Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Adviniacare Newport, Llc during CMS and state inspections, most recent first.
The facility did not follow physician orders for scheduled weights and failed to implement its own reweigh policy for significant weight changes in two residents. One resident with hemiplegia, hemiparesis, and adult failure to thrive did not have monthly weights obtained as ordered, and multiple documented weight losses were not rechecked within the required timeframe. Another resident with type 2 DM experienced repeated large weight gains without any documented confirmation weights, despite facility policy requiring reweighs for substantial changes. The Dietitian and DON acknowledged that ordered weights and required reweights were not completed or could not be verified in the clinical record.
Food Storage and Nourishment Unit Sanitation Deficiencies: Surveyors found expired cultured buttermilk in the main kitchen, an unlabeled tuna sandwich in a refrigerator, and dirty microwaves with food residue and rust in two nourishment units. Staff acknowledged the expired food, the unlabeled item, the unclean microwaves, and that a staff member’s milk was stored in a resident freezer.
The facility failed to maintain an effective, comprehensive, data-driven QAPI program related to 2 of 2 CMT evaluations reviewed. A tracking system for employee evaluations, including CMT evaluations, was in place, but it did not show that the quarterly evaluations for two CMTs were completed until the surveyor identified the issue. The RDON was unable to provide evidence that the QAPI program was effectively implemented and maintained.
Lack of Privacy for Resident Council Meetings: Residents reported that monthly resident council meetings were held in the 1st floor dining room without privacy, and surveyors observed repeated staff interruptions during the meeting, including the DNS entering for water and to access her office, as well as other staff entering to use the kitchenette and sink. The Activities Director acknowledged that staff frequently interrupted the meetings and that the facility did not have another area for a private resident council meeting.
Failure to Follow Bowel Evacuation Protocol: The facility did not follow ordered bowel protocol interventions for two residents who went more than three days without a BM. One resident, who was on hospice and had abdominal complaints, also had a KUB ordered to rule out obstruction, but the record did not show it was completed. For both residents, the MAR and staff interviews showed that ordered MOM, bisacodyl suppository, and Fleet enema interventions were not carried out as required, and the DON could not provide evidence that the bowel protocol had been followed.
Unlocked Treatment Cart and Missing Smoking Assessments: A treatment cart on a secured unit was left unlocked and unattended while it contained treatment meds and clean razors, with two cognitively impaired residents observed nearby in the hallways. The facility also lacked required quarterly smoking capability evaluations for a resident who wished to smoke and remained on the smoker list, and the DNS acknowledged the missing re-evaluations.
A resident’s privacy curtain was observed with large brown staining and remained dirty on repeat observation. Surveyors also observed flies in resident rooms and common areas, while resident council minutes and resident interviews described ongoing housekeeping problems, including limited coverage, unclean bathrooms, unemptied trash, and unrefilled supplies. Staffing records showed only one housekeeper on many days, with coverage limited to specific floors, and the DON acknowledged housekeeping staffing was insufficient.
A resident with a history of acute DVT/embolism had an active order for Eliquis 5 mg BID in the EMR, but the paper MAR showed the order as discontinued without provider documentation. The MAR also did not show Eliquis administration for 5 opportunities, and an LPN and the DON acknowledged the order remained active and should not have been discontinued.
Failure to provide ADL care for a resident receiving hospice services. The resident had severe malnutrition, depression, cataracts, adult failure to thrive, and moderately impaired cognition, and required max assistance with personal hygiene, bathing, and toileting due to bowel and bladder incontinence. The resident reported being uncomfortable because care had not been provided for two days, while staff and record review showed no evidence of ADL care during the day shift on two consecutive days. Staff also indicated they believed hospice would provide the care, but the hospice aide had not come in, and the DON could not verify that the resident received the needed care.
Failure to Monitor Foley Catheter Output: A resident with an indwelling Foley catheter and urinary retention had urine output monitoring gaps. The physician ordered catheter drainage checks every shift, and facility policy required the drainage bag to be emptied at least every 8 hours. However, the record showed multiple missed opportunities to document urine output, including failures to record output and to measure/document it in mL every shift. Both the NA and DON acknowledged that staff were responsible for emptying the bag, measuring the urine, and documenting the output each shift.
A resident with a J-tube and diagnoses including adult failure to thrive and GERD was observed receiving continuous enteral feeding while lying flat, despite an order to keep the HOB elevated to 30 degrees continuously. Surveyors also found the enteral feeding bag was not labeled or dated as required by policy. An RN acknowledged both issues, and the DON stated the HOB should have been elevated and the bag labeled and dated.
Medication Administration Error Rate Exceeded Threshold: Surveyors observed a 16% med error rate during 25 medication passes, involving four residents. A CMT gave carvedilol to a resident despite a HR of 42 when the order required holding it if HR was below 60. An RN failed to sanitize an insulin pen hub and did not prime insulin pen needles for three residents before administering Humalog or lispro insulin, and the DON acknowledged the errors.
Failure to follow EBP precautions occurred when a CNA dressed, bathed, and transferred residents without wearing a gown as required by posted signage, and a laundry aide moved between rooms of residents on EBP without sanitizing her hands. The DON acknowledged that the residents were on EBP and that staff should have worn a gown and gloves for dressing, bathing, and transferring, while the aide initially claimed to have used room sanitizers even though the dispensers were empty.
