Inspection Report
Annual Inspection
Deficiencies: 0
Oct 16, 2025
Visit Reason
A state recertification survey was conducted at the facility from 10/14/2025 through 10/16/2025.
Findings
No deficiencies were identified during the survey.
Inspection Report
Renewal
Deficiencies: 0
Nov 26, 2024
Visit Reason
A licensure survey was conducted at the facility from 11/25/2024 to 11/26/2024 to assess compliance with regulatory requirements.
Findings
No deficiencies were identified during the licensure survey conducted at the facility.
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 7, 2024
Visit Reason
An off-site desk audit was conducted on February 7, 2024, to review all previous deficiencies cited on December 7, 2023.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected. The facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Deficiencies: 4
Dec 7, 2023
Visit Reason
The annual State licensure survey was conducted at the facility from 2023-12-05 through 2023-12-07 to assess compliance with state regulations.
Findings
Deficiencies were identified related to nursing service management, resident care services including nutritional status and weight loss monitoring, care plan updates, dietetic services, and food service compliance with Rhode Island Food Code standards. The facility failed to ensure proper coordination of nursing care, timely updates to care plans, adequate dietitian oversight, and compliance with food safety regulations.
Deficiencies (4)
| Description |
|---|
| Failure to coordinate nursing care services related to nutritional status for residents, including inadequate monitoring and notification of significant weight loss. |
| Failure to review and revise resident care plans timely when there was a significant change in health status for residents. |
| Failure to have qualified dietitian review menus and conduct regularly scheduled in-service education programs for staff. |
| Failure to comply with Rhode Island Food Code in the main kitchen, including improper food labeling, storage, and sanitation. |
Report Facts
Dates of survey: Survey conducted from 2023-12-05 through 2023-12-07
Weight loss: 9.2
Number of residents reviewed: 6
Number of residents with care plan issues: 2
Number of staff missing in-service education: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Resident's physician interviewed regarding weight loss awareness | |
| Director of Nursing Services | DNS | Acknowledged resident weight loss and care plan issues during survey interviews |
| Registered Dietitian | RD | Interviewed regarding oversight of resident nutritional status and menu reviews |
| Food Service Director | FSD | Acknowledged food storage and labeling deficiencies and lack of in-service education |
| Administrator | Acknowledged lack of regularly scheduled in-service education for staff |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 3, 2023
Visit Reason
An off-site desk audit was conducted on February 3, 2023, to review all previous deficiencies cited on December 22, 2022.
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
Renewal
Deficiencies: 4
Dec 22, 2022
Visit Reason
A State recertification survey was conducted at the facility from 12/19/2022 through 12/22/2022 to assess compliance with state regulations and identify deficiencies.
Findings
The facility was found deficient in several areas including failure to provide ongoing in-service education for staff, failure to provide care and services in accordance with the prevailing community standard for residents requiring oxygen, failure to maintain resident care plans including interventions, and failure to comply with Rhode Island Food Code standards in the kitchen and food service areas.
Deficiencies (4)
| Description |
|---|
| Failure to provide an ongoing in-service educational program for staff including orientation and annual training on infection control, food services, emergency preparedness, confidentiality, and resident rights. |
| Failure to provide care and services in accordance with the prevailing community standard for residents receiving oxygen therapy, including monitoring and documentation of oxygen saturation levels and proper administration. |
| Failure to maintain resident care plans including interventions for residents at risk for aspiration and supervised eating. |
| Failure to comply with Rhode Island Food Code standards including cleanliness of equipment, food-contact surfaces, and proper labeling and dating of food containers. |
Report Facts
Inspection duration days: 4
Number of residents reviewed for oxygen administration: 3
Number of residents reviewed for supervised eating: 1
Number of kitchen areas observed: 2
Chemical test strip result: 10
Inspection Report
Annual Inspection
Deficiencies: 9
Dec 31, 2021
Visit Reason
The annual State licensure and a complaint investigation survey were conducted at the Village at Waterman Lake Nursing facility to assess compliance with the Rules & Regulations for Licensing of Nursing Facilities (R23 17-NR).
Findings
The facility was found not in compliance with several regulatory requirements including criminal background checks for staff, employee immunization and screening, in-service education, infection control, resident immunization policies, dietetic services, pharmaceutical services, and emergency power testing and maintenance.
Complaint Details
The inspection included a complaint investigation component as noted in the initial comments section.
Deficiencies (9)
| Description |
|---|
| Failure to provide evidence that criminal background checks were obtained prior to or within one week of employment for multiple staff members. |
| Failure to obtain evidence of immunity for all health care workers in accordance with immunization, testing, and health screening regulations. |
| Failure to provide an ongoing in-service educational program including orientation and annual training in food services and sanitation. |
| Failure to develop and implement written policies and procedures for infection control related to urinary catheter care. |
| Failure to ensure residents receive vaccinations in accordance with CDC standards and facility policies. |
| Failure to provide adequate storage and refrigeration for food service operation and medication carts. |
| Failure to maintain proper temperature logs and date supplements and medications appropriately. |
| Failure to ensure medication carts are locked when not in use and not left unattended. |
| Failure to ensure emergency power generator testing and preventive maintenance were conducted as required. |
Report Facts
Staff reviewed for criminal background check: 9
Sample staff reviewed for immunity: 9
Residents reviewed for vaccination compliance: 5
Medication carts observed: 1
Temperature readings recorded: 6
Hours for generator testing: 30
Hours offline notification threshold: 8
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