Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Woonsocket Health Center during CMS and state inspections, most recent first.
Surveyors identified multiple food service safety violations, including a dietary aide preparing food without a beard restraint, an ice machine drainage pipe lacking the required air gap, and ice build-up from a leaking freezer fan contaminating an unsealed box of cheddar cheese omelets. The Food Service Director confirmed each of these deficiencies during interviews.
The facility failed to ensure safe and appropriate dialysis care for a resident on peritoneal dialysis by not maintaining required physician orders, documentation, and monitoring, and for two residents on hemodialysis by not administering or notifying providers about missed medications and supplements on dialysis days, in violation of facility policy and professional standards.
The facility did not implement required antibiotic reviews or time outs for residents prescribed antibiotics for conditions such as cellulitis, surgical wound infection, elevated WBC, and endocarditis. Medical records lacked documentation of antibiotic reassessment, and both the Infection Preventionist and DON confirmed that these reviews were not completed, reflecting a failure to follow the facility's antibiotic stewardship protocols.
Surveyors found that the facility did not document whether several residents received, refused, or had contraindications to pneumococcal vaccination. Immunization records for these residents lacked evidence of the required vaccines being offered or administered, and staff interviews confirmed that documentation was missing until the issue was identified during the survey.
A resident with a stage III coccyx pressure ulcer and low body weight was found lying on an air mattress set to an inappropriate weight setting, causing discomfort and pain. The mattress was set to 'firm' or 'max inflate' at 350 lbs, despite the resident weighing 98.5 lbs. There was no physician order or care plan for the air mattress, and both an LPN and the DON confirmed these omissions when interviewed.
A resident with end stage renal disease and anxiety related to dialysis did not receive prescribed Lorazepam on multiple occasions because the medication aide failed to notify the charge nurse about the need for a new prescription, and the pharmacy did not deliver the medication without it. This lapse in communication among staff resulted in missed doses as ordered by the provider.
The Medical Director failed to implement a resident care policy for the transcription and implementation of orders, leading to inconsistencies in how orders were documented and coordinated. Staff interviews revealed a lack of standardized procedures, and there was no evidence of comprehensive training for all nurses on the use of the verbal/telephone order book.
The facility failed to maintain a sanitary environment in four kitchenettes. Observations revealed food debris, sticky substances, and accumulated dirt in various appliances and surfaces. The Director of Environmental Services acknowledged the need for cleaning.
The facility failed to implement comprehensive care plans for three residents on anticoagulation therapy, specifically in monitoring for signs of abnormal bleeding. Despite having care plans that included interventions to observe for symptoms like unexplained bruising and nosebleeds, there was no evidence that these plans were being followed, as confirmed by staff interviews and record reviews.
The facility failed to follow its emergency cart equipment procedure, resulting in missing essential items and empty oxygen tanks. Additionally, the facility did not follow psychiatric consultant orders for a resident, leading to missed lab tests and unreported low valproic acid levels.
The facility failed to act on a pharmacist's recommendation to monitor a resident's phenytoin trough concentration in a timely manner. Despite the nurse practitioner authorizing the test, it was not conducted until over a month later, revealing a high concentration of the medication. Interviews confirmed that the test should have been done shortly after the order was given.
The facility failed to administer medications as ordered for two residents. One resident with serious conditions did not receive Lasix and Potassium, despite their availability, and expired shortly after. Another resident missed multiple doses of essential medications, and the provider was not notified in a timely manner. The Director of Nursing Services acknowledged these failures.
The facility failed to promptly identify and intervene for acute changes in a resident's condition, leading to the resident's death. Despite significant findings from a chest X-ray, ordered medications were not administered, and emergency services were not called. Interviews revealed a lack of communication and failure to follow protocols.
The facility failed to provide appropriate catheter care for two residents. One resident's urine output was not consistently documented, and another resident's suprapubic catheter was not changed monthly as required. Both the LPN and DON acknowledged these deficiencies during the surveyor interviews.
A facility failed to ensure a resident with a G-tube received appropriate care by not maintaining the head of the bed at 30 degrees as required by the care plan and physician's orders. The resident was found lying flat during tube feeding, and staff acknowledged the oversight.
The facility failed to ensure that nursing staff had the appropriate competencies to provide care for a resident with a change in condition, leading to inadequate response to the resident's respiratory distress and hypoxia. The resident, who had multiple diagnoses including COPD, was not properly assessed or treated, and the Nurse Practitioner was not notified in a timely manner. The facility lacked evidence of training and competencies related to changes in condition for the involved nursing staff.
