Sunny View Nursing Home
83 Corona Street, Warwick, RI 02886 · For profit - Limited Liability company · 57 certified beds · (401) 737-9193 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 5 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $90,716 in federal fines (most recent 2026-03-30)
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (70%) runs well above the national median (45%)
- about 18% of its spending goes to commonly-owned related companies
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 | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 1 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 | 31.1% | 19.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 11.8% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.9% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.8% | 2.5% | 2.0% | worse |
| 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 | 1.5% | 3.6% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 25.8% | 16.8% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 15.2% | 16.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 94.3% | 95.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.8% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 22.8% | 22.3% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.8% | 22.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.7% | 2.0% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 64.8% | 78.2% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 40.2% | 24.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.5% | 14.6% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.68 | 1.59 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.95 | 1.68 | 1.80 | typical |
* 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.
63.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 144 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 71.7% 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 46 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 0.48 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 27% 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 | 63.5%CMS range 54.6–68.8 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.8%CMS range 8.6–17.4 | 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 | 71.7% | 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 | 71.7% | 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 | 73.9% | 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 | 91.1% | 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 | 84.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 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 | 3.6% | 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 | 7.8%CMS range 4.2–11.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.87 | 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 57 beds and averages 51.5 residents a day — about 90% occupied, or roughly 6 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 3.66 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.65 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.44 hrs/resident/day on weekends vs 3.74 on weekdays — 8% thinner on weekends. RN hours go from 0.69 to 0.57 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 70% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
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.
30 citations, most serious first. The 15 most serious are shown; the remaining 15 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-03-30 · 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, clinical record review, and staff interview, the facility failed to provide the necessary supervision to prevent the elopement of a cognitively impaired resident. This failure placed the resident in a situation of Immediate Jeopardy, as the resident exited the facility, undetected with another resident's visitor, and remained unsupervised in the community for approximately six hours.During this time, the resident's whereabouts were unknown, placing the resident at risk for serious harm, injury, or death. The resident was not located until s/he arrived independently at his/her former residence, where his/her spouse currently resides. The spouse then notified the facility of the resident's presence. The resident was subsequently transported to the hospital for medical clearance. Additionally, upon the resident's return to the facility, the facility failed to test the wander guard device the resident was wearing at the time of elopement and instead discarded the device without…
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.
- Immediate jeopardy · Jcited before2025-06-23 · 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 record review and staff interview, it has been determined that the facility failed to ensure that each resident receives assistive devices to prevent accidents relative to the placement of a TekTone device (a device that allows at-risk residents to move freely about a facility, while preventing them from exiting the facility) for 1 of 1 resident who successfully eloped from the facility and sustained a major injury, Resident ID #1. Findings are as follows: Review of the facility policy titled Elopement Assessment dated 10/27/2022 states in part, .It is the facility policy to maintain a safe and secure environment for all residents. In order to achieve this goal residents who are at risk for wandering/elopement need to be identified and a care plan developed with interventions to minimize or eliminate the risk as outlined below .Residents who are at risk for elopement include those with dementia, confusion .may warrant close watching .if the resident is assessed to be at risk for elopement, then 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.
- Immediate jeopardy · Jcited before2025-06-23 · 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 ensure that resident records are complete and accurately documented, relative to the monitoring of an elopement prevention device, a TekTone device (a device that allows at-risk residents to move freely about a facility, while preventing them from exiting the facility), for 1 of 1 resident reviewed who eloped from the facility and sustained a hip fracture, Resident ID #1. Findings are as follows: Review of a facility's policy titled Wanderguard [TekTone device] System and Assessments checks states in part .The bracelet will be checked each shift to assure placement, the nurse will sign this as checked in the treatment record . Record review of a facility reported incident submitted to the Rhode Island Department on Health on 6/16/2025 revealed that Resident ID #1 was found in the rear parking lot of the facility by a staff on the overnight shift on 6/12/2025. S/he was noted to have a large hematoma above the left eye, his/her left leg was externally rotated and s/he complained of pain.…
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.
