Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grace Barker Nursing Center during CMS and state inspections, most recent first.
The facility failed to maintain proper infection control practices, as observed in the handling of glucose meters, dressing changes, and inhaler administration. An LPN did not follow disinfection protocols for glucose meters and dressing changes, while a Medication Technician failed to use a barrier and disinfect an inhaler. These actions were contrary to the facility's policies and procedures.
A resident with dementia and skin cancer did not receive wound care as per physician's orders. The dressing on the resident's face was not changed daily as required, and a dressing on the elbow was outdated with no treatment order or documentation. The DON was unaware of the elbow condition, and the facility failed to provide evidence of completed treatments.
A facility failed to provide adequate respiratory care for a resident diagnosed with pneumonia. Despite having a physician's order for antibiotics, the required Respiratory Event document was not completed, which is essential for triggering necessary assessments like temperature and oxygen saturation checks. Additionally, no care plan was developed for the resident's pneumonia, as confirmed by staff interviews.
A resident with severe cognitive impairment and a diagnosis of dementia did not receive a PRN dose of Trazodone for crying and distress during morning care. The nursing assistant did not inform the nursing staff of the resident's condition, considering it common behavior, resulting in the failure to administer the medication as needed.
A resident with intact cognition reported being sexually abused by a nursing assistant, Staff B, who engaged in inappropriate touching. Another resident with impaired cognition also reported inappropriate behavior by the same staff member. The facility's abuse prevention policy was not followed, and security footage supported the allegations. Staff B was arrested, and the facility failed to ensure the resident's safety.
A resident with dementia and moderately impaired cognition reported that a nursing assistant jumped on top of them in bed, but the facility failed to investigate the allegation. The incident was reported by a physical therapy assistant after another resident made a similar claim. The facility administrator could not provide evidence of an investigation or report to the State Survey Agency.
Infection Control Deficiencies in Equipment Handling and Dressing Changes
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of improper handling and disinfection of medical equipment and supplies. During the use of a glucose meter for two residents with diabetes, a Licensed Practical Nurse (LPN) did not follow the facility's policy for cleaning and disinfecting the meter. The LPN used only one disposable wipe instead of the required two and failed to disinfect the treatment cart and other surfaces after handling the used glucose meter. This was observed during blood sugar checks for two residents, where the LPN also touched multiple surfaces without proper disinfection. In another instance, the same LPN did not adhere to proper infection control procedures during dressing changes for a resident with a gastrostomy tube and stage 4 pressure ulcers. The LPN failed to change gloves and perform hand hygiene after removing old dressings and before applying new treatments and dressings. This was observed during the care of the resident's G-tube site, left ankle, and coccyx wounds, where the LPN continued to use the same gloves throughout the procedure, contrary to the facility's competency validation for a clean dressing change. Additionally, a Medication Technician did not follow infection control protocols during the administration of an inhaler to a resident whose roommate was on contact precautions. The technician placed the inhaler on a bureau without a barrier and failed to disinfect it before returning it to the medication cart. The Director of Nursing Services acknowledged that the staff should have used a barrier and disinfected the inhaler before placing it back on the cart, highlighting a lapse in infection control practices.
Deficiency in Wound Care Management
Penalty
Summary
The facility failed to provide services that meet professional standards of practice for a resident with wound care needs. The resident, who was admitted with diagnoses including dementia and skin cancer, had a physician's order to cleanse an open area on the left side of the face with normal saline, apply A&D ointment, and cover it with a non-adhesive pad and transparent dressing once daily. However, the Treatment Administration Record (TAR) indicated that the treatment was signed off as completed on two consecutive days, but observations revealed that the dressing had not been changed as per the order. The dressing was dated two days prior, and the initials on the dressing matched a staff member who confirmed completing the dressing change only on the first day. Additionally, during the survey, a dressing on the resident's right elbow was observed with a date indicating it had not been changed for several days. Upon removal, a bruise and a small scab were noted, but there was no physician's order or documentation for treatment of the elbow. The Director of Nursing Services was unaware of the bruise and scab and acknowledged that staff should have notified the physician and obtained a treatment order. The facility could not provide evidence that the ordered treatment for the resident's face was completed as required.
