The Dawn Hill Home for Rehab and Healthcare
One Dawn Hill Road, Bristol, RI 02809 · For profit - Corporation · 133 certified beds · (401) 253-2300 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $33,765 in federal fines (most recent 2024-10-15)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 22.5% | 19.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.6% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.4% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.7% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 19.8% | 17.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 7.1% | 3.6% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 16.4% | 16.8% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 14.0% | 16.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.8% | 95.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.0% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 32.0% | 22.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.7% | 22.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 2.0% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 79.7% | 78.2% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 24.7% | 24.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 11.1% | 14.6% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.40 | 1.59 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.52 | 1.68 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
58.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 110 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 56.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 37 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 55% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 30% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 58.5%CMS range 51.4–67.8 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.8%CMS range 6.3–13.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 56.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 54.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 64.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.7%CMS range 5.2–14.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.87 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 133 beds and averages 120.1 residents a day — about 90% occupied, or roughly 13 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.70 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.65 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.52 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.07 hrs/resident/day on weekends vs 3.96 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.73 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.
- Immediate jeopardy · J2024-01-22 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to provide a safe and sanitary environment to help prevent the transmission of infections relative to disinfecting glucometers (a device used to monitor blood glucose) for 3 of 4 residents observed who require blood glucose monitoring, Resident ID #s 43, 317 and 108. Findings are as follows: 1. According to the facility's policy last revised in March of 2015 titled, diabetes-care of equipment states in part, .5. If a glucometer is to be used for one resident and then reused for another, the device must be cleaned and disinfected between uses. Directions vary between manufacturers and even between models within brands. Follow the glucometer manufacturer's recommendations for cleaning . Review of the glucometer manufacturer's User Instruction Manual Reference titled, Assure Prism Multi Blood Glucose Monitoring System, states in part, .Cleaning and Disinfecting: The disinfection procedure is needed to prevent transmission of blood-borne pathogens. The meter should be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2024-10-31 · tag F0635 — isolatedProvide doctor's orders for the resident's immediate care at the time the resident was admitted.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it has been determined that the facility failed to obtain complete admission orders for the resident's immediate care for 1 of 1 resident reviewed who was not administered the prescribed medications after being readmitted to the nursing facility from the hospital, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 10/29/2024 alleges that the resident was not administered the prescribed amiodarone (a medication that treats a fast or irregular heart rhythm by reducing symptoms and helps avoid life-threatening complications) on his/her readmission to the facility from the hospital on [DATE]. Additionally, the allegation indicates that the failure resulted in his/her return to the hospital. Record review revealed that Resident ID #1 was initially admitted to the facility on [DATE] with diagnoses including, but not limited to, congestive heart failure (CHF, a condition that happens…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-06-04 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed with an indwelling foley catheter (a flexible tube that collects urine from the bladder and empties the urine into a drainage bag), Resident ID #14.Findings are as follows:Record review revealed the resident was admitted to the facility in January of 2026 with diagnoses including, but not limited to, obstructive uropathy (a structural or functional hindrance of normal urine flow) and urinary retention.Record review of a hospital discharge document titled, Discharge summary dated [DATE] revealed the resident was treated for a catheter associated urinary tract infection with an order for a urology follow-up and consideration of a Transurethral Resection of the Prostate (TURP, a surgical procedure to remove excess prostate tissue through the urethra to relieve urinary problems).Record review revealed that the resident's hospital Discharge summary, dated [DATE] revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-04 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that services were provided in accordance with professional standards of quality by failing to implement and follow physician orders. Specifically, the facility failed to follow a physician's order for a cancer center referral for 1 