Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Bayview Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with CHF, afib, moderate cognitive impairment, and low body weight was mistakenly given another resident’s clozapine 150 mg and melatonin 3 mg by a CMT who entered the wrong room and failed to verify identity, contrary to facility policy requiring multiple resident-identification checks. The resident did not receive ordered warfarin and metoprolol during this pass. Subsequently, the resident was found unresponsive with abnormal respirations, tachycardia, and hypoxia, required EMS intervention with suctioning, high-flow oxygen via BVM, and IV emergency cardiac medication, and was admitted to the hospital with altered mental status, profound hypothermia, pleural effusion, and aspiration pneumonia, later transitioning to comfort care and expiring. The DON was unable to show the resident was kept free from significant medication errors, and the Medical Director stated she expected correct medications to be given to the correct resident.
The facility failed to ensure that a CMT had demonstrated competency in resident identification during medication administration and did not complete the required quarterly medication aide evaluations. Despite only one documented evaluation and no evidence of competency in verifying resident identity, the CMT was scheduled to pass medications and entered the wrong room, administering clozapine 150 mg and melatonin 3 mg intended for another resident to a frail, elderly resident with CHF and Afib. The resident, who weighed 79.2 pounds, subsequently developed tachycardia, shortness of breath, altered mental status, profound hypothermia, a small pleural effusion, and aspiration pneumonia, was admitted to the hospital for comfort measures only, and later died. The DON acknowledged that quarterly evaluations were required and could not provide evidence that the CMT had demonstrated competency in medication administration per state requirements.
A resident with hypotension did not receive Midodrine as ordered for multiple low blood pressure readings, and prescribed wound care for the resident's left posterior calf was not completed on one occasion, with documentation indicating the resident was sleeping. Both failures were acknowledged by nursing staff and the DON.
A resident with atrial fibrillation and hypotension received Metoprolol Tartrate despite consistently low blood pressure readings, after medication administration parameters were inadvertently removed from the order. Staff administered the medication without holding it for low systolic BP as originally directed, resulting in the resident receiving unnecessary medication.
A resident receiving Warfarin for deep vein thrombosis did not receive two scheduled doses after a PT/INR test, due to a lack of documentation of test result review and absence of a new Warfarin order. The Coumadin Alert order, which helps ensure proper medication administration, was not transcribed until several days later, and staff confirmed the missed doses and documentation gaps.
Ordered meds, treatments, and nutrition support were not documented as given for two residents, including wound care, catheter care, skin checks, topical meds, and other ordered interventions. One resident was also observed with a right forearm dressing with old bloody drainage, but staff could not produce an order for it. A third resident with Parkinson’s disease and GERD was not receiving Ensure Plus as ordered, and the DON could not verify that the ordered care and meds had been provided.
Incorrect oxygen administration and missing documentation were found for two residents. One resident with COPD was observed receiving oxygen above the ordered 2 LPM on multiple occasions, and an RN acknowledged the resident was not receiving the prescribed amount. Another resident with pneumonia had an order for 1 to 2 L via NC to keep O2 above 90%, but staff did not document O2 sats each shift, the TAR did not show the oxygen as given, and the resident was observed receiving 5 L instead of the ordered range.
Significant insulin medication errors were identified for multiple residents with DM. A resident with orders for basal and rapid-acting insulin had missed or undocumented doses and an untranscribed one-time Lispro order after an elevated blood sugar. Another resident had an elevated blood sugar with an NP-noted one-time Lispro order that was not found in the orders or MAR. A third resident had missing blood sugar checks and unsigned insulin doses, and an RN documented giving Lispro despite the order to hold it for a blood sugar under 100.
Infection control failed during a wound care treatment for a resident with multiple right foot wounds, including a DTI, a stage 4 pressure wound, and a vascular wound with eschar. An LPN used the same gauze to cleanse all three wounds and then used the same gauze again to apply betadine to each wound. The ADNS acknowledged the observation and stated separate gauze should have been used for each wound.
Incomplete and inaccurate skin assessment documentation was found for two residents with pressure injuries. One resident’s healed pressure injury continued to be documented as an active ulcer on weekly skin checks, while another resident’s right heel blister and later DTI were not consistently reflected in the weekly skin assessments, and one ordered weekly skin check could not be verified. The DON/DNS acknowledged the documentation problems.
A facility failed to conduct a quarterly care plan meeting for a resident with Parkinson's Disease and muscle wasting, as required by their policy. Despite a complaint from a family member and the facility's policy mandating such meetings, only one meeting was held since the resident's admission. Interviews with staff confirmed the oversight.
