Deficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
174% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 2, 2025
Visit Reason
The inspection was conducted in response to a community complaint submitted on 2025-11-28 alleging unsanitary conditions in the kitchen that caused death and sickness among residents, including concerns about unclean dishes, silverware, cups, and coffee mugs.
Complaint Details
Complaint was substantiated based on observations and interviews confirming unsanitary kitchen conditions contributing to resident harm.
Findings
The facility failed to ensure food was stored, served, and distributed according to professional food service safety standards, with observations of unclean dishes, improperly labeled and stored food, and buildup of residue on kitchen equipment. The Food Service Director and Administrator acknowledged these deficiencies and the lack of evidence for maintaining sanitary conditions.
Deficiencies (1)
Food was not procured from approved sources or stored, prepared, distributed, and served in accordance with professional standards, including unclean dishes and kitchen equipment.
Report Facts
Coffee cups with visible brown staining: 51
Coffee pitchers with visible residue: 7
Coffee carafes with visible residue: 2
Hot dogs in opened zip-lock bag: 4
Undated trays of prepared lettuce: 3
Muffins in container labeled 11/22/2025: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Acknowledged deficiencies in kitchen cleanliness and food storage | |
| Administrator | Unable to provide evidence of sanitary maintenance and expected FSD responsibility |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jun 11, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of care related to treatment and wound care for residents, including review of skin assessments, physician orders, and care plans for residents with wounds and pressure ulcers.
Findings
The facility failed to ensure appropriate treatment and care for residents with skin impairments and pressure ulcers, including failure to obtain treatment orders for rashes and excoriations, and failure to implement wound care treatments as ordered. This resulted in residents being transferred to the hospital with worsening conditions.
Deficiencies (2)
Failure to provide appropriate treatment and care according to orders and care plans for a resident with non-pressure wounds, including lack of treatment orders for a rash on the vertebrae.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including lack of treatment orders and failure to implement wound care treatments as ordered for residents with pressure ulcers.
Report Facts
Blood pressure reading: 240
Blood pressure reading: 120
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Admitting nurse interviewed regarding treatment orders and skin assessments |
| Director of Nursing Services | Director of Nursing Services | Acknowledged lack of treatment orders and expectations for skin assessments and treatment orders |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 3, 2025
Visit Reason
The inspection was conducted following complaints and reported incidents regarding physical abuse and improper use of physical restraints on residents at West View Nursing & Rehabilitation Center.
Complaint Details
The complaint investigation was substantiated as the facility failed to prevent physical abuse of Resident ID #7 and failed to prevent improper physical restraint of Resident ID #1. The staff member who pushed the wheelchair was suspended pending investigation.
Findings
The facility failed to keep one resident free from physical abuse when an Activity Aide pushed a resident's wheelchair aggressively causing it to hit a wall, and failed to ensure that one resident was free from physical restraints as a bed sheet was tied across the resident without a physician's order or proper documentation. The staff member involved in the abuse was suspended and additional abuse training was provided to staff.
Deficiencies (2)
Failed to protect a resident from physical abuse when an Activity Aide pushed the resident's wheelchair aggressively causing it to hit a wall.
Failed to ensure a resident was free from physical restraints; resident was found tied to bed with a sheet without physician order or proper documentation.
Report Facts
Residents reviewed for abuse: 7
Residents reviewed for restraint: 1
Date of survey completion: Mar 3, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Activity Aide | Acknowledged pushing Resident ID #7's wheelchair aggressively causing it to hit the wall. |
| Staff F | Nursing Assistant | Witnessed Staff G pushing the resident's wheelchair aggressively. |
| Staff A | Certified Nursing Assistant | Admitted to tying Resident ID #1 to bed with a sheet. |
| Staff B | Certified Nursing Assistant | Reported finding Resident ID #1 tied to bed with a sheet. |
| Staff D | Registered Nurse | Described tucking Resident ID #1 in bed with a sheet, acknowledged as a restraint. |
| Staff E | Certified Nursing Assistant | Observed Staff D placing sheet across Resident ID #1's stomach and tucking it under mattress. |
Inspection Report
Routine
Deficiencies: 10
Date: Nov 21, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility standards, including resident care, medication management, infection control, and food service safety.
