 8/5/2024 through 8/6/2024
Date resident moved in: Resident ID #1 moved into the facility on 5/20/2024
Assessment date: Resident's comprehensive assessment dated 5/14/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karyn Vandalen | Executive Director | Interviewed during survey on 8/5/2024 regarding completion of resident's comprehensive assessment |
| Resident Care Director | Interviewed on 8/6/2024 acknowledging incomplete assessment |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 10, 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: 0
Mar 26, 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 unannounced and complaint/incident based; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 2, 2023
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
Oct 16, 2023
Visit Reason
A complaint/incident investigation survey was conducted at the facility based on ACTS reference numbers 91134, 92361, and 92429.
Findings
No deficiencies were identified during the complaint/incident investigation survey conducted on 10/16/2023.
Complaint Details
The investigation was based on complaints/incidents referenced by ACTS numbers 91134, 92361, and 92429. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 12, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the complaint investigation survey.
Complaint Details
An unannounced complaint/incident investigation survey was conducted. No deficiencies were identified.
Inspection Report
Complaint Investigation
Deficiencies: 4
Jun 22, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at Highlands on the East Side residence to assess compliance with care and service standards related to skin assessment and wound care for residents.
Findings
The residence failed to provide care and services in accordance with prevailing community standards of care, specifically regarding skin assessment and wound care documentation for three sample residents. Deficiencies included lack of weekly wound measurements, incomplete wound staging, failure to document skin assessments, and failure to notify physicians about difficulties obtaining urine specimens.
Complaint Details
The investigation was complaint/incident triggered. Deficiencies were identified related to wound care and resident records. The Resident Care Director was unable to provide evidence of required wound assessment documentation and physician notifications during the survey.
Deficiencies (4)
| Description |
|---|
| Failure to provide adequate skin assessment and wound care documentation for residents, including weekly wound measurements and staging. |
| Failure to maintain complete resident records including wound care notes and physician notifications. |
| Failure to provide evidence of notification to physician regarding inability to obtain urine specimens for analysis. |
| Failure to maintain information about specific health problems of residents useful in medical emergencies for 2 of 3 sample residents. |
Report Facts
Dates of skilled nursing notes reviewed: 10/9/2022 to 3/27/2023 and 4/4/2023 to 6/15/2023
Date of survey completion: Jun 22, 2023
Number of sample residents reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Van Orden | Signed as Laboratory Director or Provider/Supplier Representative on the report |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 11, 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
Renewal
Deficiencies: 5
Feb 9, 2023
Visit Reason
An unannounced biennial State Licensure survey was conducted at this residence to assess compliance with residency requirements, service plans, dietetic services, and medication services.
Findings
Deficiencies were identified in updating resident assessments and service plans within required timeframes after hospital readmission, failure to comply with Rhode Island Food Code including expired food items and improper handwashing by kitchen staff, and failure to conduct and document quarterly medication aide evaluations and proper medication storage and administration.
Deficiencies (5)
| Description |
|---|
| Failure to update comprehensive assessment within five working days of resident readmission from a health care facility. |
| Failure to review and update service plans to reflect significant resident condition changes. |
| Non-compliance with Rhode Island Food Code including food employees not washing hands before handling dishes and expired condiments found in kitchen. |
| Failure to conduct and document quarterly evaluations of registered medication aides. |
| Failure to ensure medications are stored securely and properly, including expired and undated medications found in medication carts and refrigerators. |
Report Facts
Date of survey completion: Feb 9, 2023
Date of resident readmission: Dec 13, 2022
Date of resident hospitalization: Nov 5, 2022
Number of medication aide personnel records reviewed: 4
Number of medication carts observed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Kitchen Staff | Observed placing soiled dishes into dishwasher without washing hands |
| Staff B | Registered Medication Aide | Medication aide evaluation reviewed; hired 6/2/2022 |
| Staff C | Registered Medication Aide | Medication aide evaluation reviewed; hired 7/6/2022 |
| Staff D | Certified Medication Technician | Observed with expired and undated medications in medication cart |
| Executive Director | Interviewed regarding failure to update assessments and service plans and medication evaluations | |
| Food Service Director | FSD | Interviewed regarding food service deficiencies and handwashing observations |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 15, 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 complaint-related; no deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 2, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the facility.
Findings
No deficiencies were identified during the investigation.
Complaint Details
Unannounced complaint/incident investigation survey with no deficiencies identified.
Inspection Report
Complaint Investigation
Deficiencies: 4
Mar 29, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence to investigate identified deficiencies.
Findings
The investigation found deficiencies related to the resident assessment and service plans, including failure to accurately reflect residents' falls, needs, and changes in condition in the comprehensive assessments and service plans for multiple residents.
Complaint Details
The visit was triggered by an unannounced complaint/incident investigation. Deficiencies were identified related to resident assessments and service plans.
Deficiencies (4)
| Description |
|---|
| Failure to use the Department-approved assessment form to complete individualized service plans reflecting residents' needs and preferences. |
| Resident #1's comprehensive assessment failed to accurately reflect falls risk and needs, with multiple undocumented falls. |
| Resident #2's comprehensive assessment was not reviewed at required intervals or updated to reflect admission to hospice services. |
| Resident #2's assessment was not updated within five working days of readmission from a skilled nursing facility. |
Report Facts
Fall risk scores: 6
Fall risk scores: 44
Fall dates: 15
Assessment review interval: 12
Readmission assessment timeframe: 5
48: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Van Norden | Executive Director | Signed the plan of correction on 4/19/22. |
| Acting Director of Wellness | Acknowledged inaccuracies in comprehensive assessments during interviews on 03/29/2022. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 9, 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
Renewal
Deficiencies: 2
Apr 14, 2021
Visit Reason
A biennial State Licensure survey was conducted at the residence to assess compliance with residency requirements and medication services.
Findings
Deficiencies were identified related to failure to update comprehensive resident assessments for condition changes and medication administration issues including expired medications and discrepancies in medication directions.
Deficiencies (2)
| Description |
|---|
| Failure to ensure comprehensive assessments reflected changes in condition for three residents. |
| Failure to ensure medications were stored securely and administered properly, including expired medications found on medication carts and discrepancies in medication administration records. |
Report Facts
Number of residents with failed comprehensive assessments: 3
Number of residents with medication storage issues: 6
Number of expired medications found: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Acknowledged deficiencies during exit interview | |
| Director of Wellness | Acknowledged deficiencies and medication discrepancies during exit interview and survey observations |
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