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Golden Crest Nursing Centre

100 Smithfield Road, North Providence, RI 02904 · For profit - Corporation · 152 certified beds · (401) 353-1710 Medicare & Medicaid certified

Call the home — (401) 353-1710 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Oct 20232 actual-harm citations$70,868 in federal fines
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2023
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $70,868 in federal fines (most recent 2025-12-11)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1515 Smith St · (401) 353-1110 · Call to confirm hours
Pharmacy
1665 Mineral Spring Ave · (401) 353-3113 · Call to confirm hours
Grocery
Shaw's<0.1 mi
15 Smithfield Rd · (401) 353-2075 · Call to confirm hours
Park
1160 Douglas Ave · (401) 233-1446 · Typically dawn to dusk
Place of worship

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 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased16.2%19.6%15.4%typical
Long-stay residents who lose too much weight7.6%5.1%5.4%worse
Long-stay residents with a catheter left in their bladder0.4%0.9%0.9%better
Long-stay residents with a urinary tract infection1.5%2.5%2.0%better
Long-stay residents with depressive symptoms1.9%17.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.6%3.6%3.3%typical
Long-stay residents whose ability to walk worsened13.1%16.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication11.6%16.7%18.9%better
Long-stay residents given the seasonal flu vaccine92.4%95.2%95.3%typical
Long-stay residents with pressure ulcers7.1%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control22.3%22.3%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table10.0%22.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%2.0%1.4%better
Short-stay residents given the seasonal flu vaccine44.0%78.2%79.4%worse
Short-stay residents rehospitalized after admission32.9%24.3%22.6%worse
Short-stay residents with an outpatient ER visit8.6%14.6%12.0%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.

60.0% 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 78 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

60.0%U.S. median 51.5%
Got home and stayed home
11.9%U.S. median 10.7%
Went back to hospital
40.0%U.S. median 56.6%
Met the expected recovery
0.27U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 40.0% 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 25 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 0.27 therapist hours per resident per day in 2026Q1 — more than 39% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 38% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF60.0%CMS range 47.8–70.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.9%CMS range 8.7–16.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge40.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge36.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge56.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.0%CMS range 4.1–13.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.831.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.47
RN hours/ resident / day
0.52
LPN hours/ resident / day
2.74
Aide hours/ resident / day
3.73
Total nurse hours/ resident / day
0.28
RN hoursweekends
45.2%
Total nursing turnover
41.2%
RN turnover

How full it usually is: this home is certified for 152 beds and averages 143.9 residents a day — about 95% 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 3.73 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.74 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 3.44 hrs/resident/day on weekends vs 3.85 on weekdays — 11% thinner on weekends. RN hours go from 0.54 to 0.28 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

4
deficiencies at the latest standard inspection (2025-12-11)
7
at the previous standard inspection (2024-09-20)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

