Holiday Operator, LLC DBA Holiday Rehabilitation a
30 Sayles Hill Road, Manville, RI 02838 · For profit - Individual · 170 certified beds · (401) 765-1440 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 Dec 2023
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 4 actual-harm citations
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $46,118 in federal fines (most recent 2024-08-22)
- its independent health-inspection 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) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
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 | 3 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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.
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 | 24.2% | 19.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.4% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.5% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.7% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 17.2% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.3% | 3.6% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 21.1% | 16.8% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 14.1% | 16.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.6% | 95.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.9% | 4.2% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 34.9% | 22.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.1% | 22.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.6% | 2.0% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 73.0% | 78.2% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 20.3% | 24.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 0.0% | 14.6% | 12.0% | check this* — see note marked star below the table |
| Long-stay hospitalizations per 1,000 resident days | 2.18 | 1.59 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.36 | 1.68 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ 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.
51.2% 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 75 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 50.0% 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 26 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 0.21 therapist hours per resident per day in 2026Q1 — more than 25% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% 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 | 51.2%CMS range 41.2–60.8 | 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 | 10.1%CMS range 7.2–14.4 | 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 | 50.0% | 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 | 57.7% | 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 | 38.5% | 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 | 90.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.3% | 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 | 7.0%CMS range 3.6–11.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.78 | 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 170 beds and averages 136.2 residents a day — about 80% occupied, or roughly 34 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.26 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.27 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.28 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 4.08 hrs/resident/day on weekends vs 4.34 on weekdays — 6% thinner on weekends. RN hours go from 0.27 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% 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.
29 citations, most serious first. The 14 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · Gcited before2026-06-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and staff and resident interview, the facility failed ensure that Resident ID #2's environment remained free of accident hazards, as possible, relative to the resident's assessed transfer needs and facility policy. Specifically, the facility failed to implement the Physical Therapist's recommendation for the use of a mechanical lift following the resident's identified decline in strength and mobility on 5/11/2026 and failed to ensure staff utilized a gait belt during manual transfers. As a result, Resident ID #2 was subjected to unsafe transfer practices including, being lifted under the arm and elbow area, which resulted in swelling, extensive bruising, and increased pain to the resident's left upper extremity. Requiring medical evaluation, diagnostic testing, pain medication, and ongoing monitoring. These failures resulted in actual harm for 1 of 1 resident reviewed with an injury of unknown origin, Resident ID #2.Based on clinical record review and staff and resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2026-05-08 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff interview, the facility failed to ensure that a resident receives timely and appropriate pain and symptom management consistent with professional standards of practice, for end-of life-care including the prompt administration of physician-ordered medications for pain and anxiety, for 1 of 2 residents reviewed who were receiving hospice services, Resident ID #1. This failure resulted in the resident experiencing unmanaged pain, terminal agitation, and psychosocial distress during his/her final hours of life.Findings are as follows:According to the American Nurses Association (2018) Position Statement titled, The Ethical Responsibility to Manage Pain and the Suffering It Causes, nurses have an ethical responsibility to relieve pain and suffering through individualized interventions, ongoing assessment, and coordinated approaches to pain management.Record review of a community-reported complaint submitted to the Rhode Island Department of Health on [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.
- Actual harm · G2024-08-22 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview it has been determined that the facility failed to ensure that residents receive foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) relative to peripheral vascular disease for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review revealed that the resident was readmitted to the facility in August of 2024 with diagnoses including, but not limited to, cellulitis (a bacterial infection of the skin and the soft tissues underneath) and peripheral vascular disease (a condition where narrowed arteries reduce blood flow to the arms or legs). Review of a Minimum Data Set assessment dated [DATE] revealed the resident is dependent for lower body dressing and putting on/taking his/her shoes. Review of a community reported complaint received by the Rhode Island Department of Health on 8/14/2024 alleged that the resident was treated at 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.