A resident with severe cognitive impairment and Parkinson's disease did not have a bowel movement for seven days, despite interventions. The facility lacked a formal bowel protocol, and staff failed to notify a physician, leading to a deficiency in care.
The facility failed to maintain an effective infection prevention and control program during a Covid-19 outbreak. Staff used ineffective disinfecting wipes and did not adhere to Enhanced Barrier Precautions for a resident with a foley catheter. Additionally, staff did not comply with PPE requirements, using KN95 masks instead of N95 masks and failing to wear gowns in rooms under contact precautions.
A resident with impulse control issues following a stroke physically abused another resident with severe cognitive impairment, resulting in skin tears. The incident was unprovoked and witnessed by staff, highlighting a failure in the facility's responsibility to protect residents from abuse.
A resident with bipolar disorder and schizophrenia did not receive a scheduled dose of Risperdal, leading to a relapse in psychosis with homicidal ideations and auditory hallucinations. The facility failed to transcribe and administer the medication as ordered, resulting in a deficiency.
The facility failed to develop and implement comprehensive care plans for two residents, one with PTSD and another with wandering behaviors. A resident with adjustment disorder and psychosis was documented as wandering without a care plan in place, despite residing on a secured unit. Another resident with PTSD lacked a trauma-informed care plan, despite regular psychiatric evaluations. Staff interviews confirmed the absence of appropriate care plans for these residents.
A resident with dementia experienced a deficiency in wound care management due to the facility's failure to obtain a timely wound care consult and inconsistent documentation of wound assessments. Despite a care plan requiring regular evaluation, a wound care consult ordered in April was delayed until August. Staff interviews revealed a lack of awareness and adherence to the wound care order, with inconsistent documentation of wound details.
The facility did not complete annual performance reviews for NAs, as required. A review of personnel files showed that three NAs, hired between July 2022 and July 2023, did not have documented annual evaluations. The Administrator confirmed the absence of these evaluations during an interview.
The facility failed to maintain food safety standards, with improperly labeled and stored food items in the main kitchen and kitchenettes. Uncooked chicken, pureed chicken, and egg rolls were found with expired or missing labels. Additionally, during lunch service, several meal options were held at unsafe temperatures above 41°F. The FSD acknowledged these issues, indicating a lapse in food safety protocols.
A resident with dementia and hearing impairment had a physician's order for daily use of hearing aids, but the facility failed to accurately document this. Despite records indicating compliance, the resident was observed without hearing aids, and staff admitted the right hearing aid had been broken for weeks.
A resident with bipolar disorder and schizophrenia exhibited homicidal ideations, leading to a recommendation for plastic utensils and 15-minute safety checks, which were not implemented. Additionally, a recommendation for weekly orthostatic blood pressure monitoring was overlooked, with no evidence of it being conducted. Staff interviews confirmed the oversight and lack of communication regarding these safety measures.
A resident with an indwelling Foley catheter experienced a deficiency in care when the facility failed to change the catheter before obtaining a urine sample, leading to contamination. Despite a care plan to monitor for UTIs, the urine sample was contaminated, and the order for urinalysis and culture was discontinued. Staff interviews confirmed the expectation to change the catheter, but no evidence was provided that this was done.
A facility was found to have a medication error rate of 10.34% during a survey, exceeding the acceptable limit of 5%. Errors included mixing Lorazepam and Oxycodone in the same cup, administering only one Senna tablet instead of two, and using insufficient water to flush a g-tube. The LPN involved acknowledged the errors, and the DON could not provide evidence of proper administration.
The facility failed to ensure proper storage and labeling of medications, as well as maintaining security of medication carts. A medication cart was left unlocked and unattended, and several medications were found expired or improperly labeled. Staff acknowledged these issues, and the Director of Nursing could not provide evidence of proper storage.
