Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 17, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations.
Findings
No deficiency was identified during the investigation.
Complaint Details
The investigation was based on ACTS reference numbers 102459 and found no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 28, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the facility from 10/28/2025 through 10/29/2025 to determine compliance with state regulations.
Findings
No deficiency was identified as a result of this survey.
Complaint Details
The investigation was based on multiple ACTS reference numbers: 101223, 101224, 101402, 102247, 101782, 102018, 102154, 102282, 102301, 102310.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 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 investigation was based on ACTS reference number 100555 and found no deficiencies.
Inspection Report
Plan of Correction
Deficiencies: 3
Apr 14, 2025
Visit Reason
An unannounced biennial State Licensure survey was conducted at Victoria Court Memory Care on 4/14/2025 through 4/15/2025 to assess compliance with state licensure requirements.
Findings
Deficiencies were identified related to personnel records lacking signed job descriptions for 3 of 6 staff reviewed, failure to provide care and services according to physician's orders for one resident, and medication storage and administration issues including expired and improperly labeled medications.
Deficiencies (3)
| Description |
|---|
| Personnel records did not contain signed job descriptions for 3 of 6 sample staff reviewed. |
| The residence failed to provide care and services in accordance with physician's orders for Resident ID #1, including failure to monitor blood pressure as ordered. |
| Medications were not stored securely and properly; expired medications and medications without expiration dates were observed in the medication cart. |
Report Facts
Staff with missing signed job descriptions: 3
Resident sample size: 3
Medication expiration issues: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in personnel records deficiency for missing signed job description. | |
| Staff B | Named in personnel records deficiency for missing signed job description. | |
| Staff C | Named in personnel records deficiency for missing signed job description. | |
| Staff D | Certified Medication Technician | Could not produce evidence of medications during surveyor interview. |
| Executive Director | Executive Director | Acknowledged missing signed job descriptions and involved in corrective action plans. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 9, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations at Victoria Court Memory Care.
Findings
The facility failed to update comprehensive assessments for residents when their conditions changed significantly, specifically for activities of daily living (ADLs) and receipt of skilled nursing services. Two residents' assessments were not updated timely to reflect changes in condition and services received.
Complaint Details
The investigation was triggered by complaint reference number 98565. The complaint was substantiated as deficiencies were identified regarding resident assessments.
Deficiencies (1)
| Description |
|---|
| Failure to update comprehensive assessment each time a resident's condition changed significantly for 1 of 3 residents reviewed for ADLs and 1 of 1 resident reviewed for outside services. |
Report Facts
Residents reviewed for ADLs: 3
Residents reviewed for outside services: 1
Dates of assessments: Jul 25, 2024
Dates of assessments: Oct 22, 2024
Start of care date: Oct 29, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Wellness | Interviewed during survey, could not provide evidence that assessments were updated | |
| Executive Director | Signed plan of correction document |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jul 31, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted on 7/31/2024 following a community reported complaint to the Rhode Island Department of Health on 7/29/2024 alleging a resident eloped from the residence on 7/27/2024 and was found on a different street.
Findings
The facility failed to provide a secure distinct living environment appropriate for residents with dementia, as evidenced by multiple elopements including one on 7/27/2024. Deficiencies included unlocked 'servery doors' allowing resident egress, lack of secure environment for the resident, and failure to prevent elopement despite prior citations. Staff have been instructed on corrective actions including reassessment of the resident, use of wander guard bracelets, alarm system checks, and staff re-education. One staff member was terminated due to safety violations.
Complaint Details
Complaint investigation triggered by a community reported complaint on 7/29/2024 alleging resident elopement on 7/27/2024. The complaint was substantiated by survey findings of multiple elopements and environmental/security deficiencies.
Deficiencies (2)
| Description |
|---|
| Failure to provide a secure distinct living environment for residents with dementia, resulting in resident elopement. |
| Unlocked servery door allowing resident to exit the facility unsupervised. |
Report Facts
Date of resident elopement: Jul 27, 2024
Date of complaint: Jul 29, 2024
Date of survey: Jul 31, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Acknowledged leaving the servery door open during survey interview; terminated due to safety violations | |
| Staff B | Nursing Assistant | Interpreted during survey interview with Staff A |
| Resident Care Director / RN | Instructed on medication adjustments and resident reassessment; involved in wander guard bracelet tracking | |
| Administrator | Acknowledged resident eloped through servery door during survey interview |
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 25, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the facility due to concerns about resident elopement and safety.
