Brentwood Health Center

4000 Post Road, Warwick, RI 02886 (401) 884-8020
For profit - Limited Liability company 96 Beds EDEN HEALTHCARE Data: November 2025
Trust Grade
40/100
#35 of 72 in RI
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Last Inspection: July 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Brentwood Health Center received a Trust Grade of D, indicating below-average performance with some concerns. Ranked #35 out of 72 facilities in Rhode Island, they are positioned in the top half, but still have room for improvement. The facility is showing signs of improvement, with the number of issues decreasing from 13 in 2024 to 9 in 2025. Staffing is an area of concern, with a 63% turnover rate significantly higher than the state average of 41%, although they maintain average RN coverage. Recent inspections uncovered serious and concerning incidents, including significant weight loss in some residents and failures in food safety and staff performance evaluations, indicating a need for better oversight and care practices.

Trust Score
D
40/100
In Rhode Island
#35/72
Top 48%
Safety Record
Moderate
Needs review
Inspections
Getting Better
13 → 9 violations
Staff Stability
⚠ Watch
63% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties
✓ Good
$82,492 in fines. Lower than most Rhode Island facilities. Relatively clean record.
Skilled Nurses
○ Average
Each resident gets 40 minutes of Registered Nurse (RN) attention daily — about average for Rhode Island. RNs are the most trained staff who monitor for health changes.
Violations
⚠ Watch
33 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 13 issues
2025: 9 issues

The Good

  • 4-Star Quality Measures · Strong clinical quality outcomes
  • No fines on record

Facility shows strength in quality measures.

The Bad

3-Star Overall Rating

Near Rhode Island average (3.1)

Meets federal standards, typical of most facilities

Staff Turnover: 63%

17pts above Rhode Island avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $82,492

Well above median ($33,413)

Moderate penalties - review what triggered them

Chain: EDEN HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (63%)

15 points above Rhode Island average of 48%

The Ugly 33 deficiencies on record

1 actual harm
Jul 2025 7 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to immediately inform the resident's physician of his/her change of condition, which resulted in the transfe...

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Based on record review and staff interview, it has been determined that the facility failed to immediately inform the resident's physician of his/her change of condition, which resulted in the transfer of the resident to an acute care hospital for 1 of 4 residents reviewed, Resident ID #8.Findings are as follows:Record review of a facility reported incident submitted to the Rhode Island Department of Health on 7/20/2025 states in part, .Incident of unknown origin.facility informed.about an injury of fractured ribs and lacerated spleen.Family and MD [medical doctor] all aware. Investigation to be completed.Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/25/2025 alleges in part, that the resident arrived at the hospital after a suspected unwitnessed fall. S/he had bruising on left flank, a grade 4 splenic laceration (classified as a severe injury involving significant vascular injury and active bleeding), and displaced fractures of the left 10th and 11th ribs.Record review of a facility policy dated 10/17/2023 titled Resident Change in Condition states in part, .Changes in condition require assessment by the Nurse and notification to the MD (both to be done timely). Timely depends upon the level/severity of the change and the Nurse should use professional assessment and judgment to make that decision. Timely is certainly no later than the shift of the change.Record review revealed the resident was re-admitted to the facility in June of 2025 with a diagnosis including, but not limited to, sepsis (a systemic infection that can to tissue damage, organ failure and possible death). Record review of the resident's progress note dated 7/20/2025 at 7:52 AM authored by third shift, Licensed Practical Nurse (LPN), Staff A, revealed that the resident was found by the nursing assistant in bed full of watery stool from head to toe at 6:00 AM and his/her vital signs were obtained which revealed, respirations of 24 (normal range 12-16), pulse oximetry of 77% (a normal oxygen saturation level ranges between 95% to 100%; a low reading below 95% increases the risk of damage to your tissues and organs), and a blood pressure of 98/58 (normal blood pressure is 120/80).Further record review of the progress notes dated 7/20/2025 at 7:30 AM authored by first shift, Registered Nurse (RN), Staff B, revealed that upon his arrival, the resident was found to be moaning and not responding. The resident was placed on 2 liters of oxygen via nasal cannula (a medical device that provides supplemental oxygen therapy to people who have lower oxygen levels) due to an oxygen saturation of 77%, emergency medical services arrived and the resident was transported to the emergency department.During a surveyor interview on 7/24/2025 at 10:07 AM with Staff A, he revealed that at approximately 5:00 AM, a nursing assistant notified him that the resident was found in bed with a large amount of watery stools. He further indicated that he later went in to administer a medication to the resident a little after 5:00 AM, and the resident was observed to be uncomfortable, restless and kicking [his/her] arms and lifting [his/her] hips off of the bed. Additionally, he revealed that he asked RN, Staff C, to assist him with the resident around 5:30 AM - 5:45 AM. He further revealed that Staff C instructed him to call the provider, but he was unable to do so, as the tablet did not work. During a surveyor interview on 7/24/2025 at approximately 11:00 AM with Staff C, she revealed that Staff A came down to get her to look at [Resident ID #8] around 6:00 AM because s/he was restless and kept moving his/her arms and lifting his/her knees up. Additionally, she revealed that she was unaware that Staff A did not notify the on-call provider.During a surveyor interview on 7/24/2025 at 11:10 AM with the resident's medical doctor, Staff D, he revealed that he would expect the staff to call him if they were unable to contact the on-call provider related to the resident's change in condition.During a surveyor interview on 7/25/2025 at 11:35 AM with the Director Nursing Services and the Assistant Director of Nursing Services, they were unable to provide evidence that the resident's provider was immediately notified of his/her change in condition until the day shift nurse Staff B arrived for his shift at 7:00 AM, which was approximately two hours after the initial change in condition was identified. Record review of an RI EMS [Rhode Island emergency medical services] Patient care report revealed that dispatch was notified at 7:34 AM and the unit was dispatched to the facility at 7:36 AM. Additionally, the report revealed upon EMS arrival that the resident was lying in bed unresponsive with left and right-side weakness. Cross reference F 658, F 684, F 690, F 726.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality relative to followin...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality relative to following physician's orders for 1 of 4 residents reviewed related to oxygen utilization, for 1 of 1 resident reviewed relative to orthostatic blood pressure (measurements of blood pressure taken while a patient is in different positions), Resident ID #8, and for 3 of 7 residents reviewed relative to weight discrepancies, Resident ID #s 16, 29, and 75.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.1. Record review of a facility reported incident submitted to the Rhode Island Department of Health on 7/20/2025 states in part, .Incident of unknown origin.facility informed.about an injury of fractured ribs and lacerated spleen.Family and MD [medical doctor] all aware. Investigation to be completed.Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/25/2025 alleges in part, that the resident arrived at the hospital after a suspected unwitnessed fall. S/he had bruising on left flank, a grade 4 splenic laceration (classified as a severe injury involving significant vascular injury and active bleeding), and displaced fractures of the left 10th and 11th ribs.Record review revealed that Resident ID #8 was re-admitted to the facility in June of 2025 with a diagnosis including, but not limited to, sepsis (a systemic infection that can to tissue damage, organ failure and possible death). a. Record review revealed a physician's order dated 1/28/2025 to administer oxygen 1 to 4 liters per minute via nasal cannula (a medical device that provides supplemental oxygen therapy to people who have lower oxygen levels) as needed. During a surveyor interview on 7/24/2025 at 10:07 AM with Licensed Practical Nurse (LPN) Staff A, he revealed that he went in to administer a medication to Resident ID #8 a little after 5:00 AM. Resident ID #8 was observed to be uncomfortable, restless and kicking [his/her] arms and lifting [his/her] hips off of the bed. Additionally, Staff A, revealed that he was able to obtain pulse oximetry readings (used to monitor arterial oxygen saturation non-invasively) of 79% and 84% (a normal oxygen saturation [SpO2] level range is between 95% to 100%; a reading below 95% increases the risk of damage to your tissues and organs) for the resident. When questioned by the surveyor why oxygen was not administered to the resident when the resident had an SpO2 readings of 79% and 84% indicating that s/he was hypoxic (low blood oxygen level), Staff A was unable to answer and acknowledged that the oxygen was not administered as ordered.b. According to Jensen's Fourth Edition, Nursing Health Assessment, page 118 states, Orthostatic vital signs are measured in patients to assess for a drop in BP [blood pressure].with position changes .Some medications can have the adverse effect causing orthostatic hypotension.Assess BP.with the patient [lying], sitting, and standing.waiting 1-2 minutes after each position change to assess the readings.Drop in SBP [systolic blood pressure] of 15 mmHg [millimeters of mercury] or greater, drop of DBP [diastolic blood pressure] of 10 mmHg or greater.indicates orthostatic hypotension.Record review revealed a physician's order dated 7/15/2025 to obtain orthostatic blood pressures once a day for 3 days then weekly for four weeks.Review of the July 2025 Medication Administration Record from 7/15/2025 to 7/20/2025 failed to reveal evidence that orthostatic blood pressures were obtained.During a surveyor interview on 7/24/2025 at approximately 2:10 PM with the Director of Nursing Services (DNS), she was unable to provide evidence that the physician's orders were followed for Resident ID #8 for the utilization of oxygen when needed and that orthostatic blood pressures were obtained. 2. Review of the facility policy titled, Weight Loss/Gain Protocol . revealed the following:-The resident will be weighed on the day of admission-The resident will then be weighed weekly for three weeks and after the first four weeks of admission, the frequency of weights will then be decided by the interdisciplinary team.-A significant weight discrepancy is defined as:A weight change of 3 pounds or more in one weekA loss/gain of 5% or greater in one month.-When a significant weight loss/gain is noted, a reweigh shall be done within 48 hours of the initial weight.-If the reweigh is accurate and there has been a significant weight loss/gain, nursing must notify the physician, dietician, DNS, and the resident representative.a. Record review revealed that Resident ID #16 was admitted to the facility in July of 2025 with a diagnosis including, but not limited to, Type II diabetes mellitus.Record review of the resident's weights revealed the following:-7/14/2025 188.5 lbs. (pounds) -7/20/2025 155.8 lbs. (32.7 lbs. difference with no evidence of reweigh)Further record review failed to reveal evidence that a reweigh was completed until it was brought to the facility's attention by the surveyor on 7/24/2025. During a surveyor interview on 7/24/2025 at 1:14 PM with Licensed Practical Nurse (LPN), Staff E, she indicated that the residents are weighed on admission but if there is an admission weight discrepancy, a reweigh must be obtained. She acknowledged that there was no reweigh on 7/20/2025, and that she would have expected the staff to have reweighed the resident on that day or the next day.During a surveyor interview on 7/25/2025 at approximately 1:00 PM with the Dietitian, she acknowledged that she noted the 32.7 lbs. weight discrepancy and had requested a reweigh to be obtained for Resident ID #16. However, she acknowledged the weight was not obtained until it was brought to the facility's attention by the surveyor on 7/24/2025.b. Record review revealed Resident ID #29 was readmitted to the facility in July of 2025 with a diagnosis including, but not limited to, urinary tract infection.Review of the resident's weights revealed the following:-7/10/2025 weight 207 lbs.-7/15/2025 weight 215.5 lbs. (8.5 lbs. difference with no evidence of reweigh)-7/22/2025 weight 211.8 lbs. (3.7 lbs. difference with no evidence of reweigh)During a surveyor interview on 7/25/2025 at 11:02 AM with LPN, Staff F, she acknowledged that she entered the 215.5 lbs. weight on 7/15/2025 but did not reweigh the resident.c. Record review revealed Resident ID #75 was admitted to the facility in December of 2022 with a diagnosis including, but not limited to, abnormal weight loss.Review of the resident's weights revealed the following:-6/17/2025 weight 193.6 lbs. -6/24/2025 weight 197.4 lbs. (3.8 lbs. discrepancy with no evidence of reweigh)-7/8/2025 - weight 197.5 lbs.-7/22/2025 - weight 190.6 lbs. (6.9 lbs. discrepancy with no evidence of reweigh)During a surveyor interview on 7/25/2025 at 12:44 PM with the Dietitian, she acknowledged the weight discrepancies but indicated she was not notified by nursing staff. She indicated that the resident should have been reweighed after the 190.6 lbs. weight documented on 7/22/2025.During a surveyor interview on 7/25/2025 at 11:19 AM and 2:09 PM with the Director of Nursing Services, she indicated that it would be her expectation that when a weight discrepancy is identified, a reweigh will be obtained.Cross reference F 580, F 684, F 690 and F 726.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to provide the necessary treatment and care in accordance with professional standards of practice relative t...

