Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Golden Crest Nursing Centre during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease and a femur fracture, who was on a diuretic and had a care plan for altered fluid maintenance, did not receive consistent monitoring and documentation of fluid intake as required. Nursing standards cited in the record indicated a minimum desirable adult intake of 1,500 mL per day, yet EMR review showed missing intake documentation for most shifts over several weeks and recorded intake below 1,500 mL on nearly all days reviewed. Lab results showed an increase in creatinine, noted as a possible sign of dehydration. An LPN and the ADON both acknowledged that staff were expected to monitor and document the resident’s fluid intake in the EMR each shift, but this did not occur as expected.
The facility failed to ensure complete and accurate clinical records for two residents who required extensive staff assistance with ADLs, including personal hygiene and toileting. Despite documented needs such as a left femur fracture with Alzheimer’s disease and paraplegia with staff dependence for care, the NA Point of Care records for a specific day shift contained no entries showing that ADL assistance was provided. A complainant alleged inadequate staffing and lack of assistance for one resident during that shift, and the ADNS acknowledged that NAs did not document the care provided as required by professional documentation standards.
The facility failed to develop and implement individualized care plans for residents, leading to inadequate assistance and care. Residents with specific needs, such as those with multiple sclerosis, dementia, and PTSD, did not have care plans that detailed the necessary level of assistance. Staff relied on verbal communication rather than comprehensive care plans, resulting in inconsistencies in resident care.
A resident with arthritis and muscle weakness was found to have five unopened lidocaine patches in their room without an assessment for self-administration. A physician's order required the application of a lidocaine patch daily, but there was no evidence of an assessment for self-administration. An LPN and the Assistant DON confirmed that the patches should have been stored in the medication cart.
The facility failed to properly store and label medications, as observed during a survey. Expired medications were found on the 2 East Medication Cart, and undated medications were discovered on the 2 [NAME] Medication Cart. Additionally, an undated multidose vial of Aplisol was found in the 2 East Medication Room. Staff acknowledged the oversight, and the DON expected medications to be dated and discarded appropriately.
A facility failed to maintain an infection prevention and control program for a resident using a BIPAP device. The resident, who had sleep apnea and acute respiratory failure, reported that their BIPAP machine was not cleaned by the facility. The manufacturer's instructions require daily cleaning of the device, but the facility did not have an order to clean the equipment, and the Director of Nursing Services could not provide evidence of cleaning.
A resident with GERD refused Famotidine on multiple occasions due to its liquid form, but the facility failed to notify the physician of these refusals. Staff interviews confirmed the lack of communication, and the DON acknowledged the oversight, unable to provide evidence of physician notification.
A resident with a history of Peripheral Artery Disease and bilateral below-knee amputations was observed to have pressure ulcers. During a dressing change, an LPN did not follow physician orders for wound care, soaking a wound for only 2 minutes instead of 10 and failing to apply skin prep. The DON could not provide evidence that treatments were administered as ordered.
A resident with multiple health conditions, including Crohn's disease and chronic osteomyelitis, experienced a significant weight gain of 12.27% over one month, which was not addressed according to facility policy. Despite the requirement for reweights and physician notification, these actions were not taken until identified by a surveyor. Interviews with staff revealed a lack of awareness and action regarding the resident's weight gain.
A pharmacist failed to report medication irregularities for a resident prescribed as-needed Seroquel, an antipsychotic, without a stop date. Despite facility policy requiring monthly reviews and reporting of irregularities, the pharmacist's recommendations were not communicated to the facility, resulting in the resident receiving the medication without the recommended 14-day stop date.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.25% error rate. A resident's Depakote was crushed against packaging instructions, and MiraLAX was not administered but signed off as given. A CMT acknowledged the error, and an RN confirmed the discrepancies.
A resident with multiple health issues, including muscle weakness and failure to thrive, was found unable to reach their call light, which was tied to the bed rail on the opposite side of the bed. This oversight was acknowledged by a nursing assistant and the DON, who confirmed the care plan was not followed.
A resident with significant weight loss and multiple diagnoses did not receive a prescribed nutritional supplement for 5 out of 16 opportunities due to the supplement being on back order. The deficiency was acknowledged by the DON.
The facility failed to ensure that the environment was free from accident hazards for two residents at moderate risk for falls. One resident with dementia was observed trying to get up from a wheelchair without the call light within reach, and another resident with bipolar disorder was in pain and unable to locate the call light. Staff acknowledged that the call lights were not within reach as required.
