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Stillwater Assisted Living and Skilled Nursing Com

20 Austin Avenue, Greenville, RI 02828 · For profit - Limited Liability company · 80 certified beds · (401) 949-3880 Medicare & Medicaid certified

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1 immediate-jeopardy citation
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)
  • no federal fines or payment denials on record
Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
600 Putnam Pike · (401) 349-4303 · Call to confirm hours
Pharmacy
446 Putnam Pike · (401) 949-1848 · Call to confirm hours
Park
Lisa Ann Cir · Typically dawn to dusk
Place of worship
622 Putnam Pike · (401) 949-1500

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 1 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 improved from 3 to 4 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 rating4★
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 increased38.8%19.6%15.4%worse
Long-stay residents who lose too much weight7.3%5.1%5.4%worse
Long-stay residents with a catheter left in their bladder0.3%0.9%0.9%better
Long-stay residents with a urinary tract infection6.9%2.5%2.0%worse
Long-stay residents with depressive symptoms0.4%17.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.3%3.6%3.3%typical
Long-stay residents whose ability to walk worsened27.8%16.8%16.1%worse
Long-stay residents on antianxiety or hypnotic medication18.2%16.7%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%95.2%95.3%typical
Long-stay residents with pressure ulcers6.0%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control18.9%22.3%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table25.1%22.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.9%2.0%1.4%better
Short-stay residents given the seasonal flu vaccine92.4%78.2%79.4%better
Short-stay residents rehospitalized after admission29.5%24.3%22.6%worse
Short-stay residents with an outpatient ER visit11.4%14.6%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.621.591.67typical
Long-stay outpatient ER visits per 1,000 resident days1.581.681.80better

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.

64.8% 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 113 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

64.8%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
76.9%U.S. median 56.6%
Met the expected recovery
0.39U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.19hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 76.9% 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 39 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 0.39 therapist hours per resident per day in 2026Q1 — more than 67% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 40% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF64.8%CMS range 54.3–73.051.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 7.5–14.710.7%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 discharge76.9%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 discharge69.2%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 discharge74.4%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 discharge90.9%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 hospitalization6.3%CMS range 3.7–9.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.791.02Oct 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

0.72
RN hours/ resident / day
0.48
LPN hours/ resident / day
2.25
Aide hours/ resident / day
3.45
Total nurse hours/ resident / day
0.39
RN hoursweekends
36.9%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 74.6 residents a day — about 93% occupied, or roughly 5 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 3.45 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.25 is below 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 3.03 hrs/resident/day on weekends vs 3.63 on weekdays — 17% thinner on weekends. RN hours go from 0.86 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

5
deficiencies at the latest standard inspection (2025-03-19)
6
at the previous standard inspection (2024-04-11)

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.

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

  • Immediate jeopardy · K2023-02-20 · tag F0880 — failed to prevent and control infections — pattern
    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 a norovirus outbreak and COVID-19, Resident ID #'s 2, 4, 6, 11, 16, 21, 29, 33, 37, 43, 47, 51, 60, 65, 70, 132, 135, 136, 137,138, and 238. Findings are as follows: 1. Record review of a facility provided policy titled Isolation states in part, if equipment must be shared remove from the room it must be adequately disinfected before another use . According to the CDC document provided by the facility titled Key Infection Control Recommendations for the control of Norovirus Outbreak [Norovirus is a very contagious virus that causes vomiting and diarrhea] in Healthcare Settings states in part, .disinfection of patient care areas and frequently touched surfaces during outbreaks of norovirus gastroenteritis .disinfected .using EPA [Environmental Protection Agency]-approved products [products that are approved to kill specific bacteria,…

    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 · Ecited before2026-03-03 · 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 clinical record review and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 2 of 3 residents reviewed relative to physician's orders for laboratory testing, Resident ID #s 1 and 2.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 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 October of 2024 with a diagnosis including, but not limited to, a history of acute pulmonary edema (the buildup of fluid in the lungs).Record review of the Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15, indicating the resident has intact cognition.During a surveyor interview on 3/2/2026 at…

