Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Brentwood Health Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, dependent on staff for toileting and repositioning, was admitted with an unstageable sacral pressure ulcer and a spinal surgical incision. A NA reported finding the resident lying on a bedpan during an afternoon care episode, with no information on when or by whom the resident had been placed on it. Following this undetermined period on the bedpan, clinical assessments by a NP and wound care physician documented a new crescent-shaped pressure-related injury over the coccyx, significant enlargement of the existing sacral ulcer, and a new stage 3 pressure ulcer on the right thigh, with the wound pattern described as following the line of a bedpan. The DON acknowledged that the duration the resident remained on the bedpan was unknown and that the resident’s pressure areas had worsened after this incident.
A resident with moderate cognitive impairment, dependent on staff for toileting and repositioning, had an existing unstageable sacral pressure ulcer and a spinal surgical incision. After being left on a bedpan for an extended, undetermined period, the resident’s sacral ulcer significantly worsened and a new stage 3 pressure ulcer developed on the right thigh, as documented by the NP and wound care physician. Facility policy required immediate reporting of suspected neglect and notification of the Department of Health within 2 hours when serious bodily injury occurred, but the DON acknowledged the neglect and could not provide evidence that this allegation was reported to the State Survey Agency within the required timeframe.
A resident with chronic respiratory failure and hypoxia was readmitted with physician orders for BiPAP therapy during naps and nightly. The facility did not provide the BiPAP as ordered for several days, as confirmed by treatment records and staff interviews, resulting in a worsening of the resident's respiratory condition.
Food Storage and Service Safety Deficiencies: Surveyors found unsanitary conditions and food safety lapses in the main kitchen and a kitchenette, including food splatter on walls, dirty ice machine and ice chest gaskets, chipped food carts, and unlabeled food items in a reach-in refrigerator. Lunch trays were transported on open carts with preset silverware left uncovered, the dry storage room was 85 F, and an opened soup container exceeded the facility's 3-day dating policy. The DFS acknowledged the issues.
Failure to promptly notify the MD of a resident’s change in condition. A resident with sepsis was found in bed covered in watery stool with abnormal VS, including O2 sat of 77% and BP of 98/58. Staff observed restlessness and discomfort, but the provider was not notified until the day shift RN arrived about 2 hours later. The resident later became moaning and unresponsive, required O2, and was sent to the ED by EMS.
Failure to follow physician orders and weight protocols: an LPN did not administer ordered PRN oxygen to a resident with low SpO2 readings, orthostatic BP checks were not documented as ordered, and three residents had significant weight discrepancies without timely reweighs. Staff interviews confirmed the missed actions, and the DON stated reweighs were expected when discrepancies were identified.
A resident with diagnoses including sepsis and constipation went 5 days without a documented BM, and the record did not show that the provider was notified. The NP and DON both stated they would expect nursing staff to contact the provider after 3 days without a BM for further interventions.
Staff Competency Failures in Assessment, Oxygen Administration, Medication Documentation, and Progress Notes: An LPN observed a resident with sepsis, agitation, and very low SpO2 readings, but did not administer ordered oxygen and instead only raised the HOB while continuing to pass meds to other residents. The LPN also pre-poured Synthroid and signed it off in the EMR before administration, and admitted to copying nursing progress notes from a USB drive rather than completing an accurate assessment. The DON could not show that the LPN was competent in assessment, med administration documentation, or progress note documentation.
Uncovered food trays with partially consumed meals were repeatedly left in the hallway on the first-floor nursing unit after meal hours. Surveyors observed multiple trays from breakfast and lunch left uncovered on several occasions, and the DFS acknowledged that the food trucks were left uncovered in the hallway with partially consumed food on the trays.
A resident with a hx of falls, sepsis, and Seroquel use had a care plan calling for orthostatic VS monitoring and physician/NP notification with changes. After multiple falls and a subsequent hospitalization involving fractured ribs and a splenic laceration, the chart lacked evidence that the ordered orthostatic BP checks were completed, and the DON could not provide proof they were obtained.
Four residents with chronic pain and other serious conditions did not have their pain management care plan interventions implemented or documented, despite care plans specifying actions such as administering pain medication and monitoring effectiveness. Staff confirmed that pain was not documented as required, and only verbal inquiries were made, resulting in a lack of evidence that residents' pain was properly managed.