Failure to Monitor and Document Hydration for a Resident on Diuretics
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate monitoring and assistance with hydration for a resident with identified fluid maintenance needs. The resident was admitted with a left femur fracture and Alzheimer’s disease and had a care plan problem of altered fluid maintenance related to diuretic use and poor insight into hydration needs. An intervention to monitor the resident’s fluid intake was initiated on 3/19/2026. Fundamentals of Nursing 7th Edition (2011) was cited, indicating that desirable adult fluid intake ranges from 1,500 to 3,500 mL per 24 hours, averaging 2,500 to 2,600 mL per day, and that intake records should be initiated and maintained for patients with real or potential water or electrolyte problems. A community complaint alleged that the facility was short staffed and allowing the resident’s health to decline, including inconsistent assistance with hydration. Clinical record review showed that laboratory results on 4/9/2026 revealed a creatinine level of 1.47 mg/dL, elevated from 1.25 mg/dL on 4/2/2026, with the report noting that elevated creatinine may be a sign of dehydration. Staff interviews confirmed that staff were expected to monitor and document the resident’s fluid intake in the electronic medical record (EMR) every shift. However, EMR review from 3/21/2026 through 4/14/2026 showed missing fluid intake documentation for 53 of 75 shifts and that the resident’s recorded intake did not meet the minimum recommended 1,500 mL per day for 24 of 25 days reviewed. The Assistant Director of Nursing Services stated that she expected staff to document the resident’s fluid intake in the EMR as required, confirming that the facility did not follow its own expectations for monitoring and documenting the resident’s hydration status.
Failure to Accurately Document ADL Assistance in Clinical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for residents in accordance with accepted professional standards, specifically related to documentation of assistance with activities of daily living (ADLs). A community complaint reported to the Rhode Island Department of Health alleged that the facility was short staffed and allowing one resident’s health to decline, including an allegation that there was not enough staff to assist this resident during a specified day shift. Fundamentals of Nursing, Seventh Edition (2011), was cited regarding the requirement that nursing documentation be complete, accurate, current, factual, and organized, and that care not documented is considered not done. Record review showed that one resident, admitted in March 2026 with a left femur fracture and Alzheimer’s disease, had a Comprehensive MDS indicating a need for maximal assistance with personal hygiene and toileting, yet the NA Point of Care History for the referenced day shift contained no documentation that assistance with care was provided. A second resident, admitted in November 2022 with paraplegia and identified on a Quarterly MDS as staff-dependent for personal hygiene and toileting, also had no documented assistance with care on the NA Point of Care History for the same day shift. During interview, the Assistant Director of Nursing Services acknowledged that NAs failed to document in the clinical record the care provided to these two residents during that shift, as required.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans with measurable objectives and timeframes to meet the medical, nursing, mental, and psychosocial needs of residents. This deficiency was identified for five residents, each with specific needs related to their diagnoses and conditions. For instance, one resident with multiple sclerosis and spastic quadriplegia experienced a fall from bed due to inadequate assistance during morning care, highlighting the lack of a focused care plan addressing their ADL needs. Another resident with muscle weakness and dementia required substantial assistance with ADLs, yet their care plan lacked a person-specific approach detailing the level of staff assistance required. Similarly, a resident with PTSD and Parkinson's disease had a care plan that failed to address their specific needs, including a culturally competent and trauma-informed approach for PTSD. The deficiency was further compounded by the facility's reliance on verbal communication among staff to determine the level of assistance needed for residents, rather than utilizing comprehensive care plans. Interviews with staff revealed inconsistencies in the documentation and communication of residents' care needs, with some staff unaware of the care plans or relying on undated and incomplete documents.
