Inspection Report
Annual Inspection
Deficiencies: 5
Oct 31, 2024
Visit Reason
An unannounced biennial State Licensure survey was conducted from 10/28/2024 through 10/31/2024 at this residence to assess compliance with Rhode Island State Licensure regulations.
Findings
Deficiencies were identified related to management of services, comprehensive resident assessments, medication management, and variance requests for catheter care. The facility failed to ensure proper self-administration of medication, timely updates of resident assessments, and appropriate medication storage and disposal.
Deficiencies (5)
| Description |
|---|
| Failure to provide care and services in accordance with prevailing community standards for self-administration of medication for Resident #1. |
| Failure to complete and update comprehensive assessments for residents when condition changed, specifically Resident #4. |
| Failure to update comprehensive assessment within five working days of readmission from a healthcare facility for Resident #4. |
| Medication management deficiencies including improper storage, expired medications, and lack of evidence of proper disposal procedures. |
| Lack of evidence that variance requests for catheter care exceeding 45 days were submitted to Rhode Island Department of Health for Residents #2 and #3. |
Report Facts
Survey duration days: 4
Residents reviewed for self-administration: 3
Residents reviewed for assessment updates: 2
Medication expiration dates noted: 4
Variance approval days exceeded: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Messina | Executive Director | Signed plan of correction and responsible for compliance |
| Director of Wellness | Acknowledged medication disposal issues and responsible for monitoring compliance | |
| Staff A | Certified Medication Technician (CMT) | Observed during medication cart inspections |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 10, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence to determine compliance with state regulations.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was based on ACTS reference numbers 95422, 95530, and 97794 and found no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 22, 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 investigation was unannounced and no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 7, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at Wingate Residences on the East Side to investigate deficiencies related to resident assessments and service plans.
Findings
The facility failed to review comprehensive resident assessments at required intervals not to exceed 12 months for 3 of 8 sampled residents. Additionally, the facility failed to complete nurse reviews every 90 days for 5 of 8 sampled residents. The Director of Wellness was unable to provide evidence that required assessments and nurse reviews were completed as mandated.
Complaint Details
The visit was triggered by an unannounced complaint/incident investigation. The Director of Wellness was unable to provide evidence that comprehensive assessments and 90-day nurse reviews had been completed as required for the residents mentioned.
Deficiencies (2)
| Description |
|---|
| Failure to review comprehensive resident assessments at intervals not to exceed 12 months for 3 of 8 sampled residents. |
| Failure to complete nurse reviews every 90 days for 5 of 8 sampled residents. |
Report Facts
Sample residents reviewed: 8
Residents with missed assessment reviews: 3
Residents with missed nurse reviews: 5
Inspection Report
Routine
Deficiencies: 0
Aug 10, 2023
Visit Reason
An administrative review/offsite investigation was conducted at the residence as part of a routine survey.
Findings
No deficiencies were identified during the survey; the facility was found to be deficiency free.
Inspection Report
Routine
Deficiencies: 0
Aug 10, 2023
Visit Reason
An administrative review/offsite investigation was conducted at this residence as part of a routine survey.
Findings
No deficiencies were identified during the survey.
Inspection Report
Follow-Up
Deficiencies: 6
Jan 12, 2023
Visit Reason
An unannounced biennial State Licensure survey was conducted at this residence to identify deficiencies and verify compliance with state regulations.
Findings
The survey identified multiple deficiencies including failure to provide scheduled nurse administration of controlled substance medication, incomplete nurse reviews for residents, inaccurate resident service plans reflecting outside services, and non-compliance with Rhode Island Food Code in the main kitchen including accumulation of debris and improper food temperature control.
Deficiencies (6)
| Description |
|---|
| Failure to provide a scheduled nurse to administer controlled substance medication to a resident as needed. |
| Nurse reviews for residents were not completed up to standards or timely, including failure to complete quarterly evaluations and 90-day nurse reviews. |
| Resident service plans did not accurately reflect outside services received by residents. |
| Main kitchen failed to comply with Rhode Island Food Code; accumulation of dust, dirt, food residue, and other debris on non-food-contact surfaces. |
| Heavy accumulation of black substance and clear yellow dripping substance observed in hood compartments above stove. |
| Food temperatures on steam table did not meet required safety standards; fried chicken and diced squash and turnip were below required temperatures. |
Report Facts
Deficiencies cited: 6
Observation time: 14.25
Observation time: 15.5
Observation time: 9.25
Observation time: 11.75
Food temperature: 120
Food temperature: 130
Food temperature: 110
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 22, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
Unannounced complaint/incident investigation survey; no deficiencies identified.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 6, 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 visit was complaint-related and no deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 4
Apr 7, 2021
Visit Reason
A biennial State licensure survey and a complaint/incident investigation survey were conducted at this assisted living residence to assess compliance with state licensure requirements.
Findings
Deficiencies were identified related to the facility's failure to retain residents according to the level of licensure, incomplete resident assessments and service plans, inadequate staff in-service training, and failure to establish proper infection control policies.
Complaint Details
The visit included a complaint/incident investigation survey (HFDK11) conducted on 04/07/2021. Deficiencies were substantiated related to licensure and care issues for residents.
Deficiencies (4)
| Description |
|---|
| Failure to retain residents according to the level of licensure for two of four sample residents. |
| Resident assessments and service plans did not reflect skilled nursing services or updated care needs for residents admitted to hospital and discharged back. |
| Personnel records failed to show evidence of required ongoing in-service training and initial training for staff. |
| Failure to establish proper infection control provisions including discharge planning and transfer protocols. |
Report Facts
Number of sample residents reviewed: 4
Number of residents needing to secure appropriate licensure: 2
Staff reviewed for training compliance: 6
Days for resident assessment update after hospital admission: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Technician (CMT) | Named in findings for lack of evidence of ongoing in-service training. |
| Staff B | Certified Nursing Assistant | Named in findings for lack of evidence of ongoing in-service training. |
| Staff C | Certified Medication Technician (CMT) | Named in findings for lack of evidence of initial training. |
| Regional Director of Wellness | Interviewed and acknowledged deficiencies and lack of evidence for required trainings and assessments. | |
| Executive Director | Responsible for auditing staff training and compliance as part of quality assurance. | |
| Wellness Director | Responsible for conducting audits, monitoring compliance, and reporting findings monthly. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 7, 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 investigation survey.
Complaint Details
Complaint investigation was unannounced and no deficiencies were found.
Inspection Report
Follow-Up
Deficiencies: 0
Feb 17, 2021
Visit Reason
A follow-up survey to a complaint investigation survey and a new complaint investigation survey were conducted at this residence on 02/17/2021.
Findings
No deficient practice was identified during the follow-up and complaint investigation surveys conducted on 02/17/2021.
Complaint Details
The visit was related to a complaint investigation and a follow-up to a COVID-19 infection control survey. No deficient practice was identified.
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