Adviniacare Newport, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Newport, Rhode Island.
- Location
- 398 Bellevue Avenue, Newport, Rhode Island 02840
- CMS Provider Number
- 415033
- Inspections on file
- 34
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 18
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.
Latest citations in Rhode Island
The facility failed to follow physician orders for post-fall care for three anticoagulated residents who experienced falls. One resident on a blood thinner with a head injury was ordered to be transferred to the ED after a telehealth evaluation, but an LPN did not send the resident, citing instructions to contact a supervisor first and inability to reach that supervisor. For two other residents on anticoagulants, providers ordered intensive neuro checks (every 15 minutes, then every 30 minutes, then hourly, then every 4 hours), but staff instead performed neuro checks only once per shift for 72 hours. The DON and Medical Director acknowledged that the transfer and monitoring orders were not implemented as written.
A resident with intact cognition and psychiatric diagnoses sustained a left eyebrow laceration when another resident with a documented history of escalating aggressive and threatening behaviors struck them with a cane during a hallway dispute. The aggressive resident had multiple prior documented incidents, including verbal threats to kill others, attacking a roommate with a cane over TV volume, throwing objects during activities, and throwing a lunch plate at staff. Despite these events, the care plan was not updated with interventions to address physical aggression toward other residents, and a psychiatric recommendation for PRN trazodone for agitation, anxiety, and insomnia was only implemented as PRN for insomnia. The failure to assess, monitor, and implement effective interventions for the aggressive resident’s behaviors led to the assault and injury and, per the report, placed this and other residents at risk of serious physical and psychosocial harm.
A resident with impulse disorder, mood and anxiety diagnoses, and a history of escalating verbal and physical aggression had multiple documented incidents of threats, object throwing, and assault with a cane. Despite a psychiatric consult recommending PRN trazodone for agitation, anxiety, and insomnia, the provider order listed insomnia only, and the care plan was not updated with specific interventions to address the resident’s physically aggressive behaviors after several documented events. Subsequently, the resident struck another resident with a cane, causing a facial laceration that required wound closure and ongoing treatment.
The facility failed to properly screen and document clearance for a NA with disqualifying criminal history information before hire, as required by its abuse, neglect, and exploitation policy. A BCI check showed disqualifying information, yet the NA was hired, completed orientation, and worked independently based only on verbal disclosure of an old drug-related charge, without written details or verification. Later, a staff member reported witnessing this NA grab a resident’s face and kiss the resident on the lips, and a community complaint alleged inappropriate interactions with the same resident, prompting involvement of local police.
A resident with anxiety disorder and PTSD was unable to attend meals and activities with peers because the facility lost the resident's clothing after it was sent to laundry. The resident was observed in a hospital gown with only a few clothing items in the room, and the record lacked an admission inventory of belongings. The DON/Administrator reported that laundry was handled by an outside vendor without a tracking system or item documentation.
A resident with dementia and severely impaired cognition was subjected to repeated non-consensual kissing on the lips by an NA, who entered the resident’s room during care, verbally expressed affection, and then kissed the resident on the mouth on at least two separate occasions witnessed by staff. One staff member delayed reporting the first incident due to fear of the NA. These actions occurred despite a facility policy defining sexual abuse as any non-consensual sexual act and requiring protections of residents’ rights and well-being.
Failure to investigate allegations of resident-to-resident sexual inappropriateness: A resident with dementia and TBI was documented as being inappropriate with another resident, and psych notes later described increased sexually inappropriate behaviors toward other residents. Staff interviews showed the resident had been observed touching others and needing frequent redirection, but the DON, ADON, and Administrator acknowledged the facility did not complete an investigation or recognize the allegation as possible abuse.
A resident with dementia and a hearing deficit did not receive ear care as ordered because the chart lacked the Debrox order and the ear was flushed before the intended Debrox course was completed. In a separate incident, staff witnessed inappropriate kissing of a resident with dementia, but the allegation was not reported to the provider and the care plan was not updated. A third resident’s wound care was also not completed as ordered when an RN used normal saline instead of the prescribed Vashe wound wash.
