Inspection Reports for Holiday Retirement Home Inc
30 SAYLES HILL ROAD, RI, 02838
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Inspection Report
Life Safety
Deficiencies: 0
Aug 15, 2025
Visit Reason
An off-site desk audit was conducted on 08/15/2025 to review all previous Life Safety Code deficiencies re-cited on 07/31/2025.
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.
Report Facts
Previous deficiency recitation date: Jul 31, 2025
Desk audit date: Aug 15, 2025
Inspection Report
Follow-Up
Deficiencies: 1
Jul 31, 2025
Visit Reason
A revisit survey was conducted on July 31, 2025, to assess correction of previous deficiencies cited on June 12, 2025, related to the Life Safety Code survey.
Findings
The facility remains not in compliance with all regulations surveyed. Specifically, the Emergency Power Supply System (EPSS) generator maintenance and testing did not meet required standards, including failure to document load calculations and confirm minimum load requirements during monthly tests.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the Emergency Power Supply System (EPSS) generator was maintained and tested in accordance with NFPA standards, including lack of documentation of load calculations and failure to meet minimum load requirements. | SS=F |
Report Facts
Date survey completed: Jul 31, 2025
Completion date for plan of correction: Aug 7, 2025
Frequency of generator inspection: 12
Minimum load requirement: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory C Hopfording | Administrator | Signed as Laboratory Director's or Provider/Supplier Representative's Signature on plan of correction |
| acting Maintenance Director | Interviewed on 7/31/2025 regarding generator load calculations |
Inspection Report
Re-Inspection
Deficiencies: 1
Jul 31, 2025
Visit Reason
A revisit survey was conducted on July 31, 2025, to assess all previous deficiencies cited on June 12, 2025, during the Life Safety Code survey.
Findings
The facility was found to be not in compliance with all regulations surveyed. Specifically, the Emergency Power Supply System (EPSS) generator maintenance and testing standards were not met, as the facility failed to document load calculations and provide evidence of meeting minimum load requirements.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the Emergency Power Supply System (EPSS) generator was maintained in accordance with NFPA standards, including lack of documentation of load calculations and failure to confirm minimum load requirements. | F |
Report Facts
Deficiencies cited: 1
Date of previous deficiencies: Jun 12, 2025
Date of completion for corrective action: Jul 13, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| acting Maintenance Director | Interviewed on 7/31/2025 at approximately 1:10 PM; unable to provide evidence of load calculations |
Inspection Report
Follow-Up
Deficiencies: 0
Jul 22, 2025
Visit Reason
An off-site desk audit was conducted to review all previous deficiencies cited on June 13, 2025, and verify correction.
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
Census: 143
Capacity: 170
Deficiencies: 12
Jun 13, 2025
Visit Reason
A recertification and complaint surveys were conducted at Holiday Retirement Home from 6/9/2025 through 6/13/2025 to determine compliance with Long Term Care Facilities regulations, state licensure, and emergency preparedness requirements.
Findings
Deficiencies were identified related to professional standards of care, quality of care, infection prevention and control, antibiotic stewardship, immunizations, and life safety code compliance. The facility failed to meet requirements in areas including comprehensive care plans, notification of physician for changes in condition, infection control practices, and maintenance of fire safety systems.
Severity Breakdown
SS=D: 4
SS=E: 3
SS=F: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Services Provided Meet Professional Standards - Failure to ensure residents receive treatment and care in accordance with professional standards for air mattress settings, oxygen administration, and daily weights. | — |
| Quality of Care - Failure to ensure residents receive treatment and care in accordance with professional standards, including notification of physician for changes in condition and proper documentation. | SS=D |
| Resident Records - Identifiable Information - Failure to maintain accurate and complete medical records for residents, including documentation of mattress settings, oxygen flow, and incentive spirometer use. | SS=E |
| Infection Prevention & Control - Failure to establish and maintain an infection prevention and control program, including proper use of PPE and wound care procedures. | SS=D |
| Antibiotic Stewardship Program - Failure to establish an antibiotic stewardship program including monitoring antibiotic use and ensuring timely completion of antibiotic time outs. | SS=E |
| Influenza and Pneumococcal Immunizations - Failure to ensure residents are offered and receive pneumococcal vaccinations and education. | SS=D |
| Safe/Functional/Sanitary/Comfortable Environment - Failure to maintain a safe, functional, and comfortable environment including kitchen and food service areas. | SS=D |
| Means of Egress - Failure to maintain means of egress free of obstructions and in good repair, impacting 20 residents. | — |
| Fire Alarm System - Failure to maintain and test fire alarm system quarterly as required. | SS=E |
| Sprinkler System - Failure to maintain automatic sprinkler system and provide documentation of testing and maintenance. | — |
| Electrical Systems - Failure to conduct required load testing and battery maintenance for emergency power systems. | SS=F |
| Emergency Preparedness - Facility found in compliance with emergency preparedness requirements. | — |
Report Facts
Capacity: 170
Census: 143
Residents impacted: 20
Deficiency counts: 12
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 15, 2024
Visit Reason
An off-site desk audit was conducted on July 15, 2024, to review all previous deficiencies cited on May 16, 2024, to verify correction.
Findings
All previously cited deficiencies have been corrected based on an acceptable plan of correction and supporting documentation. The facility is in compliance with all surveyed regulations.
Inspection Report
Plan of Correction
Census: 147
Capacity: 170
Deficiencies: 7
May 16, 2024
Visit Reason
A recertification survey and complaint investigation were conducted from 5/13/2024 through 5/16/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities. Additionally, a State licensure and emergency preparedness survey were conducted.
