Inspection Reports for
Grace Barker Nursing Center
54 BARKER AVENUE, WARREN, RI, 02885
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
135% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
100% occupied
Based on a February 2025 inspection.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 20, 2025
Visit Reason
A revisit survey was conducted on March 20, 2025, for all previous deficiencies cited on the February 5, 2025, Life Safety Code survey.
Findings
All deficiencies have been corrected at this time. The facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Census: 82
Capacity: 82
Deficiencies: 7
Date: Feb 5, 2025
Visit Reason
A recertification survey was conducted at Grace Barker Nursing Center from 2/3/2025 through 2/5/2025 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were identified related to professional standards of care, respiratory/tracheostomy care, treatment/service for dementia, infection prevention and control, medication administration, and life safety code compliance. The facility failed to meet several regulatory requirements as evidenced by observations, record reviews, and staff interviews.
Deficiencies (7)
Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i) - Facility failed to provide services that meet professional standards of practice for wound care for Resident ID #23.
Respiratory/Tracheostomy Care and Suctioning CFR(s): 483.25(f) - Facility failed to provide respiratory care consistent with professional standards for Resident ID #13.
Treatment/Service for Dementia CFR(s): 483.40(b)(3) - Facility failed to provide appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Resident ID #23 with dementia.
Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f) - Facility failed to maintain an infection prevention and control program to prevent the development and transmission of communicable diseases and infections.
Life Safety Code - Emergency Lighting CFR(s): NFPA 101 - Facility failed to maintain emergency lighting systems in accordance with National Fire Protection Association standards.
Life Safety Code - Sprinkler System Maintenance CFR(s): NFPA 101 - Facility failed to maintain required clearance between sprinkler heads and combustible storage.
Life Safety Code - Gas Equipment Storage CFR(s): NFPA 101 - Facility failed to properly store oxygen cylinders and maintain safety measures for gas equipment.
Report Facts
Capacity: 82
Census: 82
Deficiencies cited: 7
Inspection Report
Routine
Deficiencies: 4
Date: Feb 5, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, infection control, and treatment services at Grace Barker Nursing Center.
Findings
The facility was found deficient in multiple areas including wound care, respiratory care, dementia treatment, and infection prevention and control practices. Several residents did not receive care consistent with physician orders or facility policies, and staff failed to follow proper infection control procedures during treatments and medication administration.
Deficiencies (4)
F 0658: The facility failed to provide wound care as ordered for Resident #23, including incomplete dressing changes and lack of physician orders for a bruise on the right elbow.
F 0695: The facility failed to provide appropriate respiratory care for Resident #13 diagnosed with pneumonia, including failure to complete required Respiratory Event documentation and develop a care plan.
F 0744: The facility failed to provide appropriate treatment and services for Resident #23 with dementia, including failure to administer PRN medication when resident was observed crying.
F 0880: The facility failed to maintain infection prevention and control, including improper cleaning and disinfecting of glucose meters, failure to perform hand hygiene and glove changes during dressing changes for Resident #179, and failure to disinfect an inhaler used for Resident #268.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 1
Wound size: 1.5
Wound size: 4.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Acknowledged wound dressing dated 2/3/2025 and incomplete treatment on 2/4/2025 for Resident #23 |
| Staff B | Licensed Practical Nurse | Completed dressing change on 2/3/2025 for Resident #23 |
| Staff C | Licensed Practical Nurse | Signed off treatment on 2/4/2025 for Resident #23 but dressing dated 2/3/2025 |
| Staff D | Licensed Practical Nurse | Observed failing to properly clean and disinfect glucose meters and failing hand hygiene during dressing changes |
| Staff E | Registered Nurse | Acknowledged failure to complete Respiratory Event document and care plan for Resident #13 |
| Staff F | Registered Nurse | Acknowledged no care plan developed for pneumonia for Resident #13 |
| Staff G | Nursing Assistant | Observed providing morning care to Resident #23 and did not notify nurses of resident crying |
| Staff I | Medication Technician | Observed failing to disinfect inhaler and use barrier during medication administration for Resident #268 |
| Director of Nursing Services | Director of Nursing Services | Acknowledged multiple care and infection control deficiencies including wound care, respiratory care, and infection prevention |
| Education Coordinator | Education Coordinator | Expected proper cleaning and disinfecting of glucose meters by Staff D |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 15, 2024
Visit Reason
The inspection was conducted due to allegations of sexual abuse by a staff member reported by residents, triggering a complaint investigation.
