Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 West Shore Health Center Inc during CMS and state inspections, most recent first.
Staff failed to follow proper contact precautions for a resident with MRSA and VRE, despite clear facility policies and competency training. Multiple staff members from different departments entered the resident's room without required PPE or failed to perform hand hygiene, and facility leadership demonstrated confusion between Enhanced Barrier Precautions and contact precautions, leading to improper infection control practices.
Surveyors found that medications, including inhalers and Lorazepam, were not properly dated when opened and, in some cases, were not discarded after expiration. Both RNs and an LPN acknowledged the deficiencies, and the DON confirmed that medications should be dated and expired drugs discarded according to policy.
A resident continued to receive a higher dose of Trazodone for 14 days after a pharmacy-recommended and provider-signed gradual dose reduction (GDR) was not implemented. The delay was attributed to staff waiting for family approval, but the family member reported not being contacted until later. Facility policy requires timely action on such recommendations, which was not followed.
Surveyors identified that two residents did not receive care in accordance with physician orders: one resident continued to have a wound dressing applied after the order was discontinued, and another resident's air mattress was not set to the prescribed setting for pressure ulcer prevention. Staff interviews confirmed the discrepancies, and the DON acknowledged the issues with the wound dressing order.
A resident with hypothyroidism had a TSH lab ordered and drawn, but the facility failed to promptly obtain and report the abnormal result to the provider. The TSH result, which was significantly elevated, was not communicated to the practitioner until surveyors brought the issue to staff attention, and this occurred after the resident had already seen an endocrinologist.
Staff failed to follow contact precaution protocols for a resident with MRSA and VRE, repeatedly entering the room without required PPE and neglecting hand hygiene, despite clear facility policy and signage. Multiple staff, including nursing, maintenance, housekeeping, and laundry, were observed not wearing gowns or gloves and touching shared surfaces, while leadership interviews revealed misunderstanding of infection control requirements.
The facility failed to implement a water management program to prevent Legionella growth, as required by industry standards and the CDC toolkit. The risk management plan identified high risk due to low water flow, but the facility did not identify low-use areas or perform weekly flushing. The Maintenance Director, DON, and Administrator could not provide evidence of compliance with the plan.
The facility failed to prevent significant medication errors for two residents regarding antibiotic administration. A resident with chronic respiratory issues received only 6 out of 7 prescribed days of Augmentin, while another resident with a severe infection received 19 out of 20 doses of Cefepime. The DON acknowledged these errors during a surveyor interview.
The facility failed to provide food and beverages in the appropriate form for residents with dysphagia. A resident received beverages not thickened to the ordered honey thick consistency, and meals were not prepared according to mechanical soft diet requirements. Staff acknowledged the discrepancies, and the facility could not provide evidence of compliance with dietary orders.
A facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of an Appropriateness of Antibiotic Assessment Observation for a resident on antibiotics. The resident, with chronic respiratory failure and COPD, was prescribed Augmentin for a lung infiltrate. The DON acknowledged the failure to complete the required assessment and antibiotic review process.
Failure to Ensure Staff Competency in Contact Precautions for MDROs
Penalty
Summary
Facility staff failed to demonstrate competency in implementing proper infection prevention techniques for residents requiring contact precautions, despite having received annual education and competency training. The facility's policy and competency documents clearly differentiate between Enhanced Barrier Precautions (EBP) and Contact Precautions, specifying that for residents with multi-drug resistant organisms (MDROs) such as MRSA and VRE, staff must don gown and gloves upon entering the room and perform hand hygiene upon exit. However, multiple staff members, including nursing assistants, a maintenance assistant, a certified medication technician, and a laundry aide, were observed entering a resident's room on contact precautions without the required personal protective equipment (PPE) or failing to perform hand hygiene as required. The resident involved had been readmitted with diagnoses of MRSA in the nares and VRE in the rectum, and was placed on contact precautions as indicated by signage on the resident's doorway. Despite this, staff were observed entering the room without donning gowns or gloves, and in some cases, not performing hand hygiene upon exiting. These observations occurred over several days and involved staff from various departments, all of whom had attended the facility's annual infection prevention competency training. Interviews with facility leadership, including the DON, Infection Preventionist, and Assistant DON, revealed a lack of understanding regarding the distinction between EBP and contact precautions. Leadership incorrectly stated that PPE was only necessary when providing direct care, which is contrary to both facility policy and the posted contact precaution signage. This confusion and failure to follow established protocols resulted in staff not implementing the required precautions for a resident with active MDRO infections.