Food Service Safety and Sanitation Deficiencies in Main Kitchen
Penalty
Summary
Surveyor observations in the main kitchen revealed several failures to comply with professional food service safety standards. A dietary aide with full facial hair was observed preparing food on two separate occasions without wearing a required beard restraint, as mandated by the Rhode Island Food Code. The Food Service Director (FSD) confirmed during interviews that the staff member was not in compliance with the beard restraint requirement. Additionally, the ice machine's drainage pipe was found inserted directly into the floor drain without the required minimum one-inch air gap, a violation of plumbing code designed to prevent contamination. The FSD acknowledged this deficiency. Furthermore, in the walk-in freezer, surveyors observed a significant ice build-up from the freezer fan dripping onto an unsealed box containing an opened package of cheddar cheese omelets. The FSD confirmed the presence of the leak and the ice accumulation on the food packaging, stating that the food should be discarded.
Failure to Provide Safe and Appropriate Dialysis Care and Medication Administration
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for residents requiring peritoneal dialysis (PD) and hemodialysis, as evidenced by multiple deficiencies in following professional standards, facility policy, and physician orders. For one resident on PD, there was no individualized physician order specifying the dialysis prescription details such as number of cycles, fill volume, dwell time, glucose concentration, or technique, despite facility policy requiring this information. Staff interviews confirmed that the PD prescription was managed remotely by an offsite dialysis nurse and not documented in the resident's medical record. Additionally, the facility did not obtain or document a full set of vital signs before, during, and after PD treatments, nor did they consistently assess or document the resident's stability, level of consciousness, comfort, or signs of complications as required by policy. Further deficiencies were noted in the documentation and handling of PD therapy. The facility did not maintain a resident binder in the room to record required information such as initial drain volume, total ultrafiltration, or average dwell time. Staff reported that fluid from the PD machine was routinely drained directly into the toilet rather than into a collection bag as specified in policy, with the tubing sometimes coming into contact with toilet water. The Director of Nursing Services was unaware of the resident's PD prescription and could not provide evidence of required documentation or adherence to policy regarding monitoring and documentation of the PD process and catheter site. For two residents receiving hemodialysis, the facility failed to administer or offer multiple prescribed medications and nutritional supplements on dialysis days, as documented in the Medication Administration Records. There was no evidence that the physician or dialysis center was notified of these missed medications. Staff and nurse practitioners confirmed that they were not informed of the missed doses and would have expected to be notified to adjust medication timing. The facility was unable to provide evidence of effective communication with the dialysis center or providers regarding these missed medications, as required by physician orders and facility policy.
Failure to Monitor and Reassess Antibiotic Use
Penalty
Summary
The facility failed to establish and implement an effective Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program with protocols and a system to monitor antibiotic use. Specifically, for four residents who were prescribed antibiotics for various conditions—including cellulitis, surgical wound infection, elevated white blood cell count, and endocarditis—there was no evidence in the medical records of an antibiotic review or an antibiotic time out being conducted as required by facility policy and CDC guidelines. The policy required reassessment of antibiotic therapy within 2-3 days of initiation to determine appropriateness, but this process was not documented for any of the residents reviewed. Interviews with the Infection Preventionist and the Director of Nursing Services confirmed that antibiotic time outs were not being completed, and neither could provide evidence that such reviews had occurred for the residents in question. The lack of documentation and process for antibiotic review was consistent across all four cases reviewed, indicating a systemic failure to monitor and reassess antibiotic use as part of the facility's infection control practices.
Failure to Document Pneumococcal Vaccination Status in Resident Records
Penalty
Summary
The facility failed to ensure that the medical records of four residents included documentation regarding the administration, refusal, or contraindication of the pneumococcal vaccination. Record reviews for these residents, who were admitted or readmitted between July 2024 and October 2023, did not show evidence that the pneumococcal vaccines (PCV13, PCV15, PCV20, or PPSV23) were offered, received, or declined. This lack of documentation was identified during a review of immunization records. During interviews, the Infection Preventionist stated that pneumococcal vaccinations are typically administered soon after consent is obtained at admission, but was unable to provide documentation for the affected residents. The Director of Nursing Services also could not provide evidence that the required immunization documentation was present in the residents' medical records until the issue was brought up by surveyors.