of 1 resident reviewed, Resident ID #102, and failed to appropriately manage and follow physician orders related to a peripherally inserted central catheter (PICC) line-a thin, flexible tube inserted into a peripheral vein in the upper arm and advanced to a large central vein near the heart-for 1 of 1 resident reviewed with a PICC line, Resident ID #138. Findings are as follows:1. According to Mosby's 4th Edition, Fundamentals of Nursing page 314, which states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.Record review revealed Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-04 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 26 opportunities for error observed during the medication administration task, there were 2 errors resulting in an error rate of 7.69% affecting Resident ID #s 51 and 75.Findings are as follows:Review of a facility policy titled, Medication Administration General Guidelines dated February 2026, states in part, .Medication Preparation: Prior to administration, review and confirm medication orders for each individual client on the Medication Administration Record (MAR). Compare the medication and dosage schedule on the client's MAR with the medication label.Medications are administered in accordance with written orders of the prescriber.1. Record review revealed Resident ID #75 has a physician's order for Miralax (a medication prescribed to treat constipation) oral powder 17 Gram two times a day, dilute with at least 4 ounces (oz) of fluid.During a surveyor observation during the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-24 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, staff, and resident representative interview, the facility failed to immediately inform the resident's representative of a significant change in condition, which included an injury of unknown origin as the resident was found to have sustained fractures of his/her right ankle for 1 of 2 residents reviewed, Resident ID #1.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health, on 3/19/2026 alleged that the resident's representative was not informed of an injury the resident sustained and the possible cause.Review of the facility's policy dated 10/19/2023 and titled Notification of Change in Resident's Condition states in part, .responsible family members or legal representatives shall be notified as soon as possible, or within 24 hours, of any changes in the resident's condition. The nurse on duty shall be responsible for notifying the resident's responsible family members when a change occurs.these changes shall include significant changes in physical.as well as any accidents that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-24 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, the facility failed to ensure that all alleged violations including injuries of unknown origin, were reported to the Rhode Island Department of Health (RIDOH) immediately, but not later than 2 hours after the injuries were identified, for 1 of 1 resident reviewed who sustained an injury of unknown origin, Resident ID #1. Findings are as follows:Record review of a community reported complaint submitted to RIDOH on 3/19/2026 alleged that Resident ID #1 sustained an injury of unknown origin and that the resident's family was not notified by the facility at the time of the discovery. The complainant reported that notification was received from the hospice agency.Record review revealed that the resident was admitted to the facility in October of 2025 with a diagnosis including, but not limited to, Alzheimer's disease. The resident was admitted on and continues to receive hospice services (a specialized care for individuals with a terminal illness and are…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-24 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to ensure that an injury of unknown origin was thoroughly investigated for 1 of 1 resident reviewed who sustained fractures to his/her right ankle, Resident ID #1. Findings are as follows:Record review of a community-reported complaint submitted to the Rhode Island Department of Health on 3/19/2026 alleged that the resident sustained an injury of unknown origin and that the resident's representative was not informed of the injury or the possible cause.Record review revealed the resident was admitted to the facility in October of 2025 with a diagnosis including, but not limited to, Alzheimer's disease. The resident was admitted to the facility while receiving and continues to receive hospice services (a specialized care for individuals with a terminal illness who are approaching the end of life). Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident is non-ambulatory (a person who is unable to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-05 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of the clinical record and staff interviews, the facility failed to ensure that services were provided in accordance with professional standards of quality by not following the physician's orders. This failure involved 1 of 1 resident reviewed who was prescribed a medication to prevent an adverse reaction after being served food to which the resident had a known allergy, Resident ID #2.According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.Review of a community reported complaint submitted to the Rhode Island Department of Health on 1/27/2026 alleges that Resident ID #2 experienced an acute medical episode as a result of an allergic reaction.Record review revealed the resident was admitted to the facility in July of 2024 with a diagnosis including, but not limited to, dementia.Review of the resident's listed allergies revealed s/he has an allergy to tomatoes.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-05 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record and staff interview, the facility served food to a resident that s/he had a known allergy to, Resident ID #2. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 1/27/2026 alleges that Resident ID #2 experienced an acute medical episode as a result of an allergic reaction.Record review revealed the resident was admitted to the facility in July of 2024 with a diagnosis including, but not limited to, dementia.Review of the resident's listed allergies revealed s/he has an allergy to tomatoes. Further review revealed the tomato sauce allergy was entered into his/her electronic health record on 6/24/2025. Additionally, it revealed the severity of the tomato allergy was unknown.Review of a progress note authored by the Nurse Practitioner dated 10/9/2025 at 10:30 AM states in part, .Patient [Resident ID #2] was also noted to have eaten red tomato sauce in [his/her] food this afternoon which [s/he] has an allergy to.continued close monitoring for any signs and symptoms of allergic reaction.During a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-05 · tag F0757 — failed to avoid unnecessary drugs — patternEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 2 of 3 residents reviewed receiving an antihypertensive (a medication prescribed to lower blood pressure) medication, Resident ID #s 1 and 2. Findings are as follows: 1. Record review revealed Resident ID #1 was admitted to the facility with a diagnosis including, but not limited to, essential hypertension (high blood pressure). Record review revealed a physician's order dated 5/27/2025 for Hydralazine 50 milligrams (mg) three times a day, give if the systolic blood pressure (SBP; refers to the top number of a blood pressure reading and indicates the pressure in your arteries when your heart contracts) is greater than 160. Record review of the May and June 2025 Medication Administration Records (MARs) revealed on the following dates and times the Hydralazine was administered when the SBP was less than 160: -5/27 at 2:00 PM, SBP of 118 -5/27 at 8:00 PM, SBP of 117 -5/28 at 9:00 AM, SBP of 132 -5/28 at 2:00 PM, SBP of 132…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-13 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it has been determined that the facility failed to ensure that adequate pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 residents reviewed for pain, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 3/12/2025 alleged in part that Resident ID #1 was discharged from a hospital at 11:00 AM and admitted to the facility on [DATE] after undergoing extensive back surgery. Additionally, the facility did not have any of his/her medications available, and s/he was subsequently transferred back to the hospital for pain management later that same day. Further, his/her neurosurgeon had ordered Decadron (a steroid medication prescribed to treat inflammation), however the nursing facility was unaware s/he was prescribed it. 1.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 21 citations
- Potential for harm · Dcited before2025-03-13 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 3 residents reviewed for medication administration, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 3/12/2025 alleged in part that Resident ID #1 was discharged from a hospital at 11:00 AM and admitted to the facility on [DATE] after undergoing extensive back surgery. Additionally, the facility did not have any of his/her medications available, and s/he was subsequently transferred back to the hospital for pain management later that same day. Review of an undated facility provided document titled, Medication Administration/Ordering Education states in part, .To avoid medications being unavailable it is important for nursing staff to order medications in a timely manner and/or utilize all other avenues of obtaining medication such as the Ekit [Emergency…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-13 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it has been determined that the facility failed to accurately maintain the resident's medical record in accordance with accepted professional standards and practices for 1 of 1 newly admitted resident reviewed, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 3/12/2025 alleged in part that Resident ID #1 was discharged from a hospital at 11:00 AM and admitted to the facility on [DATE] after undergoing extensive back surgery. Additionally, the facility did not have any of his/her medications available, and s/he was subsequently transferred back to the hospital for pain management later that same day. Further, the resident's neurosurgeon had ordered Decadron (a steroid medication prescribed to treat inflammation), however the nursing facility was unaware s/he was prescribed it. Record review revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-28 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, it has been determined that the facility failed to provide care consistent with professional standards of practice for 1 of 2 residents reviewed with an ostomy (colostomy/ileostomy; a surgical procedure that creates an opening (stoma) in the abdomen to divert waste products from the body to an external pouch), Resident ID #1. Findings are as follows: Record review of a community reported complaint allegation submitted to the Rhode Island Department of Health on 1/26/2025 alleges that the facility did not have appropriate ostomy bag or staff trained to care for a resident in need of ostomy care. Review of a facility policy titled, Colostomy and Ileostomy Care last revised on 11/13/2024, states in part, .Applying or changing the pouch .Inspect the color and skin integrity of the stoma and peristomal skin .If applying a two-piece appliance with a separate skin barrier, peel off the paper backing of the prepared skin barrier, center the barrier over the stoma, and press gently to ensure adhesion .Document .type and size of appliance used…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-12-19 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional standards for 2 of 3 medication storage rooms observed. Findings are as follows: Record review of a facility policy titled Medication Storage, last revised on 2/4/2022 states in part, .Medications and biologicals labeled in accordance with currently accepted professional principles, and include: -Appropriate accessory and cautionary instructions . -Expiration date, when applicable . Multi-dose vials which have been opened or accessed (e.g. needle