Findings
The facility was found deficient in multiple areas including failure to support resident choice in bathing, inadequate pressure ulcer care, improper foot care, failure to change suprapubic catheters timely, administration of unnecessary medications, improper medication storage, failure to assist residents in obtaining dental care, failure to provide food and fluids in prescribed consistencies, unsafe food temperatures, and inadequate infection prevention practices related to Enhanced Barrier Precautions.
Deficiencies (10)
Failed to promote and facilitate resident self-determination through support of resident choice related to weekly showers for Resident ID #29.
Failed to ensure residents with pressure ulcers receive necessary treatment and services consistent with professional standards for Residents ID #65 and #84.
Failed to ensure residents receive proper foot care and treatment for Resident ID #29.
Failed to provide appropriate care for Resident ID #16 with a suprapubic catheter, including failure to obtain orders for catheter changes and failure to ensure urology follow-up.
Failed to ensure resident's drug regimen is free from unnecessary drugs; Midodrine was administered despite parameters to hold for Resident ID #74.
Failed to store drugs and biologicals in accordance with professional principles, including expired medications and improper storage of controlled substances.
Failed to assist Resident ID #62 in obtaining routine and emergency dental care, resulting in missed appointments and untreated dental pain.
Failed to provide and prepare food and fluids in a form designed to meet individual needs for Residents ID #7, #26, and #98 with prescribed thickened fluids; fluids were not prepared to prescribed consistencies.
Failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, including unsafe food temperatures for Resident ID #45 and ice machines without air gaps.
Failed to maintain an infection prevention and control program, including failure to implement Enhanced Barrier Precautions for Residents ID #84 and #458.
Report Facts
Shower opportunities: 40
Bed baths documented: 25
No shower documented: 7
Not applicable: 8
Pressure ulcer size: 3.5
Pressure ulcer size: 8.5
Pressure ulcer size: 0.1
Pressure ulcer size: 3
Pressure ulcer size: 1.4
Pressure ulcer size: 0.1
Wound measurement: 0.3
Wound measurement: 0.2
Wound measurement: 0.1
SP catheter change interval: 6
Missed catheter changes: 3
Midodrine administration errors: 9
Expired medications: 22
Food temperature: 66.6
Food temperature: 63.7
Safe food temperature: 41
Ice machines without air gap: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Nursing Assistant | Mentioned in relation to failure to provide showers to Resident ID #29 |
| Staff G | Registered Nurse | Observed applying incorrect wound dressing to Resident ID #65 |
| Staff F | Nursing Assistant | Acknowledged likely not assisting Resident ID #29 with shower on scheduled day |
| Staff E | Registered Nurse | Acknowledged Resident ID #29's foot care deficiencies and failure to provide podiatry services |
| Staff N | Certified Medication Technician | Administered Midodrine despite parameters to hold for Resident ID #74 |
| Staff P | Certified Medication Technician | Observed with improperly stored medications in medication cart |
| Staff R | Unit Secretary | Documented dental appointment scheduling and issues for Resident ID #62 |
| Staff A | Nursing Assistant | Prepared thickened fluids improperly for Resident ID #26 |
| Staff B | Nursing Assistant | Prepared thickened fluids improperly for Resident ID #7 |
| Staff C | Registered Nurse | Observed with Resident ID #98 regarding thickened fluids |
| Staff S | Nursing Assistant | Observed attempting to feed Resident ID #45 and acknowledged food had been sitting too long |
| Staff T | Nursing Assistant | Revealed no gown use for Resident ID #458 on Enhanced Barrier Precautions |
| Staff M | Licensed Practical Nurse | Acknowledged resident catheter issues and improper medication storage |
| Staff J | Wound Nurse | Acknowledged Resident ID #84 was not placed on Enhanced Barrier Precautions |
| Medical Director | Physician | Provided information on catheter orders and expectations |
| Director of Nursing Services | DNS | Acknowledged multiple deficiencies including catheter care, medication administration, thickened fluids, infection control, and medication storage |
| Administrator | Acknowledged dental transportation issues and food safety expectations | |
| Food Service Director | FSD | Acknowledged food temperature and ice machine deficiencies |
| Dietary Aid | Placed thickening packets on trays without training |
Inspection Report
Routine
Deficiencies: 5
Date: Jan 5, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, nutritional status, supervision, and data transmission of Minimum Data Set (MDS) assessments.
