Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Schervier Pavilion during CMS and state inspections, most recent first.
A resident with multiple medical conditions was found to have several medications and wound care supplies stored in their room, including nasal spray, topical powder, eye drops, and cream, without a physician's order or care plan authorizing self-administration. The resident reported using these medications independently, while interviews with nursing staff and the Medical Director confirmed that such storage and self-administration were not permitted without proper documentation.
The facility did not ensure an Infection Preventionist was working at least part-time on-site, as required for the Infection Control Program. The Systems Director for Infection Prevention provided oversight mostly remotely, while a Quality Assurance RN, who was not yet certified, handled daily infection surveillance.
Two residents in an LTC facility did not receive adequate pressure ulcer care, leading to deficiencies. One resident developed a Stage 2 ulcer not present on admission, with inconsistent documentation and treatment. Another resident with a Stage 4 ulcer experienced worsening symptoms and inadequate documentation. Staff interviews revealed challenges with electronic medical records and wound care procedures, with the Wound Care Coordinator on vacation contributing to the issues.
The facility failed to maintain infection control practices, with deficiencies observed in oxygen tubing management for a resident, improper handling of wound vacuum and Foley catheter tubing for another, and lack of enhanced barrier precautions for a resident with a pressure ulcer. Staff were unsure of policies, leading to inadequate documentation and oversight.
The facility failed to create comprehensive care plans for three residents, leading to deficiencies. A resident on anticoagulants and diuretics, another on long-term antibiotics, and a third on oxygen therapy lacked appropriate care plans. Staff acknowledged the oversight, highlighting a lapse in care planning responsibilities.
A facility failed to ensure the attending physician documented their review and response to drug regimen review irregularities for a resident with osteomyelitis and dementia. The Medical Director, overwhelmed by their dual role and high admission rates, did not address the pharmacist's recommendations regarding antipsychotic use and furosemide orders, leading to a deficiency.
The facility failed to store food according to professional standards, with expired and unlabeled items found in the walk-in refrigerator, freezer, and dry storage. The Director of Food Services acknowledged the issue, noting staff discarded boxes with expiration dates to reduce clutter.
The Medical Director, overwhelmed by dual roles and lacking support, struggled to coordinate medical care, leading to deficiencies in Pressure Ulcer Care and Unnecessary Medication management. The facility acknowledged the issue and was seeking additional support for the Medical Director.
Medications Improperly Stored in Resident Room Without Authorization
Penalty
Summary
Surveyors found that the facility failed to ensure that drugs and biologicals were stored in accordance with professional standards and manufacturer specifications for one resident. Multiple medications and wound care supplies, including deep sea nasal spray, nystatin topical powder, latanoprost eye drops, refresh tears, and Preparation H cream, were observed in the resident's room on the bedside table, nightstand, and windowsill. There was no documented evidence of a physician's order allowing the resident to self-administer these medications, nor was there a care plan in place for self-administration. The resident, who had diagnoses including glaucoma, blepharitis, and foot drop, was assessed as having intact cognition. The resident reported self-administering several of the medications, stating that nurses had left them in the room or that they had received some as gifts. The resident also indicated that they preferred to apply certain treatments themselves, such as the nystatin powder and eye drops, and used the nasal spray independently. However, staff interviews confirmed that there were no orders or care plans authorizing self-administration, and that medications should not be left in resident rooms unless such authorization exists. Nursing staff, including an LPN, RN Unit Manager, and the Medical Director, all stated that medications are not to be kept in resident rooms without proper orders and care planning. The Medical Director confirmed that no order had been written for self-administration, and the interim DON reiterated that medications should not be left in resident rooms. The presence of these medications and supplies in the resident's room, without appropriate documentation or authorization, constituted a failure to comply with medication storage regulations.
