Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 30, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted from 09/29/2025 through 09/30/2025 to determine compliance with state regulations.
Findings
No deficiencies were identified during the complaint/incident investigation survey.
Complaint Details
The investigation was related to multiple ACTS reference numbers: 101328, 101565, 101747, 101792, 101940, 101968, 102006, 102174, 102115, and 102119.
Inspection Report
Complaint Investigation
Deficiencies: 2
Apr 18, 2025
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the residence from 4/17/2025 through 4/18/2025.
Findings
Deficiencies were identified related to the State Licensure survey including failure to post the most recent state licensure survey results and failure to ensure fire drills contained all required components such as documentation of time taken and person conducting the drill.
Complaint Details
The visit included a complaint/incident investigation survey as part of the unannounced biennial licensure survey.
Deficiencies (2)
| Description |
|---|
| The residence failed to post the most recent state licensure survey results as required. |
| The residence failed to ensure fire drills simulating fire emergencies contained the amount of time taken to complete the drill and the person conducting the drill. |
Report Facts
Dates of fire drills conducted: Fire drills were conducted on 1/25, 3/27, 5/20, 7/30, 9/30, and 11/12 in 2024.
Number of fire drills required per year: 6
Date survey completed: 04/18/2025
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 13, 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 investigation was based on complaint/incident ACTS reference numbers 99319, 99345, 99497, and 99541. No deficiencies were found, indicating no substantiated violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 23, 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: 0
Sep 6, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the 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
Apr 16, 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.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 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 complaint/incident related; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 26, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the facility.
Findings
No deficiencies were identified during the complaint investigation survey.
Complaint Details
The survey was conducted in response to a complaint or incident investigation; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 8
Jun 13, 2023
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility on 06/13/2023.
Findings
Multiple deficiencies were identified including failure to establish a quality improvement committee, failure to maintain a safe resident handling program, incomplete personnel records including background checks, failure to complete smoking assessments, incomplete resident records, failure to conduct nurse reviews every 90 days, failure to comply with food safety regulations, and failure to conduct required fire drills.
Complaint Details
The inspection included a complaint/incident investigation survey as indicated in the initial comments section.
Deficiencies (8)
| Description |
|---|
| Failed to establish a quality improvement committee including required members. |
| Failed to maintain a safe resident handling program compliant with regulations. |
| Personnel records lacked required written statements of references and criminal background checks for some staff. |
| Failed to complete smoking assessments upon admission and quarterly for residents who smoke. |
| Failed to maintain complete resident records including physician orders and service plans. |
| Failed to complete nurse reviews every 90 days for some residents. |
| Failed to comply with Rhode Island Food Code including sanitizing dishwashers and hair restraints. |
| Failed to conduct required fire drills and maintain documentation as required by fire safety regulations. |
Report Facts
Dates of quality assurance meeting minutes missing required attendees: 5
Number of staff missing criminal background checks: 6
Number of residents missing smoking assessments: 2
Number of residents missing nurse reviews every 90 days: 2
Number of fire drills missed: 3
Number of on-site managers certified in food safety: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Wellness | Acknowledged lack of safe resident handling program and incomplete nurse reviews. | |
| Staff A | Personnel record lacked evidence of reference check and BCI check. | |
| Staff B | Personnel record lacked evidence of reference check and BCI check. | |
| Staff C | Personnel record lacked evidence of BCI check. | |
| Staff D | Personnel record lacked evidence of BCI check. | |
| Staff E | Personnel record lacked evidence of BCI check. | |
| Staff F | Personnel record lacked evidence of BCI check. | |
| Nurse/Wellness Director | Responsible for nurse reviews and acknowledged staffing needs. | |
| Staff H | Cook hired on 1/22/2022, current employee, awaiting food safety test results. |
Inspection Report
Deficiencies: 0
May 26, 2023
Visit Reason
An offsite survey was conducted on 05/26/2023 to assess compliance and deficiencies at Spring Villa Memory Care.
Findings
All deficiencies identified during the offsite survey were corrected.