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Based on record review and staff interview, it has been determined that the facility failed to provide the necessary treatment and care in accordance with professional standards of practice relative to obtaining orthostatic vital signs per a physician's order, identifying a change in a resident's condition and physician notification, for 1 of 1 resident reviewed for hospitalization, Resident ID #8. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe that the orders are in error or would harm the clients. According to Jensen's Fourth Edition, Nursing Health Assessment, page 118 states, Orthostatic vital signs are measured in patients to assess for a drop in BP [blood pressure].with position changes .Some medications can have the adverse effect causing orthostatic hypotension.Assess BP.with the patient [lying], sitting, and standing.waiting 1-2 minutes after each position change to assess the readings.Drop in SBP [systolic blood pressure] of 15 mmHg [millimeters of mercury] or greater, drop of DBP [diastolic blood pressure] of 10 mmHg or greater.indicates orthostatic hypotension. Record review of a facility reported incident submitted to the Rhode Island Department of Health on 7/20/2025 states in part, .Incident of unknown origin.facility informed.about an injury of fractured ribs and lacerated spleen.Family and MD [medical doctor] all aware. Investigation to be completed. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/25/2025 alleges in part, that the resident arrived at the hospital after a suspected unwitnessed fall. S/he had bruising on the left flank, a grade 4 splenic laceration (classified as a severe injury involving significant vascular injury and active bleeding), and displaced fractures of the left 10th and 11th ribs. Record review revealed the resident was re-admitted to the facility in June of 2025 with a diagnosis including, but not limited to, sepsis (a systemic infection that can lead to tissue damage, organ failure and even death). Record review of the care plan last revised on 7/21/2025 with a focus area indicating the resident has a history of falling and is at risk of future falls with interventions including, but not limited to, orthostatic vital sign monitoring (measurements of blood pressure and heart rate taken while a patient is in different positions, primarily to assess for orthostatic hypotension and other cardiovascular issues) due to the use of Seroquel (an antipsychotic medication) and update the physician or nurse practitioner (NP) with changes as needed. 1.Record review of the progress notes revealed that the resident sustained falls on the following dates: -7/13/2025 found kneeling in front of the sink -7/13/2025 resident noted on the floor in the middle of his/her room -7/14/2025 found on the floor of his/her bathroom -7/14/2025 resident was found kneeling next to his/her bed Record review revealed a physician's order to monitor the resident's orthostatic blood pressure daily for three days dated 7/15/2025 with a discontinue date of 7/17/2025, then weekly for four weeks. Review of the July 2025 Medication Administration Record failed to reveal evidence that orthostatic blood pressures were obtained, as ordered. During a surveyor interview on 7/24/2025 at 11:30 AM with the Director Nursing Services, she was unable to provide evidence that the orthostatic blood pressures were obtained for Resident ID #8. Cross reference F 580, F 690, F 726.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to provide the appropriate treatment and services for 1 of 1 resident reviewed for constipation, Resident ID...

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Based on record review and staff interview, it has been determined that the facility failed to provide the appropriate treatment and services for 1 of 1 resident reviewed for constipation, Resident ID #8.Findings are as follows:Review of the facility policy titled, Bowel function management, states in part, It is the policy of this facility to manage each resident's bowel function in order to promote regular, voluntary, controlled bowel evacuation of normal consistency. Normal bowel function involves passage of soft, formed stools in adequate volumes without straining .Every resident's bowel function is to be monitored every day on every shift.The charge nurse is responsible to monitor the resident's bowel activity daily.Interventions to promote adequate bowel function: 1. Determine the resident's bowel function by regular review of the bowel documentation .Assess the success of the .interventions .Record review revealed the resident was readmitted to the facility in June of 2025 with a diagnosis including, but not limited to, sepsis (a systemic infection that can cause tissue damage, organ failure, and possible death), constipation.Review of the bowel records failed to reveal evidence that the resident had a bowel movement from 7/9/2025 through 7/13/2025, indicating that s/he did not have a bowel movement for 5 days. Record review failed to reveal evidence that the physician was notified of the resident's lack of bowel movements over the 5-day time period.During a surveyor interview on 7/25/2025 at 1:52 PM with Nurse Practitioner, Staff G, she indicated that she would expect to be notified when a resident went without a bowel movement for three days for further interventions.During a surveyor interview on 7/25/2025 at 2:20 PM with the Director of Nursing Services, she revealed that it would be her expectation that nursing staff would contact the provider if a resident went without a bowel movement for three days for further interventions.Cross reference F 580, F 658, F 684 and F 726.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to ensure that staff were competent to provide nursing and related services to assure resident safety to att...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that staff were competent to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as the facility staff were unable to identify a change in condition, administer oxygen in the setting of hypoxia (low blood oxygen level), document accurately, and administering medications as ordered for one of four residents reviewed, Resident ID #8. Findings are as follows:1.Record review revealed Resident #8 was re-admitted to the facility in June of 2025 with a diagnosis including, but not limited to, sepsis (a systemic infection that can lead to tissue damage, organ failure and possible death). Record review revealed a physician's order dated 1/28/2025 to administer oxygen at 1-4 liters per minute via nasal cannula (a medical device that provides supplemental oxygen therapy to people who have lower oxygen levels) as needed for shortness of breath or hypoxia (low blood oxygen level).Record review of a nursing progress note dated 7/20/2025 at 7:52 AM states in part, 0600 upon am rounds, resident was found by cna [Certified Nursing Assistant] in bed full of watery stool from head to toe. Resident was washed up and bed changed. Resident seems to be agitated and thrashing around in bed. VS [vital signs] obtained, and temp [temperature] was 98.4 [F], Resp [respirations] 24 [normal range 12-16], BP [blood pressure] 98/58 [normal blood pressure is 120/80], not a perfect bp due to resident thrashing around. [oxygen saturation, SpO2] @ [at] 77% [a normal SpO2 level ranges between 95% to 100%; a reading below 95% increases the risk of damage to your tissues and organs] During a surveyor interview on 7/24/2025 at 10:07 AM with Licensed Practical Nurse (LPN), Staff A, he revealed that he went in to administer a medication to Resident ID #8 a little after 5:00 AM. Resident ID #8 was observed to be uncomfortable, restless and kicking [his/her] arms and lifting [his/her] hips off of the bed. Additionally, Staff A, revealed that he was able to obtain pulse oximetry readings (used to monitor arterial oxygen saturation non-invasively) of 79% and 84%. When questioned by the surveyor why oxygen was not administered to the resident per the physician's order when the resident had SpO2 readings of 79% and 84% indicating that s/he was hypoxic, Staff A was unable to answer and acknowledged that the oxygen was not administered as ordered. When questioned what intervention was put in place for the resident related to the abnormal SpO2 readings and the appearance of discomfort, restlessness and the inability to obtain vital signs, Staff A revealed that he raised the resident's head of the bed to 90 degrees. Furthermore, Staff A acknowledged that he was unable to get the tablet working to contact the on-call provider related to the resident's change in condition. When questioned by the surveyor what other interventions were attempted, he revealed that he continued passing medications to the other residents.2. Record review revealed a physician's order dated 6/11/2025 for Synthroid (a medication prescribed to treat hypothyroidism) 88 micrograms once daily in the morning.Record review of the July 2025 Medication Administration Record revealed that the Synthroid was signed as administered on 7/20/2025 at 5:26 AM.During a surveyor interview on 7/24/2025 at 10:07 AM with Staff A, he revealed that he pre-poured the Synthroid medication for Resident ID #8, signed it off in the electronic medical record prior to administering the medication, and indicated that he was unaware that he was not supposed to sign it off before administering it to the resident. 3. Record review revealed a progress note dated 7/20/2025 at 1:34 AM, which states, Resident alert w/confusion at baseline. Call light for assistance with transfers and ambulation. Resident verbalizes understanding but has poor follow through. Neuro signs [observable physical indicators that can help diagnose neurological disorders] are stable. AROM [active range of motions refers to unassisted range of movement of a joint] to all extremities. Resident was compliant with diet orders. Resident slept throughout the night with no c/o [complain of] pain or discomfort.During an interview with Staff A on 7/24/2025 at 10:07 AM, he revealed that he has a USB (universal serial bus) drive with a pre-written notes that he copies information from to write his nursing progress notes. Staff A acknowledged that he did not assess the resident's range of motion and neurological status, and that he inaccurately copied that information from his USB drive.During a surveyor interview on 7/24/2025 at 11:30 AM with the Director Nursing Services, she was unable to provide evidence that Staff A was competent in assessing, providing accurate documentation of medication administration and nursing progress notes, despite receiving competencies. Cross reference F 580, F 658, F 684 and F 690
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

Based on surveyor observation and staff interview, it has been determined that the facility failed to maintain a sanitary and comfortable environment relative to food trays being left in the hallways ...

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Based on surveyor observation and staff interview, it has been determined that the facility failed to maintain a sanitary and comfortable environment relative to food trays being left in the hallways on one of two nursing units after meal hours with partially consumed meals. Findings are as follows:During surveyor observations of the first-floor nursing unit, the following was revealed:7/22/2025 at 11:30 AM, four food trays uncovered from the breakfast meal with partially consumed food 7/22/2025 at 3:45 PM, two food trays uncovered from the lunch meal with partially consumed food 7/23/2025 at 11:30 AM, four trays uncovered from the breakfast meal with partially consumed food 7/24/2025 11:00 AM, three trays uncovered from the breakfast meal with partially consumed food7/24/2025 at 4:00 PM, four trays uncovered from the lunch meal with partially consumed foodDuring a surveyor interview on 7/25/2025 at 11:40 AM with the Director of Food Service, he acknowledged that the food trucks were left uncovered in the hallway after meal hours and contained partially consumed food on the trays.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards...