27 citations, most serious first. The 12 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · Gcited before2025-12-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, clinical record review, and staff interview, the facility failed to prevent a new pressure ulcer from developing for 1 of 1 resident reviewed (Resident ID #7) with a physician's order to off load heels. The physician-ordered intervention to offload the resident's heels was not consistently implemented for Resident ID #7, despite the resident's identified risk factors for pressure ulcer development, including impaired mobility, malnutrition, and a moderate risk score on the Norton Plus Pressure Ulcer Scale (a tool utilized to assess a resident's risk for developing a pressure ulcer). This failure resulted in the development of a deep tissue injury (DTI) to the resident's left heel, which was identified during a skin assessment requested by the surveyor. Findings are as follows:Review of the facility policy last revised in September of 2013 titled Prevention of Pressure Ulcers, states in part, .Pressure Ulcers are usually formed when a resident remains in the same position for an…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · H2023-10-13 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    Protect 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 surveyor observation, record review, and staff and resident interviews, it has been determined that the facility failed to protect the resident's right to be free from abuse for 1 of 3 residents reviewed, Resident ID #102. Findings are as follows: Review of the facility policy titled, Abuse Prohibition, states in part, .Resident abuse is defined as willful infliction of .unreasonable confinement, intimidation, or punishment resulting in .mental anguish; and included mental abuse. Examples of abuse include, but are not limited to the following .mental abuse .threats of punishment or deprivation . Review of the resident record revealed s/he was admitted to the facility in April of 2021 with diagnoses including, but not limited to, schizophrenia [characterized by delusions, hallucinations, unusually physical behaviors, and disorganized thinking and speech], obsessive-compulsive disorder, bipolar disorder, post-traumatic stress disorder, and anxiety. Review of the Quarterly Minimum Data Set (MDS)…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-16 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, and family and staff interview, the facility failed to ensure a resident received the necessary monitoring and assistance to maintain proper hydration for 1 of 3 residents reviewed, Resident ID #1.Findings are as follows:According to Fundamentals of Nursing 7th Edition (2011), .Fluid Balance.The desirable amount of fluid intake.in adult ranges from 1,500 to 3,500 milliliter (mL) each 24 hours, with most people averaging 2,500 to 2,600 mL per day.Parameters to be considered in clinical assessment for fluid, electrolyte, and acid-base balance.Records may be initiated by the nurse for any patient with a real or potential water or electrolyte problem.Intake should include all fluids taken into the body.If monitoring of a patient's intake.is required, the patient, family, and all caregivers must be alert to the need to measure all fluids entering.the body.Record review of a community reported complaint sent to the Rhode Island Department of Health on 4/2/2026 alleged in part, that the facility is short staffed and has been letting Resident ID #1's health…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-16 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and family and staff interview, the facility failed to ensure that resident records are complete and accurately documented related to assistance with activities of daily living for 2 of 3 residents reviewed, Resident ID #s 1 and 2.Findings are as follows:According to Fundamentals of Nursing, Seventh Edition dated 2011, states in part, Documenting Nursing Care .Remembering the legal truth 'It wasn't done if it wasn't documented'.Documentation Guidelines.Aim: Complete, accurate, concise, current, factual, and organized data communicated in a timely and confidential manner to facilitate care coordination and serve as a legal document.Record review of a community reported complaint sent to the Rhode Island Department of Health on 4/2/2026 alleged in part, that the facility is short staffed and has been letting Resident ID #1's health decline.During a surveyor interview on 4/15/2026 at 11:31 AM, with the complainant, s/he alleges that the facility did not have enough staff to assist…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-11 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on surveyor observation, clinical 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 2 of 6 residents reviewed with an identified skin impairment, Resident ID #s 21, and 67 and 1 of 3 residents reviewed who are dependent on staff for activities of daily living (ADLs), Resident ID #118.Findings are as follows:1. Record review revealed Resident ID #21 was readmitted to the facility in July of 2025 with diagnoses including, but not limited to, stage 4 pressure injury (full thickness skin loss, involving subcutaneous tissue, exposing muscle and possibly tendon or bone) of the right foot second toe.Record review of wound detail report dated 9/3/2025 at 11:09 AM revealed, Resident ID #21 has an ulcer to the right foot 2nd toe, measuring 0.1 centimeters by 0.1 centimeters.Record review revealed a physician's order dated 12/2/2025 to cleanse the right 2nd toe with wound cleanser, apply Iodosorb (a medication prescribed to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, clinical