- Actual harm · G2024-08-22 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure 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 have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well being of each resident relative to skin assessments for 6 of 6 licensed nursing staff reviewed, Staff IDs A, C, D, E, F and G. Findings are as follows: Review of a facility policy titled, Skin Care Program states in part, .The weekly skin assessments (documented under assessments) will be done for every resident . Review of the 2024 Facility Assessment revealed competencies to be provided to staff including, Resident assessment and examinations .skin assessment . Review of a community reported complaint received by the Rhode Island Department of Health on 8/14/2024 alleged that the resident was treated at the hospital on 8/4/2024 for multiple wounds to his/her feet. Additionally, maggots were present in the wounds. Review of photographs taken at the hospital dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-10 · 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
Based on clinical record review and staff interview, the facility failed to ensure that a resident with an injury of unknown origin was thoroughly investigated for 1 of 1 resident reviewed for bruising, Resident ID #2.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 5/29/2026 alleged that Resident ID #2 was identified with new significant bruising. The resident's spouse had visited the resident the night prior and there was no bruising. The report further alleged that when the complainant asked about the incident s/he was told two Nursing Assistants (NA) used the wrong equipment to transfer the resident.Review of a facility policy titled, Abuse prohibition states in part, .Injuries of unknown origin .the source of the injury was not observed, or the source cannot be explained by the resident .Investigation .begin the initial investigation .obtain statements from witnesses, notify the appropriate administrative personnel so that a comprehensive internal facility investigation can be carried out .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 · D2026-06-10 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each resident.
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 resident and staff interviews, the facility failed to provide dental services for 1 of 2 residents reviewed with dentures, Resident ID #1. Additionally, the facility failed to have a policy that addressed instances when a resident's dentures are lost or damaged.Findings are as follows:Record review of a community reported complaint submitted to Rhode Island Department of Health on 5/29/2026, alleged the resident's family has been required to purchase several sets of dentures lost by the facility.Record review revealed the resident was originally admitted to the facility in September of 2022 with diagnoses including, but not limited to, stroke and dysphagia (difficulty swallowing).Record review of a Significant Change Minimum Data Set assessment dated [DATE] revealed, the resident is edentulous (having no natural teeth).Record review revealed a Brief Interview for Mental Status dated 6/4/2026 with a score of 12 out of 15, indicating moderately impaired cognition.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 · D2026-05-08 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to ensure that an allegation involving an accident resulting in serious injury, which occurred prior to a resident's death, was reported to the appropriate authorities, including the State Survey Agency, as required by State law, for 1 of 1 resident reviewed Resident ID #1.Findings are as follows:Record review of a community-reported complaint submitted to the Rhode Island Department of Health on [DATE] alleged that Resident ID #1 sustained a fall with a head injury. The complaint further alleged that the resident expired approximately six hours after his/her fall.Record review revealed that Resident ID #1 was readmitted to the facility in October of 2025 with diagnoses including, but not limited to, acute respiratory failure with hypoxia (a condition where the tissues and cells of the body do not receive enough oxygen to function properly) and heart failure.Record review of a progress note dated, [DATE] at 7:02 PM, authored by Licensed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-08 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and staff interview, the facility failed to ensure each resident's care plan is revised by the interdisciplinary team, for 1 of 2 residents reviewed relative to falls, Resident ID #2.Findings are as follows:Record review of a facility reported incident submitted to the Rhode Island Department of Health on 4/3/2026 revealed Resident ID #2 had a fall on 3/30/2026 and was subsequently diagnosed with a left wrist fracture.Record review revealed Resident ID #2 was admitted to the facility in July of 2025 with diagnoses including, but not limited to, Alzheimer's disease and a history of falls. Record review revealed Resident ID #2 sustained falls on 3/29/2026 and 3/30/2026.Further record review revealed the resident was transferred to the hospital following the 3/30/2026 fall and was subsequently diagnosed with a left wrist fracture. Additional record review revealed that on 4/4/2026, the resident was diagnosed with a left hip fracture.Record review of the resident's care plan revealed a problem area initiated on 3/25/2026 addressing the resident'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 · Dcited before2026-05-08 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and staff interview, the facility failed to ensure that residents receive treatment and services in accordance with professional standards of practice and physician orders, relative to the transcription and implementation of physician-approved hospice medication orders, for 1 of 2 residents reviewed, Resident ID #1.Findings are as follows:Record review of a community-reported complaint submitted to the Rhode Island Department of Health on 5/5/2026 alleged that Resident ID #1 was experiencing terminal agitation and was not provided prescribed medications promptly to provide comfort, relief, and dignity at the end of his/her life.According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.Record review revealed Resident ID #1 was readmitted to the facility in October of 2025 with diagnoses, including, but not limited to, acute respiratory failure with hypoxia…
