Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 52 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
1K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
27D
13E
4F
Potential for minimal harm
0A
1B
0C
June 16, 2026Standard inspection · 11 citations
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on surveyor observations, clinical record review, and resident and staff interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 3 of 4 units observed.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on surveyor observations, clinical record reviews, and staff interviews, the facility failed to ensure that services were provided in accordance with professional standards of quality relative to not following physician orders, for 3 of 3 residents. This included failing to change a wound dressing daily, as ordered, for Resident #10, failing to implement interventions related to weight loss, for Resident #11, and failing to provide seizure pads while in bed, as ordered, for Resident #157.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, surveyor observation, and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to 1 of 1 resident reviewed who complained of chest pain and requested a hospital transfer, Resident ID #104.
- D
Provide appropriate foot care.
Inspectors wroteBased on surveyor observation, clinical record review, and staff and resident interviews, the facility failed to provide treatment and care to maintain good foot health for 1 of 1 resident reviewed who complained of foot pain who is a type II diabetic and has a history of diabetic foot ulcers, Resident ID #40.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on surveyor observations, clinical record review, and staff interview, the facility failed to complete quarterly smoking assessments for 2 of 5 residents reviewed who smoke, Resident ID #s 79 and 116.
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that residents who are trauma survivors, receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents experiences, and preferences, in order to eliminate, or mitigate triggers that may cause re-traumatization of the resident, for 1 of 1 resident reviewed with a history of trauma, Resident ID #13.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that bed rails were used only when assessed, clinically indicated, and implemented in accordance with the resident's needs for 2 of 2 residents reviewed with bed rails, Resident ID #s 124 and 158.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on surveyor observation, clinical record review, and staff interviews, the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 27 opportunities for errors observed during the medication administration task, 2 errors occurred, resulting in an error rate of 7.41% affecting Resident ID #s 128 and 133.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to accurately maintain the resident's medical record in accordance with accepted professional standards and practices relative to 1 of 1 closed record missing a discharge summary, Resident ID #171.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on clinical record review, surveyor observation, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and the use of Enhanced Barrier Precautions (EBP; refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and glove use during high contact resident care activities), for 2 of 2 residents reviewed with wounds, Resident ID #s 63 and 93, and for 1 of 1 resident reviewed with a Peripherally Inserted Central Catheter (PICC, a long, flexible, thin tube inserted through a vein in the upper arm and advanced into a large vein near the heart) Resident ID # 66.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections relative to the pneumonia vaccine policy's failure to align with current guidelines, as recommended, by the Advisory Council on Immunization Practices (ACIP) and Centers for Disease Control and Prevention (CDC).
August 5, 2025Complaint inspection · 3 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, staff and resident interview it has been determined that the facility failed to keep a resident free from neglect relative to 1 of 1 resident reviewed who was left unattended outside of the facility for approximately 3 hours and 20 minutes during a heat advisory resulting in cardiac arrest, Resident ID #1.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality relative to following physician's orders for 1 of 3 residents reviewed, Resident ID #1.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from significant medication errors for 1 of 1 resident reviewed receiving amoxicillin-clavalanate (an antibiotic) and divalproex (a medication used to treat mood disorders) and 1 of 2 residents reviewed requiring insulin, Resident ID #1.
March 3, 2025Standard inspection, Complaint inspection · 17 citations
- K
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on surveyor observation, resident, and staff interview, it has been determined that the facility failed to ensure a safe environment was maintained relative to unsafe water temperatures, for 4 of 4 floors observed.
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed ensure the director of food and nutrition services met the minimum qualifications of a Certified Food Safety Manager.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the Director of Food and Nutrition Services met the minimum qualifications of a Certified Food Safety Manager for 1 of 1 Food Service Director (FSD) reviewed. Additionally, the facility failed to ensure that food is stored and distributed, in accordance with professional standards for food safety relative to the main kitchen and 4 of 4 kitchenettes.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that the assessment accurately reflected the resident's status for 2 of 2 residents reviewed for dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to.), Resident ID #s 35 and 137, 1 of 2 residents reviewed for elopement, Resident ID #161, 1 of 2 residents reviewed for wounds infected with a Multidrug Resistant Organism (MDRO), Resident ID #83 and 1 of 2 closed records reviewed, Resident ID #169.
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to review and revise the resident's care plan by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments relative to 29 of 29 long term care residents reviewed, Resident ID #s, 3, 5, 6, 9, 10, 15, 21, 22, 23, 25, 29, 35, 38, 44, 67, 70, 75, 78, 83, 88, 95, 123, 129, 137, 139, 140, 142, 161, and 520.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice for 1 of 1 resident reviewed relative to Narcan administration, Resident ID #25, 2 of 6 residents reviewed for following physician orders relative to unnecessary medication, Resident ID #s 44 and 123, 1 of 1 resident seen by the podiatrist, Resident ID #78, 1 of 2 residents observed with a non-pressure wound, Resident ID #83 and 1 of 3 residents receiving a medication that requires blood levels to be monitored, Resident ID #95.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 1 resident reviewed for suctioning, Resident ID #96.
- E
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.
Inspectors wroteBased on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 3 of 8 medication carts observed on 3 of 4 units and 1 of 2 medication storage rooms observed.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide food that is palatable, attractive, and at an appetizing temperature.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to contact precautions (utilized when a resident is known or suspected to be infected with a Multidrug Resistant Organism [MDRO] that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces in the resident's room), for 3 of 3 residents reviewed on contact precautions, Resident ID #s 25, 38, and 83; for 3 of 5 residents reviewed for enhanced barrier precautions (EBP- refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) Resident ID #s 3, 123 and 161; [...]