A resident with multiple serious diagnoses and under hospice care did not receive PRN morphine for pain as ordered, despite repeated complaints and requests, with staff confirming no additional doses were given before hospital transfer. Additionally, an air mattress was in use for the resident without a physician's order or documented settings, as confirmed by staff and record review.
The facility failed to document physician-ordered weekly skin evaluations for two residents. One resident, with malnutrition and fractures, had evaluations signed off without evidence of completion. Another resident, with dementia and syncope, also had evaluations signed off without documentation. The DON could not provide evidence of completed assessments.
The facility did not ensure that NAs Staff A and B had the necessary competencies for safe patient handling with mechanical lifts. Despite the facility's requirement for training during orientation and annually, there was no evidence that these competencies were completed for Staff A and B before they began resident care. This was confirmed during an interview with the Regional Nurse.
The facility did not complete annual performance reviews for NAs, as required. A review of personnel files showed no evidence of evaluations for five NAs hired between 2005 and 2023. The DON could not provide documentation of evaluations within the last year.
The facility did not offer bedtime snacks to residents, resulting in more than 14 hours between supper and breakfast, as reported by several residents during a council meeting. The Administrator confirmed the meal schedule and could not provide evidence of snack offerings.
The facility failed to meet food safety and sanitation standards, with unlabeled and expired food items found in the kitchen and nourishment areas. Food packaging was compromised, and the dishwasher did not reach the required sanitization temperature. The FSD was observed serving food without a beard restraint, and there was no certified food safety manager present during certain hours due to an expired certification.
The facility failed to implement and maintain an effective, comprehensive, data-driven QAPI program. Although QAPI plans were created for identified concerns, there was no evidence of their implementation or maintenance, including tracking and measuring performance, and establishing goals and thresholds. The facility Administrator could not provide evidence of an effective QAPI program focusing on care outcomes and quality of life.
A long-term care facility was found deficient in infection control practices, including improper hand hygiene and PPE use by staff, inadequate precautions for MDROs, and improper handling of soiled linens. A Nursing Assistant failed to use gloves and perform hand hygiene, a housekeeper did not wear PPE in a Contact Precaution room, and the laundry process lacked proper gown use and lint filter maintenance.
The facility failed to provide appropriate dialysis care for two residents with end-stage renal disease. One resident lacked documentation for AVF dressing care and inconsistent thrill and bruit assessments, while another resident removed their own AVF dressing without staff orders. Staff interviews confirmed the absence of necessary orders and incomplete documentation.
The facility failed to properly store and label medications in three medication carts. An Arnuity Ellipta inhaler and an Insulin Glargine Pen were found opened and undated, contrary to manufacturer instructions. An unopened Insulin Glargine vial was improperly stored outside refrigeration, and a Breo Ellipta inhaler was also opened and undated. The Regional Clinical Nurse could not explain the improper storage and acknowledged the need for dating medications upon opening.
A Spanish-speaking resident in a LTC facility experienced distress due to communication barriers with staff who did not speak Spanish. Despite having intact cognition, the resident struggled to convey personal needs, leading to inadequate care and feelings of sadness. Staff relied on gestures and other Spanish-speaking employees, but these were insufficient. The facility lacked effective communication tools, and the social worker and DON failed to ensure proper use of translation services.
Two residents experienced significant medication errors. A resident with diabetes did not receive their Tresiba Insulin due to an LPN's inability to locate it, with no documentation of provider notification. Another resident with end-stage renal disease missed several doses of Sevelamer Carbonate due to being unavailable or at dialysis, with no evidence of administration as ordered.
The facility failed to notify the State LTC Ombudsman of the discharges of two residents. One resident, admitted with hemiplegia and hemiparesis, was discharged to the hospital, while another, admitted with hyponatremia, was discharged home with services. Record reviews and staff interviews confirmed the lack of notification.
A resident did not receive medication administration verification by a second nurse as ordered, according to a physician's directive. The MAR for May and June showed no evidence of compliance, and interviews with LPNs confirmed the oversight. The DON could not provide evidence of the required verification.
