Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 St Antoine Residence during CMS and state inspections, most recent first.
The facility failed to implement and document required antibiotic stewardship "time outs" or day-three reviews for multiple residents receiving antibiotics for conditions such as dementia with suspected infection, diverticulitis, pneumonia, and sepsis. Clinical records for several antibiotic courses, including Doxycycline, Cefpodoxime, Clindamycin, and IV Meropenem, did not contain evidence of a review two to three days after initiation to assess infection status, appropriateness of the antibiotic, or potential de-escalation. The IP reported that antibiotics are discussed verbally in staff meetings but that time outs or reviews are not documented without a physician order, and the DON could not provide documentation that such reviews were completed.
A resident with hemiplegia, partial foot amputation, vascular dementia, and total dependence for transfers experienced multiple incidents while using a stand aid, including sliding to the floor, falling backward, and being lowered to the floor when knees buckled. Despite facility policy requiring post-fall rehab screens, no rehab screens were documented after several of these falls, and the rehab director was unaware of the events and the resident’s non-compliance and knee buckling. Later, rehab formally recommended use of a full-body Hoyer lift with two staff for all transfers, but nursing did not update the care plan or the NA assignment sheet, which continued to direct use of a stand aid, and leadership acknowledged that the resident’s changed transfer status was not clearly communicated to caregivers.
A resident with pneumonia and acute respiratory failure had a physician order for PRN oxygen at 2 L/min, but surveyors repeatedly observed the resident receiving 3 L/min. An RN initially stated there was an order for 3 L/min, but upon review of the EMR acknowledged the order was for 2 L/min, and the Unit Manager also confirmed the discrepancy. Despite the surveyor notifying staff of the incorrect flow rate, the resident continued to receive oxygen at 3 L/min, contrary to facility policy and professional standards requiring adherence to the ordered oxygen flow rate.
A resident with dementia and a history of pre-cancerous scalp lesions developed a cancerous wound on the right temple. After an initial course of topical treatment, the wound was left unassessed and untreated for several months, despite facility policy requiring weekly skin checks. The wound deteriorated, and maggots were eventually discovered, leading to hospital transfer. Staff and DON interviews confirmed the lack of wound monitoring and treatment during this period.
The facility did not update its facility-wide assessment to include wound vac therapy, despite providing this service to a resident with osteomyelitis and other conditions. The assessment failed to reflect the resources and services actually offered, and the Administrator was unable to provide documentation showing that the assessment was revised when wound vac treatment was initiated.
A resident with a surgical wound and a PICC line did not have Enhanced Barrier Precautions (EBP) implemented as required by facility policy. PPE such as gowns and gloves were not available near the room, and staff did not wear gowns during care. Nursing staff and the DON confirmed that EBP should have been in place for this resident.
A resident with advanced dementia and severe cognitive impairment was subjected to physical abuse by staff, including being dragged, forcefully pushed into a chair, and pinned in bed, instead of being redirected as per the care plan. Staff used manual restraint and unreasonable force, causing distress to the resident, and did not follow established interventions for managing resistive behavior.
A facility failed to act on pharmacy recommendations for a resident prescribed Clozapine, leading to a lapse in medication administration. The resident, with Alzheimer's and schizophrenia, did not receive the medication for 11 days due to an error. Despite a pharmacy recommendation for prompt action, the issue was not addressed until the resident was hospitalized for suicidal ideation and self-harm. Staff interviews revealed no system to highlight priority recommendations, risking resident safety.
A resident with Alzheimer's and schizophrenia was readmitted to a facility without proper medication reconciliation, leading to the discontinuation of essential medications like Clozapine and Trazadone. Despite recommendations to continue these medications, they were not updated, resulting in the resident experiencing delusions, paranoia, and self-harm, ultimately requiring hospitalization. The facility's failure to adhere to its medication reconciliation policy was confirmed by staff interviews.
Surveyors observed significant cleanliness issues in the kitchen, including dust and grease accumulation on equipment and floors. A dietary cook was found working with exposed food while wearing acrylic nails without gloves. Trash containers were also left uncovered when not in use. The Food Service Director acknowledged these deficiencies.