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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety relative to the main kitchen and for one of two kitchenettes.Findings are as follows:1. The Rhode Island Food Code 2022 Edition 4-601.11 states in part, .nonfood contact surfaces of equipment shall be kept from an accumulation of dust, dirt, food residue and other debris.During surveyor observations of the main kitchen on 7/22/2025 at 8:50 AM and 7/24/2025 at 10:57 AM revealed the following:-the walls behind the dish machine, stove and worktables were observed to have an accumulation of food spills/splatters -Formica topped food carts were observed to have chips in the corners of the carts -the gaskets of the ice chest had an accumulation of a black substance2. The Rhode Island Food Code 2022 Edition 4-602.11 states in part, .equipment of the food contact surfaces.shall be cleaned at any time during the operation when contamination may have occurred.During a surveyor observation on 7/22/2025 at 8:50 AM of the main kitchen, the delivery chute of the ice machine had a pink substance along the upper rim of the chute.3. The Rhode Island Food Code 2022 Edition 3-302.12 states in part, .except for containers that can be readily and unmistakably recognized, working containers holding food that are removed from the original packages shall be identified with the common name of the food.During a surveyor observation on 7/22/2025 at 8:50 AM of the main kitchen, one reach in refrigerator unit revealed the following:-One package of a white colored meat product that was cut up into cubes without a label-1/4-inch pan that contained a red substance was without a label4. The Rhode Island Food Code 2022 Edition 4-904.13 states in part, .tableware that is preset shall be protected from contamination by being wrapped or covered.During surveyor observations of the lunch meal service on 7/22/2025, 7/23/2025 and 7/24/2025 the individual lunch trays were observed on an open cart while being transported on the elevators and along the hallways with preset silverware that were not covered or wrapped.5. Record review of a document from The United States Department of Agriculture recommends dry food storage temperatures between 50 F (Fahrenheit) and 70 F for quality and for the control of bacterial growth.During a surveyor observation on 7/25/2025 at 10:57 AM, the ambient temperature of the dry storage room read 85 F.6. Record review of a facility document titled, Brentwood Nursing Home Refrigerator Dating Guidelines states in part, .if a product is opened, then a 3-day expiration must be placed on the product.During a surveyor observation on 7/22/2025 at 11:30 AM of the first-floor dining room refrigerator, an opened container of a product with a manufacturer's label of Market Basket Hearty Chicken Noodle soup had a date of 7/16/2025.During a surveyor interview on 7/25/2025 at 11:40 AM with the Director of Food Service he acknowledged the walls, the ice machine and the gaskets on the ice chest needed to be cleaned. Additionally, he acknowledged that the Formica food carts needed to be replaced, the temperature in the dry storage room was too hot, the labels were missing on unidentifiable food items, the chicken soup exceeded the facility's 3-day policy, and that the silverware on meal trays should have been covered.
Apr 2025 2 deficiencies
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of qu...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality related to following physician's orders for 1 of 4 residents reviewed for pain and anxiety medication administration, and for 1 of 3 residents reviewed for the use of an air mattress, Resident ID #1. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients . Review of a facility policy titled Medication Administration Safety Program states in part, .It is the policy of this facility that residents shall receive medications in a safe and timely manner and in accordance with established regulations and guidelines . 1. Review of a community reported complaint submitted to the Rhode Island Department of Health on 4/14/2025 alleged that Resident ID #1 was not receiving his/her pain medications from staff even though s/he complained of an 8 out of 10 pain level. Record review revealed Resident ID #1 was admitted to the facility in December of 2021 with diagnoses including, but not limited to, cellulitis (a bacterial skin infection) of left lower limb, acute respiratory failure and emphysema (a chronic lung disease that damage the lungs' air sacs making the breathing difficult). Record review of his/her significant change status Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition. Review of the resident's care plan dated 2/19/2025, revealed s/he is receiving Hospice care with interventions to administer pain medications, monitor and record its effectiveness, document, assess for pain and ensure a comfortable end of life. Additional record review of the care plan dated 2/19/2025 revealed s/he is receiving psychotropic drugs related to anxiety and panic, with fear and distressing delusions. Record review of the physician's orders revealed the following medications: - MS Contin/ morphine (a medication prescribed to treat severe pain) 15 Milligram (MG) three time a day. - Morphine concentrate 0.75 Milliliters (ML) every 3 hours as needed (PRN) for pain. Record review of the nursing progress notes dated 4/11/2025 revealed the following: - 2:47 PM- the resident requested pain medication every hour on the 7:00 AM to 3:00 PM shift. - 6:03 PM- Resident with complaints of uncontrolled pain. In addition to scheduled medication the resident requests as needed medications, approximately every hour. - 6:47 PM- the resident was sent to the hospital at 4:05 PM for an evaluation of his/her pain. The note also indicated that the resident had stated to the facility nurses and hospice nurses that s/he did not receive his/her PRN medications. Record review of the April 2025 Medication Administration Record (MAR) failed to reveal evidence that the resident received any PRN pain medication after 9:54 AM, when the record reveals that s/he was complaining of pain approximately every hour. During a surveyor interview on 3/14/2025 at approximately 11:00 AM with Licensed Practical Nurse (LPN), Staff A, she revealed that the resident was transferred to the hospital on 4/11/2025 at 4:00 PM because the facility was unable to manage his/her pain. Additionally, Staff A indicated that the resident was administered his/her PRN Morphine concentrate at approximately 10:00 AM. Staff A indicated she did not administer any additional PRN pain medication during her shift. During a surveyor interview on 4/14/2025 at 11:18 AM with Registered Nurse, Staff B, she acknowledged the physician's PRN order for Morphine concentrate. When asked why the PRN Morphine concentrate was not administered to the resident after 1:00 PM or prior to the resident being transported to an acute care hospital she stated, we couldn't manage [his/her] pain. During a surveyor interview on 4/14/2025 at 2:17 PM with the Nurse Practitioner, she revealed that she was not aware that the PRN Morphine concentrate was not administered to the resident before his/her transfer to the hospital. During a surveyor interview on 4/14/2025 at 2:22 PM with the Assistant Director of Nursing, she indicated that the resident was doing well in the morning, but s/he started to become agitated around 1:30 to 2:00 PM because s/he believed his/her medications were not being administered to him/her. Additionally, she was unable to provide evidence that the PRN Morphine concentrate was administered before the resident's transfer to an acute care hospital. 2. Review of an additional community reported complaint submitted to the Rhode Island Department of Health on 4/17/2025 alleged multiple concerns which included the above-mentioned issues but also that the resident was having issues with his/her air mattress (a medical-grade support surface that uses alternating air pressure or low air loss technology to reduce the risk of pressure injuries). Record review of the physician's orders failed to reveal evidence of an order for the use of an air mattress, including the settings and specifications that the mattress should be set to. Record review of a nursing progress note dated 4/8/2025 authored by LPN, Staff C, indicated that the Hospice team was contacted to request a new air mattress due to the intermittent beeping from the bed. During a surveyor observation on 4/18/2025 at 10:40 AM in presence of the ADNS, there was an air mattress in the resident's room. During a surveyor interview following the above observation on 4/18/2025 at approximately 11:00 AM with the ADNS, she acknowledged that the resident had an air mattress before his/her transfer to the hospital. Additionally, she acknowledged that there was no evidence of a physician's order with settings or specifications for the air mattress.
CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to implement a comprehensive person-...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan for 4 of 4 residents reviewed relative to pain medication administration, Resident ID #s 1, 2, 3, and 4. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 4/14/2025 alleged that Resident ID #1 was not receiving his/her pain medications from staff even though s/he complained of an 8 out 10 pain level. 1. Record review revealed Resident ID #1 was admitted to the facility in December of 2021 with diagnoses including, but are not limited to, left lower limb cellulitis (a bacterial skin infection), acute respiratory failure and emphysema (a chronic lung disease that damage the lungs' air sacs making the breathing difficult). Record review of the resident's significant change status Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating an intact cognition. Review of the resident's care plan revised on 2/18/2025 revealed the resident has chronic pain with interventions to administer pain medications, monitor and record its effectiveness, document the pain's location, frequency, intensity, alleviating and aggravating factors. Further record review of the care plan dated 2/19/2025 revealed s/he is receiving Hospice care with interventions to monitor and assess for pain and ensure a comfortable end of life. Review of the Resident ID #1's medical record failed to reveal evidence that the above-mentioned interventions related to his/her pain were being implemented. 2. Record review revealed Resident ID #2 was readmitted to the facility in December of 2022 with diagnoses including, but not limited to, stage 2 pressure ulcer (injury to the skin resulting from prolonged pressure on the skin) of right and left heels and chronic pain syndrome (a condition characterized by persistent pain that lasts longer than expected with change in skin temperature, color and sweating). Record review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15, indicating severe cognitive impairment. Review of the resident's care plan revised on 2/19/2024 revealed the resident complains of chronic pain with interventions to administer the pain medications, evaluate, monitor, record and report the effectiveness and any adverse side effects. Additional review revealed an intervention to monitor and record any complaints of pain, its location, frequency, intensity, its effect on function, the alleviating and aggravating factors. Review of the Resident ID #2's medical record failed to reveal evidence that the above-mentioned interventions related to his/her pain were being implemented. 3. Record review revealed Resident ID #3 was admitted to the facility in April of 2024 with a diagnosis including, but not limited to, adult failure to thrive (a condition characterized by a significant decline in physical and emotional well-being, leading to an inability to maintain a healthy and functional life). Record review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 0 out of 15 indicating, severe cognition impairment. Review of the care plan dated 2/19/2025 revealed the resident receives Hospice care related to adult failure to thrive with interventions to monitor and assess for pain. Review of Resident ID #3's medical record failed to reveal evidence that the above-mentioned interventions related to his/her pain were being implemented. 4. Record review revealed Resident ID #4 was admitted to the facility in November of 2020 with a diagnosis including, but not limited to, depression. Record review of the resident's MDS assessment dated [DATE] revealed a BIMS score of 6 out of 15, indicating severe impaired cognition. Review of the care plan dated 4/22/2024 revealed the resident has chronic pain related to neuropathy with interventions to anticipate the resident's need for pain relief and to identify, record, and treat the resident's condition. Review of Resident ID #4's medical record failed to reveal evidence that the above-mentioned interventions related to his/her pain were being implemented. During a surveyor interview on 4/15/2025 at approximately 1:00 PM, with Registered Nurse, Staff B, she acknowledged that they do not document the residents' pain even though it is outlined in the care plan. Additionally, Staff B indicated they only ask the resident about their pain. During a surveyor interview on 4/15/2025 at 1:04 PM with the Assistant Director of Nursing (ADNS), she indicated that she would expect the staff to follow the care plans. Cross reference F 658
Oct 2024 2 deficiencies
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skills sets to provide nursing and relate...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skills sets to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment as required for 2 of 5 staff reviewed, Nursing Assistants (NA), Staff A and B. Findings are as follows: Record review of the facility assessment states staff training and education on mechanical lifts will be completed on orientation and annually. Record review failed to reveal evidence of competencies and skills sets for safe patient handling on orientation relative to transfers with a mechanical lift for the following staff: - NA, Staff A with a hire date of 8/21/2024 - NA, Staff B with a hire date of 8/30/2024 During a surveyor interview on 10/10/2024 at 1:20 PM with the Regional Nurse, she was unable to provide evidence that the mechanical lift competencies were completed with Staff A and B prior to providing care to the resident's.
CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality for 2 of 3 residents reviewed for physician's orders, Resident ID ...

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Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality for 2 of 3 residents reviewed for physician's orders, Resident ID #s 1 and 2. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 10/7/2024 alleges that the resident's .calves were often banged up from bad transfers . 1. Record review revealed Resident ID #1 was admitted to the facility in January of 2023 with diagnoses including, but are not limited to, malnutrition, left upper arm, left ribs, and left upper leg fractures. Record review revealed a physician's order dated 6/30/2024 to complete a weekly skin evaluation and document the findings under observations. Record review of the July, August and September 2024 Medication Administration Records revealed the weekly skin evaluations were signed off as completed on the following dates: -7/5/2024 -7/12/2024 -7/26/2024 -8/2/2024 -8/9/2024 -8/16/2024 -9/6/2024 -9/13/2024 Record review of the Weekly Skin Evaluation Observations failed to reveal evidence that the weekly skin assessments were completed and documented for the on the above-mentioned dates, although they were signed off as being completed. 2. Record review revealed Resident ID #2 was admitted to the facility in October of 2022 with diagnoses including, but is not limited to, dementia, difficulty in walking and syncope (fainting). Record review revealed a physician's order dated 6/30/2024, to complete a weekly skin evaluation and document the findings under observations. Record review of the September 2024 Medication Administration Record revealed the weekly skin evaluations were signed off as completed on 9/10/2024 and 9/17/2024. Record review of the Weekly Skin Evaluation Observations failed to reveal evidence that the weekly skin assessments were completed and documented on 9/10/2024 and 9/17/2024, although they were signed off as being completed. During a surveyor interview on 10/9/2024 at approximately 3:41 PM with the Director of Nursing Services, she was unable to provide evidence that weekly skin assessments were completed per the physician's order.
Jul 2024 10 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, record review, staff and resident interview, it has been determined that the facility failed to ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, record review, staff and resident interview, it has been determined that the facility failed to treat each resident with respect and dignity, and is cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life relative to providing activities of daily living(ADL) for a resident whose primary language is not the dominant language of the facility, Resident ID #2. Findings are as follows: Record review revealed that Resident ID #281 was admitted to the facility on [DATE] with diagnoses including, but not limited to, malignant neoplasm (abnormal tissue growth characteristic of cancer), fracture of femur and right artificial hip joint. Review of a care plan dated 7/6/2024 revealed the resident is Spanish speaking with interventions that include, staff may assist with communication and pictures. Record review of the Minimum Data Set (MDS) completed on 7/10/2024 revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident's cognition is intact. It further revealed that the resident requires moderate assistance to rise from sitting to standing, and that toilet transfers are not attempted due to his/her medical conditions. Additionally, it revealed that the resident is dependent on staff for personal hygiene and requires a walker for mobility. During a surveyor interview on 7/9/2024 at 12:28 PM with the resident in the presence of his/her family member, the family member expressed concerns related to the resident not receiving rehabilitation services. Additionally, s/he reveals that staff do not speak his/her language (Spanish) and when s/he requests help by using the call light they do not come back because they do not understand what s/he is requesting. The family member indicates that they ask him/her to use the bathroom after s/he already went, and the resident does not understand that it is for therapy. In addition, they express that the social worker has not visited or addressed his/her individual needs. During a surveyor interview on 7/10/2024 at 10:02 AM with Nursing Assistant (NA), Staff B, she stated that she has a difficult time communicating with the resident because s/he does not speak English. Additionally, she revealed that she tries to utilize staff that speak Spanish and gestures to communicate with the resident. During a surveyor interview on 7/10/2024 at 5:31 PM with Social Worker, Staff A, he revealed that he performs his assessment that includes the resident's background and individual needs within 48 hours of admission. He further revealed that the resident is Spanish speaking and requires the use of an interpreter. Additionally, he acknowledged he completed the assessment on 7/10/2024. During a surveyor observation on 7/11/2024 at 9:59 AM, the surveyor entered the resident's room, the call light was on, and the resident was holding his/her stomach. The resident stated in Spanish that staff came in but did not understand that s/he had pain and needed to go to the bathroom, so they walked away. Further surveyor observation revealed, Licensed Practical Nurse (LPN), Staff C, entered the room and spoke to the resident in English. The resident continued rocking from side to side while holding his/her abdomen, with a grimace on his/her face. Staff C was unable to understand the needs of the resident or make herself understood to the resident. No communication board, or any other assistive communication devices were noted in the resident's room. During surveyor interviews with Staff C, immediately following the above observation and at 3:28 PM, she acknowledged that there was a communication/language barrier when assessing the resident's needs. Additionally, she acknowledged she was unaware of how to access the translation line. During a surveyor interview on 7/11/2024 at 10:07 AM with the resident s/he revealed (in Spanish) that she feels sad and suffers in the facility because no one understands when s/he speaks. During a surveyor observation on 7/11/2024 at 10:11 AM revealed Staff C entering the resident's room with a cell phone. Additionally, it was revealed that the resident continued to show frustration and was not understanding the concept of the translator on the phone. At approximately 10:16 AM Staff C indicated to the surveyor that the resident has a stomachache and was experiencing diarrhea and left the resident's room. The surveyor stayed with the resident for an additional 5 minutes, and no other staff entered the room. During a surveyor interview on 7/11/2024 at 10:28 AM with Occupational Therapy Assistant, Staff E, she acknowledged that she was speaking Portuguese to the resident on 7/10/2024, however the resident was not understanding her, and she could not understand the resident. Additionally, Staff E revealed that she relies on a Spanish speaking NA and the housekeeper to help her translate when they are working. During a surveyor interview on 7/11/2024 at 10:36 AM LPN, Staff D, he revealed that he relies on other staff members to communicate with the resident. During a surveyor interview on 7/11/2024 at 2:40 PM with Social Worker, Staff A, he revealed that his expectation is for staff to be aware of and be able to utilize the translation lines. During a surveyor interview on 7/11/2024 at 3:04 PM, with the Director of Nursing Services she revealed that she would expect for the nurse to tend to the resident within a reasonable amount of time, depending on the acuity. Additionally, she was unable to explain why staff were not using the translation line to communicate with Resident ID #281.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 2 of 9 residents reviewed for med...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 2 of 9 residents reviewed for medication administration, Resident ID #s 15 and 40. Findings are as follows: 1. Record review revealed Resident ID #15 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, type 2 diabetes mellitus. During a surveyor interview with the resident's family member on 7/9/2024 at 2:10 PM, s/he revealed the resident did not receive his/her Tresiba Insulin as ordered one day last week from one of the agency nurses, Licensed Practical Nurse, Staff L. Further, s/he revealed Staff L told them she was unable to locate the insulin. Record review revealed a physician's order dated 5/29/2024 for Tresiba FlexTouch 100 unit per milliliter, 12 units subcutaneous once a day. Record review of the July 2024 Medication Administration Record (MAR) indicated the Tresiba Insulin was not administered on 7/3/2024. According to Staff L's documentation the medication was not available. Record review of the nursing progress notes failed to reveal evidence of a note written by the nurse relative to not administering the medication or that she informed the provider that the medication was not administered. 2. Record review revealed Resident ID #40 was admitted to the facility in June of 2024 with diagnoses including, but not limited to, end stage renal disease and dependence on renal dialysis. Record review revealed a physician's order dated 6/17/2024 for Sevelamer Carbonate (used to lower high blood phosphorus) 1600 milligrams three times a day. Record review of the June and July 2024 MARs revealed the medication was not administered on the following dates and times due to the resident being unavailable or at dialysis: -6/20/2024 -6/22/2024 -6/27/2024 -7/6/2024 During surveyor interviews on 7/11/2024 at 9:46 AM and at 2:08 PM with the Director of Nursing Services, she was unable to provide evidence that the Tresiba Insulin or the Sevelamer was administered as ordered. Furthermore, she revealed that if a medication is not available or not administered the provider must be notified.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected multiple residents

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that residents who required dialysis (a procedure to remove waste products a...