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 before2026-05-08 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to ensure residents receive care and services in accordance with professional standards of practice related to post-fall assessments, neurological monitoring, care plan revision, and adherence to advance directives, for 1 of 1 resident who sustained a fall with head injury, Resident ID #1.Findings are as follows:Review of a community reported complaint received by the Rhode Island Department of Health on [DATE], alleged that Resident ID #1 experienced a fall with a head injury and passed away in the facility within 6 hours. The complaint further alleged that the facility failed to implement new or enhanced fall interventions and his/her Advance Directive wishes were not followed.Record review revealed Resident ID #1 was readmitted to the facility in October of 2025 with diagnoses including, but not limited to, acute respiratory failure with hypoxia (a condition where the tissues and cells of the body do not receive enough oxygen to function…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-08 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and staff interview, it has been determined that the facility failed to ensure that hospice services meet professional standards of principles that apply to individuals providing services in the facility for 1 of 2 residents reviewed who are receiving hospice services, Resident ID #1.Findings are as follows:Record review of a community-reported complaint submitted to the Rhode Island Department of Health on 5/5/2026 alleged that Resident ID #1 was admitted to hospice services on 5/1/2026. Additionally, the complaint alleged s/he was experiencing terminal agitation and the facility failed to timely implement hospice recommendations promptly to provide comfort, relief, and dignity at the end of his/her life. Record review revealed that Resident ID #1 was readmitted to the facility in October of 2025 with diagnoses including, but not limited to, acute respiratory failure with hypoxia (a condition where the tissues and cells of the body do not receive enough oxygen to function properly) and heart failure.Record review revealed that the resident was…
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 before2026-04-17 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interview, the facility failed to keep a resident free of significant medication errors for one of two residents reviewed, Resident ID #3. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 2/24/2026, alleges in part that on 1/31/20266, a nurse incorrectly transcribed Farxiga (a medication used to treat type 2 diabetes, kidney disease, and congestive heart failure) into the medical records of two residents. The error was identified 18 days later. Record review revealed Resident ID #3 was readmitted to the facility on [DATE], with diagnoses including, but not limited to, edema and hypokalemia. Record review of a Medication Error Form dated 2/18/2026, revealed that the Nurse Practitioner identified that the resident had been receiving Farxiga 5 milligrams daily, which was intended for another resident. This error persisted for 19 days. Record review of a written statement by the Assistant…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-23 · 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
Based on clinical record review and staff interview, the facility failed to ensure that a resident with an injury of unknown origin was thoroughly investigated for 1 of 1 resident reviewed for bruising, Resident ID #3.Findings are as follows:Review of a facility policy titled, Abuse prohibition states in part, .Injuries of unknown origin .the source of the injury was not observed, or the source cannot be explained by the resident .Investigation .begin the initial investigation .obtain statements from witnesses, notify the appropriate administrative personnel so that a comprehensive internal facility investigation can be carried out .Record review revealed the resident was readmitted to the facility in July of 2025, with diagnoses including, but not limited to, chronic inflammatory demyelinating polyneuropathy (an autoimmune disorder that affects the protective layer surrounding peripheral nerves) and lymphedema (an accumulation of protein rich fluid in the body's tissues).Record review of the progress notes revealed the following:-8/26/2025 at 7:26 PM a large bruise was noted to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-23 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and staff interview, the facility failed to ensure that residents receive care, consistent with professional standards of practice relative to physician's orders, for 1 of 1 resident who requires two staff members at all times during care, Resident ID #3 and for 1 of 1 resident who requires a cardiology consult, Resident ID #1.Findings are as follows:Review of a facility reported incident submitted to the Rhode Island Department of Health on 8/28/2025 revealed in part, on 8/27/2025 Resident ID #3 was taken to the shower room and a hospice Nursing Assistant (NA) attended to him/her for his/her shower. During the shower the resident was noted with active bleeding from an unidentified source. A skin assessment was completed, and the resident was observed with an open area to his/her great toe.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 that the orders are in error or would harm 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.