Inadequate On-Site Infection Preventionist Presence
Penalty
Summary
The facility failed to ensure that an Infection Preventionist (IP) was working at least part-time in the facility, as required for the Infection Control Program. The facility's policy, reviewed in August 2024, delegated the authority for the Infection Prevention and Control Program to the System Director of Infection Prevention and Control. However, the System Director did not spend 50 percent of their time working in the facility. Instead, the day-to-day infection prevention and control duties were being managed by a Quality Assurance Registered Nurse who was in the process of obtaining Infection Preventionist certification. Interviews with the facility Administrator, Quality Assurance Coordinator Registered Nurse, and the Systems Director for Infection Prevention revealed that the Systems Director provided oversight mostly remotely and was available 24/7 by telephone or video conference. The Quality Assurance Registered Nurse, who had not yet completed their Infection Preventionist Certification Training, was responsible for daily infection surveillance. The Systems Director attended monthly Quality Assurance meetings remotely, and infection control concerns were addressed via email or telephone discussions.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies identified during a recertification survey. Resident #3, who had diagnoses including Muscular Dystrophy, Type 2 Diabetes, and Chronic Obstructive Pulmonary Disease, developed a Stage 2 pressure ulcer that was not present upon admission. Despite having a care plan and physician orders for treatment, the facility's documentation was inconsistent and incomplete. Weekly skin assessments and wound tracking records were missing or lacked necessary details such as location, size, and characteristics of the ulcer. Interviews with staff revealed a lack of awareness and documentation regarding the resident's condition, with the Director of Nursing acknowledging the issue but attributing it to the Nurse Educator's absence due to vacation. Resident #39, with diagnoses of osteomyelitis and dementia, had a Stage 4 pressure ulcer upon admission. The facility's care plan required notifying the Medical Director if the wound did not improve within 14 days. However, nursing notes indicated inconsistent documentation of the wound's characteristics, and the resident experienced worsening symptoms, including brown foul-smelling drainage. The Medical Director was informed, and treatment orders were adjusted, but the facility's documentation remained inadequate. Interviews with staff highlighted challenges in adjusting to the facility's electronic medical record system and wound care documentation procedures. The Director of Nursing and the Quality Assurance Committee Leader acknowledged the deficiencies in wound care assessment and documentation. The Wound Care Coordinator, who was responsible for tracking wound progression, was on vacation, contributing to the lack of consistent documentation. The facility identified these issues as part of a performance improvement project, with Nurse Managers responsible for comprehensive weekly skin assessments. However, the deficiencies in documentation and care were evident during the survey, leading to the identified deficiencies.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by several deficiencies observed during the survey. Resident #44's oxygen tubing was found to be soiled and undated, contrary to the facility's policy that requires weekly changes and documentation. The staff, including the Registered Nurse Unit Manager and Licensed Practical Nurse, were unsure of the policy details and responsibilities, leading to a lack of proper documentation and oversight. The Director of Nursing confirmed the policy but acknowledged that the order and care plan for Resident #44 were not in place. Resident #58 was observed with both wound vacuum and Foley catheter tubing touching the floor, which poses a risk of infection. Certified Nurse Aide #8 handled the tubing without performing hand hygiene or sanitizing the tubing, despite having received infection control training. The tubing was inadequately secured, and the use of leg bags was limited to specific circumstances, increasing the risk of the tubing touching the floor. The Registered Nurse Manager acknowledged the issue but cited concerns about infection risks associated with handling the tubing. Resident #3, who had a Stage 2 pressure ulcer, was not placed under enhanced barrier precautions as required. The care card, medical record, and physician orders lacked documentation for these precautions. During care, staff did not wear the necessary protective equipment, and there was no signage or equipment available in the resident's room. Interviews with staff revealed a lack of awareness and implementation of the precautions, despite multiple educational sessions. The Registered Nurse Quality Assurance Performance and Improvement Coordinator and the Unit Manager confirmed the oversight and the need for proper signage and equipment availability.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies identified during a recertification survey. Resident #14, who had diagnoses including cerebral infarction, hemiplegia, and heart failure, was receiving anticoagulants and diuretics but did not have a care plan addressing these medications. The Quality Assurance Performance Improvement Coordinator confirmed that the nurse managers were responsible for creating such care plans, which were missing in this case. Similarly, Resident #52, diagnosed with heart failure, psychosis, and osteoarthritis, was on long-term antibiotic therapy for infective endocarditis but lacked a corresponding care plan. The Registered Nurse Manager acknowledged the importance of having care plans with interventions for monitoring purposes. Additionally, Resident #44, with diagnoses including metabolic encephalopathy and chronic atrial fibrillation, was on intermittent oxygen therapy without a care plan for oxygen administration. The Director of Nursing confirmed the absence of an oxygen care plan, indicating a lapse in the nursing staff's responsibilities.