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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that residents who required dialysis (a procedure to remove waste products and excess fluids from the blood when the kidney stops working properly) receive such services, consistent with professional standards of practice for 2 of 2 residents reviewed who receive dialysis treatments, Resident ID #s 40 and 9. Findings are as follows: According to the facility policy titled, Dialysis Patients; Care of states in part, .Care of the dialysis patient/resident will include .7. The thrill [vibration felt of blood flow] and bruit [audible vascular sound associated with turbulent blood flow], when applicable, will be checked every shift and/or per MD [medical doctor] order and recorded in the medical record . 1. Record review revealed Resident ID #40 was admitted to the facility in June of 2024 with diagnoses including, but not limited to, end stage renal disease and dependence on renal dialysis. Further record review revealed the resident receives outpatient hemodialysis three times a week, on Tuesday, Thursday, and Saturday. Record review revealed the resident has an Arteriovenous Fistula (AVF-a connection between an artery and a vein for dialysis access) to his/her left upper extremity for dialysis. Record review failed to reveal evidence of a physician's order for the AVF dressing, including when the dressing should be removed post dialysis. Additionally, the record failed to reveal an order to assess the resident's thrill and bruit in the administration record where it could be signed off as completed by the nurses. Additional review of the progress notes revealed the resident's thrill and bruit were only assessed 7 out of 70 opportunities, since his/her admission in June. They were assessed on the following dates and times: -6/17 at 6:55 PM -6/18 at 7:05 PM -6/20 at 11:48 PM -6/23 at 9:46 PM -6/24 at 9:43 PM -7/3 at 7:27 PM -7/4 at 7:12 PM Further record review of the remaining nursing progress notes indicated that only the thrill was being assessed. During a surveyor observation of the resident on 7/10/2024 at 12:14 PM, revealed a dressing was in place to his/her AVF site. 2. Record review revealed Resident ID #9 was re-admitted to the facility in June of 2024 with diagnoses including, but not limited to, end stage renal disease and dependence on renal dialysis. Further record review revealed the resident receives outpatient hemodialysis three times a week, on Monday, Wednesday, and Friday. Record review revealed the resident has an AVF to his/her right upper extremity for dialysis. Record review of the physician's orders failed to reveal evidence of an order for the AVF dressing, including when the dressing should be removed post dialysis. During a surveyor observation of the resident and simultaneous interview on 7/10/2024 at 11:44 AM, s/he was observed to have an AVF which was uncovered without a dressing. When the resident was asked about the care of his/her AVF dressing, s/he revealed s/he takes the dressing off him/herself by 12:00 PM on the same day that s/he receives his/her dialysis treatment. During a surveyor interview on 7/11/2024 at 3:04 PM with Registered Nurse, Staff F, she revealed the resident refuses to allow staff to remove the dressing from the AVF. Additionally, she acknowledged there is no AVF dressing order. During a surveyor interview on 7/11/2024 at approximately 1:45 PM and at the exit with the Regional Clinical Nurse, she acknowledged there were no orders pertaining to the AVF site dressings for both residents. She further revealed that orders were obtained after it was brought to the facility's attention by the surveyor. Additionally, she acknowledged that Resident ID #40's order to assess the thrill and bruit each shift was not transcribed to the administration record, so she could not provide evidence that it was completed each shift as ordered.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Based on surveyor observation and staff interview, it has been determined that the facility failed to store drugs and biologicals in accordance with currently accepted professional principles for 3 of...

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Based on surveyor observation and staff interview, it has been determined that the facility failed to store drugs and biologicals in accordance with currently accepted professional principles for 3 of 4 medication carts observed. Findings are as follows: 1. During a surveyor observation of the Upper Unit medication cart on 7/11/2024 at approximately 11:00 AM revealed the following: -Arnuity Ellipta (used for wheezing or shortness of breath) 100 mcg (micrograms)/actuation inhaler, opened and not dated. Manufacturer instructions states in part, .expires 6 weeks after you have opened the lid of the tray . 2. During a surveyor observation of the North Unit medication cart on 7/11/2024 at approximately 11:30 AM revealed the following: -Insulin Glargine Pen 100 Units/milliliters (ML), opened and not dated. Manufacturer instructions states in part, .Discard 28 days after opening . 3. During a surveyor observation of the East Unit medication cart on 7/11/2024 at approximately 1:30 PM revealed the following: -Insulin Glargine 100 Units/ML vial, unopened. Manufacturer instructions states in part .must be stored in the fridge before opening . -Breo Ellipta (used to treat chronic obstructive pulmonary disease)100-25 mcg opened and not dated. Manufacturer instructions states in part, .Discard Breo Ellipta 6 weeks after opening . During a surveyor interview on 7/11/2024 at 1:59 PM with the Regional Clinical Nurse, she was unable to explain why the insulin was stored, unopened in the medication cart. Additionally, she revealed she would expect medications are dated, when opened.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected most or all residents

Based on record review and staff interview, it has been determined that the facility failed to complete an annual performance review for every nursing assistant (NA), at least once every 12 months, fo...

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Based on record review and staff interview, it has been determined that the facility failed to complete an annual performance review for every nursing assistant (NA), at least once every 12 months, for 5 of 5 NA personnel records reviewed, Staff G, H, I, J, and K. Findings are as follows: Record review of the personnel files failed to reveal evidence that an annual performance evaluation was completed for the following NAs: -Staff G, - Date of hire 2/12/2005 -Staff H, - Date of hire 1/16/2023 -Staff I, - Date of hire 3/21/2022 -Staff J, -Date of hire 9/5/2017 -Staff K, - Date of hire 8/22/2016 During a surveyor interview with the Director of Nursing Services on 7/10/2024 at 2:09 PM she was unable to provide evidence of a completed performance evaluation within the last 12 months for the above-mentioned employees.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0809 (Tag F0809)

Could have caused harm · This affected most or all residents

Based on record review, resident, and staff interview, it has been determined that the facility failed to ensure that nourishing snacks were offered to residents at bedtime, for 5 of 9 residents inter...

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Based on record review, resident, and staff interview, it has been determined that the facility failed to ensure that nourishing snacks were offered to residents at bedtime, for 5 of 9 residents interviewed for bedtime snacks, Resident ID #s 2, 3, 5, 18, and 36. Findings are as follows: According to the State Operations Manual for Long Term Care regarding Frequency of Meals, it states in part, There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime . During the resident council meeting held on 7/10/2024 at 11:00 AM, 5 out of 9 resident council members who were in attendance indicated that bedtime snacks are not offered. Additionally, they indicated they would enjoy being offered bedtime snacks. During a surveyor interview on 7/11/2024 at 9:45 AM with the Administrator, he indicated that they start serving breakfast at 8:00 AM and supper starts at approximately 5:00 PM. Additionally, he acknowledged that there are more than 14 hours between the evening meal and the breakfast meal the following day. Lastly, the Administrator was unable to provide evidence that all residents were offered or received bedtime snacks every night.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to prepare, store, and distribute food according to professional standards of food se...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to prepare, store, and distribute food according to professional standards of food service safety, relative to the main kitchen and 2 of 3 nourishment areas observed. Findings are as follows: 1.Review of the Rhode Island Food Code, 2018 Edition, section 3-501.17 states in part, .(B) .refrigerated, ready-to-eat time/temperature control for safety food .shall be clearly marked, at the time the original container is opened in a food establishment .and: (1) the day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date . a)During a surveyor observation in the presence of the Food Service Director (FSD) on 7/9/2024 at approximately 7:45 AM during the initial tour of the kitchen, of a large refrigerator located in the main cooking space, revealed the following: A pan of what appeared to be pasta salad covered in plastic wrap, not labeled, or dated. b)During a surveyor observation in the presence of the FSD on 7/9/2024 at approximately 7:45 AM during the initial tour of the kitchen, of a small refrigerator located in the main cooking space, revealed the following: A pan containing 2 hard-boiled eggs covered in plastic wrap, not labeled, or dated. During a surveyor interview at the time of the above observations, the FSD could not provide evidence that the above food items were clearly marked with the contents and the date. c)During a surveyor observation on 7/9/2024 at approximately 1:30 PM of a kitchenette in the upstairs lounge, revealed the following: 9 Dannon light and fit 4-ounce yogurt cups which expired on 7/6/2024. During a surveyor interview with Registered Nurse, Staff F, she acknowledged the yogurt was expired and should be thrown away. d) During a surveyor observation on 7/9/2024 at approximately 1:45 PM of a kitchenette in the downstairs lounge, revealed the following: 13 Dannon light and fit 4-ounce yogurt cups which expired on 7/6/2024. A clear 4-quart container with a green lid containing a granulated brown substance that wasn't labeled or dated. The container had a white plastic spoon inside resting directly on the contents of the container. During a surveyor interview on 7/9/2024 at 2:00 PM with the FSD, he acknowledged the yogurts were expired. He also acknowledged that the 4-quart container should have been labeled and dated, and that the spoon should have not been stored in the container. 2. Record review of the Rhode Island Food Code 2018 edition, section 3-202.15 Package Integrity states in part, Food Packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants . During a surveyor observation in the presence of the FSD on 7/9/2024 during the initial tour of the kitchen, of a freezer located in the room that you enter from the elevator, revealed the following: 10 Chicken patties in a metal pan dated 6/21 which was only half covered in plastic. A large, opened box containing an internal plastic bag with a large quantity of beef patties inside. The bag was not sealed, wide open, and not dated when opened. During a surveyor observation in the presence of the FSD on 7/9/2024 during the initial tour of the kitchen, of a freezer located in the storage room, revealed the following: A large, opened box containing an internal plastic bag with a large quantity of cookie dough balls. The bag was not sealed, wide open, and not dated when opened. During a surveyor interview at the time of the above observations, the FSD was unable to provide evidence that the food packages were in good condition to protect the integrity of the contents. 3. Record review of the Rhode Island Food Code, 2018 Edition, section 4-703.11 states in part, .(B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under .4-501.15. 4-501.112, and 4-501.113 and achieving a UTENSIL surface temperature of 71 C (160 F) as measured by an irreversible registering temperature indicator . During a surveyor observation on 7/10/2024 at 9:30 AM of the stationary rack high temperature dishwasher, in the presence of the FSD, the surveyor requested the use of a temperature sensitive label in the dishwasher to determine whether the required temperatures for sanitation have been reached. The FSD used a temperature sensitive label called ECOLAB. While running the load of dishes, the temperature gauge on the front of the dishwasher read 114-117 Fahrenheit (F) degrees during the wash cycle and 190 degrees during the rinse cycle. The temperature sensitive label, which was placed on a plate, did not react, and turn black( a square on the label is supposed to turn black when the temperature has been achieved.) The fact that it didn't turn black indicated that the proper temperature had not been achieved for sanitization. During an interview with the FSD immediately following the above observation the surveyor expressed concern regarding the label not reacting and therefore not reaching the proper temperature to sanitizing dishes. He acknowledged that the temperature sensitive strip did not react and turn black. He said the gauge on the dishwasher is fine but sometimes the dishwasher needs a break and that we should retry in 10 minutes. He said that he tests the dishwasher with the temperature sensitive labels once per week, but could not provide evidence, stating that he throws them away and doesn't document the results. During a surveyor observation approximately 10 minutes later, the FSD used two types of temperature sensitive labels (an Ecolab and a 3-temp Thermolabel) placed them on plates and again they did not react and turn black indicating the proper temperature had not been achieved for sanitation. The surveyor questioned whether the temperature gauge on the outside of the dishwasher is broken, because the labels are not reacting indicating that the proper temperature had not been achieved for sanitation. He revealed that he felt that the plates were too heavy, and that might be why the labels were not reacting. He stated that he was going to try thin metal plate covers that they use to transport food plates. During a surveyor observation the FSD placed the metal plate covers into the dishwasher with the temperature sensitive labels attached, they reacted with the square turning black at 160 Fahrenheit on the ECOLAB and 160 F and170 F on the 3 temp thermolabel. At that point the Food Service Director said that the labels are working. During a surveyor observation on 7/10/2024 at 10:06 AM the FSD placed a large plastic tray into the dishwasher, the temperature sensitive labels again did not react indicating that the proper temperature had not been achieved for sanitation. During a surveyor interview after the above observation, the surveyor asked the FSD what he plans to do, he revealed that they will get someone to look at the machine and use paper products for lunch. During a surveyor interview on 7/10/2024 at 2:21 PM with the repairman from [company name redacted] he revealed that the dishwasher's thermostat was faulty, and that the thermostat connector was blocked so the machine would think the water reached the required temperature and shut the electrical off, preventing the wash tank to heat to the required temperature for sanitation. 4. Review of the Rhode Island Food Code, 2018 Edition, section 2-402.11 states in part, .Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens . During a surveyor observation on 7/9/2024 at 12:14 PM until 12:30 PM of the FSD, in the first-floor lounge, serving food onto plates from the steam table. He was not wearing a beard restraint. During a surveyor interview on 7/9/2024 at 12:44 PM with the FSD, he acknowledged that he should have been wearing a beard covering while serving food onto plates from the steam table. 5.Record review of the Rhode Island Food Code, 2018 Edition, section 2-101.11 states in part, .the permit holder shall be the PERSON IN CHARGE or shall Designate a Person in charge and shall ensure that a PERSON IN CHARGE is present at the FOOD ESTABLISHMENT during all hours of operation . Record review of the Certified Food Safety Managers license for Dietary Cook, Staff M, with a date of hire of 6/17/2024, revealed that his license expired on 10/11/2019. Record review of the dietary staffing schedule for June 23, 2024, through July 7, 2024, revealed that Staff M was the only cook, and there failed to be a staff member who had an active Certified Food Safety Managers license in the kitchen during all hours of operation on the following dates and times: June 23, 2024, from 9:00 AM until 11:00 AM June 25, 2024, from 4:00 PM until 7:00 PM June 26, 2024, from 4:00 PM until 7:00 PM June 27, 2024, from 1:30 PM until 7:00 PM June 28, 2024, from 4:00 PM until 7:00 PM July 2, 2024, from 4:00 PM until 7:00 PM July 4, 2024, from 2:00 PM until 7:00 PM July 5, 2024, from 4:00PM until 7:00 PM July 6, 2024, from 1:30 PM until 7:00 PM July 7, 2024, from 5:30 AM until 11:00 AM During a surveyor interview on 7/11/2024 at 4:36 PM with the facility Administrator he could not provide evidence that there was a staff member who had an active Certified Food Safety Managers license in the kitchen during all hours of operation on the above dates and times.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0865 (Tag F0865)

