Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Steere House Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Improper Thermometer Sanitization During Meal Temperature Checks: A Dietary Cook checked holding temps for multiple lunch items without sanitizing the thermometer probe between foods, including peas, mashed potatoes, and ground broccoli. Before checking baked fish, she dipped the probe in sanitizer but then wiped it with her bare hands before inserting it into the fish. The FSD stated the probe should be sanitized between every food item and wiped with a clean cloth after sanitizing.
A resident with a PICC line and IV antibiotics did not have confirmed catheter tip placement in the SVC before the line was used, and the record showed repeated antibiotic administration without that verification. PICC dressing changes were also documented without required external length and arm circumference measurements, and when the catheter was later charted as migrated 6 cm, the provider was not notified; the DON and physician both stated they expected placement confirmation and notification of migration.
A resident with ESRD and severe cognitive impairment did not have required pre- and post-dialysis weights documented after dialysis trips, and the COC paperwork was missing on return from the dialysis center. Staff also failed to notify the provider of the dialysis center’s recommendation to discontinue calcitriol, and the resident continued receiving the medication despite those recommendations.
Missing Annual Competencies for Direct Care Staff and PICC Line Care: Record review showed the facility did not have evidence that several direct care staff, including an RN, LPN, and NA, completed required annual education and competencies. The facility assessment required competency-based mandatory training upon hire and annually, and the education files for multiple nurses also lacked yearly competencies for PICC line care, including midline/central line dressing changes. The ADON was unable to provide evidence of the required competencies during interview.
A resident with type 2 DM had an order for an HbA1c to support diabetes management, but the lab test was not obtained as ordered. The Infection Preventionist acknowledged the missed test and could not show that the provider was notified or that staff attempted to follow up with the lab, and the DON stated she would have expected the nurse and/or provider to follow up.
The facility failed to provide appropriate ground texture diets for three residents, leading to them being served foods that were not safe for their conditions. A resident with dysphagia was given toasted garlic bread and donut holes, another with acute respiratory failure was served whole grilled cheese sandwiches, and a third with dementia received inappropriate foods like toast and salad. Staff were unaware of dietary requirements, and the Director of Nursing could not provide evidence of compliance with prescribed diets.
The facility failed to store medications properly, with expired drugs found in medication rooms and carts, and a resident with dementia had medications left unattended at their bedside without proper evaluation or physician's order. Staff acknowledged the oversight, and the DON could not explain the lapses.
The facility failed to maintain an effective infection prevention and control program, with deficiencies including a resident with ESBL not on Enhanced Barrier Precautions, improper cleaning of a BIPAP device, and inadequate hand hygiene during meal service. These issues were acknowledged by staff, indicating lapses in infection control practices.
A resident with moderately impaired cognition was physically abused by a roommate with intact cognition, resulting in a significant injury. The facility's investigation confirmed the abuse, but the Director of Nursing and Administrator could not provide evidence that the resident was kept free from harm, indicating a failure in the facility's protective measures.
A resident with cognitive impairment and a history of falls was able to leave the facility unsupervised, resulting in a fall and injuries. The resident's Elopement Risk Evaluation was inaccurately coded, and staff failed to provide necessary supervision, leading to the incident.
A facility failed to develop a comprehensive care plan for a resident diagnosed with a UTI after returning from the hospital. The resident, with mild cognitive impairment and a history of falling, was prescribed Cephalexin. However, no care plan was created for the UTI treatment. Staff interviews confirmed the oversight.
Improper Thermometer Sanitization During Meal Temperature Checks
Penalty
Summary
The facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety when a Dietary Cook obtained food temperatures for the lunch meal without properly sanitizing the thermometer probe between items. During observation in the main kitchen, the cook measured the holding temperature of peas, then moved directly to mashed potatoes without cleaning and sanitizing the probe, and then moved from the mashed potatoes to ground broccoli without cleaning and sanitizing the probe. Before checking baked fish, she dipped the probe in sanitizer but then wiped it with her bare hands before inserting it into the fish. In interview, the cook acknowledged that she did not sanitize the thermometer after each vegetable and should not have used her bare hands to wipe the thermometer before using it on the fish. The Food Service Director stated that the thermometer should be sanitized between every food item and wiped with a clean cloth after sanitizing.