Fatal Medication Error Due to Failure to Verify Resident Identity
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a Certified Medication Technician (CMT) administered another resident’s medications without verifying identity. On the evening medication pass, the CMT, identified as Staff A, entered the wrong room and gave clozapine 150 mg and melatonin 3 mg, which were prescribed for a different resident, to Resident ID #1. This administration occurred despite a facility policy requiring staff to verify resident identity using methods such as checking an identification band, reviewing a photograph attached to the medical record, and, if necessary, confirming identity with other personnel. All patient identifiers were missed, and the resident did not receive his or her regularly scheduled medications, including warfarin 0.5 mg and metoprolol 12.5 mg. Resident ID #1 had been admitted in October 2025 with diagnoses including congestive heart failure and atrial fibrillation and was over a specified advanced age. A recent MDS assessment showed moderately impaired cognition with a Brief Interview for Mental Status score of 10 out of 15. The resident weighed 79.2 pounds, and the provider documented that the clozapine dose administered in error was a significant concern given the resident’s small body habitus. Record review confirmed there were no physician orders for clozapine 150 mg or melatonin 3 mg for this resident. Following the medication error, progress notes documented that late on the night of the error, the LPN (Staff B) recorded that the resident had received another resident’s medications and had missed his or her own scheduled warfarin and metoprolol. The next morning, staff found the resident unresponsive with abnormal breathing, pale skin, a heart rate of 136 bpm, and an oxygen saturation of 90%, prompting transfer via EMS. EMS records described the resident as unresponsive with audible gurgling, excessive oral secretions requiring suctioning, a fast and irregular heart rate between 150–190 bpm, and severely depressed respirations requiring bag-valve-mask support and IV emergency heart medication. Hospital records documented elevated heart rate, shortness of breath, altered mental status, profound hypothermia, a chest x-ray showing a small left pleural effusion and aspiration pneumonia, and subsequent transition to end-of-life care, with the resident expiring several days later. During interviews, the DON could not demonstrate that the resident was kept free from significant medication errors, and the Medical Director stated she would have expected the correct medications to be administered to the right resident.
Failure to Ensure CMT Medication Competency and Required Quarterly Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a Certified Medication Technician (CMT) had the required competencies and quarterly evaluations to safely administer medications, as required by Rhode Island regulations. State regulations mandate that medication technicians must complete a State‑approved course, demonstrate competency in drug administration, and receive quarterly evaluations by the Director of Nursing (DON) or RN designee, with documentation placed in personnel files. The facility’s own assessment stated that department‑specific training and competencies are completed throughout employment to ensure staff can safely and competently provide the required care. However, review of the CMT’s personnel record showed she was hired as a CMT/Nursing Assistant and had only one medication administration evaluation since hire, with no evidence of the four required quarterly evaluations. Record review of the CMT’s “Medication Administration Competency” document showed no evidence that she had demonstrated competency in identifying a resident prior to medication administration. Despite this, she was scheduled to administer medications periodically. On the evening in question, the CMT entered the wrong room and administered medications intended for another resident to Resident ID #1, without verifying the resident’s identity and missing all patient identifiers. The medications administered in error included clozapine 150 mg and melatonin 3 mg, which were prescribed for another resident. Resident ID #1 had been admitted in October 2025 with diagnoses including congestive heart failure and atrial fibrillation and was over a specified advanced age. Following the medication error, a provider note documented that the CMT had administered the wrong medications by entering the wrong room and failing to verify identity, and that the clozapine dose was of significant concern given the resident’s low body weight of 79.2 pounds. The resident subsequently presented to the hospital with elevated heart rate, shortness of breath, and altered mental status, was found to have profound hypothermia, a small left pleural effusion, and aspiration pneumonia, and was admitted for inpatient comfort measures only. The resident later expired. The DON acknowledged that medication aide evaluations are required at least quarterly and was unable to provide evidence that the CMT had demonstrated competency in medication administration per state requirements.
Failure to Follow Physician Orders for Medication and Wound Care
Penalty
Summary
The facility failed to ensure that nursing services were provided in accordance with professional standards of quality by not following physician's orders for a resident with hypotension. The resident had a physician's order for Midodrine 5 mg to be administered three times daily as needed for low blood pressure, specifically when systolic was less than 100 or diastolic less than 60, and for vital signs to be taken every shift for seven days. Despite multiple documented instances where the resident's blood pressure readings met the criteria for administration of Midodrine, there was no evidence in the Medication Administration Record that the medication was given as ordered. Both a registered nurse and the Director of Nursing Services confirmed that the medication was not administered when indicated. Additionally, the facility did not follow a physician's order for wound care for the same resident. The order specified cleansing the left posterior calf with normal saline, patting dry, applying calcium alginate, and covering with bordered gauze every evening shift. On one evening shift, the wound treatment was not completed, and the nurse documented that the resident was sleeping. The Director of Nursing Services was unable to provide evidence that the wound care was performed as ordered on that date.
Failure to Ensure Drug Regimen Free from Unnecessary Medications
Penalty
Summary
A resident with a history of atrial fibrillation and hypotension was admitted to the facility and prescribed Metoprolol Tartrate, with specific parameters to hold the medication if the systolic blood pressure was less than 100. Upon admission, the resident's blood pressure readings were consistently low, with the highest being 78/48. Despite these low readings, the medication was administered on multiple occasions, as documented in the Medication Administration Record (MAR). The original physician's order included parameters to hold Metoprolol for low systolic blood pressure, but after a revision to the administration times by a registered nurse, these parameters were no longer visible in the order. Staff interviews confirmed that the medication was given even when the resident's blood pressure was below the specified threshold, and staff were unaware that the parameters had been removed from the order. This resulted in the resident receiving unnecessary medication contrary to the original physician's instructions.