Failure to Properly Label and Store Medications
Penalty
Summary
Surveyors identified that drugs and biologicals were not stored in accordance with accepted professional principles in multiple medication carts and storage rooms. Specifically, on the first-floor north medication cart, an RN acknowledged that two inhalers (Trelegy Ellipta and Breo Ellipta) were opened and undated, despite manufacturer instructions requiring disposal six weeks after opening. In the second-floor medication room, an LPN confirmed that three opened bottles of Lorazepam were undated, even though the manufacturer requires discarding the medication 90 days after opening. Additionally, in the first-floor medication room, a bottle of Lorazepam was found to be expired, having been opened and not discarded after the required 90-day period. The RN present acknowledged that the expired medication should have been discarded. The DON stated that her expectation was for Lorazepam to be dated when opened and for expired medication to be discarded, confirming that these procedures were not followed as required.
Failure to Timely Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident prescribed psychotropic medication received a gradual dose reduction (GDR) as recommended by the pharmacy and signed by the provider. Specifically, the pharmacy recommended reducing the resident's Trazodone 50 mg dose to 37.5 mg at bedtime, and this recommendation was signed by the provider. However, the facility did not act on this recommendation for 14 days, and the resident continued to receive the higher dose during this period. Staff interviews revealed that the delay was attributed to waiting for approval from the resident's family member, who was reportedly unavailable due to illness. However, the family member later stated they were on vacation and had not received any calls from the facility regarding the GDR prior to being contacted. Facility policy requires timely action on pharmacy recommendations, but this was not followed in this instance.
Failure to Follow Physician Orders for Wound Care and Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by not following physician's orders for two residents. For one resident with severe protein-calorie malnutrition, a dressing was observed on the left hand during a survey, despite the physician's order for the dressing having been discontinued several weeks prior. There was no evidence in the medical record of any new wound care orders after the discontinuation, and both the LPN and the Director of Nursing Services acknowledged that the dressing should not have been in place. For another resident with a history of pressure ulcers and a diagnosis of adult failure to thrive, the physician had ordered an air mattress to be set at 100 and checked every shift. However, during multiple surveyor observations, the air mattress was found to be set at 150. Both a nursing assistant and a registered nurse confirmed the incorrect setting, and upon review of the physician's order, acknowledged the discrepancy. The Director of Nursing Services did not acknowledge that the order was not followed but stated her expectation that the order would also include comfort.
Failure to Promptly Notify Provider of Abnormal TSH Lab Result
Penalty
Summary
A resident with a diagnosis including hypothyroidism was admitted to the facility and had a physician order for laboratory tests, including a thyroid stimulating hormone (TSH) test, due to an elevated previous result. The TSH lab was drawn, but the result was pending at the time other lab results were reported to the nurse practitioner. Documentation indicated that all lab results were reported to the provider, but the TSH result was not available at that time. The facility failed to obtain and communicate the TSH result, which was significantly elevated, to the ordering practitioner in a timely manner. The TSH result became available later on the same day it was drawn, but there was no evidence that the facility obtained or reported this result to the provider until it was brought to their attention by surveyors during the survey. The nurse practitioner was only notified of the abnormal TSH result after the surveyor's inquiry, and this notification occurred after the resident had already attended an endocrinology appointment. Staff interviews confirmed that the TSH result was not communicated to the provider prior to the surveyor's intervention.
Failure to Implement Contact Precautions for Resident with MDROs
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding the implementation of contact precautions for a resident with active Methicillin-resistant Staphylococcus Aureus (MRSA) in the nares and Vancomycin Resistant Enterococci (VRE) in the rectum. The resident, who had severely impaired cognition, was ambulatory with supervision, incontinent of stool, and had recently experienced loose stools. Facility policy required staff to don gown and gloves before entering the resident's room and to perform hand hygiene upon exit, as indicated by signage on the resident's door and the presence of a PPE bin outside the room. Despite these requirements, multiple staff members, including nursing assistants, maintenance, housekeeping, medication technician, and laundry staff, were observed entering the resident's room without appropriate PPE, such as gowns and gloves, and in some cases, failed to perform hand hygiene after leaving the room. Staff were seen touching shared surfaces like privacy curtains and beds, and transporting items between rooms without following proper infection control procedures. Interviews with the DON and Infection Preventionist revealed a misunderstanding of the facility's policy, as they believed PPE was only necessary for direct care, not for all room entry, which contradicted both facility policy and posted instructions.