Improper Storage of Medications in Resident's Room
Penalty
Summary
The facility failed to store medications in accordance with currently accepted professional principles for a resident who was admitted with diagnoses including arthritis and muscle weakness. A physician's order dated October 1, 2024, prescribed a lidocaine adhesive patch 4% to be applied to the resident's right shoulder every morning and removed at bedtime. However, there was no evidence of an assessment for the resident's self-administration of the medication, which would indicate the resident's safety in storing and administering their medications. During a surveyor observation on November 4, 2024, five unopened lidocaine patches were found in the resident's room. Interviews with an LPN and the Assistant Director of Nursing Services confirmed that the patches should not have been in the resident's room and should have been stored in the medication cart instead.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles, as observed during a survey. On the 2 East Medication Cart, several medications, including Latanoprost Solution, Timolol Maleate Gel Forming Solution, Artificial Tears Ophthalmic Solution, and brimonidine-timolol drops, were found to be expired but not discarded. The Certified Medication Technician, Staff E, acknowledged the oversight during the surveyor's observation. Additionally, the Registered Nurse, Staff D, confirmed that staff should be dating medications when opened and discarding them upon expiration. Further observations on the 2 [NAME] Medication Cart revealed multiple bottles of eye drops, such as Cosopt, Artificial Tears Ophthalmic Solution, Systane Complete PF, and brimonidine-timolol drops, that were opened but undated, leaving their expiration status unknown. Staff F admitted to being unsure of the expiration dates. In the 2 East Medication Room, a multidose vial of Aplisol was found opened and undated, with RN Staff D unable to provide evidence of when it was opened. The Director of Nursing Services expressed that staff are expected to date medications when opened and discard them appropriately.
Failure to Maintain Infection Control for BIPAP Device
Penalty
Summary
The facility failed to maintain an infection prevention and control program for a resident using a Bilevel Positive Airway Pressure (BIPAP) device. The manufacturer's instructions for the BIPAP device, dated July 2017, require that the flexible tube and mask be cleaned before first use and daily thereafter. However, the facility did not follow these instructions for Resident ID #77, who was readmitted in August 2024 with diagnoses including sleep apnea and acute respiratory failure. The resident, who had intact cognition, reported to the surveyor that the facility did not clean their BIPAP machine. A review of the Treatment Administration Record for August and September 2024 showed that the resident had an order to use the BIPAP machine every night, but there was no order to clean the mask and tubing. The Director of Nursing Services confirmed that the facility's policy is to follow the manufacturer's instructions for cleaning the BIPAP equipment, but acknowledged that there was no order to clean the equipment for the resident and could not provide evidence that the machine was cleaned as required.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to meet professional standards of quality for a resident with medication refusals. The resident, who was readmitted to the facility with a diagnosis of gastro-esophageal reflux disease (GERD), had a physician's order for Famotidine, a medication prescribed to treat GERD. The medication was not administered on multiple occasions due to the resident's refusal, specifically on six different dates. Despite these refusals, there was no evidence that the provider was notified about the resident's refusal to take the medication. Interviews with facility staff revealed that the resident often refused the medication because it was in liquid form, although the resident was willing to take pills. Both a Certified Medication Technician and a Licensed Practical Nurse acknowledged that the provider had not been informed of the refusals. The Director of Nursing Services confirmed that the physician should have been notified if a patient was not taking a medication, but he was unable to provide evidence that this notification occurred.
Failure to Follow Wound Care Orders for Resident at Risk for Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident at risk for pressure ulcers, as observed during a survey. The resident, who was admitted in May 2023, has a medical history that includes Peripheral Artery Disease, Peripheral Vascular Disease, and bilateral below-knee amputations. The resident's care plan identified a risk for impaired skin integrity, with existing pressure ulcers on the coccyx, right lower shin, and right lateral knee. Physician orders specified detailed wound care procedures, including the use of Vashe wound cleanser and skin prep application to peri-wounds. During a dressing change observation, it was noted that the LPN, Staff C, did not adhere to the physician's orders. The coccyx wound was soaked with Vashe for only 2 minutes instead of the prescribed 10 minutes, and skin prep was not applied to the peri-wounds as required. Staff C acknowledged the failure to follow the orders during interviews. The Director of Nursing Services could not provide evidence that the treatments were administered as ordered, indicating a lapse in following professional standards of practice for wound care.
Failure to Address Significant Weight Gain in Resident
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, as evidenced by a significant weight gain that was not addressed in accordance with the facility's policy. The resident, who was admitted with conditions including Crohn's disease, rectal abscess, pressure ulcer, and chronic osteomyelitis, experienced a weight gain of 14.4 pounds, or 12.27%, over the course of one month. Despite the facility's policy requiring reweights and notification of the physician if a significant weight discrepancy is noted, there was no evidence that these actions were taken until the issue was identified by a surveyor. Interviews with facility staff, including a registered nurse, the dietitian, and the Director of Nursing Services, revealed a lack of awareness and action regarding the resident's significant weight gain. The registered nurse acknowledged the alarming nature of the weight gain, especially given the resident's fluid restriction, but confirmed that no reweights were obtained and the physician was not notified. The dietitian, who reviews weights weekly, was unaware of the extent of the weight gain and had not reported it to the physician. The Director of Nursing Services also confirmed that he was unaware of the situation until it was brought to his attention by the surveyor.
