Cherry Hill Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Johnston, Rhode Island.
- Location
- 2 Cherry Hill Road, Johnston, Rhode Island 02919
- CMS Provider Number
- 415053
- Inspections on file
- 25
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Cherry Hill Manor during CMS and state inspections, most recent first.
A hospice resident with severe cognitive impairment, COPD, CHF, and a documented comfort‑focused care goal experienced unmanaged pain and terminal agitation when PRN morphine and lorazepam ordered for pain, SOB, and anxiety were not administered in a timely manner. A provider ordered sublingual morphine and lorazepam intensol early in the afternoon, and a hospice RN later documented that the resident was actively dying with severe pain, moaning, labored breathing, and terminal agitation, noting that pain management was ineffective and that the unit LPN was seeking an override for needed medications. MAR review showed morphine was not given until several hours after the order and after the hospice assessment, and lorazepam was delayed even longer, despite both drugs being available in the Omnicell and E‑Kit. In interviews, the LPN stated she did not feel the resident needed morphine and waited for a pharmacy code, and she did not consider the E‑Kit lorazepam, while the DON acknowledged the facility nurse was responsible for assessing and administering PRN medications and could not show that care met professional standards; a family member reported the resident appeared to be in agonizing pain and anxiety during this period.
A resident admitted after spinal surgery with a Hemovac drain and surgical wound did not have a baseline care plan developed within 48 hours that addressed care instructions for the wound or drain. Nursing leadership confirmed the omission when interviewed, and the resident was later hospitalized after presenting with signs of infection.
A resident with a Hemovac drain following spinal surgery did not have their drain output monitored or documented as required by facility policy. There were no physician orders for drain management, and staff could not provide evidence of required monitoring or documentation. This failure was confirmed by interviews with nursing staff, the DON, and the facility physician, as well as by the lack of documentation provided to the surgeon's office.
Two LPNs provided care to a resident with a Hemovac drain following spinal surgery without having received training or competency assessment specific to Hemovac drain care, as confirmed by staff interviews and facility records. The facility did not provide required education or competencies for this procedure, despite policy and resident needs.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a wound requiring dressing. Despite signage indicating the need for gown and glove use during high-contact care activities, staff were observed not adhering to these precautions. Interviews revealed a lack of understanding and adherence to the EBP policy, and the facility was unable to provide evidence of consistent EBP implementation.
Failure to Provide Timely End‑of‑Life Pain and Anxiety Management for a Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate end‑of‑life pain and symptom management for a hospice resident in accordance with physician orders and professional standards of practice. The resident was admitted with multiple chronic conditions, including COPD and CHF, and had severe cognitive impairment, requiring moderate to maximum assistance with ADLs. A provider note documented that the resident had recently presented with fever, shortness of breath, hypoxia, lethargy, and crackles throughout the lungs, and that the family’s and resident’s primary goal of care was comfort. The provider discussed hospice with the family, obtained consent for PRN morphine, lorazepam, and atropine drops for comfort, and sent a hospice referral, with the expectation that hospice would assess the resident that evening. Physician orders were entered for lorazepam intensol 0.25 mL every 4 hours PRN for anxiety/agitation and morphine 0.25 mL every 4 hours PRN for pain/shortness of breath early in the afternoon. A hospice RN assessed the resident later that day and documented that the resident was actively dying, with abnormal vital signs, severe pain (pain score 7/10), moaning, labored breathing, hyperventilation episodes, loud moaning or groaning, crying, and inability to be consoled, as well as agitation, disorientation, lethargy, and restlessness attributed to terminal agitation. The hospice RN noted that an order for sublingual morphine had been written earlier in the day but that the medication had not yet arrived from the pharmacy, and that the unit LPN was calling to obtain an override for needed medications. The hospice RN documented that current pain management was not effective and that they were awaiting morphine from the pharmacy. Medication administration records showed that morphine was not administered until 6:39 PM, approximately four and a half hours after it was ordered and about two hours after the hospice nurse’s assessment documenting severe pain. Lorazepam intensol was not administered until 10:40 PM, approximately nine hours after it was ordered and about six and a half hours after the hospice nurse’s assessment documenting anxiety and terminal agitation. Review of the Omnicell and the emergency E‑Kit showed that morphine and lorazepam intensol were available in the facility and could have been administered earlier. In interviews, the hospice nurse reported that the resident had periods of extreme anxiety and agitation and that the LPN stated she was waiting for a code from the pharmacy before administering morphine. The LPN who cared for the resident during the 3 PM–11 PM shift stated that the resident was sweaty, warm, reaching out for people’s hands, and had arthritis pain, and that she did not feel the resident needed morphine, so she waited to get a code from the pharmacy and administered it later in the evening; she also stated she did not think about the availability of lorazepam intensol in the E‑Kit. The DON acknowledged that the hospice nurse is not employed by the facility and that the facility nurse is responsible for assessing the resident and administering PRN medications, and could not provide evidence that the resident received treatment and care in accordance with professional standards of practice for end‑of‑life medications. Additionally, earlier in the resident’s course, a progress note documented that hospice services had been discussed with the family and that an informational consult in Spanish was requested, with the writer indicating an intent to contact hospice agencies to advocate for that request. Record review did not show evidence that the facility contacted a hospice agency to facilitate the requested informational consultation in Spanish at that time. The hospice agency’s director later reported that the agency did not receive a referral for the resident prior to the date the resident was ultimately admitted to hospice. A family member complainant reported that on the afternoon before the resident’s death there was a delay in providing the ordered morphine and lorazepam, that the resident appeared to be in agonizing pain and anxiety, and that the resident’s feet were hanging off the bed when the family member entered the room. The facility’s failure to use available medications from the Omnicell and E‑Kit and to administer ordered morphine and lorazepam in a timely manner, despite clear signs of severe pain and terminal agitation and the established comfort‑focused goals of care, led to unmanaged pain, terminal agitation, and psychosocial distress during the resident’s final hours of life.