record review, resident representative, and staff interview, the facility failed to provide the necessary services to a resident who is unable to carry out activities of daily living (ADLs); for 1 of 1 resident reviewed with a delay in personal care, Resident ID #40, and for 1 of 3 residents reviewed relative to transfers, Resident ID #118.Findings are as follows: 1. Record review revealed Resident ID #40 was readmitted to the facility in June of 2024 with diagnoses including, but not limited to, dementia and diabetes.Record review of a Minimum Data Set assessment dated [DATE] revealed that the resident is rarely/never understood and has severe cognitive impairment. Additional record review revealed that s/he is always incontinent of bowel and bladder and is totally dependent on two staff members for Activities of Daily Living (ADLs), including, toileting, hygiene, and dressing.Record review of the ADL documentation dated 12/8/2025, failed to reveal evidence that 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-11 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on surveyor observation, clinical record review, and staff interview, the facility failed to provide an ongoing activity program to support a resident in his/her choice of activities based on the comprehensive assessment, care plan, and preferences for 1 of 1 resident reviewed, Resident ID #118.Findings are as follows:Record review revealed Resident ID #118 was readmitted to the facility in September of 2025 with diagnoses including, but not limited to, Alzheimer's disease and hemiplegia (a paralysis or weakness of the face, arm or leg.)Review of an admission Minimum Data Set assessment, Section F, titled, Preferences for Customary Routine and Activities, dated 9/17/2025 revealed, it is very important for the resident to listen to music.Review of the resident's care plan last revised on 6/25/2024 revealed, the resident has Alzheimer's and is non-verbal with the intervention to ensure the TV or some type of music is available for the resident.Surveyor observations of the resident on the following dates and times failed to reveal evidence that the resident was offered or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-19 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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 develop and implement individualized care plans that includes measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment relative to Activities of Daily Living (ADL's, e.g. eating, oral hygiene, toileting hygiene, showering and bathing, personal hygiene, dressing, rolling to the left and right, all transfers and mobility) for 5 of 5 residents reviewed, Resident ID #s 1, 4, 5, 6, and 7. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/5/2024 alleged that Resident ID #1 had fallen out of his/her bed a couple months ago resulting in bruising and a hospital evaluation. 1. Record review revealed Resident ID #1 was admitted to the facility in July of 2022 with diagnoses including, but not limited to, multiple sclerosis (chronic neurological disorder), spastic quadriplegia (a form of cerebral palsy that affects both arms 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-04 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to store medications in accordance with currently accepted professional principles for 1 of 1 resident reviewed relative to storing lidocaine patches in his/her room without an assessment for self-application, Resident ID #2. Findings are as follows: Record review revealed the resident was admitted to the facility in November of 2022 with diagnoses including, but not limited to, arthritis and muscle weakness. Review of a physician's order dated 10/1/2024 revealed Lidocaine adhesive patch 4% (a medication prescribed for pain), apply 1 patch to the right shoulder every morning and to be removed at bedtime. Record review failed to reveal evidence of an assessment for the self administration of the medication, which indicated the resident is safe to store and administer his/her medications. During a surveyor observation on 11/4/2024 at approximately 12:00 PM, there was a total of 5 unopened lidocaine patches in the opened manufacturer's box observed in the resident's room.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-20 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 2 of 5 medication carts reviewed and 1 of 2 medication rooms. Findings are as follows: Review of a facility policy titled, Storage of Medications last revised [DATE] states in part, The facility shall store all drugs and biological's in a safe, secure, and orderly manner . 1. During a surveyor observation of the 2 East Medication Cart on [DATE] at 8:25 AM, in the presence of Certified Medication Technician (CMT), Staff E, revealed the following: - 1 bottle of Latanoprost Solution (eye drops used to treat glaucoma) 0.005 % with an open date of [DATE]. Manufacturer's instructions indicate to discard the eye drops 6 weeks after opening, revealing the medication should have been discarded on [DATE]. - 1 bottle of Timolol Maleate Gel Forming Solution 0.5 % (eye drops used to treat high pressure inside the eye)…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-20 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff and resident interviews, it has been determined that the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment and to help prevent the development of infections for 1 of 1 resident reviewed relative to the use of a Bilevel positive airway pressure (BIPAP, a device that provides breathing support which is administered through a face mask or nasal mask) device, Resident ID #77. Findings are as follows: Review of the