PICC Line Placement and Monitoring Not Verified
Penalty
Summary
The facility failed to ensure that a resident with a PICC line received treatment and care in accordance with professional standards of practice. The resident was admitted in February 2026 with diagnoses including dementia with severe agitation and bacteremia, and had a PICC line placed after removing the first one. Physician orders directed IV cefazolin and required weekly PICC dressing changes with measurement of the external catheter length and arm circumference. After the PICC was replaced on 2/10/2026, the record did not show that the facility verified correct catheter tip placement in the SVC before using the line, yet the resident received antibiotics on 63 occasions without confirmation that the PICC tip was in the appropriate location. The record also showed that PICC dressing changes were documented without the required measurements. On 2/13/2026, the dressing was changed due to the resident’s complaint of discomfort and itching, but there was no evidence that external catheter length or arm circumference were measured. Later documentation showed a catheter length of 00 cm on 2/21/2026 and 6 cm on 2/28/2026, with an arm circumference of 27 cm, but the record did not show that the provider was notified when the catheter was documented as migrating 6 cm from the initial placement. The resident continued to receive antibiotics 15 more times without confirmation that the PICC tip was in the correct location. During interviews, the DON stated she expected confirmation of catheter placement before antibiotics were given and expected the provider to be notified if the catheter migrated 6 cm; the physician stated she expected the facility to obtain confirmation of placement and external catheter length on admission and said she was not notified of the migration.
Dialysis care documentation and medication communication failures
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care for a resident with end stage renal disease and dependence on renal dialysis. The resident had severe cognitive impairment with a BIMS score of 5 out of 15 and was ordered to receive dialysis every Monday, Wednesday, and Friday. A physician order also required the resident to be weighed before and after dialysis and for the post-dialysis weight to be recorded in the electronic medical record. Record review showed no evidence of pre- and post-dialysis weights documented in the resident’s electronic medical record for two dialysis treatments. The record also did not contain continuity of care documents received back from the dialysis center for those dates, including the required weights. Staff interviews confirmed that on one occasion the resident returned from dialysis without a continuity of care document and the LPN called the dialysis center but did not obtain the weights, and on another occasion the RN stated the resident returned without the document and she was unable to provide evidence that the weights were obtained. The record also showed a physician order for calcitriol three times weekly, while dialysis center progress notes stated the medication should be discontinued because it was being given at the dialysis center and should not be administered by the facility. The record did not show that the provider was notified of these recommendations, and the MAR showed the resident continued to receive calcitriol for weeks after the dialysis center’s recommendations. The resident’s physician and the DON both stated they would have expected staff to obtain the weights from the dialysis center and notify the provider of the dialysis center’s recommendations.
Missing Annual Competencies for Direct Care Staff and PICC Line Care
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide nursing and related services for resident safety and to support residents in attaining or maintaining the highest practicable physical, mental, and psychosocial well-being, as determined by resident assessments and the facility assessment. Based on record review, annual education and competencies were not found for RN Staff C, RN Staff D, LPN Staff E, and NA Staff F, despite the facility assessment stating that competency-based mandatory trainings are required for direct care staff and are completed upon hire and annually. The facility also failed to ensure that staff had the appropriate competencies and skill sets for PICC line care. Record review of the facility assessment showed that the facility provides IV medication administration and PICC line care and dressing changes, but the education and competency files for Staff C, D, E, G, and H did not show yearly competencies, including midline/central line dressing changes. During interview, the ADON was unable to provide evidence that these direct care staff members had completed their yearly competencies according to the facility assessment.
