Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westerly Health Center during CMS and state inspections, most recent first.
Failure to Notify Ombudsman of Resident Hospitalization and Discharge: The facility failed to notify the State LTC Ombudsman when two residents were hospitalized or discharged and return was not anticipated. One resident was transferred to the hospital and another was discharged to the community, but neither was listed on the facility’s Ombudsman notification log. The SW acknowledged the omission, and the DON could not provide evidence that the Ombudsman had been notified.
Failure to Provide Scheduled Showers: Two residents who required extensive assistance with bathing/hygiene did not receive showers at their preferred frequency. One resident with intact cognition had a care plan for twice-weekly showers, but the CNA task record showed missed showers and only one documented shower. Another resident with moderate cognitive impairment had a weekly shower schedule, but the task record showed no showers in the last 30 days. Staff and leadership could not provide evidence that the showers were offered or completed as scheduled.
Failure to ensure adequate supervision for residents at elopement risk was cited for three residents with dementia-related diagnoses. Two residents were observed ambulating independently on a secured unit while wearing wander management devices, and one resident was documented packing belongings and running down the hall after a family member while stating a desire to go home. The record showed missing physician orders or missing implementation for daily device functionality checks, and the DON acknowledged the orders were not in place.
Failure to monitor urinary output for residents with indwelling catheters. Two residents had catheter care orders, but one resident lacked an order to monitor urine color, odor, and output, and another resident had 10 missed urine output documentation opportunities out of 59. The DON acknowledged the missed monitoring and the missing order.
Improper Storage and Labeling of Medications: Surveyors found a resident keeping diazepam tablets in the room, along with multiple medication storage issues in carts and med rooms. These included an opened, undated lidocaine vial without a resident name, expired ointment and aspirin, and several opened, undated lorazepam bottles, one with an illegible resident name and another wet to the touch. Staff acknowledged the medications were expired or improperly labeled.
Failure to accommodate a resident’s request for a power wheelchair. A cognitively intact resident with bilateral lower extremity amputations used a slide board and manual wheelchair, but reported bilateral shoulder pain from self-propelling throughout the day and said staff did not respond to the request for a motorized wheelchair. OT did not document a power wheelchair recommendation or address the pain, x-rays showed bilateral shoulder OA, and the NP and orthopedic provider documented chronic shoulder pain from overuse with the ortho provider stating a power wheelchair would be a reasonable accommodation.
A facility failed to ensure MDS assessments accurately reflected resident status for two residents. One resident’s MDS incorrectly indicated no current tobacco use despite a smoking order and smoking safety evaluation showing current cigarette use, and another resident’s Entry MDS contained a misspelled last name that was not corrected even though a later MDS listed the name correctly. The RCM acknowledged the coding errors, and the DON stated MDS assessments should accurately reflect resident status.
A resident with dementia and adjustment disorder was identified as an elopement/wandering risk, with exit-seeking behavior noted and a wander management device placed. The record did not show a completed baseline care plan within 48 hours of admission that addressed the resident’s elopement risk, and the DON stated this should have been included.
A resident with COPD had a physician order allowing smoking up to four times daily and requiring all smoking implements to be stored in the medication cart, but the care plan still stated the resident could keep smoking materials in the room. The DON acknowledged the care plan was not revised by the IDT.
A resident with severe cognitive impairment and highly impaired hearing did not receive ordered Debrox doses and was not using a hearing aid or other hearing device per the care plan. Staff were unaware of the family-provided amplifier until the surveyor intervened, and the DON and provider could not show that the ordered ear treatment or hearing support had been provided.
A resident with impaired ROM, a prior femur/hip fracture, and difficulty walking was observed sitting in a wheelchair with both feet in a pronounced plantar-flexed position. PT had discharged the resident with a recommendation for PF contracture boots to address bilateral foot positioning and promote dorsiflexion, but the recommended vendor fitting appointment had not been scheduled and no follow-up had occurred. The DON was unaware of the PT discharge recommendation, and the Medical Director stated he would expect communication and timely follow-up for the fitting.
Significant medication error with intramuscular antibiotic administration: A resident with CKD and a UTI had an order for IM Ertapenem for 5 days, but the MAR did not show one scheduled dose as given. Surveyors found two unopened doses in the med cart, and the RN acknowledged the missed sign-off while the DON could not explain how the ordered doses were administered if doses remained in the cart.