Findings
The facility failed to timely transmit accurate MDS data for 9 of 10 residents, failed to ensure adequate treatment and care for a resident with a change in condition resulting in actual harm, failed to provide adequate supervision to prevent accidents for a resident with dysphagia, failed to maintain residents' nutritional status and hydration for multiple residents, and failed to prevent significant medication errors for a resident who expired.
Deficiencies (5)
Failure to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to CMS within 14 days for 9 of 10 residents reviewed.
Failure to ensure residents receive treatment and care in accordance with professional standards for Resident ID #202, resulting in actual harm including dehydration and medication errors.
Failure to ensure adequate supervision to prevent accidents for Resident ID #81 during eating.
Failure to provide sufficient food/fluids to maintain health and failure to offer therapeutic diet when nutritional problems exist for multiple residents.
Failure to ensure residents are free from significant medication errors for Resident ID #202, including administration of medication despite physician orders to hold.
Report Facts
Residents with late MDS transmission: 9
Oral fluid intake: 580
Oral fluid intake: 840
Oral fluid intake: 0
Oral fluid intake: 1080
Oral fluid intake: 960
Oral fluid intake: 480
Oral fluid intake: 600
Weight loss: 5.8
Weight loss: 13.3
Weight loss: 6.58
Weight loss: 13.8
Weight loss: 6.83
Elevated sodium lab value: 146
Elevated BUN lab value: 31
Elevated sodium lab value: 150
Elevated BUN lab value: 32
Elevated sodium lab value: 148
Elevated BUN lab value: 29
Elevated sodium lab value: 148
Elevated BUN lab value: 32
Elevated sodium lab value: 152
Elevated BUN lab value: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nurse Practitioner | Authored progress notes and interviewed regarding medication errors and resident condition |
| Staff B | Registered Nurse | Interviewed regarding resident care, medication errors, and hydration |
| Staff C | Nursing Assistant | Acknowledged lack of supervision during resident eating |
| Staff D | Registered Nurse | Interviewed regarding diet orders and resident weight loss |
| Director of Nursing Services | Interviewed regarding supervision, medication errors, and hydration | |
| Registered Dietitian | Authored progress notes and interviewed regarding nutritional status and interventions |
Inspection Report
Routine
Deficiencies: 8
Date: Oct 14, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, pressure ulcer care, catheter care, respiratory care, medication administration, infection control, medication storage, and vaccination documentation at West View Nursing & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including inconsistent advance directive documentation, improper pressure ulcer treatment, inadequate catheter care, failure to provide ordered oxygen therapy, medication administration omissions, unlocked medication carts, failure to maintain infection control precautions especially for MRSA and quarantine residents, and lack of documentation for pneumococcal vaccinations.
Deficiencies (8)
Failed to ensure a resident's code status was consistent with advance directive and physician orders.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for 2 residents.
Failed to provide appropriate catheter care and prevent urinary tract infections for 1 resident.
Failed to provide respiratory care consistent with physician orders for oxygen therapy for 1 resident.
Failed to ensure residents were free from significant medication errors related to medication omissions for 2 residents.
Failed to ensure medication carts were kept locked or under direct observation for 1 medication cart.
Failed to maintain infection prevention and control program including failure to maintain contact precautions for MRSA positive resident and quarantine precautions for 2 residents.
Failed to document pneumococcal vaccination status for 4 residents.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Medication cart observed unlocked: 1
Residents affected: 1
Residents affected: 2
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Acknowledged not using appropriate wound care solution and medication cart unlocked and unattended |
| Staff D | Nurse Practitioner | Expected nurse to complete wound treatment as ordered |
| Staff E | Registered Nurse | Acknowledged lack of current wound treatment documentation |
| Staff F | Physical Therapist | Observed resident with uncovered urinary catheter bag and acknowledged it should have been covered |
| Staff G | Registered Nurse | Acknowledged resident was receiving less oxygen than ordered |
| Staff H | Licensed Practical Nurse | Acknowledged medication cart was left unlocked and unattended |
| Staff C | Wound Nurse/Infection Preventionist | Acknowledged failure to transcribe wound treatment order and lack of evidence for MRSA contact precautions |
| Staff I | Nursing Assistant | Failed to wear full PPE and perform hand hygiene entering quarantine rooms |
| Director of Nursing Services | Acknowledged discrepancies in advance directives, catheter bag covering, oxygen therapy, medication administration, medication cart security, infection control PPE, and vaccination documentation |
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