Failure to Ensure Resident Free from Significant Medication Errors with Warfarin Administration
Penalty
Summary
A resident with a diagnosis of deep vein thrombosis was admitted to the facility and prescribed Warfarin to treat and prevent blood clots. The physician ordered a PT/INR test to be performed, which was completed as scheduled. However, there was no evidence that the PT/INR results were reviewed or that the provider was notified of the results. Additionally, there was no documentation of a new Warfarin order for continued therapy following the test. As a result, the resident did not receive Warfarin doses on two consecutive days. Further review showed that a Coumadin Alert order, intended to ensure staff awareness and proper administration of Warfarin, was not transcribed until several days after the missed doses. Staff interviews confirmed the lack of documentation regarding the PT/INR results and the absence of a Warfarin order during the period in question. The Director of Nursing acknowledged the delay in transcribing the Coumadin Alert and confirmed the missed medication doses.
Failure to Document and Provide Ordered Medications, Treatments, and Nutritional Supplement
Penalty
Summary
The facility failed to follow physician’s orders for two residents whose medications and treatments were not documented as administered on the treatment and medication records. Resident ID #1, who was readmitted with diagnoses including diabetes with foot ulcers and obstructive/reflux uropathy, had multiple orders for diabetic foot care, urinary catheter care, urinary output monitoring, skin prep to the left heel, skin checks after removing a left AFO, enhanced barrier precautions, offloading the left lower extremity, and monitoring the dressing to the left foot. The September 2025 TAR did not show evidence that several of these treatments and care tasks were completed on the evening shift of 9/6/2025, and it also did not show urinary output documentation on the evening shifts of 9/2/2025 and 9/6/2025 or the day shift of 9/5/2025, or dressing monitoring on the day shift of 9/5/2025. Resident ID #6, who was readmitted with diagnoses including diabetes, back and lower extremity pain, and anxiety disorder, also had ordered care and medications that were not signed off as given. Orders included monitoring for anxiousness, side effects of anti-anxiety medications, signs and symptoms of bleeding and bruising, non-weight bearing to the right lower extremity, and frequent skin checks to the left wrist splint site every shift. The September 2025 TAR did not show evidence that these treatments and care were provided on the evening shift of 9/6/2025. In addition, orders for Diclofenac Sodium External Gel 1% to the left shoulder four times daily and Triamcinolone Acetonide Cream 0.1% to a rash below the knee amputation site twice daily were not documented as administered on the day shift of 9/5/2025 and the evening shift of 9/6/2025. Surveyor observations also identified a white bandage on Resident ID #6’s right forearm with moderate old dried bloody drainage on 9/9/2025 and again on 9/11/2025. The dressing was dated 9/8/2025, but the record did not reveal a physician’s order for treatment to the right forearm. The Unit Manager acknowledged the dressing and stated she was unaware of any injury or dressing order, and the DON was unable to provide evidence that Residents ID #1 and #6 received all ordered medications and treatments on the dates reviewed. The facility also failed to provide Ensure Plus 120 ml three times daily for Resident ID #90, who had diagnoses including Parkinson’s disease and GERD and a care plan addressing nutritional problems with a nutritional supplement intervention. The MAR did not show the supplement being given as ordered, and staff acknowledged the order change and that the resident was not receiving it three times daily.
Incorrect Oxygen Administration and Missing Documentation
Penalty
Summary
Safe and appropriate respiratory care was not provided for two residents receiving oxygen therapy. Resident ID #11, admitted with chronic obstructive pulmonary disease, had a physician order dated 11/22/2024 for oxygen at 2 LPM via nasal cannula every shift. Surveyor observations found the resident receiving 2.5 LPM on 9/8/2025 at 9:53 AM and 3 LPM on 9/10/2025 at 11:34 AM and 2:42 PM. During an interview immediately after the 2:42 PM observation, an RN acknowledged the resident was not receiving the ordered 2 liters. On 9/11/2025, the DNS, in the presence of the RDCS, could not provide evidence that the resident was receiving oxygen at 2 liters as ordered. Resident ID #46, admitted with diagnoses including pneumonia and diagnosed with pneumonia on 9/7/2025, had a physician order for supplemental oxygen at 1 to 2 liters via nasal cannula to maintain oxygen above 90% as needed for wheezing, coughing, and shortness of breath. The record did not show that oxygen saturation was obtained each shift as ordered. Surveyors observed the resident receiving oxygen at 2 L on 9/8/2025 at 2:27 PM and 9/9/2025 at 9:13 AM, and at 5 L on 9/11/2025 at 9:32 AM, 9:41 AM, 9:48 AM, and 9:53 AM. The September 2025 TAR did not document oxygen administration for the noted dates and times, and an RN acknowledged the resident was receiving 5 liters instead of the ordered 1 to 2 liters and that the TAR was not signed off as given. The DNS and RDCS stated staff should document oxygen saturation each shift, and the DNS could not provide evidence that the resident was receiving oxygen at 1 to 2 liters as ordered.
