Inspection Reports for The Phyllis Siperstein Tamarisk Assisted Living Residence
RI
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Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 12, 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 ACTS reference numbers 101106 and 99688; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 4
Feb 20, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted on 02/20/2025 to determine compliance with state regulations following complaints regarding medication management and service plan deficiencies.
Findings
Deficiencies were identified related to medication management, including missed and incorrect medication doses for multiple residents, failure to update medication orders and service plans in a timely manner, and failure to ensure residents received medications as ordered by physicians.
Complaint Details
The investigation was initiated based on a community reported complaint sent to the Rhode Island Department of Health on 2/13/2025 from a medical provider alleging missed medication doses and incorrect medication administration for residents #1, #2, and #3. The complaint was substantiated by record reviews and staff interviews.
Deficiencies (4)
| Description |
|---|
| Failure to provide care and services in accordance with the prevailing community standard of care relative to administering medications in accordance with written physician's orders for three sample residents. |
| Failure to ensure the daily vitamin D order was sent with an accompanying discharge order for the weekly vitamin D, resulting in duplication and confusion. |
| Failure to discontinue Vitamin D3 50,000 units weekly and Vitamin D3 2,000 units daily per primary care physician orders in November, resulting in continued administration beyond physician orders. |
| Failure to update the service plan to reflect changes in resident's skin condition and required treatments such as dressing and Tubi-grips. |
Report Facts
Medication dosage: 40
Medication dosage: 20
Medication dosage: 50
Medication dosage: 2000
Medication dosage: 1000
Dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willeyne G Roaming | Executive Director | Signed the statement of deficiencies and plan of correction |
| Director of Wellness | Interviewed during survey and acknowledged medication and service plan deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 4
Dec 27, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted on 12/27/2024 to determine compliance with state regulations based on ACTS reference numbers 98425, 98836, and 98851.
Findings
Deficiencies were identified related to administrative management, failure to establish written policies for resident transfers, inadequate management of residents' conditions including falls, failure to use approved assessment forms, and failure to report and prevent future incidents. Specific issues included lack of policy on resident refusals for emergency treatment, failure to assess and document falls especially in memory care residents, and incomplete or unapproved resident assessments.
Complaint Details
The investigation was complaint-driven based on ACTS reference numbers 98425, 98836, and 98851. The complaint was substantiated as deficiencies were identified in multiple areas including resident care, assessment, and incident reporting.
Deficiencies (4)
| Description |
|---|
| Failure to establish written policies and procedures relative to transferring residents to a higher level of care when a change of condition occurs. |
| Failure to provide all care and services in accordance with the prevailing community standard of care relative to monitoring blood pressure for one resident. |
| Failure to use Department-approved assessment forms for completing comprehensive assessments on residents. |
| Failure to appropriately report and prevent future incidents for an unwitnessed fall in a memory care resident. |
Report Facts
Residents reviewed: 4
Date of survey completion: Dec 27, 2024
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 18, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations based on complaint reference numbers 97851, 96574, and 97922.
Findings
Deficiencies were identified related to failure to complete and update comprehensive assessments and service plans for Resident ID #1, specifically regarding speech therapy services and documentation of outside services.
Complaint Details
The investigation was complaint-driven based on multiple complaint reference numbers. The findings showed failure to update assessments and service plans as required. Substantiation status is not explicitly stated.
Deficiencies (2)
| Description |
|---|
| Resident failed to complete and update the comprehensive assessment each time the resident's condition changed significantly, specifically missing documentation of receipt of speech therapy services. |
| Service plan was not updated to accurately reflect that the resident was receiving speech therapy from an outside agency at the time of the service plan review. |
Report Facts
Care plans and assessments corrected: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed during survey; acknowledged deficiencies related to resident's assessments and service plans. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Jul 2, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at The Phyllis Siperstein Tamarisk Assisted Living Residence to investigate non-compliance issues and deficiencies related to resident assessments, service plans, nurse reviews, reporting requirements, and variance procedures.