Resident identifying information was left visible in a State Survey Results binder posted in the public entrance area. The binder included rosters linking resident names to survey ID numbers for multiple surveys, along with physician orders and medical diagnoses. The Administrator acknowledged that the names and corresponding identifiers were available to view and should not have been.
Surveyors identified several deficiencies in dietary services, including unsanitary kitchen conditions, improper food cooling and storage, serving milk above safe temperatures, storing frozen supplements in the refrigerator, a malfunctioning dish machine, and failure of dietary staff to follow hand hygiene protocols after handling soiled equipment.
A survey revealed multiple deficiencies in food safety and cleanliness at a LTC facility. The dish machine was improperly sanitized due to incorrect test strips, and various kitchen areas had significant cleanliness issues. Additionally, improper food thawing and cold holding temperatures were observed, along with improper drying of meal trays and an unclean ice machine.
A resident with a history of pressure ulcers and other medical conditions developed an open wound on the right heel due to the facility's failure to conduct weekly skin checks and provide necessary treatment. The wound was not identified or treated until a surveyor's observation, and staff failed to notify the physician or apply appropriate care.
The facility failed to ensure that nursing staff, including two RNs and four NAs, had documented competencies necessary for providing adequate care. A review of records and staff interviews revealed no evidence of completed competencies for these staff members, and the Infection Preventionist could not provide documentation during a surveyor interview.
The facility failed to ensure menus met residents' nutritional needs according to national guidelines. The diet manual was outdated, and the menu lacked therapeutic exchanges for specific diets. Portion sizes did not match packaging labels, and there was no nutritional analysis for meals. The FSD could not provide evidence of standardized recipes or staff training on therapeutic diets. The Registered Dietitian was not involved in menu planning or review.
A facility failed to maintain an effective training program for its staff, as required by its own assessment. Training records for eight staff members, including RNs and NAs, showed significant gaps in areas such as abuse, resident rights, infection control, dementia care, and the QAPI program. The Director of Nursing was unable to provide evidence of completed in-services, indicating a systemic issue in the facility's training program.
The facility failed to apply hand splints as ordered for three residents with hemiplegia, leading to a deficiency in care. Despite physician orders for daytime use of resting hand splints, observations revealed the splints were not applied, and there was no documentation of resident refusal. The DNS and ADNS acknowledged the oversight but could not provide explanations.
A facility failed to adhere to its policy of replacing oxygen tubing weekly for a resident with COPD. Despite a physician's order for supplemental oxygen and a policy requiring weekly changes, surveyors observed the resident using discolored tubing dated over a month old. The DNS confirmed the expectation for weekly changes but could not explain the oversight.
The facility failed to properly store and secure medications, with expired drugs found in a medication room, unlocked and unattended medication carts, and medications left at the bedside of two residents. Staff acknowledged these lapses, and the DON emphasized the importance of proper medication handling.
The facility failed to accurately document medical records for three residents, leading to discrepancies in the application of prescribed devices. A resident with a stroke was found without a required hand splint, despite records indicating it was applied. Another resident with heart disease and pulmonary embolism was observed with only one TED stocking, contrary to physician orders. The DNS and staff were unable to explain these inaccuracies.
The facility failed to maintain a sanitary environment in the basement conference room due to water leakage from a ceiling light, caused by an overflowing toilet on the second floor. This issue had occurred previously, but the Assistant Director of Maintenance did not report it, believing it was resolved. The Administrator and DON were unaware of the problem, and the room's sanitation after previous incidents was not explained.
The facility failed to follow physician's orders for three residents, including not documenting weights for a dialysis-dependent resident, incorrect air mattress settings for a resident with Alzheimer's, and missing TED stockings for a resident with heart disease. Staff were unable to explain these discrepancies.
A resident with a gastrostomy tube was self-administering bolus feedings without proper checks for tube placement, contrary to facility policy. The resident and an LPN confirmed that tube placement was not consistently checked before feeding. The DON acknowledged the resident's self-administration but lacked evidence of a competency assessment for safe self-administration.
A pharmacist failed to report medication irregularities for a resident with type 2 diabetes mellitus. The resident's insulin was administered outside the ordered parameters multiple times in August 2024, but the pharmacist's report did not identify these issues, nor were they reported to the attending physician, Medical Director, or DON as required.
The facility failed to prevent significant medication errors for two residents. One resident with diabetes received incorrect insulin dosages, while another with schizophrenia missed doses of Quetiapine due to unavailability. The DON acknowledged these issues, highlighting a lapse in medication management.
A facility failed to provide a resident with food in the appropriate form as per their mechanical soft diet order. The resident's Salisbury Steak was cut into strips larger than the required size. A nursing assistant acknowledged cutting the steak incorrectly, and a speech-language pathologist confirmed the proper size was not adhered to.
A resident with severe cognitive impairment, including dementia and delusional disorder, eloped from a secured unit in an LTC facility due to inadequate supervision. Despite being redirected multiple times by staff during activities, the resident managed to leave the facility unsupervised. The facility's administrator acknowledged the resident's exit-seeking behavior as a change in condition but failed to ensure adequate supervision to prevent the incident.