Findings
The facility failed to provide a secure distinct living environment in the Alzheimer Dementia Special Care Unit to ensure resident safety, specifically related to elopement risk. A resident with Alzheimer's disease eloped due to a malfunctioning wander guard bracelet and unlocked doors, placing the resident at risk of harm.
Complaint Details
The complaint was substantiated. The investigation found that a resident with Alzheimer's disease and no history of elopement eloped from the secure unit due to a dead battery in the wander guard bracelet and unlocked doors, indicating a failure in the facility's elopement prevention system.
Deficiencies (1)
| Description |
|---|
| Failure to provide a secure distinct living environment in the Alzheimer Dementia Special Care Unit to ensure resident safety relative to elopement. |
Report Facts
Date of initial report to RIDOH: Mar 9, 2024
Date of survey completion: Apr 25, 2024
Time of police arrival: 1450
Time of police callback: 1506
Time of interview with Administrator: 1100
Time of interview with resident: 920
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 21, 2024
Visit Reason
An unannounced complaint/incident investigation survey and a follow-up survey were conducted at the facility to investigate deficiencies related to reporting requirements for incidents resulting in hospital admissions.
Findings
The facility failed to report incidents involving Resident ID #8 and Resident ID #13 to the Center for Health Facilities Regulation in a timely manner, resulting in non-compliance with reporting requirements. The Executive Director and Resident Care Director were re-educated on reporting procedures to ensure compliance.
Complaint Details
The investigation was triggered by a complaint/incident. It was substantiated that the facility did not report incidents for Resident ID #8 and Resident ID #13 as required. Resident ID #8 had an incident on 1/20/2024 resulting in hospital admission due to agitation. Resident ID #13 had a fall on 3/1/2024 resulting in hospital admission for a left hip fracture. Both incidents were reported late to the Center for Health Facilities Regulation.
Deficiencies (1)
| Description |
|---|
| Failure to report incidents resulting in out-of-residence emergency medical services and hospital admissions for Resident ID #8 and Resident ID #13 within the required timeframe. |
Report Facts
Incident date: Jan 20, 2024
Incident date: Mar 1, 2024
Incident report submission date: Jan 23, 2024
Incident report submission date: Mar 5, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Acknowledged incidents were not reported on the next working day and was re-educated on reporting requirements | |
| Resident Care Director | Re-educated on reporting requirements and responsible for discussing reportable incidents during morning meetings | |
| Business Office Manager | Trained on RIDOH Residency Requirements pertaining to Reporting Requirements to ensure timely compliance |
Inspection Report
Renewal
Deficiencies: 5
May 31, 2023
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted from 5/30/2023 through 5/31/2023 at Pacifica Senior Living Victoria Court.
Findings
Multiple deficiencies were identified related to residency requirements, resident assessments and service plans, reporting requirements, dietetic services, and special care license requirements. Deficiencies included failure to maintain complete resident records, incomplete or outdated service plans, failure to report incidents timely, and food service sanitation issues.
Complaint Details
The survey included a complaint/incident investigation component related to resident care and incident reporting.
Deficiencies (5)
| Description |
|---|
| Resident records lacked evidence of services provided by outside agencies and required resident information. |
| Resident assessments and service plans were not updated to reflect outside services or reviewed at required intervals. |
| Failure to report accidents, incidents, and medication errors resulting in hospital admissions to the Center for Health Facilities Regulation by the next working day. |
| Food service area failed to comply with Rhode Island Food Code, including accumulation of dirt and debris on equipment and lack of air gap in ice machine drain line. |
| Special Care License requirements not met; failure to operate and provide services according to community standards for residents with dementia and failure to follow physician orders for medication and monitoring. |
Report Facts
Dates of survey: 2
Incident report date: 4142023
Fall incident date: 472023
Hospital admission date: 4112023
Resident medication order dates: 82023
Medication administration record missing dates: 4
Medication administration record missing dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in multiple findings including resident record deficiencies, service plan audits, incident reporting, food service observations, and medication monitoring. | |
| Residence Care Director | Named in findings related to resident record audits, service plan reviews, and medication administration monitoring. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 18, 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 complaint/incident investigation was unannounced and resulted in no identified deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 5
Oct 25, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at Pacifica Senior Living Victoria Court due to identified deficiencies.