Complaint Details
The investigation was complaint-related based on allegations reported by Resident ID #1 and Resident ID #2 that Nursing Assistant Staff B touched them inappropriately. The facility did not investigate or report the allegation involving Resident ID #2 as required.
Findings
The facility failed to ensure that all alleged sexual abuse violations involving a staff member and two residents were thoroughly investigated and reported to the State Survey Agency as required by law.
Deficiencies (1)
F 0610: The facility failed to thoroughly investigate and report allegations of sexual abuse involving Nursing Assistant Staff B and Resident ID #2 as required by state law.
Report Facts
Residents reviewed: 2
Brief Interview for Mental Status score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Physical Therapy Assistant | Reported the sexual abuse allegations to the charge nurse and was interviewed by surveyors. |
| Staff B | Nursing Assistant | Alleged perpetrator of sexual abuse against residents. |
| Administrator | Interviewed by surveyors and unable to provide evidence of investigation or reporting of the allegation. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 28, 2024
Visit Reason
An off-site desk audit was conducted to review all previous deficiencies cited on February 23, 2024, and verify correction based on the submitted plan of correction and supporting documentation.
Findings
All previously cited deficiencies have been corrected, and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 7, 2024
Visit Reason
The inspection was conducted in response to a community reported complaint alleging that a resident eloped from the nursing home on 3/3/2024 and the facility failed to report the elopement to the Department of Health as required by state law.
Complaint Details
The complaint was substantiated. A community complaint was received alleging a resident eloped on 3/3/2024 and the facility failed to report the incident to the Department of Health as required by state law.
Findings
The facility failed to timely report an elopement event involving Resident ID #1 to the Department of Health within 24 hours as required by state regulations. The resident was found at a neighbor's house and returned to the facility with police assistance, but the administrator acknowledged not reporting the incident.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and the results of the investigation to proper authorities for one resident who eloped. The elopement was not reported to the Department of Health within the required timeframe.
Report Facts
Date of elopement: Mar 3, 2024
Date complaint received: Mar 6, 2024
Date survey completed: Mar 7, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Assistant | Staff A assisted in transporting the resident back to the facility | |
| Administrator | Acknowledged failure to report the elopement to the Department of Health |
Inspection Report
Recertification Survey
Census: 82
Capacity: 86
Deficiencies: 2
Date: Feb 23, 2024
Visit Reason
A Recertification Survey and complaint investigation were conducted at Grace Barker Nursing Center from 02/20/2024 through 02/23/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Complaint Details
The complaint investigation was part of the recertification survey, referenced by ACTS Reference Number 93745. Deficiencies related to bowel care and medication administration were substantiated.
Findings
Deficiencies were cited related to quality of care, specifically failure to provide care in accordance with professional standards and the facility's bowel protocol for multiple residents. Additional deficiencies were found in medication administration and drug regimen review. The facility submitted plans of correction addressing these issues. The annual Federal Life Safety Code survey found no deficiencies.
Deficiencies (2)
Failure to provide care in accordance with professional standards and the facility's bowel protocol for multiple residents.
Failure to ensure residents are free from significant medication errors and failure to conduct proper drug regimen reviews.
Report Facts
Deficiencies cited: 2
Census: 82
Total Capacity: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bryan C. | Administrator | Signed the Plan of Correction on 03/11/2024 |
Inspection Report
Routine
Deficiencies: 3
Date: Feb 23, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of practice, medication administration, and implementation of care protocols, including bowel management and medication regimen reviews.
Findings
The facility failed to follow the bowel protocol for 7 of 20 residents, resulting in inadequate bowel care. Additionally, the facility did not ensure that the Clinical Consultant Pharmacist identified medication irregularities during monthly reviews for one resident. Medication administration errors were found for 4 of 18 residents, including incorrect dosages, late administration, and failure to notify physicians of missed doses.
Deficiencies (3)
F 0684: The facility failed to provide care according to the bowel protocol for 7 residents, including failure to administer ordered medications and notify physicians after ineffective treatments.
