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  5. Hattie Ide Chaffee Nursing Home Inc

Hattie Ide Chaffee Nursing Home Inc

Company Details

Name: Hattie Ide Chaffee Nursing Home Inc
Jurisdiction: Rhode Island
Entity type: Domestic Non-Profit Corporation
Status: Activ
Date of Organization in Rhode Island: 23 Jun 1948 (77 years ago)
Identification Number: 000028527
ZIP code: 02915
County: Providence County
Principal Address: 200 WAMPANOAG TRAIL, RIVERSIDE, RI, 02915, USA
Purpose: LONG TERM NURSING HOME CARE
Fictitious names: Hattie Ide Chaffee Home (trading name, 2022-09-20 - )
Historical names: Rhode Island Cancer Society Convalescent Home
Hattie Ide Chaffee Nursing Home

Industry & Business Activity

NAICS

622310 Specialty (except Psychiatric and Substance Abuse) Hospitals

This industry comprises establishments known and licensed as specialty hospitals primarily engaged in providing diagnostic and medical treatment to inpatients with a specific type of disease or medical condition (except psychiatric or substance abuse). Hospitals providing long-term care for the chronically ill and hospitals providing rehabilitation, restorative, and adjustive services to physically challenged or disabled people are included in this industry. These establishments maintain inpatient beds and provide patients with food services that meet their nutritional requirements. They have an organized staff of physicians and other medical staff to provide patient care services. These hospitals may provide other services, such as outpatient services, diagnostic X-ray services, clinical laboratory services, operating room services, physical therapy services, educational and vocational services, and psychological and social work services. Learn more at the U.S. Census Bureau

Companies doing Specialty (except psychiatric and substance abuse) hospitals

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1700912458 2007-02-26 2020-08-22 200 WAMPANOAG TRL, RIVERSIDE, RI, 029152206, US 200 WAMPANOAG TRL, RIVERSIDE, RI, 029152206, US

Contacts
Phone +1 401-434-1520
Fax 4014388494

Authorized person
Name MRS. DEBORAH M GRIFFIN
Role ADMINISTRATOR
Phone 4014341520

Taxonomy
Taxonomy Code 314000000X - Skilled Nursing Facility
License Number 223
State RI
Is Primary Yes

Other Provider Identifiers
Issuer UNITED HEALTHCARE
Number 71-09045
State RI
Issuer BLUE CROSS BLUE SHIELD
Number 5024-7
State RI
Issuer BLUE CHIP PROVIDER #
Number 401299
State RI
Issuer MEDICAID
Number 4105002
State RI

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
HATTIE IDE CHAFFEE 401(K) PLAN 2023 050258818 2024-10-10 HATTIE IDE CHAFFEE NURSING HOME 84
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2024-10-10
Name of individual signing BARRY ZELTZER
Valid signature Filed with authorized/valid electronic signature
HATTIE IDE CHAFFEE 401(K) PLAN 2022 050258818 2023-10-03 HATTIE IDE CHAFFEE NURSING HOME 76
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2023-10-03
Name of individual signing BARRY ZELTZER
Valid signature Filed with authorized/valid electronic signature
HATTIE IDE CHAFFEE 401(K) PLAN 2021 050258818 2022-10-12 HATTIE IDE CHAFFEE NURSING HOME 55
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2022-10-12
Name of individual signing BARRY ZELTZER
Valid signature Filed with authorized/valid electronic signature
HATTIE IDE CHAFFEE 401(K) PLAN 2020 050258818 2021-09-29 HATTIE IDE CHAFFEE NURSING HOME 66
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2021-09-29
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature
HATTIE IDE CHAFFEE 401(K) PLAN 2019 050258818 2020-09-28 HATTIE IDE CHAFFEE NURSING HOME 68
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2020-09-28
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature
HATTIE IDE CHAFFEE 401(K) PLAN 2018 050258818 2019-10-10 HATTIE IDE CHAFFEE NURSING HOME 64
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2019-10-10
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature
HATTIE IDE CHAFFEE 401(K) PLAN 2017 050258818 2018-10-09 HATTIE IDE CHAFFEE NURSING HOME 81
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915
HATTIE IDE CHAFFEE 401(K) PLAN 2016 050258818 2017-10-03 HATTIE IDE CHAFFEE NURSING HOME 94
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2017-10-03
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature
HATTIE IDE CHAFFEE 401(K) PLAN 2015 050258818 2017-10-03 HATTIE IDE CHAFFEE NURSING HOME 85
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2017-10-03
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature
HATTIE IDE CHAFFEE 401(K)PLAN 2014 050258818 2015-10-14 HATTIE IDE CHAFFEE NURSING HOME 74
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2015-10-14
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2014/07/15/20140715122518P040039975703001.pdf
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2014-07-15
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2013/10/09/20131009152546P030027446979001.pdf
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2013-10-09
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2012/10/01/20121001125826P030005275184001.pdf
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Plan administrator’s name and address
Administrator’s EIN 050258818
Plan administrator’s name HATTIE IDE CHAFFEE NURSING HOME
Plan administrator’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915
Administrator’s telephone number 4014341520