Failure to Obtain Ordered HbA1c Testing
Penalty
Summary
The facility failed to obtain laboratory services to meet the needs of 1 resident with type 2 diabetes mellitus who had a provider plan to check a Hemoglobin A1c level for diabetes management because the resident's last documented HbA1c was 11.5. A physician order was entered to obtain the HbA1c on 2/24/2026, but the laboratory record did not show that the test was obtained as ordered. During interview, the Infection Preventionist acknowledged that the HbA1c was not obtained and could not provide evidence that the provider was notified or that the facility attempted to obtain the ordered bloodwork after the due date. The DON stated she would have expected the nurse and/or provider to follow up with the laboratory to obtain the ordered bloodwork.
Failure to Provide Appropriate Ground Texture Diets
Penalty
Summary
The facility failed to provide and prepare food in a form designed to meet individual needs for three residents with a physician's order for a ground texture diet. Resident ID #58, who was admitted with dysphagia, was observed being served inappropriate foods such as toasted garlic bread and whole dry donut holes, which were not cut into bite-sized pieces as ordered. Despite the resident's coughing while eating, staff members, including a Certified Medication Technician and a Dietary Aide, were unaware of the specific dietary requirements for a ground diet, leading to the resident being served foods that were not safe for their condition. Resident ID #44, readmitted with acute respiratory failure and end-stage renal disease, was observed eating whole slices of toasted white bread and grilled cheese sandwiches, contrary to the physician's order for a ground texture diet. Staff members, including a Nursing Assistant and an LPN, were unaware that these foods were inappropriate for the resident's dietary needs, indicating a lack of communication and understanding of the dietary orders among the staff. Resident ID #365, admitted with dementia and dysphagia, was served over medium eggs with toasted bread and a garden salad with large pieces of grilled chicken and watermelon with seeds, despite having a ground texture diet order. The resident's son had to prompt the resident to swallow, highlighting the risk posed by the inappropriate food texture. The SLP confirmed that the resident should not have received these foods, and the diet was subsequently downgraded to a pureed texture. The Director of Nursing Services was unable to provide evidence that the residents were served a therapeutic diet as prescribed, demonstrating a systemic failure in adhering to dietary orders.
Medication Storage 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 of five medication carts, and at the bedside of a resident. In the third-floor medication room, a bottle of Lorazepam intensol was found expired and not discarded, which was acknowledged by the Licensed Practical Nurse present. On the second-floor medication cart, expired Latanoprost ophthalmic solution and Stye sterile lubricant eye ointment were found, with the Certified Medication Technician confirming they should have been discarded. Additionally, on the third-floor medication cart, Latanoprost and Brimonidine tartrate eye drops were found, with the latter being undated and the technician unable to provide evidence of when it was opened. A resident with dementia and chronic pain was observed with medications left unattended at their bedside, including Asper Cream, vaporizing rub, and a penetrating heat rub. The resident indicated self-application of these medications, but there was no evidence of an evaluation for self-administration or a physician's order for these medications. The Registered Nurse and Director of Nursing Services were unaware of the medications at the resident's bedside and could not explain why the expired medications were not discarded appropriately.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue involved a resident with a Multi-Drug Resistant Organism (MDRO) infection, specifically Extended Spectrum Beta Lactamase (ESBL), who was not placed on Enhanced Barrier Precautions (EBP). Despite the resident's dependency on staff for toileting and frequent incontinence, there was no evidence of isolation measures such as an isolation cart or signage outside the resident's room. The Infection Preventionist acknowledged that the facility did not utilize EBP for ESBL and could not provide evidence of follow-up urine cultures to confirm the resident was no longer positive for ESBL. Another deficiency was noted in the care of a resident using a Bilevel Positive Airway Pressure (BIPAP) device. The facility failed to follow the manufacturer's cleaning instructions for the BIPAP machine, as there was no documentation or physician's order for cleaning the equipment. During an observation, the BIPAP mask was found to have an accumulation of pink and white matter, and