Failure to Prevent Worsening Pressure Ulcer and New Pressure Injury After Prolonged Time on Bedpan
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services to promote wound healing and prevent pressure ulcers for a resident with an existing unstageable sacral pressure ulcer and a spinal surgical incision. The resident, admitted with an unstageable sacral ulcer and dependent on staff for toileting and rolling, had moderate cognitive impairment per a Minimum Data Set assessment. A wound care physician documented on 3/17/2026 that the sacral ulcer measured 4 cm by 4.2 cm by 0.1 cm. On 3/21/2026, a NA reported arriving for her shift at 7:20 AM and attempting to provide care at multiple times during the morning, which the resident declined. At approximately 2:00 PM, when the NA removed the sheet and rolled the resident, she discovered the resident lying on a bedpan, and stated that no one had informed her that the resident had been placed on a bedpan. The RN later reported that the NA told her about finding the resident on the bedpan but could not say how long the resident had been on it. Subsequent clinical assessments documented new and worsened pressure-related injuries following this incident. On 3/23/2026, a NP documented a newly identified crescent-shaped area of skin breakdown over the coccyx, approximately 8 cm by 2 cm, with purple nonblanchable discoloration and loss of skin integrity, described as a new onset pressure-related injury since the prior skin assessment. On 3/24/2026, the wound care physician documented that an incident occurred in which the resident was on a bedpan for an extended period of time, resulting in a worsened unstageable sacral wound and a new pressure ulcer on the right thigh. At that time, the sacral ulcer had increased in size to 10.5 cm by 11 cm by 0.1 cm, and a new stage 3 pressure ulcer on the right thigh measured 1.5 cm by 3.5 cm by 0.1 cm. The wound care physician later stated that the crescent-shaped wound extended from the initial sacral wound and appeared to follow the line of a bedpan. During surveyor observation on 4/21/2026, the sacral ulcer measured 11.2 cm by 8.5 cm by 1 cm and the right thigh ulcer measured 1.1 cm by 2.6 cm by 0.1 cm. The DON acknowledged that the length of time the resident remained on the bedpan could not be determined and that the resident’s pressure areas had deteriorated after being found on the bedpan for an undetermined period.
Failure to Timely Report Alleged Neglect After Resident Left on Bedpan
Penalty
Summary
The facility failed to immediately report an allegation of neglect to the State Survey Agency as required by state law after a resident was left on a bedpan for an undetermined length of time, resulting in worsening and new pressure ulcers. Facility policy defined neglect as the failure to provide goods and/or services necessary to avoid physical harm and required that any instance of actual or suspected neglect, including injuries of unknown origin, be reported immediately to the Director of Nursing Services and to the Department of Health within 2 hours if it resulted in serious bodily injury. A community complaint submitted to the Rhode Island Department of Health alleged that a patient was left on a bedpan and injured. During a surveyor interview, the Director of Nursing Services acknowledged that the resident’s worsened pressure area was due to being left on the bedpan for an undetermined amount of time and was unable to provide evidence that this incident was reported within the required 2-hour timeframe. The resident involved had been admitted in March 2026 with an unstageable sacral pressure ulcer and a 43 cm spinal surgical incision and had moderate cognitive impairment, requiring staff assistance for toileting and rolling from side to side. Wound care documentation on 3/17/2026 showed a sacral pressure ulcer measuring 4 cm by 4.2 cm by 0.1 cm. A nurse practitioner note on 3/23/2026 described a newly identified crescent-shaped area of skin breakdown over the coccyx, 8 cm by 2 cm, with purple nonblanchable discoloration and loss of skin integrity, concerning for a pressure-related injury. On 3/24/2026, the wound care physician documented that an incident occurred in which the resident was on a bedpan for an extended period of time, which worsened the unstageable sacral wound and caused a new stage 3 pressure ulcer on the right thigh measuring 1.5 cm by 3.5 cm by 0.1 cm, with the sacral ulcer now measuring 10.5 cm by 11 cm by 0.1 cm. Despite these findings and the acknowledged neglect, the facility did not demonstrate that the allegation was reported to the State Survey Agency within the required reporting timeframe.
Failure to Provide Timely BiPAP Therapy for Resident with Chronic Respiratory Failure
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for a resident requiring a BiPAP device. The resident, who had a diagnosis of chronic respiratory failure with hypoxia, was readmitted to the facility with physician discharge instructions and orders specifying the need for BiPAP use during naps and nightly. However, review of the treatment administration record showed no evidence that the BiPAP was administered for several days following readmission. Progress notes indicated that the resident's condition worsened, with symptoms such as shortness of breath and cough, due to the lack of BiPAP therapy. Nursing staff and nurse practitioners confirmed that the BiPAP machine was not available or adjusted for use until several days after the resident's return, and the Director of Nursing Services acknowledged that the device was not provided as ordered within the expected timeframe. The deficiency was identified through record review and staff interviews, which confirmed the delay in providing the prescribed respiratory care.
