Morgan Health Center
80 Morgan Avenue, Johnston, RI 02919 · For profit - Corporation · 120 certified beds · (401) 944-7800 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $61,780 in federal fines (most recent 2026-04-30)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 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 fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 18.4% | 19.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.3% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 55.8% | 17.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.9% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 2.6% | 3.6% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 15.8% | 16.8% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 15.6% | 16.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.0% | 95.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.6% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 15.1% | 22.3% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.9% | 22.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 2.0% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 67.7% | 78.2% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 21.6% | 24.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 10.2% | 14.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.31 | 1.59 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.84 | 1.68 | 1.80 | better |
‡ 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.
54.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
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 65 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 0.29 therapist hours per resident per day in 2026Q1 — more than 46% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 21% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 54.1%CMS range 41.6–69.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.6%CMS range 6.6–14.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 76.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 70.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 72.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.9%CMS range 3.2–12.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 112.0 residents a day — about 93% occupied, or roughly 8 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 3.75 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.60 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 3.12 hrs/resident/day on weekends vs 4.00 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.79 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Immediate jeopardy · Kcited before2026-04-30 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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
Based on clinical record review and staff interview, the facility failed to ensure that residents received care and services in accordance with professional standards of practice, resulting in Immediate Jeopardy. Specifically, for 3 of 3 residents reviewed who were prescribed anticoagulant (blood-thinning) medications and experienced falls, the facility failed to implement physician orders for post-fall care. This included failure to conduct timely and frequent neurological monitoring (e.g., every 15 minutes for the first hour) and/or the failure to transfer residents to the hospital as ordered. This deficient practice placed Resident IDs #1, #2, and #3 at risk for serious harm, serious impairment, serious injury or death. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 4/27/2026 alleged that Resident ID #1 was transferred to the hospital on 4/24/2026 following a fall at the facility on 4/20/2026 with noted head bruising and a last known well date of 4/21/2026. The complaint further alleged that a family member…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
Based on clinical record review and staff interview, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed, who had nausea and vomiting for approximately 21 days and was later transferred and admitted to the hospital with renal failure (a condition in which the kidneys lose their ability to effectively filter waste products, excess fluids, and toxins from the blood. Common signs and symptoms of renal failure may include nausea, vomiting, abdominal pain and weight loss), Resident ID #1. Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 5/5/2026 alleged that the resident experienced nausea and vomiting for weeks prior to hospitalization. The complaint further, alleged the family requested a hospital transfer, but the facility staff stated the hospital would send [him/her] back without doing anything. The complaint indicated that the resident continued to suffer nausea, vomiting and mouth sores 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.
- Potential for harm · D2025-12-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 2 residents reviewed with a pressure ulcer (a localized injury to the skin and/or underlying skin usually over a boney prominence), Resident ID #1. Findings are as follows:The Rhode Island Department of Health received a community reported complaint on 12/11/2025 alleging that the facility did not have any hygiene supplies for patients and that Resident ID #1 developed bed sores and s/he was re-admitted to the hospital on [DATE] with a pressure ulcer that was not present when s/he was initially discharged from the hospital 11/25/2025. Record review revealed the resident was admitted to the facility in November of 2025 with diagnoses including, but not limited to, laminectomy (back surgery), diabetes mellitus (a chronic condition where the body is unable to regulate blood sugar)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-07-23 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following physician's orders for 1 of 3 residents reviewed, Resident ID #3. Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/16/2025, alleged in part that Resident ID #3's medications were not administered according to the physician's orders.According to Mosby's 4th Edition, Fundamentals of Nursing page 314, states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.Record review revealed that Resident ID #3 was admitted to the facility in April of 2025 with a diagnosis including, but not limited to, hypertension. Record review revealed the following physician's orders:-Metoprolol Succinate (a medication prescribed to treat hypertension) ER 50 milligram (mg) one…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-07-23 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 pharmacist failed to report irregularities to the attending physician, the facility's Medical Director, and the Director of Nursing Services (DNS) for 1 of 3 residents reviewed, Resident ID #3. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/16/2025, alleged in part that Resident ID #3's medications were not administered according to the physician's orders.Record review of a facility policy titled, Medication Regimen Reviews [MRR] states in part, .A licensed pharmacist reviews the medication regimen of each resident at least monthly.The MRR includes a review of the medical record to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities, for example, the use of medication.administered without adequate monitoring or in the presence of adverse consequences. 'Irregularities' may also include.other medication errors, including those related to documentation.Record review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-05-22 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 2 of 3 units observed and for 1 of 1 resident observed with medications stored in their room, Resident ID #309. Findings are as follows: Review of a facility policy titled Medication Labeling and Storage dated 2021 states in part, .Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received .Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents . 1a. During the medication storage and labeling task on 5/20/2025 at 5:12 PM, in the presence of Certified Medication Technician (CMT), Staff F, observations of the 3rd Floor CMT medication cart revealed 17 medication cups labeled with residents' last names. Further observation revealed the medication cups containing multiple medications in each, were stacked on top…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-22 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 are prescribed psychotropic medications (medications prescribed to affect behavior, mood, thoughts, or perception) receive gradual dose reductions (GDR), unless clinically contraindicated, in an effort to discontinue these medications, for 1 of 2 residents reviewed with a recommendation for a GDR, Resident ID #84. Findings are as follows: Record review of the policy titled Psychotropic Medication Use dated 2/2025 states in part, Gradual Dose Reduction .Residents on psychotropic medication receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, to determine whether the continued use of the medication is benefitting the resident, to find an optimal dose, or in an effort to discontinue the medication . Record review revealed the resident has a physician's order for quetiapine (a psychotropic medication) 25 milligrams (mg) two times a day. Record review of the document titled Psychiatric Evaluation &…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-22 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident related to antibiotic administration for 1 of 2 residents reviewed, Resident ID #49. Findings are as follows: Record review revealed the resident was admitted to the facility in May of 2025 with a diagnosis including, but not limited to, pneumonia. Record review revealed the following physician's orders: -Amoxicillin-Potassium Clavulanate (Augmentin-an antibiotic) 875-125 milligrams (mg) give one tablet every twelve hours for ten days. This order had a start date of 5/1/2025 and it was discontinued on 5/1/2025. -Amoxicillin-Potassium Clavulanate (Augmentin) 875-125 mg give one tablet every twelve hours for seven days. This order had a start date of 5/1/2025. Record review of the May 2025 Medication Administration Record revealed the Augmentin was not administered per the order, because it was not available, on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-22 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 27 opportunities for errors observed during the medication administration task, there were 2 errors resulting in an error rate of 7.41%, involving Resident ID #359. Findings are as follows: Review of the facility policy titled, Administering Oral Medications last revised October 2010, states in part, .Prepare the correct dose of medication .For liquid medication .Place cup on a level surface and read the poured amount at eye level to check accuracy . Record review revealed the following physician's orders: - Amantadine (a medication prescribed to treat stiffness or tremors) oral solution 50 milligrams (mg) per 5 milliliters (mL), administer 10 mL via G-tube (gastrostomy tube - a medical device inserted through the abdomen into the stomach to provide nutrition, fluids, and nutrients to residents) two times a day. - Cholecalciferol (Vitamin D3) 1000 units,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-08 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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
Based on record review, staff and resident interview, it has been determined that the facility failed to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical well-being for 2 of 3 residents reviewed relative to follow up appointments, Resident ID #s 1 and 2. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 4/7/2025 alleges that Resident ID #s 1 and 2 have been trying to get to appointments for his/her hernia (an abnormal exit of tissue or an organ, such as the bowel, through the wall of the cavity in which it normally resides) and a neurologist. Additionally, the report alleges that the facility did not get these appointments and that the residents had to schedule the appointments themselves after waiting almost a year. 1. Record review revealed that Resident ID #1 was admitted to the facility in April of 2023 with diagnoses including, but not limited to, spinal stenosis and diabetes. Review of the progress notes revealed the following: -…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-09 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident interview, it has been determined that the facility failed to protect a resident's right to be free from abuse for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of facility reported incident submitted to the Rhode Island Department of Health on 8/28/2024 indicates that Resident ID #2 was witnessed by staff with his/her hand under the blanket of Resident ID #1 rubbing between his/her legs asking him/her do you like that? When staff approached to separate the residents, Resident ID #2 moved his/her hand away quickly. Record review revealed that Resident ID #1, the victim, was admitted to the facility in August of 2024 with diagnoses including but not limited to dementia, difficulty in walking, weakness, and lack of coordination. Further review revealed a Minimum Data Set (MDS) Assessment for Resident ID #1 dated 8/28/2024 revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition. 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.
