Cycle 1
Health 2025-06-09 · Fire 2025-06-09
6 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Warwick, RI
West Shore Health Center Inc
3-star overall rating with 4-star inspections with 6 recent health deficiencies
109 West Shore Road, Warwick, RI
(401) 739-9440
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
145
Certified beds
Average residents
130
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Health Concepts, Ltd.
Operator or chain grouping
Approved since
1970-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 4 overall / 4 health / 3 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.06
Nurse aide staffing · state 2.46 · national 2.35
Total nurse hours
3.08
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.01
RN + LPN hours · state 1.25 · national 1.54
Weekend hours
2.76
Weekend nurse staffing · state 3.30 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.10
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
48%
Annual RN turnover · state 38% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,395
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.04
Composite VBP score used to determine payment impact.
Payment multiplier
0.9875
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.10% · Performance 21.69% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
8.50
Baseline 8.85% · Performance 5.38% · Measure score 8.50 · Achievement 8.21 · Improvement 8.50
Total nurse turnover
4.60
Baseline 45.98% · Performance 44.86% · Measure score 4.60 · Achievement 4.60 · Improvement 0.03
Adjusted total nurse staffing
0.11
Baseline 2.95 hours · Performance 3.12 hours · Measure score 0.11 · Achievement 0 · Improvement 0.11
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.36% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 126 · Observed rate 9.52% · Lower 95% interval 7.18% |
| Discharge to community | 45.42% |
50.57%
5.1 pts worse
|
No Different than the National Rate · Eligible stays 108 · Observed rate 38.89% · Lower 95% interval 36.92% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 65 · Denominator 65 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 65 |
| Discharge self-care score | 46.43% |
53.69%
7.3 pts worse
|
Numerator 26 · Denominator 56 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 28 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 1.54% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 65 · Adjusted rate 1.99% |
| Healthcare-associated infections requiring hospitalization | 5.38% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 72 · Observed rate 0% · Lower 95% interval 2.84% |
| Staff COVID-19 vaccination coverage | 4.24% |
8.2%
4 pts worse
|
Numerator 7 · Denominator 165 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 28 · Denominator 56 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 37 · Denominator 37 |
| Resident COVID-19 vaccinations up to date | 26.67% |
25.2%
1.5 pts better
|
Numerator 8 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.7
0.1 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 68.3% |
93.2%
24.9 pts worse
|
93.4%
25.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 72.3% · Q2 63.8% · Q3 61.3% · Q4 75.7% · 4Q avg 68.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 85.6% |
95.3%
9.7 pts worse
|
95.5%
9.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 85.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
3.6%
1.6 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 6.9% · Q3 4.5% · Q4 4.3% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
14.6%
13.9 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 1.8% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 3.8% |
5.3%
1.5 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.0% · Q3 4.3% · Q4 4.0% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.3% |
16.4%
1.9 pts worse
|
19.6%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 17.8% · Q3 17.0% · Q4 19.2% · 4Q avg 18.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 30.7% |
23.6%
7.1 pts worse
|
16.7%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.1% · Q2 25.9% · Q3 35.4% · Q4 31.7% · 4Q avg 30.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.1% |
17.0%
9.1 pts worse
|
16.3%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.7% · Q2 24.3% · Q3 24.0% · Q4 25.1% · 4Q avg 26.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.4% |
18.4%
11 pts worse
|
14.9%
14.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 28.0% · Q3 19.0% · Q4 36.3% · 4Q avg 29.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.0%
0.7 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 0.7% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.7% |
2.2%
1.5 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.9% · Q3 5.5% · Q4 7.8% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.6% |
22.3%
10.7 pts better
|
19.8%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 11.7% · Q3 14.1% · Q4 7.1% · 4Q avg 11.6% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
4.7%
0.8 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.1% · Q3 5.3% · Q4 3.8% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.4% |
77.2%
1.8 pts worse
|
81.7%
6.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 78.7% · Q2 76.8% · Q3 74.8% · Q4 72.0% · 4Q avg 75.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.8% |
15.8%
6 pts worse
|
12.0%
9.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.8% · Observed 20.8% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
1.9%
0.7 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 2.0% · Q3 3.6% · Q4 3.2% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.8% |
78.2%
1.6 pts better
|
79.7%
0.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.7% |
25.1%
1.6 pts worse
|
23.9%
2.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.7% · Observed 20.8% · Expected 18.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-07 · Fire 2024-06-07
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-05-11 · Fire 2023-05-11
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-06-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-07
F · Potential for more than minimal harm
2023-05-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-09
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-07-09
E · Potential for more than minimal harm
2025-06-09
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-06-09
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-06-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-06-09
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-06-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-09
F · Potential for more than minimal harm
2024-06-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-07
E · Potential for more than minimal harm
2024-06-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-07
E · Potential for more than minimal harm
2024-06-07
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-07-07
D · Potential for more than minimal harm
2024-06-07
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-07-07
F · Potential for more than minimal harm
2023-05-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-05
D · Potential for more than minimal harm
2023-05-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-05
D · Potential for more than minimal harm
2023-05-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-05
Penalties and ownership
What sits behind the stars
Ownership
Ryan, David
5% Or Greater Direct Ownership Interest · Individual
Ryan, Sally
5% Or Greater Direct Ownership Interest · Individual
Arnold, Kelly
Operational/Managerial Control · Individual
Carragher, Terry
Corporate Officer · Individual
Darosa, Elizabeth
W-2 Managing Employee · Individual
Gelfuso, Pamela
W-2 Managing Employee · Individual
Health Concepts Ltd
Operational/Managerial Control · Organization
Ryan, David
Corporate Officer · Individual
Ryan, Sally
Corporate Director · Individual
Ryan, Sally
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Avalon Nursing Home INC
Warwick, RI
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Scandinavian Home Inc
Cranston, RI
4-star overall rating with 5-star inspections with 2 recent health deficiencies
#3
Sunny View Nursing Home
Warwick, RI
1-star overall rating with 1-star inspections with $74,833 in total fines with 15 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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