manufacturer's instructions titled RESVENT IBREESE Series user manual dated July 2017, states in part, .Clean the flexible tube and mask before first use and daily. Disconnect the flexible tube and mask from the device. Gently wash the tube and mask in a solution of warm water and a mild detergent. Rinse thoroughly. Air dry . Record review revealed that Resident ID #77 was readmitted to the facility in August of 2024 with diagnoses including, but not limited to, sleep apnea (a sleep disorder where breathing is interrupted repeatedly) and acute respiratory failure. Record review of a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-20 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, and staff interview, it has been determined that the facility failed to meet professional standards of quality for 1 of 2 residents reviewed with medication refusals, Resident ID #73. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 which 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 #73 was re-admitted to the facility in August of 2022 with a diagnosis including, but not limited to, gastro-esophageal reflux disease (GERD, a condition in which stomach acid repeatedly flows back up into the esophagus, causing irritation and discomfort). Record review revealed a physician's order with a start date of 9/12/2022 for Famotidine (a medication prescribed to treat GERD) 8 milligram (mg)/milliliter (ml), give 2.5 ml once daily. Review of the Medication Administration Record revealed the medication was not administered due to the residents refusal 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · Dcited before2024-09-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure a resident who is at risk for pressure ulcers receives the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 1 resident who was observed during a wound dressing change, Resident ID #102. Findings are as follows: Record review revealed Resident ID #102 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, Peripheral Artery Disease (PAD, a condition in which narrowed arteries reduce blood flow to the arms or legs), Peripheral Vascular Disease (PVD, a condition in which narrowed vessels reduces blood flow to the arms, legs, or other body parts), and status post-surgery for left and right below knee amputations. Record review of the resident's care plan dated 5/5/2023 revealed, the resident is at risk for impaired skin integrity related to status post bilateral knee amputations, coccyx wound, wounds to right…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, it has been determined the facility failed to ensure the residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight, relative to a weight gain for 1 of 2 residents reviewed, Resident ID #134. Findings are as follows: Review of a facility undated policy titled, Weight Policy which states in part, .Upon completion of weight, if a 3% discrepancy in one week or a 5% discrepancy in one month is noted, a reweight will be obtained in 48 hours .If a re-weight indicates a 3% discrepancy in one week or a 5% discrepancy in one month, the dietitian, physician, and resident and/or resident representative will be notified . Record review revealed Resident ID #134 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, Crohn's disease (a type of inflammatory bowel disease), rectal abscess, pressure ulcer of sacral region and chronic osteomyelitis, multiple sites (an infection in the bone). Record review of the physician's orders 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-20 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure 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 2 residents reviewed for as needed antipsychotic medications, Resident ID #67. Findings are as follows: Record review of a facility policy titled Medication Regimen Review [MRR] and Reporting which states in part, .Medication Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication .The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated .In performing medication regimen review, the consultant pharmacist incorporates federally mandated standards of care .A record of the consultant pharmacist's observations and recommendations is…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-20 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure 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 each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 32 opportunities for errors observed during the medication administration task there were 2 errors resulting in an error rate of 6.25%, involving Resident ID #62. Findings are as follows: Review of a facility policy titled, Administering Medications last revised December 2012 which states in part, .Medications shall be administered in a safe and timely manner, and as prescribed . Record review revealed that Resident ID #62 had the following physician's orders: - Depakote (divalproex) tablet, delayed release 500 milligrams (MG), twice daily - MiraLAX (polyethylene glycol 3350) powder, 17 gram dose, once daily During a surveyor observation on 9/19/2024 at 8:08 AM during the medication administration task with Certified Medication Technician, Staff E, she failed to administer the Miralax and then crushed the Depakote tablet. Review of the Depakote blister package…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-15 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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 the facility failed to provide person centered care in accordance with a resident's plan of care for 1 of 2 residents reviewed relative to his/her call light being within reach, Resident ID #67. Findings are as follows: Record review revealed the resident was admitted