Significant insulin medication errors
Penalty
Summary
Residents were not free from significant medication errors related to insulin administration for 3 of 4 residents reviewed. Resident ID #1, who had a diagnosis including type 2 diabetes mellitus, had orders for Insulin Glargine 18 units at bedtime and Insulin Aspart before meals and at bedtime, but the September 2025 MAR did not show Insulin Glargine signed off as administered on 9/6/2025 at HS, and did not show blood sugars obtained or Insulin Aspart signed off on 9/5/2025 at 11:00 AM, 9/6/2025 at 4:00 PM, and 9/6/2025 at 9:00 PM. The record also showed a blood sugar of 412 on 9/4/2025 with a provider order for a one-time dose of Lispro 12 units, but the MAR did not show that the order was transcribed or that the Lispro was administered, and the Regional Director of Clinical Services acknowledged this during interview. Resident ID #2, who also had type 2 diabetes mellitus, had an order for Insulin Lispro per sliding scale, but on 9/9/2025 at 5:00 PM the blood sugar was 431 and a progress note documented that the NP was notified and ordered 14 units of Lispro; however, the physician orders did not show the one-time order and the MAR did not show the insulin was given. Resident ID #6 had orders for sliding scale Insulin Lispro, scheduled Lispro with meals, and Insulin Glargine at bedtime, but the September 2025 MAR did not show blood sugars obtained before dinner or at HS on 9/6/2025, did not show Lispro signed off at those times, and did not show Glargine signed off at HS. The MAR also showed Lispro documented as administered on 9/8/2025 at 8:00 AM when the blood sugar was 94, and the RN acknowledged signing off the dose, but could not provide evidence that the Lispro was held as ordered for a blood sugar less than 100.
Infection Control Failure During Multi-Wound Dressing Change
Penalty
Summary
The facility failed to maintain an infection prevention and control program related to wound care for one resident with multiple right foot wounds. The resident was admitted with diagnoses including cellulitis of the left lower limb and infection and inflammation to an internal left knee prosthesis. A wound care progress note documented a deep tissue injury to the 5th right toe with a scab, a right midfoot lateral stage 4 pressure wound with 100% eschar, and a right lateral ankle vascular wound with 100% eschar. Physician orders directed staff to paint each wound with betadine and wrap with kerlix daily. During observation of the wound dressing change, staff removed the soiled dressings, sanitized hands, and donned new gloves, then used the same gauze to spray wound cleanser and wash all three wounds in sequence. Staff then sanitized hands again, applied new gloves, and used the same gauze to apply betadine to all three wounds. In interview, the LPN acknowledged using the same gauze for all three wounds, and the ADNS acknowledged the observation and stated the expectation was to use a separate piece of gauze for each wound when cleaning and applying betadine.
Incomplete and Inaccurate Skin Assessment Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for residents with pressure injuries. For Resident ID #53, who was admitted with diagnoses including mild protein-calorie malnutrition and dementia, the record showed a physician order for weekly skin checks and documentation that a pressure injury to the left ischium had healed on 8/6/2025. However, subsequent weekly skin assessments still documented a pressure ulcer after the wound had been recorded as healed. During interview, the DNS stated nurses were expected to document accurately and that weekly skin assessments should show no active skin impairments once a resident's pressure ulcer had healed. For Resident ID #114, who was admitted in June 2025 with diagnoses including cerebral infarction, dementia, and an intact blister to the right heel, the record showed a physician order for weekly skin checks and later documentation that the blister opened and was identified as a DTI on 7/22/2025. The record also showed a weekly skin assessment on 7/21/2025 indicating no skin impairments, despite other documentation showing the right heel blister and later DTI. Survey review also failed to find evidence that the ordered weekly skin check was completed during the week of 7/14/2025. The Unit Manager and Wound Nurse was unable to provide evidence that the right heel blister was included in the weekly skin checks or that the weekly skin check was completed that week, and the DNS acknowledged the documentation was inaccurate and incomplete.