F 0756: The facility failed to ensure the Clinical Consultant Pharmacist identified irregularities during monthly medication regimen reviews for 1 of 5 residents.
F 0760: The facility failed to ensure residents were free from significant medication errors for 4 of 18 residents, including incorrect dosages, late medication administration, and failure to notify physicians of missed doses.
Report Facts
Residents reviewed for bowel protocol: 20
Residents reviewed for medication errors: 18
Residents reviewed for pharmacist medication regimen review: 5
Medication regimen review dates: 6
Days without bowel movement: 6
Medication administration late times for Eliquis (Resident #9): 8
Antibiotic doses administered: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Minimum Data Set Coordinator, Registered Nurse | Acknowledged transcription error in buspirone order and failure to identify irregularities |
| Director of Nursing Services | Director of Nursing Services | Acknowledged failures in medication error prevention and bowel protocol adherence |
| Staff E | Certified Medication Technician | Reported process for notifying charge nurse of missed medication administration |
| Staff C | Registered Nurse | Described notification process for missed medications and acknowledged lack of physician notification |
| Staff D | Registered Nurse | Acknowledged resident did not receive correct amount of antibiotic doses |
| Staff B | Certified Medication Technician | Observed administering medication late and without breakfast as ordered |
| Nurse Practitioner | Nurse Practitioner | Expected staff to follow bowel protocol and medication administration times |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 29, 2023
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to provide professional nursing standards and adequate supervision, resulting in a resident sustaining a fracture and other injuries during a transfer.
Complaint Details
The complaint investigation was substantiated, revealing failures in nursing practice, supervision, and staff licensing that led to resident injury and jeopardized resident health and safety.
Findings
The facility failed to ensure that a Licensed Practical Nurse (LPN) provided services within their scope of practice, failed to ensure timely RN assessment and physician notification after a resident injury, failed to provide adequate supervision to prevent accidents, and employed nursing aides without active licenses or proper training.
Deficiencies (4)
F 0658: The facility failed to ensure services met professional nursing standards for 1 resident who sustained a fracture after an incident involving an LPN outside their scope of practice and lack of timely RN assessment or physician notification.
F 0689: The facility failed to ensure adequate supervision to prevent accidents, resulting in a resident sustaining a major injury during a transfer.
F 0728: The facility failed to ensure nurse aides employed more than 4 months completed required training and competency evaluations, with 9 of 30 nursing aides lacking evidence of such training or active licenses.
F 0835: The facility failed to administer resources effectively and efficiently to ensure nursing assistants were licensed, with multiple aides working without active licenses, including one involved in a resident injury.
Report Facts
John Hopkins Fall Risk Assessment score: 16
Number of Nursing Aides without completed training or active license: 9
Brief Interview for Mental Status score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Authored progress note on injury and applied steri strips; failed to notify physician |
| Staff B | Registered Nurse (RN) | Assessed resident 6.5 hours after injury and notified physician |
| Staff C | Nursing Assistant (NA) | Assisted in transfer during which resident was injured; worked without active NA license |
| Staff D | Charge Nurse (RN) | Did not assess resident or notify physician after injury |
| Staff E | Nursing Assistant (NA) | Assisted in transfer during which resident was injured; worked without active NA license |
| Director of Nursing Services | Director of Nursing | Could not provide evidence of timely RN assessment or professional standards compliance |
| Administrator | Facility Administrator | Acknowledged lack of system to track employee licenses and failure to ensure licensed nursing aides |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 2, 2023
Visit Reason
An off-site desk audit was conducted on February 2, 2023, to review all previous deficiencies cited on December 8, 2022.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed relative to life safety code.
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Dec 9, 2022
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with healthcare regulations and standards at Grace Barker Nursing Center.
Findings
The facility was found deficient in multiple areas including pressure ulcer care, respiratory care, food safety, and infection control. Several residents were affected by failures in treatment, documentation, and safety protocols.
Deficiencies (4)
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for 1 resident with a stage 4 pressure ulcer. Bilateral heel cuffs were not worn and the air mattress was not set to the resident's current weight as ordered.
