Cycle 1
Health 2025-09-05 · Fire 2025-09-05
9 health deficiencies
Top issue: Administration (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Providence, RI
Elmwood Nursing and Rehabilitation Center
2-star overall rating with 3-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
225 Elmwood Avenue, Providence, RI
(401) 272-0600
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
64
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Health Concepts, Ltd.
Operator or chain grouping
Approved since
1979-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 4 overall / 4 health / 3 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.69
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.30
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.44
Nurse aide staffing · state 2.46 · national 2.35
Total nurse hours
3.43
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
0.99
RN + LPN hours · state 1.25 · national 1.54
Weekend hours
3.09
Weekend nurse staffing · state 3.30 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
4.06
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 38% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,326
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.29
Composite VBP score used to determine payment impact.
Payment multiplier
0.9876
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
5.34
Performance 6.24% · Measure score 5.34 · Achievement 5.34 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.35
Baseline 41.18% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0
Adjusted total nurse staffing
1.30
Baseline 3.87 hours · Performance 3.45 hours · Measure score 1.30 · Achievement 1.30 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.46% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 8.33% · Lower 95% interval 6.51% |
| Discharge to community | 47.67% |
50.57%
2.9 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 40% · Lower 95% interval 36.35% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 90.91% |
95.27%
4.4 pts worse
|
Numerator 30 · Denominator 33 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 33 |
| Discharge self-care score | 52.38% |
53.69%
1.3 pts worse
|
Numerator 11 · Denominator 21 |
| Discharge mobility score | 61.9% |
50.94%
11 pts better
|
Numerator 13 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 33 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.24% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 0% · Lower 95% interval 3.02% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 91 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 14 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
93.2%
4.7 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.4% · Q4 94.6% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.3%
4.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.6%
1.5 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 6.7% · Q3 1.8% · Q4 3.6% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
14.6%
14.1 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
5.3%
2 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 7.0% · Q3 4.4% · Q4 0.0% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.4% |
16.4%
1 pts worse
|
19.6%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 15.8% · Q3 20.0% · Q4 18.8% · 4Q avg 17.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.2% |
23.6%
7.6 pts worse
|
16.7%
14.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 31.0% · Q3 31.4% · Q4 31.6% · 4Q avg 31.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.5% |
17.0%
6.5 pts worse
|
16.3%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 27.1% · Q3 15.2% · Q4 31.6% · 4Q avg 23.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.5% |
18.4%
7.1 pts worse
|
14.9%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 31.5% · Q3 22.0% · Q4 27.3% · 4Q avg 25.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.0%
0.4 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 1.3% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.1% |
2.2%
3.9 pts worse
|
1.7%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 8.3% · Q3 9.1% · Q4 0.0% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.2% |
22.3%
2.1 pts better
|
19.8%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 26.1% · Q3 23.2% · Q4 17.5% · 4Q avg 20.2% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
4.7%
0.8 pts worse
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 7.8% · Q3 3.7% · Q4 2.1% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 62.4% |
77.2%
14.8 pts worse
|
81.7%
19.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 84.1% · Q2 56.0% · Q3 55.6% · Q4 59.4% · 4Q avg 62.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.5% |
1.9%
1.6 pts worse
|
1.6%
1.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.6% |
78.2%
7.6 pts worse
|
79.7%
9.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-29 · Fire 2024-08-29
2 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-09-22 · Fire 2023-09-22
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-10-05
F · Potential for more than minimal harm
2025-09-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-05
F · Potential for more than minimal harm
2023-09-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-10-22
E · Potential for more than minimal harm
2023-09-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-14
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2026-02-13
D · Potential for more than minimal harm
2026-01-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-02-13
F · Potential for more than minimal harm
2025-09-05
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2025-10-05
E · Potential for more than minimal harm
2025-09-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-11-28
E · Potential for more than minimal harm
2025-09-05
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2025-10-05
E · Potential for more than minimal harm
2025-09-05
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2025-10-05
D · Potential for more than minimal harm
2025-09-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-05
D · Potential for more than minimal harm
2025-09-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-10-05
D · Potential for more than minimal harm
2025-09-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-05
F · Potential for more than minimal harm
2024-12-16
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-12-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-15
D · Potential for more than minimal harm
2023-12-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-01-06
E · Potential for more than minimal harm
2023-09-22
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-10-22
D · Potential for more than minimal harm
2023-09-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-22
D · Potential for more than minimal harm
2023-09-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-22
D · Potential for more than minimal harm
2023-09-22
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-10-22
D · Potential for more than minimal harm
2023-09-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-10-22
Penalties and ownership
What sits behind the stars
Ownership
Ryan, David
5% Or Greater Direct Ownership Interest · Individual
Arnold, Kelly
Operational/Managerial Control · Individual
Carragher, Terry
Corporate Officer · Individual
Health Concepts Ltd
Operational/Managerial Control · Organization
Lewis, Erica
W-2 Managing Employee · Individual
Nearby options
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#2
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4-star overall rating with 3-star inspections with $85,654 in total fines with 3 recent health deficiencies
#3
Tockwotton on the Waterfront
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5-star overall rating with 4-star inspections with $8,628 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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