Failure to Implement Water Management Program for Legionella Control
Penalty
Summary
The facility failed to provide a safe and sanitary environment to prevent the transmission of infections by not implementing a water management program based on industry standards and the CDC toolkit. The facility's risk management plan for Legionella control, last revised in February 2024, identified a high risk of Legionella growth due to low water flow in several areas. However, the facility did not identify areas of low water use, such as unoccupied rooms and infrequently used water fixtures, nor did it implement the control measure of weekly flushing to mitigate this risk. During the survey, the Maintenance Director was unable to provide evidence that the facility was following the risk management plan, including monitoring and flushing infrequently used water fixtures. Additionally, the Director of Nursing Services and the Administrator could not provide evidence that a water management program was maintained or implemented according to industry standards and the CDC toolkit. This lack of action and oversight led to the deficiency in infection prevention and control related to Legionella management.
Medication Errors in Antibiotic Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically concerning antibiotic administration for two residents. Resident ID #16, admitted with chronic respiratory failure and chronic obstructive pulmonary disorder, was prescribed Augmentin for 7 days following a right lower lobe infiltrate diagnosis. However, the resident received only 6 days of the medication, missing two doses. Similarly, Resident ID #102, readmitted with methicillin-resistant staphylococcus aureus infection and sepsis, was ordered to receive intravenous Cefepime every 12 hours for 10 days. The resident received only 19 doses instead of the prescribed 20 doses. During an interview, the Director of Nursing Services acknowledged the medication errors and was unable to provide evidence that the residents were kept free from significant medication errors.
Failure to Provide Appropriate Food and Beverage Consistency
Penalty
Summary
The facility failed to ensure that residents received food and beverages in the appropriate form as per their dietary needs. Resident ID #25, who was diagnosed with dysphagia, was observed receiving beverages that were not thickened to the ordered honey thick consistency. During a surveyor observation, the resident was given pre-thickened nectar apple juice instead of the prescribed honey thick consistency. Additionally, a hospice nursing assistant incorrectly prepared a honey thickened beverage using nectar thick gel packets, resulting in a beverage that was too thin. The Speech Language Pathologist (SLP) confirmed that the correct consistency required four packets of nectar gel thickener, but only three were used initially. The facility also failed to provide meals in the appropriate mechanical soft diet form for residents. Resident ID #8, who had a physician's order for a mechanical soft diet, received a slice of meatloaf that was not cut into the appropriate size as per the facility's diet manual. Similarly, Resident ID #25 received whole meatballs and slices of meatloaf that were not cut into the required size. Resident ID #62, who had specific dietary instructions, was served uncut battered fish and steak fried potatoes, contrary to the mechanical soft diet requirements. The SLP and other staff acknowledged that the meals were not prepared according to the diet manual's specifications. Interviews with the Food Service Director, Administrator, and Director of Nursing Services revealed that they were unable to provide evidence that the mechanical soft diets and thickened liquids were served in their appropriate forms. The facility's failure to adhere to the prescribed dietary orders and manual guidelines resulted in residents receiving food and beverages that were not suitable for their medical conditions, specifically dysphagia.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an Infection Prevention and Control Program (IPCP) that includes an antibiotic stewardship program with protocols and a system to monitor antibiotic use. This deficiency was identified during a review of records and staff interviews, specifically concerning a resident who was on antibiotics. The resident, admitted in April 2023 with chronic respiratory failure and chronic obstructive pulmonary disorder, was found to have a right lower lobe infiltrate based on an X-ray report dated May 28, 2024. Consequently, a new order for the antibiotic Augmentin was prescribed twice daily for seven days. The deficiency was further highlighted by the absence of an Appropriateness of Antibiotic Assessment Observation for the resident, which was ordered on June 1, 2024, but not completed. During an interview, the Director of Nursing Services acknowledged the failure to complete the assessment and was unable to provide evidence that the antibiotic review process, also known as an antibiotic time-out, was conducted as part of the antibiotic stewardship program. This lack of adherence to the established protocols and monitoring systems contributed to the identified deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Warwick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avalon Nursing Home Inc | 1.7 mi | ★★★★★ | 3 | 0 |
| Scandinavian Home Inc | 3 mi | ★★★★★ | 0 | 0 |
| Sunny View Nursing Home | 3 mi | ★★★★★ | 8 | 1 |
| Greenwood Operations Dba Greenwood Center | 3.3 mi | ★★★★★ | 12 | 2 |
| Brentwood Health Center | 4.3 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.