Failure to Conduct Quarterly Care Plan Meeting
Penalty
Summary
The facility failed to provide a resident the right to participate in the development and implementation of their person-centered plan of care. This deficiency was identified during a survey following a community-reported complaint to the Rhode Island Department of Health. The complaint, submitted on October 17, 2024, raised concerns about the care received by a resident diagnosed with Parkinson's Disease and muscle wasting and atrophy. The complainant, a family member, expressed that no care plan meeting had been held since the resident's admission in May 2024, which could have addressed the concerns raised. The facility's policy requires comprehensive, person-centered care plans to be developed by an interdisciplinary team, including the resident and/or their representative, and to be conducted on admission, quarterly, annually, and with significant changes in condition. However, the record review revealed that only one care planning meeting was conducted on May 31, 2024, and there was no evidence of a quarterly care plan meeting. Interviews with the Social Worker and the Director of Nursing Services confirmed that a quarterly care planning meeting was not conducted for the resident, which is contrary to the facility's expectations.
Failure to Manage Constipation in Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with constipation, leading to a significant health deficiency. The resident, who was admitted with diagnoses including dehydration, urinary tract infection, and Parkinson's disease, was severely cognitively impaired and dependent on staff for toileting. Despite having a care plan in place to manage constipation, the resident did not have a bowel movement for seven days. The facility's records showed that various interventions, including Milk of Magnesia, Dulcolax Suppository, and Fleet Enema, were administered but were ineffective. However, there was no evidence that a physician was notified of the resident's condition, as required by the facility's expectations. Interviews with staff revealed inconsistencies in the implementation of the bowel protocol. Registered Nurse Staff B and Licensed Practical Nurse Staff C indicated that a bowel list was generated for residents who had not had a bowel movement in 72 hours, and a protocol was to be followed. However, the Director of Nursing Services confirmed that the facility did not have a formal bowel protocol. Additionally, the Advanced Practice Registered Nurse, Staff A, was not informed of the resident's prolonged lack of bowel movements, which affected the treatment decisions. This lack of communication and protocol adherence contributed to the deficiency in care for the resident.
Infection Control Deficiencies During Covid-19 Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, particularly in response to a Covid-19 outbreak. Surveyor observations revealed that the facility used Micro-Kill+ Disinfecting, Deodorizing Cleaning Wipes with Alcohol, which are ineffective against Covid-19, to clean multi-use resident equipment. This was observed in the Country Unit, where numerous residents were on isolation precautions due to Covid-19. The facility did not have dedicated care equipment or appropriate disinfecting wipes readily available, and staff were observed using ineffective wipes to clean equipment used in Covid-19 positive rooms. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) for a resident with an indwelling foley catheter. The resident was not placed on EBP, and there was no signage or isolation cart indicating the required precautions. The Unit Manager acknowledged the oversight, noting that the resident had been moved to a new room without the necessary precautions being transferred. The facility also failed to ensure staff compliance with PPE requirements. Staff were observed entering Covid-19 positive rooms wearing KN95 masks instead of the required N95 masks and without eye protection, despite signage indicating the need for these precautions. Furthermore, a staff member entered a room under contact precautions for MRSA without donning a gown, as required by facility policy and posted signage. These failures in infection control practices were acknowledged by staff during surveyor interviews.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving two residents. Resident ID #42, who has intact cognition but impulse control issues following a stroke, approached Resident ID #46, who has severe cognitive impairment due to dementia, and began yelling before hitting Resident ID #46 on the left arm multiple times. This resulted in two skin tears on Resident ID #46's arm. The incident was witnessed by a nursing assistant who confirmed that Resident ID #42 was verbally aggressive and that the attack was unprovoked. The facility's policy on abuse prevention states that residents have the right to be free from abuse, including physical abuse by other residents. Despite this policy, the facility's investigation revealed that Resident ID #42's aggressive behavior was known due to his speech impairment and impulse control issues. The Director of Nursing Services acknowledged that Resident ID #46 was not kept free from physical abuse, indicating a failure in the facility's responsibility to protect residents from abuse by others.
Failure to Administer Scheduled Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident received necessary behavioral health care and services, leading to a deficiency. The resident, who was readmitted to the facility with diagnoses including bipolar disorder and schizophrenia, had a care plan that included the administration of anti-psychotic medication, specifically Risperdal, as ordered. However, a physician's order for an intramuscular injection of Risperdal every 14 days was not administered on the scheduled date, and the order was discontinued without a new order being transcribed or administered the following day as instructed by the Nurse Practitioner. As a result of the missed dose, the resident experienced a relapse in psychosis, exhibiting homicidal ideations and auditory hallucinations, and was considered a danger to themselves and others. The psychiatric evaluation noted the resident's worsening mood and psychosis, and the need to restart the Risperdal injection along with additional oral medication. The deficiency was identified during a surveyor interview, where it was revealed that the nurses failed to transcribe and administer the medication as expected.