    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 · Fcited before2025-03-19 · 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 prepare, serve and distribute food in accordance with professional standards for food service safety relative to the main kitchen. Additionally, the facility failed to ensure a certified food protection manager was available during the preparation of all meals. Findings are as follows: 1. Review of the Rhode Island Food Code, 2018 Edition, section 3.501.16 states in part, .Time/Temperature Control for Safety Food, Hot and Cold Holding .shall be maintained at .5 degrees (°) C [Celsius] (41°Fahrenheit [F]) or less . During surveyor observations of the lunch meal tray service on 3/17/2025 at 11:49 AM in the presence of the Food Service Director (FSD) the following was revealed: - [NAME] bean salad on a tray set in ice, with a cold holding temperature of 53 °F. - Turkey salad sandwiches on a tray set in ice, with a cold holding temperature of 49.3 °F. Following the above observation, the surveyor asked the FSD if there were any other sandwiches. The following food items…

    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 · D2025-03-19 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 respect the residents' right to personal privacy for 1 of 1 resident observed relative to his/her weight, Resident ID #10, and for 1 of 1 resident observed during a wound dressing change, Resident ID #52. Findings are as follows: 1. Record review of a policy titled POLICY/PROCEDURE PRIVACY states in part, .The resident has a right to secure and confidential personal and medical records . Surveyor observations of Resident ID #10 revealed his/her name and weight was posted at the entrance of his/her room, which was visible from the hallway on the following dates and times: - 3/17/2025 at approximately 9:30 AM and 2:00 PM - 3/18/2025 at 9:15 AM During a surveyor interview on 3/18/2025 at 10:11 AM with the Assistant Director of Nursing Services, she acknowledged that Resident ID #10's weight was posted at his/her doorway and visible to anyone who walked by. 2. Additional record review of the policy titled POLICY/PROCEDURE PRIVACY states in part, .Personal privacy…

    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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-19 · 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 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 relative obtaining laboratory test panels for 1 of 3 residents receiving Atorvastatin (a medication prescribed to treat high cholesterol, without proper monitoring Atorvastatin can lead to liver and kidney damage), Resident ID #52. Findings are as follows: Record review revealed the MRR dated 12/18/2024 had recommendations made by the pharmacist to consider an annual lipid panel (a blood test that measures the levels of various fats in the bloodstream) and a hepatic function panel (a blood test that assess liver health and function) to monitor for therapeutic effects and side effects of Atorvastatin. Additional review of the report indicated the provider signed in agreement on 1/3/2025. Record review revealed a physician's order dated 1/13/2025, to obtain a laboratory test for the lipid panel and hepatic function panel. Record review failed 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-19 · 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 record review and staff interview, it has been determined that the facility failed to meet professional standards of practice in accordance with physician orders and the comprehensive person-centered care plan, for 1 of 1 resident reviewed receiving antibiotics via a peripherally inserted central catheter (PICC; a long flexible tube that is inserted into a vein in the arm and threaded through a larger vein leading to the heart, used to administer intravenous (IV) fluids and medications), Resident ID #125. Findings are as follows: Review of a facility pharmacy policy titled, IV Site Care and Maintenance Flush Chart, indicates that a 10 milliliter (ml) IV flush with a normal saline solution (a sterile fluid containing salt and water) is required before and after using the PICC line. Additionally, the policy indicates minimum intervals for flushing each lumen (an internal tube within the catheter that allows for the administration of fluids and medications) with 10 ml of saline, every 8 hours and as needed. Record review revealed the resident was admitted to the facility in…

    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 · D2025-03-19 · 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

    Based on record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety, relative to a peripherally inserted central catheter (PICC; a long flexible tube that is inserted into a vein in the arm and threaded through a larger vein leading to the heart, used to administer intravenous (IV) fluids and medications) for 1 of 1 resident reviewed with a PICC, Resident ID #125. Findings are as follows: According to the Lippincott Nursing Procedures Ninth Edition (2023), states in part, .Peripherally Inserted Central Catheter Use .Use a sterile measuring tape or the incremental markings on the catheter to measure the external length of the catheter from hub to skin entry to make sure that the catheter hasn't migrated .Troubleshooting a PICC .if external PICC migration [unintended movement from it's intended position] is greater than 3/4 inches (2 [centimeter] cm), notify the practitioner. Obtain an order for an X-ray or other…

