Grace Barker Nursing Center
54 Barker Avenue, Warren, RI 02885 · For profit - Corporation · 86 certified beds · (401) 245-9100 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- the CMS record shows $114,806 in federal fines (most recent 2023-09-29)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 13.2% | 19.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.2% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.6% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 5.7% | 2.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 2.4% | 17.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.9% | 3.6% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 10.6% | 16.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 19.3% | 16.7% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.4% | 4.2% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 9.5% | 22.3% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.9% | 22.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.0% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 86.5% | 78.2% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 25.5% | 24.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 17.5% | 14.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.68 | 1.59 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.32 | 1.68 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
51.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 66 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 52.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 46 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.37 therapist hours per resident per day in 2026Q1 — more than 63% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 51.4%CMS range 39.1–63.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 6.2–14.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 52.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 30.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 63.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 92.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 3.0–12.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.84 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 86 beds and averages 80.5 residents a day — about 94% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.87 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.64 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.94 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.20 hrs/resident/day on weekends vs 4.14 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.76 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
14 citations, most serious first — scroll within the box to see all.
- Immediate jeopardy · K2023-09-29 · tag F0835 — failed to run the facility competently — patternAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
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 be administered in a manner that enables it to use its' resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident relative to ensuring that it's Nursing Assistants were licensed. Findings are as follows: Record review revealed Resident ID #1 was admitted to the facility in August of 2021 with diagnoses including, but not limited to, Alzheimer's disease, anxiety disorder, difficulty walking, and age-related macular degeneration (a medical condition that causes impaired vision). Record review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 3 out of 15, indicating severely impaired cognition. Further review of the assessment revealed that the resident required extensive assistance of two staff members for transfers. Record review revealed on [DATE] at approximately 10:30 AM, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2023-09-29 · tag F0728 — failed to protect against nurse-aide misconduct — isolatedEnsure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
What the surveyor found here — an excerpt from the official record, may be distressing
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 ensure that employed Nursing Aides that worked in the facility as a nurse aide for more than 4 months, on a full-time basis, completed a training and competency evaluation program, or a competency evaluation program approved by the State, for 9 of 30 Nursing Aides reviewed who were employed at the facility and listed on the working schedule. Findings are as follows: Record review revealed Resident ID #1 was admitted to the facility in August of 2021 with diagnoses including, but not limited to, Alzheimer's disease, anxiety disorder, difficulty walking, and age-related macular degeneration (a medical condition that causes impaired vision). Record review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 3 out of 15, indicating severely impaired cognition. Further review of the assessment revealed that the resident required extensive assistance of two staff members for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2023-09-29 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
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 ensure that services provided meet professional standards of quality for 1 of 1 resident reviewed who sustained a fracture following an incident, relative to the nursing scope of practice of a Licensed Practical Nurse (LPN), Resident ID #1. Findings are as follows: Review of the R.I. Gen. Laws 5-34-3. (14) states in part, 'Professional nursing' is practiced by registered nurses (R.N.s). The practice of professional nursing is a dynamic process of assessment of an individual's health status; identification of healthcare needs . Further review failed to reveal the process of assessment is included in the Licensed Practical Nurse's scope of practice. According to PracticalNursing.org, a complete assessment, which includes .establishing a nursing diagnosis, setting goals and prescribing nursing interventions to meet health care needs, evaluating the response to interventions and care plans . is the responsibility of a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2023-09-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
