Inspection Reports for Stillwater Assisted Living and Skilled Nursing Community
20 AUSTIN AVENUE, GREENVILLE, RI, 02828
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
62% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Follow-Up
Deficiencies: 0
Apr 22, 2025
Visit Reason
A follow-up to a previous survey was conducted at this facility to verify correction of prior deficiencies.
Findings
All previous deficiencies were corrected and no new deficiencies were identified during the follow-up survey.
Inspection Report
Renewal
Deficiencies: 5
Mar 19, 2025
Visit Reason
A recertification survey was conducted at Stillwater Assisted Living and Skilled Nursing Community from 3/17/2025 through 3/19/2025 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness.
Findings
Deficiencies were identified related to personal privacy/confidentiality of records, comprehensive care plans, professional standards of care, parenteral/IV fluids, and food safety requirements. The facility failed to respect residents' privacy rights, ensure proper lab testing and medication monitoring, maintain competency-based training for nursing staff, and comply with food safety standards.
Severity Breakdown
SS=D: 4
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to respect residents' right to personal privacy for 1 resident observed relative to weight posting and 1 resident observed during wound dressing change. | SS=D |
| Facility failed to ensure residents receive treatment and care in accordance with professional standards, including obtaining lab tests for a resident on Atorvastatin. | SS=D |
| Facility failed to meet professional standards for parenteral/IV fluids for 1 resident receiving antibiotics via PICC line. | SS=D |
| Facility failed to ensure nursing staff have appropriate competencies and skills to provide nursing and related services to assure resident safety related to PICC line care. | SS=D |
| Facility failed to prepare, serve, and distribute food in accordance with professional standards for food service safety, including maintaining proper cold holding temperatures. | SS=F |
Report Facts
Deficiencies cited: 5
Dates of survey: 3
Plan of Correction completion date: Apr 18, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Named in wound dressing privacy breach observation |
| Staff C | Registered Nurse | Interviewed regarding PICC line saline flush order |
| Staff D | Nursing Staff | Measured external catheter length incorrectly |
| Staff E | Nursing Staff Educator | Provided information on PICC line external catheter markings |
| Staff F | Food Service Director | Observed during lunch meal service and food temperature checks |
| Staff G | Cook | Named in food safety certification and meal preparation |
Inspection Report
Plan of Correction
Deficiencies: 0
May 22, 2024
Visit Reason
An off-site desk audit was conducted on May 22, 2024, to review all previous deficiencies cited on April 11, 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
Follow-Up
Deficiencies: 0
May 22, 2024
Visit Reason
A follow-up to a previous Life Safety Code survey was conducted at this facility to verify correction of prior deficiencies.
Findings
All previous deficiencies were corrected and no new deficiencies were identified during this follow-up survey.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 23, 2023
Visit Reason
A follow-up to a previous recertification and complaint investigation survey was conducted at this facility.
Findings
All previous deficiencies were corrected and no new deficiencies were identified.
Inspection Report
Complaint Investigation
Deficiencies: 8
Feb 20, 2023
Visit Reason
A Recertification Survey and Complaint Investigation Survey was conducted at Stillwater Assisted Living and Skilled Nursing Home from 02/13/2023 through 02/20/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey.
Findings
The facility was found deficient in infection prevention and control related to a norovirus outbreak and COVID-19, which constituted Immediate Jeopardy initially but was removed by 02/17/2023. Additional deficiencies were found related to reasonable accommodations, professional standards of care, parenteral fluids, dialysis, medication administration, food safety, and infection control.
Complaint Details
The survey included a complaint investigation with ACTS reference number 89172. Immediate Jeopardy was identified related to infection control failures exposing residents to norovirus and COVID-19. The Immediate Jeopardy was removed after corrective actions and staff education.
