West View Nursing Home, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in West Warwick, Rhode Island.
- Location
- 239 Legris Avenue, West Warwick, Rhode Island 02893
- CMS Provider Number
- 415067
- Inspections on file
- 23
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at West View Nursing Home, Inc during CMS and state inspections, most recent first.
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.
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.
Latest citations in Rhode Island
The facility failed to follow physician orders for post-fall care for three anticoagulated residents who experienced falls. One resident on a blood thinner with a head injury was ordered to be transferred to the ED after a telehealth evaluation, but an LPN did not send the resident, citing instructions to contact a supervisor first and inability to reach that supervisor. For two other residents on anticoagulants, providers ordered intensive neuro checks (every 15 minutes, then every 30 minutes, then hourly, then every 4 hours), but staff instead performed neuro checks only once per shift for 72 hours. The DON and Medical Director acknowledged that the transfer and monitoring orders were not implemented as written.
A resident with intact cognition and psychiatric diagnoses sustained a left eyebrow laceration when another resident with a documented history of escalating aggressive and threatening behaviors struck them with a cane during a hallway dispute. The aggressive resident had multiple prior documented incidents, including verbal threats to kill others, attacking a roommate with a cane over TV volume, throwing objects during activities, and throwing a lunch plate at staff. Despite these events, the care plan was not updated with interventions to address physical aggression toward other residents, and a psychiatric recommendation for PRN trazodone for agitation, anxiety, and insomnia was only implemented as PRN for insomnia. The failure to assess, monitor, and implement effective interventions for the aggressive resident’s behaviors led to the assault and injury and, per the report, placed this and other residents at risk of serious physical and psychosocial harm.
A resident with impulse disorder, mood and anxiety diagnoses, and a history of escalating verbal and physical aggression had multiple documented incidents of threats, object throwing, and assault with a cane. Despite a psychiatric consult recommending PRN trazodone for agitation, anxiety, and insomnia, the provider order listed insomnia only, and the care plan was not updated with specific interventions to address the resident’s physically aggressive behaviors after several documented events. Subsequently, the resident struck another resident with a cane, causing a facial laceration that required wound closure and ongoing treatment.
The facility failed to properly screen and document clearance for a NA with disqualifying criminal history information before hire, as required by its abuse, neglect, and exploitation policy. A BCI check showed disqualifying information, yet the NA was hired, completed orientation, and worked independently based only on verbal disclosure of an old drug-related charge, without written details or verification. Later, a staff member reported witnessing this NA grab a resident’s face and kiss the resident on the lips, and a community complaint alleged inappropriate interactions with the same resident, prompting involvement of local police.
A resident with anxiety disorder and PTSD was unable to attend meals and activities with peers because the facility lost the resident's clothing after it was sent to laundry. The resident was observed in a hospital gown with only a few clothing items in the room, and the record lacked an admission inventory of belongings. The DON/Administrator reported that laundry was handled by an outside vendor without a tracking system or item documentation.
A resident with dementia and severely impaired cognition was subjected to repeated non-consensual kissing on the lips by an NA, who entered the resident’s room during care, verbally expressed affection, and then kissed the resident on the mouth on at least two separate occasions witnessed by staff. One staff member delayed reporting the first incident due to fear of the NA. These actions occurred despite a facility policy defining sexual abuse as any non-consensual sexual act and requiring protections of residents’ rights and well-being.
Failure to investigate allegations of resident-to-resident sexual inappropriateness: A resident with dementia and TBI was documented as being inappropriate with another resident, and psych notes later described increased sexually inappropriate behaviors toward other residents. Staff interviews showed the resident had been observed touching others and needing frequent redirection, but the DON, ADON, and Administrator acknowledged the facility did not complete an investigation or recognize the allegation as possible abuse.
A resident with dementia and a hearing deficit did not receive ear care as ordered because the chart lacked the Debrox order and the ear was flushed before the intended Debrox course was completed. In a separate incident, staff witnessed inappropriate kissing of a resident with dementia, but the allegation was not reported to the provider and the care plan was not updated. A third resident’s wound care was also not completed as ordered when an RN used normal saline instead of the prescribed Vashe wound wash.
