Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Tockwotton On The Waterfront during CMS and state inspections, most recent first.
Hospice Documentation and Assessment Deficiencies: The facility failed to ensure hospice services met professional standards for two residents receiving hospice care, both with dementia. One resident did not have a timely Significant Change MDS after starting hospice, and both residents initially lacked required hospice records in their charts, including the hospice POC, physician certification/recertification, hospice orders, contact information, and other required hospice documentation.
Failure to document urinary output for two residents with urinary catheters. One resident had an indwelling Foley catheter and another had a suprapubic tube; both were identified as at risk for UTI and had orders/care plan interventions to monitor and record output each shift. RN staff and the DON acknowledged that output was not documented each shift in the EMR.
A resident was hospitalized due to a significant medication error involving Metoprolol. The resident, with a history of congestive heart failure and atrial fibrillation, received an overdose of 62.5 mg instead of the prescribed 37.5 mg. This error, caused by a CMT not following protocol, led to bradycardia and required hospital transfer.
A resident with congestive heart failure and atrial fibrillation received an overdose of Metoprolol, leading to hospitalization. The facility failed to follow a physician's order to reassess the resident after a significant change in condition, as no evidence of the reassessment was found. The Director of Nursing acknowledged the oversight during an interview.
The facility's main kitchen failed to meet food safety standards, with expired and unlabeled food items and unsanitary conditions in storage areas. The Executive Chef and Dietary Manager acknowledged the issues, including expired capers and pepperoncini, unlabeled containers, pooling blood in the refrigerator, and ice accumulation in the freezer.
A resident with dementia and mobility issues developed a pressure ulcer on the right heel. Despite physician orders to offload the heels and avoid shoes, surveyors observed the resident wearing shoes and with heels resting on the mattress. Interviews with staff revealed a lack of awareness and adherence to the care plan, indicating a failure in executing care protocols.
The facility failed to prevent significant medication errors for two residents. One resident received incorrect insulin dosages based on their blood glucose readings, while another resident's Amlodipine was administered late, contrary to physician orders. Staff interviews confirmed these discrepancies, highlighting a failure in adhering to prescribed medication schedules.
A resident with dysphagia and other conditions had a diet order change from nectar thick to honey thick liquids, but the facility failed to update the MAR and continued administering the incorrect consistency. A surveyor observed a technician preparing the wrong consistency, and both the DON and Medical Director confirmed the error.
The facility failed to accurately document medication administration for two residents. One resident received an incorrect insulin dosage, and another had medications administered late but documented as charted late. These errors were acknowledged by staff and the DNS.
A facility failed to implement proper droplet/contact precautions for a resident with influenza. Despite orders and signage requiring gloves and eye protection, a nursing assistant entered the resident's room without them. The staff member admitted to not following protocol, and both the Infection Preventionist and DON confirmed the expectation for protective equipment use.
Hospice Documentation and Assessment Deficiencies
Penalty
Summary
The facility failed to ensure that hospice services met professional standards for two residents receiving hospice care, both of whom had dementia diagnoses. Resident ID #6 began hospice services on 3/23/2026, but the record did not show that a Significant Change MDS Assessment was completed within 14 days of starting hospice services. During interview, the MDS Coordinator acknowledged that the assessment should have been completed within that timeframe and confirmed it had not been done until 4/15/2026, after the surveyor brought it to the facility’s attention. For Resident ID #6, the electronic and paper records initially did not contain the most recent hospice plan of care, physician certification and recertification of terminal illness, hospice personnel contact information, hospice medication information, hospice physician and attending physician orders, or delineation of hospice responsibilities. For Resident ID #8, who began hospice services in February 2026, the records initially did not contain the most recent hospice plan of care, hospice election form, physician certification and recertification of terminal illness, hospice personnel contact information, instructions for the hospice 24-hour on-call system, hospice medication information, hospice physician and attending physician orders, or delineation of hospice responsibilities. The DON acknowledged that the hospice documentation was obtained and placed in the residents’ charts only after it was brought to the facility’s attention by the surveyor.