Show the remaining 14 citations
- Potential for harm · D2024-07-10 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
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 promptly notify the ordering physician or a provider of laboratory results that fall outside of clinical reference ranges for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on [DATE] alleges in part, .I was called by the nurse at [facility] .told that [resident] was having a hard time breathing and there was some blood in [his/her] stool so they were going to call an ambulance and have [him/her] transported to the hospital .the attending and a surgeon informed us that [resident] had a ruptured intestine and had sepsis [a life threatening complication of an infection] .[s/he] died shortly after . Record review revealed the resident was admitted to the facility in January of 2022 with a diagnosis including, but not limited to, alcoholic cirrhosis of liver without ascites (abnormal build up of fluid 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.
- Potential for harm · Fcited before2024-06-05 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 provide a safe and sanitary environment to help prevent the transmission of infections related to implementing a water management program based upon industry standards and/or the Centers for Disease Control and Prevention (CDC) toolkit. Findings are as follows: Record review of the CDC document titled, Developing a Water Management Program to Reduce Legionella [a bacteria that may cause a very serious type of lung infection] Growth & Spread in Buildings, dated June 2021, version 1.1 states in part, .The key to preventing Legionnaires' disease is maintenance of the water systems in which Legionella may grow .Water stagnation: Encourages biofilm growth and reduces temperature and levels of disinfectant. Common issues that contribute to water stagnation include .reduced building occupancy .Stagnation can also occur when fixtures go unused, like a rarely used shower . A. Record review of the facility's water management binder failed to reveal evidence that the water flow…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-29 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observations, record review, staff, resident and resident representative interviews, it has been determined that the facility failed to treat each resident with respect and dignity, and is cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life relative to assistance with toileting and communication with a resident whose primary language is not the dominant language of the facility, Resident ID #2. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 3/25/2024 alleges that a Nursing Assistant (NA) punched the resident in his/her leg. Review of an undated facility policy titled, Translation and/or Interpretation Services states in part, .This facility will ensure that individuals who are non-English speaking or have a communication disability will have access to translation and/or interpretation methods . 1. The facility will determine a means to communicate with any…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-29 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made. If the events that cause the allegation involve abuse or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to other officials (Rhode Island Department of Health;RIDOH), in accordance with State law, for 1 of 1 resident reviewed for an allegation of abuse, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the RIDOH on 3/21/2024, alleges that the facility failed to follow up on an allegation of staff to resident sexual abuse. Record review of a facility policy last revised in September of 2022 titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, states in part, .All reports of resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-29 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it has been determined that the facility failed to provide evidence that all alleged violations are thoroughly investigated for 1 of 1 resident reviewed for allegations of abuse, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health (RIDOH) on 3/21/2024, alleges that the facility failed to follow up on an allegation of staff to resident sexual abuse. Record review of a facility policy last revised in September of 2022 titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, states in part, .All reports of resident abuse .are .thoroughly investigated by facility management .Within five (5) business days of the incident, the administrator will provide a follow-up investigation report . During a surveyor interview with the complainant on 3/22/2024 at 11:36 AM, s/he revealed that the resident reported an allegation that a male staff member inserted their…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-20 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure 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 that a resident's drug regimen is free from unnecessary drugs for 2 of 3 residents reviewed, Resident ID #s 1 and 2. Findings are as follows: 1. Record review revealed Resident ID #1 was admitted to the facility in May of 2023 with diagnoses including, but not limited to chronic diastolic heart failure and atherosclerotic heart disease (thickening or hardening of the arteries). Record review of the order summary revealed the following physician orders: - Hydralazine HCL 25 milligrams (mg) give two times daily for hypertension. Hold if Systolic Blood Pressure (SBP) is less than 110 or - Heart rate (HR) is less than 60. The order start date was 1/31/2024 and the discontinue date was 2/18/2024. Record review of the February 2024 Medication Administration Record (MAR) revealed the Hydralazine was given outside of parameters on the following dates and times: 2/1/2024 at 9:00 AM with a documented HR of 59 2/9/2024 at 9:00 AM with a documented HR of 57 2/12/2024 at 9:00 AM with a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-08 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
