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Cedar Crest Nursing Centre Inc

125 Scituate Avenue, Cranston, RI 02920 · For profit - Corporation · 156 certified beds · (401) 944-8500 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0610) — most recent Oct 20231 immediate-jeopardy citation$14,433 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (27% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, 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 (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,433 in federal fines (most recent 2024-03-01)

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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1681 Cranston St · (401) 946-8446 · Call to confirm hours
Pharmacy
205 Atwood Ave · (401) 942-4100 · Call to confirm hours
Grocery
200 Atwood Avenue
Park
Ricci Recreation Facility · Typically dawn to dusk
Place of worship
43 Scituate Ave · (401) 944-2771

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 4 of 5
Short-stay residentsrehab / post-hospital 2 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 improved from 3 to 5 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.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased21.1%19.6%15.4%worse
Long-stay residents who lose too much weight3.9%5.1%5.4%better
Long-stay residents with a catheter left in their bladder0.5%0.9%0.9%better
Long-stay residents with a urinary tract infection3.5%2.5%2.0%worse
Long-stay residents with depressive symptoms0.2%17.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained1.4%0.1%0.1%worse
Long-stay residents with falls causing major injury5.5%3.6%3.3%worse
Long-stay residents whose ability to walk worsened14.8%16.8%16.1%typical
Long-stay residents on antianxiety or hypnotic medication19.2%16.7%18.9%typical
Long-stay residents given the seasonal flu vaccine99.2%95.2%95.3%typical
Long-stay residents with pressure ulcers2.4%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control18.5%22.3%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table22.5%22.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.2%2.0%1.4%better
Short-stay residents given the seasonal flu vaccine93.2%78.2%79.4%better
Short-stay residents rehospitalized after admission25.3%24.3%22.6%worse
Short-stay residents with an outpatient ER visit15.9%14.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days0.951.591.67better
Long-stay outpatient ER visits per 1,000 resident days0.311.681.80better

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.

62.5% 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 233 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.5%U.S. median 51.5%
Got home and stayed home
11.1%U.S. median 10.7%
Went back to hospital
42.5%U.S. median 56.6%
Met the expected recovery
0.36U.S. median 0.31
Therapy hours / resident / day
0.19hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 42.5% 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 73 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 0.36 therapist hours per resident per day in 2026Q1 — more than 60% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 67% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF62.5%CMS range 56.3–69.051.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 8.5–14.410.7%Oct 2022–Sep 2024no 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 discharge42.5%56.6%Oct 2024–Sep 2025CMS 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 discharge41.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge48.0%50.0%Oct 2024–Sep 2025CMS 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 identified95.3%98.7%Oct 2024–Sep 2025CMS 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 settingnot 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.5%CMS range 2.7–10.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.701.02Oct 2022–Sep 2024CMS 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

0.75
RN hours/ resident / day
0.36
LPN hours/ resident / day
2.99
Aide hours/ resident / day
4.10
Total nurse hours/ resident / day
0.49
RN hoursweekends
27.0%
Total nursing turnover
13.0%
RN turnover

How full it usually is: this home is certified for 156 beds and averages 148.4 residents a day — about 95% occupied, or roughly 8 beds typically open. It runs essentially full — expect a waiting list. 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 4.10 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.99 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 3.71 hrs/resident/day on weekends vs 4.25 on weekdays — 13% thinner on weekends. RN hours go from 0.86 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 27% is below 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

2
deficiencies at the latest standard inspection (2025-09-25)
6
at the previous standard inspection (2024-09-20)

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.

ABCDEFGHIJKL

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.