    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 before2024-04-11 · 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 2 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 held 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 less 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 4/8/2024 at 8:15 AM, the following was observed in the main kitchen: - A 1.5-quart pan containing approximately 12 muffins, individually wrapped in plastic wrap, unlabeled and undated in 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-11 · 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 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, for 1 of 3 residents reviewed for the use of insulin, Resident ID #65. Findings are as follows: Record review revealed that Resident ID #65 was admitted to the facility in January of 2024 with diagnoses including, but not limited to, type 2 diabetes mellitus and urinary tract infection. Review of the care plan dated 2/5/2024 revealed that s/he is at increased risk for hypo/hyperglycemia (low or high blood sugar) with an intervention which includes, but is not limited to, administer medication as ordered. Record review revealed a physician's order dated 2/3/2024 for insulin glargine-yfgn (a long-acting type of insulin that works slowly), insulin pen to administer 5 units subcutaneously daily. Review of the Medication Administration Report from 3/20/2024 through 4/10/2024 revealed the follow days the insulin was not administered and was held: - 3/21/2024 - 4/6/2024 - 4/7/2024 - 4/8/2024…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 record review and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 2 residents observed for wound care, Resident ID #32. Findings are as follows: Record review revealed that the resident was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, pressure-induced deep tissue damage (pressure ulcer) and Methicillin Resistant Staphylococcus Aureus infection (multidrug resistant organism). Record review revealed a physician's order dated 3/26/2024 to cleanse the resident's left posterior calf unstageable (full thickness tissue loss in which actual depth of the ulcer is completely obscured by yellow, tan, gray, green, brown, or black tissue in the wound bed) pressure ulcer with Dakin's (wound cleanser) solution apply skin prep to the area surrounding the wound followed by medi-honey (wound treatment)…

    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 · D2024-04-11 · 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

    Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure a resident receives appropriate assistive devices to prevent accidents for 1 of 5 residents reviewed for falls, Resident ID #44. Findings are as follows: Record review revealed the resident was admitted to the facility in February of 2024 with diagnoses including, but not limited to, traumatic subdural hemorrhage (a type of bleeding near your brain that can happen after a head injury) with loss of consciousness and down syndrome. Record review of the progress notes revealed the following: - 2/4/2024: The resident was ambulating without assistance in hall outside of day room. S/he leaned over to give a staff member a hug, sustained a loss of balance, resulting in a fall. - 2/24/2024: While in the bathroom with a staff member the resident sustained a fall with a head strike and was sent to the emergency room for evaluation resulting in the resident being readmitted to the hospital. S/he returned to the facility on 2/26/2024. - 3/17/2024: The resident ambulated…

    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
Show the remaining 11 citations
  • Potential for harm · D2024-04-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 for 1 of 1 resident reviewed with a suprapubic catheter (a flexible rubber or plastic tube inserted into your bladder via a surgical opening in the abdomen), Resident ID #1. Findings are as follows: Review of a facility policy titled, Foley Catheters dated 1/16/2024 states in part, .Keep the bag below the resident's waist/bladder . Record review revealed that Resident ID #1 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, obstructive and reflux uropathy (a blockage of urinary flow), and chronic kidney disease stage 3 (mild to moderate damage to the kidneys which may lead to fluid build up). Further record review revealed that the resident has a suprapubic catheter (SP) tube in place. During multiple surveyor observations on 4/10/2024 the resident was observed with his/her drainage bag hung on the back of his/her wheelchair near his/her shoulders above the level of his/her bladder…

    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 · D2024-04-11 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    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 establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 2 of 3 residents reviewed for antibiotic use, Resident ID #s 124 and 129. Findings are as follows: Review of a facility provided policy titled Antibiotic Stewardship Program states in part, .The antibiotic stewardship program is directed toward the correct use of antibiotic- the five D's -right diagnosis, the right medication, the right dose, the right duration, and the right deceleration . 1. Record review revealed that Resident ID #124 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, urinary tract infection and vascular dementia. Record review revealed a physician's order for…

