Below 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 West View Nursing Home, Inc during CMS and state inspections, most recent first.
A resident with DM received a rapid-acting insulin dose overnight after an incomplete order was transcribed as TID every shift instead of with meals. The insulin was given without a BG check or food intake, and the resident later developed severe hypoglycemia, was found unresponsive, and required transfer to the hospital.
A resident with DM, dementia, and sleep apnea became unresponsive during a hypoglycemic episode and was found with SpO2 of 82% on room air. Staff applied oxygen at 5 LPM and then used a non-rebreather mask at the same flow rate, despite the device requiring at least 10 LPM; the nurse stated she did not know the correct flow rate and did not recheck the resident's oxygen level before EMS arrived. EMS later found the resident with snoring respirations and SpO2 of 77%, increased oxygen to 15 LPM with improvement to 99%, and the resident was transferred to the ER and diagnosed with metabolic acidosis.
Food service sanitation and hygiene deficiencies were observed in the main kitchen and satellite kitchenette. Sanitizing solutions did not register an appropriate reading, a cook used an unclean thermometer from his pocket to check pizza temperature, multiple food-contact and non-contact surfaces had grease, crumbs, debris, and black buildup, and a dietary aide served food while wearing a hair net that did not fully cover her hair.
Resident Not Allowed to Participate in Decision for Hospital Transfer: A resident with chronic respiratory failure, anxiety, and moderate cognitive impairment complained of chest pain and requested transfer to the hospital after nitroglycerin did not relieve the pain. Instead, the resident was given oxycodone and clonazepam, fell asleep, and was not sent out. The RN did not notify the MD of the request, and the DON acknowledged the resident’s rights were not observed; the MD stated the resident should have been transferred at the resident’s request.
A resident with a right thumb wound and brain damage diagnosis had a wound care order for cleansing, skin prep, calcium alginate with silver, and a foam dressing. During observation, an RN completed the dressing change but did not apply the calcium alginate with silver as ordered, and the RN acknowledged the omission. The DON stated the physician's order should have been followed.
Inaccurate Documentation of 24-Hour Fluid Intake: A resident with ESRD and dependence on renal dialysis was on a 1500 mL daily fluid restriction, and a physician ordered staff to total the 24-hour fluid intake on 3rd shift. Review of the MAR showed the resident's daily fluid intake was not accurately totaled for 24 of 24 opportunities until the issue was identified by the surveyor. An LPN and the DON acknowledged the inaccurate documentation.
Surveyors found that food storage, preparation, and serving practices did not meet professional standards, with undated and improperly stored food, visibly soiled dishes and utensils, and significant residue on kitchen equipment. The FSD and Administrator acknowledged these deficiencies and the lack of evidence for proper sanitation procedures.
A resident with ventilator dependence was admitted and re-admitted with both a groin excoriation and a rash on the back. While a physician order was obtained and followed for the groin area, no treatment order was obtained for the back rash, despite its documentation and observation by nursing staff. The resident was later hospitalized with fungal infections in both areas, and staff confirmed that only the groin rash was addressed per orders.
Two residents at risk for skin breakdown did not receive care consistent with professional standards: one resident with an excoriated sacrum did not have a physician's treatment order or documented care, and another with multiple pressure ulcers had wound treatment orders that were not transcribed onto the TAR, resulting in treatments not being administered as ordered.
A resident with neurological and communication impairments was found physically restrained in bed with a sheet tied to side rails and surrounded by pillows, restricting movement. Staff confirmed the restraint was used to prevent falls, but there was no physician order, assessment, or documentation of medical necessity or attempted alternatives. Facility leadership acknowledged the unauthorized restraint.
A resident with dementia and severe cognitive impairment was aggressively pushed in a wheelchair by an Activity Aide, causing the wheelchair to hit a wall. The incident was witnessed by another staff member, and the resident was startled but not injured. The staff member admitted to the action, and the facility could not provide evidence that all residents were kept free from abuse.
The facility failed to provide thickened fluids as prescribed for three residents with dysphagia, leading to improper preparation of beverages. Nursing staff did not follow instructions on thickening packets, resulting in fluids not meeting the required consistency. The director of nursing services acknowledged the failure to meet dietary needs.