staff were unsure of the cleaning process. The Director of Nursing Services revealed that the facility mistakenly believed an outside company was responsible for cleaning the BIPAP machines, but this was not the case. Additionally, improper hand hygiene practices were observed during meal service. A Dietary Aide was seen using the same gloves to handle food and operate a phone, without changing gloves in between tasks. This practice was acknowledged by the Food Service Director, who stated that the staff member should have changed gloves after using the phone and before handling food. These observations highlight the facility's failure to adhere to proper infection control practices, potentially increasing the risk of infection transmission among residents.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents. Resident ID #2 reported being kicked by Resident ID #3 while exiting the bathroom, resulting in a skin tear on the left leg. The facility's investigation confirmed the abuse, with Resident ID #3 admitting to hitting Resident ID #2 with a trash can. Resident ID #2, who has a history of adjustment disorder with anxiety and brain disorders, sustained a wound that required treatment for 31 days. The incident was reported to the Rhode Island Department of Health, and the facility's policy on abuse prohibition was not effectively implemented to prevent this occurrence. Resident ID #3, who has a history of being a difficult roommate and has undergone multiple room changes, was found to have intact cognition with a BIMS score of 14 out of 15. Despite this, Resident ID #3 deliberately inflicted harm on Resident ID #2, who has moderately impaired cognition with a BIMS score of 9 out of 15. The Director of Nursing Services and the Administrator were unable to provide evidence that Resident ID #2 was kept free from physical abuse, highlighting a deficiency in the facility's ability to protect its residents from harm.
Inadequate Supervision Leads to Resident Elopement and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent an accident involving a resident who was not initially identified as being at risk for elopement. The resident, who had a history of mild cognitive impairment and falls, was able to independently wheel themselves out of the facility without staff supervision. This led to the resident's wheelchair rolling downhill, resulting in a fall and subsequent injuries, including a bump to the forehead, skin tears, and a hematoma. The resident was admitted to the facility with a diagnosis of mild cognitive impairment and a history of falling. Despite these conditions, the resident had unrestricted access to the second-floor lobby and the main elevator, which led to the main entrance on the first floor. The resident's Elopement Risk Evaluation, completed by a registered nurse, did not deem the resident an elopement risk, although it noted the need for supervision when off the unit. However, the evaluation was not accurately coded according to the RAI manual, and the resident was not adequately supervised when off the unit. On the day of the incident, a nursing assistant observed the resident wheeling themselves out of the facility while on her break. The staff member was distracted by her cell phone and did not intervene until it was too late. The Director of Nursing Services acknowledged that the resident should have been in generally supervised areas but could not explain how the resident managed to exit the unit and the building without proper supervision. This lack of supervision directly contributed to the resident's accident and subsequent injuries.
Failure to Develop Comprehensive Care Plan for UTI
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was being treated for a urinary tract infection (UTI). The resident, who was admitted in March 2022 with mild cognitive impairment and a history of falling, returned from the hospital after a fall and was diagnosed with a UTI. The resident was prescribed Cephalexin, an antibiotic, to be taken every 12 hours for 7 days. However, a review of the records showed no evidence that a care plan was developed and implemented for the UTI. During interviews, both the Minimum Data Set Coordinator and the Director of Nursing Services acknowledged that the care plan should have been updated to include the UTI immediately.
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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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Nursing homes near Providence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Adviniacare Providence Dodge Rehab Center, Llc | 0.7 mi | ★★★★★ | 4 | 0 |
| Elmwood Nursing And Rehabilitation Center | 0.9 mi | ★★★★★ | 14 | 0 |
| Tockwotton On The Waterfront | 1.1 mi | ★★★★★ | 5 | 0 |
| Bethany Home Of Rhode Island | 1.8 mi | ★★★★★ | 7 | 0 |
| Adviniacare Waterview Villas, Llc | 2 mi | ★★★★★ | 12 | 0 |
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