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 ensure that each resident receive adequate supervision to prevent an accident for 1 of 1 resident reviewed with major injury, Resident ID #1. Findings are as follows: According to the Appendix PP State Operations Manual, a fall is defined in part as .An episode where a resident lost his/her balance and would have fallen, if not for another person . Record review revealed Resident ID #1 was admitted to the facility in August of 2021 with diagnoses including, but not limited to, Alzheimer's disease, anxiety disorder, difficulty walking, and age-related macular degeneration (a medical condition that causes impaired vision). Record review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 3 out of 15, indicating severely impaired cognition. Further review of the assessment revealed that the resident required extensive assistance of two staff members for transfers. Record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, clinical record review, and staff interview, 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 following proper infection control practices consistent with professional standards of practice for 1 of 1 resident observed with a disconnected indwelling catheter (a flexible tube inserted into your bladder that drains urine into a collection bag), who requires enhanced barrier precautions (EBP, personal protective equipment worn in addition to standard precautions that requires a gown and gloves for all residents with infection or colonization of a multidrug resistant organism [MDRO] and for residents with wounds or indwelling medical devices), Resident ID #8. Additionally, the facility failed to update their pneumonia vaccine policy to align with current guidelines as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-02-05 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
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 designed to provide a safe, sanitary environment, and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents observed during the use of a glucose meter to obtain a blood sugar, Resident ID #s 52 and 48, for 1 of 1 resident observed during a dressing change, Resident ID #179 and for 1 of 1 resident receiving an inhaler, Resident ID #278. Findings are as follows: 1. Review of the facility's policy titled CLEANING AND DISINFECTING THE [glucose] METER, provided to the surveyor on 2/5/2025, revealed two disposable wipes are needed for the meter, one wipe for cleaning and the second wipe for disinfecting the meter. 1a. Record review revealed Resident ID #52 was admitted to the facility with a diagnosis including, but not limited to, diabetes. Record review revealed a physician's order dated 6/25/2024 to administer Admelog SoloStar insulin per the sliding scale,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-05 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide services that meet professional standards of practice for 1 of 1 resident observed relative to wound care, Resident ID #23. 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 . Record review revealed the resident was admitted to the facility with diagnoses including, but not limited to, dementia and skin cancer. Record review revealed a physician's order dated 1/6/2025, to cleanse the open area to the left side of the face with normal saline (NS), pat dry, apply A&D ointment (a treatment used to treat minor skin irritations), followed by a non-adhesive pad and a transparent dressing, once daily. Review of the Treatment Administration Record (TAR) revealed the treatment order was signed off as completed on 2/3 and 2/4/2025. During…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 3 residents reviewed with a respiratory illness, Resident ID #13. Findings are as follows: Review of an undated facility policy titled, Practice for Change in Condition states in part, .Suspected Respiratory Illness .follow physician orders .test as ordered .follow order set for [positive] + virus .follow respiratory event orders .all other respiratory illness follow respiratory event and order set .document . Record review revealed Resident ID #13 was readmitted to the facility with a diagnosis including, but not limited to, asthma. Record review of a chest x-ray completed on 1/28/2025 indicated the resident had pneumonia. Record review of the physician's orders revealed an order, with a start date of 1/29/2025 for Levaquin (an antibiotic prescribed to treat infections), 500 mg daily for 10 days. Record review failed to reveal evidence that a Respiratory Event document was completed for the resident once…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-05 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide the appropriate treatment and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents reviewed with a diagnosis of dementia, Resident ID #23. Findings are as follows: Record review revealed the resident was admitted to the facility with a diagnosis including, but not limited to, dementia. Record review of a Quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 0 out of 15, indicating s/he has severe cognitive impairment. Record review revealed a physician's order dated 8/2/2024, to administer Trazodone (a medication prescribed to treat depression and other conditions determined by health care providers) 25 milligrams (mg) by mouth prior to morning care. Further review revealed the Trazodone is scheduled to be administered between 7:00 AM to 9:00 AM daily. Record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-15 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident, and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving sexual abuse are thoroughly investigated for 1 of 2 residents reviewed, Resident ID #2. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 7/5/2024 alleges in part, that Resident ID #1 reported to the Physical Therapy Assistant, Staff A, that Nursing Assistant (NA), Staff B, touched him/her inappropriately. Resident ID #1 reported that Staff B was on top of him/her with his clothes on. Record review revealed that the resident was admitted to the facility in February of 2024 with diagnoses including, but are not limited to, dementia, Alzheimer's disease, and anxiety disorder. Record review of the quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 9 out of 15, indicating that s/he had moderately impaired cognition. Review of Physical Therapy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-07 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
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 ensure that events that do not involve abuse and do not result in serious bodily injury (i.e. accident resulting in hospitalization admission, elopement) were reported to other officials (Department of Health), in accordance with State law for 1 of 1 resident reviewed for elopement, Resident ID #1. Findings are as follows: According to [NAME] Department of Health State Regulations for Nursing Facilities, 1.15.G, indicates that any elopement of an resident that results in the police being called must be reported in writing to the licensing agency within 24 hours or by the end of the next business day. Record review of a community reported complaint sent to the Rhode Island Department of Health on 3/6/2024 alleges that on 3/3/2024, a resident eloped from the nursing home. A neighbor allegedly alerted the police. Record review revealed that the resident was admitted to the facility in February of 2024 with diagnoses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-23 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
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 provide care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices relative to assessment and implementation of the bowel protocol for 7 of 20 residents reviewed, Resident ID #s 9, 26, 42, 54, 68, 71, and 189. Findings are as follows: Review of a facility provided policy titled, Bowel Protocol states in part, It is the policy of the facility to manage each resident's bowel function in order to promote regular, voluntary, controlled bowel evacuation of normal consistency . Further review of the policy revealed the following protocol: 1. Two days without bowel movement on day 3: 7-3 offer prune juice as ordered. 2. Two days without bowel movement day 3: 3-11 offer MOM [Milk of Magnesia] as ordered, if no bowel movement. 3. Three days without bowel movement day 4:7-3 offer Bisacodyl tabs as ordered, with no bowel movement. 4. Three days without bowel…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-23 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, it has been determined that the facility failed to ensure that the Clinical Consultant Pharmacist identified irregularities during the monthly pharmacist Medication Regimen Review (MRR) for 1 of 5 residents reviewed for unnecessary medications, Resident ID #38. Findings are as follows: Record review revealed that the resident was re-admitted to the facility in December of 2022 with diagnoses including, but not limited to, vascular dementia with other behavioral disturbance and generalized anxiety disorder. Record review revealed a progress note dated 9/1/2023 which states in part, New orders .Increase buspirone [medication used to treat anxiety] to 15 mg [milligrams] po [by mouth] bid [twice daily] . Record review revealed a physician order dated 9/1/2023 and discontinued 2/21/2024, which states, buspirone tablet; 15 mg; Amount to Administer: 1 tablet =15 mg; oral Frequency: Once a morning Special Instructions: 15mg PO BID. Review of the Medication Administration Records from September 2023 through February 2024, revealed the resident was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-23 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review and staff interview it has been determined that the facility failed to ensure that residents are free from significant medication errors for 4 out 18 residents reviewed for medication administration, Resident ID #s 9, 38, 187, and 188. Findings are as follows: Review of the facility policy titled Medication Administration; Lower Level indicates that some medications require specific administration times. Those times will be specified in the Medication Administration Record. 1a. Record review revealed Resident ID #38 was re-admitted to the facility in December of 2022 with diagnoses including, but not limited to, vascular dementia with other behavioral disturbance and generalized anxiety disorder (GAD). Record review revealed a progress note dated 9/1/2023 which states in part, New orders .Increase buspirone [Buspar, a medication used to treat anxiety] to 15 mg [milligrams] po [by mouth] bid [twice daily] . Record review revealed a physician order dated 9/1/2023, which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$114,806 in federal fines across 1 penalty.
- $114,806 — penalty dated 2023-09-29
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| LESCAULT, MARK | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER | 50% | since 11/28/2007 |
| LESCAULT, MARY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | 50% | since 03/31/2006 |
CMS files one row per role, so the 7 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $38K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in RI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Rhode Island Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 415014. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.