Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Village House Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Kitchen Food Safety and Storage Deficiencies: Surveyors observed that the ice machine in the main kitchen did not have the required 1-inch air gap, and a cell phone and portable speaker were placed on a food prep worktable. Staff H acknowledged the observations, and the Food Service Director later confirmed that personal items should not be stored on food prep areas.
Significant medication errors occurred during antibiotic treatment for a resident with infected bilateral heel wounds. Metronidazole 250 mg was incorrectly transcribed from TID to BID, resulting in 20 doses given instead of the 30 ordered, and metronidazole 500 mg sprinkles were also shorted, with 13 doses administered instead of 14. The Unit Manager acknowledged the transcription and dosing errors, and the DON could not provide evidence the resident was kept free from significant medication errors.
A facility failed to follow physician orders for a resident who needed a cervical collar, a resident on a no-straw diet, and two residents with skin tears. Surveyors observed the collar not in place when ordered, saw straws used with thickened liquids despite a no-straw order, and found wound dressings that were dated, soiled, or not supported by a physician order. Staff and the DON/DNS acknowledged the missed or unsupported orders.
Improper medication storage and labeling were found when a resident had AREDS eye vitamin and chlorhexidine mouthwash kept at the bedside, and a medication refrigerator contained opened, undated Ativan Intensol and tuberculin solution. An RN acknowledged the bedside meds and the opened, undated products, and the DON acknowledged the resident should not have had meds at the bedside and could not provide evidence that storage practices met policy.
Incomplete medication and wound treatment documentation affected two residents. One resident with infected heel wounds had metronidazole transcribed incorrectly from TID to BID, resulting in fewer doses than ordered, and another resident with a right-hand skin tear had a wound treatment documented as completed even though the dressing remained dated and appeared soiled when observed. The DON and unit manager acknowledged the documentation issues.
Failure to monitor antibiotic use and verify antibiotic orders: The facility did not maintain an effective antibiotic stewardship process for two residents. One resident with bilateral heel wounds received ciprofloxacin and metronidazole orders that were not re-evaluated, and a transcription error caused the resident to receive fewer doses of metronidazole than intended. Another resident with a UTI received Augmentin for longer than ordered, and an antibiotic appropriateness assessment failed to identify the incorrect duration. The DON acknowledged the missed re-evaluation and the unrecognized dosing error.
The facility failed to meet food safety standards, with issues including undated and improperly stored food items, accumulation of ice in the freezer, and expired nutritional shakes. The FSD acknowledged these deficiencies during the survey.
The facility failed to implement comprehensive care plans for two residents with indwelling urinary catheters. One resident, admitted with cutaneous vesicostomy and a supra pubic catheter, and another with urinary retention, both required monitoring of urinary output. However, there was no evidence of monitoring on multiple occasions. Staff interviews revealed an inability to provide evidence of the required monitoring.
A facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for a resident with a suprapubic catheter and moisture-associated skin damage. Staff were observed not wearing gowns, contrary to facility policy and CDC guidelines, which require gowns and gloves during high-contact care activities for residents with MDROs. The Director of Nursing confirmed the expectation for gown use during such procedures.
A resident with Alzheimer's disease and other conditions required substantial assistance for bed mobility, but the facility failed to provide adequate supervision, leading to the resident being found wedged between the bed and the wall. This resulted in a fracture of the left femur, requiring frequent morphine administration for pain management. The care plan did not specify the necessary assistance level, and the nursing assistant repositioned the resident alone, contrary to the facility's guidelines.
A resident experienced significant weight loss, which was not addressed according to the facility's policy. Despite a documented 11.9-pound loss over 15 days, the required re-weigh and notifications to the physician and dietician were not completed. The resident's weight continued to decline, totaling a 22.2-pound loss. Interviews revealed that staff were unaware of the initial weight loss, and no interventions were implemented until further decline occurred.
The facility failed to complete a discharge summary and medication reconciliation for a resident, resulting in the resident's representative not being informed of medication changes upon discharge. Staff interviews confirmed the lack of communication and documentation, contrary to facility policy.
Kitchen Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, served, and distributed in accordance with professional standards for food service safety in the main kitchen. During an initial walk-through of the kitchen, surveyors observed that the ice machine did not have a one-inch air gap as required by the FDA Food Code. In the same observation, a cell phone and portable speaker were seen lying on top of a food preparation worktable. Staff H acknowledged both the missing air gap at the ice machine and the personal items on the food preparation surface, and the Food Service Director later acknowledged that the ice machine did not have the required air gap and that staff personal possessions should not be stored on food preparation areas.