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to maintain an infection prevention and control program to prevent transmission of communicable diseases including norovirus and COVID-19. | Immediate Jeopardy (removed) |
| Failure to provide reasonable accommodation of resident needs and preferences related to physical environment for Resident ID #37. | Level not stated |
| Failure to meet professional standards of quality for assessing and diagnosing psychiatric disorders for Resident ID #21. | Level not stated |
| Failure to meet professional standards of practice for care and delivery of parenteral fluids for Residents ID #137, #235, and #236. | Level not stated |
| Failure to ensure residents who require dialysis receive services consistent with professional standards for Resident ID #2. | Level not stated |
| Failure to ensure residents are free of significant medication errors for Resident ID #235. | Level not stated |
| Failure to ensure food safety requirements including proper food storage and handling. | Level not stated |
| Failure to establish and maintain an infection prevention and control program including surveillance, isolation, and staff compliance with PPE use. | Level not stated |
Report Facts
Residents reviewed for parenteral fluids: 3
Residents reviewed for psychotropic medication use: 5
Residents reviewed for dialysis: 1
Residents reviewed for medication errors: 1
Residents with norovirus or COVID-19: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Interviewed regarding resident pain and foot condition |
| Staff B | Registered Nurse | Acknowledged resident's painful foot and removed foot board |
| Director of Nursing Services | DNS | Acknowledged resident pain and responsible for POC execution |
| Staff C | Licensed Practical Nurse | Acknowledged IV infusion should have been completed |
| Staff F | Food Service Director | Acknowledged food safety deficiencies |
| Staff O | Registered Nurse | Observed multiuse equipment cleaning and resident vital signs |
| Staff H | Nursing Assistant | Entered resident room without gown or gloves |
| Staff I | Nursing Assistant | Entered resident room without gown or gloves |
| Staff J | Housekeeper | Observed dragging soiled curtain |
| Staff K | Housekeeper | Observed dragging soiled curtain and not wearing PPE |
| Staff L | Nursing Assistant | Acknowledged signage and PPE use expectations |
| Staff M | Nursing Assistant | Entered resident room without gown or gloves |
| Staff N | Registered Nurse | Reported resident in common dining area without redirected care |
Inspection Report
Annual Inspection
Census: 64
Capacity: 80
Deficiencies: 9
Nov 26, 2021
Visit Reason
The annual Federal Recertification and a Complaint Investigation Survey were conducted from 11/22/2021 through 11/26/2021 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
Deficiencies were identified related to failure to meet professional standards of quality in medication refusal notifications, inadequate treatment and prevention of pressure ulcers, medication errors, and issues with medication storage and labeling. The facility submitted a Plan of Correction addressing these issues.
Complaint Details
The survey included a complaint investigation as referenced by ACTS Reference Numbers 81601 and 82463.
Deficiencies (9)
| Description |
|---|
| Facility failed to ensure services met professional standards of quality for physician notification of medication refusals for 2 residents. |
| Facility failed to provide necessary treatment and services to prevent and treat pressure ulcers for 2 of 3 residents reviewed. |
| Facility failed to ensure a resident with limited range of motion received appropriate treatment and services. |
| Facility failed to ensure a resident with urinary incontinence received appropriate services to maintain continence. |
| Facility failed to ensure a resident's drug regimen was free from unnecessary drugs for 1 of 8 residents reviewed. |
| Facility failed to ensure medication error rates were below 5 percent; error rate was 7.41% involving 2 residents. |
| Facility failed to ensure proper labeling and storage of drugs and biologicals. |
| Facility failed to ensure residents received prescribed therapeutic diets and special instructions were followed. |
| Facility failed to ensure residents' personal needs funds were properly conveyed and accounted for after death. |
Report Facts
Census: 64
Total Capacity: 80
Medication refusal opportunities: 62
Medication refusal opportunities: 47
Medication error rate: 7.41
Medication error count: 2
Medication error opportunities: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Nurse A | Staff Nurse | Failed to provide evidence of medication refusals being reported to physician |
| Staff Nurse C | Certified Medication Technician (CMT) | Prepared wrong medication during medication administration observation |
| Staff B | Interim Consultant | Acknowledged baseline care plan was never created for pressure ulcer |
| Staff D | Nurse | Observed with medication cart and acknowledged medication storage issues |
| Staff E | Certified Medication Technician (CMT) | Prepared folic acid medication during medication administration observation |
| Staff F | Nurse | Acknowledged antacid tablets on bedside table during observation |
| Staff C | Certified Medication Technician (CMT) | Observed preparing medication and noted thawed product not dated |
| Director of Nursing Services | Director of Nursing Services (DNS) | Responsible for implementation of Plan of Correction and medication refusal reporting |
| Assistant Director of Nursing | Assistant Director of Nursing | Revealed medication dose correction plan for resident |
| Food Service Director | Food Service Director | Acknowledged expired food items during kitchen observation |
| Business Office Manager | Business Office Manager | Acknowledged funds for residents were not sent to EOHHS within required timeframe |
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