Findings
The investigation found multiple deficiencies including failure to provide scheduled registered nurse administration of PRN controlled substances, inadequate skin assessments and wound care for residents, failure to maintain residency requirements, incomplete resident records, and failure to ensure possession of medication was safe. Several residents had pressure ulcers and wounds that were not properly assessed or documented by licensed nursing staff.
Complaint Details
The visit was triggered by a complaint/incident investigation. Deficiencies were identified related to medication administration, skin care, residency requirements, and resident records. The Resident Care Director acknowledged lack of awareness of some issues during interviews.
Deficiencies (5)
| Description |
|---|
| Failure to provide scheduled registered nurse to administer PRN controlled substances for one resident. |
| Failure to provide adequate skin assessments and wound care for residents with pressure ulcers and wounds. |
| Failure to meet residency requirements for residents not meeting the definition of 'resident'. |
| Failure to maintain complete and updated resident records including assessments, service plans, and documentation of changes. |
| Failure to ensure possession of medication was safe for a resident receiving oxygen therapy. |
Report Facts
Number of residents with wounds reviewed: 5
Number of residents with treatment orders reviewed: 3
Number of residents with skin assessments reviewed: 5
Number of residents not meeting residency definition: 2
Number of residents with updated nurse reviews: 6
Number of residents with pressure ulcers: 8
Number of residents with falls documented: 4
Number of sutures received: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Acknowledged lack of qualified staff for PRN medication administration and unawareness of wounds and falls during interviews | |
| Executive Director | Executive Director | Named in plan of correction and responsible for auditing and training to prevent recurrence of deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 21, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the complaint/incident investigation survey.
Complaint Details
The visit was complaint-related and no deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 16, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at Pacifica Senior Living Victoria Court due to a reported deficiency.
Findings
The facility failed to update the comprehensive assessment for Resident ID #1 to reflect a change in condition following a successful elopement attempt on 05/30/2022. The assessment form did not meet requirements to report the resident's needs and gather information for an individualized service plan.
Complaint Details
The investigation was complaint-related, focusing on Resident ID #1's assessment following an elopement. The Director of Wellness acknowledged on 06/16/2022 that the comprehensive assessment did not reflect the change in condition.
Deficiencies (1)
| Description |
|---|
| Residency Requirements 2.4.16(C) Resident Assessments and Service Plans - Resident ID #1's comprehensive assessment failed to reflect a change of condition after a successful elopement attempt. |
Report Facts
Date of successful elopement: May 30, 2022
Date of comprehensive assessment: Jan 20, 2022
Date of incident report: Jun 9, 2022
Date survey completed: Jun 16, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Wellness | Acknowledged Resident ID #1's comprehensive assessment did not reflect change in condition during interview on 06/16/2022 | |
| Executive Director | Signed the plan of correction document on 07/12/2022 |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
May 19, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at Pacifica Senior Living Victoria Court to investigate deficiencies related to weight record discrepancies and monitoring of residents' weight.
Findings
The residence failed to provide all care and services in accordance with the prevailing community standard of care related to monitoring residents' weight for 25 of 49 sampled residents. Weight record discrepancies were found, and the facility did not perform required reweighs or notify physicians for significant weight loss as per policy.
Complaint Details
The complaint investigation found the residence failed to monitor weight accurately and notify responsible parties of significant weight loss for residents. The Resident Service Director acknowledged weight record discrepancies during an interview on 05/19/2022.
Deficiencies (1)
| Description |
|---|
| Failure to provide all care and services in accordance with community standards related to weight monitoring and record accuracy. |
Report Facts
Sampled residents: 49
Residents with weight monitoring deficiencies: 25
Resident weights: 150
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Service Director | Acknowledged weight record discrepancies during interview | |
| Executive Director | Responsible for auditing weight monitoring logs and staff training |
Inspection Report
Complaint Investigation
Deficiencies: 3
Jan 13, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence to investigate identified deficiencies.