A resident with a suprapubic catheter experienced significant complications due to the facility's failure to obtain an order for catheter changes and ensure follow-up care with a urologist. The catheter was not changed for 20 weeks, leading to pain, hematuria, and hospital visits. The facility did not reschedule a missed urologist appointment until prompted by a surveyor, highlighting deficiencies in catheter management and follow-up care.
A facility failed to maintain food safety standards by leaving a resident's meal at unsafe temperatures for over an hour. The resident, with severe cognitive impairment and dysphagia, was not assisted with eating, and the food was not stored properly. Additionally, three ice machines lacked the required air gap, with one showing a buildup of black matter. The Food Service Director acknowledged these deficiencies.
Two residents experienced deficiencies in pressure ulcer care and documentation. One resident with stage 4 pressure ulcers received incorrect wound dressing, while another resident's toe wound lacked proper documentation for nine days. Both issues were acknowledged by nursing staff and the DON during a survey.
A resident with diabetes did not receive necessary podiatry services since admission, despite having a physician's order. The resident, who has intact cognition, reported not being offered these services. Observations showed the resident's feet had dry skin and long toenails, which staff acknowledged. The facility could not provide evidence of offering or providing podiatry services.
The facility failed to properly store medications, with surveyors finding expired drugs, improperly labeled medications, and a Schedule II drug not stored in a double-locked compartment. Staff acknowledged these issues, and the DNS expected weekly audits and proper storage practices.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, one with a wound requiring daily dressing and another with a suprapubic catheter. Despite policy requirements and care plans, EBP was not applied, as confirmed by staff interviews and surveyor observations. Signage and appropriate use of PPE were lacking, leading to non-compliance with infection control protocols.
A resident with intact cognition and a preference for showers did not receive a shower in three weeks, despite being scheduled for twice-weekly showers. The facility's records showed inconsistencies in scheduled shower days, and staff were unable to confirm if showers were provided. Observations revealed the resident had long toenails, long fingernails, and dry skin, indicating inadequate hygiene care.
A resident with hypotension was administered Midodrine despite parameters to hold the medication if systolic blood pressure exceeded 110. The MAR showed multiple instances where the medication was given when it should have been held. Staff N, responsible for administering the medication, could not explain the discrepancy, and the DON confirmed the expectation to follow the physician's order.
A resident with intact cognition and medical conditions, including muscle weakness and legal blindness, required dental care for mouth pain and a canker sore. Despite referrals for oral surgery, the resident did not receive necessary treatment due to the facility's failure to provide identification, paperwork, and transportation for scheduled appointments. Staff interviews confirmed these oversights, and there was no evidence of the resident receiving the recommended dental services.
Rapid-Acting Insulin Ordered and Given at Night Without Meal Intake
Penalty
Summary
The facility failed to ensure that a rapid-acting insulin order for a resident with type 2 diabetes mellitus, dementia, and sleep apnea was written, transcribed, and administered in accordance with professional standards of practice. The resident’s Novolog dose was decreased from 5 units to 4 units three times daily, but the order was written on a plain white sheet of paper without the resident’s first name, the date and time the order was written, the route of administration, or clear instructions about when the insulin was to be given. The order was intended to keep the existing meal-related administration times, but that was not documented in the written order. The order was transcribed into the MAR as Novolog 4 units every shift for 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM. Staff involved in the transcription acknowledged that the order was entered as written and that no clarification was obtained regarding whether the insulin should be given with meals or during overnight hours. The resident then received Novolog at approximately 12:30 AM without a blood glucose check and without a meal or snack. After the overnight insulin administration, the resident’s blood sugar dropped to 43 mg/dL and the resident was found pale and unresponsive with an oxygen saturation of 82%. Emergency Medical Services were called, and the resident was transferred to the hospital. The ER record documented hypoglycemia and metabolic acidosis, and the resident arrived with a blood sugar of 52 mg/dL. The physician interviewed by surveyors stated that a rapid-acting insulin should be given with meals or otherwise reconciled if scheduled outside usual meal times, and that the order should have been complete enough to prevent an adverse drug event.