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-03-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    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 observations, record review, and staff interview it has been determined that the facility failed to ensure that the residents' environment remains as free from accident hazards as possible, for 1 of 1 resident reviewed who sustained a burn from a radiator, Resident ID #1. Findings are as follows: Review of a facility reported complaint submitted to the Rhode Island Department of Health on [DATE] revealed Resident ID #1 was found with half of his/her body out of the bed with his/her legs against the radiator. Further review revealed the resident sustained burns on his/her knees and legs. Review of the Brava Stelpro Electric Baseboard heating system owner's manual revealed in part, Important Instructions .This heater is hot when in use. To avoid burns, do not let bare skin touch hot surfaces . Record review revealed the resident was admitted to the facility in July of 2021 with diagnoses including, but not limited to, dementia, vision loss of the left eye, anxiety, and a history of falling.…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-06-23 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure 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 residents received treatment and care in accordance with professional standards of practice, for 1 of 1 resident reviewed for a recommended neurosurgery (a doctor who specializes in diagnosing and treating conditions that affect the brain) follow-up following a hospitalization, Resident ID #1. Additionally, the facility failed to implement a physician's order for a foot cradle (a medical device designed to hold heavy sheets and blankets off legs and feet) for Resident ID #2.Findings are as follows:1. Record review of a facility reported incident dated 5/4/2026, states in part, Resident ID #1 was noted to have questionable seizure activity for approximately 7 minutes, became unresponsive and was sent to the hospital for evaluation. S/he returned to the facility with multiple rib fractures.Record review revealed Resident ID #1 was admitted to the facility in January of 2023, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-25 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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 residents receive treatment and care in accordance with professional standards of practice relative to 1 of 3 residents reviewed with a physician's order for lorazepam (a medication prescribed to treat anxiety), Resident ID #11, and for 1 of 1 wound dressings observed for a pressure ulcer, Resident ID #159. Findings are as follows: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. 1. Record review revealed Resident ID #11 was re-admitted to the facility in August of 2025 with a diagnosis including, but not limited to, anxiety disorder. Record review of a care plan dated 9/2/2025 revealed the resident is receiving hospice services with an approach to administer medications as ordered for comfort. Further review of the care plan with an approach start…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-25 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure 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 1 of 3 residents reviewed who were receiving an antihypertensive (a medication prescribed to lower blood pressure) medication with parameters, Resident ID #93. Findings are as follows:Record review revealed the resident was readmitted to the facility in July of 2024 with a diagnosis including, but not limited to, pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and the right side of the heart).Record review revealed a physician's order dated 4/30/2025 for Diltiazem HCL extended release (a medication prescribed to lower blood pressure) 180 milligram (mg) daily, hold the medication if the systolic blood pressure (SBP, refers to the top number of a blood pressure reading that indicates the pressure in the arteries when the heart contracts) is less than 110.Record review of the August and September 2025 Medication Administration Records (MARs) revealed the Diltiazem was administered…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-09-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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, distributed, and served in accordance with professional standards for food safety, relative to the main kitchen and 1 of 1 unit kitchenettes reviewed. Findings are as follows: 1. The Rhode Island Food Code 2018 Edition 2-402.11 states in part, .food employees shall wear hair restraints, beard restraints that are designed and worn to effectively keep their hair from contacting exposed food . During a surveyor observation on 9/16/2024 from 8:50 AM through 9:30 AM and at 11:20 AM of the main kitchen revealed the following: -Dietary Cook, Staff K and Dietary Aide, Staff L, with facial hair and not wearing a hair/beard restraint. -Dietary Cook, Staff K preparing a meat mixture for stuffed peppers not wearing a hair/beard restraint -Dietary Aide, Staff M with facial hair and not wearing a beard/hair restraint -Dietary Staff, Staff N with facial hair and not wearing 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-20 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure 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, 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's orders for 1 of 1 resident reviewed for edema, Resident ID #95 and 1 of 1 resident reviewed for aspiration precautions, Resident ID #242. Findings are as follows: 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. 1. Review of the facility policy titled Medication Administration General Guidelines which states in part, If a dose of a regularly scheduled medication is .refused .An explanatory note is entered .If two consecutive doses of a vital medication are withheld or refused, the physician is notified . Record review revealed Resident ID #95…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-20 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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 pharmaceutical services, including procedures that assure the administration of all drugs to meet the needs of each resident, relative to a diuretic (a medication used to treat fluid retention) medication for 1 of 1 resident reviewed, Resident ID #95. Findings are as follows: Record review revealed Resident ID #95 was re-admitted to the facility in March of 2024 with diagnoses including, but not limited to, acute on chronic congestive heart failure (a syndrome that results in fluid buildup in the lungs, abdomen, feet, and arms) and chronic kidney disease (mild to moderate damage to the kidneys with symptoms that may include fluid retention). Record review revealed a physician's order dated 6/20/2024 for furosemide (a diuretic medication) 40 milligram (mg) twice a day. Record review of the August 2024 Medication Administration Record revealed the above-mentioned medication was refused on the following dates and times: -8/1- PM dose -8/3- PM dose -8/4- PM dose -8/5- PM dose -8/6- PM…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-20 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and staff interview, it has been determined that the facility failed to store drugs and biologicals in accordance with currently accepted professional principles relative to 1 of 1 resident observed with medications at the bedside, Resident ID #57. Findings are as follows: Review of the facility's policy titled Medication Storage dated January 2024 which states in part, .Procedures 3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication .medication supplies should remain locked when not in use or attended by persons with authorized access . Record review revealed Resident ID #57 was admitted to the facility in March of 2023 with diagnoses including, but are not limited to, vascular dementia and recurrent depressive disorder. Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-20 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure 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