Failure to Document Urinary Output for Residents With Catheters
Penalty
Summary
The facility failed to provide appropriate monitoring of urinary output for two residents with indwelling urinary catheters. Resident ID #9 was admitted with neuromuscular dysfunction of the bladder, had an indwelling Foley catheter, and was identified in the care plan as being at risk for urinary tract infection. A physician order dated 2/19/2025 directed staff to monitor Foley output every shift, but the record did not show urine output documentation on multiple shifts, including 4/2, 4/3, 4/4, 4/7, 4/10, 4/11, and 4/13. During interview, an RN stated that urine output should be documented in the electronic medical record. Resident ID #10 was admitted with flaccid neuropathic bladder and had a suprapubic tube, with the care plan identifying risk for urinary tract infection and interventions including monitoring and recording urinary output. The record did not show urine output documentation on numerous shifts from 4/1 through 4/14, including several days with no documentation on all three shifts. During interview, an RN stated that urinary output from a urinary catheter should be documented each shift, and the DON acknowledged that urinary output had not been documented each shift for Residents ID #9 and #10.
Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in hospitalization. The incident involved a resident who was prescribed Metoprolol to manage high blood pressure and heart rate. The resident was admitted to the facility with conditions including congestive heart failure, high blood pressure, and atrial fibrillation. On a specific date, the resident received an overdose of Metoprolol, being administered 62.5 mg instead of the prescribed 37.5 mg. This error led to the resident experiencing bradycardia, with a heart rate dropping to 37 beats per minute, necessitating hospitalization. The error occurred when a Certified Medication Technician (CMT) failed to follow the facility's medication administration protocol, which requires checking the medication label three times to verify the correct dose. The CMT admitted to not referencing the resident's orders or the medication label before administering the medication. The Director of Nursing Services confirmed that the protocol was not followed, resulting in the resident's incorrect medication dosage and subsequent hospital transfer.
Failure to Follow Physician's Order for Resident with Bradycardia
Penalty
Summary
The facility failed to adhere to a physician's order regarding a significant change in condition for a resident who experienced bradycardia. The resident, who was admitted with diagnoses including congestive heart failure, high blood pressure, and atrial fibrillation, received an incorrect dosage of Metoprolol, a medication used to manage high blood pressure and heart rate. On February 23, 2025, the resident was administered 62.5 mg of Metoprolol instead of the prescribed 37.5 mg, leading to hospitalization. This incident was reported to the Rhode Island Department of Health on February 24, 2025. Additionally, a progress note from January 17, 2025, indicated that the resident had a low heart rate and high blood pressure, prompting a physician's order to hold Metoprolol and reassess the resident on January 21, 2025. However, the facility's records did not show evidence of the reassessment being conducted as ordered. During an interview, the Director of Nursing Services acknowledged the oversight and confirmed the absence of documentation for the required reassessment.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards of food service safety in the main kitchen, as observed during a survey. The surveyor noted several violations of the Rhode Island Food Code, 2018 Edition, including improperly labeled and expired food items. Specifically, a jar of capers and a jar of pepperoncini peppers were found with open dates exceeding their use-by dates, and six Styrofoam containers were unlabeled, lacking identification of contents, preparation dates, or use-by dates. The Executive Chef acknowledged these issues during an interview, confirming that the items should have been discarded or properly labeled. Further observations revealed unsanitary conditions in the kitchen's storage areas. The walk-in refrigerator had a moderate amount of red liquid pooling on the floor, identified as blood from a partially opened bag of chicken. Additionally, the walk-in freezer had icicles hanging from the ceiling, with ice accumulating on a food storage rack below. Despite these issues being brought to the facility's attention, a subsequent observation two days later found that the conditions had not been rectified. The Dietary Manager and Administrator acknowledged the ongoing issues during interviews, noting that the refrigerator floor should have been cleaned and the ice buildup addressed.