Failure to monitor antibiotic use and complete antibiotic time outs: The facility did not establish an IPCP with an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Two residents receiving antibiotics had incomplete or absent antibiotic time out documentation, and the DON could not provide evidence that the required reviews were completed.
A facility failed to reconcile a resident's pre-discharge medication orders with post-discharge orders. The resident, with conditions like polymyalgia rheumatica and osteoarthritis, was discharged with incorrect medication dosages on the COC Form. The DON acknowledged the transcription errors during a surveyor interview.
The facility did not report the results of five alleged abuse investigations to the RIDOH within the required 5 working days. The Administrator and DON acknowledged this failure during an interview.
The facility failed to provide respiratory care consistent with professional standards for four residents. Orders for oxygen administration were not followed, and documentation was incomplete or incorrect.
A resident with essential hypertension, atrial fibrillation, and atherosclerotic heart disease did not receive Hydralazine HCL as prescribed for systolic blood pressure greater than 150. Blood pressures were not checked every 6 hours, and the medication was not administered despite multiple high readings. A Certified Medication Technician and the Director of Nursing Services acknowledged the oversight.
The facility failed to store and label drugs and biologicals correctly, with multiple deficiencies noted across medication carts and a medication room. Issues included undated and improperly stored medications, as well as failure to remove controlled substances after a resident's death.
The facility failed to maintain an infection control program for a resident using a CPAP machine and another resident with an ESBL infection. The CPAP machine was not cleaned as per policy, and appropriate contact precautions were not implemented for the resident with ESBL. Staff were unaware of the required procedures, and there was no evidence of compliance with infection control policies.
Failure to Notify Ombudsman of Resident Hospitalization and Discharge
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman when two residents were hospitalized or discharged and return to the facility was not anticipated. Resident ID #117, admitted to the facility in September 2023, was transferred to and subsequently admitted to the hospital on [DATE], but was not listed on the facility’s March 2026 Ombudsman Notification Log. Resident ID #119, admitted in March 2026, was discharged to the community on 3/30/2026, and also was not listed on the March 2026 Ombudsman Notification Log. During interview, the Social Worker acknowledged that both residents were not listed on the log, and the DON was unable to provide evidence that the Ombudsman had been notified of the residents discharged in March 2026.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide necessary assistance with ADLs related to scheduled showers for 2 residents who were unable to carry out bathing needs independently. Resident #81, admitted with diagnoses including major depressive disorder and unsteady gait, had a BIMS score of 15/15, required extensive assistance for bathing/hygiene, and had a documented preference for showers that was very important. The care plan stated the resident was to receive showers twice weekly, and the CNA task list showed showers scheduled on Saturdays and Mondays, but the documented shower task record showed only one shower and indicated 7 missed scheduled showers in the last 30 days. During interview, the resident stated showers had not been offered twice a week as preferred. Resident #54, admitted with diagnoses including major depressive disorder and difficulty walking, had a BIMS score of 9/15, required extensive assistance for bathing/hygiene, and had a documented preference for showers that was very important. The care plan stated the resident was to receive showers once weekly, and the CNA list scheduled showers on Sundays, but the documented shower task record showed no showers in the last 30 days. During interview, the resident stated it would be nice if staff would provide the scheduled weekly shower. Staff interviews confirmed that showers were documented under the resident task, but the task documentation did not show that either resident received showers as scheduled per their preferred frequency, and the ADON and DON were unable to provide evidence that the showers were provided as scheduled.
Failure to Ensure Wander Management Device Orders and Monitoring for Elopement-Risk Residents
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for three residents identified as elopement risks. Resident 15 had diagnoses including Alzheimer’s disease and dementia, a BIMS score indicating the resident was unable to complete the assessment due to impaired cognition, and was documented as ambulatory with supervision and using a wander/elopement alarm daily. The care plan identified the resident as at risk for elopement after a wandering episode and included use of a wander management device, and surveyors observed the resident ambulating independently on the secured unit while wearing the device. However, the record did not contain physician’s orders for the wander management device that included checking placement each shift and functionality daily, and the DNS acknowledged those orders were not in place. Resident 36 had diagnoses including Alzheimer’s disease and dementia, a BIMS score of 12 out of 15, and was documented as ambulatory with supervision and using a wander/elopement alarm daily. The care plan identified actual or potential elopement risk and included a wander management device, and physician’s orders directed staff to check bracelet placement twice every 4 hours and monitor for exit-seeking behaviors each shift. The May 2026 MAR documented exit-seeking behaviors on multiple dates, and surveyors observed the resident ambulating independently on the secured unit while wearing the device. The record did not show a physician’s order to check device functionality daily, which the DNS said she would expect. Resident 129, admitted with diagnoses including dementia and adjustment disorder, was identified as at risk for wandering/elopement, had a physician’s order to check device placement every shift, and was observed walking independently and later packing belongings and running down the hall after a family member while stating a desire to go home. The record did not show implementation of a physician’s order to check the functionality of the wander management device daily, and the DNS acknowledged that order was not in place.