Failure to Provide Proper Pressure Ulcer Care and Mattress Management
Penalty
Summary
A resident with a history of a sacral pressure ulcer and low body weight was readmitted to the facility and was found to have a stage III pressure ulcer on the coccyx. The facility's policy states that a low air loss mattress should be used to provide therapeutic benefits for residents at risk for or suffering from pressure ulcers. However, during multiple observations, the resident was found lying on an air mattress that was set to 'firm' or 'max inflate' at a setting of 350 lbs, which was not appropriate for the resident's actual weight of 98.5 lbs. The resident reported discomfort, describing the mattress as hard and lumpy, and stated that frequent repositioning was necessary due to pain from the wound. Record review revealed there was no physician order or care plan in place for the use of the air mattress for this resident. Interviews with an LPN and the Director of Nursing confirmed that the mattress was not set according to the resident's weight and that neither a care plan nor a physician order for the air mattress was in place until after the issue was identified by the surveyor.
Failure to Administer Prescribed Lorazepam Due to Communication Breakdown
Penalty
Summary
A deficiency occurred when a resident with diagnoses including end stage renal disease, dependence on renal dialysis, and anemia did not receive Lorazepam as ordered prior to dialysis sessions. The physician had prescribed Lorazepam 1 mg to be administered once a day on Monday, Wednesday, and Friday before dialysis to address the resident's increased anxiety related to the procedure. However, review of the March 2025 Medication Administration Record showed that the medication was not administered on several specified dates. Interviews with staff revealed that the pharmacy did not deliver the Lorazepam because a new prescription was not received until later in the month. The Director of Nursing Services confirmed that the medication aide failed to communicate the need for a new prescription to the charge nurse, resulting in the resident not receiving the medication as ordered. The lack of timely communication between staff and the provider led to the failure to obtain and administer the medication as prescribed.
Failure to Implement Resident Care Policy for Order Transcription and Implementation
Penalty
Summary
The Medical Director failed to implement a resident care policy to coordinate care for residents related to the transcription and implementation of orders by providers. The facility's policy required that orders be accurately completed and entered into the Electronic Medication Administration Record (EMAR) by authorized staff. However, interviews with various staff members, including Licensed Practical Nurses (LPNs), Registered Nurses (RNs), Nurse Practitioners (NPs), and the Medical Director, revealed inconsistencies in the process of transcribing and implementing orders. Some staff members indicated that orders were written on lab slips, while others mentioned the use of a verbal/telephone order book, and some orders were verbally communicated without being transcribed into the book or EMAR promptly. This inconsistency led to a lack of proper documentation and coordination of medical care for residents. The facility's assessment highlighted the importance of having adequately trained medical practitioners and written guidance regarding current regulations and protocols developed by the Medical Director. Despite this, the surveyor interviews revealed that the Medical Director and other staff members were not fully aware of or did not consistently follow the established protocols for transcribing and implementing orders. The Director of Nursing Services and the Administrator also confirmed that there was no evidence of comprehensive education and training for all nurses regarding the use of the verbal/telephone order book. The deficiency was further evidenced by the lack of a standardized process for handling orders, as described by various staff members. The Medical Director's oversight was insufficient in ensuring that all staff members were educated and trained on the proper procedures for transcribing and implementing orders. This failure to implement and enforce a consistent policy for order transcription and implementation compromised the coordination of medical care for residents in the facility.
Facility Fails to Maintain Sanitary Kitchenettes
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment in four observed kitchenettes. On the 1st floor, the [NAME] Point unit kitchenette had a toaster oven with a buildup of food debris. On the 2nd floor, the Cold Spring Place kitchenette had a freezer with brown debris and a dry sticky red substance, a refrigerator with a red sticky substance, and a toaster oven with food debris. The Park Square unit kitchenette on the same floor had a countertop with a brown sticky substance, a microwave with brown food debris, flooring with brown and gray substances, a freezer with brown debris and a dry sticky brown substance, a refrigerator with a dry white substance and sticky yellow and red substances, and a toaster oven with food debris. On the 3rd floor, the [NAME] Hill unit kitchenette had a freezer with a dry sticky brown substance and a refrigerator with a clear sticky substance along the bottom drawers, shelving, and drawer handle. The toaster oven in this kitchenette also had a buildup of food debris. During an interview, the Director of Environmental Services acknowledged these observations and indicated that the areas needed to be cleaned.