Food Storage and Service Safety Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen and one kitchenette. Surveyor observations in the main kitchen found food spills and splatters on the walls behind the dish machine, stove, and worktables, chipped corners on Formica-topped food carts, and a black substance on the gaskets of the ice chest. The delivery chute of the ice machine also had a pink substance along the upper rim. In one reach-in refrigerator, a package of white meat cut into cubes and a 1/4-inch pan containing a red substance were both left without labels identifying the contents. During lunch meal service, individual trays were transported on an open cart through elevators and hallways with preset silverware that was not covered or wrapped. The dry storage room temperature was observed at 85 F, above the facility's stated dry storage range of 50 F to 70 F. In the first-floor dining room refrigerator, an opened container of Market Basket Hearty Chicken Noodle soup was dated 7/16/2025, exceeding the facility's 3-day dating policy. The Director of Food Service acknowledged the dirty walls, ice machine, and ice chest gaskets, the need to replace the Formica food carts, the excessive dry storage temperature, the missing labels on unidentifiable food items, the overdue soup date, and that the silverware on meal trays should have been covered.
Failure to Promptly Notify Physician of Resident Change in Condition
Penalty
Summary
The facility failed to immediately notify the resident’s physician of a change in condition for Resident ID #8, who had been readmitted in June 2025 with a diagnosis that included sepsis. On 7/20/2025 at about 6:00 AM, the resident was found in bed covered in watery stool, and vital signs showed respirations of 24, oxygen saturation of 77%, and blood pressure of 98/58. Staff A later observed the resident to be uncomfortable, restless, and moving his/her arms and hips in bed, and Staff C was asked to assist around 5:30 AM to 5:45 AM. Staff A reported that Staff C told him to call the provider, but he was unable to do so because the tablet did not work. The resident’s medical doctor stated he would expect staff to call him if they could not reach the on-call provider. Facility leadership was unable to provide evidence that the provider was notified until the day shift nurse arrived at 7:00 AM, approximately two hours after the change in condition was first identified. The resident was later found moaning and not responding, placed on oxygen for the low saturation, and transported by EMS to the emergency department.
Failure to Follow Physician Orders and Address Weight Discrepancies
Penalty
Summary
The facility failed to ensure services met professional standards of quality by not following physician orders for oxygen use and orthostatic blood pressure monitoring for one resident, and by not addressing significant weight discrepancies for three residents. For Resident ID #8, who was readmitted in June 2025 with diagnoses including sepsis, a physician ordered oxygen at 1 to 4 liters per minute via nasal cannula as needed. During a surveyor interview, an LPN reported finding the resident uncomfortable, restless, and with pulse oximetry readings of 79% and 84%, but oxygen was not administered as ordered. The same resident also had a physician order for orthostatic blood pressures once daily for 3 days and then weekly for 4 weeks, but the July 2025 MAR did not show that these measurements were obtained. The facility also did not follow its Weight Loss/Gain Protocol for Resident ID #16, Resident ID #29, and Resident ID #75. Resident ID #16 had weights of 188.5 lbs. and then 155.8 lbs., a 32.7 lb. difference, with no evidence of a reweigh until the issue was brought to the facility’s attention by the surveyor. Resident ID #29 had weights of 207 lbs., then 215.5 lbs., and later 211.8 lbs., with no evidence of reweigh after the discrepant weights were entered. Resident ID #75 had weights of 193.6 lbs., 197.4 lbs., 197.5 lbs., and then 190.6 lbs., with no evidence of reweigh after the discrepant weights were documented. The facility policy defined a significant weight discrepancy as a change of 3 lbs. or more in one week or a loss/gain of 5% or greater in one month, and required a reweigh within 48 hours. Staff interviews confirmed the discrepancies were recognized but not acted on as expected. An LPN acknowledged that Resident ID #16 was not reweighed when the discrepancy was identified, another LPN acknowledged entering Resident ID #29’s weight without reweighing the resident, and the dietitian stated Resident ID #75 should have been reweighed after the 190.6 lb. weight was documented. The DON also stated that a reweigh was expected when a weight discrepancy was identified.