- Immediate jeopardy · Jcited before2024-03-25 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview if has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice and failed to promptly identify and intervene during an acute change in a resident's condition, related to vomiting and an unknown cardiac event for 1 of 1 resident reviewed, Resident ID #38. Findings are as follows: Review of a facility policy titled, Resident Change in Condition dated 10/17/2023 states in part, .Changes in condition require assessment by the RN [registered nurse] and notification to the MD [Medical Doctor] (both to be done timely). Timely depends upon the level/severity of the change and RN should use professional assessment and judgement to make that decision. Timely is certainly no later than the shift of the change . Record review of a closed record revealed that Resident ID #38, was admitted to the facility in July of 2020 with diagnoses including, but not limited to, vascular dementia and nontraumatic intracerebral hemorrhage (emergency condition in which a blood vessel in the brain…
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.
- Immediate jeopardy · Kcited before2023-12-13 · tag F0880 — failed to prevent and control infections — patternProvide 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, surveyor observation 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 Respiratory Syncytial Virus (RSV) for 1 of 2 nursing units and affecting Resident ID #s 1,2,3,4,5, 6 and 7. Findings are as follows: Review of the Centers for Disease Control and Prevention (CDC) Appendix A, Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) revealed precautions for RSV should include standard, droplet and contact precautions throughout the duration of the illness. Review of a facility policy titled, Isolation last reviewed 8/2015 revealed in part, It is the policy of this facility to prevent the spread of infection within the facility through the use of isolation precautions .Transmission Based Precautions, as defined by the CDC, will be employed for known or suspected infections for which the route of transmission/prevention is known . 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.
- Potential for harm · E2026-04-30 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, clinical record review, and staff interview, the facility failed to develop and implement comprehensive person-centered care plans for 4 of 5 residents reviewed who indicated that participation in activities of choice were important to them on their Minimum Data Set (MDS) Assessments, Resident ID #'s 5, 6, 15, and 44.Findings are as follows:Record review of an undated facility policy titled, Resident Related Care and Services states in part, .The interdisciplinary team is responsible to develop and carry out appropriate comprehensive care plans to allow for optimal outcomes.the team is to review the resident's assessment.in order to determine appropriate interventions and plans of care have been instituted. 1. Record review of Resident ID #5's Annual MDS dated [DATE] revealed s/he has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Further review of the MDS revealed that the resident indicated participation in his/her favorite…
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 · E2026-04-30 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, clinical record review, and staff and resident interviews, the facility failed to provide an ongoing daily activity program to support residents in their choice of activities based on the comprehensive assessment, care plan, and preferences. Specifically for 5 of 6 residents reviewed who indicated that participation in activities of choice were important to them, Resident ID #s 5, 6, 15, 44, and 50, although this failure affects all residents residing in the facility Findings are as follows:During a surveyor interview on 4/29/2026 at approximately 11:00 AM with the members of the Resident Council, the residents revealed that activities have not been offered in the evening or on the weekends since 3/31/2026, which was the Activities Director's last day of employment at the facility.Record review revealed the facility employed only one part-time Activities Aide for the month of April 2026.1. Record review revealed Resident ID #5 was admitted to the facility in February of 2020.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 · E2026-04-30 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure 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 surveyor observations, record review, and staff interview, the facility failed to ensure that staff were competent to provide services to assure resident safety to attain or maintain the highest practicable wellbeing of each resident, as the facility's staff were unaware of and had not been educated on the facility's personal laundry procedures for 7 of 7 staff members reviewed, Staff A, B, C, D, E, F, and G. Findings are as follows:The facility failed to provide evidence of a policy and procedure related to residents' personal laundry to ensure staff handle, store, process, and transport all laundry in accordance with accepted national standards in order to produce hygienically clean laundry and prevent the spread of infection to the extent possible, potentially affecting all residents who reside in the facility.Review of the following staff member's completed education and competencies failed to reveal evidence that the staff were educated on the expected procedures for handling and processing of residents' personal laundry:- Nursing Assistant (NA) Staff A, with a hire…
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 · D2026-04-30 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observation, clinical 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 2 residents reviewed for the use of psychotropic medications without adequate indication of use, Resident ID #8. Findings are as follows:Record review revealed the resident was admitted to the facility in September of 2025 with a diagnosis including, but not limited to, dementia without behavioral disturbance, psychotic mood disturbance, or anxiety.Record review revealed the following physician's orders: -Lexapro (a medication prescribed to treat used to treat depression and anxiety disorder) 10 milligrams (mg) tablet once daily initiated on 3/30/2026. -Mirtazapine (a medication prescribed to treat depression) administer 7.5 mg at bedtime initiated on 4/6/2026. -Seroquel (a prescribed antipsychotic medication used to treat schizophrenia, bipolar disorder, and major depressive disorder) administer 12.5 mg at bedtime initiated on 4/22/2026. -Trazodone (a medication prescribed to treat…