Findings
The survey identified multiple deficiencies including failure to review resident assessments timely, incomplete nurse reviews, failure to update service plans, failure to submit required incident investigation reports within five business days, and failure to submit a variance request for hospice services. Several residents' records showed late or missing documentation and incomplete updates reflecting changes in care.
Complaint Details
The investigation was complaint-driven, focusing on allegations related to resident care, documentation, and reporting. The complaint was substantiated by findings of non-compliance in multiple areas including resident assessments, nurse reviews, incident reporting, and variance procedures.
Deficiencies (5)
| Description |
|---|
| Failure to review resident comprehensive assessments at intervals not to exceed 12 months and when condition changes, affecting 2 of 5 sample residents. |
| Failure to complete nurse reviews every 90 days for 4 of 5 sample residents. |
| Failure to update service plans to reflect changes in resident condition and outside services for 2 of 5 sample residents. |
| Failure to submit all reportable incident investigations to the Department of Health within five business days for 4 of 4 incidents reviewed. |
| Failure to submit a variance request for hospice services within 45 days for a resident receiving hospice care. |
Report Facts
Sample residents reviewed: 5
Incident reports reviewed: 4
Days for variance submission: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melayne Ramirez | Executive Director | Interviewed during survey; unable to provide evidence of updated assessments, service plans, and timely incident reporting. |
Inspection Report
Complaint Investigation
Deficiencies: 9
Sep 27, 2023
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility to assess compliance with state licensure regulations.
Findings
Deficiencies were identified related to personnel criminal background checks, resident assessments and service plans, nurse reviews, service plan updates, rights of residents, dietetic services, medication services, fire safety requirements, and immunization and health screening for staff. Several residents' records lacked timely updates or evidence of required assessments and reviews. The facility failed to comply with multiple regulatory requirements across various domains.
Complaint Details
The visit included a complaint/incident investigation survey conducted on 09/27/2023, which identified deficiencies related to personnel background checks and other regulatory requirements.
Deficiencies (9)
| Description |
|---|
| Failure to ensure national criminal background checks were completed prior to or within one week of employment for 4 of 7 employees reviewed. |
| Failure to have a comprehensive assessment of residents' health, functional, and cognitive needs updated at required intervals for 4 of 7 residents reviewed. |
| Failure to complete nurse reviews every 90 days as required for 4 of 7 residents reviewed. |
| Failure to review and update service plans at required intervals and to reflect outside services for 4 of 7 residents reviewed. |
| Failure to implement written policies and procedures to protect residents' rights and maintain confidentiality. |
| Failure to comply with Rhode Island Food Code including improper storage and labeling of food items and inadequate sanitization temperatures. |
| Failure to ensure medication services were provided in accordance with licensure requirements, including proper labeling and storage. |
| Failure to conduct and document required fire drills and evacuation procedures. |
| Failure to ensure all nursing staff were immunized, tested, and counseled as required by regulations. |
Report Facts
Employees with incomplete background checks: 4
Residents with incomplete assessments: 4
Residents with incomplete nurse reviews: 4
Medication carts audited: 4
Fire drills required per year: 6
Residents receiving hospice services: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in deficiency related to incomplete criminal background check and health screenings. | |
| Staff B | Named in deficiency related to incomplete criminal background check and health screenings. | |
| Staff C | Named in deficiency related to incomplete criminal background check and health screenings. | |
| Staff D | Named in deficiency related to incomplete criminal background check. | |
| Staff F | Certified Medication Technician (CMT) | Observed administering medications without resident identifiers and directions. |
| Staff G | Acknowledged insulin pens were opened and not dated. | |
| Staff E | Acknowledged dishwashing machine did not reach required sanitization temperature. | |
| Director of Wellness | Interviewed and unable to provide evidence of required assessments and service plans. | |
| Administrator | Unable to provide evidence of national criminal background checks for certain staff. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Nov 14, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence following a report of inappropriate behavior between residents.
Findings
The investigation found that Resident ID #1 was observed using the hand of Resident ID #2 to rub his/her genitalia, and the facility failed to document appropriate interventions or monitoring after the incident. The facility also failed to provide adequate services and training related to behaviors associated with dementia for residents in the Special Care Unit.