punctured) should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. During a surveyor observation of the North Medication Storage Room on 12/18/2024 at 10:30 AM, in the presence of Licensed Practical Nurse (LPN), Staff E, 1 vial of Tuberculin Purified Protein Derivative (tuberculin skin test solution) opened and not dated. Staff E acknowledged that the vial should have been…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-19 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain professional standards of practice relative to a peripherally inserted central catheter (PICC - a type of vascular access device [VAD] used to deliver medications directly to the large central veins near the heart) to 1 of 1 resident observed for intravenous (IV) antibiotic administration via a PICC line, Resident ID #321, and 1 of 3 residents reviewed who receive medication in crushed form, Resident ID #77. Findings are as follows: 1) Review of a facility policy titled, SETTING UP A PRIMARY INFUSION (HYDRATION or MEDICATION) dated 8/2021 states in part, .Attach flush syringe, aspirate for a blood return to determine patency and then flush resident's IV catheter with appropriate flush solution as ordered .Scrub needleless connector on resident's catheter with antiseptic wipe .Attach primed IV tubing to the needleless connector . Record review revealed Resident ID #321 was admitted to the facility in December of 2024 with a diagnosis including, but not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide appropriate treatment and services to 1 of 2 residents reviewed with a Suprapubic Catheter (SPC) (a flexible plastic tube inserted into your bladder via a surgical opening in the abdomen), Resident ID #67. Findings are as follows: Record review revealed that the resident was admitted to the facility with a diagnosis including, but not limited to, obstructive and reflux uropathy (condition in which urine flows backward from the bladder to one or both kidneys). Record review of the textbook, Lippincott Nursing Procedures, 9th Edition, pages 432-33 states in part, Catheter care .Keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder, which increases the risk of CAUTI [A catheter-associated urinary tract infection caused by germs entering the urinary tract through a catheter]. Record review revealed a physician's order dated 7/27/2024 for catheter care to be provided every shift and as needed relative to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-19 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it has been determined that the facility failed to maintain medical records that are complete and accurately documented on each resident, in accordance with accepted professional standards and practices, for 1 of 4 residents reviewed related to urinary catheter (a flexible tube inserted into the bladder to drain urine), and for 1 of 3 residents reviewed related to advance directives, Resident ID #105. Findings are as follows: Record review revealed the resident was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, urinary retention. 1. Record review of the resident's physician order list revealed the following conflicting orders related to the size of catheter being utilized for the resident: - Change the resident's foley catheter monthly and as needed with 16 Fr (French sizing system - measurement of the urinary catheter based on its outer diameter) with 10 mL (milliliter) balloon as needed with a start date of [DATE]. -…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-19 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 3 residents reviewed related to calling for assistance for pain, Resident ID #75. Findings are as follows: Record review of the policy titled Call Bell Policy revealed that the staff should ensure the resident is safe and the call bell is within reach. Record review of the Minimum Data Set assessment dated [DATE] revealed a Brief interview for Mental Status score of 15 of 15, indicating intact cognition. During a surveyor observation on 12/17/2024 from 12:28 PM through 12:50 PM, the resident was noted to be yelling out for help asking for assistance related to his/her pain for the past half hour. During a surveyor interview on 12/17/2024 at 12:55 PM with Nursing Assistant, Staff C, she acknowledged that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-10 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following physician orders for obtaining weights for 2 of 3 residents reviewed, Resident ID #s 1 and 2. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing page 314, states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients. 1. Record review revealed Resident ID #1 was admitted to the facility in December of 2024 with diagnoses including, but not limited to, atherosclerotic heart disease (artery is narrowed or clogged and it is unable to bring enough blood to organs and tissues) with unstable angina pectoris (chest pain), and congestive heart failure. Record review of a care plan dated 12/4/2024 revealed the resident is at risk for complications related to congestive heart failure with interventions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-15 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, it has been determined that the facility failed to treat each resident with respect and dignity in an environment that promotes maintenance of his or her quality of life for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 10/10/2024 alleged that Resident ID #1 was found by his/her family on 10/6/2024, in bed, covered in large amount of dried blood and feces. Additional review of the complaint revealed a photograph of Resident ID#1 lying in bed with dark brown matter, which appeared to be dry and cracking on both of his/her legs, on the bed sheet and on his/her shirt. During a surveyor interview on 10/11/2024 at 11:42 AM with the complainant, s/he stated that when a family member arrived on 10/6/2024 the resident was found in bed with his/her legs covered in stool. The complainant stated the stool was so dry it was cracking on his/her skin. Record review revealed the resident was readmitted to the facility in September of 2024…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-15 