Deficiencies (last 4 years)
Deficiencies (over 4 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
62% better than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
92% occupied
Based on a March 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 25, 2024
Visit Reason
An off-site desk audit was conducted on March 25, 2024, to review all previous deficiencies cited on March 6, 2024.
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
Annual Inspection
Census: 55
Capacity: 60
Deficiencies: 2
Mar 6, 2024
Visit Reason
A Recertification Survey was conducted from 03/04/2024 through 03/06/2024 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 bowel/bladder incontinence, catheter care, and urinary tract infections due to failure to provide appropriate treatment and services for residents with indwelling catheters. Additionally, the facility failed to provide a sanitary environment for residents and staff due to issues with the ice machine. The emergency preparedness survey found the facility in compliance. The annual Federal Life Safety Code survey found no deficiencies.
Deficiencies (2)
| Description |
|---|
| Failure to ensure appropriate treatment and services for residents with indwelling catheters, including documentation of urinary output. |
| Failure to provide a safe, functional, sanitary, and comfortable environment due to black matter inside the ice machine and lack of cleaning schedule evidence. |
Report Facts
Resident reviewed with indwelling catheter: 1
Urine output documented: 5
Facility capacity: 60
Facility census: 55
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 24, 2023
Visit Reason
An off-site desk audit was conducted on March 22, 2023, to review all previous deficiencies cited on March 15, 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
Life Safety
Deficiencies: 1
Mar 14, 2023
Visit Reason
The annual Federal Life Safety Code survey was conducted by the State Survey Agency to assess compliance with the National Fire Protection Association 101 Life Safety Code, 2012 Edition.
Findings
Life Safety Code deficiencies were identified related to discharge from exits, specifically that the facility did not maintain the egress system in accordance with NFPA 101 2012 edition, including the absence of a hard packed all-weather travel surface leading from marked exits to a public way.
Deficiencies (1)
| Description |
|---|
| Discharge from exits did not have a hard packed all-weather travel surface as required by NFPA 101 2012 edition. |
Report Facts
Deficiency completion date: Mar 20, 2023
Survey start time: 1300
Survey date: Mar 14, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during surveyor observations and responsible for oversight of exit evaluations | |
| Administrator | Interviewed on 3/14/2023 regarding marked exits |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 60
Deficiencies: 2
Feb 7, 2022
Visit Reason
A recertification survey and complaint investigation were conducted 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 found not to be in compliance with requirements related to developing and implementing comprehensive person-centered care plans and ensuring treatment and services to prevent pressure ulcers. Deficiencies were identified in care planning for residents and in adherence to physician orders for off-loading pressure ulcers.
Complaint Details
The visit included a complaint investigation with ACTS reference numbers 79529, 81628, 81865, 82647, 83326. The facility was found not in compliance based on these complaints.
Deficiencies (2)
| Description |
|---|
| Failure to develop and implement a comprehensive person-centered care plan for Resident ID #36. |
| Failure to ensure residents receive necessary treatment and services to prevent new pressure ulcers for Residents #13 and #15. |
Report Facts
Resident census: 46
Total capacity: 60
Weight measurements missed: 27
Residents sampled: 5
Residents with pressure ulcer risk: 2
Dates of observations for Resident #15 heels not offloaded: 3
Audits planned: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Interviewed on 2/7/2022 regarding weight measurements and pressure ulcer care | |
| Nursing Assistant Staff A | Acknowledged that Resident #15's heels were not offloaded as ordered |
Inspection Report
Follow-Up
Deficiencies: 0
Jan 12, 2021
Visit Reason
An off-site desk audit was conducted on January 12, 2021 for all previous Life Safety Code deficiencies cited on December 16, 2021.
Findings
Based on an acceptable plan of correction, all deficiencies have been corrected. The facility is in compliance with all regulations surveyed.
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