Could have caused harm · This affected most or all residents

Based on record review and staff interview, it has been determined that the facility failed to implement and maintain an effective, comprehensive, data-driven, Quality Assurance and Performance Improv...

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Based on record review and staff interview, it has been determined that the facility failed to implement and maintain an effective, comprehensive, data-driven, Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. Findings are as follows: Review of the QAPI binders on 7/11/2024 at 10:00 AM in the presence of the facility Administrator revealed the following: Review of the August 2023, December 2023, and March 2024 QAPI meeting revealed evidence of QAPI plans created for areas identified as concerns. However, there was no evidence of implementation or maintenance of the plan, including tracking and measuring performance, and establishing goals and thresholds for performance measurement. Review of the June 2024 QAPI meeting revealed evidence of identifying concerns which would aid in the establishment of QAPI plans. However, it failed to reveal completed QAPI plans related to the identified concerns, or evidence of implementation or maintenance of the plan, including tracking, measuring performance, and establishing goals and thresholds for performance measurement. During a surveyor interview on 7/11/2024 at 11:30 AM, with the facility Administrator he was unable to provide evidence that the facility implemented and maintained an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmissi...

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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections due to utilizing Personal Protective Equipment (PPE) according to professional standards and properly disinfecting hands to prevent the transmission of potential pathogens (bacteria, virus or microorganisms that may cause disease) prior to providing care for 1 of 1 resident observed for Activities of Daily Living, Resident ID #281. Additionally, the facility failed to utilize appropriate precautions to reduce the transmission of multidrug-resistant organisms [MDROs-bacteria that are resistant to two or more classes of antibiotics] for 2 of 4 residents reviewed, Resident ID #s 32 and 48. Furthermore, the facility failed to handle, store, and transport linens appropriately, utilizing standard precautions. Findings are as follows: The Centers for Disease Control and Prevention (CDC) publication titled Guideline for Hand Hygiene in Health-Care Settings states in part, The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding handwashing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in health-care setting .Recommendations .These recommendations are designed to improve hand hygiene practices of HCWs and to reduce transmission of pathogenic microorganisms to patients and personnel in health care settings .Decontaminate hands before having direct contact with patients .Decontaminate hands after contact with body fluids or excretions .Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient . 1. During a surveyor observation on 7/10/2024 at 10:22 AM revealed Nursing Assistant (NA), Staff B entering Resident ID #281's room with towels in preparation to perform personal care. Additionally, Staff B was observed removing the basin from the commode and entering the bathroom without wearing gloves. Immediately after, Staff B was observed exiting the restroom with the basin and placing it inside the commode, failing to perform hand hygiene. Staff B began to prepare clean towels to wash the resident with, until the surveyor intervened. During a surveyor interview on 7/10/2024 at 10:25 AM with Staff B, she acknowledged that she was not wearing gloves while transferring the basin containing urine. Additionally, she stated she should have performed hand hygiene prior to continuing to provide personal care to Resident ID #281. During a surveyor interview on 7/10/2024 at 3:28 PM with the Director of Nursing Services, she revealed that she would have expected for Staff B to follow basic infection control practices by using gloves and performing hand hygiene. 2. Review of the CDC guidance titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug resistant Organisms (MDROs) last updated 7/12/2022 revealed in part, .Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities .The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions [gown and glove upon entering the room] do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization [the bacteria is living on or in the body not causing symptoms but the bacteria can be spread to others] as well as for residents with MDRO infection or colonization .Summary of Personal Protective Equipment (PPE) Use and Room Restriction When Caring for Residents in Nursing Homes .Enhanced Barrier Precautions .All residents with any of the following .Infection or colonization with an MDRO when Contact Precautions do not otherwise apply . Review of the CDC guidance titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) updated on 7/12/2022 reveals in part, .Enhanced Barrier Precautions All residents with any of the following .Wounds .During high-contact resident care activities .Dressing, Bathing .Transferring .Providing hygiene .Changing briefs or assisting with toileting .Gloves and gown prior to the high-contact care activity . Review of the facility policy titled, Guidelines for management of MDROs revealed in part, Contact Precautions- In addition to standard precautions, contact precautions or the equivalent used with specific persons known or suspected to be infected or colonized with epidemiologically important micro-organisms that can be transmitted by direct contact with the person or indirect contact with environmental surfaces or equipment. Contact precautions include proper patient placement, proper use of PPE, and proper environmental measures as recommended in .CDC Isolation Guidelines .Enhanced Barrier It has been determined by the CDC that focusing on residents with active infection fails to address the continued risk of transmission from residents with MDRO colonization, which can persist for long periods of time .and result in the silent spread of MDROs. Enhanced barrier precautions fall between Standard and Contact Precautions and requires gown and gloves for all residents with infection or colonization with an MDRO when contact precautions do not apply and for those with wounds or indwelling medical devices, regardless of MDRO colonization status during specific high contact care activities that have been found to increase the risk for MDRO transmission . a) During a surveyor observation on 7/9/2024 at 12:12 PM revealed the Housekeeper, Staff N, in Resident ID #48's room, who was on Contact Precautions, sweeping the resident's floor without wearing any gloves or additional PPE. Staff N assisted Resident ID #128, who was the roommate of Resident ID #48 with his/her telephone, dialing, putting the telephone to her ear, touching the resident's napkins, walker, and bedside table without any PPE. Staff N was then observed exiting the resident's room, without performing hand hygiene, and walked down the hallway to the housekeeping closet, retrieved a dustpan and brush, returned to the resident's room to sweep the debris from the floor. Staff N exited the room without performing hand hygiene, and then entered the resident lounge area and stood in the doorway. During a surveyor interview immediately following the above observation, Staff N acknowledged she touched all the items mentioned above, she was unable to explain why she did not wear gloves or additional PPE while she was in a contact precaution room. After the surveyor asked her if she wanted to wash her hands, Staff N entered another resident's room where she washed her hands in their sink. b) Record review revealed Resident ID #56 was admitted to the facility in March of 2022 and has diagnoses including but not limited to, unspecified open wound of right toe. Record review revealed a progress note dated 7/2/2024 at 1:47 PM which states in part, Assessed and treated by wound NP [Nurse Practitioner] Right toe trauma .raised 100% eschar [dead tissue] .excoriation [abrasion] between toes .Betadine [topical antiseptic] daily to site. Web calcium Alginate [a type of dressing] in between toes, no cover dressing . During a surveyor observation on 7/11/2024 at 11:57 AM, revealed Registered Nurse, Staff O, performing a dressing change on Resident ID # 56. He utilized the bed side table of Resident ID #32 (the roommate) to set up the items needed for the dressing change. During the dressing change, Staff O was noted to touch Resident ID #56's foot and wound with his gloved hands and then touch the bedside table with the same soiled gloves. When the dressing was completed Staff O returned Resident ID #32's bedside table to his/her bedside without cleaning it. Record review revealed Resident ID #32 was admitted to the facility in July of 2017 and has diagnoses including but not limited to, displaced fracture of greater trochanter of left femur and open wound of left elbow. Record review of a care plan dated 3/29/2024 revealed s/he was on Enhanced Barrier Precautions related to a surgical site. During an interview immediately following the above observation, Staff O acknowledged that Resident ID #32 was on Enhanced Barrier Precautions. He further acknowledged that he did not clean Resident ID #32's bedside table after utilizing it to change the wound dressing for Resident ID #56. 3. During a surveyor observation of the laundry room on 7/11/2024 at 12:30 PM, in the presence of the Director of Nursing, revealed the drying area with two large gas dryers and approximately three to four feet directly across from the dryers, a dumbwaiter [a passageway between floors used to move soiled laundry from upper floors to the laundry room]. During an interview with the laundry staff, Staff P, s/he revealed all the facility's soiled laundry is received from the dumbwaiter in bags and either carried manually or placed in a laundry bin and rolled through the drying/folding room to the soiled laundry room approximately 5-6 feet away. Additionally, s/he revealed that s/he doesn't wear a gown when carrying or sorting the laundry unless it appears visibly soiled. Review of the dryer lint removal schedule revealed the lint filters are emptied four times daily. The documentation revealed the following: -The June 2024 documentation revealed the lint trap was not signed off as emptied on 6/1, 6/3, 6/7, 6/9, 6/10, 6/15, 6/16, 6/17, 6/21, 6/23, 6/24, 6/25, 6/29, and 6/30. The July 2024 lint removal schedule revealed the lint filters were not signed off as emptied on 7/1, 7/4, 7/5, 7/7, and 7/8. During an interview with the Maintenance Director on 7/11/2024 at approximately 1:00 PM, he was unable to provide evidence that the lint filters were checked or emptied on the above days.
MINOR (B)

Minor Issue - procedural, no safety impact

Transfer Notice (Tag F0623)

Minor procedural issue · This affected multiple residents

Based on record review and staff interview, it has been determined that the facility failed to provide a written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman for...

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Based on record review and staff interview, it has been determined that the facility failed to provide a written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman for 2 of 2 sample residents who were discharged from the facility, Resident ID #s 75 and 77. Findings are as follows: 1. Record review revealed Resident ID #75 was admitted to the facility in May of 2024 with diagnoses including, but not limited to, hemiplegia (one sided paralysis) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting right dominant side, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Record review revealed that the resident was discharged to the hospital on 6/17/2024. 2. Record review revealed Resident ID #77 was originally admitted to the facility in April of 2024 with diagnoses including, but not limited to, hyponatremia (low sodium level). Record review revealed that the resident was discharged to his/her home with services on 4/15/2024. Additional record review failed to reveal evidence that the Office of the State Long-Term Care Ombudsman was notified of the discharges for Resident ID #s 75 and 77. During surveyor interviews on 7/11/2024 at 2:00 PM and 2:30 PM, with Social Worker, Staff A, he was unable to provide evidence that the Office of the State Long-Term Care Ombudsman was notified of the above discharges.
Jun 2024 1 deficiency
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice ...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice relative to following a physician's order for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing page 314 which states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review of a community reported complaint submitted to The Rhode Island Department of Health on 5/30/2024 alleges in part, that the resident did not receive his/her medications on the second shift of 5/30/2024, as ordered. Record review revealed Resident ID #1 was admitted to the facility in May of 2023, with diagnoses including, but not limited to, adult failure to thrive and pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time). Record review of a physician's order dated 10/19/2023 states in part, Medication Administration: second nurse verification twice a day 7:00 AM-11:00 AM, 7:00 PM-11:00 PM. Record review of the Medication Administration Record (MAR) for June 2024 failed to reveal evidence that a second nurse verified the medication administration on 6/3, 6/4, and 6/5/2024 during the 7:00 PM-11:00 PM medication administration, as ordered. Record review of the MAR for May 2024 failed to reveal evidence that a second nurse verified the medication administration on 5/30/2024 during the 7:00 PM-11:00 PM medication administration, as ordered. During a surveyor interview with Licensed Practical Nurse, Staff A, on 6/6/2024 at approximately 11:35 AM, he acknowledged that he worked on 6/3, 6/4, and 6/5/2024. He further acknowledged that he did not verify the medication administration with a second nurse on 6/3, 6/4, and 6/5/2024, as ordered. During a surveyor interview with Licensed Practical Nurse, Staff B, on 6/7/2024 at approximately 10:02 AM, she acknowledged that she worked on 5/30/2024. She further acknowledged that she did not verify the medication administration with a second nurse on 5/30/2024, as ordered. During a surveyor interview with the Director of Nursing Services on 6/6/2024 at approximately 2:33 PM, she was unable to provide evidence the resident's medications were verified by a second nurse on the above-mentioned dates, as ordered.
Oct 2023 1 deficiency
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to store all drugs and biologicals in locked compartments for 1 of 1 resident reviewed...