Show the remaining 15 citations
- Potential for harm · Ecited before2025-06-13 · 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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to 4 of 8 residents reviewed with an air mattress, Resident ID #s 86, 91, 111, and 135, 1 of 3 residents reviewed for oxygen administration, Resident ID #70, and for 1 of 1 resident reviewed with an order for daily weights, Resident ID #93. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. 1a. Record review revealed Resident ID #86 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, Parkinson's disease and adult failure to thrive. Record review revealed a physician's order dated 2/26/2024 which states in part, Air mattress to bed for comfort and pressure reduction. Check Setting…
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 before2025-06-13 · 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 record review and staff interview, it has been determined that the facility failed to accurately maintain the resident's medical record in accordance with accepted professional standards and practices relative to 3 of 8 residents reviewed with an mattress, Resident ID #s 86, 91, and 135, 1 of 3 residents reviewed for oxygen administration, Resident ID #70, and for 1 of 1 resident reviewed for the use of an incentive spirometer (a handheld medical device used to help patients improve the functioning of their lungs, by training patients to take slow and deep breaths), Resident ID #66. Findings are as follows: 1a. Record review revealed Resident ID #86 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, Parkinson's disease and adult failure to thrive. Record review revealed a physician's order dated 2/26/2024 which states in part, Air mattress to bed for comfort and pressure reduction. Check Setting according to resident weight. Special Instructions: Check settings every shift . Record review revealed the resident weighed 119.6 pounds…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-13 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
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 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 3 of 5 residents reviewed for antibiotic use, Resident ID #s 69, 85, and 135. Findings are as follows: According to a Centers for Disease Control and Prevention (CDC) document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes states in part, Perform antibiotic 'time outs.' .Nursing homes should have a process in place for a review of antibiotics by the clinical team two to three days after antibiotics are initiated to answer these key questions: - Does this resident have a bacterial infection that will respond to antibiotics - If so, is the resident on the most appropriate antibiotic(s), dose, and route of administration? - Can the spectrum of the antibiotic be narrowed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-13 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed with edema (swelling due to excess fluid trapped in the body's tissues), Resident ID #51. Findings are as follows: Review of an undated facility policy titled, WHEN THERE IS A CHANGE OF CONDITION states in part, .The resident's attending physician or on-call physician must be notified when a change of condition has occurred .resident responsible party must be notified. Changes in condition include but are not limited to .A need to alter resident's medical treatment . Record review revealed the resident was readmitted to the facility in June of 2024 with diagnoses including, but not limited to, Alzheimer's disease, acute kidney failure, hypertensive heart (a condition caused by chronic high blood pressure) and chronic kidney disease (a condition where the kidneys…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-13 · 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, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to staff wearing the appropriate personal protective equipment (PPE) for 1 of 1 resident observed for wound care and transfers, Resident ID #21. Findings are as follows: Review of a facility policy titled, .Policy for Enhanced Barrier Precautions [EBP] (infection control measures which require donning gown and gloves during high-contact residents' care activities) states in part, .the [facility name redacted] home is committed to ensuring the highest quality of care for our residents. It is to that end that this policy will follow CMS [Centers for Medicare and Medicaid Services] for guidance and or regulations of the RIDOH [Rhode Island Department of Health] and the Centers for Disease Control and Prevention associated with infection control practices related to Enhanced Barrier Precautions .Enhanced Barrier Precautions are indicated…
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 · D2025-06-13 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 the resident's medical record includes documentation that the resident was offered or received the indicated pneumococcal vaccination or did not receive the vaccination due to medical contraindications or a refusal for 2 of 5 residents reviewed, Resident ID #s 88 and 111. Additionally, the facility failed to have updated policies regarding pneumococcal immunizations. Findings are follows: According to the Centers for Disease Control and Prevention (CDC), pneumococcal vaccination for adults 65 years or older who have received PCV13 (a type of pneumococcal conjugate vaccination) at any age and the PPSV23 at [AGE] years of age or older, are recommended to receive a single dose of the PCV20 or PCV21 vaccine after 5 or more years from the date of the last pneumococcal vaccine. 1a. Record review revealed Resident ID #88 was readmitted to the facility in March of 2025. Review of the resident's immunization records…