Failure to Document Drug Regimen Review Responses
Penalty
Summary
The facility failed to ensure that the attending physician documented their review and response to drug regimen review irregularities identified by the pharmacist for a resident. Specifically, there was no documented evidence that the Medical Director reviewed and responded to the Drug Regimen Reviews for a resident with osteomyelitis and dementia, who was prescribed olanzapine and bumex. The pharmacist had recommended evaluating the use of multiple antipsychotics and the resident's furosemide order due to abnormal lab results, but these recommendations were not addressed in the medical record. The deficiency was attributed to the Medical Director being overwhelmed after assuming the roles of both Medical Director and Attending Physician for all residents in the facility. The Director of Nursing and the Director of Quality Assurance acknowledged the Medical Director's challenges in keeping up with documentation requirements, which were exacerbated by a high volume of admissions and discharges. The Medical Director had received training on the facility's electronic medical record system, which was intended to improve their performance, but the delay in responding to the pharmacist's recommendations persisted.
Deficiency in Food Storage Practices
Penalty
Summary
The facility failed to ensure that food was stored in accordance with professional standards for food service safety, as observed during a recertification survey. The walk-in refrigerator contained expired food products, including a bottle of Grey Poupon mustard, a container of Galbani ricotta, and cans of tuna fish, some of which lacked expiration dates. Additionally, Eggo pancakes labeled to be kept frozen were improperly stored in the refrigerator. The walk-in freezer had several unlabeled food products, including chicken pieces, ground beef patties, and breakfast sausage, with the latter showing signs of freezer burn. Many of these items lacked opening or expiration dates, violating the facility's policy on food storage. In the dry storage pantry, an expired and undated container of Citavo Brand decaffeinated coffee was found. During a follow-up tour and interview, the Director of Food Services acknowledged awareness of the expired and unlabeled products, attributing the issue to staff discarding boxes containing expiration dates to reduce clutter in the freezer. The Director confirmed that individual bags of frozen items should have been labeled with opening and expiration dates, and expired food products should have been discarded, as per the facility's policy.
Overwhelmed Medical Director Fails to Coordinate Care
Penalty
Summary
The facility failed to ensure that the Medical Director was effectively coordinating medical care, as evidenced by issues in Pressure Ulcer Care and Unnecessary Medication management. The Medical Director, who assumed the role in July 2024, was overwhelmed by the dual responsibilities of being both the Medical Director and the Attending Physician for all residents. This led to delays in completing monthly renewals and Drug Regimen Reviews, which are critical for resident care. The Director of Nursing and the Director of Quality Assurance both acknowledged the Medical Director's struggles with documentation and timely responses to Drug Regimen Review recommendations, attributing some of the delays to the Medical Director's adjustment to the facility's electronic medical record system. The Administrator confirmed that the facility was aware of the Medical Director's challenges and noted that the previous Medical Director had assistance from a Nurse Practitioner, which the current Medical Director did not have. The facility was in discussions to provide additional support to the Medical Director. The lack of adequate support and resources for the Medical Director contributed to the deficiency in coordinating medical care, as the Medical Director was unable to keep up with the demands of the position, particularly during periods of high admissions and discharges.
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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 Warwick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Valley View Center For Nursing Care And Rehab | 6.5 mi | ★★★★★ | 2 | 0 |
| Glen Arden Inc | 8.9 mi | ★★★★★ | 11 | 0 |
| Sapphire Nursing And Rehab At Goshen | 9 mi | ★★★★★ | 0 | 0 |
| Middletown Park Rehab & Health Care Center | 13.1 mi | ★★★★★ | 1 | 0 |
| Highland Rehabilitation And Nursing Center | 13.6 mi | ★★★★★ | 3 | 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.