Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Deficiencies: 4
Sep 30, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence from 9/29/2025 to 9/30/2025 to determine compliance with state regulations.
Findings
Deficiencies were identified related to management of services, resident assessment/service plans, reporting requirements, and housekeeping. Issues included failure to notify physicians of significant weight changes, failure to update service plans for hospice and therapy services, failure to report incidents timely, and failure to maintain a safe environment with a securely attached toilet grab bar.
Complaint Details
The investigation was complaint/incident driven with ACTS reference numbers 101674, 101711, 101842, 101777, 101880, and 101989. The complaint involved issues such as failure to notify physicians of weight changes, failure to update service plans, failure to report incidents, and unsafe environmental conditions leading to resident injury.
Deficiencies (4)
| Description |
|---|
| Failure to provide care and services in accordance with prevailing community standards for weight monitoring and physician notification for Resident ID#5. |
| Failure to update residents' service plans with accurate and timely information for Residents ID#1, 2, and 6 regarding hospice and therapy services. |
| Failure to report incidents, accidents, and medication errors resulting in out-of-residence emergency medical services and hospital admissions within required timeframes. |
| Failure to maintain a comfortable, safe, clean, sanitary, and orderly environment as evidenced by a toilet grab bar that was not securely attached to the wall. |
Report Facts
Weight measurements: 11
Residents reviewed: 6
Incident dates: 1
Date of toilet grab bar incident: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Wellness | Acknowledged failure to notify physician of weight gains and failure to report resident fall; involved in corrective action plans and audits | |
| Executive Director | Acknowledged toilet grab bar was loose and not affixed to the wall causing resident injury |
Inspection Report
Complaint Investigation
Deficiencies: 2
Apr 16, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations based on ACTS reference numbers 99532 and 100410.
Findings
Two deficiencies were identified: failure to update a resident's comprehensive assessment within five days of readmission from a higher level of care, and failure to timely report suspected abuse resulting in bruising to a resident's arm.
Complaint Details
The investigation was triggered by complaints related to failure to update resident assessments and failure to report suspected abuse. The complaint was substantiated based on record reviews and staff interviews.
Deficiencies (2)
| Description |
|---|
| The residence failed to ensure the resident's comprehensive assessment was updated within five working days of readmission from a health care facility for one resident. |
| Facility staff failed to report suspected abuse resulting in bruises on a resident's right upper arm within the required timeframe. |
Report Facts
Date of survey completion: Apr 16, 2025
Number of residents reviewed for deficiency 1: 1
Number of residents reviewed for deficiency 2: 1
Timeframe for assessment update: 5
Timeframe for abuse reporting: 24
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 21, 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 visit was triggered by complaint reference numbers 99244; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 4, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted on 02/04/2025 to determine compliance with state regulations following complaint ACTS reference numbers 99351, 99269, and 99280.
Findings
Deficiencies were identified related to failure to review residents' comprehensive assessments at required intervals and failure to complete nurse reviews every 90 days for one resident. The resident had a documented fall with a right femur fracture and lacked evidence of required annual and 90-day reviews.
Complaint Details
The investigation was complaint-driven based on reports to the Rhode Island Department of Health on 1/22/2025 regarding a resident found on the floor unable to move, later admitted with a right femur fracture. The complaint was substantiated by findings of deficient assessment and nurse review practices.
Deficiencies (2)
| Description |
|---|
| Failure to review the resident's comprehensive assessment at intervals not to exceed 12 months and when condition changes significantly for 1 of 3 residents reviewed. |
| Failure to complete nurse reviews every 90 days as required for 1 of 3 residents reviewed. |
Report Facts
Residents reviewed: 3
Incident report date: Jan 22, 2025
Last comprehensive assessment date: Feb 10, 2022
Last 90-day nurse review date: Jun 4, 2024
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 15, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence from 01/13/2025 to 01/15/2025 to determine compliance with state regulations.
Findings
A deficiency was identified as a result of this survey.
Complaint Details
The visit was complaint-related as an unannounced complaint/incident investigation survey was conducted.
Deficiencies (1)
| Description |
|---|
| A deficiency was identified as a result of this survey. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 17, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations following multiple complaint reference numbers.