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed for insulin use, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 10/10/2024 alleged that the failed to manage the resident's insulin. Record review revealed the resident was readmitted to the facility in September of 2024 with diagnoses including, but not limited to, presence of joint implant (hip replacement), type 2 diabetes mellitus, and congestive heart failure. The resident was receiving hospice care. Record review of a physician's order dated 9/27/2024 for Humalog (insulin) 50/50 kwikpen 100 units/milliliter, inject 6 units at bedtime for diabetes mellitus. Record review of the Medication Administration Record failed to reveal evidence that the resident received his/her Humalog on 9/27, 9/28, 9/29, and 9/30/2024. It was documented that the insulin was unavailable. Further record review failed to reveal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-15 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, it has been determined that the facility failed to maintain medical records on each resident that are complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review revealed the resident was readmitted to the facility in September of 2024 with diagnoses including, but not limited to, presence of joint implant (hip replacement), diabetes mellitus, and congestive heart failure. The resident was receiving hospice care. Record review of a Health Status Note dated 9/30/2024 written by the Nurse Practitioner reveals in part, .Hospice level of care- Focus on comfort .use Ativan for anxiety. The note indicated that the resident continued to have an order for Ativan. Record review of the Health Status Note dated 10/4/2024 written by the Nurse Practitioner reveals in part, .Hospice level of care- Focus on comfort .use Ativan for anxiety. The note indicated that the resident continued to have an order for Ativan. Record review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-15 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, it has been determined that the facility failed to ensure that hospice services meet professional standards of principles that apply to individuals providing services in the facility for 1 of 2 residents reviewed who are receiving hospice services, Resident ID #1. Findings are as follows: Record review revealed a physician's order dated 9/27/2024 for Hospice Evaluation and admit as indicated. Further record review of the Hospice Certification and Plan of Care revealed the resident had a start of care date of 9/28/2024. It reveals that the resident will be seen by the Nurse 3 times a week for the first week, then 1 time a week for the next 10 weeks. It further reveals the Hospice nurse will observe and assess signs and symptoms of declining status and imminent death and coordinate plan of care with facility staff. Review of the Hospice paperwork provided by the facility failed to reveal evidence of the Hospice Recommendation forms for all hospice nursing visits. These forms are used by hospice to communicate recommendations and resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-19 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it has been determined that the facility failed to ensure residents are free from abuse for 1 of 3 residents reviewed, Resident ID # 1. Findings are as follows: According to State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last revised 2/2023, .Abuse is the willful infliction of injury .with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Resident to Resident Abuse of Any Type A resident to resident altercation should be reviewed as a potential situation of abuse .Also, when investigating an allegation of abuse between residents, the surveyor should not automatically assume that abuse did not occur, especially in cases where either or both residents…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-01-22 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored, served and distributed in accordance with professional standards for food service safety, relative to the main kitchen. Findings are as follows: 1) The Rhode Island Food Code 2018 Edition 4-601.11 states in part, .nonfood contact surfaces of equipment shall be kept free of an accumulation of dirt .and other debris . During a surveyor observation, in the presence of the Food Service Director (FSD) on 1/16/2024 during the initial walk through of the main kitchen at approximately 10:15 AM the following was observed: - a build up of a crusted black substance along the inner rim of the stove hood - liquid spills along the back side of the stove hood - food accumulation in the drain spout of the steamer - dust accumulation in the side vents of the steamer - the convection oven had a build up of grease and grime in the corners of the unit - the reach in refrigerator unit had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-22 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality for 1 of 1 resident reviewed relative to the use of an upper extremity splint and for 1 of 5 residents reviewed for offloading heels while in bed, Residents ID #s 13 and 24. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. 1. Record review of Resident ID #13 revealed s/he was admitted to the facility in May of 2023 with diagnoses including, but not limited to, cerebrovascular disease affecting left non-dominant side (stroke) and contractures of muscle of left upper arm. Further record review revealed a physician's order dated 5/19/2023 for a blue splint to the left hand during the day then remove at night before applying the white splint. Additionally, review of a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-22 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide food prepared in a form designed to meet individual needs for 1 of 2 residents reviewed for foods being served in a form to meet their individual nutritional needs. Resident ID #62. Findings are as follows: Record review of The International Dysphagia Diet Standardization Initiative(IDDSI), reads in part, ice cream is only allowed if the person can tolerate thin liquids . Record review revealed that the resident