Signature of
Role Plan administrator
Date 2012-10-01
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2011/09/27/20110927105009P040045945895001.pdf
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 029152206

Plan administrator’s name and address
Administrator’s EIN 050258818
Plan administrator’s name HATTIE IDE CHAFFEE NURSING HOME
Plan administrator’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 029152206
Administrator’s telephone number 4014341520

Signature of
Role Plan administrator
Date 2011-09-27
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2010/09/13/20100913103322P070002535877001.pdf
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 029152206

Plan administrator’s name and address
Administrator’s EIN 050258818
Plan administrator’s name HATTIE IDE CHAFFEE NURSING HOME
Plan administrator’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 029152206
Administrator’s telephone number 4014341520

Signature of
Role Plan administrator
Date 2010-09-13
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
BARRY B. ZELTZER, PHD Agent 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915, USA

PRESIDENT

Name Role Address
DAVID R MATERNE PRESIDENT 6 DANA ROAD BARRINGTON, RI 02806 USA

TREASURER

Name Role Address
AMY GULDHAUGE TREASURER 60 CATAMORE BLVD EAST PROVIDENCE, RI 02914 USA

SECRETARY

Name Role Address
TEDFORD B RADWAY SECRETARY 1738 BROAD ST CRANSTON, RI 02905 USA

VICE PRESIDENT

Name Role Address
KAREN RICE VICE PRESIDENT 951 NORTH MAIN STREET PROVIDENCE, RI 02806 USA

DIRECTOR

Name Role Address
KIMBERLY SERRA DIRECTOR 735 WILLETT AVENUE RIVERSIDE, RI 02915 USA
SHARLEEN BOWEN DIRECTOR 172 NAYATT ROAD BARRINGTON, RI 02806 USA
MICHAEL REUTER DPM DIRECTOR 950 WARREN AVENUE EAST PROVIDENCE, RI 02915 USA
BENJAMIN CHWALK DIRECTOR 3 WOOLETT COURT BARRINGTON, RI 02806 USA
PETER J MINIATI DIRECTOR 9 ELIZABETH ROAD BARRINGTON, RI 02806 USA
CHRISTINA SCOLA DIRECTOR 301 PROMENADE STREET PROVIDENCE, RI 02908 USA
JAY GREGORY DIRECTOR 40 FAIRWAY DRIVE SEEKONK, RI 02771 USA

Events

Type Date Old Value New Value
Name Change 2019-12-04 Hattie Ide Chaffee Nursing Home Hattie Ide Chaffee Nursing Home Inc
Name Change 1950-04-10 Rhode Island Cancer Society Convalescent Home Hattie Ide Chaffee Nursing Home

Filings

Number Name File Date
202451685610 Annual Report 2024-04-19
202328404610 Annual Report 2023-02-15
202222913830 Fictitious Business Name Statement 2022-09-20
202219948450 Statement of Change of Registered/Resident Agent 2022-06-24
202212598580 Annual Report 2022-03-10
202197803280 Annual Report 2021-06-04
202042256140 Annual Report 2020-06-16
201929327500 Articles of Amendment 2019-12-04
201993631530 Annual Report 2019-05-20
201869485920 Annual Report 2018-06-13

OSHA's Inspections within Industry

Inspection Nr Report ID Date Opened Site Address
346744501 0112300 2023-06-01 200 WAMPANOAG TRAIL, RIVERSIDE, RI, 02915
Inspection Type Complaint
Scope Partial
Safety/Health Health
Close Conference 2023-06-01
Emphasis N: HEATNEP
Case Closed 2023-11-29

Related Activity
Type Complaint
Activity Nr 2035891
Health Yes
Type Inspection
Activity Nr 1674447
Health Yes