    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 provide and prepare food in a form designed to meet individual needs for 2 of 2 residents reviewed with a pureed diet, Resident ID #s 1 and 71. Findings are as follows: Record review revealed the facility is utilizing the Becky [NAME], Diet and Nutrition Care Manual, Simplified Edition. Additional record review of the Diet and Nutrition Care Manual revealed .IDDSI [International Dysphagia Diet Standardization Initiative, a national guideline for texture modified diets] Level 4: Pureed Diet .All foods are pureed .eliminating the chewing phase. Further review of the manual states in part, Protein Foods (i.e .eggs .) Pureed consistency foods only .Sample Daily Meal Plan .Level 4: Pureed Diet .Breakfast .1 serving Pureed Egg . 1. Record review revealed Resident ID #1 was admitted to the facility in March of 2021 with diagnoses including, but not limited to, severe vascular dementia and dysphagia,…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 observation, record review, and staff interview, it has been determined that the facility failed to maintain Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) for 1 of 2 residents reviewed with EBP related to Extended-Spectrum Beta-Lactamase (ESBL, an enzyme produced by some bacteria that can make them resistant to certain antibiotics) in the urine, Resident ID #19. Additionally, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to 1 of 1 resident reviewed for wound care, Resident ID #27. 1. Review of the Center for Disease Control and Prevention document titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) Last Reviewed: August 1, 2023, states in part, Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-05 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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 record review and staff interview, it has been determined that the facility failed to store drugs and biological's in accordance with currently accepted professional principles for 1 of 1 medication cart reviewed. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 7/19/2024 revealed that Resident ID #1 was unable to receive his/her 10:00 PM dose of Lyrica (a controlled medication used to treat pain) 25 milligrams (mg) on July 18, 2024, because the facility was unable to locate the 16 pills that were documented as available in the narcotic book. Record review of a facility policy titled, Controlled Medication storage revealed in part, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the nursing care center in accordance with federal, state, and other applicable laws and regulations .Only authorized licensed nursing and pharmacy personnel have access to controlled…

    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.

    Pharmacy Service Deficiencies · Past Non-Compliance
Show the remaining 12 citations
  • Potential for harm · D2024-03-01 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 licensed nurses have the specific skill sets necessary to care for residents' needs for 1 of 1 resident reviewed relative to the need for a non-rebreather oxygen mask, Resident ID #1. Findings are as follows: According to the ScienceDirect Journal article, titled Emergency Oxygen Administration, dated 2008, states in part, .Non-Rebreather Mask 1. The non-rebreather mask is the first choice when considering constant flow supplemental O2 [oxygen] in an acute medical emergency. It consists of a mask, reservoir bag, and two or three one-way valves, one separating the reservoir from the mask and the other one or two on the sides of the mask. Oxygen flows into the reservoir bag so that when the victim inhales, he or she inhales O2 from the reservoir. The one-way valves on the sides of the mask keep air from coming into the mask and diluting the O2. When the victim exhales, expired air goes out of the mask through…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-10-05 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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

    Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed in accordance with professional standards for food service safety, relative to the main kitchen and 1 of 2 kitchenettes observed. Findings are as follows: 1. Record review of Rhode Island Food Code, 2018 Edition, Section 3-501.17 states in part, .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and help in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees Celsius or 41 degrees Fahrenheit or bless for a maximum of 7 days. The day of preparation shall be counted as Day 1 . During the initial tour of the kitchen in the presence of the Food Service Director (FSD), on 10/2/2023 at 8:55 AM, the following was observed in the walk-in refrigerator: - A 1.5 quart pan of liquefied strawberries dated 9/1 - A half-size hotel pan covered in plastic wrap labeled Diet…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-05 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure 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 meet professional standards of quality relative to physician's orders for 1 of 1 resident reviewed for suctioning, Resident ID #31, 1 of 1 resident reviewed for wheelchair equipment, Resident ID #9, 1 of 6 residents reviewed for psychiatry recommendations, Resident ID #29, 1 of 2 residents reviewed for restraints, Resident ID #22 and 1 of 1 residents reviewed for the use of a Geri Chair, Resident ID #41. Findings are as follows: 1. Record review revealed Resident ID #31 was admitted to the facility in December of 2018 with diagnoses including, but not limited to, stroke, history of aspiration (ingesting food or liquid into an airway), and dysphagia (difficulty swallowing foods or liquids). Surveyor observations on the following dates and times, revealed a suctioning machine in the resident's room: - 10/2/2023 at 9:15 AM - 10/3/2023 at 11:45 AM - 10/4/2023 at 1:35 PM - 10/5/2023 at 10:30 AM Review of a physician order summary document failed to reveal evidence of an…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-05 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard 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 surveyor observations, record review, 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 1 of 2 residents reviewed for wounds, Resident ID #395; 1 of 1 resident reviewed for restraint/adaptive equipment assessments, Resident ID #22 and 1 of 5 residents reviewed for adaptive wheelchair equipment, Resident ID #9. Findings are as follows: 1. Record review of a facility policy titled, Skin Care Protocol states in part, POLICY: [facility] will follow appropriate standards of care as they relate to residents' skin care; identification of those at risk, weekly skin checks, and appropriate interventions and documentation. Record review revealed Resident ID #395 was admitted to the facility in September of 2023 with a diagnosis including, but not limited to, pneumonia. Record review revealed a progress note dated, 9/20/2023 at 10:45 PM that states in part, .Pt [patient] has no…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-05 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 residents have the right to be free from any physical restraint not required to treat the resident's medical symptoms for 1 of 2 residents reviewed, Resident ID #41. Findings are as follows: According to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities last revised on 2/03/2023 revealed in part, As described under Definitions, a physical restraint is any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed by the resident in the same manner as it was applied by staff. The resident's physical condition and his/her cognitive status may be contributing factors in determining whether the resident has the ability to remove it. Examples of facility practices that meet the definition of a physical restraint include, but are not limited to: .Placing a resident in a chair,…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-05 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 the comprehensive care plan was revised and updated after a hospital stay for 1 of 1 resident reviewed, Resident ID #45. Findings are as follows: Record review revealed the resident was readmitted to the facility in September 2023. S/he has diagnoses to include, but are not limited to, chronic obstructive pulmonary disease, acute kidney failure, and congestive heart failure. Review of the resident's medical record revealed that s/he was sent to the hospital following a fall on 9/18/2023 and returned to the facility on 9/26/2023. Review of a physician's order dated 9/27/2023 revealed a Hoyer lift (a mechanical lift used for lifting patients from the floor, bed or chair. The lift also can assist in other surface-to-surface patient transfers, such as moving from a bed to a bath or chair) was to be used for transfers three times a day. Review of a progress note dated 10/2/2023 revealed .On exam today [the resident] is physically weak d/t [due to] time spent in hospital bed. Hoyer…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-05 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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 provide an ongoing program to support a resident in their choice of activities designed to meet the interests of and support the well-being of each resident, based on the comprehensive assessment, care plan and preferences for 1 of 1 resident reviewed for activities, Resident ID #31. Findings are as follows: Record review of a document titled, Generations' Special Care Program, states in part, Generations, the Special Care Neighborhood offered by Cedar Crest Nursing Centre, exists to provide optimal care and services to individuals and their families confronting Alzheimer's disease and other dementia .the mission is to provide person-centered care and specializing programming for each resident within a safe, structured environment thereby enhancing quality of life .Activity Program: activity programming is designed to maximize independence while focusing on resident strengths and abilities…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-05 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    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 observations, record review, resident and staff interview, it has been determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice for 1 of 2 residents observed for assessments and documentation relative to wound care, Resident ID #395, and 1 of 1 resident reviewed for free floating of heels, Resident ID #45. Findings are as follows: 1. According to Wound Care Education Institute, 2020, Wound care documentation should be carried out weekly including type of wound, measurements, type of tissue, symptoms of infection, presence of drainage, wound edges, pain, and current treatment. According to the National Pressure Ulcer Advisory Panel, February 2007, a pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or in combination with shear and/or friction. Record review of a facility policy titled, Skin Care Protocol states in part, POLICY:…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    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 the resident environment remains as free of accident hazards as is possible related to falls for 1 of 4 residents reviewed that sustained a fall from a reclined Geri Chair, Resident ID #41. Findings are as follows: Record review revealed the resident was admitted to the facility in May of 2023 with diagnoses that include, but are not limited to, dementia and anxiety disorder. Review of a quarterly Minimum Data Set assessment dated [DATE] revealed the resident is ambulatory and utilizes a walker. The assessment further revealed that the resident is able to stabilize him/herself without staff assistance when walking. Record review of a Resident Incident Report dated 7/16/2023 revealed the resident had a fall in the supervised television area. The resident was in the Geri Chair (recliner chair) with the footrest elevated and s/he scooted to the end of the footrest and fell to the floor.…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-05 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    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 meet professional standards of practice for care related to a peripherally inserted central catheter (PICC) for 2 of 2 residents reviewed for PICCs, Resident ID #s 345 and 349. Findings are as follows: a. Review of a facility provided document titled, Administration of IV Fluids and Medications states in part, .to correctly and aseptically set up the primary IV [intravenous] bag and tubing .perform hand hygiene .attach primed IV tubing to the needleless connector . Record review revealed Resident ID #349 was admitted to the facility in September of 2023 with diagnoses including, but not limited to, osteoporosis with current pathological fracture and infection of intervertebral disc. Review of a physician's order dated 9/29/2023 revealed Cefepime (medication to treat infection) in sodium chloride 0.9% piggyback 2 gram/50 ml (milliliter); amount 2 grams for 14 days for bone and joint infection every 8 hours. During a surveyor observation on 10/5/2023 at approximately…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-05 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to staff wearing appropriate personal protective equipment (PPE) for 2 of 2 residents in isolation for COVID-19 (SARS-CoV-2), Resident ID #'s 41 and 125, and 1 of 1 resident reviewed for Peripherally Inserted Central Catheter (PICC) line medication administration, Resident ID #349. Findings are as follows: 1. According to the Centers for Disease Control and Prevention guidance updated on May 8, 2023, the recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection include the following: .Personal Protective Equipment Health Care Personnel who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-06 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond 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 record review and staff interview it has been determined that the facility failed to provide evidence that all alleged violations were thoroughly investigated for 1 of 2 residents reviewed for an allegation of abuse, Resident ID #2. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 8/3/2023 alleges the resident stated that a Nursing Assistant (Staff A) was rough and threw him/her in bed. The report also alleges that the resident stated the incident was witnessed by a Licensed Practical Nurse (Staff B). Record review of the facility policy titled, Abuse Prohibition, indicates that it is the Director of Nursing Services (DNS) or designee's responsibility to act immediately to begin the initial investigation. The policy further indicates that it is the DNS's responsibility to ensure that the investigation is comprehensive, timely, and documented appropriately. Furthermore, the policy indicates that immediate response to allegations…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$14,433 in federal fines across 1 penalty.

  • $14,433 — penalty dated 2024-03-01

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.

Who owns this facility

Owner / managerTypeRoleShareSince
WHIPPLE, THOMASIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNF32%since 03/29/1991
PEZZELLI WHIPPLE, SUSANIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/29/1991
MARANDOLA, SUSANIndividualCORPORATE OFFICER; ADP OF THE SNFsince 01/01/2000
FONTAINE, LYNNEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 02/01/2003
KRUSZ, STEPHANIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/02/2025
PEZZELLI, LISAIndividualADP OF THE SNFsince 03/29/1991
UNDEN, JESSICAIndividualADP OF THE SNFsince 01/01/2010

CMS files one row per role, so the 15 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$17.3M
Net patient revenuemost recent cost report
-5.8%
Operating marginrevenue minus expenses
$245K
Related-party expense1% of expenses
Who pays — share of resident-days
Medicaid 61%Medicare 6%Other / private 33%

This home reported $245K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$345per resident / day
operating cost
$10,476per month
≈ monthly operating cost
$326per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Rhode Island
$12,106/mo
Nursing home (semi-private)
$13,383/mo
Nursing home (private)
$7,781/mo
Assisted living

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 415032. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-25, 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.

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