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 a resident received incontinence care as per the resident's plan of care for 1 of 1 resident observed, Resident ID #1. Findings are as follows: Record review of the community reported complaint sent to the Department of Health (DOH) on 2/5/2024 alleged that .someone from DOH needs to pay attention to these poor, vulnerable residents, They sit all day in 1 position at table . Record review revealed the resident was admitted to the facility in November of 2022 with diagnoses including but not limited to; Alzheimer's disease, impaired visual function and lack of coordination. A review of an Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 6 out of 15, indicating severe cognitive loss. Additionally, the MDS indicates the resident required extensive assistance from staff for transfers, hygiene and toileting.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases for 1 of 3 residents reviewed who tested positive for Influenza A, Resident ID #1. Findings are as follows: Record review of an undated facility's policy and procedure for Influenza Outbreak, states in part .2. Contact and droplet precautions are implemented during care of a resident with suspected or confirmed influenza, in addition to standard precautions used with all residents regardless of symptoms. 3. Contact and droplet precautions are continued for seven (7) days after illness onset or until after 24 hours the resolution of fever and respiratory symptoms, whichever is longer. Precaution may continue for longer periods based on clinical judgement . During a surveyor interview with the Infection Control Nurse on 2/7/2024 at 11:20 AM, she revealed they have 40 residents on the third floor unit and 16 residents had tested positive for Influenza A since…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-17 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observation, record review, staff and resident 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 entering a COVID-19 (SARS-CoV-2) positive room without wearing personal protective equipment (PPE) for 1 of 3 residents reviewed for COVID-19, Resident ID #4. Findings are as follows: According to the Centers for Disease Control and Prevention guidance, last 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 (i.e., goggles or a face shield that covers the front and sides of the face) . Review of a facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
Based on surveyor observation, record review, resident, 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 1 resident reviewed for a non-pressure related skin conditions, Resident ID #1. Findings are as follows: Record review of a facility policy titled, Skin tears - abrasions and minor breaks, care of, states in part, .The purpose of this procedure is to guide the prevention and treatment of abrasions, skin tears, and minor breaks in the skin .1. Obtain a physician's order as needed. Document physician notification in medical record . Record review revealed the resident was admitted to the facility in April of 2022 with diagnoses including, but not limited to, non-infective disorder of the lymphatic vessels (small tubes that carry fluid) and lymph nodes (small bean shaped organs that fight infection) and seborrheic dermatitis (skin condition). Record review revealed a physician order dated 6/9/2023 to conduct weekly skin checks on Thursday's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-04-19 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety relative to the main kitchen and one of three nursing unit kitchenettes on the second floor. Findings are as follows: Record review of the facility policy titled, Food Receiving and Storage,states in part, .All foods stored in the refrigerator .are .labeled and dated .Foods and Snacks Kept on Nursing units .All foods belonging to residents are labeled with the resident's name .and the 'use by' date . Record review of the facility policy titled Use and Storage of Food Brought in by Visitors, indicates that all food items brought to residents from outside sources are to be stored appropriately and labeled with the resident's name and the date. 1. During a surveyor observation of the main kitchen on 4/17/2023 at 8:01 AM, the walk-in refrigerator unit revealed the following: - five, approximately 10-pound, packages of pork loin thawing, not labeled with a date.