Failure to Notify Provider of Prolonged Constipation
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident reviewed for constipation. The resident was readmitted to the facility in June 2025 with diagnoses including sepsis and constipation. Review of the bowel records showed no documented bowel movement from 7/9/2025 through 7/13/2025, indicating the resident went 5 days without a bowel movement. The record did not show that the physician was notified of the resident's lack of bowel movements during that 5-day period. During interview, the Nurse Practitioner stated she would expect to be notified when a resident had no bowel movement for 3 days for further interventions, and the DON stated it was her expectation that nursing staff contact the provider if a resident went without a bowel movement for 3 days for further interventions.
Staff Competency Failures in Assessment, Oxygen Administration, Medication Documentation, and Progress Notes
Penalty
Summary
The facility failed to ensure that staff were competent to provide nursing and related services to maintain resident safety and the highest practicable well-being for Resident ID #8. The resident was re-admitted in June 2025 with diagnoses including sepsis, and had a physician order dated 1/28/2025 for oxygen at 1-4 liters per minute via nasal cannula as needed for shortness of breath or hypoxia. On 7/20/2025 at about 6:00 AM, the resident was found by a CNA in bed covered in watery stool from head to toe, was washed up and the bed was changed, and was described as agitated and thrashing in bed. Vital signs showed a temperature of 98.4 F, respirations of 24, blood pressure of 98/58, and SpO2 of 77%. During interview, the LPN stated he had gone in shortly after 5:00 AM to administer medication and observed the resident uncomfortable, restless, kicking arms, and lifting hips off the bed. He obtained pulse oximetry readings of 79% and 84% but did not administer oxygen as ordered, and when asked about interventions for the abnormal oxygen saturation and change in condition, he said he raised the head of the bed to 90 degrees and continued passing medications to other residents. The same LPN also stated he pre-poured Synthroid, signed it off in the EMR before administering it, and was unaware he was not supposed to sign before giving the medication. In addition, he acknowledged using a USB drive with pre-written notes to copy nursing progress notes, and admitted he did not assess range of motion or neurological status but inaccurately copied that information into the note. The DON was unable to provide evidence that the LPN was competent in assessing, documenting medication administration accurately, or writing nursing progress notes, despite receiving competencies.
Uncovered Food Trays Left in Hallway After Meals
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment when food trays with partially consumed meals were left uncovered in the hallway on the first-floor nursing unit after meal hours. Surveyor observations documented four uncovered breakfast trays at 11:30 AM on 7/22/2025, two uncovered lunch trays at 3:45 PM on 7/22/2025, four uncovered breakfast trays at 11:30 AM on 7/23/2025, three uncovered breakfast trays at 11:00 AM on 7/24/2025, and four uncovered lunch trays at 4:00 PM on 7/24/2025. During interview on 7/25/2025 at 11:40 AM, the Director of Food Service acknowledged that the food trucks were left uncovered in the hallway after meal hours and contained partially consumed food on the trays.
Failure to Obtain Ordered Orthostatic Vital Signs After Multiple Falls
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for Resident ID #8 by not obtaining orthostatic vital signs as ordered. The record showed a physician's order dated 7/15/2025 to monitor the resident's orthostatic blood pressure daily for three days, then weekly for four weeks, but review of the July 2025 Medication Administration Record did not show evidence that the orthostatic blood pressures were obtained. During a surveyor interview on 7/24/2025, the Director of Nursing Services was unable to provide evidence that the orthostatic blood pressures had been completed for the resident. Resident ID #8 had been readmitted to the facility in June 2025 with diagnoses including sepsis and had a care plan revised on 7/21/2025 identifying a history of falls and risk for future falls. The care plan included orthostatic vital sign monitoring due to Seroquel use and updating the physician or NP with changes as needed. The progress notes documented multiple falls on 7/13/2025 and 7/14/2025, including being found kneeling in front of the sink, on the floor in the middle of the room, on the bathroom floor, and kneeling next to the bed. The record also included a facility-reported incident of unknown origin involving fractured ribs and a lacerated spleen, and a complaint alleging the resident arrived at the hospital after a suspected unwitnessed fall with bruising on the left flank, a grade 4 splenic laceration, and displaced fractures of the left 10th and 11th ribs.
