Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Saint Elizabeth Home East Greenwich during CMS and state inspections, most recent first.
The facility failed to complete annual performance reviews for 3 of 3 nurse aides reviewed. Record review showed each aide’s last performance review was completed in 2024, and the DON acknowledged during interview that the nurse aides had not received yearly reviews since then.
A resident with dementia and elopement risk had a wanderguard noted on the walker during surveyor observations, but the record lacked a physician order for the device and orders for shift placement checks and weekly functionality checks. The chart also did not show documentation that the wanderguard was being monitored per policy, and the RN UM and DON acknowledged the missing orders.
A resident with severe cognitive impairment and a history of wandering entered another resident's room and was found in a compromising situation, while the required motion sensor alarm meant to alert staff was not activated. The incident occurred despite care plans and physician orders for safety interventions, and documentation confirming the alarm's use was missing. Staff confirmed the alarm was not functioning at the time of the event.
A resident with a history of physical aggression and severe cognitive impairment physically assaulted another cognitively impaired resident in the dining room when no staff were present. The victim sustained bruises and scratches, and the incident was unprovoked. The facility's lack of supervision and failure to prevent the altercation resulted in a deficiency related to resident protection from abuse.
The facility was found deficient in food storage and labeling practices, with multiple instances of improperly labeled or unlabeled food items in various kitchens. Additionally, equipment food contact surfaces, such as microwaves, were not maintained clean, with accumulations of food matter and debris observed. The Director of Dining Services acknowledged these issues, indicating a failure to adhere to the facility's food service policy and cleaning schedule.
Two residents did not receive care according to physician's orders, as a nurse failed to administer prescribed nutritional supplements and monitor blood pressure during medication administration. Despite this, the MAR inaccurately documented that these tasks were completed. The DON expected adherence to physician's orders.
A resident with a history of confusion eloped from a facility after staff failed to supervise adequately and disabled door alarms. The resident was found on a main road, confused and cold, and was taken to a hospital. Staff did not notice the resident's absence until the next morning, and the family was not informed until after emergency services had located the resident. The facility's missing resident policy was not followed, and the Director of Nursing Services acknowledged the failure to provide adequate supervision.
A resident eloped from the facility unsupervised, leading to an Immediate Jeopardy citation. The resident was unaccounted for approximately 10 hours and was found on a busy roadway. Staff failed to follow the missing resident policy, did not notify family or police timely, and did not respond to alarms. The facility's Administrator acknowledged that the alarms had been turned off by staff, contributing to the incident.
A resident with severe cognitive impairment and dysphagia, requiring a pureed diet, was given a regular textured cookie by a staff member, leading to a fatal choking incident. Despite immediate intervention, the resident expired. The staff member acknowledged the error, and the Director of Nursing confirmed the resident was given food not in the prescribed form.
A resident with dementia pinched another resident with Alzheimer's, causing a skin tear that required treatment. Staff confirmed the incident occurred during an attempt to separate the residents after one tried to touch the other's food. Both residents were unable to recall the event due to impaired cognition, and the facility failed to provide evidence of protection from abuse.
A resident with Alzheimer's and diabetes suffered a skin tear after being pinched by another resident. Despite a physician's order for wound care, the facility failed to document the wound's size, edges, and surrounding tissue condition. Interviews with the Unit Manager and DON confirmed the lack of proper documentation.
Failure to Complete Annual Nurse Aide Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for every nurse aide at least once every 12 months for 3 of 3 nurse aide personnel records reviewed, including Staff B, Staff C, and Staff D. Record review showed Staff B was hired in January 2000 and her last annual performance review was completed on 4/8/2024. Staff C was hired in January 2008 and her last annual performance review was completed on 2/13/2024. Staff D was hired in February 2023 and her last annual performance review was completed on 3/11/2024. During an interview on 4/22/206 at 10:22 AM, the DON acknowledged that these nurse aides had not had a yearly performance review since 2024.
Missing Orders and Monitoring for Wanderguard Device
Penalty
Summary
The facility failed to ensure that a resident at risk for elopement received adequate supervision and assistance devices to prevent accidents. The resident was admitted in November 2025 with a diagnosis including dementia, and an elopement assessment showed a score of 3, indicating risk for elopement. The care plan, initiated on 11/17/2025, identified the resident as at risk for elopement related to recent wandering and verbalizing wanting to go home, with interventions including a wanderguard in place and staff checking placement and functionality per physician's order. Surveyor observations on 4/20/2026, 4/21/2026, and 4/22/2026 noted the resident's wanderguard on the walker. Review of the record did not reveal a physician's order for the wanderguard device, an order to check placement each shift, or an order to check functionality weekly. The record also lacked documentation that the wanderguard was being monitored for placement and functionality per facility policy. During interview, the RN Unit Manager acknowledged there were no active physician's orders for the wanderguard checks, and the DON stated there should be physician's orders in place for the device and for checking placement and functionality.