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-04-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a resident who requires catheterization receives appropriate treatment and services for 1 of 1 residents reviewed relative to an indwelling catheter, Resident ID #47. Findings are as follows: Review of the facility policy titled, Catheter Care, Urinary revealed General Guidelines .Ensure that the catheter remains secured with a securement device to reduce friction and movement at the insertion site . Record review revealed the resident was initially admitted to the facility in March of 2020 with diagnoses including, but not limited to, neuromuscular dysfunction of the bladder (when either the nerves or the brain cannot communicate effectively with the muscles in the bladder), presence of urogenital implants (artificial material in your urinary organs or genitals), and dementia. Record review of the resident's care plan last revised on 3/25/2023 revealed the resident required an indwelling catheter related to a neurogenic bladder (when the relationship…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-04-19 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 1 of 2 medication storage rooms and 2 of 5 medication carts observed. Findings are as follows: 1. Surveyor observation on 4/18/2023 at 8:10 AM of a second floor medication cart, in the presence of Certified Medication Technician (CMT), Staff D, revealed one Arnuity Ellipta 200 mcg (microgram)/actuation Inhaler in use, open and not dated. Manufacturer's instructions read to discard the inhaler 6 weeks after opening. During a surveyor interview immediately following the observation with Staff D, she acknowledged the medication should have been dated when opened. 2. During a surveyor observation on 4/18/2023 at 8:58 AM of a third floor medication cart, in the presence of CMT, Staff E, revealed one Spiriva Respimat 1.25 mcg/actuation inhaler in use, open and not dated. Manufacturer's instructions read to discard 3 months after insertion of the cartridge. During a surveyor interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-04-19 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records in accordance with professional standards and practices for 2 of 6 residents reviewed for nutritional intake, Resident ID #'s 30 and 357 and for 1 of 1 resident reviewed relative to indwelling catheters, Resident ID #47. Findings are as follows: 1. Review of the facility policy titled, Food and Nutrition Services, states in part, .Nursing personnel, with the assistance of the food and nutrition services staff, will evaluate and document intake . a. Review of the record for Resident ID #30 revealed that s/he was admitted to the facility in April of 2015 with diagnoses including, but not limited to, gastritis (when the stomach lining gets red and swollen), encephalopathy (a disease in which the functioning of the brain is affected). During a surveyor observation of the breakfast meal pass on 4/18/2023, it was revealed that the resident failed to receive his/her breakfast meal. Further surveyor observation on 4/18/2023 at 12:02 PM and 12:21 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$61,780 in federal fines across 2 penalties.
- $17,060 — penalty dated 2026-04-30
- $44,720 — penalty dated 2024-07-10
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to MARQUIS HEALTH SERVICES — 87 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.0 | ≈ chain avg |
| Health inspection | 2 of 5 | 2.6 | -0.6 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 86 homes this chain runs (chain average 3.0★, per CMS)
Showing 40 of 86; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| CIBC BANK USA | Organization | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST | since 11/01/2022 |
| HARMAN, DINA | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 11/01/2022 |
| SECHIO, ROBERT | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2022 |
| STEVENS, JOEL | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 08/26/2024 |
| VIROJA, YOGESH | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 11/01/2022 |
| POSEN, MINDEE | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 11/01/2022 |
| MARQUIS LIMITED LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/17/2025 |
| RELIANT PRO REHAB LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/17/2025 |
| SUHAIL, FAIZUL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2022 |
| MORGAN PROPERTY LLC | Organization | ADP OF THE SNF | since 11/01/2022 |
| NFR 2020 IRRV TR | Organization | ADP OF THE SNF | since 11/01/2022 |
| QUINTO NEXGEN LLC | Organization | ADP OF THE SNF | since 11/01/2022 |
| RSBRMK HOLDINGS LLC | Organization | ADP OF THE SNF | since 11/01/2022 |
| SK NEXGEN TR | Organization | ADP OF THE SNF | since 11/01/2022 |
| TRYKO NEXGEN HOLDINGS LLC | Organization | ADP OF THE SNF | since 11/01/2022 |
| UAK 2020 IRRV TR | Organization | ADP OF THE SNF | since 11/01/2022 |
| UKR NEXGEN LLC | Organization | ADP OF THE SNF | since 11/01/2022 |
| YK NEXGEN TR | Organization | ADP OF THE SNF | since 11/01/2022 |
| YR NEXGEN TR | Organization | ADP OF THE SNF | since 11/01/2022 |
CMS files one row per role, so the 30 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
13 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in RI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Rhode Island Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 415062. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-22, 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 →
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