Failure to Implement and Document Pain Management Interventions
Penalty
Summary
The facility failed to implement comprehensive, person-centered care plans for four residents regarding pain medication administration. For each resident, although care plans were developed with specific interventions such as administering pain medications, monitoring and recording pain levels, and documenting effectiveness and side effects, there was no evidence in the medical records that these interventions were carried out. The residents involved had various diagnoses, including chronic pain, pressure ulcers, adult failure to thrive, and depression, with cognitive statuses ranging from intact to severely impaired. Despite care plans being in place and revised as needed, the required documentation and follow-through on pain management interventions were absent. Staff interviews confirmed these deficiencies, with a registered nurse acknowledging that pain was not documented as outlined in the care plans and that staff only verbally inquired about pain. The Assistant Director of Nursing stated that staff were expected to follow care plans, but the records did not reflect implementation of the pain management interventions. These findings were based on record reviews and staff interviews, as well as a community complaint regarding a resident not receiving pain medication despite reporting significant pain.
Failure to Follow Physician's Orders for Pain Management and Air Mattress Use
Penalty
Summary
The facility failed to meet professional standards of quality by not following physician's orders for pain medication administration and by not ensuring proper documentation and orders for the use of an air mattress for a resident. The resident, who was admitted with diagnoses including cellulitis, acute respiratory failure, and emphysema, was under hospice care and had physician's orders for both scheduled and PRN morphine for pain management, as well as psychotropic medications for anxiety. Despite repeated complaints of severe pain throughout the day, the Medication Administration Record did not show that PRN morphine was administered after the morning dose, even though the resident continued to request pain relief and staff documented ongoing pain complaints. Staff interviews confirmed that no additional PRN pain medication was given prior to the resident's transfer to the hospital for pain management, and the nurse practitioner was unaware that the PRN medication had not been administered as ordered. Additionally, the facility failed to obtain or document a physician's order for the use of an air mattress, including necessary settings and specifications, for the same resident. Nursing notes indicated that the hospice team was contacted to request a new air mattress due to equipment issues, and surveyor observation confirmed the presence of an air mattress in the resident's room. However, there was no evidence in the medical record of a physician's order authorizing the use of the air mattress or specifying its settings, as acknowledged by the Assistant Director of Nursing. These deficiencies were identified through record review, staff interviews, and direct observation, and were substantiated by community complaints submitted to the state health department. The facility's failure to follow physician's orders for pain management and to ensure proper documentation and authorization for medical equipment use resulted in noncompliance with professional standards of quality care.
Failure to Document Physician-Ordered Skin Evaluations
Penalty
Summary
The facility failed to meet professional standards of quality for two residents regarding the completion and documentation of physician-ordered weekly skin evaluations. Resident ID #1, admitted in January 2023 with diagnoses including malnutrition and multiple fractures, had a physician's order dated June 30, 2024, for weekly skin evaluations. However, the Medication Administration Records for July, August, and September 2024 indicated that these evaluations were signed off as completed on several dates, but there was no evidence in the Weekly Skin Evaluation Observations to confirm that the assessments were actually performed and documented. Similarly, Resident ID #2, admitted in October 2022 with diagnoses including dementia and syncope, also had a physician's order for weekly skin evaluations dated June 30, 2024. The September 2024 Medication Administration Record showed that the evaluations were signed off as completed on two dates, but again, there was no evidence in the Weekly Skin Evaluation Observations to support that the assessments were conducted and documented. During an interview, the Director of Nursing Services was unable to provide evidence that the weekly skin assessments were completed as per the physician's orders.
Failure to Ensure Competency in Mechanical Lift Use
Penalty
Summary
The facility failed to ensure that nursing staff, specifically Nursing Assistants (NAs) Staff A and B, possessed the necessary competencies and skills to provide safe and effective care to residents. This deficiency was identified through a review of records and staff interviews, which revealed that the facility did not have evidence of completed competencies and skills sets for safe patient handling, particularly regarding the use of mechanical lifts. The facility's assessment indicated that staff training and education on mechanical lifts should be completed during orientation and annually. However, for Staff A, hired on 8/21/2024, and Staff B, hired on 8/30/2024, there was no documentation to confirm that these competencies were completed before they began providing care to residents. During an interview with the Regional Nurse, it was confirmed that the mechanical lift competencies for these staff members were not completed prior to their engagement in resident care.
Failure to Conduct Annual Performance Reviews for NAs
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 there was no evidence of completed annual performance evaluations for five NAs: Staff G, H, I, J, and K. The dates of hire for these staff members ranged from 2005 to 2023. During an interview with the Director of Nursing Services, she was unable to provide documentation of a completed performance evaluation within the last 12 months for these employees.