Significant Medication Errors in Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a resident with bilateral heel pressure ulcers and infected wounds was free from significant medication errors during treatment with antibiotics. After wound cultures were positive for infection, the provider ordered ciprofloxacin 250 mg twice daily for 10 days and metronidazole 250 mg three times daily for 10 days. The metronidazole 250 mg order was incorrectly transcribed as twice daily instead of three times daily, and the February 2026 MAR showed the resident received 20 doses rather than the 30 doses intended. The Unit Manager acknowledged the transcription error, and the physician stated the medication should have been transcribed for three times daily as typical treatment. The resident also received metronidazole 500 mg sprinkles ordered for the bilateral heel wounds. A progress note documented the provider ordered the additional antibiotic, and the physician order indicated the medication was to be sprinkled on both heel wounds once daily, with the order later discontinued. The February 2026 MAR showed the resident received 13 doses instead of the 14 doses intended. The Unit Manager acknowledged the resident received only 13 of the 14 ordered doses, and the DON was unable to provide evidence that the resident was kept free from significant medication errors.
Failure to Follow Physician Orders for Devices, Diet Restrictions, and Wound Care
Penalty
Summary
The facility failed to follow physician orders for a resident with Parkinson’s disease, scoliosis, and abnormal posture who had an order for a cervical collar to be applied when out of bed and removed later in the day as tolerated. Surveyor observations found the resident without the collar on multiple occasions, and the resident stated staff had not offered or applied it. An LPN acknowledged the collar was not applied when the resident wanted to wear it, and the DNS could not provide evidence that the collar had been applied as ordered. The facility also failed to follow a no-straw order for a resident with cerebral infarction, dysphagia, and hospice services. The resident had a physician order for a ground diet with nectar-thick liquids and no straws, based on hospice recommendations. Surveyors observed thickened drinks with straws on the bedside table and later observed the resident being assisted with lunch while a straw was in the drink. The NA assisting the resident stated the resident had a straw and indicated the resident liked to use them, while the DNS stated the no-straw order should have been followed. In addition, the facility failed to carry out wound care orders for two residents with non-pressure wounds. One resident had a right hand skin tear with an order for daily cleansing and an optifoam dressing, but the dressing remained dated and soiled during observation, and staff acknowledged the dated bandage. Another resident had a right upper arm skin tear/abrasion with a dressing in place, but the record did not show a physician order for dressing changes. Staff acknowledged the lack of an order, and the DNS could not provide evidence of an order for treatment of the wound.
Improper Medication Storage and Labeling
Penalty
Summary
Drugs and biologicals were not stored in accordance with currently accepted professional principles for one resident observed with medications at the bedside and for one of two medication rooms observed. Resident ID #9 was observed with one bottle of AREDS eye vitamin and one 16-ounce bottle of chlorhexidine mouthwash on the bedside table during multiple surveyor observations. During interview, an RN acknowledged that the AREDS and chlorhexidine mouthwash were at the bedside and stated that the medications should not have been stored there. During observation of the Specialty Care Unit medication refrigerator, surveyors found two opened, undated 30 mL bottles of Ativan Intensol concentrate and one opened, undated bottle of tuberculin purified protein solution. Manufacturer instructions reviewed by surveyors stated that opened Ativan should be discarded after 90 days and opened tuberculin solution should be discarded after 30 days. An RN acknowledged that the Ativan and tuberculin solution were opened, undated, and in use. The DON later acknowledged that Resident ID #9 should not have medications at the bedside and was unable to provide evidence that the facility ensured proper storage of drugs and biologicals per facility policy.
Incomplete Medication and Wound Treatment Documentation
Penalty
Summary
Resident ID #3 was readmitted in January 2026 with diagnoses including pressure ulcers of the right and left heels and had wound cultures obtained from both heel wounds. A progress note dated 2/8/2026 documented that the wound cultures were positive for infectious organisms and the provider ordered ciprofloxacin 250 mg twice daily for 10 days and metronidazole 250 mg three times daily for 10 days. The physician order for metronidazole was incorrectly transcribed as twice daily instead of three times daily, and the February 2026 MAR showed the resident received only 20 doses rather than the intended 30 doses. The Unit Manager RN acknowledged the transcription error, and the physician stated the metronidazole should have been transcribed as three times daily. Resident ID #88 was admitted in November 2025 with mild cognitive impairment and sustained a 3.5-centimeter skin tear on the top of the right hand. A progress note dated 3/6/2026 documented a provider order to cleanse the skin tear with vashe every day and cover with optifoam, and a physician order dated 3/7/2026 directed the wound to be washed with normal saline daily and covered with optifoam until resolved. The March 2026 Treatment Administration Record documented the treatment as completed on 3/8/2026 by RN Staff D, but during observation on 3/9/2026 the resident's optifoam bandage was still dated 3/7 and appeared soiled with a dark discoloration visible through it. The Unit Manager RN acknowledged the bandage date, and the DON stated she would expect wound treatments to be completed as ordered and nurses to sign off only on treatments they complete themselves.