Two residents at risk for pressure ulcers did not receive the required offloading of heels as per physician orders. One resident with a stroke and severe cognitive impairment had a Deep Tissue Pressure Injury, and another resident with protein calorie malnutrition was at risk for skin breakdown. Observations showed non-compliance with orders, confirmed by LPNs and acknowledged by the DON.
The facility failed to maintain proper infection control practices for residents with wounds, as staff did not change gloves or perform hand hygiene during wound care. Additionally, two residents with pressure injuries were not placed on Enhanced Barrier Precautions (EBP), and staff did not wear protective gowns during care. These deficiencies were acknowledged by staff and the Infection Preventionist.
A facility failed to ensure a Nurse Practitioner provided necessary orders for a resident's care. The resident, with vascular dementia and cerebrovascular disease, showed signs of acute cystitis, but a urine culture and sensitivity order was not provided. The NP acknowledged the oversight, and the Medical Director expected the NP to follow up with the order.
Failure to Implement and Document Antibiotic Stewardship Time-Outs
Penalty
Summary
The deficiency involves the facility’s failure to establish and implement an Infection Prevention and Control Program that includes an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use, specifically the lack of documented antibiotic “time outs” or day-three reviews. For five residents receiving antibiotics, clinical record review did not show evidence that a review was conducted two to three days after antibiotic initiation to determine if a bacterial infection was present, whether the antibiotic, dose, and route were appropriate, or if therapy could be narrowed or shortened. One resident admitted with dementia received Doxycycline 100 mg twice daily for 10 days, and another resident with diverticulitis of the large intestine received Doxycycline 100 mg twice daily for seven days, with no documentation of an antibiotic time out or day-three review for either course. A resident admitted with pneumonia received Cefpodoxime Proxetil 200 mg twice daily for seven days, another resident with dementia received Clindamycin 300 mg three times daily for 10 days, and a resident with sepsis received Meropenem 500 mg IV every 12 hours for six days; in all three cases, records lacked documentation of an antibiotic time out or day-three review. During an interview, the Infection Preventionist stated that antibiotics are discussed verbally at staff meetings but that antibiotic time outs or reviews are not documented unless there is a physician’s order. In a subsequent interview, the Director of Nursing Services was unable to provide evidence that antibiotic time outs or reviews had been completed for these residents.
Failure to Update Transfer Status and Rehab Screening After Multiple Stand-Aid Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate assistive devices and supervision to prevent accidents for a resident who used a stand aid for transfers. The facility’s Falls Prevention & Management policy and post-fall guidelines required submission of rehab screens after falls for residents not on hospice and communication of changes in status to the interdisciplinary team. Resident ID #165, admitted in 2018 with hemiplegia/hemiparesis following cerebrovascular disease, partial traumatic amputation of the left foot, and vascular dementia, was non-ambulatory and dependent on staff for all transfers, with intact cognition per a recent MDS. Progress notes documented multiple stand-aid related incidents: on 10/17/2025 the resident lost balance and slid to the floor; on 10/31/2025 the resident fell backwards from the stand aid; on 11/1/2025 the resident was noted to be non-compliant with instructions while using the stand aid; on 12/29/2025 the resident was lowered to the floor by two NAs during a stand-aid transfer and was described as non-compliant and at high risk for falling; and on 12/30/2025 the resident was again lowered to the floor when knees buckled during a stand-aid transfer in the shower room. Despite these repeated falls and documented concerns, record review did not show that rehab screens were submitted after the falls on 10/31/2025, 11/1/2025, 12/29/2025, and 12/30/2025, contrary to the facility’s fall procedure. The Unit Manager RN stated that rehab screens should be submitted after a fall and that all screens are scanned into the EMR, but no such documentation was found. The Director of Rehabilitation confirmed she could not provide evidence that rehab screens were completed following these falls and reported she was unaware that the resident had fallen from the stand aid, had been non-compliant with instructions, or had experienced knee buckling during transfers with the device. This lack of post-fall rehab screening and communication meant that the rehab department was not informed of the resident’s repeated stand-aid related incidents. Additionally, the facility failed to update and communicate changes in the resident’s transfer status and assistive device needs after a rehab evaluation. Assignment documentation indicated the resident required assistance of 1–2 staff with a stand aid for all transfers, and the fall care plan last revised on 12/30/2025 continued to direct use of a stand aid. After a hospitalization for change in medical status, a rehab evaluation on 1/13/2026 recommended use of a full-body Hoyer lift with two staff for all transfers, documented on a Transfer Status Form signed by OT and PT. The Director of Rehabilitation stated this recommendation was communicated in writing to nursing and that the resident’s whiteboard was updated. However, record review showed the care plan was not revised and the NA assignment sheet was not updated to reflect the new Hoyer lift requirement. The Unit Manager RN acknowledged that the resident’s transfer status had not been updated on the assignment sheet or in the care plan, and the DON acknowledged that rehab screens were not provided after each fall and that the facility failed to clearly communicate the resident’s status to NAs, contributing to ongoing risks during transfers.