Failure to Protect Resident from Abuse Due to Inactive Safety Interventions
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse during a resident-to-resident incident. On the morning of the incident, a nursing assistant found one resident on top of another in a private room, with the resident on top disrobed from the waist down and making thrusting motions, while the other resident was fully clothed. The incident was discovered during routine rounds, and both residents were separated and assessed. The resident who was found on the bottom had severe cognitive impairment, a history of wandering, and had previously entered other residents' rooms, including the room of the resident involved in this incident. The care plan for this resident included interventions such as monitoring whereabouts, redirecting from other rooms, and placing a stop sign at the doorway to deter entry. The resident whose room was entered had a diagnosis of dementia but was cognitively intact according to recent assessments. This resident's care plan included a motion sensor at the door to alert staff if someone entered the room, as well as a stop sign to deter entry. Previous nursing notes documented prior incidents of the wandering resident entering this room and touching the resident inappropriately, which led to the implementation of the motion sensor and stop sign interventions. Physician orders required the motion sensor to be plugged in at a specific time each morning and unplugged at night, with documentation in the treatment administration record (TAR). On the day of the incident, staff interviews and record reviews revealed that the motion sensor alarm was not plugged in as ordered, and there was no documentation in the TAR to confirm it was activated. Staff who responded to the incident noted that the alarm did not sound when they entered the room, and the Director of Nursing confirmed that the sensor was not plugged in at the time. There was no evidence provided that the resident was kept free from abuse, as required by facility policy and regulatory standards.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident with a known history of physical aggression struck another resident multiple times in the face while in the dining room. At the time of the incident, both residents, who had severe cognitive impairment and dementia, were seated at opposite ends of a table. The aggressor resident became physically violent without provocation, and staff were not present in the dining room when the incident began, as one had just left to assist with care elsewhere. The incident was witnessed by a hospice RN who intervened and called for additional staff. Following the altercation, the victim was assessed and initially showed no visible injuries. However, a subsequent skin assessment revealed multiple bruises and scratches on the victim's hands and forearms, consistent with defensive wounds. The victim, who was unable to recall the incident due to cognitive impairment, was otherwise calm and in good spirits during later observations. The aggressor was sent for a psychiatric evaluation after the event. The facility's abuse prohibition policy requires that all residents be free from abuse, including physical harm. Despite the known behavioral history of the aggressor and interventions in place, the lack of staff supervision in the dining room at the time of the incident allowed the abuse to occur. The facility was unable to provide evidence that the victim was kept free from abuse, as required by policy.
Deficiencies in Food Storage and Equipment Cleanliness
Penalty
Summary
The facility failed to ensure proper food storage and labeling practices in accordance with professional standards for food service safety. During an inspection, surveyors observed multiple instances of improperly labeled or unlabeled food items in the main kitchen, kitchenettes, and house kitchens. These included sliced lemon wedges, frozen waffles, bagels, fish sticks, cooked chicken legs, pasta, eggplant parmesan, diced tomatoes, ice cream with freezer burn, and English muffins past their sell-by date. The Director of Dining Services acknowledged these findings and confirmed that the items should have been labeled, dated, and discarded as per the facility's food service policy and regulations. Additionally, the facility did not maintain cleanliness of equipment food contact surfaces as required. Surveyors found microwaves in several units with accumulations of dried food matter and greasy residue, as well as a freezer drawer with food particles and debris. The Director of Dining Services noted that the Shahbaz staff, responsible for cleaning these areas, were expected to follow a weekly cleaning schedule, which was not adhered to, resulting in the observed deficiencies.
Failure to Administer Supplements and Monitor Blood Pressure
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, specifically in following physician's orders for nutritional supplements and blood pressure monitoring. Resident ID #6, who was admitted with diagnoses including dementia and diabetes, had physician's orders for a house supplement and Pro-Stat AWC for weight loss and wound care, respectively. During a surveyor observation, RN Staff A was seen administering morning medications to Resident ID #6 but did not administer the prescribed supplements. Despite this, the February 2025 Medication Administration Record (MAR) indicated that the supplements were documented as administered by RN Staff A. Similarly, Resident ID #54, with diagnoses including dementia and hypertensive heart disease with heart failure, had physician's orders for furosemide and Pro-Stat AWC, with instructions to monitor blood pressure. During the same observation, RN Staff A administered furosemide but did not administer the supplement or obtain the resident's blood pressure. The MAR inaccurately documented that the supplement was given and the blood pressure was recorded. In an interview, RN Staff A admitted to not administering the supplements or obtaining the blood pressure, despite documenting otherwise. The Director of Nursing Services expressed that it was expected for nurses to follow physician's orders.
