Inspection Reports for Wingate Residences on Blackstone Boulevard

An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility on 9/12/2025.

Deficiencies were identified related to quality assurance, dietetic services, and medication administration. Issues included failure to establish a written quality improvement plan, food service violations such as improper food handling and sanitation, and medication administration errors including missing medications and improper storage.

The visit included a complaint/incident investigation survey. Specific complaint details are not explicitly stated, but findings relate to medication administration errors and food service issues.

An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations.

No deficiencies were identified during the investigation.

The investigation was based on ACTS reference numbers 101241 and 100481. No deficiencies were found, indicating the complaint was not substantiated.

An unannounced complaint/incident investigation survey was conducted from 4/8/2025 through 4/9/2025 to determine compliance with state regulations based on complaints received by the Rhode Island Department of Health.

The investigation identified a deficiency related to the failure to protect medical information and obtain proper consent from residents or their authorized representatives before performing genetic testing. Specifically, two residents' records lacked evidence that Power of Attorney was notified and gave consent in advance of IDgenetix testing.

The complaint received on 3/26/25 alleged that a provider was accessing residents without the expressed consent of their medical decision makers. The complaint was substantiated by findings related to two residents admitted with diagnoses including Alzheimer's disease and mental/behavioral disorders, where consent for genetic testing was not properly obtained.

An unannounced complaint/incident investigation survey was conducted on 11/12/2024 to determine compliance with state regulations following complaints referenced by ACTS numbers 98014 and 98262.

The investigation found that the residence failed to maintain evidence that corrective actions mitigated risk related to an incident of misappropriation of a resident's property. Specifically, a housekeeper working for a contracted company asked a resident for money, and the facility did not conduct a timely internal investigation or ensure all residents were free from exploitation.

The complaint investigation was substantiated. The RI Department of Health received a report on 10/14/2024 about an employee of a contracted housekeeping company soliciting money from a resident. The facility's internal investigation was incomplete at the time of the survey, and the employee was suspended and terminated after the incident was reported to the employer. The Executive Director referred the incident to the vendor for investigation and resolution.

An unannounced complaint/incident investigation survey was conducted at this residence.

No deficiencies were identified during the investigation.

The investigation was unannounced and no deficiencies were found, indicating no substantiated issues.

An unannounced complaint/incident investigation survey was conducted from 7/29/2024 through 7/30/2024 at this residence due to a reportable incident alleging a resident was pacing throughout the hallways and eventually exited through the stairwell.

The residence failed to review the service plan each time a resident's condition changed significantly for Resident ID #4, and individualized interventions for exit-seeking behaviors were not documented in the resident's service plan. Interviews with the Executive Director and Director of Wellness confirmed the resident's behaviors and the lack of documented interventions.

The complaint was a reportable incident submitted on 7/19/2024 alleging that the resident was pacing throughout the hallways and exited through the stairwell. The investigation included record reviews and interviews confirming the resident's behaviors and the absence of appropriate service plan updates.

An unannounced complaint/incident investigation survey was conducted at this residence.

No deficiencies were identified during the investigation.

The investigation was unannounced and no deficiencies were found, indicating no substantiated issues.

An unannounced complaint/incident investigation survey was conducted at this residence.

No deficiencies were identified during the investigation.

The investigation was unannounced and related to a complaint or incident; no deficiencies were found.

An unannounced complaint/incident investigation survey was conducted at the residence on 12/29/2023 following complaints referenced by numbers 93312, 93244, and 93533.

Deficiencies were identified related to medication errors, failure to provide care in accordance with community standards, incomplete resident assessments, and failure to ensure nurse reviews were completed every ninety days. Specific issues included medication given without a physician's order, failure to update assessments after hospice admission, and failure to discard discontinued medications timely.

The investigation was triggered by complaints referenced as 93312, 93244, and 93533. The medication error was substantiated by record reviews and interviews, including admission diagnoses, hospice care coordination notes, and interviews with Resident Services Director and Administrator acknowledging medication given without a physician's order.

An unannounced biennial State Licensure survey was conducted at Wingate Residences on Blackstone to assess compliance with licensure requirements and quality assurance standards.

Deficiencies were identified related to the failure to maintain a documented ongoing quality assurance program, incomplete nurse reviews every 90 days for residents, failure to protect residents' rights including removal of identifying information from survey binders, non-compliance with Rhode Island Food Code requirements in food storage and expiration monitoring, and failure to obtain physician orders prior to delivering limited health services to residents.

