Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 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.
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.
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.
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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 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 | — | 5 | 0 |
| Royal Middletown Nursing Center | 3.7 mi | — | 16 | 0 |
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