Failure to Develop Baseline Care Plan for Surgical Wound and Hemovac Drain
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted following spinal fusion surgery and required orthopedic aftercare. Upon admission, documentation indicated the presence of a surgical dressing on the posterior back and a Hemovac drain with serosanguineous drainage. However, review of the baseline care plan revealed no evidence of care planning related to the surgical wound or the Hemovac drain, including necessary treatments or interventions. A complaint submitted to the state health department indicated that the resident was later found to be not alert, babbling, lethargic, and altered during a post-operative visit, with lab results showing elevated white blood cells. The resident was subsequently sent to the emergency room and admitted to the hospital for further care. During interviews, facility nursing leadership acknowledged the omission of instructions in the baseline care plan regarding the surgical wound and Hemovac drain.
Failure to Monitor and Document Hemovac Drain Output per Professional Standards
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality in the care of a resident with a Hemovac drain following spinal surgery. Upon admission, documentation noted the presence of a surgical dressing and Hemovac drain with serosanguineous drainage, but there was no evidence that the output from the drain was measured or recorded according to facility policy, which requires emptying and measuring every 4 to 8 hours. Review of the resident's medical record revealed a lack of physician orders for monitoring, emptying, or documenting the Hemovac drain's function and output during the resident's stay. Staff interviews confirmed that there was no documentation or recollection of orders related to the drain, and the Assistant Director of Nursing and Director of Nursing were unable to provide evidence of required monitoring or orders for the drain during the relevant period. Further, during a follow-up appointment, the facility was unable to provide documentation of the Hemovac drain's output to the surgeon's physician assistant, who expected at least twice-daily monitoring and documentation. The facility physician also stated that standard practice includes having orders to monitor drainage, ensure proper function, and observe for infection. The lack of documentation and physician orders for the Hemovac drain's management, as well as the absence of output monitoring, constituted a failure to meet professional standards of quality for this resident.
Lack of Nurse Competency for Hemovac Drain Care
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to provide care for residents with specific needs, as required by the facility assessment. Record review showed that the facility's resident population may include individuals with surgical wounds, and that nurse competencies should be completed during orientation, annually, and as dictated by resident care needs. Despite this, two LPNs who cared for a resident with a Hemovac drain following spinal fusion surgery reported not receiving any training specific to Hemovac drain care prior to providing care. The facility's policy on surgical wound treatment outlines the importance of proper management of closed-wound drains, including Hemovac drains, but the required competencies were not provided to the nursing staff. Interviews with the LPNs and the Director of Nursing Services confirmed that the facility did not provide education or competencies related to Hemovac drain care for any nursing staff. Documentation showed that a resident was admitted with a surgical wound and Hemovac drain, and staff were responsible for the care of this device without having received the necessary training. This lack of training and competency assessment was identified for 2 of 5 staff reviewed, resulting in a failure to ensure resident safety and the maintenance of the highest practicable well-being as required by regulation.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for a resident with a wound requiring dressing. The resident, admitted in July 2024, had a wound on the coccyx that required various treatments from October to December 2024. Despite the presence of signage indicating the need for gown and glove use during high-contact care activities, staff members were observed not adhering to these precautions. On December 10, 2024, Nursing Assistants and an LPN were seen assisting the resident without wearing the required protective gear, despite the posted instructions. Interviews with staff revealed a lack of understanding and adherence to the EBP policy. Staff acknowledged the signage but failed to comply with the requirements during care activities. The Infection Preventionist and other nursing leaders were unable to provide evidence that the facility consistently followed EBP protocols as per their policy. The deficiency was highlighted by the absence of EBP implementation for the resident, who had a wound requiring a dressing since October 29, 2024, but was not placed on EBP until December 10, 2024.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