Inspection Report
Complaint Investigation
Deficiencies: 2
Apr 3, 2023
Visit Reason
An unannounced complaint/incident investigation was conducted at Spring Villa Memory Care on 04/03/2023 due to an ACTS reference number 89702 complaint.
Findings
The investigation identified deficiencies related to residency requirements for resident assessments and service plans, specifically failure to ensure comprehensive assessments reflecting skin impairment conditions. Additionally, deficiencies were found in medication services, including failure to administer medications as ordered and inadequate documentation of medication administration.
Complaint Details
Complaint investigation was unannounced and related to resident care concerns including skin impairment assessment and medication administration. Deficiencies were substantiated based on record review and staff interviews.
Deficiencies (2)
| Description |
|---|
| Failure to ensure the comprehensive assessment accurately reflects the resident condition for 1 of 2 sample residents reviewed, specifically regarding skin impairment. |
| Failure to ensure all medications were administered in accordance with written physician's orders for 1 of 2 residents reviewed, with multiple missed doses documented. |
Report Facts
Deficiencies identified: 2
Missed medication doses: 2
Missed medication doses: 3
Missed medication doses: 2
Missed medication doses: 2
Missed medication doses: 6
Missed medication doses: 4
Missed medication doses: 6
Missed medication doses: 11
Missed medication doses: 4
Missed medication doses: 2
Missed medication doses: 3
Missed medication doses: 4
Missed medication doses: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 28, 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 investigation was unannounced and no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 12, 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 investigation was unannounced and complaint/incident based; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 18, 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 complaint/incident based; no deficiencies were found.
Inspection Report
Renewal
Deficiencies: 5
Jun 17, 2021
Visit Reason
A biennial state licensure survey was conducted at this assisted living residence to assess compliance with state licensure requirements and quality assurance standards.
Findings
The facility was found deficient in multiple areas including failure to maintain a documented quality assurance program, safe resident handling program compliance, employee training and personnel records, and fire safety requirements such as conducting required fire drills and maintaining fire extinguishers.
Deficiencies (5)
| Description |
|---|
| Failure to maintain a documented Quality Assurance Program including quarterly meetings and inclusion of dietary services representative. |
| Failure to ensure safe resident handling committee met regulatory requirements including membership and performance evaluations. |
| Failure to provide required employee training documentation for basic sanitation, food service, cultural differences, dementia care, personal assistance, medication assistance, safety, body mechanics, and resident transfers. |
| Failure to maintain complete personnel records including reference checks prior to hire and ongoing training documentation. |
| Failure to conduct required fire drills at least six times per year on a bimonthly basis and failure to maintain fire extinguishers in usable condition with current inspections. |
Report Facts
Personnel training documentation: 3
Ongoing training documentation: 6
Reference checks: 6
Fire drills: 6
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 10, 2021
Visit Reason
An unannounced off-site 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
May 28, 2021
Visit Reason
A biennial modified State licensure survey and complaint/incident investigation survey were conducted at the residence on 5/21/2021 to assess compliance with licensure requirements.
Findings
Deficiencies were identified related to dietetic services, medication services, and physical plant safety requirements including improper cleaning and sanitation of food service equipment, medication administration record discrepancies, and failure to conduct required fire drills.
Complaint Details
The visit included a complaint/incident investigation survey as part of the biennial licensure survey.
Deficiencies (3)
| Description |
|---|
| The refrigerator storing creamer and condiments had brown/black substance on tubing and fan, and a hand sink near the coffee station lacked a paper towel dispenser. |
| Medication administration records for residents #2 and #3 had discrepancies between MAR and medication labels, including failure to reflect extended release tablets. |
| The facility failed to conduct fire drills at least six times per year on a bimonthly basis, with no drills conducted since November 2020. |
Report Facts
Date survey completed: May 28, 2021
Frequency of required fire drills: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Acknowledged medication administration record observation during exit interview |
| Executive Director | Executive Director | Acknowledged absence of paper towel dispenser and fire drills during exit interviews |
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