A resident with migraines and chronic pain did not receive timely pain management after repeatedly reporting a migraine and appearing in visible distress. An NA notified an LPN, an RN said she could not access the med cart, and the resident continued waiting while the LPN was off the unit; the PRN migraine medication was not given until 40 minutes after the first complaint. The DON acknowledged the resident should not have waited that long for pain medication.
A resident missed 6 doses of a prescribed antibiotic, and the MAR did not show that the provider was notified. The RN acknowledged the missed doses and said they should have been reported, while the Medical Director stated she was unaware of the missed doses and would have extended the antibiotic course if informed. The DON also confirmed the missed doses and expected provider notification for any missed antibiotic dose.
Failure to Follow Post-Fall Physician Orders for Anticoagulated Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for post-fall care, including hospital transfer and neurological monitoring, for residents on anticoagulant therapy. One resident with atrial fibrillation on Xarelto experienced an unwitnessed fall with a scalp laceration and head lump. The on-call provider, after a telehealth evaluation, ordered transfer to the ED and wrote an order directing that the resident be sent to the hospital. The resident was not transferred as ordered, and an additional order for vital signs and neuro checks every shift for 72 hours after the fall was not completed as ordered on one of the shifts. The LPN caring for this resident stated she did not send the resident to the ED because she had been instructed to call a supervisor before sending residents out, and she was unable to reach the supervisor during the shift. A second resident, also with atrial fibrillation and on Xarelto, had an unwitnessed fall with injury. The on-call provider was notified and ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, then every four hours for an additional 24 hours. A physician’s order reflecting this schedule was scanned into the EMR. However, the neuro checks were not completed as ordered; instead, they were performed only once per shift for 72 hours. The RN who authored the progress note documented the fall and the resident’s anticoagulant use, and later stated she could not remember why she did not transcribe and complete the neuro checks as ordered. A third resident with atrial fibrillation on Apixaban had a non-injury fall after attempting to walk independently. The on-call provider ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, and then every four hours for an additional 24 hours, and this order was scanned into the EMR. The record did not show that these neuro checks were completed as ordered; instead, neuro checks were documented only once per shift for 72 hours. The Medical Director stated he would have expected the first resident to be transferred to the ED as ordered and that the facility should not override a provider’s order. The DON acknowledged that the transfer order and the ordered monitoring for the first resident were not followed as written, and that for the second and third residents, staff performed only once-per-shift neuro checks instead of the more frequent monitoring ordered by the providers.
Failure to Manage Escalating Aggression Leading to Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident, Resident ID #1, from abuse by another resident with a known history of escalating aggression, Resident ID #2. Resident ID #1 was admitted in October 2025 with diagnoses including paranoid schizophrenia and adjustment disorder with mixed anxiety and depressed mood, and had a BIMS score of 14/15, indicating intact cognition. On 4/27/2026, progress notes documented that Resident ID #1 was on the receiving end of a physical altercation with another resident and was found with a deep bleeding abrasion to the left eyebrow. A subsequent nursing note described a new laceration to the left eyebrow measuring 0.5 cm by 2.0 cm by 0.1 cm, related to a resident-to-resident incident, for which wound closure strips were applied. Resident ID #1 requested police involvement and a police report, and refused transfer to the hospital for sutures. Resident ID #2 had been admitted in December 2024 with multiple psychiatric and behavioral diagnoses, including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed a BIMS score of 13/15 and documented both physical and verbal behaviors during the look-back period. Progress notes over several months recorded a pattern of escalating aggressive and threatening behaviors: on 9/13/2025, Resident ID #2 threatened to slit another resident’s throat and made additional threats toward staff; on 11/7/2025, the resident was involved in a verbal dispute with raised voice, name-calling, and verbal threats; on 12/28/2025, after another resident struck Resident ID #2 with a helmet, Resident ID #2 was overheard threatening to kill that resident if touched again. On 2/21/2026, the on-call provider documented that Resident ID #2 attacked a roommate