Failure to Provide Bedtime Snacks
Penalty
Summary
The facility failed to ensure that nourishing snacks were offered to residents at bedtime, as required by the State Operations Manual for Long Term Care. This deficiency was identified during a resident council meeting where 5 out of 9 members reported that bedtime snacks were not offered, despite expressing a desire for them. The facility's meal schedule, with supper starting at approximately 5:00 PM and breakfast at 8:00 AM, results in more than 14 hours between meals, which necessitates the provision of a bedtime snack. The Administrator acknowledged this gap and was unable to provide evidence that all residents were offered or received bedtime snacks every night.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as observed during a survey. In the main kitchen, food items such as pasta salad and hard-boiled eggs were found unlabeled and undated, violating the Rhode Island Food Code's requirement for marking refrigerated, ready-to-eat time/temperature control for safety food. Additionally, expired yogurt cups were found in two nourishment areas, and a container with an unlabeled brown substance was improperly stored with a spoon resting inside. The Food Service Director (FSD) acknowledged these issues during interviews. Further deficiencies were noted in the storage and packaging of food items. In the kitchen's freezer, chicken patties were only partially covered, and large quantities of beef patties and cookie dough balls were found in unsealed, undated bags, compromising the integrity of the food packages. The FSD was unable to provide evidence that these packages were in good condition to protect the contents from contamination. The facility also failed to maintain proper sanitation and hygiene standards. The high-temperature dishwasher did not achieve the required temperature for sanitization, as indicated by non-reactive temperature-sensitive labels. The FSD acknowledged the issue and noted that the dishwasher's thermostat was faulty. Additionally, the FSD was observed serving food without a beard restraint, and there was a lack of a certified food safety manager during certain hours of operation, as the dietary cook's certification had expired. The facility administrator could not provide evidence of a certified manager being present during these times.
Failure to Implement and Maintain Effective QAPI Program
Penalty
Summary
The facility failed to implement and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program. During a review of the QAPI binders, it was found that although QAPI plans were created for areas identified as concerns in August 2023, December 2023, and March 2024, there was no evidence of their implementation or maintenance. This included a lack of tracking and measuring performance, as well as establishing goals and thresholds for performance measurement. Similarly, the June 2024 QAPI meeting identified concerns that could aid in establishing QAPI plans, but there were no completed plans or evidence of their implementation and maintenance. During an interview with the facility Administrator, he was unable to provide evidence that the facility had implemented and maintained an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. One incident involved a Nursing Assistant, Staff B, who did not adhere to proper hand hygiene and PPE protocols while providing personal care to a resident. Staff B was observed entering a resident's room without gloves, handling a basin containing urine, and failing to perform hand hygiene before continuing with personal care tasks. This lapse in infection control practices was acknowledged by Staff B and the Director of Nursing Services. Another deficiency was noted with the improper use of PPE in a room under Contact Precautions. A housekeeper, Staff N, was observed in a resident's room without wearing gloves or additional PPE, despite the room being under Contact Precautions due to the presence of multidrug-resistant organisms (MDROs). Staff N touched various items in the room and assisted a resident without performing hand hygiene, potentially facilitating the spread of infections. This was acknowledged by Staff N during an interview with the surveyor. Additionally, the facility failed to handle, store, and transport linens appropriately. The laundry process involved moving soiled laundry through areas where clean laundry was processed, without the use of gowns unless the laundry appeared visibly soiled. Furthermore, the facility did not consistently document the regular emptying of dryer lint filters, which is a critical component of maintaining a clean and safe laundry environment. These deficiencies highlight significant lapses in the facility's infection control practices.