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 before2026-04-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to meet professional standards of practice for 1 of 1 resident reviewed who had an order to obtain a stool sample to rule out an infectious disease, Resident ID #57.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients .Record review revealed the resident was admitted to the facility in April of 2025 with a diagnosis including, but not limited to, functional diarrhea.Record review of the Minimum Data Set assessment dated [DATE] revealed the resident is always continent of stool.Record review revealed a physician's order for loperamide tablet (a medication prescribed for loose stool), 2 milligrams, every 8 hours as needed for loose stool.Additional record review revealed the loperamide was administered in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-23 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, it has been determined that the facility failed to ensure that the Minimum Data Set (MDS) Assessment accurately reflected the resident's status for 1 of 2 residents reviewed who are assessed an an elopement risk, Resident ID #5. Findings are as follows: Record review revealed Resident ID #5 was readmitted to the facility's semi-secure unit in March of 2025 with diagnoses including, but not limited to, mild cognitive impairment and muscle weakness. Record review revealed that a care plan was initiated on 6/9/2025 indicating the resident requires the use of a TekTONE elopement prevention bracelet related to episodes of attempting to leave the facility with approaches/interventions including, but not limited to, ensuring that the TekTone elopement prevention bracelet is in place and its functionality, providing visual checks/supervision for safety. Review of the quarterly MDS Assessments dated 2/26/2025 and 4/3/2025 section Restraints and Alarms failed to reveal evidence that the resident was coded as having a TekTone elopement prevention…
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 before2025-05-06 · 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 interview, it has been determined that the facility failed to meet professional standards of quality for 2 of 3 residents reviewed for physician's orders, Resident ID #s 1 and 3. 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 of a community reported complaint submitted to the Rhode Island Department of Health on 5/5/2025 alleged that Resident ID #1 was complaining of abdominal pain and was observed with large purple bruising extending from his/her upper chest to the upper abdomen. 1. Record review revealed Resident ID #1 was admitted to the facility in February of 2025 with diagnoses including, but not limited to, altered menial status and a fall. Record review revealed a physician's order dated 3/6/2025 to complete a weekly skin evaluation and document the findings under observations. Record review of the April 2025…
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 before2025-03-25 · 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, resident, 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 for 1 of 1 resident reviewed with updated medication orders, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 3/19/2025, alleged that Resident ID #'s 1 medical needs have not been met. Record review revealed that the resident was admitted to the facility in January of 2025 with diagnoses including, but not limited to, exocrine pancreatic insufficiency (a condition in which the pancreas does not produce enough digestive enzymes, leading to problems breaking down food), orthostatic hypotension (a condition when the blood pressure drops significantly when a person stands up from a sitting or lying position), and repeated falls. A. Record review of a progress note dated 3/24/2025 authored by Licensed Practical Nurse (LPN), Staff A, revealed in part, that the Nurse Practitioner…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-03-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety, relative to the main kitchen and the main dining room. Findings are as follows: 1. Review of the Rhode Island Food Code, 2018 Edition, section 3-501.17 states in part, .(B) .refrigerated, ready-to-eat time/temperature control for safety food .shall be clearly marked, at the time the original container is opened in a food establishment .and: (1) the day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date . During the initial tour of the main kitchen on 3/10/2025 at approximately 8:25 AM of the reach in refrigerator, the following was observed: -One, 8 pound (lb.) container of Cross Valley Farms Fruit Salad Deluxe in light syrup approximately ¾ full, open…
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 · F2025-03-12 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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 measure success and track performance of Quality Assurance and Performance Improvement (QAPI) actions to ensure that problem areas are identified, and good faith efforts for improvements are achieved and sustained demonstrated by measurable objectives with statistical data documented. Findings are as follows: Record review of the facility's 2025 QAPI plan states in part, .the QAPI Committee will utilize a formal and consistent methodology for planning, designing, measuring, assessing, and improving organizational performance and resident outcomes . Record review of the facility's 2024 and 2025 QAPI binder failed to reveal evidence of any actions, measurements, or tracking to ensure efforts for improvements of identified problem areas within the facility. During a surveyor interview on 3/12/2025 at approximately 12:30 PM with the Administrator, she acknowledged that the facility failed to develop actions, measurements, or tracking systems to measure and track performance of identified…
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 · E2025-03-12 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and staff interview, it has been determined that the facility failed to complete an annual performance review for every nurse aide (NA) at least once every 12 months for 4 of 4 NA personnel records reviewed, Staff E, F, G, and H. Findings are as follows: Record review of the personnel files failed to reveal evidence that an annual performance evaluation was completed for the following NA's: -Staff E with a date of hire of 5/30/2023 -Staff F with a date of hire of 9/27/2021 -Staff G with a date of hire of 7/19/2021 -Staff H with a date of hire of 4/16/2023 During a surveyor interview on 3/12/2025 at approximately 10:00 AM with the Administrator, she was unable to provide evidence of a completed performance evaluation within the last 12 months for Staff E, F, G, and H.