Failure to Monitor Antibiotic Use and Verify Antibiotic Orders
Penalty
Summary
The facility failed to establish an Infection Prevention and Control Program that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use for 2 of 5 residents reviewed, Resident IDs #2 and #3. A facility policy titled, Antibiotic Stewardship Program, stated the program was intended to monitor antibiotic use and support correct use of antibiotics through the five D's. However, record review and staff interview showed no evidence that the antibiotics ordered for Resident ID #3 were monitored or re-evaluated for accuracy and appropriateness after the resident's bilateral heel wounds were noted to be tender, reddened, and foul smelling and wound cultures were obtained. For Resident ID #3, the provider ordered ciprofloxacin 250 mg twice daily for 10 days, metronidazole 250 mg three times daily for 10 days, and later metronidazole 500 mg sprinkled directly onto both heel wounds once daily. The metronidazole 250 mg order was incorrectly transcribed as twice daily instead of three times daily, and the resident received 20 doses rather than the intended 30. The metronidazole 500 mg sprinkle order was discontinued after the resident received 13 doses instead of 14, and there was no evidence the three antibiotics were re-evaluated. For Resident ID #2, the provider ordered Augmentin twice daily for 7 days for a UTI, but the resident received 15 doses instead of 14. Although an Appropriateness of Antibiotics Assessment was completed, it did not identify the incorrect duration, and the DON acknowledged the antibiotics for Resident ID #3 were not re-evaluated and that the incorrect duration for Resident ID #2 was not identified.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food service safety in both the main kitchen and one of the nourishment areas. During an inspection, it was observed that a bottle of Hershey's syrup was opened and undated, contrary to the manufacturer's instructions to refrigerate after opening. Additionally, a box of fish cakes was found open and undated in the walk-in freezer, exposing the food to potential contamination. The Food Service Director (FSD) acknowledged these oversights during the surveyor interview. Further observations revealed that the walk-in freezer had a fan unit with frozen drips of ice and a box of grilled chicken breast with an accumulation of ice on top. Boxes of turkey breast roasts and frozen biscuits were improperly stored directly on the floor of the freezer. In the second-floor nourishment area, a microwave was found with a moderate accumulation of dried food matter. Additionally, five bottles of Ensure high protein nutritional shakes were found with expiration dates of June 2024, indicating they were expired and should have been discarded. The FSD acknowledged these deficiencies during the surveyor interviews.
Failure to Implement Comprehensive Care Plans for Residents with Urinary Catheters
Penalty
Summary
The facility failed to implement comprehensive person-centered care plans for residents with indwelling urinary catheters. Resident ID #38, admitted in October 2024 with a diagnosis including cutaneous vesicostomy and a supra pubic catheter, had a care plan requiring monitoring of urinary output due to obstructive uropathy and neurogenic bladder. However, there was no evidence of urinary output monitoring on multiple dates and times between December 2024 and January 2025. During an interview, a Licensed Practical Nurse was unable to provide evidence of monitoring for the specified periods. Similarly, Resident ID #33, admitted in October 2024 with urinary retention, required an indwelling urinary catheter due to obstructive uropathy. The care plan included monitoring urinary output and reporting abnormal findings. However, there was no evidence of monitoring on several dates in January 2025. The Director of Nursing Services was unable to provide evidence that the care plans for both residents were implemented regarding urinary output monitoring during surveyor interviews.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for a resident with a wound treatment. The deficiency was identified during a surveyor observation where Registered Nurse, Staff B, and Licensed Practical Nurse, Staff A, were seen providing wound care to a resident without wearing a gown, which is required under EBP guidelines. The facility's policy, aligned with CDC recommendations, mandates the use of gowns and gloves during high-contact care activities for residents with MDROs or those in close proximity to such residents, to prevent the transmission of infections. The resident involved was admitted with a diagnosis that included a cutaneous vesicostomy and had a physician order for EBP related to a suprapubic catheter. Additionally, there was an order to apply a foam dressing to the resident's buttocks due to moisture-associated skin damage. During an interview, Staff A and B acknowledged not wearing a gown during the dressing change, mistakenly believing it was only necessary when handling the resident's suprapubic catheter. The Director of Nursing Services confirmed that staff should have worn both gloves and a gown during the wound care procedure for a resident on EBP.