Failure to Implement Comprehensive Care Plans for Residents with PTSD and Wandering Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, one with post-traumatic stress disorder (PTSD) and another with wandering behaviors. Resident ID #65, who was readmitted with diagnoses including adjustment disorder and psychosis, was documented as wandering during a Minimum Data Set (MDS) assessment. Despite residing on a secured unit, the resident had multiple incidents of wandering outside the building, as noted in progress notes. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing Services, confirmed the absence of a care plan addressing the resident's wandering behaviors. Resident ID #49, readmitted with a diagnosis of PTSD, was also found to lack a trauma-informed care plan. The resident's comprehensive MDS assessment indicated PTSD, anxiety, and depression, and psychiatric services documented ongoing concerns related to the resident's past traumas and current mental health status. Despite regular psychiatric evaluations and supportive therapy sessions, there was no evidence of a care plan identifying trauma triggers and interventions for the resident's PTSD. Interviews with the Social Worker and the Director of Nursing Services revealed a lack of awareness of the resident's PTSD diagnosis and the absence of a corresponding care plan. The deficiency highlights the facility's failure to create and implement individualized care plans for residents with specific needs, such as those with PTSD and wandering tendencies. This oversight was acknowledged by the facility's staff during interviews, indicating a gap in the facility's care planning process for addressing the unique needs of these residents.
Failure in Timely Wound Care Management
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding wound care management. A resident with a diagnosis including dementia was admitted with impaired skin integrity related to an abrasion. The care plan required regular evaluation and documentation of the healing process, as well as monitoring for signs of complications. However, a wound care consult ordered in April was not obtained until August, approximately four months later. The resident's wound care documentation was inconsistent and did not adhere to the facility's policy or professional standards. The facility's policy required detailed documentation of wound assessments, including wound bed color, size, and drainage, which was not consistently recorded. The resident's wound was noted to have changed over time, with various treatments applied, but the documentation failed to provide comprehensive details as required. Interviews with facility staff revealed a lack of awareness and adherence to the wound care consult order. The Unit Manager was unaware of the initial order for a wound consult, and the Director of Nursing Services expected weekly wound measurements and descriptions, which were not consistently documented. The Wound Physician confirmed that the resident's initial wound consult was delayed, and the facility was expected to measure the wound weekly in her absence.
Failure to Conduct Annual Performance Reviews for Nursing Assistants
Penalty
Summary
The facility failed to complete an annual performance review for every Nursing Assistant (NA) at least once every 12 months, as required. This deficiency was identified during a record review and staff interview, which revealed that three NA personnel records, specifically those of Staff D, E, and F, lacked evidence of a completed annual performance evaluation. Staff D was hired in February 2023, Staff E in July 2022, and Staff F in July 2023. During an interview with the Administrator, it was acknowledged that these NAs had not received their yearly performance evaluations, and there was no evidence to suggest that these evaluations had been conducted within the last 12 months.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. In the main kitchen, several food items were improperly labeled and stored. Uncooked chicken and pureed chicken were found with expired use-by dates, and a package of egg rolls was unlabeled and undated. In the Ocean Unit Kitchenette, cooked oatmeal and vanilla ice cream were found without proper labeling or with expired dates. Similarly, in the Country Unit Kitchenette, a dessert was found without a use-by date. The Food Service Director (FSD) acknowledged these items should have been labeled, dated, and discarded according to the dates. During a lunch service observation, several plated meal options were found at unsafe temperatures. A salad plate, a chicken salad sandwich, and a tossed salad with cottage cheese were all held at temperatures above the safe limit of 41 degrees Fahrenheit. The FSD confirmed that these temperatures were not safe for serving and that the food should have been refrigerated. These observations indicate a failure to maintain proper food storage and temperature control, which are critical for ensuring food safety in the facility.
Inaccurate Documentation of Hearing Aid Use
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with hearing impairment. The resident, who was admitted with a diagnosis including dementia, was noted to have bilateral hearing limitations and required the use of hearing aids. A physician's order was in place for the insertion of bilateral hearing aids every morning and removal at bedtime. However, the Medication Administration Records (MAR) for July and August 2024 inaccurately documented that this order was completed daily, despite the resident being observed without hearing aids on August 21, 2024. During interviews, staff acknowledged the discrepancy, revealing that the resident's right hearing aid had been broken for several weeks, and the order was inaccurately documented as completed. The Unit Manager confirmed that the hearing aid had been broken for approximately six weeks. The Director of Nursing Services expressed an expectation for staff to accurately document the resident's use of hearing aids as ordered, highlighting a failure in maintaining accurate medical records for the resident's hearing aid use.