Failure to Implement Anticoagulation Therapy Monitoring
Penalty
Summary
The facility failed to implement comprehensive person-centered care plans for three residents receiving anticoagulation therapy, specifically in monitoring for signs and symptoms of abnormal bleeding. Resident ID #48, admitted with diagnoses including a fracture of the left tibia and hypertension, had a care plan that included monitoring for abnormal bleeding due to anticoagulation therapy. However, there was no evidence that this care plan was being implemented, as confirmed by a registered nurse during a surveyor interview. Similarly, Resident ID #62, admitted with conditions such as an intertrochanteric fracture of the right femur and pulmonary embolism, had a care plan to monitor for abnormal bleeding, but again, no evidence was found that this was being followed, as confirmed by staff during an interview. Lastly, Resident ID #118, who had diagnoses including venous thrombosis and gastrointestinal hemorrhage, also had a care plan to monitor for abnormal bleeding. The Director of Nursing Services acknowledged that the care plans for these residents were not being implemented as required. The deficiency was identified through record reviews and staff interviews, which revealed that the facility's policy on anticoagulation therapy monitoring was not being followed. The care plans for the residents included specific interventions to observe for signs of abnormal bleeding, such as unexplained bruising, nosebleeds, and bleeding gums. Despite these documented interventions, there was no evidence that the staff were actively monitoring the residents for these symptoms. The Director of Nursing Services confirmed the lack of implementation of the care plans during a surveyor interview, acknowledging that the residents were receiving anticoagulant medications but were not being adequately monitored for potential side effects as outlined in their care plans.
Failure to Follow Emergency Cart Procedures and Psychiatric Consultant Orders
Penalty
Summary
The facility failed to meet professional standards of quality by not following its emergency cart equipment procedure for four out of four emergency carts observed. Specifically, the emergency carts were missing essential items such as a blood spill kit, normal saline, an ambu bag, a canister for the suction machine, and non-rebreather masks. Additionally, some oxygen tanks were found to be empty or nearly empty. These deficiencies were acknowledged by the respective staff members present during the surveyor observations. The Director of Nursing Services was unable to provide evidence that the 11:00 PM to 7:00 AM nurse checks the emergency cart nightly to ensure all equipment is available. The facility also failed to follow psychiatric consultant orders for a resident admitted with anxiety and depression. The geriatric psychiatry recommendation to check valproic acid level and liver function tests was not transcribed or completed as ordered. This oversight was only identified when brought to the facility's attention by the surveyor. The Director of Nursing Services acknowledged that the orders for the labs were missed, and they weren't completed until after the surveyor's intervention. The resident's valproic acid level was found to be below the therapeutic range, and there was no evidence that this low level was reported to the Nurse Practitioner prior to the surveyor's notification.
Failure to Act on Pharmacist's Recommendation for Phenytoin Monitoring
Penalty
Summary
The facility failed to ensure that irregularities identified by the Clinical Consultant Pharmacist during the monthly Medication Regimen Review (RR) were acted upon for a resident taking phenytoin, a medication used to control seizures. The resident, who was readmitted to the facility with diagnoses including vascular dementia and epilepsy, had a recommendation from the pharmacist to monitor phenytoin trough concentration. This recommendation was accepted and authorized by the nurse practitioner, but the order was not processed in a timely manner. The phenytoin trough level was not obtained until over a month later, revealing a high concentration of the medication. Interviews with the nurse practitioner and the Director of Nursing Services confirmed that the phenytoin trough level should have been obtained shortly after the order was given. The delay in obtaining the phenytoin concentration resulted in a high level being detected, which could have been avoided with timely monitoring. The facility's failure to act promptly on the pharmacist's recommendation led to this deficiency.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to keep residents free from significant medication errors for two residents. Resident ID #118, who had diagnoses including hypertensive heart disease and chronic obstructive pulmonary disease, was observed with labored breathing and other symptoms. A STAT chest x-ray revealed several serious conditions, and the physician ordered Lasix and Potassium. However, the medications were not administered as ordered, despite being available in the facility. The resident expired shortly after the missed doses, and interviews with staff confirmed the expectation that the medications should have been administered promptly. Resident ID #119, admitted with diagnoses including hepatic encephalopathy, essential tremor, COVID-19, and alcoholic cirrhosis of the liver, also experienced significant medication errors. The resident missed multiple doses of prescribed medications, including Xifaxan, Lactulose, Benztropine, and Lagevrio. The record review failed to show evidence that the provider was notified of the missed doses in a timely manner. The Director of Nursing Services acknowledged the missed doses and confirmed that the provider should have been notified if medications were unavailable and not administered as ordered.
