Cycle 1
Health 2025-12-04 · Fire 2025-12-04
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cumberland, RI
Mount St Rita Health Centre
3-star overall rating with 2-star inspections with $228,829 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
15 Sumner Brown Road, Cumberland, RI
(401) 333-6352
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
98
Certified beds
Average residents
85
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Covenant Health
Operator or chain grouping
Approved since
1990-02-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 3 overall / 3 health / 5 staffing / 3 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
0.71
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.55
Nurse aide staffing · state 2.46 · national 2.35
Total nurse hours
4.01
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.47
RN + LPN hours · state 1.25 · national 1.54
Weekend hours
3.57
Weekend nurse staffing · state 3.30 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
4.61
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 38% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,291
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9858
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.73% · Performance 22.98% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.24
Baseline 5.45% · Performance 6.87% · Measure score 3.24 · Achievement 3.24 · Improvement 0
Total nurse turnover
4.2
Baseline 52.50% · Performance 46.51% · Measure score 4.2 · Achievement 4.2 · Improvement 1.67
Adjusted total nurse staffing
4.63
Baseline 3.81 hours · Performance 4.39 hours · Measure score 4.63 · Achievement 4.63 · Improvement 2.46
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.92% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 89 · Observed rate 13.48% · Lower 95% interval 8.12% |
| Discharge to community | 53.44% |
50.57%
2.9 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 48.19% · Lower 95% interval 43.42% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 92.42% |
95.27%
2.8 pts worse
|
Numerator 61 · Denominator 66 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 66 |
| Discharge self-care score | 53.85% |
53.69%
0.2 pts better
|
Numerator 28 · Denominator 52 |
| Discharge mobility score | 73.08% |
50.94%
22.1 pts better
|
Numerator 38 · Denominator 52 |
| Pressure ulcers or injuries, new or worsened | 6.06% |
2.29%
3.8 pts worse
|
Numerator 4 · Denominator 66 · Adjusted rate 5.14% |
| Healthcare-associated infections requiring hospitalization | 6.86% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 5.17% · Lower 95% interval 3.79% |
| Staff COVID-19 vaccination coverage | 11.22% |
8.2%
3 pts better
|
Numerator 11 · Denominator 98 |
| Staff flu vaccination coverage | 90% |
42%
48 pts better
|
Numerator 90 · Denominator 100 |
| Discharge function score | 73.08% |
56.45%
16.6 pts better
|
Numerator 38 · Denominator 52 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 48 · Denominator 48 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 38.89% |
25.2%
13.7 pts better
|
Numerator 14 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.5
0.9 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.8 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.7
0.1 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 74.5% |
93.2%
18.7 pts worse
|
93.4%
18.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 75.0% · Q2 79.1% · Q3 73.6% · Q4 70.8% · 4Q avg 74.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.3% |
95.3%
5 pts worse
|
95.5%
5.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.6%
0.4 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 6.0% · Q3 4.2% · Q4 2.8% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
14.6%
12 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.6% · Q3 2.9% · Q4 2.8% · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 7.5% |
5.3%
2.2 pts worse
|
5.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 10.5% · Q3 6.3% · Q4 1.6% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.6% |
16.4%
1.8 pts better
|
19.6%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 14.8% · Q3 12.3% · Q4 12.7% · 4Q avg 14.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.2% |
23.6%
3.4 pts better
|
16.7%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 22.4% · Q3 18.2% · Q4 16.4% · 4Q avg 20.2% · 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 | 27.7% |
17.0%
10.7 pts worse
|
16.3%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.4% · Q2 28.8% · Q3 26.1% · Q4 20.1% · 4Q avg 27.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.7% |
18.4%
9.3 pts worse
|
14.9%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 33.3% · Q3 23.0% · Q4 26.7% · 4Q avg 27.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.0%
0.2 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
2.2%
0.3 pts better
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.7% · Q4 1.4% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.5% |
22.3%
6.2 pts worse
|
19.8%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 39.3% · Q3 24.5% · Q4 27.8% · 4Q avg 28.5% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
4.7%
0.5 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 6.6% · Q3 3.3% · Q4 4.7% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 44.4% |
77.2%
32.8 pts worse
|
81.7%
37.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 42.4% · Q2 43.8% · Q3 44.4% · Q4 47.1% · 4Q avg 44.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.1% |
15.8%
1.3 pts worse
|
12.0%
5.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 14.8% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
1.9%
1.1 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.6% · Q4 5.7% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.3% |
78.2%
14.9 pts worse
|
79.7%
16.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.4% |
25.1%
4.3 pts worse
|
23.9%
5.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.4% · Observed 26.2% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-26 · Fire 2024-09-26
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-10-25 · Fire 2023-10-25
16 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-04
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2026-01-03
F · Potential for more than minimal harm
2023-10-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-11-24
F · Potential for more than minimal harm
2023-10-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-11-24
F · Potential for more than minimal harm
2023-10-25
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2023-11-24
F · Potential for more than minimal harm
2023-10-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-24
F · Potential for more than minimal harm
2023-10-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-24
F · Potential for more than minimal harm
2023-10-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-24
Inspection history
Recent health citations
G · Actual harm
2025-12-30
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 2026-01-15
E · Potential for more than minimal harm
2025-12-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-30
E · Potential for more than minimal harm
2025-12-04
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 2026-01-03
D · Potential for more than minimal harm
2025-12-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-03
D · Potential for more than minimal harm
2025-12-04
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 2026-01-03
D · Potential for more than minimal harm
2025-12-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-03
E · Potential for more than minimal harm
2024-09-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-26
E · Potential for more than minimal harm
2024-09-26
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-10-26
D · Potential for more than minimal harm
2024-09-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-26
D · Potential for more than minimal harm
2024-09-26
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-10-26
D · Potential for more than minimal harm
2024-05-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-05
G · Actual harm
2023-10-25
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-11-24
F · Potential for more than minimal harm
2023-10-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-24
E · Potential for more than minimal harm
2023-10-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-24
E · Potential for more than minimal harm
2023-10-25
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-25
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-25
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-25
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-25
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 2023-11-24
D · Potential for more than minimal harm
2023-10-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-09-14
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2023-10-14
D · Potential for more than minimal harm
2023-09-14
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 2023-10-14
D · Potential for more than minimal harm
2023-09-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-06
K · Immediate jeopardy
2023-08-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-05
D · Potential for more than minimal harm
2023-06-12
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-06-23
Penalties and ownership
What sits behind the stars
$3,176
2023-11-13
Fine
Fine · fine $3,176
Fine
$15,366
2023-10-25
Fine
Fine · fine $15,366
Fine
$0
2023-10-25
Payment Denial
Payment Denial · denial start 2023-11-22 · 2 days
2 day denial
$7,409
2023-10-23
Fine
Fine · fine $7,409
Fine
$202,878
2023-08-09
Fine
Fine · fine $202,878
Fine
$0
2023-08-09
Payment Denial
Payment Denial · denial start 2023-09-05 · 39 days
39 day denial
Ownership
Covenant Health
5% Or Greater Indirect Ownership Interest · Organization
Castillo, Nicole
W-2 Managing Employee · Individual
Fleming, William
Corporate Officer · Individual
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