was admitted to the facility in March of 2021 with a diagnosis that included but not limited to dysphagia (difficulty swallowing). Further record review revealed a current physician's order that reads in part .Regular diet, Pureed texture, Honey/Moderately Thick consistency . During a surveyor observation on 1/17/2024 at approximately 12:15 PM, the resident received ice cream for dessert. Additionally, the soup on her/his lunch tray was thickened with a packet that reads in part, .Hormel Thick & Easy Instant Food & Beverage Thickener, Nectar…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-22 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide special adaptive eating equipment and utensils for 2 of 5 residents reviewed who require special eating equipment, Resident ID #s 60 and 11. Findings are as follows: 1. Record review revealed that Resident ID #60 was admitted to the facility in October of 2022 with diagnoses including, but not limited to, unspecified macular degeneration (a disease that affects a person's central vision), legal blindness, and dysphagia (difficulty swallowing). Record review revealed a physician order dated 11/10/2022, which states Divided lip plate with all meals as needed. Surveyor observations during the lunch meal on 1/17/2024, 1/18/2024, and 1/19/2024 revealed the resident did not receive the divided lip plate as ordered. During a surveyor interview on 1/19/2024 at approximately 12:45 PM, with Resident ID #60, s/he acknowledged that s/he needs the divided plate due to his/her visual impairment. During a surveyor interview on 1/19/2024 during the lunch meal service with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-22 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 2 of 6 residents reviewed for inaccurate documentation, relative to the usage of an upper extremity splint and offloading heels while in bed, Residents ID #s 13 and 24. Findings are as follows: 1. Record review for Resident ID #13 revealed s/he was admitted to the facility in May of 2023 with diagnoses including, but not limited to, cerebrovascular disease affecting left non-dominant side (stroke) and contractures of muscle of left upper arm. Further record review revealed a physician's order dated 5/19/2023 for a blue splint to the left hand during the day then remove at night before applying the white splint. Additionally, review of the physician's order dated 9/23/2023 revealed a left upper extremity elbow splint daily for 4 hours as tolerated. During a surveyor observation and interview on 1/16/2024 at 10:13 AM with the resident, s/he…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-27 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview it has been determined that the facility failed to protect the resident's right to be free from physical abuse for 1 of 4 resident's reviewed, Resident ID #2. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 12/26/2023 indicated that on 12/22/2023, Resident ID #2 (victim) revealed to a staff member that s/he was choked by their roommate, Resident ID #1 (perpetrator). Review of the facility policy titled, Abuse Prohibition states in part, It is the policy of this facility to ensure that all residents are treated with respect and dignity and that all residents are free from abuse .Definitions: Abuse = [equals] willful infliction of injury . 1) Record review revealed Resident ID #1 was admitted to the facility in May of 2021 with a diagnosis including, but not limited to, unspecified dementia without behavioral disturbance. Record review of his/her quarterly Minimum Data Set (MDS) assessment dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-08 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 1 resident reviewed for pressure ulcers, Resident ID #1. Findings are as follows: According to the 1/30/2020 Center for Disease Control (CDC) document titled, Hand Hygiene Guidance, it states in part, .Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications .Before moving from work on a soiled body site to a clean body site on the same patient .after contact with blood, body fluids, or contaminated surfaces .immediately after glove removal . Review of the facility policy titled, Clean Dressing Technique, revealed in part, .PROCEDURE .1. Check the physician order for current, correct treatment . Review of the resident's record revealed s/he was admitted to the facility in July of 2023 with diagnoses including, but not limited to,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$33,765 in federal fines across 2 penalties. 1 Medicare payment denial on record.
- $12,387 — penalty dated 2024-10-15
- $21,378 — penalty dated 2023-12-27
- Medicare payment denial — starting 2024-02-10 for 3 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to GREEN TREE HEALTHCARE MANAGEMENT — 4 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.3 | +1.7 vs chain |
| Health inspection | 4 of 5 | 2.3 | +1.7 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 3 of 5 | 2.8 | +0.2 vs chain |
The other 3 homes this chain runs (chain average 2.3★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| RHODE ISLAND HEALTHCARE HOLDCO 2 LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 11/09/2020 |
| DASAY 2019 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/14/2020 |
| GAMTA 2020 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/21/2020 |
| GRI SNF INVESTORS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/04/2020 |
| MRI SNF INVESTORS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/04/2020 |
| STERN, AHARON | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 04/01/2021 |
| STERN, SIMON | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2021 |
| DASARI, NARESH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2021 |
| KLEIN, DOUGLAS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/09/2025 |
CMS files one row per role, so the 15 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in RI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Rhode Island Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 415050. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-04, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.