Findings
The facility failed to maintain accurate documentation of an incident involving the use of a heated food cart as a smoker, which triggered a smoke detector. The food cart was not designed for smoking food, and the Executive Director could not provide evidence that the cart was intended for such use.
Complaint Details
The investigation was triggered by complaints with reference numbers 97479, 96422, 97610, 98010, and 97982. The complaint was substantiated by findings that the residence failed to maintain accurate incident documentation and used a heated food cart as a smoker, which is not designed for that purpose.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain accurate documentation of an incident that jeopardized resident health and safety related to the use of a heated food cart as a smoker. | D |
Report Facts
Complaint reference numbers: 5
Incident report date: Oct 11, 2024
Internal investigation date: Oct 15, 2024
Surveyor interview date and time: Oct 17, 2024
Retention period for documentation: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Interviewed during surveyor visit regarding use of heated food cart as smoker | |
| Executive Director | Interviewed during surveyor visit; unable to provide evidence that heated food cart was designed for smoking food | |
| Administrator | Signed plan of correction document |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 23, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the assisted living residence due to allegations of abuse involving a resident.
Findings
The investigation found that staff failed to report suspected abuse of Resident ID #1 in a timely manner as required by regulations. The resident was found to have evidence of sexual assault and bruising, and the visitor involved was issued a no trespass order.
Complaint Details
The complaint investigation was substantiated. Staff A observed inappropriate contact between a visitor and Resident ID #1 but did not report the incident immediately. The resident's hospital evaluation confirmed sexual assault and bruising. The visitor was issued a no trespass order and supervised visits only.
Deficiencies (1)
| Description |
|---|
| Failure to report suspected abuse, exploitation, neglect, or mistreatment within required timeframes as per licensure requirements. |
Report Facts
Dates related to incident and reporting: Incident observed on 05/20/2024, reported on 05/21/2024, police report dated 05/24/2024, surveyor interview on 05/23/2024.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Observed abuse but failed to report immediately; interviewed during survey. | |
| Administrator | Acknowledged failure to report abuse immediately by Staff A during interview. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 26, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the facility.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The complaint/incident investigation was unannounced and no deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 3
Nov 15, 2023
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility on 11/15/2023.
Findings
The facility failed to review and update residents' comprehensive assessments and service plans to reflect outside services received, specifically for residents with dementia receiving palliative care and occupational therapy. Additionally, the facility failed to submit a required variance for a resident receiving palliative care services.
Complaint Details
The visit included a complaint/incident investigation survey as part of the unannounced biennial State Licensure survey.
Deficiencies (3)
| Description |
|---|
| Failure to review residents' comprehensive assessments at intervals not to exceed twelve months and when condition changes significantly, resulting in incomplete documentation of outside services for residents #4 and #6. |
| Failure to review and update residents' service plans to reflect outside services for residents #4 and #6. |
| Failure to submit a variance for a resident (#4) receiving palliative care services as required by the Department. |
Report Facts
Number of sample residents reviewed: 7
Residents with deficiencies: 2
Dates of palliative care services for Resident #4: January 26, 2023 through September 12, 2023, resumed on October 23, 2023
Start of occupational therapy for Resident #6: October 10, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Memory Care Nurse Manager | Acknowledged residents receiving outside services and deficiencies in documentation during surveyor interviews | |
| Assisted Living Administrator or designee | Responsible for bringing copies of addendum sheets to quarterly QI meetings for audit and evaluation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 25, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the facility on 08/25/2023 based on ACTS reference numbers 91354, 91751, 91736, and 91100.
Findings
A deficiency was identified related to failure to provide all care and services in accordance with the prevailing community standard of care for residents with dementia, including inadequate documentation of changes in condition and overall health decline for one resident with Alzheimer's disease.
Complaint Details
The investigation was complaint-driven, with substantiation implied by the identification of a deficiency related to care and documentation for Resident ID #1 with dementia and Alzheimer's disease.