Failure to Follow Physician Orders and Reweigh Policy for Significant Weight Changes
Penalty
Summary
The facility failed to meet professional standards of quality by not following physician orders and its own weight assessment policy for multiple residents. For one resident with hemiplegia, hemiparesis, and adult failure to thrive who was readmitted in October 2025, physician orders required monthly weights beginning in August 2025 and weekly weights for four weeks starting in January 2026. The clinical record showed weights documented in September, November, January, and February, but there was no evidence that weights were obtained in October and December as ordered. During interviews, the Dietitian and the Director of Nursing Services acknowledged that the ordered weights for this resident in October and December 2025 could not be verified. The facility also failed to follow its policy titled “Weight Assessment and Interventions,” which requires that any weight change of 5 lbs in a month or 3 lbs in a week be rechecked within 72 hours for confirmation and verified by nursing. For the first resident, the record showed a 13.4 lb loss between early November and early January, a 3.8 lb loss between early and mid-January, and a 4.2 lb loss between late January and mid-February, with no documentation that any of these weights were rechecked. For a second resident admitted in November 2025 with type 2 diabetes mellitus and ordered to have weekly weights for four weeks, the record showed multiple significant weight gains between early November and early February, including gains of 7.8 lbs, 10.4 lbs, 7.8 lbs, and 6 lbs between successive weigh dates, without evidence of required reweights. The Dietitian confirmed that reweights were not obtained per policy for these residents, and the Director of Nursing Services was unable to provide documentation of the required reweights.
Food Storage and Nourishment Unit Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen and in two nourishment units. During observation of the main kitchen, eight one-quart cartons of cultured buttermilk were found with a use-by date of 12/8/2025, and the Food Service Director acknowledged that the buttermilk was expired and should be discarded. At the second-floor nourishment unit, surveyors observed a packaged tuna fish sandwich in the refrigerator without a label or date, and the inside of the microwave had brown food matter stuck to the ceiling and walls, a greasy residue on the door, and a rotating plate covered in a brown liquid. At the third-floor nourishment unit, surveyors observed a 16 oz Styrofoam cup with a plastic bag inside that appeared to contain milk and was labeled in Spanish, "Don't touch please," stored in the freezer, and the inside of the microwave had rust lining the edges of the ceiling that flaked off when touched. Staff acknowledged the unlabeled sandwich, dirty microwave, rusted microwave, and that the milk belonged to another staff member and should not have been stored in the resident freezer.
QAPI Program Failed to Track Required CMT Evaluations
Penalty
Summary
The facility failed to implement and maintain an effective, comprehensive, data-driven QAPI program focused on indicators of outcomes of care and quality of life, related to 2 of 2 certified medication technician (CMT) evaluations reviewed, Staff N and O. Review of the QAPI binder with the Administrator and Regional Director of Nursing Services showed that a performance improvement plan had been implemented on 6/17/2024 to establish a tracking system for employee evaluations, including CMT evaluations. However, this tracking system did not show evidence that the quarterly evaluations for CMTs Staff N and O were completed until the surveyor brought the issue to the facility's attention during the survey. During interview, the Regional Director of Nursing Services was unable to provide evidence that the facility had implemented and maintained an effective QAPI program.
Lack of Privacy for Resident Council Meetings
Penalty
Summary
The facility failed to provide a private space for monthly resident council meetings, and residents reported that their meetings were typically held in the 1st floor dining room without privacy. During the resident council meeting, surveyors observed multiple interruptions by staff entering the room, including a staff member going into the kitchenette area, the DNS entering to get water from the cooler and later entering again to go into her adjacent office, another staff member using the sink, and a staff member entering for an unknown reason. During interview, the Activities Director stated she was aware that staff frequently interrupted the resident council meetings and that the facility did not have another area for residents to conduct a private meeting, while also stating she would expect the facility to provide a private space for the resident council meetings.
Failure to Follow Bowel Evacuation Protocol
Penalty
Summary
The facility failed to follow and implement physician orders related to its bowel evacuation protocol for two residents who had no bowel movement for more than three days. The facility policy stated that if a resident had no bowel movement for 9 consecutive shifts, the bowel protocol was to begin with Milk of Magnesia on the 3:00 PM to 11:00 PM shift, followed by a bisacodyl suppository if ineffective, then a Fleet enema if still ineffective, with results recorded and the physician notified if the protocol did not work. One resident was admitted with severe protein-calorie malnutrition and was receiving hospice services. The resident was dependent for ADLs, toileting, and had bowel and bladder incontinence. Nursing notes documented abdominal complaints and a PA ordered a KUB to rule out bowel obstruction, but the record did not show the KUB was completed. The resident had no bowel movement for five days, and the MAR did not show that the ordered bowel protocol medications were given after three days without a bowel movement until the issue was brought to the facility’s attention by the surveyor. During interview, an RN acknowledged the resident had not had a bowel movement recorded in five days, no interventions had been implemented as ordered, and the KUB had not been completed. The second resident was admitted with diagnoses including adult failure to thrive and constipation and had moderately impaired cognition, bowel and bladder incontinence, and dependence on staff for ADLs, toileting, and hygiene. The resident had no bowel movement for five days, but the record did not show that Milk of Magnesia was administered after three days without a bowel movement. Milk of Magnesia was instead given on the fifth day, and the record did not show that the remaining ordered interventions were given or that the provider was notified per facility policy. During interview, the RN acknowledged the resident had not had a bowel movement recorded in five days and no interventions were implemented as ordered.