with a cane over TV volume and required ER transfer for psychiatric evaluation. Subsequent notes on 3/9/2026 and 4/10/2026 described the resident throwing poker chips on the floor, yelling and swearing at staff and residents, and throwing a lunch plate across the nurses’ station at a nursing assistant due to dissatisfaction with portion size. Despite this documented pattern, the care plan for Resident ID #2, dated 1/16/2025, only indicated a behavior problem of being verbally aggressive toward staff with resident-to-resident altercations on 12/28/2025, 2/21/2026, and 4/27/2026, and record review failed to show added interventions to mitigate the risk of physical aggression toward other residents after the 2/21/2026 cane attack and the object-throwing incidents on 3/9/2026 and 4/10/2026. A psychiatric evaluation on 4/23/2026 recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order entered on 4/24/2026 specified trazodone 25 mg twice daily as needed only for insomnia, and record review did not show that agitation and anxiety were included as indications for use. During interviews, the RNP and the DON stated it was their expectation that agitation and anxiety would have been included in the trazodone order, and the DON was unable to provide evidence that the care plan had been updated with interventions to address Resident ID #2’s physically aggressive behaviors documented on 2/21/2026, 3/9/2026, and 4/10/2026. On 4/27/2026, the DON documented that Resident ID #2 was ambulating down the hall toward his/her room while Resident ID #1 was walking in the opposite direction, and the two residents began a verbal dispute. Before staff could intervene, Resident ID #2 used his/her cane to make contact with Resident ID #1, resulting in the eyebrow laceration that required steri-strips and ongoing wound treatment. A police incident report recorded that Resident ID #1 stated being struck with a walking cane, wanted to press charges, and that Resident ID #2 admitted to striking Resident ID #1, leading to an arrest on one count of felony assault with a dangerous weapon. The facility’s failure to assess, monitor, and implement effective interventions for Resident ID #2’s known and escalating aggressive behaviors, including failure to update the care plan after prior incidents and failure to fully implement psychiatric recommendations, resulted in this resident-to-resident altercation and injury, and the report states that this failure placed Resident ID #1 and other residents at risk of serious physical and psychosocial harm.
Failure to Implement Psychiatric Recommendations and Update Behavior Care Plan Leading to Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health services and care planning for a resident with a documented history of psychiatric conditions and aggressive behaviors. The resident was admitted in December 2024 with diagnoses including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed intact cognition with a BIMS score of 13/15 and documented physical and verbal behaviors during the look-back period. Over time, multiple behavioral incidents were recorded, including threats to slit another resident’s throat during a smoking session, verbal disputes with name-calling and threats, and a statement to another resident that if touched again the resident would be killed. Further documentation showed escalating behaviors, including an incident where the resident attacked a roommate with a cane over television volume and required ER transfer for psychiatric evaluation, throwing poker chips and yelling when not winning at Bingo, causing the roommate to avoid the shared bathroom due to inappropriate comments and frustration over the light being turned on at night, and throwing a lunch plate across the nurses’ station at a nursing assistant over portion size. The care plan, initiated in January 2025 for verbal aggression and resident-to-resident altercations, did not contain added interventions to address the resident’s physically aggressive behaviors toward others after the incidents on 2/21/2026, 3/9/2026, and 4/10/2026. The DNS later could not provide evidence that the care plan had been updated with interventions to mitigate the risk of these physically aggressive behaviors or to guide staff in ensuring the safety of other residents. On 4/23/2026, a psychiatric evaluation recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order dated 4/24/2026 implemented trazodone 25 mg twice daily as needed for insomnia only, and the record lacked evidence that agitation and anxiety were included as indications for use as recommended by the consulting psychiatrist. Both the RNP and the DNS stated it was their expectation that the trazodone order would have included agitation and anxiety. Following this incomplete implementation of the psychiatric recommendation and the lack of updated behavioral interventions in the care plan, a resident-to-resident altercation occurred on 4/27/2026 in which the resident struck another resident with a cane, causing a laceration to the left eyebrow that required closure with steri-strips and ongoing wound treatment.
