Holiday Retirement Home Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Manville, Rhode Island.
- Location
- 30 Sayles Hill Road, Manville, Rhode Island 02838
- CMS Provider Number
- 415075
- Inspections on file
- 30
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Holiday Retirement Home Inc during CMS and state inspections, most recent first.
A nurse’s transcription error led to a Farxiga order, intended for one resident, being entered into another resident’s chart, causing that resident—who had diagnoses including edema and hypokalemia—to receive Farxiga 5 mg daily for an extended period before the mistake was discovered. The issue came to light following a community complaint and was confirmed through record review, a Medication Error Form, staff statements, and an interview with the DON, all documenting that the incorrect medication was administered for many days.
A resident with chronic inflammatory demyelinating polyneuropathy and lymphedema developed large bruises on the right upper buttock and later on the left proximal thigh, described as deep purple and measuring approximately 18 cm by 22 cm. Facility policy on abuse and injuries of unknown origin requires initiation of an investigation, obtaining witness statements, notifying administrative personnel, and documenting a comprehensive internal investigation in the clinical record. Record review showed no evidence that any investigation was conducted to determine the origin of either bruise, and the DON confirmed that while new bruising should be investigated and documented, he could not provide evidence that this was done in these instances.
Two residents did not receive care consistent with physician orders and professional standards. One resident with significant neuromuscular and edema-related conditions had an order requiring two staff members at all times for care, yet was showered by a hospice NA alone after being transferred with assistance, during which active bleeding occurred and a traumatic wound to the great toe was later documented. Another resident with a history of MI and stroke, on dual antiplatelet therapy with aspirin and Plavix, had a physician order for a cardiology consult prior to possible discontinuation of Plavix, but no evidence was found that the consult was scheduled, and the Scheduler reported being unaware of the need for the appointment.
Surveyors found that several residents did not receive care in accordance with physician orders and professional standards, including improper air mattress settings, incorrect oxygen administration, and failure to notify a physician of significant weight gain. Staff were unaware of correct procedures, and documentation did not reflect required notifications.
Nursing staff failed to accurately document and follow physician orders for several residents, including not verifying air mattress settings according to weight, not ensuring correct oxygen flow rates, and documenting encouragement of incentive spirometer use when the device was not present. Staff acknowledged documenting completion of these tasks without performing them, resulting in inaccurate medical records.
The facility did not conduct required antibiotic 'time outs' or reviews for three residents who were prescribed antibiotics for conditions such as a toe infection, a surgical incision, and pneumonia. Medical records lacked documentation of clinical reviews within the recommended timeframe, and the Infection Preventionist confirmed that no staff member was assigned to complete these reviews during her absence.
A resident with multiple chronic conditions was not assessed or monitored for respiratory status, edema, and congestion as ordered, despite exhibiting symptoms such as lower extremity swelling and a persistent cough. Staff failed to document required assessments, did not notify the physician of the change in condition in a timely manner, and only performed necessary evaluations after surveyor intervention. Facility policy requiring prompt notification and assessment was not followed.
A resident with a stage two pressure ulcer and orders for Enhanced Barrier Precautions did not receive care in accordance with infection control protocols. During wound care, an RN failed to don a gown before starting the procedure, placed soiled materials on the bedside table without disinfecting it, and exited the room wearing the gown. Additionally, two NAs performed a transfer using a Hoyer lift without wearing the required PPE, despite clear signage and orders. All involved staff acknowledged not following the EBP protocol.
The facility did not ensure that two residents' medical records included documentation of being offered, receiving, or refusing the updated pneumococcal vaccine (PCV20 or PCV21), despite prior vaccinations with PCV13 and PPSV23. Staff interviews confirmed the absence of this documentation, and the facility's vaccination policy was found to be outdated and not aligned with current CDC recommendations.
Surveyors observed that the main kitchen's walk-in freezer had significant ice buildup on the sprinkler head and fan, and a kitchenette microwave was severely cracked with peeling paint. The Food Service Director confirmed both issues during the inspection.