    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 before2023-09-01 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure 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 the resident was free from significant medication errors for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review for Resident ID #1 revealed that s/he was admitted to the facility in August of 2023 with diagnoses including, but not limited to, pain disorder with related psychological factors, vascular dementia with agitation, Hodgkin lymphoma (cancer of the immune system involving the lymphatic system), and congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). Record review of the physician's orders revealed the following: -Vimpat (a medication prescribed to treat seizures) 50 milligram (mg) twice per day daily (7:00 AM- 11:00 PM and from 7:00 PM- 11:00 PM) with a start date of 8/25/2023 and an end date of 8/31/2023. -Lasix (a medication prescribed to treat fluid retention and congestive heart failure) 40 mg daily (7:00 AM- 11:00 AM) with a start date of 8/25/2023 and an end date of 8/28/2023.…

    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 before2023-08-31 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such 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 residents who require dialysis receive such services, consistent with professional standards of practice relative to observation and assessment of an access site and comprehensive care plan for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities revised 2/3/2023 states in part, Nursing facilities .must develop dialysis specific policies/procedures, based upon current standards of practice. This includes the care of a resident receiving dialysis services whether in the facility or at an offsite location .The development and implementation of a coordinated comprehensive care plan(s) that identifies nursing home and dialysis responsibilities and provides direction for nursing home staff; and .The development and implementation of interventions, based upon current standards of practice including, but not limited to documentation and monitoring of complications,…

    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 · D2023-08-31 · 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 the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 out 3 residents reviewed, Resident ID #1. Findings are as follows: Record review revealed the resident was admitted to the facility in June of 2023 with a diagnosis of, but is not limited to, chronic kidney disease. Record review of a facility provided bowel protocol revealed that if the resident doesn't have a bowel movement (BM) in 48 hours to administer prune juice. It further revealed that if the resident doesn't have a bowel movement in 72 hours administer Miralax. Additionally, if there is no effect from the above interventions to administer Bisacodyl 10 milligrams by mouth or rectally. Lastly the document states If no BM after the above interventions-conduct a bowel assessment and notify MD [Medical Doctor] for new orders. Record review revealed a progress note dated 8/28/2023 at 9:00 PM authored by Registered Nurse (RN), Staff A, which states Resident has no documented BM since coming back from the hospital on…

    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 before2023-02-20 · 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

    Based on surveyor observation 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. Findings are as follows: During the initial tour of the main kitchen on 2/13/2023 at 8:10 AM revealed the following observations: - Server, Staff F's hairnet was not covering her bangs while she was serving breakfast. - A fan, with an accumulation of dust (on the blades and encasement), blowing in the direction of the food preparation area during breakfast. -9 stacked pans that were ready to be used had food matter and dried substance stuck to the inside of the pans. - An accumulation of dust and grease on the metal slats within the exhaust hood, located behind the stove. -The back of the oven blower had an accumulation of dust and grease. During a surveyor interview with the Food Service Director following the above observations, he acknowledged that Staff F not wearing her hair net appropriately, the dirty fan blowing in the direction of 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-02-20 · 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

    Based on record review and staff interview it has been determined that the facility failed to meet professional standards of quality for assessing and diagnosing a resident with a psychiatric disorder for use of an antipsychotic medication for 1 of 5 residents reviewed for psychotropic medication use, Resident ID #21 Findings are as follows: According to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, Revised 10/21/2022 states in part, .the regulations and guidance are intended to ensure psychotropic medications are used only when the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition . Record review revealed the resident was admitted to the facility in May of 2018 with diagnoses including, but not limited to, unspecified psychosis not due to a substance or known physiological condition and major depressive disorder. Review of the physician's orders revealed an order dated 2/12/2021, for Risperidone tablet 0.5 mg (milligram) oral, twice daily with diagnosis for use as schizoaffective…

    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 · Ecited before2023-02-20 · tag F0694 — pattern
    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, resident and staff interview it has been determined that the facility failed to meet professional standards of practice for care and delivery of parenteral hydration for 3 of 3 residents reviewed for intravenous (IV) use, Resident ID #'s 137, 235 and 236. Findings are as follows: 1. Record review revealed Resident ID #137 was admitted to the facility in January of 2023 with diagnoses including, but not limited to, urinary tract infection and Covid-19. Record review revealed a progress note dated 2/15/2023 that states in part, .STAT (immediately) D 5 ½ NS (dextrose mixed with normal saline) 60 ml/hr (milliliters per hour) . Review of the physician's orders revealed an order for, D 5 1/2 NS 60 ml/hr x 1 L Special Instructions: D/C (discontinue) order after .infusion . Surveyor observation on 2/16/2023 at 8:12 AM revealed the resident was receiving IV therapy. The IV bag was noted to be hung to gravity (when hanging an IV bag to gravity, the nurse must calculate the drops per minute to ensure the ordered infusion rate is being followed, by…