Deficiency in Dialysis Care for Residents
Penalty
Summary
The facility failed to provide appropriate dialysis care for two residents requiring such services, as identified during a survey. Resident ID #40, admitted with end-stage renal disease and dependent on renal dialysis, was found to have insufficient documentation regarding the care of their arteriovenous fistula (AVF). Specifically, there was no physician's order for the AVF dressing or instructions on when it should be removed post-dialysis. Additionally, the resident's thrill and bruit were not consistently assessed, with only 7 out of 70 opportunities documented since admission. During an observation, the resident was found with a dressing in place at the AVF site, but the necessary assessments were not recorded in the administration record. Similarly, Resident ID #9, also with end-stage renal disease and dependent on dialysis, lacked a physician's order for AVF dressing care. The resident was observed with an uncovered AVF and reported removing the dressing themselves after dialysis. Staff interviews revealed that the resident refused staff assistance with dressing removal, and there were no orders for AVF site dressings. The Regional Clinical Nurse confirmed the absence of such orders and acknowledged that the order to assess thrill and bruit for Resident ID #40 was not transcribed, leading to incomplete documentation of the required assessments.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with currently accepted professional principles, as observed in three out of four medication carts. On the Upper Unit medication cart, an Arnuity Ellipta inhaler was found opened and not dated, despite manufacturer instructions stating it expires six weeks after opening. On the North Unit medication cart, an Insulin Glargine Pen was also opened and not dated, with manufacturer instructions indicating it should be discarded 28 days after opening. Additionally, on the East Unit medication cart, an unopened Insulin Glargine vial was improperly stored outside of refrigeration, contrary to manufacturer instructions requiring refrigeration before opening. A Breo Ellipta inhaler was also found opened and not dated, with instructions to discard six weeks after opening. During an interview, the Regional Clinical Nurse could not explain why the insulin was stored in the medication cart and acknowledged that medications should be dated when opened.
Communication Barriers Lead to Resident's Distress
Penalty
Summary
The facility failed to treat a Spanish-speaking resident with respect and dignity, as required by regulations, due to inadequate communication support. The resident, who has intact cognition and requires assistance with activities of daily living, was unable to effectively communicate with staff because they did not speak Spanish. This communication barrier led to the resident not receiving timely assistance for personal needs, such as using the bathroom, and not understanding the purpose of certain therapies. The resident expressed feelings of sadness and suffering due to the lack of understanding from the staff. Surveyor observations and interviews revealed that staff members, including nursing assistants and licensed practical nurses, struggled to communicate with the resident. They often relied on other staff members who spoke Spanish or used gestures, but these methods were insufficient. The facility had not provided adequate resources, such as communication boards or effective use of translation services, to bridge the language gap. The social worker acknowledged the need for an interpreter but had not addressed the resident's individual needs in a timely manner. The Director of Nursing Services was unable to explain why staff were not utilizing available translation lines to assist the resident.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident ID #15, who was admitted with type 2 diabetes mellitus, did not receive their prescribed Tresiba Insulin on one occasion. The family member reported that an agency nurse, identified as Staff L, was unable to locate the insulin. The Medication Administration Record (MAR) confirmed that the insulin was not administered on the specified date, and there was no documentation in the nursing progress notes indicating that the nurse informed the provider about the missed medication. Resident ID #40, admitted with end-stage renal disease and dependence on renal dialysis, did not receive their prescribed Sevelamer Carbonate on multiple occasions due to being unavailable or at dialysis. The MARs for June and July showed missed doses on several dates. During interviews, the Director of Nursing Services could not provide evidence that the medications were administered as ordered and acknowledged that the provider must be notified if a medication is not available or administered.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman for two residents who were discharged. Resident ID #75 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction and was discharged to the hospital. Resident ID #77 was admitted with hyponatremia and was discharged to their home with services. Record reviews did not show evidence that the Ombudsman was notified of these discharges. During interviews, the social worker was unable to provide evidence of such notifications.
Failure to Verify Medication Administration
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following a physician's order for medication administration verification. The deficiency was identified through a record review and staff interviews, revealing that a resident, admitted in May 2023 with diagnoses including adult failure to thrive and pressure ulcers, did not have their medication administration verified by a second nurse as ordered. The physician's order required a second nurse verification of medication administration twice daily, but the Medication Administration Record (MAR) for May and June 2024 showed no evidence of this verification on specific dates. Interviews with Licensed Practical Nurses (LPNs) confirmed the failure to verify medication administration with a second nurse on the specified dates. LPN Staff A acknowledged not verifying the medication administration on three consecutive days in June 2024, while LPN Staff B admitted to the same oversight on a day in May 2024. The Director of Nursing Services was unable to provide evidence that the required second nurse verification occurred on these dates, as ordered by the physician.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 598 citations issued within 25 miles in the last 12 months — including the 24 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Warwick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kent Regency Center | 2 mi | ★★★★★ | 6 | 0 |
| Greenwood Operations Dba Greenwood Center | 2.4 mi | ★★★★★ | 12 | 2 |
| Sunny View Nursing Home | 2.8 mi | ★★★★★ | 8 | 1 |
| West View Nursing Home, Inc | 3 mi | ★★★★★ | 7 | 2 |
| Saint Elizabeth Home East Greenwich | 3.2 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.