A resident with peripheral vascular disease was found to have severe foot wounds infested with maggots, indicating a failure in providing adequate foot care. Despite being dependent on staff for lower body dressing, the resident's wounds were not identified during routine assessments. An LPN noted significant wounds with maggots, but other staff failed to conduct thorough skin checks. The DON admitted the lack of preventive care protocols for residents prone to foot problems.
A facility failed to ensure nursing staff had the necessary competencies for conducting thorough skin assessments, leading to a resident being hospitalized with untreated foot wounds and maggots. The facility's policy required weekly skin assessments, but a nurse did not check between the resident's toes, missing the wounds. Six nursing staff members lacked competency-based training, and the facility did not follow its assessment plan, putting all residents at risk.
A facility failed to maintain accurate medical records for a resident, as a skin assessment did not identify foot wounds later found at a hospital. The RN admitted to not checking between the toes, and the DON confirmed this was expected. The facility could not prove the assessment was done accurately.
A facility failed to follow professional standards by not having a physician's order or documentation for a resident's Freestyle Libre sensor, a continuous glucose monitoring system. The resident, with diabetes and COPD, indicated the sensor should be changed every 14 days, but records lacked evidence of orders or change history. The DON confirmed the absence of necessary documentation and orders.
A resident with diabetes received incorrect insulin dosages on multiple occasions due to a failure to follow physician's orders. Despite blood sugar levels indicating the need for 35 units of Humalog Mix 75-25 insulin, only 25 units were administered. This error was acknowledged by the DON during a surveyor interview.
Prolonged Administration of Incorrect Medication Due to Transcription Error
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when a nurse incorrectly transcribed a Farxiga order into the wrong resident’s medical record, resulting in the resident receiving another resident’s medication for an extended period. A community complaint reported that a nurse had transcribed Farxiga, a medication used to treat type 2 diabetes, kidney disease, and congestive heart failure, into the records of two residents, and the error was not identified for 18 days. Clinical record review showed that Resident ID #3, who had been readmitted with diagnoses including edema and hypokalemia, was administered Farxiga 5 mg daily that was intended for a different resident, and this error persisted for 19 days. A Medication Error Form and a written statement from the Assistant Director of Nursing documented that Staff A mistakenly entered the Farxiga order into the wrong chart, and during an interview the Director of Nursing Services acknowledged that the resident received Farxiga in error for 19 days. These findings were based on review of the community complaint, the resident’s clinical record, the Medication Error Form, staff written statements, and an interview with the Director of Nursing Services, all confirming the prolonged administration of an incorrect medication to Resident ID #3.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate injuries of unknown origin for a resident who had significant bruising on two occasions. The facility’s abuse prohibition policy defines injuries of unknown origin and requires that an initial investigation be started, witness statements obtained, appropriate administrative personnel notified, and a comprehensive internal investigation carried out, with documentation in the clinical record. The resident, readmitted in July 2025, had diagnoses including chronic inflammatory demyelinating polyneuropathy and lymphedema. Progress notes showed that on 8/26/2025 a large bruise was noted on the right upper buttock, and on 9/8/2025 staff found a large, deep purple bruise on the left proximal thigh measuring approximately 18 cm by 22 cm during care at 12 AM. Further record review did not show any evidence that an investigation was conducted to determine the origin of either bruise. In an interview, the Director of Nursing Services stated that new bruising should trigger an investigation to determine etiology and be documented in the clinical record, but he was unable to provide evidence that such investigations were completed for the bruising documented on 8/26/2025 and 9/8/2025.