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 · D2025-06-13 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 maintain a safe, functional, and comfortable environment relative to 1 of 3 kitchenettes and the main kitchen. Findings are as follows: 1. During the initial tour of the kitchen on 6/9/2025 at 9:54 AM, in the presence of the Food Service Director (FSD), the walk-in freezer was noted to have an accumulation of ice buildup on the sprinkler head and on the left fan, located near the ceiling of the freezer. During a surveyor interview, immediately following the above observation, the FSD acknowledged the ice buildup and indicated it should be cleaned. 2. During a surveyor observation on 6/9/2025 at approximately 10:30 AM, of the Jamestown Unit Kitchenette, in the presence of the FSD, revealed one microwave, mounted above the counter, which was noted to be severely cracked with peeling paint on the exterior of the microwave. During a surveyor interview, immediately following the above observation, the FSD acknowledged the cracks and peeling paint on the exterior of the microwave and…
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 before2024-08-22 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, it has been determined that the facility failed to maintain medical records on each resident that are complete and accurately documented relative to skin assessments for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a facility policy titled, Skin Care Program states in part, .Weekly skin assessments will be done and documented appropriately . Review of a community reported complaint received by the Rhode Island Department of Health on 8/14/2024 alleged that the resident was treated at the hospital on 8/4/2024 for multiple wounds to his/her feet that contained maggots. Review of photographs taken at the hospital dated 8/4/2024 revealed the resident had wounds between multiple toes with visible black tissue and white maggots. Review of hospital admission paperwork for Resident ID #1 dated 8/4/2024 states in part, .Upon removing a kerlix dressing to [the resident's] rt [right] foot noted to have old blood, black colored tissue with maggots in between toes, top of right foot with redness. Pedal pulse weak .Seen…
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 before2024-05-16 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, and staff and resident interview, it has been determined that the facility failed to meet professional standards of quality relative to following physician's orders for 1 of 1 resident reviewed for the utilization of a Freestyle Libre sensor (a continuous glucose monitoring system that is designed to replace finger sticks and lessen the need for test strips for persons with diabetes), Resident ID #2. Findings are as follows: Review of the Freestyle Libre 2 User Manual revealed that the sensor is to be changed every 14 days. Record review revealed that the resident was admitted to the facility in April of 2024 with diagnoses including, but not limited to, diabetes and chronic obstructive pulmonary disease. During a surveyor interview with the resident on 5/14/2024 at 11:04 AM, s/he revealed that s/he has a Freestyle Libre sensor. Additionally, s/he revealed that the Freestyle Libre sensor needs to be changed every 14 days. Record review failed to reveal evidence of a physician order for a Freestyle Libre sensor. Record review failed to reveal evidence of…
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 before2024-05-16 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview it has been determined that the facility failed to keep residents free from significant medication errors for 1 of 3 residents reviewed for insulin, Resident ID #2. Findings are as follows: Record review revealed that the resident was admitted to the facility in April of 2024 with diagnoses including, but not limited to, diabetes and chronic obstructive pulmonary disease. Review of a physician's order dated 4/19/2024 revealed Humalog Mix 75-25 insulin once a day with special instructions to, GIVE 25 UNITS IF BLOOD SUGAR IS LESS THAN 150 or GIVE 35 UNITS IF BLOOD SUGAR ABOVE 150. Review of the April and May 2024 Medication Administration Record revealed the following dates when the resident's blood sugar was greater than 150 and the resident received 25 units of insulin when s/he should have received 35 units of insulin per the physician's order: -4/21/2024 with a blood sugar of 155 -4/22/2024 with a blood sugar of 206 -4/26/2024 with a blood sugar of 189 -4/29/2024 with a blood sugar of 159 -5/2/2024 with a blood sugar of 178 -5/4/2024 with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-06 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview it has been determined that the facility failed to keep a resident free from physical abuse for 1 of 3 residents reviewed for staff to resident abuse, Resident ID #1. Findings are as follows: On 12/1/2023 the Rhode Island Department of Health received a facility reported incident that states in part .Reported to this writer on 12/1/2023 via statements, resident did not want a shower. When approached by CNA [Nursing Assistant], according to witnesses CNA then got resident out of recliner, put his arms around [him/her] and pushed [him/her] down in the wheelchair. He proceeded to give [him/her] a shower . Record review of a facility policy revised on October 31, 2022, titled POLICY/PROCEDURE .Abuse Prohibition states in part, .It is the policy of this facility to ensure that all resident are treated with respect and dignity and that all resident are free from abuse, mistreatment, neglect .Abuse: Willful infliction of injury, intimidation, or punishment with resulting…