Failure to Properly Screen and Clear NA with Disqualifying Criminal History
Penalty
Summary
The facility failed to ensure that a prospective employee was properly screened and cleared for a history of abuse, neglect, exploitation, or misappropriation of resident property before hire. A nursing assistant, identified as Staff A, was hired on 11/18/2025 and was working independently as a NA. Prior to hire, a Bureau of Criminal Identification (BCI) check dated 11/6/2025 showed that Staff A had disqualifying information under federal and state law. Surveyor review after discovery of the positive BCI revealed that Staff A had an extensive criminal history. Despite this, the facility proceeded with the hire and allowed Staff A to complete orientation and work independently without obtaining or maintaining documentation specifying the nature of the disqualifying information, contrary to the facility’s Abuse, Neglect and Exploitation Policy, which requires screening and documentation of proof that such screening occurred. Subsequently, a facility-reported incident submitted on 4/17/2026 documented that a staff member reported witnessing Staff A grab a resident’s face and kiss the resident on the lips. A community-reported complaint submitted on 4/22/2026 alleged inappropriate interactions between the same NA and the same resident, and included a local police incident report indicating the resident’s family intended to pursue charges related to the incident. During interviews, the Human Resource Director stated that Staff A had disclosed disqualifying information related to a prior drug-related charge from about ten years earlier, but acknowledged there was no documentation specifying the nature of the disqualifying information and that this was known only by word of mouth. The Administrator stated she was aware that the BCI contained disqualifying information and that she exercised her own judgment in proceeding with the hire, and further acknowledged she did not receive documentation detailing the disqualifying information until it was brought to her attention by the surveyor.
Failure to Maintain Resident Clothing and Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when the resident was unable to attend meals and activities with other residents because of a lack of appropriate clothing. The resident was admitted in May 2025 with diagnoses including anxiety disorder and post-traumatic stress disorder, and a care plan revised on 8/25/2025 described the resident as highly social and willing to participate in a variety of activities, with an intervention to provide reminders of scheduled events. During observation on 4/29/2026, the resident was found in the room wearing a hospital gown while other residents were in the dining room for lunch. Only one pair of pants and two T-shirts were observed in the room. The resident stated that the facility lost all of the resident's clothing, including shirts, pants, shorts, and socks, after they were sent to laundry services several months earlier and were never returned. The resident reported that the Administrator was told about the missing clothing, but no follow-up occurred and the clothing was neither located nor replaced. The record did not contain an admission inventory list of the resident's belongings, and the Administrator stated that laundry was handled by an outsourced company without a tracking system or documentation identifying which items belonged to which resident.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse when a nursing assistant (NA) was observed kissing the resident on the lips on more than one occasion. The resident, identified as having dementia and a Brief Interview for Mental Status (BIMS) score of 0/15 indicating severely impaired cognition, had been admitted in March 2026. On one occasion, a Certified Medication Technician (CMT) reported that while she was assisting the resident with breakfast, the NA entered the room, verbally expressed affection for the resident, made a kissing noise, leaned forward, and kissed the resident on the lips. This incident made the CMT uncomfortable, and she later discussed it with another NA. A separate staff member, another NA, reported that two days earlier she had observed the same NA enter the resident’s room while morning care was being provided, ask the resident if they remembered her, state that she loved the resident, then lean toward the resident, make a kissing sound, and kiss the resident on the mouth with full lip-to-lip contact. This second NA did not report the incident at the time because she was fearful of the NA involved and only came forward after learning of the later incident. The facility’s abuse, neglect, and exploitation policy defined sexual abuse as a non-consensual sexual act of any type with a resident and required protections for each resident’s health, welfare, and rights, as well as screening of potential employees for a history of abuse. Despite this policy, the resident with severely impaired cognition was subjected to repeated non-consensual kissing by the NA.
Failure to Investigate Allegations of Resident-to-Resident Sexual Inappropriateness
Penalty
Summary
The facility failed to ensure that allegations made by residents were recognized as possible abuse by staff and that all allegations were investigated for Resident ID #41, who was admitted with diagnoses including dementia and traumatic brain injury. A facility policy titled, Abuse, Neglect and Exploitation, stated that an immediate investigation is warranted when suspicion of abuse, neglect, exploitation, or reports of abuse, neglect, or exploitation occur. A progress note written by an RN documented that a resident reported Resident ID #41 was being inappropriate with another resident. Subsequent records included psychiatric evaluations stating the resident was being seen due to increased sexually inappropriate behaviors toward other residents and that sexual impulses may present an unsafe environment for other patients in the facility. Staff interviews revealed that Resident ID #41 had been observed touching other residents' shoulders and hands and required frequent redirection. The RN who documented the incident stated the behavior involved an attempted hug without contact and that both residents were separated and assessed, while the ADON and DON acknowledged they were unaware of the behavior or that the facility had not investigated the allegations. The Administrator also acknowledged that an investigation had not been completed to determine what sexually inappropriate behavior had occurred and that staff did not identify the allegation as possible abuse or investigate it immediately.
