Inspection Reports for
Tockwotton on the Waterfront
500 WATERFRONT DR, EAST PROVIDENCE, RI, 02914
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
47% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
98% occupied
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 10, 2025
Visit Reason
An off-site desk audit was conducted on 4/10/2025 to review all previous deficiencies cited on 3/20/2025 and verify correction.
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
Plan of Correction
Deficiencies: 0
Date: Apr 10, 2025
Visit Reason
An off-site desk audit was conducted on 4/10/2025 to review all previous deficiencies cited on 2/13/2025 and verify correction based on the submitted plan of correction and supporting documentation.
Findings
All previously cited deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Mar 19, 2025
Visit Reason
A follow-up to a previous recertification survey was conducted from 3/19/2025 to 3/20/2025 to verify correction of previously identified deficiencies related to food procurement, storage, preparation, and sanitary practices.
Findings
The facility continued to fail in preparing, storing, and distributing food according to professional food safety standards, including issues with staff jewelry, handwashing, glove use, uncovered trash receptacles, improper sanitizing solution concentration, dust accumulation, and improper cooling logs. The facility implemented re-education and training for dietary staff, improved monitoring and auditing processes, and updated cleaning schedules to ensure compliance.
Deficiencies (1)
Food safety requirements not met: staff observed wearing unauthorized jewelry, improper handwashing and glove use, uncovered trash receptacles, sanitizing solution concentration below required levels, dust accumulation on kitchen equipment, and improper cooling logs for seafood salad.
Report Facts
Date range of survey: Survey conducted from 3/19/2025 to 3/20/2025
Sanitizing solution concentration: 100
Internal temperature: 49.6
Sanitizer bucket change frequency: 2
Inspection Report
Renewal
Census: 51
Capacity: 52
Deficiencies: 7
Date: Feb 13, 2025
Visit Reason
A recertification survey was conducted at Tockwotton On the Waterfront from 2/10/2025 through 2/13/2025 to determine compliance with 42 C.F.R. Part 483, requirements for Long Term Care Facilities. State licensure and emergency preparedness surveys were also conducted at this facility.
Findings
Deficiencies were identified related to treatment and services to prevent and heal pressure ulcers, medication administration errors, food preparation and safety, infection control, and life safety code compliance. The facility implemented corrective actions including staff re-education, audits, and policy updates to address these deficiencies.
Deficiencies (7)
Treatment/Services to Prevent/Heal Pressure Ulcer - Facility failed to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards.
Residents are Free of Significant Medication Errors - Facility failed to ensure residents were free from significant medication errors.
Food in Form to Meet Individual Needs - Facility failed to provide and prepare food in a form designed to meet individual needs for 1 of 2 residents reviewed.
Food Procurement, Store, Prepare, Serve - Sanitary - Facility failed to prepare, store, and distribute food according to professional standards of food service safety.
Resident Records - Identifiable Information - Facility failed to maintain medical records on each resident that are complete, accurate, accessible, and systematically organized.
Infection Prevention & Control - Facility failed to establish and maintain an infection prevention and control program to prevent and control communicable diseases and infections.
Life Safety Code Deficiencies - Facility failed to conduct fire drills quarterly on all shifts and maintain documentation of fire drills.
Report Facts
Capacity: 52
Census: 51
Dates of Survey: 2025-02-10 to 2025-02-13
Number of residents reviewed for medication errors: 2
Number of residents reviewed for food consistency: 2
Number of residents reviewed for infection control: 2
Number of residents reviewed for pressure ulcers: 1
Number of residents reviewed for medication administration: 4
Number of residents reviewed for medical records: 2
Number of residents reviewed for infection control: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to pressure ulcer treatment and audits |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in relation to audits and medication administration |
| Certified Medication Technician | Certified Medication Technician | Named in relation to re-education on medication administration |
| Certified Nursing Assistant | Certified Nursing Assistant | Named in relation to pressure ulcer care |
| Nursing Assistant Staff A | Nursing Assistant | Interviewed regarding pressure ulcer care |
| Registered Nurse Staff B | Registered Nurse | Interviewed regarding pressure ulcer care |
| Registered Nurse Staff C | Registered Nurse | Interviewed regarding medication administration |
| Certified Medication Technician Staff D | Certified Medication Technician | Interviewed regarding medication administration |
| Certified Medication Technician Staff E | Certified Medication Technician | Observed administering diet supplements |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety and preparation |
| Executive Chef | Executive Chef | Interviewed regarding kitchen sanitation and food safety |
| Medical Director | Medical Director | Interviewed regarding diet order changes |
| Infection Control Preventionist | Infection Control Preventionist | Interviewed regarding infection control practices |
| Maintenance Director | Maintenance Director | Interviewed regarding fire drill documentation |
| Nursing Assistant Staff F | Nursing Assistant | Observed not wearing gloves and eye protection |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 26, 2024
Visit Reason
An off-site desk audit was conducted on March 26, 2024, to review all previous deficiencies cited on February 29, 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
Renewal
Census: 48
Capacity: 55
Deficiencies: 2
Date: Feb 29, 2024
Visit Reason
A recertification survey was conducted from 2/26/2024 through 2/29/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a state licensure and emergency preparedness survey.
