PRINTED: 04/27/2020
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

415038

OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________
B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

04/14/2020

STREET ADDRESS, CITY, STATE, ZIP CODE

135 DODGE STREET

BANNISTER CTR FOR REHABILITATION AND HEALTH CARE
(X4) ID
PREFIX
TAG

(X3) DATE SURVEY
COMPLETED

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 000 INITIAL COMMENTS

PROVIDENCE, RI 02907
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 000

A COVID-19 Focused Infection Control Survey
was conducted by the Centers for Medicare &
Medicaid Services (CMS) on April 14. 2020. The
facility was found to be in compliance with 42
CFR §483.80 infection control regulations and
has implemented the CMS and Centers for
Disease Control and Prevention (CDC)
recommended practices to prepare for
COVID-19.
Capacity 161 Total residents: 150

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

(X6) DATE

TITLE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 0U7H11

Facility ID: 415038

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