Failure to Monitor Urinary Output for Residents With Indwelling Catheters
Penalty
Summary
Appropriate care for residents with indwelling urinary catheters was not provided for 2 of 3 residents reviewed. Resident ID #6 was admitted with urinary retention and had a care plan identifying an indwelling urinary catheter. Physician orders were in place for catheter care every shift and for the catheter to be changed on the 21st of each month, but the record did not show an order to monitor urine color, odor, and output to adequately assess renal function and urinary drainage. During surveyor review, the Director of Nursing Services acknowledged that Resident ID #6 did not have an order to monitor urinary output and should have had one. Resident ID #103 was admitted with type 2 diabetes mellitus and also had a care plan identifying an indwelling urinary catheter. Physician orders directed staff to provide catheter care every shift and to measure urinary output every shift and document it in milliliters. Review of the May 2026 MAR showed the facility failed to document urine output for 10 of 59 opportunities, representing about a 17% failure rate. During interview, the DON acknowledged that the facility failed to accurately monitor urinary output for Resident ID #6 and Resident ID #103.
Improper Storage and Labeling of Medications
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles. The facility policy required medications to be stored in an orderly manner, labeled with the resident's name and expiration date when applicable, and opened multi-dose vials to be dated and discarded within the required timeframe. Surveyors found Resident ID #27, admitted with anxiety disorder and ordered diazepam 1 mg twice daily, had three 1/2 tablets and one 1/4 tablet of diazepam in the resident's room. During the observation, the resident handed the pills to the RN, and staff acknowledged the resident should not have had the medication in the room. Surveyors also found multiple medication storage problems in carts and medication rooms. An opened, undated lidocaine multi-dose bottle on a medication cart had no resident name. In the second-floor medication room, expired hemorrhoidal ointment and aspirin were present, along with opened and undated lorazepam bottles, including one bottle with an illegible resident name and another that was wet to the touch. In the first-floor medication room, another opened and undated lorazepam bottle was observed. Staff acknowledged the expired and improperly labeled medications and that the opened medications should have been dated.
Failure to Accommodate Resident’s Request for Power Wheelchair
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a cognitively intact resident with bilateral lower extremity amputations who used a slide board for transfers and a manual wheelchair for mobility. The resident reported bilateral shoulder pain from lifting his/her body and pushing the wheelchair throughout the day and stated that he/she had asked staff about obtaining a power wheelchair but had not received a response. A quarterly MDS assessment showed a BIMS score of 15 out of 15, and the care plan included an intervention to refer to PT and/or OT as needed for potential pain. Clinical records showed the resident was evaluated by OT for bilateral shoulder pain and believed a power wheelchair might help, but the OT evaluation did not document a recommendation for a power wheelchair or address the shoulder pain. X-rays showed osteoarthritis of both shoulders and shoulder joints, and an NP note documented chronic bilateral shoulder pain and discomfort with known osteoarthritis, with the resident constantly using both arms to get around and suspected overuse worsening the pain and arthritis. An orthopedic provider later documented that the resident’s request for a power wheelchair would be a reasonable accommodation, and facility rounds included a recommendation for use of a powered wheelchair three days per week. During interview, the DON acknowledged awareness of the resident’s request for a motorized wheelchair due to bilateral upper extremity pain but could not provide evidence that the facility followed up or provided the accommodation.