Improper Oxygen Flow With Non-Rebreather Mask
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards of practice for a resident with type 2 diabetes mellitus, dementia, and sleep apnea. During a hypoglycemic emergency, the resident was found pale and unresponsive with an oxygen saturation of 82% on room air. Staff administered supplemental oxygen at 5 LPM and then placed the resident on a non-rebreather mask while keeping the oxygen flow at 5 LPM. The resident's nurse stated she was unaware that a non-rebreather mask requires a minimum flow rate of 10 LPM to prevent rebreathing of carbon dioxide, and she acknowledged that she did not recheck the resident's oxygen level before EMS arrived. EMS later found the resident unresponsive with snoring respirations and an SpO2 of 77% while facility staff were still providing oxygen at 5 LPM via a non-rebreather mask. EMS increased the oxygen flow to 15 LPM, after which the resident's SpO2 improved to 99%. The resident was transferred to the ER, where records showed abnormal venous blood gas results, including elevated pCO2 and low pH, and the resident was diagnosed with metabolic acidosis. The facility's oxygen administration policy stated that a non-rebreather mask requires 10 LPM minimum and 15 LPM maximum, and the resident's physician stated he would expect staff to know how to use non-rebreather masks. Surveyors were unable to obtain evidence that respiratory services were provided consistent with professional standards of practice.
Food Service Sanitation and Hygiene Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the main kitchen and satellite kitchenette. During observation of the main kitchen, the 3-bay sink was being used to wash and sanitize pots and pans, but the test strip used to check the sanitizing solution did not register a pH level, and the Director of Food Service acknowledged that the quaternary ammonium sanitizing solution was not reading at the appropriate level. On another observation in the main kitchen, a sanitizing container holding a wet cloth also failed to register a pH level when tested, and the Director of Food Service again acknowledged the solution did not register a pH level. Additional observations showed a dietary cook removing a thermometer from his pant pocket and inserting it into a slice of pizza without cleaning the thermometer first. Surveyors also observed accumulated grease, food crumbs, and debris on kitchen equipment and carts in the main kitchen, along with dried food spills and black buildup on the refrigerator unit and door gaskets in the satellite kitchenette. The main kitchen had black grime on walls, floors, corners, and behind equipment, as well as dust accumulation along piping behind the stove. In the satellite kitchenette, a dietary aide serving food in the dining room was repeatedly observed wearing a hair net that did not cover the front portion of her hair, and the Director of Food Service acknowledged the equipment cleaning issues, the thermometer practice, and the hair restraint issue.
Resident Not Allowed to Participate in Decision for Hospital Transfer
Penalty
Summary
The facility failed to allow a resident to participate in his or her treatment when the resident requested a hospital transfer for chest pain. The resident was admitted with diagnoses including chronic respiratory failure and anxiety, and a Quarterly MDS assessment showed a BIMS score of 10, indicating moderate cognitive impairment. On 3/19/2026, the resident complained of chest pain and was given nitroglycerin 0.4 mg without relief. The record further showed that the resident requested to go to the hospital, but was instead treated with oxycodone and clonazepam and then fell asleep; the resident was not transferred. The following day, the resident was documented as angry that he or she had not been sent to the hospital as requested. During interview, the resident stated that he or she had bad chest pain and asked to go to the hospital, and that a nurse told him or her that transfer would not occur. The RN acknowledged that the resident complained of chest pain, requested hospital transfer, and was not sent, and also acknowledged that she did not notify the doctor of the resident’s request. The DON stated that the resident was not sent to the hospital at his or her request and that the resident’s rights were not observed per facility policy or regulation. The physician stated that the resident should have been transferred to the hospital at his or her request.
Failure to Follow Wound Care Physician Order
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality when a physician's wound care order was not followed for Resident ID #4. The resident was readmitted in August 2025 with diagnoses including brain damage and had a wound to the right thumb that was being followed by a wound specialist. A physician's order dated 3/2/2026 directed staff to cleanse the right thumb with wound cleanser, pat dry, apply skin prep to the perimeter of the wound, then apply calcium alginate with silver to the wound bed, and cover with a foam dressing daily and as needed. During a surveyor observation on 3/24/2026 at 10:06 AM, RN Staff C performed the dressing change but failed to apply the calcium alginate with silver as ordered. In an immediate interview after the observation, Staff C acknowledged that she failed to apply the calcium alginate with silver. The DON later stated that she would expect the physician's order to be followed.