A resident with migraines and chronic pain did not receive timely pain management after repeatedly reporting a migraine and appearing in visible distress. An NA notified an LPN, an RN said she could not access the med cart, and the resident continued waiting while the LPN was off the unit; the PRN migraine medication was not given until 40 minutes after the first complaint. The DON acknowledged the resident should not have waited that long for pain medication.
A resident missed 6 doses of a prescribed antibiotic, and the MAR did not show that the provider was notified. The RN acknowledged the missed doses and said they should have been reported, while the Medical Director stated she was unaware of the missed doses and would have extended the antibiotic course if informed. The DON also confirmed the missed doses and expected provider notification for any missed antibiotic dose.
Failure to Follow Post-Fall Physician Orders for Anticoagulated Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for post-fall care, including hospital transfer and neurological monitoring, for residents on anticoagulant therapy. One resident with atrial fibrillation on Xarelto experienced an unwitnessed fall with a scalp laceration and head lump. The on-call provider, after a telehealth evaluation, ordered transfer to the ED and wrote an order directing that the resident be sent to the hospital. The resident was not transferred as ordered, and an additional order for vital signs and neuro checks every shift for 72 hours after the fall was not completed as ordered on one of the shifts. The LPN caring for this resident stated she did not send the resident to the ED because she had been instructed to call a supervisor before sending residents out, and she was unable to reach the supervisor during the shift. A second resident, also with atrial fibrillation and on Xarelto, had an unwitnessed fall with injury. The on-call provider was notified and ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, then every four hours for an additional 24 hours. A physician’s order reflecting this schedule was scanned into the EMR. However, the neuro checks were not completed as ordered; instead, they were performed only once per shift for 72 hours. The RN who authored the progress note documented the fall and the resident’s anticoagulant use, and later stated she could not remember why she did not transcribe and complete the neuro checks as ordered. A third resident with atrial fibrillation on Apixaban had a non-injury fall after attempting to walk independently. The on-call provider ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, and then every four hours for an additional 24 hours, and this order was scanned into the EMR. The record did not show that these neuro checks were completed as ordered; instead, neuro checks were documented only once per shift for 72 hours. The Medical Director stated he would have expected the first resident to be transferred to the ED as ordered and that the facility should not override a provider’s order. The DON acknowledged that the transfer order and the ordered monitoring for the first resident were not followed as written, and that for the second and third residents, staff performed only once-per-shift neuro checks instead of the more frequent monitoring ordered by the providers.
Failure to Manage Escalating Aggression Leading to Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident, Resident ID #1, from abuse by another resident with a known history of escalating aggression, Resident ID #2. Resident ID #1 was admitted in October 2025 with diagnoses including paranoid schizophrenia and adjustment disorder with mixed anxiety and depressed mood, and had a BIMS score of 14/15, indicating intact cognition. On 4/27/2026, progress notes documented that Resident ID #1 was on the receiving end of a physical altercation with another resident and was found with a deep bleeding abrasion to the left eyebrow. A subsequent nursing note described a new laceration to the left eyebrow measuring 0.5 cm by 2.0 cm by 0.1 cm, related to a resident-to-resident incident, for which wound closure strips were applied. Resident ID #1 requested police involvement and a police report, and refused transfer to the hospital for sutures. Resident ID #2 had been admitted in December 2024 with multiple psychiatric and behavioral diagnoses, including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed a BIMS score of 13/15 and documented both physical and verbal behaviors during the look-back period. Progress notes over several months recorded a pattern of escalating aggressive and threatening behaviors: on 9/13/2025, Resident ID #2 threatened to slit another resident’s throat and made additional threats toward staff; on 11/7/2025, the resident was involved in a verbal dispute with raised voice, name-calling, and verbal threats; on 12/28/2025, after another resident struck Resident ID #2 with a helmet, Resident ID #2 was overheard threatening to kill that resident if touched again. On 2/21/2026, the on-call provider documented that Resident ID #2 attacked a roommate