Findings
Deficiencies were cited related to professional standards of care, resident records, and medication administration documentation. The facility failed to ensure services met professional standards for one resident and failed to maintain accurate and complete medical records for another resident. No life safety code deficiencies were identified.
Deficiencies (2)
Facility failed to ensure services met professional standards of quality for one resident related to respiratory diagnosis and medication administration.
Facility failed to maintain accurate and complete resident records for one resident related to falls and Foley catheter documentation.
Report Facts
Capacity: 55
Census: 48
Missed medication opportunities: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician | Interviewed regarding medication administration and notification | |
| Director of Nursing | Interviewed regarding staff notification and documentation expectations | |
| Assistant Director of Nursing | Responsible for running daily missed medication reports | |
| Unit Manager | Interviewed regarding resident Foley catheter status and documentation | |
| Licensed Practical Nurse | Provided information about resident Foley catheter trial void and documentation | |
| Staff A | Interviewed regarding progress notes and documentation accuracy | |
| Medical Director | Reviewed progress notes and educated staff on documentation | |
| Nursing Supervisors | Reviewed progress notes and events for accuracy |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 15, 2023
Visit Reason
An off-site desk audit was conducted on February 15, 2023 for all previous deficiencies cited on January 13, 2023.
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: 6
Date: Jan 13, 2023
Visit Reason
A recertification survey was conducted at Tockwotton Skilled Nursing Home from 01/10/2023 through 01/13/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey.
Findings
Deficiencies were cited related to food procurement, storage, preparation, and sanitary standards, including issues with cleanliness of freezer and refrigerator floors, ice accumulation, dirty pans, unclean microwaves and juice dispensers, improper glove use, and failure to maintain safe operating condition of patient care equipment such as dryers.
Deficiencies (6)
Food procurement, store, prepare, serve sanitary standards not met; sticky floors, ice accumulation, and crumbs in freezer and refrigerator.
Dirty hotel pans with crumbs stuck to them.
Microwave, toaster, and juice dispensers not kept clean; brown matter and debris found.
Assistant Food Service Director observed not performing proper hand hygiene and not wearing hairnet.
Homemaker staff observed wearing same gloves without performing hand hygiene.
Essential equipment (dryer) missing exhaust hose, not maintained in safe operating condition.
Report Facts
Meatballs counted: 140
Dryers observed: 3
Other dryers inspected: 12
Microwaves inspected: 7
Hotel pans inspected: 100
Toasters inspected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Food Service Director | Assistant Food Service Director (FSD) | Observed not performing proper hand hygiene, not wearing hairnet, and acknowledged juice dispensers not kept clean. |
| Staff A | Acknowledged pans were not free of debris and needed washing. | |
| Staff B | Certified Nursing Assistant/Homemaker | Acknowledged microwave, toaster, and juice dispensers were not kept clean. |
| Staff C | Homemaker Staff | Observed wearing same gloves without performing hand hygiene and acknowledged not changing gloves between tasks. |
| Staff D | Nursing Assistant | Revealed all dryers on Everett unit were in use. |
| Maintenance Director | Maintenance Director | Reinstalled missing dryer exhaust hose and acknowledged accumulation of lint and missing hose. |
| PM | Administrator | Acknowledged dryer should have exhaust hose attached for proper ventilation. |
Inspection Report
Recertification
Deficiencies: 4
Date: Nov 4, 2021
Visit Reason
A Recertification Survey and Complaint/Incident Investigation Survey were conducted from 11/01/2021 through 11/04/2021 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Complaint Details
The survey included a complaint/incident investigation based on ACTS Reference Numbers 79674, 80217, and 80822.
Findings
The facility was determined not to be in compliance with several requirements related to quality of care, bowel/bladder incontinence, respiratory/tracheostomy care, and medication errors. Specific deficiencies included failure to implement bowel protocols, inadequate infection control related to catheter care, failure to provide appropriate respiratory care, and a medication error rate exceeding 5%.
Deficiencies (4)
Failure to ensure residents received treatment and care in accordance with professional standards related to bowel protocol and management.
Failure to ensure residents with urinary incontinence and catheter care received appropriate treatment and services to prevent infections.
Failure to provide appropriate respiratory care including tracheostomy suctioning consistent with professional standards.
Medication error rate exceeded 5%, with errors involving residents #37 and #40.
Report Facts
Days with no evidence of bowel movement: 4
Days with no evidence of bowel movement: 4
Days with no evidence of bowel movement: 5
Days with no evidence of bowel movement: 6
Days with no evidence of bowel movement: 10
Medication error rate: 8
Medication error rate: 5
Pulse oximetry monitoring failures: 4
Pulse oximetry monitoring failures: 10
Pulse oximetry monitoring failures: 4
Pulse oximetry monitoring failures: 6
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