Failure to Follow Physician Order for Oxygen Flow Rate
Penalty
Summary
The deficiency involves the facility’s failure to provide oxygen therapy in accordance with physician orders and professional standards of practice for one resident using supplemental oxygen. Facility policy and Lippincott Nursing Procedure require a practitioner’s order for oxygen therapy and that the oxygen flow rate be set at the amount specified in the order, with documentation of the rate of flow. The resident, admitted with diagnoses including pneumonia and acute respiratory failure, had a physician’s order dated 12/13/2025 for oxygen at 2 liters per minute as needed. Despite this, surveyor observations on multiple dates and times showed the resident receiving oxygen at 3 liters per minute instead of the ordered 2 liters per minute. During an observation and interview, an RN stated that the resident was receiving oxygen at 3 liters per minute and asserted there was an order for 3 liters per minute. Upon review of the electronic medical record at the surveyor’s request, the RN acknowledged that the actual order was for 2 liters per minute. The Unit Manager also acknowledged that the order indicated 2 liters, not 3 liters, as observed. Later the same day, after the facility had been informed by the surveyor that the oxygen flow rate was incorrect, the resident was again observed receiving 3 liters per minute. The Director of Nursing Services stated she would have expected the resident to receive oxygen at 2 liters per minute, as ordered.
Failure to Monitor and Treat Resident's Cancerous Lesion Resulting in Maggot Infestation
Penalty
Summary
A resident with dementia and severe cognitive impairment was admitted to the facility with multiple pre-cancerous lesions on the scalp, including one on the right temple. Dermatology consultations identified the need for follow-up and, eventually, a MOHS procedure after a biopsy confirmed squamous cell carcinoma. Despite initial treatment with Aquaphor ointment as ordered, documentation shows that after this course ended, the lesion was left untreated for several months, from February to late June, with no evidence of ongoing assessment or monitoring of the wound during this period. The facility's policy required weekly skin checks and documentation of any wounds, but records failed to show that the right temple lesion was assessed or documented in weekly skin checks from December through early September. During this time, the resident's family declined further dermatology appointments and requested in-house wound care, but there was no evidence of consistent wound assessment or treatment until the wound's condition worsened. Orders for topical antibiotics and other treatments were only initiated after a significant lapse in care. The deficiency culminated when staff discovered maggots in the resident's right temple wound, prompting transfer to an acute care hospital. Hospital records confirmed a large, necrotic wound with maggot infestation, and interviews with facility staff and the DON acknowledged the lack of wound assessment and treatment for several months. The failure to monitor, assess, and treat the resident's wound in accordance with professional standards led to the development of a severe wound with maggot infestation.
Failure to Update Facility Assessment for Wound Vac Therapy
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. Record review showed that the facility's assessment, dated 1/30/2025, listed several special treatments and conditions but did not include wound vac therapy, which was a service provided to at least one resident. The assessment also did not reflect updates or modifications when new services, such as wound vac treatment, were introduced. A resident was admitted with multiple diagnoses, including osteomyelitis and was receiving wound vac therapy to the left foot. The facility's documentation did not show that wound vac treatment was considered in their resource planning or assessment. During an interview, the Administrator confirmed that not all services listed in the assessment were actually provided and could not provide evidence that the assessment was updated to include wound vac therapy during the resident's admission.