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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to store all drugs and biologicals in locked compartments for 1 of 1 resident reviewed relative to medications left at the bedside, Resident ID #1. Findings are as follows: Record review of a community reported complaint received by the Department of Health on 10/13/2023 revealed in part, My Medications were wrong yet again this morning. I took a picture as proof of my complaint . According to Pharmacology, A Nursing Approach 2nd edition, Guidelines for Correct Administration of Medication directs the practitioner to stay with the client until the medication is taken. Record review revealed the following physician's orders: - Administer two tablets of gabapentin 100 mg (milligram) for a total dose of 200 mg orally twice daily. - Administer one tablet of folic acid 1 mg orally once a morning. - Administer one tablet of cyanocobalamin (vitamin B-12) 1,000 mcg (micrograms) orally once a morning. - Administer one tablet of Eliquis (blood thinner) 5 mg orally twice a day. - Administer one tablet of metoprolol succinate (medication that lowers blood pressure) tablet extended release 24-hour 25 mg orally once a morning. - Administer acetaminophen 500 mg two capsules twice daily orally. Record review of the electronic medication administration record revealed the above medications were signed off as being administered by the Registered Nurse, Staff A, on 10/16/2023 during the 7 AM - 11 AM medication pass. During a surveyor observation on 10/16/2023 at 9:58 AM revealed a medication cup containing several pills placed on the bedside tray of Resident ID #1. During a surveyor interview immediately following the above observation, the resident indicated that all but one facility staff member leaves his/her medications on his/her tray table to self-administer. S/he further revealed that s/he has not requested to self-administer his/her medications. During a surveyor interview with Staff A on 10/16/2023 at approximately 10:05 AM, she acknowledged that she left the medication cup in residents' room unattended. She further revealed that she always leaves his/her medications for him/her to take independently, During a surveyor interview with Director of Nursing Services (DNS) and the Administrator on 10/16/2023 at 2:37 PM, the DNS acknowledged that it was a common practice for facility staff to leave medications unattended in the room of Resident ID #1. She further acknowledged the resident has not been assessed for competency for self administration of medications.
Oct 2023 1 deficiency
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of quality related to Nursing Assistants ...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of quality related to Nursing Assistants scope of practice for 1 of 3 residents reviewed for medication administration, Resident ID #1. Findings are as follows: Review of the facility policy titled Medication Administration General Guidelines states in part, .Medications are administered as prescribed in accordance with .good nursing principles and practices and only by persons legally authorized to do so . Review of the State of Rhode Island regulation 216-RICR-40-05-22.12.1. D. 1. A nursing assistant may only remind a patient to take medication, unless the nursing assistant is licensed with the Department as a medication aide. Review of a community reported complaint submitted to the Rhode Island Department of Health on 10/4/2023 alleges that Resident ID #1 had been given the wrong medications on several occasions and feels his/her life had been put in danger. Record review revealed Resident ID #1 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, adult failure to thrive and anorexia. Record review of a care plan dated 5/22/2023 revealed the resident requires a high-risk medication, Eliquis (a blood thinner) and to monitor for signs and symptoms of bleeding. Record review revealed the following physician's orders: -Acetaminophen 500 Milligram (mg) twice a day -Eliquis 5 mg twice a day -Gabapentin (medication for pain) 200 mg twice a day -Mirtazapine (medication to treat depression) 7.5 mg at bedtime -Trazodone (medication to treat depression) 25 mg twice a day Record review of the October Medication Administration record revealed Licensed Practical Nurse (LPN), Staff A, documented that the above medications were administered to the resident on 10/4/2023. During a surveyor interview on 10/5/2023 at approximately 11:20 AM with the resident, s/he indicated that on the evening of 10/4/2023, s/he received his/her medications from a Nursing Assistant (NA). During a surveyor interview on 10/5/2023 at 12:51 PM with NA, Staff B, she indicated that on the evening of 10/4/2023 the unit nurse, Staff A asked her to administer the resident's medications. She further revealed that she administered the medications, given to her by Staff A, to the resident on 10/4/2023. Additionally, she acknowledged that she is not licensed to administer medications and should not have administered the medications to the resident. During a surveyor interview on 10/5/2023 at approximately 2:45 PM with Staff A, she revealed that on the evening of 10/4/2023, she gave the resident's medications to Staff B to administer to the resident. She further revealed that she remained in the hallway and did not observe the resident taking the medications. Additionally, she acknowledged that she should not have delegated medication administration to the NA. During a surveyor interview on 10/5/2023 at 2:21 PM with the Director of Nursing Services, she revealed NAs should never administer medications to residents. Additionally, she could not provide evidence that services being provided meet professional standards of quality.
May 2023 8 deficiencies 1 Harm
SERIOUS (H)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0692 (Tag F0692)

A resident was harmed · This affected multiple residents

Based on record review and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight or prote...

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Based on record review and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight or protein levels for 4 of 10 residents reviewed for nutrition, Resident ID#s 12, 65, 72, and 74. Findings are as follows: Record review of the State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities, revised on 2/3/2023, reveals a weight loss of 5% in 1 month, 7.5% in 3 months, and 10% in 6 months is significant weight loss. Additionally, greater than 5% in 1 month, greater than 7.5% in 3 months, and greater than 10% in 6 months is severe weight loss. Review of the facility's policy and procedure undated and untitled, provided to surveyors on 5/22/2023, states in part, .Goal Resident will not have a significant weight loss. Policy and Procedure: 1. Resident will be weighted on admission and at least monthly. 2. Provider and /family/responsible party will be notified re [relative to] significant weight loss. 3. Dietician consult on admission, quarterly and as indicates. 4. IDT [Interdisciplinary Team] will implement interventions and will adjust according to resident preferences . Although, the above policy and procedure indicates a provider and family/responsibly party will be notified relative to significant weight loss, the policy failed to specify a definition of significant weight loss. Additionally, the policy failed to specify a procedure indicating the steps to take when a weight discrepancy is noted. 1. Record review for Resident ID #12 revealed s/he was admitted to the facility in September of 2022 with diagnoses to include, but not limited to, dementia, anemia (a lower-than-normal amount of red blood cells in blood level), hypothyroidism (thyroid grand does not produce enough hormones), protein-calorie malnutrition, and dysphagia (difficulty swallowing). Review of the Care Area Assessment (CAA, a process that provides guidance on how to focus on key issues identified during a comprehensive assessment) summary dated 9/21/2022 revealed the resident was triggered for nutrition, this CAA was due to receiving a mechanically altered diet and having an order for aspiration precaution. This CAA indicates a care plan for nutrition would be developed. Record review failed to reveal a care plan was developed as indicated according to the above CAA summary. Further record review revealed the resident had a physician's order dated 9/29/2022 for weekly weights to be obtained on Thursdays. Review of the weight records for April and May 2023 failed to reveal evidence the resident's weights were obtained as ordered on the following days; -4/13/023 -4/27/2023 -5/4/2023 -5/11/2023 Record review revealed the resident's weight was documented as 129.2 - 137.1 pound (lbs) between 12/15/2022 and 3/30/2023. Further record review revealed the resident's weight was 130.4 lbs on 4/6/2023 and 105.8 lbs on 4/20/2023, which indicates a 24.6 lbs (18.87 %) weight loss in 2 weeks and lost (28.6 lbs or 21.34 % in approximately 4 months). Additionally, the record revealed the resident's weight was 105 lbs on 5/10/2023, which indicated a 25.4 lbs (19.48 %) weight loss in approximately 1 month and lost (29 lbs or 21.64 %) in approximately 5 months. Record review failed to reveal evidence that the provider and /family/responsible party were notified or that the dietician was consulted when the resident experienced a severe weight loss. During a surveyor interview with the Director of Nursing Services (DNS) on 5/17/2023 at 11:17 AM, she revealed that she was unaware of the above-mentioned weight loss. Additionally, she was unable to provide evidence any steps were taken to verify if the weights were accurate or that a care plan for nutrition was developed to address the nutritional status as indicated in the CAA. Additionally, she was unable to provide evidence that the resident's provider, family/responsible party or the dietitian were notified as per the facility policy. During an interview with the Minimum Data Set Coordinator, on 5/17/2023 at 11:28 AM, she revealed that the dietitian assesses the resident's nutritional status and if it is triggered on the CAA, a care plan for nutrition will be developed by the dietitian. Additionally, she was unable to provide evidence that a care plan for nutrition was developed or implemented for the resident when it was triggered on the CAA on 9/21/2022. During a surveyor interview with the resident's provider, Nurse Practitioner, Staff F, on 5/17/2023 at 11:30 AM, she revealed that she was unaware of the resident's severe weight loss, until the DNS informed her a few minutes prior to this interview. She further revealed that she would expect staff to obtain the resident's weight every week as ordered. Staff F then revealed that she would expect staff to notify her if a resident has a significant weight gain or loss. Additionally she indicated that a significant weight gain or loss would be when a resident gained or lost 3 lbs. or more from their previous weight. Staff F further revealed that she would expect residents with weight changes of 3lbs. or more lbs from their previous reading to be reweighed. During a telephone interview with Dietitian, Staff G, on 5/17/2023 at 1:02 PM, she revealed that she was unaware of the above-mentioned weight loss. She further revealed that she is new to the facility and was not aware that the resident did not have a plan of care for nutrition. Additionally she indicated that she is not familiar with the facility's policy. During a surveyor interview with Licensed Practical Nurse, Staff H, in present of the Corporate Nurse, Staff I, on 5/18/2023 at 12:56 PM, she revealed that she monitors all resident weights for weight loss and/or discrepancies. She further revealed that she runs the weight report once a month and the last time she ran the weight report was for the month of April, 2023. Additionally, she revealed that she was not informed of the above-mentioned weight loss on 4/20/2023 and 5/10/2023 and would expect staff to inform her when a resident experiences a significant weight loss. 2. Record review for Resident ID #65 revealed s/he was admitted to the facility in February of 2023 with diagnoses to include, but not limited to, dementia, gastro-esophageal reflux disease (acid reflux) and severe protein-calorie malnutrition. Record review revealed the resident's weight was 92.2 lbs on 4/18/2023 and 85 lbs on 5/9/2023, which indicates a 7.2 lbs (7.81%) weight loss, in 3 weeks. Further record review revealed the resident's weight was 85.6 lbs on 5/16/2023, which indicates a 6.6 lbs weight loss (7.16 %), in approximately 1 month. During a surveyor interview with the DNS on 5/18/2023 at 3:45 PM, she revealed she was unaware of the above-mentioned weight loss. The DNS was unable to provide evidence that the resident's provider, family/responsible party and/or dietitian were notified as per the facility policy. Additionally, the DNS was unable to provide evidence that a new intervention was implemented to the plan of care to address the resident's severe weight loss. 3. Record review for Resident ID #72 revealed s/he was admitted to the facility in January of 2022 with diagnoses to include, but not limited to, dementia and anemia. Record review revealed the resident has a physician's order dated 9/19/2022 to administer Promod Protein (protein supplement) liquid, 30 milliliters by mouth once a day between 7:00 AM - 11:00 AM. Record review of the Medication Administration Records for April and May, 2023 revealed that the Promod protein supplement had not been administered as ordered since 4/18/2023 (approximately 4 weeks). Review of the Quarterly Nutritional Note dated 10/31/2022 revealed 1 Promod protein supplement provides approximately 18 grams of protein/day. The note further revealed that the resident's protein levels (Albumin and Prealbumin levels, both serum proteins use to evaluate protein malnutrition and overall nutrition health) have been running low with some improvement. Review of the Quarterly Nutritional Note dated 5/1/2023 revealed to continue the supplement as ordered. During a surveyor interview with Medication Technician, Staff C, on 5/16/2023 at 8:30 AM, she revealed that the resident had not been receiving Promod protein supplement because it is unavailable. Review of the record revealed the resident's albumin level was 3.5 g/dl (grams per deciliter) and prealbumin level was 14.8 g/dl on 12/8/2023 and decreased to 3.1 g/dl and prealbumin level was 13.8 g/dl on 5/17/2023 (normal range for albumin is 3.5 - 5 g/dL. Low albumin levels can lead to edema, fatigue, and weakness. The normal range for prealbumin is 15 - 36 mg/dL). During a surveyor interview with the DNS on 5/16/2023 at 4:48 PM, she was unable to provide evidence that the resident had been receiving Promod protein supplement as ordered since 4/18/2023. 4. Record review revealed Resident ID #74 was admitted to the facility in December of 2022 with diagnoses that include but are not limited to, dementia and vitamin deficiency. Record review of the care plan, last reviewed on 5/9/2023 revealed that s/he is at risk for an alteration in nutritional status due to receiving a therapeutic diet. Record review revealed a physician's order with a start date of 3/25/2023 which indicates the resident's weight is to be obtained weekly. Record review of the resident's weekly weights from 4/7/2023 through 5/12/2023 revealed the following: - 4/7/2023, weight 133 lbs. - 4/14/2023, weight 132 lbs. - 4/21/2023, weight 133 lbs. - 4/28/2023, weight 136.6 lbs. - 5/12/2023, weight 124.6 lbs Indicating the resident experienced an 8.4 lbs weight loss from 4/7/2023 to 5/12/2023 6.32% weight loss in 5 weeks, and a weight loss of 7.4 lbs. between 4/14/2023 and 5/12/2023 which is a 5.61 % weight loss in approximately 1 month. Additional record review failed to reveal evidence that the provider/family/responsible party were notified or that the dietician was consulted when the resident experienced a severe weight loss. During a surveyor telephone interview with Staff G on 5/16/2023 at 5:06 PM, she indicated that she was not aware of the resident's severe weight loss and would have expected staff to obtain a reweigh if the resident had a loss or gain of 3 lbs. or more from the previous weight. During a surveyor interview with the DNS on 5/17/2023 at 9:07 AM, she was unable to provide evidence that the resident was reweighed to verify the weight discrepancy until it was brought to the attention of the facility by the surveyor. Additionally, she was unable to provide evidence that the Dietitian was notified of the resident's documented weight on 5/12/2023.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and resident and staff interview, it has been determined that the facility failed ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and resident and staff interview, it has been determined that the facility failed to ensure that a resident who requires catheterization receives appropriate treatment and services for 1 of 5 residents reviewed, relative to an indwelling catheter, Resident ID #83. Findings are as follows: Review of the facility policy titled, Foley Catheter Care dated 2/1/2023, states in part, .Resident's requiring a foley catheter will remain free of complications including infection, trauma .Ensure drainage bag .remains .off the floor . Record review revealed that the resident was admitted to the facility in March of 2023 with diagnoses including, but not limited to, urinary tract infection and benign prostatic hyperplasia (enlargement of prostate that impedes the flow of urine). Record review of an admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15 indicating the resident has intact cognition. Record review of a care plan last revised on 3/24/2023 revealed that the resident requires an indwelling catheter related to urinary obstruction. Further record review revealed an approach dated 3/24/2023, which indicates to position the drainage bag below the level of the bladder and off the floor at all times. Further record review failed to reveal evidence that the resident was taught to keep the Foley catheter drainage bag off of the floor at all times. Record review revealed a physician's order dated 3/24/2023 for Foley Catheter 16 [French] WITH ML [milliliters] BALOON [sic] . Record review of a Continuity of Care Form dated 5/5/2023 from the urology clinic revealed consultation notes including, .Foley catheter changed today .New 18 [French] Coude [a type of catheter that is bent at the tip which helps the catheter move past a blockage] inserted . During surveyor observations the resident was observed sitting in his/her room in a recliner chair next to the window. Additionally, the resident's Foley catheter drainage bag was observed to be directly on the floor, not placed in a privacy bag or the side pocket of the recliner. Addition observations revealed a black privacy bag, for the resident's drainage bag was observed on the resident's rolling walker on the following dates and times: - 5/15/2023 at 9:40 AM and 4:27 PM - 5/17/2023 at 8:51 AM During a surveyor interview with Nursing Assistant, Staff D on 5/17/2023 at 8:52 AM, she acknowledged that the resident's catheter drainage bag was placed directly on the floor and not in a privacy bag or the side pocket of the recliner. During a surveyor interview with the resident on 5/17/2023 at 9:12 AM, s/he acknowledged that sometimes the catheter drainage bag is placed directly on the floor and not in a privacy bag. Additionally, the resident was unable to recall if staff provided him/her with education relative to keeping the drainage bag off of the floor at all times. During a surveyor interview with the Director of Nursing Services on 5/17/2023 at 9:02 AM, she indicated that she would expect that the catheter drainage would remain off of the floor at all times. Additionally, she indicated that she would have expected the physician's order for the catheter to be updated when the resident returned from the urology appointment on 5/5/2023. During a surveyor interview with the Infection Control Nurse on 5/17/2023 at 9:25 AM, she indicated that she would expect the catheter drainage bag to be kept off the floor at all times. Additionally, she was unable to provide evidence that the resident has]d been educated to keep the foley drainage bag off of the floor at all times per the facility policy.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