Failure to Ensure Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment for a resident, leading to an accident that resulted in a fracture. The resident, who was admitted with Alzheimer's disease, vitamin D deficiency, and heart failure, required substantial to maximal assistance for bed mobility and other activities of daily living. Despite this, the care plan and assistance documentation did not adequately address the level of assistance needed for bed mobility, and the resident was found wedged between the bed and the wall by a nursing assistant who repositioned the resident without additional help. The incident was reported to the Rhode Island Department of Health after an x-ray confirmed a fracture of the resident's left femur. The nursing assistant, Staff B, acknowledged repositioning the resident alone, contrary to the Safe Resident Handling document, which indicated that the resident required the assistance of two caregivers for bed mobility. The facility's care plan failed to specify the necessary level of assistance for bed mobility for the resident and others on the unit, contributing to the accident hazard. Following the incident, the resident experienced significant pain, requiring frequent administration of morphine for pain management. The resident's condition included speaking in word salad, grimacing, and refusing food and supplements, indicating ongoing discomfort. The facility's administrator could not provide evidence that the injury was unrelated to the incident, highlighting a deficiency in maintaining a safe environment and adequate supervision to prevent accidents.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, resulting in significant weight loss. The resident, who was admitted in April 2024 with multiple diagnoses including Parkinson's disease, type 2 diabetes, and dementia, experienced a weight loss of 11.9 pounds over 15 days, which was not addressed according to the facility's policy. The policy required re-weighing within two days and notifying the physician and dietician, but these steps were not taken. The resident's weight was documented as 273.6 pounds on June 18, 2024, indicating a 4.17% weight loss. However, there was no evidence of a re-weigh or notification to the dietician or physician. The dietician was unaware of the weight loss and did not implement any interventions until further weight loss occurred. The resident's weight continued to decline, totaling a 22.2-pound loss by July 2, 2024, representing a 7.78% decrease from the initial weight recorded on June 3, 2024. Interviews with the resident's primary care physician and the dietician revealed expectations for re-weighing and notification, which were not met. The Director of Nursing and the Administrator acknowledged the oversight and the lack of documentation or intervention following the initial weight loss. This deficiency highlights a failure in the facility's protocol to monitor and address significant weight changes in residents, potentially impacting their health and well-being.
Failure to Complete Discharge Summary and Medication Reconciliation
Penalty
Summary
The facility failed to complete a discharge summary that included a final summary of the resident's status and a reconciliation of the resident's medications for one of the two discharged residents reviewed. Specifically, for Resident ID #2, the facility did not provide an inter-agency transfer form or review medication changes with the resident or their representative at the time of discharge. The resident was admitted with diagnoses including type 2 diabetes mellitus, chronic systolic heart failure, and chronic kidney disease. During the resident's stay, there were changes made to their medications, including adjustments to dosages of Metoprolol, Morphine, and Senna Plus. However, these changes were not communicated to the resident or their representative upon discharge, as required by the facility's policy on medication reconciliation and discharge procedures. Interviews with the resident's representative and facility staff confirmed the lack of communication and documentation. The resident's representative reported not being informed of any medication changes and only receiving a bag of medications without further instructions. Staff A, a registered nurse, acknowledged that she did not review the medications with the resident or their representative and failed to provide the inter-agency transfer form. The Director of Nursing Services also confirmed that the expected procedure was not followed, and there was no evidence that the required documentation was provided to the resident or their representative at discharge.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Newport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Adviniacare Newport, Llc | 0.9 mi | ★★★★★ | 18 | 0 |
| St Clare Home | 0.9 mi | ★★★★★ | 0 | 0 |
| John Clarke Senior Living | 2.9 mi | ★★★★★ | 2 | 1 |
| Grand Islander Center | 3.1 mi | ★★★★★ | 7 | 0 |
| Royal Middletown Nursing Center | 4.3 mi | ★★★★★ | 16 | 0 |
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