- E
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to implement and maintain an effective training program for all newly hired employees, consistent with their expected roles, relative to orientation education, as outlined in the facility assessment, for 4 of 5 newly hired employees, Staff J, X, Y, and the Food Service Director (FSD).
- D
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that they not employ or otherwise engage individuals who have been found guilty of abuse or mistreatment by a court of law, for 1 of 1 personnel record reviewed for disqualifying information, Maintenance Assistant, Staff A.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased 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 and the comprehensive care plan relative to 1 of 3 wounds observed, Resident ID #137.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on surveyor observation, 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, prevent infection, and prevent new ulcers from developing for 1 of 1 resident observed with a pressure ulcer, Resident ID #3.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed with a nephrostomy tube (PCN, a catheter that is inserted through your skin and into your kidney), Resident ID #64.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 2 residents reviewed for warfarin (Coumadin, a medication prescribed to prevent blood clots), Resident ID #23.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to obtain laboratory services to meet the needs of its residents for 1 of 2 reviewed for warfarin (Coumadin, a medication prescribed to prevent blood clots), Resident ID #23 and for 1 of 2 residents reviewed with an elevated white blood count (WBC), Resident ID #420.
January 13, 2025Complaint inspection · 1 citation
- F
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on surveyor observation, record review, and resident and staff interviews, it has been determined that the facility failed to provide a safe, sanitary, and comfortable environment on 4 of 4 nursing units observed.
November 20, 2024Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that a resident received adequate supervision for 1 of 1 resident reviewed who was assessed to be a moderate risk for wandering, previously displayed exit seeing behavior and was able to successfully elope from the facility, Resident ID #1.
June 24, 2024Complaint inspection · 3 citations
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety, relative to a peripherally inserted central catheter (PICC- which is inserted into a vein in the arm and passed through to the larger veins near your heart), for 1 of 1 resident reviewed, Resident ID #1.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) to meet the needs of each resident for 1 of 3 residents reviewed, Resident ID #1. Record review of a community reported complaint received by the Rhode Island Department of Health on 6/19/2024 alleges that Resident ID #1 has not received his/her methadone (a medication used to treat opioid use disorder) and other medications for two days. The complaint further indicates that the resident tried to speak with the facility staff about this and was told they were checking with the pharmacy. [...]
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure that residents are free significant medication errors for 1 of 1 resident reviewed, Resident ID #1.
March 15, 2024Standard inspection, Complaint inspection · 13 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased 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 1 of 3 wound treatments observed, Resident ID #129.
- G
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 2 of 11 residents reviewed for nutrition, Resident ID #s 98 and 129.
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on surveyor observation, record review, and staff interviews, it has been determined that the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 wound treatments observed, Resident ID #79.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed, in accordance with professional standards for food safety relative to the main kitchen and 2 of 2 ice machines.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased 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 incontinence care for 1 out of 1 incidence of incontinence care observed, Resident ID #129 and relative to the weekly scheduled showers for 9 out of 32 residents reviewed, Resident ID #s 1, 11, 38, 41, 46, 63, 82, 112, and 118.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to keep residents free from significant medication errors for 6 of 32 residents reviewed, Resident ID #s 7, 42, 48, 70, 112 and 123.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to 2 of 3 residents observed for a wound dressing change, Resident ID #s 87 and 105. Additionally, the facility staff failed to conduct appropriate infection control practices relative to hand hygiene for 4 of 4 residents observed during the medication administration task, Resident ID #s 7, 33, 86, and 443.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to other officials (Department of Health), in accordance with State law, for 1 of 1 resident reviewed for an injury of unknown origin, Resident ID #129.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to following a physician's order for 1 of 1 resident reviewed for carbon dioxide retention, Resident ID #3, 1 of 1 resident reviewed for off-loading heel booties, Resident ID #66, 1 of 1 resident reviewed for knee splints, Resident ID #75, and 1 of 2 residents reviewed for edema (swelling), Resident ID #105.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 2 of 5 residents reviewed with an indwelling catheter (a flexible tube that collects urine from the bladder and leads to a drainage bag), Resident ID #s 79 and 129.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased 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 25 opportunities for errors observed during the medication administration task there were 2 errors resulting in an error rate of 8%, involving Resident ID #s 7 and 86.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to maintain medical records on each resident that are accurately documented for 1 of 1 resident reviewed for heel boots, Resident ID #66 and 1 of 1 resident reviewed for off-loading wounds and elevating legs, Residents ID #105.
- B
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased 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 2 of 4 residents discharged from Medicare Part A Services that remained in the facility, Resident ID #s 111 and 143.
February 7, 2024Complaint inspection · 1 citation
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on surveyor observation, record review, and resident and staff interview, it has been determined that the facility failed to maintain a safe, clean, sanitary, homelike environment relative to mouse droppings in resident rooms for 2 of 4 units reviewed.
December 26, 2023Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide adequate supervision to prevent an accident hazard for 1 of 2 residents reviewed for elopement, Resident ID #1.
October 11, 2023Complaint inspection · 1 citation
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to maintain acceptable parameters of nutritional status for 2 of 3 residents reviewed for weight loss, Resident ID #s 2 and 3.
Fire safety inspections
10 fire safety citations on file: 2 on June 16, 2026, 2 on March 3, 2025, 6 on March 15, 2024.
Every fire safety citation10 citations
- F
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · June 16, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 16, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · March 3, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 3, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 15, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · March 15, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 15, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 15, 2024 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · March 15, 2024 · Corrected (the home has a date of correction)
- D
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · March 15, 2024 · Corrected (the home has a date of correction)