with a cane over TV volume and required ER transfer for psychiatric evaluation. Subsequent notes on 3/9/2026 and 4/10/2026 described the resident throwing poker chips on the floor, yelling and swearing at staff and residents, and throwing a lunch plate across the nurses’ station at a nursing assistant due to dissatisfaction with portion size. Despite this documented pattern, the care plan for Resident ID #2, dated 1/16/2025, only indicated a behavior problem of being verbally aggressive toward staff with resident-to-resident altercations on 12/28/2025, 2/21/2026, and 4/27/2026, and record review failed to show added interventions to mitigate the risk of physical aggression toward other residents after the 2/21/2026 cane attack and the object-throwing incidents on 3/9/2026 and 4/10/2026. A psychiatric evaluation on 4/23/2026 recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order entered on 4/24/2026 specified trazodone 25 mg twice daily as needed only for insomnia, and record review did not show that agitation and anxiety were included as indications for use. During interviews, the RNP and the DON stated it was their expectation that agitation and anxiety would have been included in the trazodone order, and the DON was unable to provide evidence that the care plan had been updated with interventions to address Resident ID #2’s physically aggressive behaviors documented on 2/21/2026, 3/9/2026, and 4/10/2026. On 4/27/2026, the DON documented that Resident ID #2 was ambulating down the hall toward his/her room while Resident ID #1 was walking in the opposite direction, and the two residents began a verbal dispute. Before staff could intervene, Resident ID #2 used his/her cane to make contact with Resident ID #1, resulting in the eyebrow laceration that required steri-strips and ongoing wound treatment. A police incident report recorded that Resident ID #1 stated being struck with a walking cane, wanted to press charges, and that Resident ID #2 admitted to striking Resident ID #1, leading to an arrest on one count of felony assault with a dangerous weapon. The facility’s failure to assess, monitor, and implement effective interventions for Resident ID #2’s known and escalating aggressive behaviors, including failure to update the care plan after prior incidents and failure to fully implement psychiatric recommendations, resulted in this resident-to-resident altercation and injury, and the report states that this failure placed Resident ID #1 and other residents at risk of serious physical and psychosocial harm.
Failure to Implement Psychiatric Recommendations and Update Behavior Care Plan Leading to Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health services and care planning for a resident with a documented history of psychiatric conditions and aggressive behaviors. The resident was admitted in December 2024 with diagnoses including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed intact cognition with a BIMS score of 13/15 and documented physical and verbal behaviors during the look-back period. Over time, multiple behavioral incidents were recorded, including threats to slit another resident’s throat during a smoking session, verbal disputes with name-calling and threats, and a statement to another resident that if touched again the resident would be killed. Further documentation showed escalating behaviors, including an incident where the resident attacked a roommate with a cane over television volume and required ER transfer for psychiatric evaluation, throwing poker chips and yelling when not winning at Bingo, causing the roommate to avoid the shared bathroom due to inappropriate comments and frustration over the light being turned on at night, and throwing a lunch plate across the nurses’ station at a nursing assistant over portion size. The care plan, initiated in January 2025 for verbal aggression and resident-to-resident altercations, did not contain added interventions to address the resident’s physically aggressive behaviors toward others after the incidents on 2/21/2026, 3/9/2026, and 4/10/2026. The DNS later could not provide evidence that the care plan had been updated with interventions to mitigate the risk of these physically aggressive behaviors or to guide staff in ensuring the safety of other residents. On 4/23/2026, a psychiatric evaluation recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order dated 4/24/2026 implemented trazodone 25 mg twice daily as needed for insomnia only, and the record lacked evidence that agitation and anxiety were included as indications for use as recommended by the consulting psychiatrist. Both the RNP and the DNS stated it was their expectation that the trazodone order would have included agitation and anxiety. Following this incomplete implementation of the psychiatric recommendation and the lack of updated behavioral interventions in the care plan, a resident-to-resident altercation occurred on 4/27/2026 in which the resident struck another resident with a cane, causing a laceration to the left eyebrow that required closure with steri-strips and ongoing wound treatment.