- Potential for harm · E2025-03-12 · tag F0940 — failed to train staff — patternDevelop, implement, and/or maintain an effective training program for all new and existing staff members.
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, implement, and maintain an effective training program for annual training for existing employees consistent with their expected roles, relative to education involving abuse, infection control, and dementia, per the facility assessment, for 8 of 10 employees reviewed, Staff E, F, G, H, J, K, L, and M. Findings are as follows: Review of the Facility Assessment, dated 1/1/2024, revealed in part, training topics are completed upon hire and annually for all staff, which include, but are not limited to, abuse and neglect, dementia management, and infection control. Record review revealed Nursing Assistant (NA), Staff E, was hired on 5/30/2023. Review of her training records failed to reveal evidence that she received annual education or training relative to abuse and neglect, or infection control. Record review revealed NA, Staff F, was hired on 9/27/2021. Review of his training records failed to reveal evidence that he received annual education or training relative to abuse 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 · D2025-03-12 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, it has been determined that the facility failed to provide written information to the resident or resident's representative that specifies the facility's bed-hold payment policy upon transfer to the hospital from the facility for 1 of 2 residents reviewed, Resident ID #42. Findings are as follows: Record review of a facility policy titled, Bed Hold Notification upon Transfer for Hospitalization or upon Taking Therapeutic Leave revealed in part, .Procedure: Whenever a resident is sent to the hospital or takes a therapeutic leave as required by state and federal regulations. Procedure: A copy of the Resident Bed Hold Notice .is to be filled out with the resident's name and the date and time of the hospital transfer by the charge nurse who is preparing the transfer papers .Emergency transfer: a. A copy of the resident's Bed Hold Notice is to be attached to the resident's interagency transfer papers by the charge nurse .b. The person who is responsible for notifying the representative of the emergency transfer .will review the Resident Bed…
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 · D2025-03-12 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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 a resident is given the appropriate treatment and services to maintain his or her ability to carry out activities of daily living, for 1 of 1 resident reviewed with unwanted facial hair, Resident ID #94. Findings are as follows: Record review revealed the resident was admitted to the facility in January of 2025 with diagnoses including, but not limited to, pelvic fracture and osteoarthritis (a form of arthritis, commonly affecting the joints in the hands). Record review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required supervision or touching assistance for personal hygiene. Further review revealed that assistance may be provided throughout the activity or intermittently. Surveyor observations on 3/10/2025 at 9:34 AM and 3/11/2025 at approximately 1:00 PM, revealed the resident was observed to have a moderate amount of facial hair to his/her chin, approximately a half…
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 before2025-03-12 · 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 record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, for 1 of 2 residents reviewed for hospitalization, Resident ID #7. Findings are as follows: Record review revealed the resident was re-admitted to the facility in October of 2024 following a hospital stay where s/he was diagnosed with a fecal impaction (hardened stool accumulated in the rectum) and a urinary tract infection. Record review of the provider's progress note dated 10/19/2024 states in part, .re-admission History and Physical .at [hospital], 9 cm [centimeter] ball of stool manually removed from resident, enema and bowel meds given . Record review of the physician's orders revealed an order dated 3/3/2022 which included the following: Bowel Protocol 1. Administer the Prune Juice if no bowel movement (BM) in 2 days 2. Give Milk of Magnesia (MOM) suspension by mouth for no BM in 3 days 3. Administer Dulcolax…
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 before2025-03-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it has been determined that the facility failed to ensure that residents with pressure ulcers receive the necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 3 residents reviewed with a pressure ulcer (skin and tissue injuries caused by constant pressure to a specific area of the body), Resident ID #196. Findings are as follows: Record review revealed the resident was admitted to the facility in January of 2025 with a diagnosis including, but not limited to, pressure ulcer with unspecified stage. Record review of the wound specialist assessment dated [DATE] revealed the resident developed a stage 3 pressure wound (full-thickness skin loss where subcutaneous fat is visible) to the right ischium (lower back part of the hip bone). Further record review revealed a dressing treatment recommendation dated 3/4/2025 to apply a foam silicone dressing (a type of wound dressing) three times, weekly. 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.