Failure to Follow Orders, Report Abuse, and Perform Ordered Wound Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for a resident with dementia and anxiety disorder who had a hearing deficit and complained of right ear wax buildup. The medical record showed an order for Debrox ear drops and a separate order to flush the right ear with warm water two times a day following Debrox usage for 5 days, but the record did not include a physician order for the Debrox solution. The April 2026 MAR showed the resident’s right ear was flushed six times, and the resident stated that the right ear still felt blocked. The RN acknowledged flushing the ear and was unaware whether Debrox had been given, while the DON stated the order had been entered incorrectly and that the ear should not have been flushed before Debrox administration. The NP stated the intended order was for Debrox twice daily for five days before irrigation and that she would not have ordered daily ear flushing. The facility also failed to report an allegation of abuse and failed to update the care plan for a resident with dementia after staff reported inappropriate interactions with a nursing assistant. A community complaint and police incident report indicated the family wanted to press charges, and the Administrator and DON confirmed that staff had reported witnessing the nursing assistant kiss the resident on two occasions. The record did not show that the allegation was reported to the provider, and the comprehensive care plan was not updated to reflect the allegation or any interventions related to the incident. The NP stated she was unaware of the incident and would have expected to be notified, and the ADNS acknowledged that the provider had not been notified and the care plan had not been updated. The facility further failed to follow a wound care order for a resident readmitted with peripheral vascular disease and cellulitis of the lower limb. The physician ordered cleansing open areas on the left lower leg with Vashe wound wash, applying xeroform to the wound bed, and wrapping with kling. During observation, the RN performing wound care did not use Vashe wash and instead cleansed the wound with normal saline. The RN acknowledged using normal saline rather than the ordered cleanser, and the DON stated she would expect the nurse to follow the wound orders as written.
Delayed Pain Medication for Resident with Migraine
Penalty
Summary
Safe, appropriate pain management was not provided for Resident ID #17, who was admitted with diagnoses including migraines and chronic pain. The resident’s care plan dated 4/20/2026 included a goal for the resident to verbalize adequate pain relief and an intervention to respond immediately to any complaint of pain. The physician ordered Butalbital-APAP-Caffeine 50-300-40 mg, 1 capsule every 12 hours as needed for migraine pain. On 4/29/2026 at 10:30 AM, the resident was observed in the hallway complaining of a migraine, moaning in pain, and holding his/her head. At 10:34 AM, an NA reported to an LPN that the resident wanted pain medication, and at 10:37 AM the resident continued to complain of migraine pain and told an RN about the pain, but the RN stated she did not have keys to the medication cart and could not get any pain medication. The resident continued to complain of severe head pain, returned to the room to lie down at 10:40 AM, and the LPN was still off the unit at 10:42 AM. The resident was not assessed when the LPN returned, and the medication was not administered until 11:10 AM, 40 minutes after the initial complaint. The resident later reported pain rated 7 out of 10, and the DON acknowledged that a resident should not wait 40 minutes for pain medication.
Missed Antibiotic Doses Not Reported to Provider
Penalty
Summary
The facility failed to ensure that Resident ID #17 was free from significant medication errors when the resident missed 6 doses of a prescribed antibiotic. The resident was admitted in April 2026 with diagnoses including surgical aftercare and complication of surgical and medical care, and had a physician order dated 4/3/2026 for Cefadroxil 500 mg by mouth twice daily for 14 days. Review of the April 2026 MAR showed missed doses on 4/3 at 8:00 PM, 4/6 at 8:00 PM, 4/11 at 8:00 PM, 4/12 at 8:00 AM, 4/14 at 8:00 PM, and 4/17 at 8:00 AM. The record did not show that the provider was notified of the missed antibiotic doses. During interview, the RN acknowledged the 6 missed doses and stated they should have been reported to the provider. The Medical Director stated she was unaware of the missed doses and said she would have extended the antibiotic course if she had known. The DON also acknowledged the missed doses and stated she would expect the provider to be informed if a resident misses any dose of an antibiotic.
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