Inspection Reports for Stillwater Assisted Living And Skilled Nursing Community

An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations following a complaint reference number 102191.

The investigation found that the assisted living residence failed to complete accurate and updated comprehensive assessments and service plans for residents, specifically related to a resident who eloped to a hardware store. There was no evidence of interventions or care plans in place prior to the elopement to prevent risk.

The complaint investigation was substantiated by findings that Resident ID #1 eloped from the facility to a nearby hardware store on 10/3/2025. The facility failed to have a care plan or interventions in place prior to the elopement and did not ensure resident safety following the incident.

An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at Stillwater Assisted Living and Skilled on 08/27/2025.

The facility failed to establish a written quality improvement plan including all required components, failed to conduct safe resident handling evaluations quarterly for residents on the Dementia Special Care Unit, failed to maintain required resident records including wound measurements and service plans, failed to comply with food service sanitation standards, and failed to have operable locks on bedroom doors with a master key. Corrective actions and plans of correction were provided for each deficiency.

The inspection included a complaint/incident investigation survey conducted on 08/27/2025. Findings included failure to establish a quality improvement plan and failure to conduct safe resident handling evaluations, among others.

An unannounced complaint/incident investigation survey was conducted at the residence on 08/14/2024 due to an allegation that Resident ID #1 did not receive appropriate care resulting in skin breakdown.

The investigation found that the facility failed to provide care and services in accordance with prevailing community standards for skin assessment for the resident at risk. The resident had a Stage 3 pressure injury that was not properly monitored or documented. The facility lacked evidence of routine skin checks and accurate skin assessments, and the Director of Wellness revised policies to improve skin check frequency and staff education.

A community reported complaint submitted to the Rhode Island Department of Health on 08/01/2024 alleged that Resident ID #1 did not receive appropriate care resulting in skin breakdown. The complaint was substantiated by findings during the investigation.

An unannounced complaint/incident investigation survey was conducted at the facility.

No deficiencies were identified during the investigation.

The investigation was unannounced and no deficiencies were found.

An unannounced complaint/incident investigation survey was conducted at this residence.

No deficiencies were identified during the investigation.

The investigation was complaint-related and no deficiencies were found, indicating no substantiated issues.

A biennial State Licensure survey was conducted at Stillwater Assisted Living and Skilled Nursing from 8/31/2023 through 9/1/2023 to assess compliance with state licensure regulations.

Deficiencies were identified related to employee training, resident assessments and service plans, and medication administration and labeling. The facility submitted a Plan of Correction (POC) outlining steps to address these issues, including staff re-education, monitoring, and audits.

An unannounced complaint/incident investigation survey was conducted at this residence.

No deficiencies were identified during the investigation.

The investigation was unannounced and complaint/incident related; no deficiencies were found, indicating no substantiated issues.

An unannounced complaint/incident investigation survey was conducted at Stillwater Assisted Living and Skilled residence following a reported incident involving Resident ID #1.

The investigation found that Resident ID #1's comprehensive assessment was incomplete, specifically missing the 'Behavioral Information' section related to wandering behavior. The Administrator and Wellness Director acknowledged the deficiencies and have implemented a Plan of Correction including staff re-education and ongoing audits.

The complaint investigation was substantiated based on record review and staff interviews. The facility received a call from a nearby attorney's office regarding Resident ID #1 needing to be picked up. The resident's assessment was incomplete and unsigned by the Administrator as required.

An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted on 09/10/2021 to assess compliance with state licensure requirements related to resident care and facility operations.

The survey identified deficiencies in the Safe Resident Handling program, Management of Services, and Medication Services. Key issues included failure to maintain a safe resident handling committee, lack of quarterly meetings and annual performance evaluations, delayed meal service due to staffing shortages, and improper labeling and storage of medications.

The visit included a complaint/incident investigation component as part of the biennial licensure survey. Specific complaint substantiation status was not stated.