Failure to Follow Physician Orders for Two-Person Care and Cardiology Consult
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and professional standards of practice for two residents. One resident, readmitted in July 2025 with chronic inflammatory demyelinating polyneuropathy and lymphedema, had a physician’s order dated 7/10/2025 requiring two staff members at all times for resident care. On 8/27/2025 during the 7:00 AM to 3:00 PM shift, the resident was taken to the shower room by a facility NA and a hospice NA. The facility NA assisted with transferring the resident into the shower chair via a Hoyer lift along with the hospice NA, but the hospice NA then showered the resident alone. During the shower, the hospice NA observed active bleeding from an unidentified source, and when nursing staff arrived, a pool of blood was noted in the bathroom. A skin assessment revealed an open area with a split to the skin on the top of the right great toe, and progress notes documented a traumatic wound to the distal tip of the right great toe with copious blood drainage and active bleeding. The NA assigned to the resident stated she was not aware that the resident required two staff members for care at all times, and record review did not show evidence that two staff members were present for care during the shower as ordered. The second deficiency concerns a failure to carry out a physician’s order for a cardiology consult for another resident. This resident was readmitted in September 2025 with diagnoses including myocardial infarction and cerebral infarction and had existing physician’s orders for aspirin 81 mg daily and Plavix 75 mg daily. A progress note dated 10/30/2025 documented that the resident was on dual antiplatelet therapy with aspirin and Plavix, and the pharmacy recommended discontinuation of Plavix. This recommendation was reported to the physician, who issued a new order to obtain a cardiology consult prior to discontinuing the medication. A physician’s order dated 10/31/2025 directed staff to obtain a cardiology consult for possible discontinuation of Plavix. Record review failed to show evidence that a cardiology consult had been scheduled, and the Scheduler reported being unaware that the resident needed a cardiology appointment and had not reached out to schedule it.
Failure to Follow Physician Orders and Professional Standards of Care
Penalty
Summary
Surveyor observations, record reviews, and staff interviews revealed that the facility failed to ensure residents received care in accordance with professional standards and physician orders. Multiple residents with air mattresses had their mattress settings incorrectly adjusted, not matching either the physician's order or the resident's current weight. For example, one resident weighing 119.6 lbs had their air mattress set to 300 lbs, while another resident weighing 141 lbs had their mattress set to 350 lbs. Staff interviewed were unaware of the correct settings, and the Director of Nursing Services confirmed that the settings should have matched the residents' weights or the specific physician orders. Additionally, a resident with a physician's order for continuous oxygen at 2 liters per minute was observed receiving oxygen at 4 liters per minute on several occasions. Staff acknowledged that the oxygen was not being administered as ordered, and the DNS stated that the physician's order should have been followed regarding the oxygen flow rate. Another deficiency was identified for a resident with an order for daily weights three times per week, with instructions to notify the physician if there was a weight gain greater than 3 lbs in a day or 5 lbs in a week. The resident experienced a weight gain of 5.4 lbs in one week, but there was no evidence that the physician was notified as required. Staff interviews confirmed that the weight gain was not reported to the physician, and the nurse practitioner and DNS both indicated that notification should have occurred per the order.
Failure to Accurately Maintain Medical Records and Follow Physician Orders
Penalty
Summary
The facility failed to accurately maintain medical records and safeguard resident-identifiable information in accordance with accepted professional standards for several residents. For three residents with air mattresses, physician orders required that the mattress settings be checked every shift and set according to the resident's weight. However, surveyor observations revealed that the air mattresses were not set to the correct weights, and nursing staff documented in the Treatment Administration Record (TAR) that the checks were completed without verifying or adjusting the settings. Staff interviews confirmed that the documentation was completed without actually performing the required checks. For a resident receiving oxygen therapy, a physician's order specified oxygen at 2 liters per minute via nasal cannula continuously. Despite this, the resident was observed receiving oxygen at 4 liters per minute on multiple occasions. The Medication Administration Record (MAR) indicated that the resident was documented as receiving the ordered amount, but staff acknowledged that they signed off on the order without verifying the actual oxygen flow rate. Additionally, for a resident with an order to encourage the use of an incentive spirometer every shift, surveyors found that the device was not present in the resident's room during multiple observations. Despite this, the TAR reflected that staff had documented the order as completed. Staff interviews confirmed that documentation was made without ensuring the resident had access to or used the incentive spirometer.
Failure to Monitor and Review Antibiotic Use
Penalty
Summary
The facility failed to establish and implement an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program with protocols and a system to monitor antibiotic use. Specifically, for three residents who were prescribed antibiotics for various conditions—including an infection of the great toe, a surgical incision, and pneumonia—there was no evidence in the medical records that an antibiotic 'time out' or review was conducted within 48 to 72 hours after the initiation of antibiotic therapy, as recommended by the CDC's Core Elements of Antibiotic Stewardship for Nursing Homes. Record reviews for these residents showed that antibiotics such as doxycycline and cephalexin were administered, but documentation of a clinical review to assess the appropriateness of the antibiotic, its dose, route, or duration was absent. During an interview, the Infection Preventionist confirmed that no antibiotic timeouts were completed for these residents and further disclosed that, during her leave of absence, there was no designated staff member responsible for completing these reviews.