Violation Items
Citation ID 01001
Citaton Type Other
Standard Cited 19040041 A02
Issuance Date 2023-08-30
Current Penalty 500.0
Initial Penalty 1707.0
Final Order 2023-09-06
Nr Instances 1
Nr Exposed 125
Related Event Code (REC) Complaint
FTA Current Penalty 0.0
Citation text line 29 CFR 1904.41(a)(2): Annual electronic submission of OSHA Form 300A Summary of Work-Related Injuries and Illnesses by establishments with 20 or more employees but fewer than 250 employees in designated industries. If your establishment had 20 or more employees but fewer than 250 employees at any time during the previous calendar year, and your establishment is classified in an industry listed in appendix A to subpart E of this part, then you must electronically submit information from OSHA Form 300A Summary of Work-Related Injuries and Illnesses to OSHA or OSHA's designee. You must submit the information once a year, no later than the date listed in paragraph (c) of this section of the year after the calendar year covered by the form: a) Hattie Ide Chaffee Nursing Home, Inc., 200 Wampanoag Tr. Riverside RI 02915: On or about June, 1, 2023 the employer failed to electronically submit information from their OSHA Form 300A or equivalent for calendar year 2022 by March 2, 2023. The establishment employed 125 employees and is classified in NAICS Code 623110 (Nursing facility, Skilled Nursing Facility) during calendar year 2022.
304993629 0112300 2003-09-16 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915
Inspection Type Planned
Scope Partial
Safety/Health Health
Close Conference 2003-11-13
Emphasis N: NURSING, S: NURSING HOMES
Case Closed 2003-12-17

Violation Items
Citation ID 01001
Citaton Type Other
Standard Cited 19101030 C01 IIC
Issuance Date 2003-11-20
Abatement Due Date 2004-01-09
Nr Instances 2
Nr Exposed 2
Gravity 01
Citation ID 01002
Citaton Type Other
Standard Cited 19101030 C01 IV
Issuance Date 2003-11-20
Abatement Due Date 2004-01-09
Nr Instances 1
Nr Exposed 2
Gravity 01
Citation ID 01003
Citaton Type Other
Standard Cited 19101030 C01 V
Issuance Date 2003-11-20
Abatement Due Date 2004-01-09
Nr Instances 1
Nr Exposed 2
Gravity 01
Citation ID 01004
Citaton Type Other
Standard Cited 19101030 F05
Issuance Date 2003-11-20
Abatement Due Date 2004-01-09
Nr Instances 2
Nr Exposed 2
Gravity 01
Citation ID 01005
Citaton Type Other
Standard Cited 19101030 H05 I
Issuance Date 2003-11-20
Abatement Due Date 2004-01-09
Nr Instances 2
Nr Exposed 2
Gravity 01

Tax Exempt

EIN Type of Organization Exempt Organization Status Address Ruling Date
05-0258818 Corporation Unconditional Exemption 200 WAMPANOAG TRL, RIVERSIDE, RI, 02915-2206 1951-07
In Care of Name -
Group Exemption Number 0000
Subsection Charitable Organization, Educational Organization, Literary Organization, Organization to Prevent Cruelty to Animals, Organization to Prevent Cruelty to Children, Organization for Public Safety Testing, Religious Organization, Scientific Organization
Affiliation Independent - This code is used if the organization is an independent organization or an independent auxiliary (i.e., not affiliated with a National, Regional, or Geographic grouping of organizations).
Classification Government Instrumentality, Title-Holding Corporation, Charitable Organization, Agricultural Organization, Board of Trade, Pleasure, Recreational, or Social Club, Fraternal Beneficiary Society, Order or Association, Voluntary Employees' Beneficiary Association (Non-Govt. Emps.), Domestic Fraternal Societies and Associations, Teachers Retirement Fund Assoc., Benevolent Life Insurance Assoc., Burial Association, Credit Union, Mutual Insurance Company or Assoc. Other Than Life or Marine, Corp. Financing Crop Operations, Supplemental Unemployment Compensation Trust or Plan, Employee Funded Pension Trust (Created Before 6/25/59), Post or Organization of War Veterans, Legal Service Organization, Black Lung Trust, Multiemployer Pension Plan, Veterans Assoc. Formed Prior to 1880, Trust Described in Sect. 4049 of ERISA, Title Holding Co. for Pensions, etc., State-Sponsored High Risk Health Insurance Organizations, State-Sponsored Workers' Compensation Reinsurance, ACA 1322 Qualified Nonprofit Health Insurance Issuers, Apostolic and Religious Org. (501(d)), Cooperative Hospital Service Organization (501(e)), Cooperative Service Organization of Operating Educational Organization (501(f)), Child Care Organization (501(k)), Charitable Risk Pool, Qualified State-Sponsored Tuition Program, 4947(a)(1) - Private Foundation (Form 990PF Filer)
Deductibility Contributions are deductible.
Foundation Organization that receives a substantial part of its support from a governmental unit or the general public 170(b)(1)(A)(vi)
Tax Period 2023-12
Asset 10,000,000 to 49,999,999
Income 10,000,000 to 49,999,999
Filing Requirement 990 (all other) or 990EZ return
PF Filing Requirement No 990-PF return
Accounting Period Dec
Asset Amount 22731580
Income Amount 10951841
Form 990 Revenue Amount 8211647
National Taxonomy of Exempt Entities -
Sort Name -