to the facility in April of 2024 with diagnoses including, but not limited to, adult failure to thrive, paroxysmal atrial fibrillation (a type of irregular heartbeat) and muscle weakness. Record review of a care plan dated 4/18/2024 revealed in part, .Potential for falls/injury r/t [related to]: impaired mobility, impaired cognition, impaired vision, incontinence, weakness and FTT [failure to thrive] . This care plan has interventions including, but not limited to, .Call light within reach & remind to call for assist as needed . During a surveyor observation on 7/15/2024 at 12:40 PM, the resident was observed to be seated in his/her wheelchair between the bed and wall, closest to the doorway, and more than halfway down the length…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-09 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following a physician's order for nutritional supplements for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 5/8/2024 alleges in part, .In the course of over a month, [Resident ID #1] has lost 20 pounds. 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 the resident was admitted to the facility in October of 2023 with diagnoses including, but not limited to, acquired absence of the right leg below the knee and type II diabetes mellitus. Record review of a progress note authored by the Licensed Dietitian/Nutritionist on 4/23/2024…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the residents' environment remains as free from accident hazards as possible for 2 of 4 residents reviewed related to fall risk prevention, Resident ID #s 2 and 3. Findings are as follows: 1. Record review revealed Resident ID #3 was re-admitted to the facility in December of 2023 with diagnoses including, but not limited to, dementia and history of falls. Record review of the document titled Risk of Falls Assessment completed on 4/2/2024 revealed that the resident was at a moderate risk for falls. Record review of the care plan last revised on 4/9/2024 revealed a problem related to a history of falling with an intervention to keep the call light within reach. During a surveyor observation on 5/9/2024 at 9:46 AM, the resident was observed sitting in his/her wheelchair attempting to get up and calling out for help. The call light was noted to be hanging on his/her bedside rail, which…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-13 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality for 1 of 1 resident reviewed related to abdominal girth measurements, Resident ID #25. 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. Record review revealed the resident was re-admitted to the facility in July of 2021 with diagnoses including, but not limited to, chronic systolic congestive heart failure (long-term condition that occurs when the heart muscle does not pump blood as well as it should), chronic kidney disease, and bladder cancer. Record review of the resident's Treatment Administration Record revealed an order dated 9/12/2023 to measure his/her abdominal girth once a day on Friday. Further review failed to reveal evidence of measurements for the resident's abdominal girth in the following dates: - 9/15/2023 -…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 provide the necessary services to a resident who is unable to carry out activities of daily living (ADLs), relative to transfers for 1 of 7 residents reviewed, Resident ID #125. Findings are as follows: Review of the resident record revealed s/he was readmitted to the facility in July of 2023 with diagnoses including, but not limited to, acquired absence of left and right leg below knee, and stage 4 pressure ulcer of the sacral region (sores extend below the subcutaneous fat into your deep tissues, including muscle, tendons, and ligaments). Record review of a care plan with a start date of 5/5/2023 revealed s/he has a deficit in ADL function/mobility due to a recent hospitalization related to a below the knee amputation on the left leg. Additionally, an intervention was in place to provide the resident assistance with ADLs as needed. Surveyor observations from 10/10/2023 to 10/12/2023 failed to reveal evidence that the resident was out of bed, or an attempt…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice to promote wound healing and prevent new ulcers from developing for 2 of 5 residents reviewed for pressure ulcers (a localized injury to the skin or the underlying tissue due to pressure), Resident ID #'s 46 and 243. Findings are as follows: According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023 states in part, .With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the [pressure ulcer/pressure injury] PU/PI should be documented. At a minimum, documentation should include the date observed and: ·Location and staging; ·Size (perpendicular measurements of the greatest extent of length and width of the PU/PI), depth; and the presence,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the residents environment remains as free of accident hazards as possible for 1 of 8 residents reviewed, relative to supervision while eating, Resident ID #46. Findings are as follows: According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023 states in part, .Supervision is an intervention and a means of mitigating accident risk. Facilities are obligated to provide adequate supervision to prevent accidents. Adequacy of supervision is defined by type and frequency, based on the individual resident's assessed needs, and identified hazards . Record review revealed the resident was admitted to the facility in May of 2023, with diagnoses to include, but not limited to, dysphagia (difficulty swallowing foods and liquids). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-13 · tag F0691 — failed to provide colostomy / ostomy care — isolated
    Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident with a nephrostomy receives care, consistent with professional standards of practice and the comprehensive person-centered care plan, for 1 of 1 sample resident who has a PCN (percutaneous nephrostomy - an artificial opening created between the kidney and the skin which allows for urinary drainage), Resident ID #243. Findings are as follows: Review of the facility's policy titled, Nephrostomy Tube , Care of, states in part: .The purpose of this procedure is to provide guidelines for the care of the resident with a percutaneous nephrostomy tube . 1.Verify that there is a physician's order for this procedure .2. Review the residents care plan to assess for any special needs of the resident . General Guidelines . 8. Change dressing every 1-3 days, or as ordered . 9. Use clean technique during dressing changes . Record review revealed the resident was readmitted to the facility in October of 2023 and has diagnoses including, but not limited to, acute Cystitis (bladder…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-13 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 1 resident reviewed related to abdominal girth measurements, Resident ID #25. 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. Record review revealed the resident was re-admitted to the facility in July of 2021 with diagnoses including, but not limited to, chronic systolic congestive heart failure (long-term condition that occurs when the heart muscle does not pump blood as well as it should), chronic kidney disease, and bladder cancer. Record review of the resident's Treatment Administration Record revealed an order dated 9/12/2023 to measure his/her abdominal girth once a day every Friday. Further review failed to reveal evidence of measurements for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to follow standard precautions to prevent the spread of infection for 1 of 3 residents observed for wound care, Resident ID #84. Findings are as follows: Record review of the facility policy titled, Multidrug-Resistant Organisms [MDRO, are bacteria that resist treatment with more than one antibiotic], with a revision date of 2014, states in part, .Appropriate precautions will be taken when caring for individuals known or suspected to have infection with a multidrug-resistant organism .c. Risks for transmission including .draining wounds .may increase the risk for transmission may indicate the need for Contact Precautions .19. Disposable gloves should be worn if contact with body fluids is expected and hand hygiene performed after removing the gloves .21. The resident's environment should be cleaned routinely and when soiled with body fluids . Record review revealed that the resident was re-admitted to the facility in February of 2023. S/he has diagnoses which include,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-10-13 · tag F0636 — pattern
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 staff interview and record review, it has been determined that the facility failed to conduct a Minimum Data Set (MDS) Assessment within 14 days of discharge for 2 of 8 resident closed clinical records reviewed, Resident ID #s 77 and 120. Findings are as follows: 483.20 (f) (2) Comprehensive Assessments & Timing Transmittal Requirements: Within 14 days after a facility resident is discharged , a facility must electronically transmit encoded, accurate and completed MDS data to the CMS system, including the following: .(vii) A subset of items upon a resident's discharge from the facility. 1. Record review for Resident ID #77 revealed s/he was admitted to the facility on [DATE] and discharged on 5/8/2023. Further record review failed to reveal evidence that an MDS discharge assessment was completed, as required, within 14 days of discharge. 2. Record review for Resident ID #120 revealed s/he was admitted to the facility on [DATE] and discharged on 5/6/2023. Further record review failed to reveal evidence…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$70,868 in federal fines across 2 penalties.

  • $30,360 — penalty dated 2025-12-11
  • $40,508 — penalty dated 2023-10-13

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
PEZZELLI, PAULIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF40%since 06/02/2023
HICKEY, RAYMONDIndividualDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 01/01/2012
NICHOLS, MICHELLEIndividualDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 01/01/2012
PEZZELLI WHIPPLE, SUSANIndividualDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 01/01/2012
PEZZELLI, LISAIndividualDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 01/01/2012
MAJEKODUNMI, AKINDELEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2020

CMS files one row per role, so the 16 rows in the source record cover these 6 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.

$15.6M
Net patient revenuemost recent cost report
+0.6%
Operating marginrevenue minus expenses
$374K
Related-party expense2% of expenses
Who pays — share of resident-days
Medicaid 79%Medicare 3%Other / private 18%

About 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $374K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$295per resident / day
operating cost
$8,966per month
≈ monthly operating cost
$297per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in RI

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Rhode Island Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 415029. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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