Failure to Provide Adequate Respiratory Care for Resident with Pneumonia
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident diagnosed with pneumonia. The resident, who was readmitted with a diagnosis including asthma, had a chest x-ray on January 28, 2025, indicating pneumonia. Despite having a physician's order for Levaquin, an antibiotic, there was no evidence that a Respiratory Event document was completed for the resident as required by the facility's policy. This document is crucial as it triggers necessary physician orders such as obtaining temperature, oxygen saturation levels, and assessing lung sounds every shift. Additionally, the facility did not develop a care plan for the resident's pneumonia diagnosis. Interviews with staff, including a Registered Nurse and the Director of Nursing Services, confirmed the absence of the Respiratory Event document and the care plan. The Director of Nursing Services acknowledged that the resident should have had their temperature, oxygen saturation level, and lung sounds assessed every shift, which was not done, indicating a lapse in following the facility's policy for managing respiratory illnesses.
Failure to Administer PRN Medication for Resident with Dementia
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, identified as having severe cognitive impairment. The resident had a physician's order for Trazodone to be administered daily and as needed for symptoms such as restlessness, anxiety, irritability, or inconsolable crying. On the day of the surveyor's observation, the resident was found crying and sobbing during morning care, but the PRN dose of Trazodone was not administered as the nursing assistant did not inform the nursing staff of the resident's distress. The nursing assistant, who was providing care to the resident, did not notify the nurses about the resident's crying, considering it common behavior. Consequently, the nurses were unaware of the resident's condition and did not administer the PRN medication. The Director of Nursing Services indicated that the nursing assistant should have informed the nurses so that the resident could receive the PRN Trazodone as ordered. This lack of communication and failure to administer the medication as needed led to the deficiency in care for the resident.
Failure to Protect Resident from Sexual Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a staff member, as determined by surveyor observations, record reviews, and interviews with residents and staff. The incident involved a resident with intact cognition who reported inappropriate touching by a nursing assistant, Staff B. The resident described the incident as unwanted intimate contact, which was corroborated by a physical therapy assistant who reported the allegations to the charge nurse. Another resident with moderately impaired cognition also reported inappropriate behavior by the same staff member. The facility's policy on abuse prohibition, which emphasizes the right of residents to be free from abuse, was not adhered to in this case. The incident was reported to the Rhode Island Department of Health, and security footage supported the resident's claims, showing Staff B entering and exiting the resident's room under suspicious circumstances. Staff B's behavior was inconsistent with the facility's procedures for resident care, as he was observed to be agitated and insisted on working independently, contrary to the usual practice of working collaboratively with another staff member. Interviews with staff and residents, along with video evidence, indicated that Staff B engaged in inappropriate conduct, leading to his arrest by local authorities. The facility was unable to provide evidence that the resident was kept free from sexual abuse, highlighting a significant deficiency in ensuring resident safety and adherence to abuse prevention policies.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving sexual abuse were thoroughly investigated for one of the two residents reviewed, identified as Resident ID #2. The resident, who was admitted with diagnoses including dementia, Alzheimer's disease, and anxiety disorder, had a Brief Interview for Mental Status score indicating moderately impaired cognition. During a physical therapy session, the resident reported to the Physical Therapy Assistant, Staff A, that Nursing Assistant, Staff B, had jumped on top of them while they were in bed, but they had told him they were not interested. Staff A did not immediately report this allegation and only did so after another resident reported a similar incident involving Staff B. The record review did not reveal any evidence that the facility investigated the allegation of sexual abuse by Staff B against Resident ID #2. During interviews, Resident ID #2 recounted the incident, stating that Staff B was sitting on their bed and stood very close, but left after being told to go away. The facility administrator was unable to provide evidence that the allegation was thoroughly investigated or reported to the State Survey Agency as required by State law.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Warren
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crestwood Nursing & Rehabilitation Center Inc | 0.6 mi | — | 3 | 0 |
| Warren Operations Ri, Llc Dba Warren Center | 1 mi | — | 3 | 0 |
| Country Gardens Health And Rehabilitation Center | 2.4 mi | — | 3 | 0 |
| The Dawn Hill Home For Rehab And Healthcare | 2.8 mi | — | 5 | 0 |
| Silver Creek Rehab And Healthcare Center | 3.4 mi | — | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.