Inaccurate Documentation of 24-Hour Fluid Intake
Penalty
Summary
The facility failed to ensure that the resident record was complete and accurately documented for a resident with end stage renal disease and dependence on renal dialysis who was on a 1500 milliliter daily fluid restriction. A physician's order dated 2/4/2026 directed staff to total the resident's 24-hour fluid intake on third shift between 11:00 PM and 7:00 AM, but review of the March 2026 Licensed Nurse Administration Record showed the resident's daily fluid intake was not accurately totaled for 24 out of 24 opportunities until the concern was brought to the facility's attention by the surveyor. During interview, an LPN acknowledged the order and acknowledged that the amounts documented did not accurately reflect the resident's 24-hour fluid intake. The DON also acknowledged the inaccurate documentation and stated that third shift nurses would be expected to accurately calculate the resident's total 24-hour fluid intake. A physician's order dated 3/25/2026 was entered after the concern was identified, directing staff to add all fluid intake for all 3 shifts and document the total for 24 hours.
Failure to Maintain Sanitary Conditions in Food Service Operations
Penalty
Summary
Surveyor observations, record reviews, and staff interviews revealed that the facility failed to maintain sanitary conditions in the storage, preparation, and distribution of food in accordance with professional standards. Specific findings included undated and improperly stored food items in the main kitchen refrigerator, such as trays of lettuce, hot dogs in an opened zip-lock bag, and muffins past their labeled date. The Food Service Director (FSD) acknowledged that these items should have been labeled or discarded. Additionally, multiple pieces of kitchen equipment and utensils, including coffee pitchers, carafes, and cups, were found with visible residue and staining, indicating inadequate cleaning practices. The FSD confirmed that dietary aides were expected to thoroughly clean these items after each use. Further observations identified significant build-up of residue and food debris on the flat-top grill, stove, and surrounding areas, as well as accumulation of brown flakes and matter on the coffee machine and its table. The FSD acknowledged these unsanitary conditions and stated that all kitchen staff were responsible for equipment cleanliness. The Administrator was unable to provide evidence that the kitchen equipment was maintained in a sanitary condition and stated that she expected dietary staff to replace soiled items and the FSD to address kitchen issues. These findings were consistent with a community complaint alleging unsanitary kitchen conditions and improper cleaning of dishes and utensils.
Failure to Obtain Treatment Orders for Non-Pressure Wound
Penalty
Summary
A resident with a history of ventilator dependence was admitted to the facility with a rash on the upper-mid vertebrae and an excoriation in the groin area. Physician orders were obtained for Miconazole Nitrate powder to treat the groin excoriation, but no treatment order was obtained for the rash on the vertebrae. Upon the resident's re-admission after a hospital transfer, the skin assessment again noted a rash on the vertebrae and an excoriation in the groin, with a continued lack of treatment orders for the vertebral rash. Staff interviews confirmed that although the rash on the back was observed, no treatment order was sought for this area during either the initial admission or re-admission. The resident was subsequently transferred to the hospital with complaints of a fungal rash on the back and a fungal infection in the groin and genital area. Hospital documentation indicated that the resident's labile blood pressure was likely due to the fungal infection. The Director of Nursing Services acknowledged that treatment orders were not initiated for the vertebral rash, and staff confirmed that only the groin rash was addressed per physician orders, despite the presence of additional skin impairments.
Failure to Provide and Document Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents at risk for skin breakdown. For one resident dependent on a ventilator, the admission and re-admission skin assessments documented an excoriation to the sacrum, but there was no evidence of a physician's treatment order for this area. The resident was later transferred to the hospital, where a Stage II pressure injury to the sacrum was identified. Both the admitting nurse and the Director of Nursing Services acknowledged that no treatment order was obtained or implemented for the excoriated sacrum, despite facility expectations for skin assessment and treatment orders upon admission. For another resident admitted with multiple pressure ulcers, including a sacral stage II ulcer and ulcers in the gluteal folds, the physician's wound treatment orders were entered into the computer system but were not transcribed onto the Treatment Administration Record (TAR). As a result, the prescribed treatments were not available for staff to administer as ordered. The Director of Nursing Services was unable to provide evidence that the wound treatments were implemented for these pressure ulcers.