Failure to Monitor and Notify Physician of Resident's Change in Condition
Penalty
Summary
A resident with a history of Alzheimer's disease, acute kidney failure, hypertensive heart disease, and chronic kidney disease was readmitted to the facility and had physician's orders in place for diuretic use, monitoring for edema, congestion, and weight changes every shift, as well as specific orders to assess and document respiratory status every shift for three days. Despite these orders, there was no evidence that the resident's respiratory status was assessed and documented as required on multiple shifts. Additionally, staff failed to monitor and document the presence of edema and congestion as ordered. Surveyor observations revealed that the resident exhibited swelling in the lower legs and a congested, non-productive cough over several days. Staff interviews confirmed that the resident was observed coughing, but assessments were not performed or documented, and the physician was not notified of the change in condition in a timely manner. One LPN admitted to documenting that an assessment was completed when it was not, and only assessed the resident for edema after the surveyor brought the issue to her attention. The resident was found to have severe pitting edema at that time. The facility's policy required notification of the physician and responsible party when a change in condition occurred, including the need to alter medical treatment. However, the physician was not notified of the resident's change in condition until several days after the initial assessment, and only after the surveyor intervened. Staff and leadership interviews confirmed that the expected standard of care was not met, as the resident was not assessed or monitored according to physician orders and professional standards of practice.
Failure to Follow Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as required by policy and physician orders, specifically regarding the use of Enhanced Barrier Precautions (EBP) for a resident with a stage two pressure ulcer. The resident, who was readmitted with muscle weakness and difficulty walking, had physician orders for EBP and wound care, including the use of gowns and gloves during high-contact care activities such as transfers and dressing changes. Despite clear signage and documented orders, staff did not consistently follow these protocols. During a wound dressing change, a registered nurse began the procedure without donning a gown, only putting it on after realizing the omission. The nurse also placed soiled dressing materials directly on the bedside table and failed to disinfect the area afterward. Additionally, the nurse exited the resident's room into the hallway while still wearing the gown, only returning to remove it after noticing the error. Further observations revealed that two nursing assistants entered the resident's room and performed a transfer using a Hoyer lift without wearing the required gown or gloves, despite the EBP signage and orders. Both nursing assistants acknowledged after the fact that they did not follow the EBP protocol. The staff educator confirmed that the expectation was for staff to adhere to infection control protocols and wear appropriate PPE as indicated by orders and signage. These actions and inactions directly led to the identified deficiency in the facility's infection prevention and control program.
Failure to Document and Update Pneumococcal Vaccination Practices
Penalty
Summary
The facility failed to ensure that residents' medical records included documentation indicating whether the pneumococcal vaccine (PCV20 or PCV21) was offered, received, or refused, or if there were medical contraindications. Specifically, for two residents who were readmitted to the facility, their immunization records showed they had previously received PCV13 and PPSV23 vaccines, but there was no evidence in their records regarding the offering or administration of the updated pneumococcal vaccines as recommended by current CDC guidelines. During staff interviews, the Infection Preventionist was unable to provide documentation that these residents had been offered or had declined the PCV20 or PCV21 vaccine. Additionally, the facility's policy on resident vaccination for flu and pneumonia was found to be outdated. The policy referenced guidelines from 2019 and did not include the most recent recommendations for pneumococcal immunizations. The Director of Nursing Services acknowledged during an interview that the current policy did not reflect the latest guidance, contributing to the lack of proper documentation and adherence to updated vaccination protocols.
Environmental Deficiencies in Kitchen and Kitchenette Areas
Penalty
Summary
Surveyor observations identified that the facility failed to maintain a safe, functional, and comfortable environment in both the main kitchen and one of three kitchenettes. In the main kitchen, the walk-in freezer was found to have an accumulation of ice buildup on the sprinkler head and the left fan near the ceiling, as confirmed by the Food Service Director (FSD) during the inspection. Additionally, in the Jamestown Unit Kitchenette, a microwave mounted above the counter was observed to be severely cracked with peeling paint on its exterior, which was also acknowledged by the FSD. These conditions were directly observed by surveyors and confirmed by staff interviews.