Failure to Promptly Identify and Intervene in Resident's Acute Change in Condition
Penalty
Summary
The facility failed to promptly identify and intervene for acute changes in a resident's condition, leading to the death of a resident with a history of COPD, heart disease, and gastrointestinal hemorrhage. The resident exhibited labored breathing, abdominal distention, and abnormal vital signs, but the LPN did not notify the NP, expecting her to complete her routine rounds. The chest X-ray revealed significant findings, including pneumonia and congestive heart failure, but the ordered medications were not administered promptly. On the morning of the resident's acute change, the Nursing Assistant notified the LPN, who assessed the resident but did not contact the NP. The NP was only informed during her routine visit later that day. Despite the critical findings from the chest X-ray, the medications Lasix and KCL were not administered as ordered. The resident's condition deteriorated, and emergency services were not called, leading to the resident's death. Interviews with staff revealed a lack of communication and failure to follow protocols for acute changes in condition. The resident's Primary Care Provider and the Medical Director both indicated that they would have expected the resident to be sent to the hospital given the severity of the condition. The Director of Nursing Services acknowledged the failure to promptly identify and intervene in the resident's acute change in condition.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for two residents with suprapubic catheters. Resident ID #78, admitted with chronic kidney disease, urinary tract infection, hematuria, and obstructive and reflux uropathy, had a physician's order to empty the Foley drainage bag every shift. However, the facility did not consistently document urine output measurements as required. Out of 90 opportunities, 27 instances lacked documentation, and 17 instances recorded urine output inaccurately using terms like small, medium, or large instead of precise measurements. The Director of Nursing Services could not provide evidence of proper documentation during the surveyor interview. Resident ID #115, admitted with a disorder of the urinary system, urinary tract infection, obstructive and reflux uropathy, and urine retention, had a suprapubic catheter in place. The facility failed to maintain a current order to change the suprapubic catheter monthly. The last recorded change was on 3/21/2024, and there was no current order for subsequent changes. Both the Licensed Practical Nurse and the Director of Nursing Services acknowledged the absence of a current order during their interviews with the surveyor.
Failure to Maintain Proper Bed Elevation for Resident with G-Tube
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube (G-tube) received appropriate treatment and services to prevent complications. The resident, who was readmitted to the facility in January 2024 with diagnoses including adult failure to thrive and gastro-esophageal reflux disease, had a care plan and physician's orders specifying that the head of the bed (HOB) should be elevated at 30 degrees continuously during tube feeding to prevent aspiration. However, during a surveyor observation on April 22, 2024, the resident was found lying flat in bed while the tube feeding was running, contrary to the prescribed orders and care plan instructions. A registered nurse acknowledged the oversight and immediately corrected the bed position, but this indicated a lapse in following the prescribed care plan and physician's orders for the resident's safety and well-being. Further interviews with the Director of Nursing Services confirmed that the expectation was for the HOB to remain elevated at 30 degrees or more for residents receiving continuous tube feeding. The Director was unable to provide evidence that the resident had consistently received the appropriate treatment to prevent complications related to tube feedings. This deficiency highlights a failure in adhering to established protocols and ensuring the resident's care plan was properly implemented to prevent potential complications such as aspiration.
Failure to Ensure Nursing Staff Competencies
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to provide nursing and related services to assure resident safety, as identified in the plan of care for a resident with a change in condition. The resident, who had diagnoses including gastrointestinal hemorrhage, hypertensive heart disease without heart failure, and COPD, was observed with labored breathing and a grossly distended abdomen. The following day, the resident was found cold, clammy, and non-responsive, with a pulse oximetry reading of 68% on room air. Despite being placed on a non-rebreather mask with oxygen, the resident's condition did not improve, and they were pronounced dead shortly after. There was no evidence that the Nurse Practitioner was notified of the resident's change in condition at the time of the assessments. Interviews with the Nurse Practitioner and Medical Director revealed that they were not informed of the resident's respiratory distress and hypoxia in a timely manner. The facility's Education Coordinator was unable to provide evidence of education or competencies related to changes in condition for the nurses who cared for the resident. The Director of Nursing Services was also unaware that assessment and early identification of problems were part of the staff training and competencies section of the facility assessment. This lack of appropriate training and competency assessment contributed to the failure to provide adequate care for the resident during a critical change in condition.
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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.
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Illustrative
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Nursing homes near Woonsocket
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Adviniacare Oakland Grove Llc | 0.8 mi | ★★★★★ | 12 | 0 |
| Cedar Haven Operations Holding Llc Valley View Hea | 1.3 mi | ★★★★★ | 0 | 0 |
| The Friendly Home | 2.4 mi | ★★★★★ | 13 | 0 |
| St Antoine Residence | 2.7 mi | ★★★★★ | 4 | 0 |
| Holiday Retirement Home Inc | 3 mi | ★★★★★ | 9 | 0 |
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