    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 · D2023-02-20 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, resident, and staff interview, it has been determined that the facility failed to provide reasonable accommodation of resident needs and preferences, relative to individualizing the physical environment relative to the resident's bed, for 1 of 1 residents reviewed, Resident ID # 37. Findings are as follows: Record review revealed the resident was admitted to the facility in November of 2018 with diagnoses including, but not limited to, Parkinson's disease and chronic heart failure. Review of a care plan revealed an approach dated 7/29/2020, that stated in part, [Resident] has chronic issues with bilateral lower edema . During a surveyor interview on 2/13/2023 at 9:50 AM, with the resident s/he revealed that his/her right foot was in pain. Additionally, the surveyor observed that the resident's right foot was resting on the wood foot board and his/her toes and heel were purple in color. During a surveyor interview with Registered Nurse (RN), Staff A, she revealed that pain and discoloration of toes and heel was not the resident's baseline. During a surveyor…

    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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-20 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such 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 residents who require dialysis receive such services, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 1 sample residents related to dialysis, Resident ID #2. Findings are as follows: Record review for Resident ID #2 revealed s/he was re-admitted to the facility in October of 2022, with diagnoses to include, but not limited to, end stage renal disease (ESRD) (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). This resident is currently receiving dialysis. Record review revealed a physician's order dated 1/27/2023 for a 960 ml (milliliters) fluid restriction over 24 hours. Record review of the resident's vitals for fluid documentation revealed the following dates where the resident exceeded the fluid restriction order: - 2/13/2023 - 1440 ml - 2/12/2023 - 1080 ml - 2/11/2023 - 1440…

    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 before2023-02-20 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure 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 a resident's drug regimen is free from significant medication errors for 1 of 1 residents reviewed for medication administration relative to Coumadin therapy, Resident ID #235. Findings are as follows: Record review revealed the resident was admitted to the facility in February of 2023 with diagnoses including, but not limited to, long term (current) use of anticoagulants (medicines that help prevent blood clots). Record review revealed the following physician's orders: - 2/7/2023 - resident is on coumadin therapy. Verify lab order is in place and coumadin order is followed. - 2/9/2023 - 2/13/2023 - warfarin (coumadin) tablet; 1 mg (milligrams); Amount to Administer: 1.5mg; Once A Day. - 2/13/2023 - 2/13/2023 - PT/INR (prothrombin time/international normalized ratio; test measures the time it takes for a clot to form in a blood sample) Record review of a progress note dated 2/13/2023 at 3:20 PM revealed, INR reported to (Name redacted) with new order to hold warfarin until…

    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

“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

No federal fines in the current CMS record.

Part of a chain

This home belongs to EDEN HEALTHCARE — 7 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 →

RatingThis homeChain avg
Overall 4 of 53.0+1.0 vs chain
Health inspection 4 of 52.9+1.1 vs chain
Staffing 3 of 53.4-0.4 vs chain
Quality measures 3 of 52.4+0.6 vs chain
The other 6 homes this chain runs (chain average 3.0★, 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 / managerTypeRoleShareSince
CORTLAND PLACE HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/04/2019
WF CORTLAND LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/18/2018
FOGEL, JOSHUAIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/18/2018
GELLIS, LOUISIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 10/18/2018
WEISS, MOSHEIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/18/2018
WEISS, NAFTALIIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/18/2018
MISTO, SUSANIndividualW-2 MANAGING EMPLOYEEsince 12/04/2019
EDEN HEALTHCARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/04/2019

CMS files one row per role, so the 9 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$12.4M
Net patient revenuemost recent cost report
-5.2%
Operating marginrevenue minus expenses
$1.9M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 53%Medicare 6%Other / private 40%

This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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. 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

$495per resident / day
operating cost
$15,042per month
≈ monthly operating cost
$471per 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 415123. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-19, 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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