Unlocked Treatment Cart and Missing Smoking Assessments
Penalty
Summary
The facility failed to ensure the residents' environment remained as free of accident hazards as possible on a secured unit when a nursing treatment cart was observed unlocked and unattended in the hallway for 17 minutes. The cart contained treatment medications, including diclofenac gel, antifungal creams, hemorrhoidal cream, and a box of clean razors. During the observation, Resident ID #9, who had dementia and a BIMS score of 3 of 15, was wandering in the hallways in a wheelchair, and Resident ID #14, who had Alzheimer's disease and a BIMS score of 0 of 15, was walking independently in the hallways. The facility also failed to document quarterly smoking capability evaluations for Resident ID #21, who had an Occasional/Former Smoker Evaluation dated 3/14/2025 stating that the resident wished to smoke and remained on the facility's smoker list. The record did not show evidence of the required quarterly evaluations on 6/14/2025 and 9/14/2025. The DNS acknowledged that the resident was not re-evaluated for smoking capabilities quarterly as required by the facility's smoking policy.
Dirty privacy curtain and insufficient housekeeping coverage
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents when a privacy curtain in Resident ID #94’s room was observed with large brown stains splattered across its length. Resident ID #94 was admitted in March 2024 with a diagnosis including dementia. The curtain was observed on 12/16/2025 and again on 12/19/2025 with the same staining still present and not changed. A NA acknowledged the curtain was dirty, an LPN stated it was dirty and expected housekeeping and laundry to clean it, and the DON stated the curtain should have been removed and cleaned by housekeeping. The facility also failed to maintain housekeeping coverage for 2 of 3 units reviewed. Surveyors observed flies in occupied resident rooms and common areas, including inside a resident room and outside the nurses’ station. Resident council minutes from October and November 2025 documented concerns about flies in rooms and common areas. During resident council interview, several residents reported housekeeping was a problem and said only one housekeeper was on duty most of the time, with the second floor often going a week or longer without bathrooms cleaned, floors swept, trash emptied, or paper products refilled. Staffing records showed multiple dates when only one housekeeper was scheduled for the entire building, with that housekeeper assigned only to the first floor, and other dates when only two housekeepers were scheduled for the facility. The Director of Maintenance, housekeepers, and the Regional DON acknowledged the staffing was insufficient to provide residents with a safe, functional, sanitary, and comfortable environment.
Failure to Follow Eliquis Physician Order
Penalty
Summary
The facility failed to ensure that treatment and care were provided in accordance with professional standards of practice for a resident receiving Eliquis. The resident was admitted with a diagnosis including acute embolism and thrombosis of the right lower extremity deep veins and had a physician's order for Eliquis 5 mg twice daily entered in the EMR. The paper MAR showed the Eliquis order as discontinued on 12/16/2025, but the record did not show that the provider discontinued the order. During interview, an LPN acknowledged that the resident's Eliquis order was still active in the EMR, and the paper MAR did not show Eliquis administration for 5 opportunities from 12/16/2025 through 12/19/2025. The DON was unable to provide evidence that Eliquis had been administered as ordered and acknowledged that the order should not have been discontinued on 12/16/2025.
Failure to Provide ADL Care for a Hospice Resident
Penalty
Summary
The facility failed to provide ADL care for one resident receiving hospice services who was admitted with severe protein-calorie malnutrition, major depressive disorder, cataracts, and adult failure to thrive. The resident’s MDS assessment showed a BIMS score of 11 out of 15, indicating moderately impaired cognition, and the resident required maximum assistance with ADLs including personal hygiene, bathing, and toileting due to bowel and bladder incontinence. During interview, the resident stated being very uncomfortable because ADL care had not been provided that morning or the day before, and said a hospice aide usually comes in but had not been there for two days. The resident also stated being angry because he or she should have been cleaned and dressed by the time of the interview. Surveyor interviews and record review showed no evidence that the resident received ADL care on the day shift of two consecutive days, including toileting hygiene, bathing, and dressing. A NA stated she thought the hospice aide usually provided ADL care, but the aide had not yet come into the facility, and she acknowledged the resident had not received ADL care at the time of the interview. An RN later stated that a hospice NA comes once a week, not daily, and could not provide evidence that the resident received care on the first shift of either day before the issue was brought to staff attention. The DON also could not provide evidence that the resident received ADL care on the first shift of either day and stated she would expect staff to document when ADL care is provided.
