Inspection Report
Annual Inspection
Deficiencies: 6
Oct 28, 2025
Visit Reason
A state licensure survey was conducted at the assisted living residence Saint Elizabeth Court from 10/28/2025 through 10/29/2025 to assess compliance with state regulations and identify any deficiencies.
Findings
Multiple deficiencies were identified including failure to prominently display the administrator's name and contact information, incomplete resident assessments and service plans, failure to prominently display the most recent state survey results, noncompliance with Rhode Island Food Code related to kitchen sanitation, and medication administration issues including lack of physician orders for self-administered medications.
Deficiencies (6)
| Description |
|---|
| Failure to display the name and contact information of the current administrator in a conspicuous public area of the residence. |
| Failure to update comprehensive assessments for residents receiving outside services such as hospice and skilled nursing facility admissions. |
| Failure to review and update service plans to reflect significant changes in residents' conditions and outside services received. |
| Failure to prominently display the most recent state licensing survey results in the residence lobby. |
| Noncompliance with Rhode Island Food Code including unclean ice machine surfaces, improper drainage tubing, failure to sanitize thermometers, and staff not washing hands before handling clean dishes. |
| Failure to obtain and maintain physician orders for residents self-administering medications, specifically Oxycodone. |
Report Facts
Number of residents reviewed for outside services: 4
Number of residents reviewed for service plan updates: 3
Dates of survey: Survey conducted from 2025-10-28 to 2025-10-29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maggie Connelly | Administrator | Acknowledged deficiencies related to posting of administrator information and survey results |
| Director of Wellness | Acknowledged incomplete resident assessments and service plans during interviews | |
| Food Service Director | Acknowledged food code violations and lack of sanitation in kitchen | |
| Staff A | Observed failing to sanitize thermometer before use | |
| Staff B | Observed failing to wash hands before handling clean dishes |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 8, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence on 01/08/2025 to determine compliance with state regulations.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was related to complaint reference numbers 97114 and 96049 and was unannounced.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 22, 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 related; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 7
Dec 19, 2023
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the residence on 12/19/2023.
Findings
Deficiencies were identified related to employee training, personnel records, resident assessments and service plans, dietetic services, medication administration, and variance procedures. Specific issues included failure to provide required orientation and training to new employees, incomplete personnel records, failure to update resident assessments and service plans timely, food safety violations, improper medication storage and labeling, and failure to obtain required variances for hospice services.
Complaint Details
The visit included a complaint/incident investigation survey (Q36511) conducted on 12/19/2023. Deficiencies were identified related to employee training and personnel records.
Deficiencies (7)
| Description |
|---|
| Failure to ensure all new employees received at least two hours of orientation and training within ten days of hire prior to working alone. |
| Personnel records lacked written statements of references or documentation of verbal reference checks for sample staff. |
| Resident comprehensive assessments were not reviewed at intervals not to exceed 12 months and were not updated to reflect outside services. |
| Service plans were not reviewed timely or updated to reflect changes in resident condition or outside services. |
| Food service failed to comply with Rhode Island Food Code requirements including missing labels and dates on food items and accumulation of dirt and debris on equipment. |
| Medications were not stored securely or labeled properly; medication carts contained items without resident identifiers or directions for use. |
| Failure to obtain a required variance for a resident receiving hospice services. |
Report Facts
Number of sample staff missing reference checks: 3
Number of sample residents reviewed for assessments: 4
Number of medication carts observed with deficiencies: 3
Date of survey: Dec 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Technician (CMT) | Named in deficiency related to missing orientation and training evidence. |
| Staff B | Licensed Practical Nurse | Named in deficiency related to missing personnel reference checks. |
| Staff C | Certified Medication Technician (CMT) | Named in deficiency related to missing personnel reference checks. |
| Staff D | Certified Medication Technician (CMT) | Named in deficiency related to missing personnel reference checks. |
| Director of Wellness | Interviewed regarding employee training and resident assessments; acknowledged missing evidence and deficiencies. | |
| Food Service Director | FSD | Interviewed and observed during food safety deficiencies. |
| Staff E | Acknowledged medication storage deficiencies during interview. | |
| Staff F | Observed during medication cart inspection with deficiencies. | |
| Wellness Director | Responsible for conducting audits of medication storage and labeling. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 5, 2023
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 identified.
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 13, 2022
Visit Reason
The inspection was conducted as a complaint/incident investigation survey related to ACTS reference number 87975 at Saint Elizabeth Court on 12/13/2022.
Findings
Deficiencies were identified related to failure to complete a comprehensive resident assessment within five working days of readmission, failure to update the service plan to reflect physical therapy and use of a TLSO brace, and failure to timely report an incident involving hospitalization of a resident.
Complaint Details
The complaint/incident investigation was related to ACTS reference number 87975. The resident had a fall on 10/30/2022 resulting in hospitalization and skilled nursing facility admission. The incident was reported late. The complaint was substantiated by findings of deficiencies in assessment, service plan updates, and reporting.
Deficiencies (3)
| Description |
|---|
| Failure to complete a comprehensive assessment within five working days of readmission for Resident ID #1. |
| Failure to update the service plan to include physical therapy and TLSO back brace for Resident ID #1. |
| Failure to report accidents, incidents, and medication errors resulting in out-of-residence emergency medical services within required timeframe for Resident ID #1. |
Report Facts
Date of fall: Oct 30, 2022
Skilled nursing facility admission period: From 11/01/2022 to 12/05/2022
Assessment update timeframe: 5
Incident reporting deadline: 1
Audit period: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Margaret Connelly | Manager | Signed the plan of correction |
| Charles Russell | Laboratory Director or Provider/Supplier Representative | Signed the plan of correction |
| Director of Resident Care | Acknowledged deficiencies during interviews on 12/14/2022 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 29, 2021
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility on 12/29/2021.
Findings
The facility failed to ensure comprehensive resident assessments and service plans were reviewed and updated at required intervals for multiple residents, with specific failures noted in the timeliness and accuracy of assessments for five residents. The Administrator and Director of Nursing were unable to provide evidence of periodic review and update of assessments as required.
Complaint Details
The visit was complaint-related as indicated by the combined biennial licensure and complaint/incident investigation survey. The Administrator and Director of Nursing could not provide evidence that assessments had been reviewed and updated as required.
Deficiencies (1)
| Description |
|---|
| Failure to ensure comprehensive assessments had been reviewed and updated on a periodic basis (annually) and each time the resident's condition changed significantly for multiple residents. |
Report Facts
Resident ID numbers with deficient assessments: 5
Dates of last comprehensive assessments: Examples include 09/05/2017, 08/03/2018, 12/09/2021, 09/10/2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Margie Connelly | Administrator | Signed the plan of correction and involved in review of resident files. |
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