Failure to Prevent Unauthorized Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints not required for medical treatment. A resident with a history of epilepsy, stroke, and aphasia was found in bed with a sheet tied across their waist, with each end secured to the side rails, effectively restraining them. Multiple staff statements confirmed that the resident was intentionally restrained in this manner to prevent movement or falls, and that this practice had occurred previously. Additionally, pillows were placed and tucked under the fitted sheet on both sides of the resident, further restricting their ability to get out of bed. Record review did not reveal any physician order, assessment, or documentation of medical symptoms justifying the use of a restraint, nor evidence of alternative interventions attempted prior to restraint use. Staff interviews and facility statements acknowledged the use of the sheet as a restraint and confirmed that the resident was unable to move or get out of bed independently while restrained. The Administrator and Director of Nursing also acknowledged that the resident was physically restrained by staff.
Resident Subjected to Physical Abuse by Staff Member
Penalty
Summary
A deficiency occurred when a staff member failed to protect a resident from physical abuse. An Activity Aide was observed wheeling a resident with dementia and anxiety disorder erratically down the hall, then aggressively pushing and releasing the resident's wheelchair, causing it to roll several feet and hit a wall. The resident, who had severe cognitive impairment and was able to self-propel in a wheelchair, was startled by the incident but did not sustain any physical injury. A Nursing Assistant witnessed the event and confirmed the aggressive handling of the resident. The Activity Aide admitted to pushing the resident's wheelchair and acknowledged that her own anxiety was heightened at the time due to the resident's behavior during an activity. The Administrator confirmed that the resident was pushed aggressively and that the wheelchair hit the wall. The facility was unable to provide evidence that all residents were consistently treated with respect and dignity and kept free from abuse, as required by facility policy.
Failure to Provide Prescribed Thickened Fluids
Penalty
Summary
The facility failed to provide and prepare food in a form designed to meet individual needs for three residents with physician's orders for thickened consistency fluids. Resident ID #26, who has dysphagia and a history of aspiration, was observed to have been served beverages that were not thickened to the prescribed nectar consistency. Nursing staff responsible for preparing the beverages did not follow the instructions on the thickening packets, resulting in fluids that were not adequately thickened. The nursing assistant admitted to not measuring the fluids or reading the instructions, leading to improper preparation of the resident's beverages. Resident ID #7, diagnosed with dysphagia, was also not provided with the prescribed honey thickened fluids. During a meal observation, the resident was served beverages that were not thickened to the required consistency. The nursing assistant responsible for preparing the fluids used only one thickening packet per beverage, despite the need for more to achieve the correct consistency. This oversight was acknowledged by the assistant director of nursing services, who confirmed that the beverages did not meet the prescribed consistency. Resident ID #98, who requires nectar thickened fluids due to aspiration risk, was observed with unopened thickening packets on their tray. The registered nurse indicated that if the resident had accepted the meal, she would have used an insufficient number of packets to achieve the required consistency. The director of nursing services was unable to provide evidence that the residents received fluids at the appropriate consistency, acknowledging the facility's failure to meet the prescribed dietary needs.
Failure in Catheter Management and Follow-Up Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a suprapubic catheter (SP catheter). The resident, admitted in August 2023 with obstructive and reflux uropathy, did not have an order for the SP catheter to be changed, and the catheter was not changed from May 13, 2024, until October 19, 2024. This resulted in missed opportunities for catheter changes, leading to complications such as hematuria, pain, and catheter malfunction. The resident experienced significant discomfort and was sent to the hospital twice in October 2024 due to these issues. The facility's policy required catheter changes per medical orders, but there was no evidence that such an order was obtained. The resident's care plan included interventions for catheter management, but these were not followed. Progress notes indicated multiple instances of catheter-related issues, including wet clothing, blood in the catheter bag, and severe pain. Despite these symptoms, the facility did not obtain an order for catheter change until it was prompted by a surveyor. Additionally, the facility failed to ensure the resident attended follow-up appointments with a urologist, as required by their policy. The resident missed a scheduled appointment in July 2024, and there was no evidence of rescheduling until the surveyor's intervention. The Medical Director and Director of Nursing Services acknowledged the lack of appropriate catheter management and follow-up care, which contributed to the resident's ongoing complications and discomfort.