Based on surveyor observation, record review, and resident and staff interview, it has been determined that the services provided by the facility failed to meet professional standards of quality relat...

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Based on surveyor observation, record review, and resident and staff interview, it has been determined that the services provided by the facility failed to meet professional standards of quality relative to physician's orders for 8 of 18 residents reviewed relative to weekly integrity observation documentation, Residents ID#s 3, 38, 59, 66, 74, 77, 78, and 80 and for 1 of 4 resident observed during the medication administration task who was administered medication outside of the manufacturer's instructions, Resident ID #62. Findings are as follows: 1. According to Mosby's 4th Edition, Fundamentals of Nursing, page 314, states in part, .The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients . A. Record review revealed Resident ID #3 was admitted to the facility in January of 2023 with diagnosis including, but not limited to, encephalopathy (a term for any disease of the brain that alters brain function or structure). Record review revealed a physician's order dated 2/14/2023 for a weekly skin integrity observation once daily on Sunday during the 7:00 AM to 3:00 PM shift. Record review revealed skin integrity observations were not completed when due for 11 of 13 opportunities between 2/14/2023 and 5/17/2023. During a surveyor interview with the Director of Nursing Services (DNS) on 5/17/2023 at 1:54 PM, she revealed that they have implemented a new skin integrity observation documentation, which need to be completed every week, even when there are no new skin issues. The DNS acknowledged that there were multiple weekly skin integrity observation documentation were not completed on the above-mentioned dates. B. Record review for Resident ID #38 revealed s/he was admitted to the facility in November of 2022 with a diagnosis including, but not limited to, dementia. Record review revealed a physician's order dated 9/29/2022 to complete a weekly skin integrity observation once daily on Tuesday during the 3:00 PM to 11:00 PM shift. Record review of the weekly skin integrity observation documentation revealed they were not completed when due for 13 of 15 opportunities between 2/7 and 5/16/2023. C. Review of the record for Resident ID #59 revealed s/he was admitted to the facility in January of 2023 with a diagnosis including, but not limited to, amyotrophic lateral sclerosis (a disease affecting the brain and spinal cord). Record review revealed a physician's order dated 1/28/2023 to complete a weekly skin integrity observation once daily on Monday during the 7:00 AM to 3:00 PM shift. Record review of the weekly skin integrity observation documentation failed to reveal evidence that they were completed for 11 out of 15 opportunities between 1/28/2023 through 5/13/2023. During a surveyor interview with Licensed Practical Nurse (LPN), Staff B on 5/16/2023 at 5:00 PM, she acknowledged that the above-mentioned skin integrity observation documentation were not completed. Furthermore, she revealed that she would expect them to have been completed as ordered. D. Record review revealed Resident ID #66 was admitted to the facility in February of 2023 with diagnosis including, but not limited to, Alzheimer's disease. Record review revealed a physician's order dated 3/9/2023 order to complete a weekly skin integrity observation once daily on Friday during the 3:00 PM to 11:00 PM shift. Record review failed to reveal evidence that the skin integrity observation documentation were completed for 4 out of 10 opportunities between 3/9/2023 and 5/13/2023. During a surveyor interview with Staff B on 5/16/2023 at 5:00 PM, she acknowledged that the above-mentioned skin observations were not completed as ordered. E. Record review revealed Resident ID #74 was admitted to the facility in December of 2022 with a diagnosis that includes, but is not limited to, dementia. Record review revealed a physician's order dated 3/25/2023 for weekly skin integrity observations to be completed weekly on Fridays during the 3:00 PM - 11:00 PM shift. Record review failed to reveal evidence that the skin integrity observation documentation were completed when due for 3 out of 7 opportunities between 3/31/2023 and 5/12/2023. F. Record review revealed Resident ID #77 was admitted to the facility in June of 2022 with diagnoses including, but not limited to, cerebral palsy (a movement disorder), quadriplegia (loss of motor or sensory function of the arms and legs), and dependence on wheelchair. Record review revealed a physician's order dated 3/8/2023 order to complete a weekly skin integrity observation on Wednesdays during the 7:00 AM to 3:00 PM shift. Record review failed to reveal evidence that a weekly skin observation documentation were completed for 4 out of 10 opportunities between 3/9/2023 and 5/13/2023. During a surveyor interview with Staff B on 5/16/2023 at 5:00 PM, she acknowledged that the above-mentioned skin observation documentation were not completed as ordered. G. Review of the record for Resident ID #78 revealed s/he was admitted to the facility in October of 2022 and has diagnoses including, but not limited to, severe dementia, and muscle wasting. Record review revealed a physician's order dated 1/25/2023 for weekly skin integrity observations to be completed weekly on Wednesdays during the 3:00 PM - 11:00 PM shift. Record review failed to reveal evidence that a weekly skin observation documentation were completed for 9 out of 12 opportunities between 3/1/2023 and 5/17/2023. During a surveyor interview with the DNS on 5/17/2023 at approximately 3:00 PM, she revealed that staff may not have understood the education provided for the new skin integrity observation documentation, and that it should be completed every week even when there are no new skin issues. H. Record review revealed Resident ID #80 was admitted to the facility in April of 2023 with diagnoses including, but not limited to, hemiplegia and hemiparesis (weakness of one side of the body), and pressure ulcer of the left buttocks. Record review revealed a physician's order dated 4/13/2023 to complete a weekly skin integrity observation once daily on Friday during the 6:00 AM to 3:00 PM shift. Record review failed to reveal evidence that the weekly skin integrity observation documentation were completed when due for 3 out of 5 opportunities between 4/13/2023 and 5/13/2023. During a surveyor interview with Staff B on 5/16/2023 at 5:00 PM, she acknowledged that the above-mentioned skin observation documentation were not completed as ordered. During a surveyor interview with the DNS on 5/17/2023 at approximately 3:00 PM, she was unable to provide evidence that the above-mentioned skin integrity observation documentation were completed as ordered. Furthermore, she indicated that the weekly skin integrity observation should be completed every week, even if the residents do not have any new skin issues. 2. Record review revealed Resident ID #62 was admitted to the facility in November of 2022 with diagnoses including but not limited to, kidney disease, over active bladder and prostatic enlargement. Record review revealed the resident has a physician's order dated 11/29/2022 to administer Myrbetriq tablet (used to treat over active bladder), extended release 24 hours (medication is released slowly over time), 50 milligrams once a day in the morning. During a surveyor observation on 5/16/2023 at 8:37 AM revealed a Medication Technician, Staff C, preparing morning medications for the resident. During this time she was observed removing a blister package of Myrbertiq tablet from the medication cart. It was noted that this blister package had a blue sticker that indicated Do not chew or crush on it. The surveyor observed Staff C crush this medication and other medications and mixed them with apple sauce. During a subsequent surveyor interview with Staff C on 5/16/2023 at 8:45 AM, she revealed that she was going to administer these medications to the resident. The surveyor requested Staff C to remove the blister package of Myrbetriq from the medication cart and read the blue sticker. After reading the blue sticker that indicated Do not chew or crush, Staff C stated, I know. I talked to the nurses and they said we can crush it. [Resident ID #62] is on choking precautions. The doctor is aware that we crush this medication. When asked how long she has been crushing this medication, she revealed that she has been administering this medication crushed and mixed with apple sauce for some time. When questioned who the nurses were that told her she could crush this medication Staff C stated she could not recall. Record review of the Medication Administration Records from March 1st through May17, 2023 revealed Staff C administered the Myrbetriq to the resident 53 times. During a surveyor interview with the DNS on 5/18/2023 at approximately 10:00 AM, when informed of the above-mentioned findings, she revealed the Myrbetriq should not be crushed.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0838 (Tag F0838)

Could have caused harm · This affected multiple residents

Based on record review and staff interview, it has been determined that the facility failed to provide training as outline in their facility assessment relative to obtaining resident weights for 7 of ...