Failure to Monitor Foley Catheter Output
Penalty
Summary
Appropriate care was not provided for a resident with an indwelling Foley catheter related to urine output monitoring. The resident was admitted in December 2024 with a diagnosis that included urinary retention, and a physician’s order dated 10/3/2025 directed staff to monitor catheter drainage every shift. Facility policy titled URINARY CATHETER CARE stated that the drainage bag should be emptied at least every 8 hours and as necessary. Review of Vital Reports from 11/18/2025 through 12/18/2025 showed no evidence that the resident’s urine output was recorded for 36 of 90 opportunities. The record also failed to show that urine output was documented in milliliters to accurately monitor output every shift for 21 of 90 opportunities. During interview, a NA acknowledged that staff are required to empty the catheter bag, measure the urine, and document the amount in milliliters every shift, and the DON acknowledged that NAs are responsible for emptying the bag, measuring the urine, and documenting the amount in milliliters in the resident’s record every shift.
Failure to Maintain Ordered Positioning and Labeling During J-Tube Feeding
Penalty
Summary
Resident ID #13, admitted in August 2024 with diagnoses including adult failure to thrive and gastroesophageal reflux disease, was receiving continuous enteral feeding through a jejunal tube. Physician orders dated 8/1/2024 directed that the resident's head of bed be elevated to 30 degrees continuously and that the enteral feeding bag be changed once daily. During surveyor observations on 12/16/2025, the resident was seen lying flat while receiving enteral feeding via the J-tube, and the head of bed was not elevated to the ordered 30 degrees. Additional observations on 12/18/2025 showed the resident again lying flat while receiving feeding from a bag via the J-tube, and the bag was not labeled with the contents or dated as required by facility policy. During the observation, the RN acknowledged the resident was lying flat while receiving the feeding and left the room without elevating the head of bed after the issue was brought to her attention. The RN also acknowledged that the enteral feeding bag was not labeled and dated. The DON stated that the head of bed should be elevated to at least 30 degrees during J-tube feeding and that the feeding bag should have been labeled and dated.
Medication Administration Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure that each resident’s medication regimen was free from a medication error rate of 5% or greater. During observation of 25 medication administration opportunities, surveyors identified four errors, resulting in a 16% error rate affecting Residents 43, 81, 62, and 101. Resident 43 had an order for carvedilol 3.125 mg twice daily with instructions to hold the medication if the heart rate was less than 60, but the CMT obtained a heart rate of 42 and still administered the carvedilol. Resident 81 had an order for Humalog Kwik Pen insulin three times daily per sliding scale, and the RN placed a needle on the insulin pen without sanitizing the hub and did not prime the needle before administering the insulin. Resident 62 had an order for lispro insulin pen 20 units daily, and the RN administered the insulin without priming the needle. Resident 101 received 10 units of lispro via insulin pen, and the RN also did not prime the needle before administration. The DON acknowledged that carvedilol should have been held for Resident 43’s heart rate of 42 and that the insulin pen hub should have been sanitized and the insulin needles primed for Residents 81, 62, and 101.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain its infection prevention and control program related to enhanced barrier precautions for 4 of 4 residents observed on EBP, including Residents 12, 13, 22, and 65. Facility signage for EBP directed staff to wear a gown and gloves before dressing, bathing, transferring, providing hygiene, and device care or use, and to clean their hands before entering and when leaving the room. Resident 22 was admitted with a diagnosis including a wound on the right hand, and Resident 13 was admitted with a diagnosis including a J-tube insertion. During observation, a nursing assistant dressed Resident 22 and later transferred the resident from bed to wheelchair without wearing a gown, despite the posted EBP signage. The same nursing assistant was also observed providing a bed bath to Resident 13 without wearing a gown as required by the signage. A laundry aide was also observed dropping off clean laundry in rooms of Residents 12 and 65, both of whom were on EBP, without sanitizing her hands between rooms or after touching items in the rooms. She entered Resident 12's room, touched a cabinet, exited without hand hygiene, then went to the clean laundry cart, entered Resident 65's room, and again exited without sanitizing her hands. During interview, the laundry aide initially stated she had used the hand sanitizers in the rooms, but both dispensers had been checked and were empty. The Director of Nursing acknowledged that Residents 13 and 22 were on EBP and stated staff should wear a gown and gloves when giving a bed bath, dressing, and transferring residents as indicated on the signage, and later was unable to provide evidence that the laundry aide maintained infection prevention practices.
Resident Identifying Information Left Visible in Survey Binder
Penalty
Summary
The facility failed to protect identifying information for 7 current residents in its posted State Survey Results binder, which was stored on a wall in the entrance area facing the public. Surveyor observation found that the binder contained resident rosters attached to the statement of deficiencies for 2 surveys, including the survey with exit date 9/18/2025 identifying Resident ID #s 74 and 99, and the survey with exit date 9/6/2024 identifying Resident ID #s 12, 32, 60, 61, and 74. The attached rosters included residents' names matched to their number identifiers and contained information including physician's orders and medical diagnoses. During interview, the Administrator acknowledged that the residents' names and corresponding number identifiers were in the binder and should not have been available to view.