Pharmacist's Failure to Report Medication Irregularities
Penalty
Summary
The deficiency involves a failure by the facility's pharmacist to report medication irregularities for a resident prescribed as-needed antipsychotic medication. The facility policy requires a monthly drug regimen review by a licensed pharmacist, who must report any irregularities to the attending physician, Medical Director, and Director of Nursing Services (DNS). However, for one resident with a history of major depressive disorder, anxiety disorder, post-traumatic stress disorder, and paranoid personality disorder, the pharmacist did not report the absence of a stop date for the antipsychotic medication Seroquel, which was prescribed as needed. The resident was admitted with a physician's order for Seroquel without a stop date, and the pharmacy made recommendations on two occasions, but these were not communicated to the facility. The DNS was unaware of the pharmacist's recommendations until the surveyor's inquiry, indicating a lapse in communication and adherence to the facility's medication regimen review policy. The failure to report and act on the pharmacist's recommendations resulted in the resident receiving the medication without the recommended 14-day stop date, highlighting a deficiency in the facility's medication management process.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6.25% error rate during a medication administration task. This deficiency involved a resident who had physician's orders for Depakote and MiraLAX. During an observation, a Certified Medication Technician failed to administer MiraLAX and crushed a Depakote tablet, despite the packaging instructions indicating not to crush or chew the medication. The technician acknowledged the error when interviewed by the surveyor. Additionally, a Registered Nurse confirmed that the MiraLAX was incorrectly signed off as administered, and acknowledged that the Depakote should not have been crushed.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide person-centered care in accordance with a resident's plan of care, specifically regarding the accessibility of the call light for a resident with multiple health issues. The resident, admitted in April 2024, had diagnoses including adult failure to thrive, paroxysmal atrial fibrillation, and muscle weakness. The care plan dated April 18, 2024, included interventions to prevent falls and injuries, such as ensuring the call light was within reach and reminding the resident to call for assistance as needed. During a surveyor observation on July 15, 2024, the resident was found seated in a wheelchair with the call light tied to the bed rail on the opposite side of the bed, out of sight and reach. The resident expressed feeling trapped and having to yell for help due to the inability to access the call light. A nursing assistant acknowledged the oversight and relocated the call bell within the resident's reach. The Director of Nursing Services also acknowledged that the care plan had not been followed in this instance.
Failure to Administer Nutritional Supplement as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following a physician's order for nutritional supplements. The resident, who was admitted in October 2023 with diagnoses including acquired absence of the right leg below the knee and type II diabetes mellitus, experienced significant weight loss over a month. A physician's order dated 4/23/2024 prescribed 60 milliliters of an oral nutritional supplement twice daily. However, the resident did not receive the supplement for 5 out of 16 opportunities in May 2024 because it was not available in the facility and was on back order. This deficiency was acknowledged by the Director of Nursing Services during a surveyor interview on 5/9/2024.
Failure to Ensure Call Lights Within Reach for Residents at Fall Risk
Penalty
Summary
The facility failed to ensure that the residents' environment remained as free from accident hazards as possible for two residents identified as being at moderate risk for falls. Resident ID #3, who has a history of dementia and falls, was observed attempting to get up from a wheelchair and calling for help, with the call light hanging approximately 8 feet away from the resident. The Registered Nurse acknowledged that the call light was not within the resident's reach, which was a required intervention in the resident's care plan. Similarly, Resident ID #2, who has a history of urinary tract infection and bipolar disorder, was observed lying in bed and experiencing pain. The resident was unable to locate the call light to request pain medication and asked the surveyor to get the nurse. The Licensed Practical Nurse confirmed that the call light was out of the resident's reach, hanging off the bedside rail. The Director of Nursing Services stated that he would expect residents to have their call lights within reach.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 629 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near North Providence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lincolnwood Rehabilitation And Healthcare Center | 1.2 mi | ★★★★★ | 9 | 0 |
| Berkshire Place | 1.4 mi | ★★★★★ | 17 | 0 |
| Elmhurst Rehabilitation And Healthcare Center | 1.5 mi | ★★★★★ | 10 | 1 |
| Heritage Hills Nursing & Rehabilitation Center | 1.8 mi | ★★★★★ | 21 | 2 |
| Cherry Hill Manor | 2.2 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Golden Crest Nursing Centre.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.