Failure to Adhere to Pressure Ulcer Care Protocols
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a pressure ulcer, consistent with professional standards of practice. The resident, who was admitted with diagnoses including dementia and mobility abnormalities, was dependent on staff for bed mobility. A pressure ulcer was identified on the resident's right heel, and physician's orders were given to offload the resident's heels while in bed and to avoid wearing shoes until the ulcer resolved. However, during multiple surveyor observations, the resident was found wearing shoes and with heels resting directly on the mattress, contrary to the physician's orders. Interviews with facility staff, including a Nursing Assistant and a Registered Nurse, revealed a lack of awareness and adherence to the care plan for the resident's pressure ulcer. The Nursing Assistant acknowledged the resident's heels were not offloaded and was unaware of the requirement to do so. The Registered Nurse confirmed the resident should not be wearing shoes and that the heels should be offloaded, yet acknowledged the failure to implement these measures. The Director of Nursing Services also indicated that the resident's heels should have been offloaded as per the orders, highlighting a breakdown in communication and execution of care protocols within the facility.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the incorrect administration of insulin to Resident ID #6 and the late administration of Amlodipine to Resident ID #13. Resident ID #6, who was admitted with a diagnosis of diabetes mellitus, had specific physician orders for Novolog insulin administration based on blood glucose readings. However, on two occasions, the resident received incorrect dosages of insulin. On February 7, 2025, during the 11:00 AM to 1:00 PM dose, the resident's blood glucose reading was 212, but six units of insulin were administered instead of the prescribed two units. Later that day, during the 4:30 PM to 6:00 PM dose, the resident's blood glucose reading was 94, yet six units were administered, contrary to the order to hold insulin for readings below 65. The Registered Nurse responsible for administering the insulin could not provide evidence of following the sliding scale orders. Resident ID #13, who was readmitted with diagnoses including dementia and hypertension, had a physician's order for Amlodipine to be administered every morning before breakfast. However, the February 2025 Medication Administration Record showed that the medication was administered late on two occasions, at 1:13 PM and 12:22 PM, instead of before breakfast. The Certified Medication Technician confirmed that the medication was given late and not as scheduled. The Director of Nursing Services acknowledged that the medication should have been administered prior to breakfast as ordered.
Failure to Provide Correct Liquid Consistency for Resident
Penalty
Summary
The facility failed to provide food in a form designed to meet the individual needs of a resident with a physician's order for thickened consistency fluids. The resident, who was admitted with diagnoses including dysphagia, pneumonia, and dementia, had a diet order change from nectar thick to honey thick consistency liquids on February 10, 2025. However, the Medication Administration Record (MAR) did not reflect this change, and the resident continued to receive nectar thick consistency liquids on February 11 and 12, 2025, contrary to the updated order. On February 13, 2025, a surveyor observed a Certified Medication Technician preparing to administer a nectar thick house supplement to the resident, despite the order for honey thick consistency. The technician acknowledged the discrepancy when questioned by the surveyor. Both the Director of Nursing Services and the Medical Director confirmed that the resident should have been receiving honey thick consistency liquids as per the updated order, indicating a failure in updating and following the resident's dietary requirements as prescribed.
Inaccurate Documentation of Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for two residents. For one resident with diabetes mellitus, the facility did not adhere to the physician's orders for sliding scale insulin administration. The resident's blood glucose reading indicated that two units of insulin should have been administered, but the Medication Administration Record (MAR) documented that six units were given. This discrepancy was acknowledged by the Registered Nurse who administered the insulin and later by the Director of Nursing Services (DNS), who noted that the MAR had been edited to reflect a different dosage. For another resident with dementia and hypertension, the facility failed to document the administration of medications accurately. The MAR showed that medications were charted late, but the Certified Medication Technician admitted that the medications were actually administered late. The DNS confirmed that medications administered later than scheduled should be documented as administered late, not just charted late. These documentation errors indicate a failure to maintain accurate medical records in accordance with professional standards.
Failure to Implement Droplet/Contact Precautions for Influenza
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in implementing droplet/contact precautions for a resident diagnosed with influenza. The resident, who was admitted with a diagnosis including dementia, tested positive for influenza. A physician's order was in place to maintain droplet/contact precautions every shift, which included wearing gloves, gowns, and eye protection when entering the resident's room. However, during a surveyor observation, a nursing assistant entered the resident's room without wearing the required gloves and eye protection, despite signage indicating the necessary precautions. The nursing assistant acknowledged not wearing the appropriate protective equipment and stated that she only used eye protection during personal care activities. Interviews with the Infection Preventionist and the Director of Nursing Services confirmed that staff were expected to wear gloves and eye protection before entering the resident's room. This lapse in following the established infection control protocols contributed to the deficiency identified by the surveyors.
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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.
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Nursing homes near East Providence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethany Home Of Rhode Island | 1 mi | ★★★★★ | 7 | 0 |
| Adviniacare Waterview Villas, Llc | 1 mi | ★★★★★ | 12 | 0 |
| Eastgate Nursing & Rehabilitation Center | 1 mi | ★★★★★ | 6 | 0 |
| Harris Health Center Llc | 1 mi | ★★★★★ | 13 | 0 |
| Steere House Nursing And Rehabilitation Center | 1.1 mi | ★★★★★ | 5 | 0 |
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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.