Multiple Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
Surveyor observations and staff interviews revealed multiple deficiencies in the facility's food storage, preparation, and sanitation practices. The main kitchen was found to have significant accumulations of grease and grime on equipment such as the stove hood and tilt skillet, as well as debris and food crumbs on worktable shelves. The bottom shelf of a worktable storing the meat slicer was rusted. Additionally, a trash container was left uncovered at the entrance to the dish room while not in use. Improper cooling procedures were observed, including cooked chicken breasts left on a worktable at 98.1°F and chicken salad stored in the refrigerator at 68.7°F, with no cooling log in place. A carton of milk was served at 45.5°F, above the required cold holding temperature, and Magic Cup nutritional supplements, which require frozen storage, were found stored in the refrigerator instead of the freezer. Further deficiencies included a malfunctioning dish machine with a non-functioning Printed Circuit Board, resulting in the inability to verify proper wash temperatures. Infection control lapses were also observed, as a dietary aide donned gloves without washing hands, handled soiled equipment, and then proceeded to unload clean dishes without removing gloves or washing hands. The Food Service Director acknowledged the need for cleaning, proper trash receptacle use, correct food storage temperatures, and appropriate hand hygiene practices.
Food Safety and Cleanliness Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The dish machine in the main kitchen was converted from a high-temperature sanitizing machine to a chlorine-based sanitizing machine. However, the facility did not have the appropriate test strips to measure the chlorine concentration, and the concentration was found to be below the required level, indicating improper sanitization. Additionally, the facility's Food Service Director (FSD) was unable to provide evidence of monitoring the sanitizing solution's concentration or the availability of appropriate test strips. The survey also revealed several cleanliness issues in the main kitchen and a nursing unit kitchenette. There was an accumulation of dirt, food residue, and grime on various surfaces, including utility carts, the steam table, and kitchen equipment. The FSD could not provide evidence of a cleaning schedule for these areas. Furthermore, 22 red lip plates were found with heavy scoring and deep scratches, which could not be effectively cleaned and sanitized, and there was no evidence of purchase orders for their replacement. Additional deficiencies included improper thawing of beef stew meat at room temperature, cold holding temperatures for certain foods being above the acceptable range, and improper drying of meal trays with a napkin. The ice machine was also found to have an accumulation of a black and pink substance, indicating a need for cleaning and service. These deficiencies highlight the facility's failure to maintain food safety and cleanliness standards, potentially leading to foodborne illnesses.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident at risk for pressure ulcers, leading to the development of an open wound on the resident's right heel. The resident, who was readmitted with a stage 3 pressure ulcer and other medical conditions such as diabetes and Parkinson's Disease, was identified as being at risk for pressure ulcers based on a Braden Scale score of 16. Despite a care plan that included weekly skin checks, the facility did not complete the required body check on 8/29/2024, and the resident's right heel wound was not identified or treated until it was brought to the facility's attention by a surveyor on 9/5/2024. During the surveyor's observation, the wound was found to be open and without a dressing or treatment order. Staff B, a registered nurse, acknowledged the presence of the wound but failed to notify the physician or provide appropriate treatment, instead applying skin prep, which is not suitable for open wounds. The Director of Nursing Services confirmed the lack of awareness and treatment for the wound, acknowledging that the facility was unaware of the resident's condition until the surveyor's intervention.
Lack of Documented Competencies for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets to provide adequate nursing and related services, which are essential for ensuring resident safety and achieving or maintaining the highest practicable physical well-being of each resident. This deficiency was identified through a record review and staff interviews, which revealed that there was no evidence of completed competencies for two Registered Nurses (RNs), Staff B and Staff D, and four Nursing Assistants (NAs), Staff E, F, G, and H. During an interview with the Infection Preventionist, conducted as part of the Staffing Task, the surveyor found that the Infection Preventionist was unable to provide documentation of any completed nursing competencies for the aforementioned staff members.
Deficiency in Nutritional Menu Planning and Oversight
Penalty
Summary
The facility failed to ensure that the menus met the nutritional needs of residents according to established national guidelines. The diet manual used by the facility was outdated, as it was based on guidelines from 2010 to 2015, while the current guidelines were revised in 2020. The facility's menu lacked evidence of therapeutic exchanges necessary for residents with specific dietary needs, such as Low Concentrated Sweets, low fat, cardiac, No Added Salt, renal, mechanical soft, and puree diets. During a surveyor observation, it was noted that the portion sizes served did not match the serving sizes indicated on packaging labels or recipes, and there was no nutritional analysis provided for the meals served. The Food Service Director (FSD) was unable to provide evidence of standardized recipes or the nutrient content of meals. Additionally, there was no documentation to support that dietary staff had been trained on therapeutic diets, despite their claims of having received such training. The Registered Dietitian revealed that she was not involved in menu planning and had not reviewed or signed off on the facility's menu to ensure its nutritional adequacy. These deficiencies indicate a lack of oversight and adherence to nutritional guidelines, potentially compromising the dietary needs of the residents.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for its staff, as required by its own facility assessment. The assessment, dated July 19, 2024, indicated that training and competencies should be completed upon hire, annually, and as needed. The required training areas included abuse, resident rights, infection control, dementia and Alzheimer's disease, behavioral health, communication, and the QAPI program. However, a review of training records for eight staff members, including registered nurses and nursing assistants, revealed significant gaps in their training. For instance, Staff B, a registered nurse hired in 2015, lacked training in communication and the QAPI program. Similarly, Staff D, another registered nurse hired in 2019, did not receive training in several critical areas, including communication, abuse, and dementia care. The deficiency was further highlighted during interviews with the Director of Nursing Services, who was unable to provide evidence that the required in-services were completed for the staff members in question. This lack of documentation and training was consistent across all eight employees reviewed, indicating a systemic issue in the facility's training program. The absence of training in essential areas such as infection control, resident rights, and behavioral health management suggests a failure to adhere to the facility's own standards and regulatory requirements, potentially impacting the quality of care provided to residents.