Failure to Properly Screen and Clear NA with Disqualifying Criminal History
Penalty
Summary
The facility failed to ensure that a prospective employee was properly screened and cleared for a history of abuse, neglect, exploitation, or misappropriation of resident property before hire. A nursing assistant, identified as Staff A, was hired on 11/18/2025 and was working independently as a NA. Prior to hire, a Bureau of Criminal Identification (BCI) check dated 11/6/2025 showed that Staff A had disqualifying information under federal and state law. Surveyor review after discovery of the positive BCI revealed that Staff A had an extensive criminal history. Despite this, the facility proceeded with the hire and allowed Staff A to complete orientation and work independently without obtaining or maintaining documentation specifying the nature of the disqualifying information, contrary to the facility’s Abuse, Neglect and Exploitation Policy, which requires screening and documentation of proof that such screening occurred. Subsequently, a facility-reported incident submitted on 4/17/2026 documented that a staff member reported witnessing Staff A grab a resident’s face and kiss the resident on the lips. A community-reported complaint submitted on 4/22/2026 alleged inappropriate interactions between the same NA and the same resident, and included a local police incident report indicating the resident’s family intended to pursue charges related to the incident. During interviews, the Human Resource Director stated that Staff A had disclosed disqualifying information related to a prior drug-related charge from about ten years earlier, but acknowledged there was no documentation specifying the nature of the disqualifying information and that this was known only by word of mouth. The Administrator stated she was aware that the BCI contained disqualifying information and that she exercised her own judgment in proceeding with the hire, and further acknowledged she did not receive documentation detailing the disqualifying information until it was brought to her attention by the surveyor.
Failure to Maintain Resident Clothing and Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when the resident was unable to attend meals and activities with other residents because of a lack of appropriate clothing. The resident was admitted in May 2025 with diagnoses including anxiety disorder and post-traumatic stress disorder, and a care plan revised on 8/25/2025 described the resident as highly social and willing to participate in a variety of activities, with an intervention to provide reminders of scheduled events. During observation on 4/29/2026, the resident was found in the room wearing a hospital gown while other residents were in the dining room for lunch. Only one pair of pants and two T-shirts were observed in the room. The resident stated that the facility lost all of the resident's clothing, including shirts, pants, shorts, and socks, after they were sent to laundry services several months earlier and were never returned. The resident reported that the Administrator was told about the missing clothing, but no follow-up occurred and the clothing was neither located nor replaced. The record did not contain an admission inventory list of the resident's belongings, and the Administrator stated that laundry was handled by an outsourced company without a tracking system or documentation identifying which items belonged to which resident.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse when a nursing assistant (NA) was observed kissing the resident on the lips on more than one occasion. The resident, identified as having dementia and a Brief Interview for Mental Status (BIMS) score of 0/15 indicating severely impaired cognition, had been admitted in March 2026. On one occasion, a Certified Medication Technician (CMT) reported that while she was assisting the resident with breakfast, the NA entered the room, verbally expressed affection for the resident, made a kissing noise, leaned forward, and kissed the resident on the lips. This incident made the CMT uncomfortable, and she later discussed it with another NA. A separate staff member, another NA, reported that two days earlier she had observed the same NA enter the resident’s room while morning care was being provided, ask the resident if they remembered her, state that she loved the resident, then lean toward the resident, make a kissing sound, and kiss the resident on the mouth with full lip-to-lip contact. This second NA did not report the incident at the time because she was fearful of the NA involved and only came forward after learning of the later incident. The facility’s abuse, neglect, and exploitation policy defined sexual abuse as a non-consensual sexual act of any type with a resident and required protections for each resident’s health, welfare, and rights, as well as screening of potential employees for a history of abuse. Despite this policy, the resident with severely impaired cognition was subjected to repeated non-consensual kissing by the NA.
Failure to Investigate Allegations of Resident-to-Resident Sexual Inappropriateness
Penalty
Summary
The facility failed to ensure that allegations made by residents were recognized as possible abuse by staff and that all allegations were investigated for Resident ID #41, who was admitted with diagnoses including dementia and traumatic brain injury. A facility policy titled, Abuse, Neglect and Exploitation, stated that an immediate investigation is warranted when suspicion of abuse, neglect, exploitation, or reports of abuse, neglect, or exploitation occur. A progress note written by an RN documented that a resident reported Resident ID #41 was being inappropriate with another resident. Subsequent records included psychiatric evaluations stating the resident was being seen due to increased sexually inappropriate behaviors toward other residents and that sexual impulses may present an unsafe environment for other patients in the facility. Staff interviews revealed that Resident ID #41 had been observed touching other residents' shoulders and hands and required frequent redirection. The RN who documented the incident stated the behavior involved an attempted hug without contact and that both residents were separated and assessed, while the ADON and DON acknowledged they were unaware of the behavior or that the facility had not investigated the allegations. The Administrator also acknowledged that an investigation had not been completed to determine what sexually inappropriate behavior had occurred and that staff did not identify the allegation as possible abuse or investigate it immediately.