Findings
Deficiencies were cited related to failure to meet professional standards of quality in comprehensive care plans, significant medication errors, and multiple Life Safety Code violations including emergency lighting, fire alarm system maintenance, sprinkler system installation, fire drills, and electrical equipment safety.
Severity Breakdown
SS=F: 4
SS=C: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to meet professional standards of quality related to physician's orders for the utilization of a Freestyle Libre sensor for Resident ID #2. | — |
| Facility failed to keep residents free of significant medication errors for 1 of 3 residents reviewed for insulin, Resident ID #2. | — |
| Emergency lighting system not maintained in accordance with NFPA 101, 2012 Edition, impacting 147 residents and staff. | SS=F |
| Fire alarm system maintenance failed to include required annual battery discharge testing, impacting 147 residents and staff. | SS=F |
| Sprinkler system installation failed to meet NFPA 13 standards; closet in activity office not sprinkler protected, impacting 147 residents and staff. | SS=F |
| Fire drills were not conducted at varied times as required, impacting 147 residents and staff. | SS=C |
| Electrical equipment and extension cords used improperly in patient care areas, impacting residents, staff, and visitors. | SS=F |
Report Facts
Census: 147
Total Capacity: 170
Inspection Dates: 2024-05-13 to 2024-05-16
Resident Reviewed for Medication Errors: 3
Resident ID with Medication Error: 2
Residents Impacted by Life Safety Deficiencies: 147
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Hopooorian | Administrator | Signed the plan of correction and involved in survey interviews |
| Director of Nursing Services | Interviewed during survey regarding medication errors and Freestyle Libre sensor | |
| Maintenance Director | Interviewed during survey regarding emergency lighting, fire alarm system, sprinkler system, fire drills, and electrical equipment |
Inspection Report
Follow-Up
Deficiencies: 0
May 11, 2023
Visit Reason
An off-site desk audit was conducted on May 9, 2023, to review all previous deficiencies cited on March 30, 2023.
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
Complaint Investigation
Deficiencies: 8
Mar 30, 2023
Visit Reason
A Recertification Survey and complaint investigation survey were conducted from 03/27/2023 through 03/30/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including State licensure and emergency preparedness surveys.
Findings
Deficiencies were cited related to free of accident hazards/supervision/devices, drug regimen free from unnecessary drugs, infection prevention and control, life safety code violations including doors with self-closing devices, stairways and smokeproof enclosures, portable fire extinguishers, fire drills, electrical systems, and emergency power supply system maintenance.
Complaint Details
The visit included a complaint investigation related to supervision to prevent elopement and medication administration issues, specifically involving Narcan use and opioid medication management.
Severity Breakdown
SS=D: 3
SS=E: 1
SS=F: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to ensure each resident receives adequate supervision to prevent elopements. | — |
| Facility failed to ensure a resident's drug regimen is free from unnecessary drugs, specifically for Narcan administration. | — |
| Facility failed to maintain an infection prevention and control program to prevent transmission of communicable diseases and infections. | SS=D |
| Facility failed to maintain doors with self-closing devices in accordance with NFPA 101. | SS=D |
| Facility failed to maintain stairways and smokeproof enclosures as exits in accordance with NFPA 101. | SS=D |
| Facility failed to maintain portable fire extinguishers in accordance with NFPA 10. | SS=E |
| Facility failed to conduct fire drills as required by NFPA 101. | SS=F |
| Facility failed to maintain electrical systems and emergency power supply system in accordance with NFPA 101 and NFPA 110. | SS=F |
Report Facts
Deficiencies cited: 8
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 132
Residents affected: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Chopoerian | Administrator | Signed the Plan of Correction and mentioned as responsible for implementing corrective actions. |
Inspection Report
Routine
Deficiencies: 0
Dec 14, 2022
Visit Reason
A Federal Infection Control Survey was conducted at the facility.
Findings
No deficiencies were cited during the infection control survey.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 16, 2022
Visit Reason
An off-site desk audit was conducted on 3/16/2022 to review all previous deficiencies cited on 2/23/2022.
Findings
Based on an acceptable plan of correction and documented evidence, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Deficiencies: 10
Feb 23, 2022
Visit Reason
A Recertification Survey was conducted at Holiday Retirement Home from 02/21/2022 through 02/23/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
The facility was determined not to be in compliance with these requirements and deficiencies were identified related to abuse reporting, medication administration, skin integrity, nutrition, respiratory care, dialysis, behavioral health services, drug regimen review, and dental services. Plans of correction were provided for each deficiency.
Severity Breakdown
Level D: 9
Level E: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately as required by law. | Level D |
| Failure to meet professional standards of quality regarding administration of insulin for one resident. | Level D |
| Failure to provide necessary treatment and services to prevent pressure ulcers for one resident. | Level D |
| Failure to maintain acceptable parameters of nutritional status for two residents. | Level E |
| Failure to ensure respiratory care consistent with professional standards for one resident. | Level D |
| Failure to ensure dialysis services consistent with professional standards for one resident. | Level D |
| Failure to ensure behavioral health services to attain or maintain highest practicable well-being for one resident. | Level D |
| Failure to ensure drug regimen review and reporting of irregularities for one resident. | Level D |
| Failure to provide or obtain dental services in a timely manner for one resident. | Level D |
| Failure to maintain medical records accurately and systematically for two residents. | Level D |
Report Facts
Deficiencies cited: 10
Resident IDs referenced: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Chopoorian | Administrator | Signed the Plan of Correction on 3/1/2022. |
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