Failure to Apply Hand Splints as Ordered
Penalty
Summary
The facility failed to ensure that residents with limited range of motion received appropriate treatment to prevent further decline. Resident ID #18, who was readmitted with diagnoses including stroke and hemiplegia, had a physician's order for a left resting hand orthosis to be worn during the day. However, observations on multiple dates revealed the resident was without the splint, and there was no evidence in the nursing progress notes that the resident removed or refused to wear it. The Assistant Director of Nursing Services acknowledged the splint was not applied and admitted she could not locate it. Similarly, Resident ID #61, admitted with stroke and hemiplegia, had an order for a right resting hand splint to be worn during the day. Observations showed the resident without the splint, which was found on the window sill, and there was no documentation of refusal. The Director of Nursing Services confirmed the splint was not applied and could not explain the oversight. Resident ID #70, also with stroke and hemiplegia, had a similar order for a right resting hand splint, but was observed without it on several occasions. Again, there was no record of refusal, and the DNS acknowledged the splint was not applied without explanation.
Failure to Replace Oxygen Tubing Weekly
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident with chronic obstructive pulmonary disease (COPD). The resident was admitted in May 2023 and had a physician's order for supplemental oxygen at 1-2 liters/minute via nasal cannula as needed every shift. The facility's policy, revised in November 2020, required that the nasal cannula and tubing be replaced and dated weekly or when visibly soiled or damaged. However, during surveyor observations on multiple occasions in September 2024, the resident was seen using discolored oxygen tubing that was dated 7/18, indicating it had not been changed weekly as per policy. During an interview, the resident confirmed the use of oxygen nightly and as needed during the day. The Director of Nursing Services (DNS) acknowledged that the tubing should have been changed weekly according to the facility's policy but could not provide evidence explaining why the tubing was not replaced.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with accepted professional principles, as observed in one of two medication rooms, two medication carts, and two residents with medications at their bedside. In the basement medication storage room, six bottles of Calcium with Vitamin D and two bottles of Acetaminophen were found to be expired. The Medication Aide, Staff I, acknowledged the expired medications and indicated they should be discarded. Additionally, on the second floor, two medication carts were found unlocked and unattended, with one cart's drawer left half ajar. Staff J, a Medication Aide, confirmed the carts were left unattended and unlocked. Furthermore, two residents were observed with medications left at their bedside. Resident ID #63 had a plastic medication cup with five medications left unattended on the bedside table while the resident was asleep. Staff K, a Nursing Assistant, and Staff C, an LPN, acknowledged the unattended medications, with Staff C unable to identify the medications as she had not yet administered them. Resident ID #22's Spiriva inhaler was found on the bedside table instead of in the medication cart. Staff J admitted to possibly leaving the inhaler at the bedside after administering it the previous day. The Director of Nursing Services expressed that medications should not be left unattended at the bedside and that expired medications should be discarded.
Inaccurate Medical Record Documentation for Resident Care
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with professional standards for three residents. Resident ID #61, who was admitted with a stroke and hemiplegia, had a physician's order for a right resting hand splint to be applied during the day. However, during a surveyor observation, the resident was found without the splint, which was inaccurately documented as applied in the Treatment Administration Record (TAR). The Director of Nursing Services (DNS) could not explain the discrepancy. Similarly, Resident ID #67, with a history of arteriosclerotic heart disease and pulmonary embolism, had an order for TED stockings to be applied daily. Observations revealed the resident was only wearing one stocking, despite records indicating both were applied. The registered nurse acknowledged the error but could not explain the inaccurate documentation. Additionally, Resident ID #70, also with a stroke and hemiplegia, was observed without the ordered right hand splint, which was falsely signed off as applied in the TAR. The DNS was again unable to account for the inaccurate record-keeping.
Unsanitary Conditions Due to Recurring Toilet Overflow
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment in the basement conference room due to water leakage from the ceiling. This issue was observed by a surveyor who noted a significant amount of water pouring from a ceiling light onto a table, affecting a surveyor's computer, resident records, and personnel training records. The source of the water was identified as an overflowing toilet on the second floor, which had been clogged by a large bowel movement. This problem had occurred on two previous occasions the prior week, but the Assistant Director of Maintenance, Staff R, did not report it, believing he had resolved the issue by plunging the toilet. The Administrator and the Director of Nursing Services were unaware of the recurring issue with the overflowing toilet and the resulting unsanitary conditions in the basement conference room. The Director of Nursing Services could not explain how the room was sanitized after the previous incidents. Staff R later disclosed that the facility had purchased a new toilet for the resident's bathroom where the overflow occurred. The lack of communication and failure to address the recurring plumbing issue led to the unsanitary conditions observed by the surveyor.