Failure to Implement Enhanced Barrier Precautions for Resident with Wound and Indwelling Device
Penalty
Summary
The facility failed to follow its own Enhanced Barrier Precautions (EBP) policy and standard infection control practices for a resident with a surgical wound and an indwelling medical device. According to the facility's EBP policy, residents with wounds or indwelling medical devices require a physician order for EBP, and personal protective equipment (PPE) such as gowns and gloves should be immediately available near or outside the resident's room. Additionally, a trash can should be positioned inside the room near the exit for discarding PPE prior to leaving. Record review showed that the resident was readmitted with osteomyelitis, enterococcus infection, a surgical wound, and a peripherally inserted central catheter (PICC) for intravenous antibiotics, but there was no physician order for EBP as required by policy. Surveyor observations revealed that gowns and gloves were not immediately available near or outside the resident's room, and a trash can for discarding PPE was not positioned as required. The resident reported that staff did not wear gowns when providing personal care. Interviews with nursing staff and the Director of Nursing confirmed that EBP should have been in place for the resident due to the presence of wounds and a PICC line, but these precautions were not implemented.
Failure to Protect Resident from Abuse through Improper Physical Restraint
Penalty
Summary
A resident with diagnoses including dementia and anxiety disorder, and severely impaired cognition as indicated by a Brief Interview for Mental Status score of 0 out of 15, was involved in an incident where staff failed to protect the resident from abuse. The resident, who was known to be at risk for self-care deficits and had care plan interventions to redirect and reapproach if resistive, became agitated and combative, attempting to enter another resident's room. Staff responded by physically escorting the resident to the common area and later to the resident's room. Multiple staff members, including a registered nurse and a licensed practical nurse, were observed by other staff to use excessive force and physical restraint on the resident. Witness accounts described the resident being dragged down the hallway by the arm and walker, forcefully pushed into a chair, and later thrown into bed and pinned down by the chest and head. Staff were also reported to have made statements indicating a punitive approach, and did not follow the care plan interventions of redirection and calm re-approach. The resident was visibly distressed and attempted to resist, including spitting and kicking at staff. The facility's own investigation, as well as staff interviews, substantiated that the actions taken by the staff constituted abuse, including the use of manual physical restraint and unreasonable confinement. The Director of Nursing confirmed that the staff did not follow expected procedures, such as monitoring the resident from a distance or leaving the resident alone once safe, and acknowledged that the resident was abused during the incident. The survey team concluded that the actions taken by staff resulted in a deficiency related to the failure to protect the resident from abuse.
Failure to Act on Pharmacy Recommendations for Clozapine
Penalty
Summary
The facility failed to develop and maintain policies and procedures to act on pharmacy-identified irregularities marked as Clinical Priority for a resident using Clozapine, an atypical antipsychotic medication. The resident, who had diagnoses including Alzheimer's disease and schizophrenia, was readmitted to the facility with a medication order for Clozapine to be administered for 30 days. However, the medication was discontinued after 30 days due to an error, and the resident did not receive the medication for 11 days. A pharmacy consultation report dated 1/28/2025 recommended a prompt response to continue the medication, but the recommendation was not signed by the Nurse Practitioner until 2/3/2025, the same day the resident was transferred to the hospital. The resident exhibited suicidal ideation, medication refusal, and self-injurious behaviors, leading to hospitalization. Interviews with staff revealed that there was no system in place to highlight priority recommendations requiring prompt responses, and the Director of Nursing Services confirmed that pharmacy recommendations marked as Clinical Priority should have been reviewed within 24 hours. The facility's lack of a system to ensure prompt action on pharmacy reports placed residents at risk for serious harm.
Failure to Conduct Medication Reconciliation Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that Resident ID #1 was free from significant medication errors, as evidenced by the lack of medication reconciliation upon the resident's readmission from the hospital. The resident, who had diagnoses including Alzheimer's disease and schizophrenia, was readmitted with specific medication orders, including Clozapine and Trazadone. However, the facility did not complete a medication reconciliation to compare the hospital's medication orders with those prior to hospitalization, as required by their policy. The error was compounded when the facility transcribed the hospital's 30-day medication orders without clinical justification, leading to the discontinuation of essential medications like Clozapine and Trazadone. Despite a psychiatric practitioner's recommendation and a nurse practitioner's agreement to continue these medications, the orders were not updated, resulting in the resident not receiving the necessary medications. This oversight was identified only after the resident exhibited increased delusions and paranoia, prompting a medication review. The resident's condition deteriorated, leading to suicidal ideation, hallucinations, and self-injurious behavior, necessitating a hospital admission. Interviews with the Nurse Practitioner and Director of Nursing Services confirmed the transcription error and the failure to conduct a medication reconciliation. The facility's actions resulted in the resident's transfer to an acute hospital for a month-long treatment, highlighting the significant medication error and its impact on the resident's health.