Failure to Provide Adequate Foot Care for Resident with Peripheral Vascular Disease
Penalty
Summary
The facility failed to provide appropriate foot care and treatment for a resident with peripheral vascular disease, leading to severe complications. The resident was readmitted to the facility with diagnoses including cellulitis and peripheral vascular disease. A complaint was reported to the Rhode Island Department of Health, alleging that the resident was treated at a hospital for multiple foot wounds infested with maggots. Hospital records confirmed the presence of wounds with black tissue and maggots, and the resident was admitted with cellulitis and started on intravenous antibiotics. The facility's staff failed to conduct thorough skin assessments, as evidenced by a registered nurse who did not inspect between the resident's toes. A nursing assistant also did not notice any wounds during a shower. However, an LPN observed a significant wound with moving maggots and redness on the resident's leg, indicating a lack of consistent and comprehensive foot care. The Director of Nursing Services acknowledged the expectation for full skin assessments, including between toes, and admitted the absence of standing orders for preventive foot care for residents with diabetes and circulatory disorders.
Inadequate Skin Assessment Competency Among Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to conduct thorough skin assessments, which compromised resident safety and well-being. A review of the facility's policy on skin care indicated that weekly skin assessments were required for every resident. However, a community-reported complaint revealed that a resident was hospitalized with multiple wounds on their feet, including maggots, which were not identified during a skin assessment conducted by a registered nurse the day before hospitalization. The nurse admitted to not checking between the resident's toes, where the wounds were located. Further investigation showed that six licensed nursing staff members lacked evidence of competency-based training on skin assessments. Interviews with the Director of Nursing Services and the Assistant Director of Nursing confirmed that the facility did not provide such training, nor did they follow their facility assessment regarding competency-based training. This oversight placed all 150 residents requiring weekly skin assessments at risk for serious injury, harm, impairment, or death.
Incomplete Skin Assessment Leads to Deficiency
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding skin assessments. A community-reported complaint alleged that a resident was treated at a hospital for multiple wounds on their feet that contained maggots. Hospital records from the admission on 8/4/2024 indicated the presence of wounds with black tissue and maggots between the toes, as well as cellulitis in the right lower extremity, necessitating intravenous antibiotics. However, a skin assessment conducted by a registered nurse on 8/3/2024, the day before the hospitalization, only noted dry skin on the resident's lower extremities and did not identify any foot wounds. During an interview, the registered nurse admitted to not examining the skin between the resident's toes during the assessment. The Director of Nursing Services confirmed that the nursing staff is expected to assess the skin between a resident's toes during skin assessments. The facility was unable to provide evidence that the skin assessment for the resident was completed accurately, leading to the deficiency in maintaining proper medical records.
Failure to Follow Physician's Orders for Glucose Monitoring
Penalty
Summary
The facility failed to meet professional standards of quality by not following physician's orders for a resident using a Freestyle Libre sensor, a continuous glucose monitoring system. The resident, who was admitted with diagnoses including diabetes and chronic obstructive pulmonary disease, reported that the sensor needs to be changed every 14 days. However, the record review did not show any evidence of a physician's order for the sensor or documentation indicating when it should be changed or when it was last changed. During an interview, the Director of Nursing Services was unable to provide documentation of the sensor's presence, the schedule for changing it, or the last change date, and acknowledged that there should be a physician's order for the sensor and its replacement schedule.
Medication Error in Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin. The resident, who was admitted in April 2024 with diagnoses including diabetes and chronic obstructive pulmonary disease, had a physician's order for Humalog Mix 75-25 insulin with specific instructions based on blood sugar levels. The order specified administering 25 units if blood sugar was less than 150 and 35 units if it was above 150. However, on multiple occasions in April and May 2024, the resident's blood sugar was recorded as greater than 150, yet only 25 units of insulin were administered instead of the prescribed 35 units. This error was acknowledged by the Director of Nursing Services during a surveyor interview, who confirmed that the resident received the incorrect insulin dosage on the specified dates.
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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