Findings
The facility failed to conduct safe resident handling hazard assessments and failed to update resident assessments and service plans as required. Infection control deficiencies related to COVID-19 protocols and resident monitoring were also identified.
Complaint Details
The visit was triggered by a complaint/incident investigation. Deficiencies were identified related to safe resident handling, resident assessments/service plans, and infection control including COVID-19 protocols.
Deficiencies (3)
| Description |
|---|
| Failed to conduct a safe resident handling hazard assessment on each resident as required by policy. |
| Failed to review resident assessments and service plans at intervals not to exceed twelve months and when condition changes significantly. |
| Failed to establish infection control provisions for mutual protection of residents, employees, and the public relative to general infection control and COVID-19 standards. |
Report Facts
Date of survey completion: Jan 13, 2022
Dates of resident assessments: Nov 20, 2020
Dates of resident assessments: Dec 14, 2020
Dates of resident assessments: Oct 25, 2020
Dates of incident reports: Oct 12, 2021
Dates of incident reports: Nov 8, 2021
Dates of COVID-19 positive tests: Jan 3, 2022
Dates of COVID-19 positive tests: Jan 7, 2022
Dates of COVID-19 positive tests: Jan 4, 2022
Dates of COVID-19 positive tests: Jan 8, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Acknowledged residents were not assessed per policy relative to safe resident handling during interview on 01/13/2022 | |
| Wellness Director | Acknowledged resident assessments and service plans were not updated as required during interviews on 01/13/2022 | |
| Staff A | Observed serving a COVID-19 positive resident while wearing a surgical mask and acknowledged Resident #11 was out of room during breakfast on 01/13/2022 | |
| Staff B | Acknowledged Resident #9 and #10 came out of their rooms for temperature checks on 01/13/2022 | |
| Administrator | Acknowledged lack of plan for tracking and monitoring residents for COVID-19 symptoms and temperature checks on 01/13/2022 |
Inspection Report
Plan of Correction
Deficiencies: 6
Mar 17, 2021
Visit Reason
An unannounced biennial State Licensure survey was conducted at the residence to assess compliance with regulatory requirements.
Findings
Deficiencies were identified in multiple areas including personnel criminal background checks, nurse reviews for residents receiving skilled services, residency assessment/service plans, infection control related to facemask usage, medication administration and storage, and health screening requirements for staff.
Deficiencies (6)
| Description |
|---|
| Failure to ensure national criminal background checks were completed within one week of employment for staff A and B. |
| Nurse reviews did not reflect changes of condition related to skilled services for two of three sampled residents. |
| Residency service plans failed to include skilled services provided by outside agencies and failed to document medical leave of absence for residents. |
| Failure to establish infection control provisions for mutual protection of residents, employees, and the public relative to COVID-19 standards, including improper use of cloth face masks by staff. |
| Medication administration deficiencies including unavailable prescribed medications and failure to maintain accurate medication administration records. |
| Failure to obtain proper employment health screenings including vaccination and two-step PPD testing for staff B, H, and I. |
Report Facts
Deficiencies cited: 6
Dates of corrective actions: Mar 24, 2021
Dates of corrective actions: Apr 5, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in deficiency for failure to complete national criminal background check within one week of hire. | |
| Staff B | Named in deficiency for failure to complete national criminal background check within one week of hire and failure to provide evidence of required health screenings. | |
| Staff C | Business Office Manager | Interviewed and unable to provide evidence of background checks for Staff A and B; involved in infection control retraining. |
| Resident Care Director | Acknowledged deficiencies in nurse reviews and infection control practices; involved in medication administration corrective actions. | |
| Staff H | Named in deficiency for failure to provide evidence of required health screenings. | |
| Staff I | Named in deficiency for failure to provide evidence of required health screenings. |
Inspection Report
Deficiencies: 0
Jan 22, 2021
Visit Reason
An administrative review/offsite investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the administrative review/offsite investigation survey.
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