F 0695: The facility failed to provide safe and appropriate respiratory care for 1 resident on oxygen therapy. The nasal cannula was not dated, oxygen administration was not documented, and there was no evidence of when the cannula was last changed.
F 0812: The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards. Several opened and rewrapped deli meats lacked use-by dates, and dietary aides were observed without required beard restraints.
F 0880: The facility failed to maintain an infection prevention and control program related to biohazard sharps containers. A medication cart's sharps container was overflowing with exposed needles accessible to residents on multiple occasions.
Report Facts
Resident weight: 156.4
Resident weight: 156.2
Oxygen flow rate: 2
Dates of observation: 9
Dates of observation: 6
Number of opened deli meats without use-by date: 3
Number of dietary aides observed without beard restraints: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse, Staff A | Acknowledged resident was not wearing heel cuffs and nasal cannula was undated | |
| Licensed Practical Nurse, Staff B | Acknowledged biohazard sharps container was overflowing and accessible to residents | |
| Director of Nursing Services | Acknowledged expectations for oxygen tubing changes and sharps container safety | |
| Food Service Director | Acknowledged dietary aides not wearing beard restraints and opened meats lacking use-by dates |
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Dec 8, 2022
Visit Reason
The document is a Plan of Correction (POC) related to deficiencies cited during a Federal Life Safety Code survey and a Recertification Survey conducted at Grace Barker Nursing Center to determine compliance with federal regulations and state licensure requirements.
Findings
Deficiencies were identified in the fire alarm system testing and maintenance, handling of resident funds, prevention and treatment of pressure ulcers, respiratory care including tracheostomy and suctioning, food safety and sanitation, and infection prevention and control. The facility failed to provide required documentation, maintain proper procedures, and ensure compliance with professional standards.
Deficiencies (6)
Fire alarm system testing and maintenance not conducted or documented as required by NFPA 70, NFPA 72, and NFPA 101 standards.
Facility failed to meet standards for handling resident funds, including lack of authorization documents and notarized statements within required timeframes.
Failure to provide necessary treatment and services to prevent and heal pressure ulcers for one resident.
Failure to provide respiratory care consistent with professional standards for residents requiring oxygen therapy and tracheostomy care.
Failure to ensure food safety requirements, including proper labeling, storage, and handling of food items and use of beard restraints by kitchen staff.
Infection prevention and control program deficiencies including improper handling of sharps containers and failure to maintain a safe environment to prevent communicable diseases.
Report Facts
Deficiencies cited: 6
Survey dates: 12/6/2022 through 12/9/2022
Resident IDs referenced: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Acknowledged resident was not wearing bilateral heel cuffs and nasal cannula was not set as ordered |
| Director of Nursing Services | Director of Nursing Services | Acknowledged sharps container overflow and expected staff to empty sharps container |
| Food Service Director | Food Service Director | Acknowledged dietary aides were not wearing beard restraints |
Inspection Report
Renewal
Deficiencies: 8
Date: Sep 17, 2021
Visit Reason
A Recertification Survey was conducted at Grace Barker Nursing Center from 09/14/2021 through 09/17/2021 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including State licensure and emergency preparedness surveys.
Findings
The facility was determined to not be in compliance with several requirements, with deficiencies identified related to residents' advance directives, professional standards of care for PICC line management, pressure ulcer treatment, mobility and range of motion, medication administration, dental services, therapeutic diets, and infection control.
Deficiencies (8)
Failure to ensure a resident's advance directive was consistent with the resident's electronic medical record and physician's orders.
Failure to ensure services provided met professional standards of quality relative to PICC line care for residents with pressure ulcers.
Failure to ensure a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice.
Failure to ensure a resident with limited range of motion received appropriate treatment to prevent further decrease in range of motion.
Failure to ensure residents were free of significant medication errors.
Failure to assist residents in obtaining routine dental care.
Failure to ensure residents received and consumed foods in the appropriate form as prescribed by a physician for therapeutic diets.
Failure to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and prevent communicable diseases and infections.
Report Facts
Survey dates: 4
Residents reviewed for medication errors: 9
Residents reviewed for dental services: 2
Residents reviewed for pressure ulcers: 4
Residents reviewed for limited range of motion: 4
Residents reviewed for therapeutic diets: 4
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