Inaccurate MDS Assessments for Smoking Status and Resident Name
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected resident status for two residents. One resident was admitted with diagnoses including major depressive disorder and anxiety disorder, had a physician order allowing smoking with staff up to 4 times per day, and had a smoking safety evaluation stating the resident currently smoked cigarettes 2-3 times daily. However, the resident’s Annual MDS assessment coded Section J1300 as indicating the resident did not currently use tobacco products. A second resident was admitted with diagnoses including congestive heart failure and dementia. The resident’s Entry MDS listed the resident’s last name incorrectly in Section A6500, while a later admission MDS listed the name correctly, but the Entry MDS was not revised to reflect the correct name. During interview, the Regional MDS Coordinator acknowledged both assessments were inaccurately coded, stating the smoking status should have reflected current tobacco use and the resident’s name should have been corrected on the Entry MDS. The DON stated she would expect MDS assessments to accurately reflect resident status.
Baseline Care Plan Not Completed for Elopement Risk
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a newly admitted resident with diagnoses including dementia and adjustment disorder who was identified as an elopement risk. An Elopement/Wandering Risk Evaluation dated 5/22/2026 documented that the resident was at risk for potential wandering/elopement. Progress notes showed that on 5/22/2026 the resident was walking independently without a rolling walker, exhibited exit-seeking behaviors, and a wander management device was placed on the resident. Additional progress notes indicated that on 5/25/2026 the resident packed belongings in a bag and ran down the hall after a family member who was attempting to leave the secure unit, and the resident stated a desire to go home. Record review did not reveal evidence of a completed baseline care plan that included interventions for the identified elopement risk, and the DON stated during interview that it was her expectation this risk would have been included in the baseline care plan.
Care Plan Not Revised After Smoking Order Change
Penalty
Summary
The facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team for Resident ID #44. The resident was admitted in August 2023 with diagnoses including chronic obstructive pulmonary disease. A physician's order dated 4/9/2026 directed that the resident may smoke up to four times per day and that all smoking implements must be stored in the medication cart. However, review of the resident's comprehensive care plan dated 10/7/2025 showed an intervention stating that the resident may store all smoking materials in his/her room, and the record did not show that the care plan was revised after the order required nursing to store all smoking implements in the medication cart. During interview, the Director of Nursing Services acknowledged that the care plan was not revised and should have been.
Failure to Provide Ordered Hearing Treatment and Hearing Device Support
Penalty
Summary
The facility failed to ensure that a resident with diagnoses including mild cognitive impairment and major depressive disorder received proper treatment to maintain hearing abilities. The resident’s care plan identified the resident as hard of hearing and included an intervention to provide appropriate hearing aids as required, while the Quarterly MDS showed a BIMS score of 7 out of 15 and that hearing ability was highly impaired. During interview, the resident stated, “I can't hear anything that you are saying,” and the record showed a physician’s order for Debrox solution to soften earwax before removal. The March 2026 MAR did not show administration of Debrox on three scheduled doses out of eight opportunities. In addition, during observation the resident was found with no hearing aid in use, and the record did not show evidence of any hearing device being provided per the care plan. Staff later acknowledged the resident had an amplifier brought by a family member, but it was not being applied until the surveyor brought it to staff’s attention. The RN stated she was unaware of the amplifier and that there was no order to apply it, the DON could not provide evidence that Debrox had been given or that the amplifier was being used, and the provider stated he would have expected the Debrox to be administered as ordered and staff to notify him to obtain an order for the hearing device.
Failure to Follow Up on PT Recommendation for Contracture Boots
Penalty
Summary
The facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM. The resident was readmitted with diagnoses including right femur fracture, difficulty walking, and chronic pain. The MDS assessment indicated intact cognition with a BIMS score of 15, and also documented impaired ROM of both lower extremities. The comprehensive care plan identified the resident’s right hip fracture related to a fall and included interventions to monitor for fracture-related complications, assess the need for adaptive devices, and consult Physical Therapy to address functional limitations and promote mobility. During observation, the resident was sitting in a wheelchair with both feet maintained in a pronounced plantar-flexed position. The resident stated that therapy had been discontinued and that continued services were desired to improve mobility. Physical Therapy services were provided from 3/24/2026 through 5/19/2026, and a PT treatment note recommended obtaining plantar flexion contracture splints to address bilateral plantar flexion and promote dorsiflexion. The PT discharge summary also recommended acquiring PF contracture boots. The Director of Rehabilitation acknowledged that the resident was discharged from PT with this recommendation and that she was responsible for arranging the vendor appointment for assessment and custom fitting, but no appointment had been scheduled and no follow-up action had occurred by 6/1/2026. The DON stated she was not aware of the PT discharge recommendation, and the Medical Director stated he would expect communication from therapy to nursing and follow-up within about two weeks to obtain the fitting appointment.