- Potential for harm · D2025-03-12 · 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 ensure residents are free of any significant medication errors for 1 of 1 resident reviewed who was receiving the medication Victoza (an injectable medication prescribed to help lower blood sugars), Resident ID #30. Findings are as follows: Record review revealed the resident was admitted to the facility in January of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus (high blood sugar caused by the body's inability to produce enough insulin). During the Resident Council Meeting on 3/11/2025 at 1:30 PM, it was revealed that Resident ID #30 did not receive his/her Victoza injection this past weekend. Record review revealed the following physician's orders: -7/3/2024 Humalog Insulin (insulin lispro) insulin pen; 100 unit/milliliter (mL); Amount to Administer: Per Sliding Scale; If Blood Sugar is less than 70, call MD. If Blood Sugar is 200 to 249, give 2 Units. If Blood Sugar is 250 to 300, give 4 Units. If Blood Sugar is 301 to 350, give 6 Units. If Blood Sugar 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.
- Potential for harm · E2025-01-15 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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, record review, 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 relative to weekly scheduled showers for 4 of 4 residents reviewed, Residents ID #s 1, 3, 4, and 5. Findings are as follows: Record review of a community reported complaint sent to the Rhode Island Department of Health on 1/10/2025 alleged that Resident ID #1 was not receiving the appropriate care at the facility. 1. Record review revealed Resident ID #1 was admitted to the facility in December of 2024 with a diagnosis including, but not limited to, multiple fractures of the ribs. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Additionally, s/he is coded as dependent on staff for his/her activities of daily living (ADLs) and indicated that showers are somewhat important 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 · Fcited before2024-03-25 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observation and staff interview, it has been determined that the facility failed to properly store and serve food under sanitary conditions relative to the serving temperatures of a potentially hazardous food item and improper cooling procedures. Findings are as follows: 1. Record review of The State of Rhode Island Food Code 2018 Edition 3-501.6 states in part, .Except during preparation, cooking or cooling .time/temperature control for safety, food shall be maintained at 5 degrees C [Celsius] 41 degrees F [Fahrenheit] or less . During a surveyor observation of the lunch meal in the dining room on 3/22/2024 at approximately 12:13 PM 19 souffle cups of tartar sauce were sitting at ambient temperature. The temperature reading was 62 degrees F. Following the above observation, a temperature recording of the tartar sauce served from the main kitchen had a temperature reading of 50 degrees F. During a surveyor interview on 3/22/2024 at approximately 12:25 PM, with the Food Service Director, he acknowledged the tartar sauce was not at the acceptable cold holding…
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 before2024-03-25 · tag F0880 — failed to prevent and control infections — patternProvide 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, surveyor observation, and staff interview it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to a potential gastrointestinal (GI) virus outbreak on 2 of 2 nursing units affecting Resident ID #s 23, 32, 33, and 38. Additionally, the facility staff failed to conduct appropriate infection control practices relative to wound dressing changes for 1 of 2 residents with observed dressing changes, Resident ID #22. Findings are as follows: Review of a facility policy titled, Surveillance Guidelines last revised 1/2018 states in part, .POLICY: It is the policy of this facility to carry out routine, regular surveillance throughout the facility .Outcome Surveillance- a process designed to identify and report evidence of infection. The process involves the collection/documenting of data on individual cases and comparing the collected data to standard written definitions of infections for the purpose of identifying the prevalence 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 before2024-03-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, it has been determined that the facility failed to ensure a resident receives care consistent with professional standards of practice to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 of 4 residents reviewed, Resident ID #36. Findings are as follows: Resident ID #36 was admitted to the facility in January of 2024 with a diagnosis that includes, but is not limited to, traumatic hemorrhage of the cerebrum(brain). Record review revealed a physician's order for, .encourage/assist to offload heels as tolerated, free float heels with pillow/blanket roll .while bed resting .every shift. Record review of a care plan developed on 1/24/2024 revealed in part, .potential for skin breakdown as a result of weakness . Further record review of the care plan revealed an approach including, but not limited to, keep bony prominences from direct contact and to offload heels to reduce pressure. Surveyor observations on the following dates and times revealed the resident in bed resting 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 · D2024-03-25 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