Deficiencies (1)
| Description |
|---|
| Failure to provide all care and services in accordance with the prevailing community standard of care for residents with dementia, including weight and nutritional status monitoring and documentation of changes in condition for one resident. |
Report Facts
ACTS reference numbers: 4
Resident weight documented: 126.2
Resident weight documented: 98.8
Falls documented: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 29, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was complaint/incident related and no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 3, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was unannounced and no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 2
May 26, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence following a reported elopement incident involving Resident ID #1.
Findings
The facility failed to provide adequate safety measures in the memory care unit to prevent elopement. Staff did not have pagers assigned consistently, and emergency exit door alarms were not sufficiently audible inside the facility. The resident eloped through a south emergency exit door leading to a bike path approximately 600 feet away.
Complaint Details
The complaint investigation was substantiated based on findings that staff failed to ensure all residents were accounted for and that safety measures to prevent elopement were inadequate. The incident involved Resident ID #1 eloping through an emergency exit door. Police and family were notified and located the resident.
Deficiencies (2)
| Description |
|---|
| Failure to operate and provide services to all residents of the memory care unit in accordance with the prevailing community standard of care for residents with dementia. |
| Failure to provide adequate safety measures in the memory care unit to prevent elopement, including inconsistent pager assignment to staff and insufficiently audible emergency exit door alarms. |
Report Facts
Date of incident: May 21, 2022
Time of surveyor interview: 1330
Time of surveyor observation: 1430
Distance from exit door to bike path: 600
Number of staff involved in incident: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Interviewed on 5/26/2022 regarding memory care unit safety and pager assignment | |
| Administrator | Interviewed on 5/26/2022; acknowledged failure to provide adequate safety measures |
Inspection Report
Complaint Investigation
Deficiencies: 6
Dec 9, 2021
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility on 12/09/2021 to assess compliance with state licensure requirements and investigate complaints.
Findings
Multiple deficiencies were identified related to personnel criminal background checks, resident assessments and service plans, medication services, and variance procedures. The facility failed to ensure timely criminal background checks for re-hired staff, failed to update resident assessments and service plans to reflect changes in condition or outside services, and failed to properly document medication administration and evaluations.
Complaint Details
The visit included a complaint/incident investigation survey triggered by concerns about personnel background checks, resident assessments, medication administration, and variance requests for outside skilled nursing services. The complaint was substantiated based on findings.
Deficiencies (6)
| Description |
|---|
| Failure to ensure personnel criminal background checks were completed upon rehire as required by R.I. Gen. Laws 23-17.4-27. |
| Failure to review resident assessments at required intervals and update to reflect changes in condition or outside services for multiple residents. |
| Failure to conduct and document quarterly evaluations of registered medication aides and medication technician evaluations. |
| Failure to ensure medications were administered and stored according to physician orders and regulatory requirements, including expired medications and lack of resident identifiers on medication carts. |
| Failure to file variance requests for outside skilled nursing services for certain residents as required. |
| Failure to obtain physician orders for limited health services and pressure ulcer treatment prior to delivery of care. |
Report Facts
Deficiencies cited: 6
Dates of personnel rehire: 2021
Dates of resident admissions: 2021
Dates of medication administration record (MAR) review: 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Technician (CMT)/Certified Nursing Assistant (CNA) | Named in findings related to incomplete criminal background check and missing quarterly medication aide evaluations. |
| Staff B | Certified Medication Technician (CMT)/Certified Nursing Assistant (CNA) | Named in findings related to missing quarterly medication aide evaluations. |
| Courtyard Resident Care Director | Acknowledged deficiencies in resident assessments and medication documentation. | |
| River's Edge Resident Care Director | Responsible for conducting audits and corrective actions related to assessments, medication evaluations, and variance requests. | |
| Courtyard Nurse Manager | Responsible for updating service plans, conducting audits, and ensuring medication compliance. | |
| Administrator | Acknowledged incomplete criminal background checks and medication aide evaluations. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 9, 2021
Visit Reason
An unannounced complaint/incident investigation survey and a biennial State licensure survey were conducted at this residence.
Findings
No deficiencies were identified relative to the complaint/incident investigation survey.
Complaint Details
The complaint/incident investigation was unannounced and no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 4, 2021
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was unannounced and no deficiencies were found.
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