An unannounced complaint/incident investigation survey was conducted at the residence to investigate identified deficiencies.

The facility failed to review and update resident assessments and service plans to reflect significant condition changes for sampled residents. Additionally, the facility failed to ensure employees reported suspected abuse, neglect, or mistreatment within required timeframes and failed to thoroughly investigate or report a specific incident of alleged sexual abuse.

The investigation was complaint-driven and substantiated deficiencies related to resident assessments, service plans, and abuse reporting and investigation. Specific incidents involved two residents, including one identified as a perpetrator and another as a victim of sexual abuse.

An unannounced complaint/incident investigation survey was conducted at this residence.

No deficiencies were identified during the investigation.

The investigation was unannounced and no deficiencies were found, indicating no substantiated issues.

An unannounced complaint/incident investigation survey was conducted at this residence.

No deficiencies were identified during the investigation.

The investigation was complaint-related and no deficiencies were found, indicating no substantiated issues.

An unannounced complaint/incident investigation survey was conducted at this assisted living residence due to an alleged incident of resident abuse.

The investigation found that the facility failed to report an alleged incident of resident abuse involving inappropriate contact between residents. The Director of Wellness could not provide evidence that the incident was investigated or reported as required by state regulations.

The complaint was substantiated as the facility did not investigate or report an incident where a resident was found exposed with another resident fondling them. The Director of Wellness was unable to provide evidence of investigation or reporting during the surveyor interview.

An unannounced complaint/incident investigation survey was conducted at this assisted living residence due to concerns about residency requirements compliance.

The investigation found that the facility retained a resident who did not meet the definition of a 'resident' under the residency requirements, including issues related to the resident's inability to ambulate, psychiatric needs, and wound care. The resident had multiple hospitalizations and was receiving care inconsistent with assisted living regulations.

The complaint investigation was substantiated by findings that the resident did not meet residency requirements, including being non-ambulatory and requiring more care than allowed in assisted living. The resident had a history of hospitalizations, psychiatric issues, and wounds, and the facility had issued a 30-day notice to vacate.

An unannounced complaint/incident investigation survey was conducted at the residence to investigate deficiencies related to residency requirements and resident assessments.

The facility failed to ensure that one out of five sample residents met residency requirements and did not update comprehensive assessments annually or when conditions changed. Resident #1 was transferred to a higher level of care after a fall and hospitalization, and the facility did not provide a 30-day notice to the resident. The community plans to audit resident charts with falls and conduct staff training.

The investigation was complaint-driven, focusing on Resident #1's fall and transfer to a higher level of care without a 30-day notice. The complaint was substantiated as the facility failed to meet residency and assessment requirements.

An unannounced complaint/incident investigation survey and a biennial State licensure survey were conducted at the residence.

No deficiencies were identified relative to the complaint investigation survey.

No deficiencies were identified relative to this complaint investigation survey.

An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility on 09/29/2021.

The survey identified deficiencies related to medication services, including failure to ensure medications were stored securely and administered properly, lack of proper medication labeling and directions, and failure to follow variance procedures and special care license requirements. The facility was found to have multiple medication administration errors and documentation issues, as well as failure to provide a secure environment for residents with dementia.

The complaint investigation was triggered by concerns regarding medication administration and resident safety, including incidents of medication errors and elopement attempts by residents with dementia. The Wellness Director acknowledged medication labeling errors and inability to provide evidence of medication administration. Documentation related to resident elopements was inadequate.

An unannounced complaint/incident investigation survey was conducted at Wingate Residences on Blackstone due to allegations of resident abuse and safety concerns.

The investigation found that the residence failed to provide adequate care and services to residents, specifically related to abuse and safety for Resident ID #1 and others. Multiple incidents of sexual abuse and neglect were documented, along with failures in resident assessments, service plans, and reporting requirements.

The complaint investigation was substantiated with findings of abuse involving Resident ID #1 and two victims of sexual abuse, Resident ID #2 and #3. The facility failed to ensure resident safety, provide adequate supervision, update assessments and service plans, and comply with reporting requirements. Family members and staff were involved in providing one-to-one supervision for Resident ID #1 after incidents. The Director of Wellness acknowledged failures in updating service plans and reporting incidents.