Significant medication error with intramuscular antibiotic administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to the administration of intramuscular Ertapenem for a urinary tract infection. The resident was admitted with diagnoses including chronic kidney disease. A lab report showed a urine specimen obtained on 5/21/2026, and on 5/25/2026 the facility received a report that the resident tested positive for a urinary tract infection and that the organism could be treated with Ertapenem. A physician order dated 5/25/2026 directed Ertapenem sodium injection solution 1 gram intramuscularly for 5 days, with a start date of 5/25/2026 through 5/29/2026, indicating 5 doses were to be administered. The pharmacy packing slip showed 5 doses were delivered to the facility, with 3 doses delivered on 5/25/2026 and 2 doses delivered on 5/27/2026. However, the May MAR did not show Ertapenem signed off as administered on 5/27/2026. During observation of the medication cart on 6/1/2026, a surveyor and an RN found two doses of Ertapenem in the cart with the resident's name on them, and the RN acknowledged the dose was not signed off as administered on 5/27/2026 and that unopened doses remained in the cart. The DON was unable to provide evidence that any Ertapenem beyond the 5 doses listed had been obtained for the resident and could not explain how the resident received the 5 ordered doses if 2 doses remained in the medication cart.
Failure to Monitor Antibiotic Use and Complete Antibiotic Time Outs
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 residents who required antibiotics. Based on record review and staff interview, the deficiency involved 2 of 4 residents reviewed for antibiotic use, Resident IDs #10 and #64. The report cited CDC guidance stating that nursing homes should perform antibiotic time outs two to three days after antibiotics are started to review whether the resident has a bacterial infection that will respond to antibiotics, whether the antibiotic, dose, and route are appropriate, and whether therapy can be narrowed or shortened. Resident ID #10 was readmitted with a diagnosis including elevated white blood cell count and had a physician's order for Amoxicillin Pot Clavulanate 875-125 mg every 12 hours for 7 days. An antibiotic time out form was initiated but was not completed. Resident ID #64 was admitted with a diagnosis including chronic kidney disease and had a physician's order for Ertapenem Sodium 1 gram daily for 5 days. The record did not show evidence that an antibiotic time out was completed for this resident. During interview, the DON was unable to provide evidence that antibiotic time outs were completed for either resident receiving antibiotics.
Medication Reconciliation Error at Discharge
Penalty
Summary
The facility failed to reconcile pre-discharge medication orders with post-discharge medication orders for a resident discharged from the facility. The resident, who was admitted with conditions including polymyalgia rheumatica, osteoarthritis, and cervical disc disorder, was discharged to their home. On the day of discharge, the active physician's orders included Acetaminophen 1000 mg three times a day, Cholecalciferol 1000 units once daily, and Gabapentin 100 mg twice daily. However, the Rhode Island Health Continuity of Care (COC) Form, completed at discharge, incorrectly listed the medications as Acetaminophen 500 mg three times a day, Cholecalciferol 1000 units twice daily, and Gabapentin 100 mg once daily. The Director of Nursing Services acknowledged the transcription errors during a surveyor interview.
Failure to Timely Report Investigation Results
Penalty
Summary
The facility failed to ensure that the results of all alleged abuse investigations were reported in accordance with State law. Specifically, the results of five facility-reported incidents (FRIs) were not submitted to the Rhode Island Department of Health (RIDOH) within the required 5 working days of the incident. These incidents were reported to RIDOH on various dates, including 7/12/2024, 7/24/2024, 8/9/2024, and 8/20/2024, but lacked evidence of timely submission of investigation results. During an interview on 9/3/2024, the Administrator and the Director of Nursing Services acknowledged the failure to report the investigation results within the mandated timeframe.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for four residents. Resident ID #4, admitted with hypertension and diabetes, had an order for 2-4 liters of oxygen via nasal cannula but was observed receiving only 1 liter on multiple occasions. The Treatment Administration Record (TAR) did not document the correct oxygen administration as per the order. Similarly, Resident ID #20, admitted with pneumonia and anxiety, had an order for 2-4 liters of oxygen but was also observed receiving only 1 liter. The TAR again failed to document the correct oxygen administration as ordered. Resident ID #105, admitted with COPD and acute respiratory failure, had an order for 1 liter of oxygen but was observed receiving 2 liters on multiple occasions. The TAR did not reflect the correct oxygen administration. Additionally, Resident ID #112, admitted with COPD, had an order to titrate continuous oxygen to maintain oxygen saturation greater than 95%, but the order lacked a specified flow rate. The Director of Nursing Services acknowledged that the oxygen orders should include a flow rate and that staff should document each administration as per the facility's policy.