Resident Elopement Due to Inadequate Supervision and Disabled Alarms
Penalty
Summary
The facility failed to ensure adequate supervision and safety for a newly admitted resident, leading to an elopement incident. The resident, who had a history of confusion and forgetfulness following a hospital stay for a brain hemorrhage, was last seen by staff between 8:00 PM and 9:00 PM. Despite the resident's known condition, staff did not maintain proper supervision, and the resident was able to leave the facility unnoticed. The door alarms, which should have alerted staff to the resident's departure, were turned off by staff members, allowing the resident to exit the building without detection. The resident was found by a newspaper delivery person on a main road, confused and inadequately dressed for the cold weather, and was taken to a police station before being transferred to a hospital for evaluation. The facility's staff failed to notice the resident's absence until the following morning, and the family was not informed until after the resident had already been located by emergency services. The facility's missing resident policy, which includes notifying the family and police within 30 minutes of discovering a resident is missing, was not followed. Interviews with staff revealed a lack of communication and adherence to protocols. The charge nurse on duty during the night shift did not conduct rounds or check on the resident, and the staff failed to respond to door alarms. The facility's Director of Nursing Services acknowledged that the staff did not follow the missing resident policy and could not provide evidence of adequate supervision to prevent the elopement. This deficiency placed the resident at risk for harm due to exposure to cold weather and confusion, as well as potential injury from being unsupervised outside the facility.
Resident Elopement Due to Policy Non-Compliance and Alarm Failure
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in the elopement of a resident, which led to an Immediate Jeopardy citation. The resident was last seen by staff at approximately 8:00 PM and was later found unsupervised on a busy roadway at 4:00 AM by a passerby. The facility's policy for a missing resident was not followed, as staff failed to notify the family and police in a timely manner. The resident was unaccounted for approximately 10 hours, and the staff did not respond to any alarms during the night shift. The facility's Director of Nursing Services and Administrator acknowledged that the resident eloped unsupervised, despite the presence of alarmed doors that should have been activated. It was revealed that the alarms had been turned off by staff, and no alarms were responded to during the night shift. The Administrator admitted that the facility staff did not follow the missing resident policy, and the resident was seen on another facility's video footage at 2:31 AM. The incident highlighted a significant lapse in the facility's procedures and staff actions, leading to the resident's elopement and subsequent Immediate Jeopardy citation.
Failure to Provide Appropriate Diet Texture Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a resident received food in the appropriate form, leading to a fatal choking incident. The resident, who had severe cognitive impairment and required a mechanically altered diet of pureed texture due to dysphagia, was given a regular textured oatmeal chocolate chip cookie by a staff member. This was contrary to the resident's dietary requirements as outlined in their care plan and physician's orders. The incident occurred during a dinner meal when the resident was observed choking, and despite immediate intervention with the Heimlich maneuver and the arrival of EMS, the resident expired. The deficiency was identified through a combination of record reviews, staff interviews, and surveyor observations. The staff member involved acknowledged the error, stating it was an accident and that they were aware of the dietary requirements documented in a binder available in the dining room. The Director of Nursing Services confirmed that the resident expired while eating a cookie that was not in pureed form. The incident highlights a critical lapse in adhering to dietary protocols for residents with specific dietary needs, resulting in a tragic outcome.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents. Resident ID #1, who has a diagnosis of dementia and severely impaired cognition, pinched Resident ID #2 on the leg, causing a skin tear. This incident occurred while Resident ID #2, who has Alzheimer's disease and severely impaired cognition, was being assisted out of a chair. The pinching incident was reported to the Rhode Island Department of Health, and the resulting skin tear required medical treatment for 22 days. Interviews with staff, including a Nursing Assistant and the Unit Manager, confirmed that Resident ID #1 pinched Resident ID #2 during an attempt to separate the two residents after Resident ID #2 attempted to touch Resident ID #1's food. Both residents were unable to recall the incident due to their impaired cognition. The Director of Nursing Services acknowledged the incident and was unable to provide evidence that Resident ID #2 was kept free from physical abuse, highlighting a deficiency in the facility's ability to protect residents from abuse.
Failure to Document Wound Care Properly
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive care plan. The resident, who was readmitted to the facility with Alzheimer's disease and type II diabetes, suffered a skin tear after being pinched by another resident. A physician's order was issued to treat the wound with normal saline, xeroform, and a foam dressing every three days. However, the facility did not document the wound's size, edges, wound bed, shape, or the condition of the surrounding tissue as required by regulations. The deficiency was further highlighted during interviews with the Unit Manager and the Director of Nursing Services, who both acknowledged the lack of proper documentation. The Unit Manager described the wound as a flap of skin that bled initially, but confirmed that no measurements or identifying characteristics were recorded. The Director of Nursing Services also confirmed the absence of documentation for the skin tear on the specified dates. An interview with the resident was attempted, but the resident was unable to recall the incident due to impaired cognition.
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What surveyors actually found near you
We read the 566 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.
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Nursing homes near East Greenwich
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bayview Rehabilitation And Healthcare Center | 2.5 mi | ★★★★★ | 12 | 1 |
| Brentwood Health Center | 3.2 mi | ★★★★★ | 3 | 0 |
| Roberts Health Centre Inc | 4.3 mi | ★★★★★ | 5 | 0 |
| Kent Regency Center | 4.3 mi | ★★★★★ | 6 | 0 |
| West View Nursing Home, Inc | 4.3 mi | ★★★★★ | 7 | 2 |
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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.