Failure to Follow Orders, Report Abuse, and Perform Ordered Wound Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for a resident with dementia and anxiety disorder who had a hearing deficit and complained of right ear wax buildup. The medical record showed an order for Debrox ear drops and a separate order to flush the right ear with warm water two times a day following Debrox usage for 5 days, but the record did not include a physician order for the Debrox solution. The April 2026 MAR showed the resident’s right ear was flushed six times, and the resident stated that the right ear still felt blocked. The RN acknowledged flushing the ear and was unaware whether Debrox had been given, while the DON stated the order had been entered incorrectly and that the ear should not have been flushed before Debrox administration. The NP stated the intended order was for Debrox twice daily for five days before irrigation and that she would not have ordered daily ear flushing. The facility also failed to report an allegation of abuse and failed to update the care plan for a resident with dementia after staff reported inappropriate interactions with a nursing assistant. A community complaint and police incident report indicated the family wanted to press charges, and the Administrator and DON confirmed that staff had reported witnessing the nursing assistant kiss the resident on two occasions. The record did not show that the allegation was reported to the provider, and the comprehensive care plan was not updated to reflect the allegation or any interventions related to the incident. The NP stated she was unaware of the incident and would have expected to be notified, and the ADNS acknowledged that the provider had not been notified and the care plan had not been updated. The facility further failed to follow a wound care order for a resident readmitted with peripheral vascular disease and cellulitis of the lower limb. The physician ordered cleansing open areas on the left lower leg with Vashe wound wash, applying xeroform to the wound bed, and wrapping with kling. During observation, the RN performing wound care did not use Vashe wash and instead cleansed the wound with normal saline. The RN acknowledged using normal saline rather than the ordered cleanser, and the DON stated she would expect the nurse to follow the wound orders as written.
Delayed Pain Medication for Resident with Migraine
Penalty
Summary
Safe, appropriate pain management was not provided for Resident ID #17, who was admitted with diagnoses including migraines and chronic pain. The resident’s care plan dated 4/20/2026 included a goal for the resident to verbalize adequate pain relief and an intervention to respond immediately to any complaint of pain. The physician ordered Butalbital-APAP-Caffeine 50-300-40 mg, 1 capsule every 12 hours as needed for migraine pain. On 4/29/2026 at 10:30 AM, the resident was observed in the hallway complaining of a migraine, moaning in pain, and holding his/her head. At 10:34 AM, an NA reported to an LPN that the resident wanted pain medication, and at 10:37 AM the resident continued to complain of migraine pain and told an RN about the pain, but the RN stated she did not have keys to the medication cart and could not get any pain medication. The resident continued to complain of severe head pain, returned to the room to lie down at 10:40 AM, and the LPN was still off the unit at 10:42 AM. The resident was not assessed when the LPN returned, and the medication was not administered until 11:10 AM, 40 minutes after the initial complaint. The resident later reported pain rated 7 out of 10, and the DON acknowledged that a resident should not wait 40 minutes for pain medication.
Missed Antibiotic Doses Not Reported to Provider
Penalty
Summary
The facility failed to ensure that Resident ID #17 was free from significant medication errors when the resident missed 6 doses of a prescribed antibiotic. The resident was admitted in April 2026 with diagnoses including surgical aftercare and complication of surgical and medical care, and had a physician order dated 4/3/2026 for Cefadroxil 500 mg by mouth twice daily for 14 days. Review of the April 2026 MAR showed missed doses on 4/3 at 8:00 PM, 4/6 at 8:00 PM, 4/11 at 8:00 PM, 4/12 at 8:00 AM, 4/14 at 8:00 PM, and 4/17 at 8:00 AM. The record did not show that the provider was notified of the missed antibiotic doses. During interview, the RN acknowledged the 6 missed doses and stated they should have been reported to the provider. The Medical Director stated she was unaware of the missed doses and said she would have extended the antibiotic course if she had known. The DON also acknowledged the missed doses and stated she would expect the provider to be informed if a resident misses any dose of an antibiotic.
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