Publication 78 Data
Description Organizations eligible to receive tax-deductible charitable contributions. Users may rely on this list in determining deductibility of their contributions.
On Publication 78 Data List Yes
Deductibility Type of organization and use of contribution: A public charity. Deductibility Limitation: 50% (60% for cash contributions)

Copies of Returns (990, 990-EZ, 990-PF, 990-T)
Organization Name HATTIE IDE CHAFFEE NURSING HOME INC
EIN 05-0258818
Tax Period 202212
Filing Type E
Return Type 990
File View File
Organization Name HATTIE IDE CHAFFEE NURSING HOME INC
EIN 05-0258818
Tax Period 202112
Filing Type E
Return Type 990
File View File
Organization Name HATTIE IDE CHAFFEE NURSING HOME INC
EIN 05-0258818
Tax Period 201912
Filing Type E
Return Type 990
File View File
Organization Name HATTIE IDE CHAFFEE NURSING HOME INC
EIN 05-0258818
Tax Period 201812
Filing Type E
Return Type 990
File View File
Organization Name HATTIE IDE CHAFFEE NURSING HOME INC
EIN 05-0258818
Tax Period 201712
Filing Type E
Return Type 990
File View File
Organization Name HATTIE IDE CHAFFEE NURSING HOME INC
EIN 05-0258818
Tax Period 201612
Filing Type E
Return Type 990
File View File
Organization Name HATTIE IDE CHAFFEE NURSING HOME INC
EIN 05-0258818
Tax Period 201512
Filing Type E
Return Type 990
File View File

Paycheck Protection Program

Loan Number Loan Funded Date SBA Origination Office Code Loan Delivery Method Borrower Street Address
7696407300 2020-04-30 0165 PPP 200 WAMPANOAG TRL, RIVERSIDE, RI, 02915-2206
Loan Status Date 2021-10-16
Loan Status Paid in Full
Loan Maturity in Months 24
SBA Guaranty Percentage 100
Loan Approval Amount (at origination) 665562
Loan Approval Amount (current) 620056
Undisbursed Amount 0
Franchise Name -
Lender Location ID 9551
Servicing Lender Name Bank of America, National Association
Servicing Lender Address 100 N Tryon St, Ste 170, CHARLOTTE, NC, 28202-4024
Rural or Urban Indicator U
Hubzone N
LMI Y
Business Age Description Existing or more than 2 years old
Project Address RIVERSIDE, PROVIDENCE, RI, 02915-2206
Project Congressional District RI-01
Number of Employees 130
NAICS code 623311
Borrower Race Unanswered
Borrower Ethnicity Unknown/NotStated
Business Type Non-Profit Organization
Originating Lender ID 9551
Originating Lender Name Bank of America, National Association
Originating Lender Address CHARLOTTE, NC
Gender Unanswered
Veteran Unanswered
Forgiveness Amount 628532.93
Forgiveness Paid Date 2021-09-23

Related by officers

AMY GULDHAUGE

Starkweather & Shepley Insurance Brokerage Incorporated Shepley Real Estate Holding Company, Inc. Rhode Island Nursing Home Group, Inc.

KAREN RICE

CompuCom Systems, Inc.

KIMBERLY SERRA

SERRA PHYSICAL THERAPY, LLC KMS REALTY, LLC

SHARLEEN BOWEN

HANDICRAFT CLUB

MICHAEL REUTER DPM

Rhode Island Podiatric Medical Association

Related by address

No related companies by address

Date of last update: 06 Apr 2025

Sources: Rhode Island Department of State

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