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 be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 1 resident reviewed for an adaptive call pad, Resident ID #34. Findings are as follows: According to, State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities last revised 2/3/2023, revealed in part that the facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside. Guidance dictates that the call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room. Record review revealed the resident was admitted to the facility in May of 2022 with a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-13 · tag F0776 — isolatedProvide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview it has been determined that the facility failed to provide or obtain radiology services to meet the needs of its residents relative to obtaining a STAT (diagnostic or therapeutic procedure that is to be performed immediately) X-Ray for 1 of 2 residents reviewed, Resident ID #8. Findings are as follows: Record review of a community reported complaint dated 12/7/2023 alleged that Resident ID #8 sustained a fall on 12/3/2023 and did not receive the appropriate medical attention until 12/5/2023. Record review revealed that the resident was admitted to the facility in December of 2023 with diagnoses including, but not limited to, right femur fracture and repeated falls. Review of a progress note dated 12/3/2023 revealed the resident sustained a fall at 4:55 AM. Additionally, it revealed that the resident complained of left groin pain. During a surveyor interview on 12/12/2023 at 11:30 AM with Registered Nurse (RN), Staff A, she revealed that the resident fell on her shift at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2025-03-12 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 properly provide notice to residents and/or representatives informing when changes in coverage are made to items and services covered by Medicare and/or the state medical plan related to the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) of Non-coverage Form for 4 of 5 residents discharged with Medicare Part A Services, Resident ID #s 294, 295, 296, and 297. Findings are as follows: Review of the Center for Medicare and Medicaid Services (CMS) Form, CMS 100-55, titled Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage, states in part, Medicare requires SNFs [Skilled Nursing Facilities] to issue the SNFABN to Original Medicare, also called fee-for-service (FFS) beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is: - not medically reasonable and necessary. - or considered custodial. The SNFABN provides information to the beneficiary so that s/he can decide whether or not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-03-25 · tag F0637 — patternAssess the resident when there is a significant change in condition
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 complete a significant change in status assessment within 14 days after there has been a significant change in the resident's physical or mental condition for 4 of 5 sample residents reviewed, Resident ID #s 7, 9, 17, and 30. Findings are as follows: According to the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual version 3.0, last updated 10/2023 Section A states in part, .If a nursing home resident elects the hospice benefit, the nursing home is required to complete an MDS Significant Change in Status Assessment (SCSA). The nursing home is required to complete an SCSA when the resident comes off the hospice benefit (revoke). See Chapter 2 for details on this requirement. It is a CMS requirement to have an SCSA completed EVERY time the hospice benefit has been elected, even if a recent MDS was done and the only change is the election of the hospice benefit . 1. Record review revealed Resident ID #7 was admitted to the facility in February of 2023 with a diagnosis…
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
$90,716 in federal fines across 3 penalties. 1 Medicare payment denial on record.
- $15,883 — penalty dated 2026-03-30
- $16,801 — penalty dated 2024-03-25
- $58,032 — penalty dated 2023-12-13
- Medicare payment denial — starting 2024-04-16 for 2 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to EDEN HEALTHCARE — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.0 | -1.0 vs chain |
| Health inspection | 2 of 5 | 2.9 | -0.9 vs chain |
| Staffing | 3 of 5 | 3.4 | -0.4 vs chain |
| Quality measures | 2 of 5 | 2.4 | -0.4 vs chain |
The other 6 homes this chain runs (chain average 3.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GELLIS, LOUIS | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 100% | since 07/27/2021 |
| POLLACK, JOSEPH | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/07/2022 |
CMS files one row per role, so the 3 rows in the source record cover these 2 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 $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in RI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Rhode Island Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 415023. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-30, 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.