Deficiencies in Food Safety and Equipment Maintenance
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper food storage and handling for a resident with severe cognitive impairment and dysphagia. The resident was observed with a lunch tray containing a ham salad sandwich and milk, which had been left in front of them for over an hour while they slept. The food items were found to be at temperatures significantly higher than the safe holding temperature of 41 degrees Fahrenheit. Staff failed to wake the resident to eat or store the food in the refrigerator, as expected by the facility's Assistant Director of Nursing Services and Food Service Director. Additionally, the facility was found to have three ice machines without the required air gap between the water supply inlet and the flood level rim, as per the Rhode Island Food Code. One of the ice machines also had a buildup of black matter on the exterior of the pipe. The Food Service Director acknowledged the absence of air gaps and the buildup on the pipe, indicating a failure to maintain equipment according to safety standards.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for two residents, leading to deficiencies in treatment and documentation. Resident ID #65, who was readmitted with paraplegia and ventilator dependence, had two stage 4 pressure ulcers. Despite physician orders specifying the use of calcium alginate AG for wound care, a registered nurse applied the incorrect dressing, using calcium alginate instead. This deviation from the prescribed treatment was acknowledged by both the nurse and the Director of Nursing Services during the surveyor's investigation. Resident ID #84, readmitted with a stroke and muscle weakness, had a wound on the right second toe that required daily dressing changes. However, there was a lack of documentation regarding the wound's staging, measurements, and pain assessment from the time it was identified until the surveyor's intervention. The wound nurse confirmed the absence of necessary documentation, and the Director of Nursing Services could not provide evidence of the required wound assessments. This oversight persisted for nine days after the wound was initially identified.
Failure to Provide Podiatry Services to Resident with Diabetes
Penalty
Summary
The facility failed to provide appropriate foot care to a resident with diabetes, as evidenced by the lack of podiatry services offered or provided since the resident's admission in March 2024. The resident, who has intact cognition, expressed during an interview that they had not been offered podiatry services despite having a physician's order for such services as needed. A review of the resident's records confirmed the absence of any documentation indicating that podiatry services were offered or provided. Surveyor observations revealed that the resident's feet had dry skin and excessively long toenails, with the great toenails extending approximately 1 inch above the toes and the remaining toenails curved over and touching the skin. Nursing staff present during the observation acknowledged these findings. Further interviews with nursing staff and the facility administrator confirmed the lack of podiatry services provided to the resident, with no evidence available to show that the resident was offered these services.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with accepted professional principles, as observed in five out of six medication carts. During a surveyor observation, it was found that several medications, including nitroglycerin sublingual tablets and permethrin cream, were either expired or lacked proper labeling, such as resident identifiers. Staff O acknowledged the presence of expired medications and the failure to discard them. Similarly, Staff I confirmed the presence of expired probiotic tablets in the Pine nurse medication cart. Further observations revealed additional deficiencies in medication storage. Staff P was found to have 22 capsules stored without identifying information, and several inhalers and a bottle of liquid protein were opened but not dated, contrary to manufacturer instructions. Expired medications, such as Geri-lanta antacid, were also found. Staff Q acknowledged the presence of expired medications, including ibuprofen oral liquid suspension and EpiPen injections, and the failure to discard them. Additionally, medications like Refresh Lacri-lube eye ointment and Active liquid protein were opened and not dated as required. A significant issue was identified with the storage of Roxanol, a Schedule II pain medication, which was not stored in a double-locked compartment as required. Staff M acknowledged this error, and the Director of Nursing Services indicated that weekly audits should be conducted to ensure expired medications are discarded and that controlled substances are stored correctly. The DNS also expected staff to date all eye drops and inhalers upon opening, as per manufacturer instructions.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for two residents. Resident ID #84, who was readmitted with a wound requiring daily dressing, was not placed on EBP as required by the facility's policy. This oversight was confirmed through multiple surveyor observations and interviews with the Wound Nurse, Infection Preventionist, and Director of Nursing Services, all of whom acknowledged the resident should have been on EBP. Similarly, Resident ID #458, who has a suprapubic catheter, was not properly managed under EBP. Despite a physician's order and a care plan indicating the need for EBP, surveyor observations revealed a lack of signage indicating the resident's EBP status. Interviews with staff, including a Nursing Assistant and a Registered Nurse, confirmed the absence of necessary precautions, such as wearing gowns during high-contact care activities. The Director of Nursing Services and Infection Preventionist also acknowledged the failure to implement EBP for this resident.