Failure to Implement Safety Measures and Monitoring for Resident with Psychiatric Needs
Penalty
Summary
The facility failed to provide services that meet professional standards of quality for a resident with a history of bipolar disorder and schizophrenia. Upon readmission, the resident exhibited homicidal ideations and auditory hallucinations, expressing a desire to harm others. A psychiatric evaluation recommended the use of plastic utensils during meals and 15-minute safety checks due to the resident's condition. However, during a surveyor observation, the resident was found using metal utensils, and the Food Service Director was unaware of the need for plastic utensils. Both the Nurse Practitioner and the Assistant Director of Nursing Services confirmed that plastic utensils should have been provided as part of the safety measures. Additionally, the facility failed to implement a recommendation to monitor the resident's orthostatic blood pressure weekly for four weeks. The psychiatric evaluation included this recommendation, but there was no evidence that the resident's blood pressure was monitored as ordered. Interviews with nursing staff revealed that the recommendation was overlooked, and no order was transcribed to carry out the monitoring. The Director of Nursing Services acknowledged the expectation for nursing to obtain the resident's orthostatic blood pressure as ordered.
Failure to Change Catheter Leads to Contaminated Urine Sample
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with an indwelling Foley catheter. The resident, who was readmitted to the facility with diagnoses including obstructive uropathy and urine retention, had a care plan that included monitoring for signs and symptoms of urinary tract infections (UTIs). A physician's progress note indicated that the resident had a recurrent UTI, and a urinalysis with urine culture was recommended. However, the urine sample obtained was contaminated, and the order for the urinalysis and culture was subsequently discontinued. Interviews with staff revealed that the resident's catheter was not changed prior to obtaining the urine sample, which led to the contamination. Both the Licensed Practical Nurse and the Nurse Practitioner acknowledged the contamination and the expectation that the catheter should have been replaced before collecting the urine specimen. The Director of Nursing Services also confirmed that the catheter should have been changed and was unable to provide evidence that this procedure was followed, resulting in the deficiency.
Medication Administration Errors via G-Tube
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 10.34% error rate observed during a medication administration task. This was determined through surveyor observation, record review, and staff interviews. Specifically, during the administration of medications via a gastrostomy tube (g-tube), three errors were identified out of 29 opportunities. These errors included the improper mixing of Lorazepam and Oxycodone in the same medication cup, administering only one Senna tablet instead of the prescribed two, and flushing the g-tube with only 15 ML of water instead of the ordered 30 ML before and after medication administration. The resident involved, identified as Resident ID #51, had specific physician orders for the administration of Senna, Lorazepam, and Oxycodone, as well as instructions to flush the feeding tube with 30 ML of water before and after medication administration. The Licensed Practical Nurse, Staff H, acknowledged these errors during a surveyor interview. Additionally, the Director of Nursing Services was unable to provide evidence that the medications were administered according to the physician's orders and the facility's policy, further confirming the deficiency.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, as well as maintaining security of medication carts. During a surveyor observation, it was found that one of the medication carts was left unlocked and unattended in an area accessible to residents. This occurred on the Ocean Unit cart, where the cart was observed unlocked and unattended multiple times within a short period. Additionally, the facility did not adhere to proper labeling and storage protocols for medications on three of the four medication carts observed. Specifically, medications such as Nitroglycerin, Fluticasone Propionate and Salmeterol inhaler, Incruse Ellipta inhaler, and Trelegy Ellipta inhaler were either expired, opened and not dated, or improperly labeled. The surveyor's findings were confirmed through interviews with the staff members responsible for the medication carts. Staff I, J, and K acknowledged the issues with the medications and the unlocked cart. Furthermore, the Director of Nursing Services was unable to provide evidence that the medications were stored appropriately as required by the facility's policy. These deficiencies highlight a failure to comply with the facility's medication labeling and storage policy, which mandates that all medications and biologicals be stored in locked compartments and properly labeled with expiration dates.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 551 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near North Kingstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saint Elizabeth Home East Greenwich | 2.5 mi | ★★★★★ | 5 | 0 |
| Brentwood Health Center | 3.3 mi | ★★★★★ | 3 | 0 |
| Kent Regency Center | 5.2 mi | ★★★★★ | 6 | 0 |
| Roberts Health Centre Inc | 5.5 mi | ★★★★★ | 5 | 0 |
| Greenwood Operations Dba Greenwood Center | 5.6 mi | ★★★★★ | 12 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bayview Rehabilitation And Healthcare Center.
100% money-back within 48 hours.
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.