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 before2023-11-22 · 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
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 services provided by the facility meet professional standards of quality relative to following a physician's order for 1 of 1 resident reviewed with 15-minute checks for behaviors, Resident ID #1. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Review of two facility reported incidents, received by the [NAME] Department of Health on 11/20/2023, revealed allegations of inappropriate behaviors against Resident ID #1 towards other residents at the facility. Review of the record revealed the resident was admitted to the facility in July of 2022 with diagnoses, including but not limited to, Alzheimer's disease and anxiety. Review of the care plan, last revised on 11/20/2023, revealed s/he had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that each resident receives adequate supervision to prevent elopements, for 1 of 1 residents reviewed for a successful elopement, Resident ID #52. Findings are as follows: Review of a facility policy titled Elopement Assessments, dated 11/1/2022, states in part, .PROCEDURE .An elopement assessment is to be performed whenever a resident exhibits a change in behaviors which signals an increase in risk, such as verbalizing a wish to leave the building, wandering with intent to leave, wandering unsafely and actually attempting to leave the building .If the resident is assessed to be a risk for elopement, then the necessary and appropriate intervention must be put in place immediately to keep the resident safe (i.e., wander guard bracelet [a device made for the purpose of keeping people with dementia from wandering, where the devices alert the caregiver whenever the resident breaches a perimeter…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-30 · 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 a resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for Narcan (a medication used for the emergency treatment of known or suspected opioid overdose) use, Resident ID #131. Findings are as follows: Review of a facility policy titled, Narcan Administration dated 10/27/2022 states in part, .The administration of Narcan is to be by a Registered Nurse, LPN [Licensed Practical Nurse] or MD/NP/PA [Medical Doctor/Nurse Practitioner/Physician Assistant] in the case of a clinical overdose .Clinical Overdose is classified as having a respiration rate of 8-10 or lower per minute, inability to arouse/unconscious, pin point pupils . Record review revealed that the resident was admitted to the facility in November of 2022 with diagnoses including, but not limited to, type 2 diabetes mellitus and dementia. Review of a progress note dated 3/28/2023 at 11:51 AM, revealed the resident was unable to be fully aroused. Additionally, it was revealed the resident was…
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 before2023-03-30 · 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
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 maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections for 1 of 1 resident's reviewed for Methicillin-resistant Staphylococcus aureus (MRSA, an infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics) and for 1 of 1 resident's reviewed for Extended spectrum beta-lactamases (ESBL, an infection that is resistant to specific types of antibiotics), Resident ID #s 3 and 89. Additionally, the facility failed to have a completed water management plan. Findings are as follows: 1a. Record review of the facility provided policy titled Guidelines for Management of MDRO's [Multidrug Resistant Organism] revealed that MRSA is transmitted primarily by contact with a person who either has a purulent site, a clinical infection of the urinary tract, or who is colonized (the resident has no symptoms of…
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
$46,118 in federal fines across 1 penalty.
- $46,118 — penalty dated 2024-08-22
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GURCHIN, JEANNE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 33% | since 10/01/2015 |
| ROY, DONALD | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER | 33% | since 10/01/2015 |
| ROY, JUDITH | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 33% | since 11/30/1983 |
| DAROSA, ELIZABETH | Individual | W-2 MANAGING EMPLOYEE | — | since 03/16/2015 |
| ROY, JEFFREY | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 10/18/2006 |
CMS files one row per role, so the 10 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $48K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 415075. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-13, 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.