Failure to Administer Blood Pressure Medication as Prescribed
Penalty
Summary
The facility failed to ensure that residents are free from significant medication errors, specifically for a resident with blood pressure parameters. The resident, admitted in January 2024 with diagnoses including essential hypertension, atrial fibrillation, and atherosclerotic heart disease, had a physician's order for Hydralazine HCL to be administered every 6 hours as needed for systolic blood pressure greater than 150. However, record reviews revealed that blood pressures were not checked every 6 hours, and the medication was not administered as prescribed since the order date of 4/3/2024. The resident's blood pressure readings on multiple dates in April and May showed systolic levels above 150, yet the medication was not given as required. During interviews, a Certified Medication Technician admitted to not taking the resident's blood pressure every 6 hours due to the PRN nature of the order. The Director of Nursing Services acknowledged the failure to check the resident's blood pressure every 6 hours and to administer the medication according to the parameters set by the physician's order. This oversight led to the resident not receiving the necessary medication despite having systolic blood pressure readings above 150 on several occasions.
Deficiencies in Drug Storage and Labeling
Penalty
Summary
The facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles. During a surveyor observation, multiple deficiencies were noted across four medication carts and one medication room. Specifically, an opened Trellegy Elipta inhaler was found undated, a bottle of Active liquid protein was opened and undated, and controlled substances such as Morphine Sulfate and Lorazepam were not removed from the medication cart after the resident's death. Additionally, three bottles of Lorazepam intensol were found opened, undated, and unrefrigerated, contrary to manufacturer instructions. Latanaprost eye drops were also found unrefrigerated despite the label indicating they should be stored in a refrigerator when unopened. Further observations revealed an unopened bottle of Lorazepam intensol with an expired manufacturer date in the medication room. Interviews with the nursing staff confirmed these findings, and the Director of Nursing Services (DNS) acknowledged that staff are expected to date medications upon opening and store them per manufacturer instructions. The DNS also stated that expired and discontinued medications should be removed from the cart in a timely manner, which was not adhered to in these instances.
Failure to Maintain Infection Control Program
Penalty
Summary
The facility failed to maintain an infection prevention and control program for Resident ID #25, who was readmitted with diagnoses including obstructive sleep apnea and chronic obstructive pulmonary disorder. The resident had an order to use a CPAP machine every night, but there was no evidence that the CPAP machine, including the mask, was cleaned or disinfected according to the facility policy. Staff interviews revealed that they were unaware of the cleaning procedures for the CPAP machine, and there were no physician's orders to ensure the cleaning was completed as required by the facility policy. The facility also failed to implement appropriate contact precautions for Resident ID #82, who was readmitted with a history of Extended-spectrum-beta-lactamase (ESBL) infection. The resident required maximum assistance for activities of daily living and was frequently incontinent. Despite a positive urine culture for ESBL and an order for antibiotics, there was no evidence that the resident was placed on contact precautions. Observations revealed no signage or personal protective equipment (PPE) supplies at the resident's door, and staff were unaware of the need for precautions during high-contact care activities. Interviews with the Director of Nursing Services confirmed the lack of evidence for both the cleaning of the CPAP machine and the implementation of contact precautions for the resident with ESBL. The facility did not maintain an infection control program that provided a sanitary environment to help prevent the development of infections, as required by their policies and CDC guidelines.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 235 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Westerly
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Royal Of Westerly Nursing Center | 2 mi | ★★★★★ | 9 | 0 |
| Apple Rehab Clipper | 3.5 mi | ★★★★★ | 7 | 0 |
| Avalon Health Care Center At Stoneridge | 6.7 mi | ★★★★★ | 1 | 0 |
| Pendleton Rehabilitation And Nursing Center | 6.8 mi | ★★★★★ | 1 | 0 |
| Apple Rehab Mystic | 7.7 mi | ★★★★★ | 4 | 0 |
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