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Based on record review and staff interview, it has been determined that the facility failed to provide training as outline in their facility assessment relative to obtaining resident weights for 7 of 7 newly hired Nursing Assistants (NAs) reviewed, Staff J, K, L, M, N,O, and P. Findings are as follows: The facility's assessment updated on 1/4/2023, states in part, .Training for Certified Nursing Assistant upon hire .Obtaining resident weights via wheelchair, mechanical lift or standing . Record review revealed the following staff members did not receive training upon hire per the above-mentioned facility assessment: 1. Staff J, hired on 5/6/2023 2. Staff K, hired on 4/13/2023 3. Staff L, hired on 3/30/2023 4. Staff M, hired on 2/14/2023 5. Staff N, hired on 1/30/2023 6. Staff O, hired on 1/21/2023 7. Staff P, hired on 1/16/2023 During a surveyor interview with the Administrator and the Director of Nursing Services on 5/22/2023 at 11:29 AM, they were unable to provide evidence that the above-mentioned NAs received training relative to obtaining resident weights via wheelchair, mechanical lift or standing, upon hired as outlined in the facility assessment. Please refer to F692.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to establish and maintain an infection prevention and control program designed to pro...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections relative to the handling of laundry on 1 of 4 units, the North Unit and for 2 of 2 residents with Vancomycin Resistant Enterococci (VRE), Residents ID#s 54 and 145, and Findings are as follows: 1. Review of an undated facility policy titled General Infection Control Strategies, states in part, .It is the policy of this facility that all activities, directly or indirectly affecting the resident will be performed in a manner that minimizes the potential for infection in residents, staff and visitors . A. During a surveyor observation of the North Unit on 5/15/2023 at 11:43 AM, Nursing Assistant (NA), Staff S, was observed exiting a resident's room while holding a loose, unbagged sheet in her hand. Additionally, the sheet was observed to be visibly soiled with brown matter on it and was dragging on the floor. During a surveyor interview with Staff S on 5/15/2023 at approximately 2:45 PM she acknowledged the above-mentioned observations. Additionally, she indicated that this is her ususal practice. During a surveyor interview with the Infection Control Nurse on 5/16/2023 at 11:03 AM, she indicated that the process for carrying soiled linen out of a resident's room is to have it rolled into a ball and away from the staff member's clothing and not touching anything else. B. During a surveyor observation of the North Unit on 5/15/2023 at 2:23 PM revealed NA, Staff D was observed to place clean, resident personal laundry on top of three linen carts in the corridor. She was overheard indicating that some of the clothing items belonged to Resident ID #74 and indicated his/her family does their laundry. She was then observed to take those items into the resident's room. During a surveyor interview with Staff D on 5/15/2023 at 2:32 PM, she acknowledged the observation and indicated that the carts in the corridor are for dirty linen and dirty resident personal laundry. Additionally, she indicated that she cleaned the top of the dirty carts at 1:00 PM, however she was unable to provide evidence of the carts being cleaned at that time and acknowledged it could have been contaminated between 1:00 PM and the time of the above-mentioned observation. During a surveyor interview with the Infection Control Nurse on 5/16/2023 at 11:03 AM, she indicated that the carts in the corridor are for dirty laundry. Additionally, she revealed that she would not expect nursing staff to sort clean personal laundry on top of dirty linen carts. 2. Review of the facility policy related to infection control states in part, .TRANSMISSION BASED PRECAUTIONS .to be used for residents documented as or suspected to be infected/colonized [colonized is the presence of growth of organisms without observable symptoms] .include .contact precautions .VRE .are enterococci bacteria usually found in the bowel .VRE is spread by direct patient-to-patient via transient carriage on the hands of personnel or indirect contact on contaminated surfaces or equipment. Enterococci can persist for weeks on environmental surfaces .Enhanced Barrier Precautions are to be utilized for those with colonization as well as those who reside in close proximity .Example of resident care activities requiring gown and glove use for Enhanced Barrier Precautions include .Dressing, Bathing/showering, Providing hygiene, Changing linens, Changing briefs or assisting with toileting . Review of the Centers for Disease Control and Prevention (CDC) article titled, Healthcare-Associated Infections (HAIs), last updated November 13, 2019 states in part, Vancomycin-resistant Enterococci (VRE) in Healthcare Settings . In 2017, VRE caused an estimated 54,500 infections among hospitalized patients and 5,400 estimated deaths in the United States . How is it spread? VRE can spread from one person to another through contact with contaminated surfaces or equipment or through person to person spread, often via contaminated hands . How can you avoid getting an infection? If you or someone in your household has VRE, you can protect yourself by: keeping your hands clean to avoid getting sick and spreading germs that can cause infections patients and their caregivers should wash their hands with soap and water or use alcohol-based hand sanitizer, particularly: after using the bathroom before and after handling medical devices . frequently cleaning areas of the home, such as bathrooms, that may become contaminated with VRE wearing gloves if hands may come in contact with body fluids that may contain VRE, such as stool (poop) . A. Record review revealed Resident ID #54 was readmitted to the facility in May of 2023 with diagnoses including but not limited to, dementia and constipation. Record review of a care plan dated 5/11/2023 revealed s/he experiences bowel incontinence. Additionally record review revealed a physician progress note dated 5/11/2023 at 1:46 PM which states in part, .VRE positive from rectal swab screening at the hospital. [S/he] is colonized and asymptomatic .continue precautions. Can repeat swab per facility protocol. Further record review failed to reveal evidence that the resident was placed on contact precautions per the facility's policy. The following surveyor observations of the residents room failed to reveal evidence of precautions signage outside of the room or a precaution cart/dedicated room equipment on the following dates and times: - 5/15/2023 at 10:35 AM - 5/16/2023 at 8:55 AM and 11:08 AM - 5/17/2023 at approximately 11:40 AM During a surveyor interview with Nursing Assistant in Training, Staff U on 5/17/2023 at 11:42 AM, she indicated that she is training and assisted the resident with personal care. Additionally, she indicated that she did not wear a protective gown when assisting the resident with personal care. B. Record review revealed Resident ID #145 was admitted to the facility in May of 2023 with a diagnosis that includes but is not limited to, gastro-esophageal reflux disease (acid reflux). Record review of a Continuity of Care form from the hospital dated 5/12/2023 revealed the resident has a prior history of VRE in April of 2023. Record review revealed a rectal swab for VRE was obtained on 5/16/2023 per the physician's order and the results were pending. Further record review failed to reveal evidence that the resident was placed on contact precautions per the facility's policy. The following surveyor observations of the resident's room failed to reveal evidence of precautions signage outside of the room or precaution bins/dedicated room equipment on the following dates and times: - 5/15/2023 at 10:35 AM - 5/16/2023 at 8:55 AM and 11:08 AM - 5/17/2023 at approximately 11:40 AM During a surveyor interview with Unit Assistant, Staff T, on 5/17/2023 at 11:41 AM, she indicated that she made the beds for both Resident ID #s 54 and 145, and was not aware of any precautions in place. Additionally, she indicated that she did not wear a gown while making the beds. During a surveyor interview with Registered Nurse Staff A on 5/17/2023 at 12:12 PM, he revealed that he was unaware of both residents VRE status and that they should be on precautions per the facility policy. During a surveyor interview with Nursing Assistant, Staff U, on 5/17/2023 at 12:13 PM, she indicated that she has been the assigned NA for both Resident ID #s 54 and 145. Additionally, she indicated that although she was aware of the resident's precautions for VRE she only uses gloves and no gown when assisting with care. Furthermore, she indicated that Resident ID #54 utilizes a bedside commode which is carried out of his/her room and emptied in another location across the hall from the resident's room. During a surveyor interview with the Infection Control Nurse on 5/17/2023 at 12:17 PM, she indicated that both Resident ID #s 54 and 145 are considered colonized. Additionally, she was unable to provide evidence that Enhanced Barrier Precautions were in place per the facility policy. She indicated that precautions instructions were posted at the nurse's station for staff communication. Record review of the NA book on the East Unit revealed a document titled, VRE PRECAUTIONS . The form indicates hand hygiene, don gloves, dedicated room equipment and to frequently disinfect the room and equipment with approved wipes. Additional review of the document failed to reveal evidence that staff should wear a precaution gown as indicated in the policy.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected multiple residents

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to be adequately equipped to allow residents to call for staff assistance through a c...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 5 of 15 residents observed to have their call lights placed out of their reach, Resident ID #s 20, 25, 54, 61, and 74. Findings are as follows: 1. Record review for Resident ID #20 revealed that s/he was admitted to the facility in March of 2021 with diagnoses including, but not limited to, heart failure. Record review revealed a care plan dated 3/1/2023 that indicates the resident has an intervention in place for the call light to be kept within reach relative to bladder/bowel incontinence and the potential for falls. During a surveyor observation with Registered Nurse, Staff Q, on 5/16/2023 at approximately at 12:15 PM, Resident ID #20 was observed to be sitting in his/her recliner without the call light within reach. The call light was observed to be on the floor approximately 6 feet away from the resident. During a subsequent interview with Staff Q following the above observation, she acknowledged the resident would not be able to access the call light if s/he needed assistance. Staff Q then proceeded to place the call light on the recliner where Resident ID #20 could reach it. 2. Record review for Resident ID #54 revealed that s/he was admitted to the facility in May of 2023 with diagnoses including, but not limited to, convulsions (seizures). Record review revealed a care plan dated 5/11/2023 which indicates an intervention dated 5/11/2023 for the call light to be kept within reach as s/he experiences bladder and bowel incontinence and has a history of falls. During a surveyor observation of the resident on 5/15/2023 at 10:45 AM, revealed the resident was in his/her room eating breakfast and the call light was observed to be out his/her reach, approximately 6 feet away. 3. Record review for Resident ID #61 revealed that s/he was admitted to the facility in August of 2022 with diagnoses including, but not limited to, diabetes. Record review revealed a care plan dated 3/21/2023 which includes an intervention dated 3/21/2023 for the call light to be kept within reach as s/he experiences bladder/bowel incontinence and has a history of falls. During surveyor observations of the resident s/he was observed to be lying in bed with his/her call light placed approximately 3 feet away from him/her and hanging on the resident's television on the following dates and times: - 5/15/2023 at 12:06 PM and 3:55 PM - 5/16/2023 at 11:49 AM and 12:15 PM During a surveyor observation and interview with Registered Nurse, Staff Q, on 5/16/2023 at 12:15 PM, she acknowledged that the call light was not within the resident's reach. 4. Record review for Resident ID #74 revealed that s/he was admitted to the facility in December of 2022 with diagnoses including, but not limited to, high blood pressure. Record review revealed a a care plan dated 5/9/2023 which includes an intervention to keep his/her call light within reach as s/he is at risk for falls related to a fall risk assessment. During a surveyor observation and interview with the resident on 5/16/2023 at 12:21 PM, the resident was observed in his/her room, sitting in a wheelchair with his/her bedside table in front of her. S/he indicated s/he was having difficulty with eating the lunch meal due to experiencing pain in his/her right arm. Additionally, the resident indicated the call light was out of his/her reach. The call light was observed to be on the floor and out his/her reach approximately a foot away. During a surveyor interview with Licensed Practical Nurse, Staff R, following the above-mentioned observation, she acknowledged that the call light was not within the resident's reach.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed, in accordance with professional standa...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed, in accordance with professional standards for food service safety, relative to the main kitchen. Findings are as follows: The United States Food and Drug Administration Food Code 2022 Edition 3-701.11, states in part, Discarding .Contaminated Food .A FOOD that is unsafe .shall be discarded . Review of the facility policy, titled, Dietary Department Infection Control Guidelines, states in part, .Food .All stock items will be monitored for expiration dates, and used and discarded as necessary . During an initial tour of the main kitchen, on 5/15/2023 at 9:22 AM, in the presence of the Food Service Director (FSD) revealed sixteen loaves of Pullman Wheat Bread with use by dates of 4/11/2023, 5/2/2023, and 5/8/2023. Additional surveyor observation revealed three of the loaves of bread had large amounts of green matter throughout the bread. During an interview with the FSD following the above observation, he acknowledged the above-mentioned observations and indicated that the loaves of bread should have been discarded.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0944 (Tag F0944)

Could have caused harm · This affected most or all residents

Based on record review and staff interview, it has been determined that the facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI), outlines mandatory training and inf...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI), outlines mandatory training and informs staff of the elements and goals of the facility's QAPI program. Findings are as follows: Review of the facility QAPI program updated on 1/4/2023 failed to reveal evidence that that it included mandatory training or an outline on how to inform staff of the elements and goals of the program. During a surveyor interview with the Administrator and the Director of Nursing Services on 5/22/2023 at 11:29 AM, they were unaware that their QAPI program must include the above-mentioned training or way to communicate the goals of the program to staff.
Nov 2022 1 deficiency
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Deficiency Text Not Available

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Deficiency Text Not Available
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Why is there high staff turnover? How do you retain staff?"
  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • Licensed and certified facility. Meets minimum state requirements.
Concerns
  • • 33 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
  • • $82,492 in fines. Extremely high, among the most fined facilities in Rhode Island. Major compliance failures.
  • • Grade D (40/100). Below average facility with significant concerns.
  • • 63% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.

About This Facility

What is Brentwood Health Center's CMS Rating?

CMS assigns Brentwood Health Center an overall rating of 3 out of 5 stars, which is considered average nationally. Within Rhode Island, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is Brentwood Health Center Staffed?

CMS rates Brentwood Health Center's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 63%, which is 17 percentage points above the Rhode Island average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 55%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Brentwood Health Center?

State health inspectors documented 33 deficiencies at Brentwood Health Center during 2022 to 2025. These included: 1 that caused actual resident harm, 31 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Brentwood Health Center?

Brentwood Health Center is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by EDEN HEALTHCARE, a chain that manages multiple nursing homes. With 96 certified beds and approximately 82 residents (about 85% occupancy), it is a smaller facility located in Warwick, Rhode Island.

How Does Brentwood Health Center Compare to Other Rhode Island Nursing Homes?

Compared to the 100 nursing homes in Rhode Island, Brentwood Health Center's overall rating (3 stars) is below the state average of 3.1, staff turnover (63%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Brentwood Health Center?

Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.

Is Brentwood Health Center Safe?

Based on CMS inspection data, Brentwood Health Center has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Rhode Island. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Brentwood Health Center Stick Around?

Staff turnover at Brentwood Health Center is high. At 63%, the facility is 17 percentage points above the Rhode Island average of 46%. Registered Nurse turnover is particularly concerning at 55%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Brentwood Health Center Ever Fined?

Brentwood Health Center has been fined $82,492 across 1 penalty action. This is above the Rhode Island average of $33,904. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.

Is Brentwood Health Center on Any Federal Watch List?

Brentwood Health Center is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Brentwood Health Center

4000 Post Road, Warwick, RI 02886 | (401) 884-8020

D
Trust Grade (40/100)
3.0
CMS Rating
33
Deficiencies

Strengths

  • 4-star quality

Concerns

  • 33 deficiencies

Ask about: Staff Retention, Rn Coverage

nursinghomedata.org | Data: CMS November 2025