Failure to Support Resident's Shower Preference
Penalty
Summary
The facility failed to promote and facilitate self-determination through support of a resident's choice regarding weekly showers for a resident with intact cognition and a preference for showers. The resident, who was admitted with hemiplegia and hemiparesis following a stroke, reported not having had a shower in three weeks despite being scheduled for showers twice a week. The resident's preference for showers was documented as very important, yet the facility's records showed inconsistencies in the scheduled shower days and a lack of documentation that showers were offered or provided. Surveyor interviews and observations revealed that the resident had long toenails, long fingernails on the contracted hand, and dry skin, indicating a lack of proper hygiene care. Nursing staff were unable to confirm if they assisted the resident with showers on the scheduled days, and the Director of Nursing Services could not provide evidence that the resident received a shower in the last 20 days. This deficiency highlights a failure in the facility's system to ensure resident preferences and care needs are met consistently.
Failure to Adhere to Medication Parameters for Hypotension
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs. The resident, who was admitted in June 2023 with a diagnosis of hypotension, had a physician's order for Midodrine to be administered with specific parameters to hold the medication if the systolic blood pressure (SBP) exceeded 110. However, the November 2024 Medication Administration Record (MAR) showed that the resident was administered Midodrine on multiple occasions when the SBP was above the specified threshold. Certified Medication Technician, Staff N, was responsible for administering the Midodrine on these occasions. During an interview, Staff N was unable to explain why the medication was given despite the parameters indicating it should have been held. The Director of Nursing Services, in the presence of the Administrator, confirmed that the expectation was for Staff N to hold the medication as per the physician's order.
Failure to Provide Dental Care and Transportation
Penalty
Summary
The facility failed to assist a resident, identified as Resident ID #62, in obtaining necessary dental care, both routine and emergency. The resident, who was admitted in December 2022 with diagnoses including muscle weakness and legal blindness, was found to have intact cognition. During interviews, the resident reported needing teeth extractions due to mouth pain and a canker sore caused by teeth rubbing against the tongue. Observations confirmed the presence of discolored, jagged teeth and a 1 cm abrasion on the tongue. Mobile dentistry notes from May, August, and October 2024 indicated the need for oral surgery due to broken and decayed teeth, with referrals provided to the facility. Despite these referrals, the resident did not receive the necessary dental care. A progress note from November 11, 2024, indicated an appointment was scheduled for November 14, 2024, but the resident was not seen due to a lack of identification and paperwork. The appointment was rescheduled for November 15, 2024, but the resident did not attend due to transportation issues. The facility's failure to provide the necessary paperwork and transportation resulted in the resident not receiving the recommended dental treatment. Interviews with facility staff, including the Unit Secretary, Administrator, and Director of Nursing Services, revealed acknowledgment of the oversight in providing the resident with the required paperwork and transportation. The Director of Nursing Services could not provide evidence that the resident received the necessary dental services. The deficiency was further highlighted by the lack of documentation regarding the resident's canker sore until it was brought to the facility's attention by the surveyor.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near West Warwick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kent Regency Center | 1.4 mi | ★★★★★ | 6 | 0 |
| Riverview Healthcare Community | 2.7 mi | ★★★★★ | 13 | 1 |
| Greenwood Operations Dba Greenwood Center | 2.7 mi | ★★★★★ | 12 | 2 |
| Brentwood Health Center | 3 mi | ★★★★★ | 3 | 0 |
| Sunny View Nursing Home | 3.1 mi | ★★★★★ | 8 | 1 |
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