Failure to Follow Physician's Orders for Residents
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by not following physician's orders for three residents. Resident ID #61, who has end-stage renal disease and is dependent on dialysis, had a physician's order to record weights on specific days. However, the facility did not document the resident's weights on multiple occasions between July and September 2024. This lack of documentation indicates a failure to adhere to the prescribed medical treatment plan. Resident ID #62, diagnosed with Alzheimer's Disease and a history of pressure injuries, had a physician's order for an air mattress to maintain skin integrity, with specific settings to be checked every shift. Observations revealed that the air mattress was set incorrectly, and staff could not explain the discrepancy. Additionally, Resident ID #67, with arteriosclerotic heart disease and pulmonary embolism, had orders for TED stockings to be applied daily. Observations showed that the resident was missing a TED stocking on multiple occasions, and staff were unable to provide an explanation for this oversight.
Failure to Ensure Safe Administration of Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving nutrition via a gastrostomy tube received appropriate treatment and services to prevent complications. The resident, who was readmitted to the facility with a diagnosis of dysphagia and gastrostomy, was found to be self-administering bolus feedings without proper checks for tube placement. The facility's policy on enteral feeding requires checking tube placement and residuals before feeding, but the resident reported that nurses did not check the tube placement before administration, and the resident also did not perform this check. Interviews with staff revealed that the Licensed Practical Nurse (LPN) sometimes did not check the tube placement before the resident administered the bolus feeding. The Director of Nursing Services acknowledged the resident's self-administration of the bolus but could not provide evidence of an assessment indicating the resident was competent to safely self-administer the feeding. This lack of oversight and failure to adhere to the facility's policy on enteral feeding contributed to the deficiency identified by the surveyors.
Pharmacist Fails to Report Insulin Administration Irregularities
Penalty
Summary
The deficiency involves a failure by the facility's pharmacist to report medication irregularities for a resident with type 2 diabetes mellitus. The resident was admitted in April 2023 and had a physician's order for Fiasp insulin with specific sliding scale instructions. However, the Medication Administration Record (MAR) for August 2024 showed that the insulin was administered outside the ordered parameters on multiple occasions between August 3 and August 13, 2024. The pharmacist's consultation report dated August 15, 2024, did not identify these irregularities, nor were they reported to the attending physician, the facility's Medical Director, or the Director of Nursing Services as required by the facility's policy. During an interview, the Regional Clinical Nurse confirmed that the pharmacist should have identified and reported these irregularities, but no evidence was provided to show that this was done.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of insulin and antipsychotic medications outside of prescribed parameters. Resident ID #59, who was admitted with type 2 diabetes mellitus, received Fiasp insulin inconsistently with the sliding scale orders on multiple occasions in August and September 2024. The insulin was administered in incorrect dosages based on the resident's blood sugar levels, which were documented in the Medication Administration Record (MAR). These errors included administering fewer units than prescribed for certain blood sugar ranges and failing to administer any insulin when it was required. Additionally, Resident ID #74, diagnosed with paranoid schizophrenia, did not receive the prescribed Quetiapine extended-release tablet on several occasions in September 2024 due to the medication being unavailable. The MAR indicated that the medication was not administered as ordered on four separate dates. During an interview, the Director of Nursing Services acknowledged the failure to administer the medications as ordered and stated that the expectation was for the physician to be notified if a medication was unavailable.
Failure to Provide Food in Appropriate Form for Resident
Penalty
Summary
The facility failed to ensure that a resident received food in the appropriate form as per their physician's diet order. The resident, admitted in January 2018 with a diagnosis including dementia, had a physician's order for a mechanical soft diet, which requires proteins to be ground or cut up. During a surveyor observation, it was noted that the resident's Salisbury Steak was cut into strips approximately 1 1/2 inch by 1 inch, instead of being cut into pieces less than 1/2 an inch as required for a mechanical soft diet. A nursing assistant admitted to cutting the steak into the incorrect size, and a speech-language pathologist confirmed the appropriate size for the diet was not followed.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent an accident involving a resident with severe cognitive impairment, who was able to elope from the facility unsupervised. The resident, diagnosed with dementia, delusional disorder, and paranoid personality disorder, was readmitted to the facility in May 2024. The resident's care plan indicated impaired cognitive skills, poor decision-making, and memory issues, with interventions including reporting changes in cognitive status and escorting the resident to activities. Despite residing on a secured unit, the resident attended an activity in a non-secured area and managed to leave the facility without staff supervision. On the day of the incident, the resident was observed to be exit-seeking and required redirection multiple times by staff. The resident expressed a desire to leave, mentioning being picked up by a spouse and wanting to go downtown. After attending activities, the resident was found outside the building unsupervised, stating confusion about the location. The facility's administrator acknowledged the resident's exit-seeking behavior as a change in condition and expected communication of such changes to the interdisciplinary team. However, there was no evidence provided that the facility ensured adequate supervision to prevent the elopement.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 371 citations issued within 25 miles in the last 12 months — including the 16 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Newport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Clare Home | 0.5 mi | ★★★★★ | 0 | 0 |
| Village House Nursing & Rehabilitation Center | 0.9 mi | ★★★★★ | 6 | 0 |
| John Clarke Senior Living | 2.2 mi | ★★★★★ | 2 | 1 |
| Grand Islander Center | 2.4 mi | ★★★★★ | 7 | 0 |
| Royal Middletown Nursing Center | 3.7 mi | ★★★★★ | 16 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.