Food Safety and Cleanliness Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in the main kitchen, as observed by surveyors. There was a significant accumulation of dust and grease on various kitchen surfaces, including the hood system, stove, flat top griddle, and convection oven. Additionally, the floor behind kitchen equipment was found to be dirty with dust and debris. These observations were made on multiple occasions, indicating a persistent issue with cleanliness and maintenance in the kitchen area. Furthermore, a dietary cook was observed working with exposed food while wearing acrylic nails and not using gloves, which is against the Rhode Island Food Code. Additionally, trash containers in the kitchen were left uncovered when not in use, contrary to the requirements of the food code. The Food Service Director acknowledged these deficiencies during an interview, confirming the need for cleaning and adherence to food safety protocols.
Failure to Offload Heels for Residents at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received the necessary treatment and services to promote healing and prevent new ulcers from developing. Resident ID #153, who was readmitted with a stroke and severe cognitive impairment, had a physician's order to offload heels at all times due to a Deep Tissue Pressure Injury on the left heel. However, surveyor observations on multiple dates revealed that the resident's heels were not offloaded as ordered. An LPN acknowledged the failure to follow the physician's order during an interview. Similarly, Resident ID #38, admitted with protein calorie malnutrition and at risk for pressure injuries, had a physician's order to offload both heels every shift. Surveyor observations on several dates showed that the resident's heels were not offloaded as required. An LPN confirmed the non-compliance during an interview, and the Director of Nursing Services expressed an expectation for staff to adhere to the physician's orders.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. Three residents with wound care needs were not provided with proper infection control measures. For Resident ID #77, the LPN did not change gloves or perform hand hygiene between cleaning the wound and applying a collagen dressing, which was acknowledged by the staff member. Similarly, for Resident ID #153, the same LPN failed to change gloves and perform hand hygiene between cleaning the wound and applying betadine. Resident ID #162 also experienced inadequate infection control practices. During a dressing change, the LPN placed a soiled dressing on the resident's bed, used a finger instead of an applicator to apply medication, and did not change gloves or perform hand hygiene before touching various items in the room. These actions were acknowledged by the staff member and the Director of Nursing Services, who expected adherence to infection control guidelines. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with pressure injuries. Resident ID #77 and Resident ID #146, both with open wounds, were not placed on EBP, and staff failed to wear protective gowns during wound care. The Infection Preventionist confirmed that these residents should have been on EBP, indicating a lack of awareness and adherence to infection control policies among staff.
Failure to Provide Necessary Physician Orders for Resident Care
Penalty
Summary
The facility failed to ensure that a Nurse Practitioner provided necessary orders for a resident's immediate care. The resident, who was admitted in October 2023, had diagnoses including vascular dementia and cerebrovascular disease. A progress note dated October 21, 2024, authored by the Nurse Practitioner, documented a late entry for October 17, 2024, indicating that the resident had abnormal weight gain, increased edema, and hypotension. A bladder scan revealed urine retention, leading to the insertion of a Foley catheter. However, a urine sample was not sent to the lab for culture and sensitivity as ordered, despite the resident showing signs of acute cystitis, such as slurred speech and disorientation. The physician's orders did not include an order for a urine culture and sensitivity. During interviews, a Licensed Practical Nurse stated she was unaware of the need for a urine culture and sensitivity. The Nurse Practitioner acknowledged failing to provide the necessary order for the urine culture and sensitivity before or on October 17, 2024, when the resident's condition changed. The Medical Director expressed that he expected the Nurse Practitioner to follow up and provide the order for the urine culture and sensitivity.
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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.
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How nearby facilities compare on the same public inspection record.
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| The Friendly Home | 0.3 mi | ★★★★★ | 13 | 0 |
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| Adviniacare Oakland Grove Llc | 2.6 mi | ★★★★★ | 12 | 0 |
| Woonsocket Health Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Holiday Retirement Home Inc | 3.9 mi | ★★★★★ | 9 | 0 |
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