Complaint Details
The complaint investigation was substantiated by observations and record reviews revealing inappropriate sexual behavior between two residents and inadequate facility response and documentation. The facility acknowledged the incident and lack of prior knowledge by staff. Training and corrective actions were planned.
Deficiencies (3)
| Description |
|---|
| Failure to develop a timely and comprehensive service plan including all services and interventions needed for residents. |
| Failure to monitor and intervene appropriately after an incident of inappropriate sexual behavior between residents. |
| Failure to provide services to residents in the Special Care Unit consistent with the prevailing community standard of care for dementia-related behaviors. |
Report Facts
Percentage of service plans audited: 10
Percentage of assessments audited: 10
Date of incident report: Nov 9, 2022
Date of comprehensive assessment for Resident ID #1: Oct 4, 2022
Date of comprehensive assessment for Resident ID #2: Dec 20, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Completed Resident ID #1's comprehensive assessment and acknowledged resident behaviors. |
| Staff A | Director of Nursing | Will ensure assessment information is accurately reflected in service plans and continue monitoring Resident ID #2. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Oct 24, 2022
Visit Reason
An unannounced complaint investigation survey was conducted at The Phyllis Siperstein Tamarisk ALR residence to assess compliance with regulatory requirements.
Findings
Deficiencies were identified related to administrative management, in-service training, personnel records, resident records including discharge summaries, and resident assessments. The facility failed to ensure staff received required training and maintain accurate personnel and resident documentation.
Complaint Details
The visit was triggered by a complaint investigation. The report documents substantiated deficiencies in staff training, personnel records, and resident documentation.
Deficiencies (4)
| Description |
|---|
| Failure to ensure new and existing staff received ongoing in-service training within required intervals. |
| Personnel records lacked updated job descriptions, evidence of credentials, and signed employee awareness of resident rights. |
| Resident records failed to include discharge summaries for three discharged residents. |
| Resident assessments were not updated within five working days of readmission for two residents. |
Report Facts
Staff with no evidence of in-service training: 7
Residents without discharge summaries: 3
Residents with incomplete assessments: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Personal Care Assistant | Named in findings for lack of in-service training and improper licensure status. |
| Staff B | Personal Care Assistant | Named in findings for lack of initial in-service education and training. |
| Staff C | Personal Care Assistant | Named in findings for lack of initial in-service education and training. |
| Staff D | Personal Care Assistant | Named in findings for lack of initial in-service education and training. |
| Staff E | Personal Care Assistant | Named in findings for lack of initial in-service education and training. |
| Staff F | Personal Care Assistant | Named in findings for lack of initial in-service education and training. |
| Staff G | Personal Care Assistant | Named in findings for lack of initial in-service education and training. |
| Interim Director of Operations | Signed plan of correction document. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Oct 19, 2021
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility to identify deficiencies relative to the State Licensure survey.
Findings
The facility failed to ensure that new staff received required in-service training within 10 days of hire and annually, and failed to review resident assessments at required intervals. Medication storage and labeling deficiencies were observed, and health screenings and immunizations for staff were incomplete.
Complaint Details
The complaint investigation was part of the unannounced survey. Deficiencies were identified related to staff training, resident assessments, medication management, and staff health screenings.
Deficiencies (4)
| Description |
|---|
| Failure to ensure new staff received all required in-service training within 10 days of hire and annually. |
| Failure to review resident assessments at intervals not to exceed 12 months and upon significant condition changes. |
| Failure to ensure medications were stored securely and labeled correctly, with expired medications present on medication carts. |
| Failure to obtain proper employment health screenings and immunizations for staff prior to delivering services. |
Report Facts
Number of sample employees reviewed for in-service training: 6
Number of sample residents reviewed for assessment: 5
Number of medication carts reviewed: 2
Number of medication expiration or labeling issues observed: 14
Number of staff reviewed for health screenings: 6
Total in-service training hours required per year: 30
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 5, 2021
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.
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