Royal Middletown Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Middletown, Rhode Island.
- Location
- 193 Forest Avenue, Middletown, Rhode Island 02842
- CMS Provider Number
- 415040
- Inspections on file
- 26
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Royal Middletown Nursing Center during CMS and state inspections, most recent first.
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.
Incomplete hospice documentation and coordination for a resident receiving hospice services. The facility failed to maintain required hospice records for a resident with dementia who was receiving hospice care, including the most recent hospice POC, election form, terminal illness certification/recertification, hospice personnel contact information, hospice medication information, and physician orders. An RN said the hospice binder was incomplete and did not know the resident’s hospice visit frequency or involved personnel, and the DON could not provide the required hospice information.
Failure to Maintain Clean Technique During Wound Care: An RN performed wound care for a resident with PVD and cellulitis without setting up a clean field, placing wound supplies on the resident’s bed, dropping a dirty glove onto clean supplies, and failing to cleanse hands between glove changes. The DON stated the nurse should have used a clean field, discarded the dirty glove, and cleansed hands between glove changes.
A resident with Alzheimer's disease and cardiac comorbidities was actively dying and experiencing increased pain and agitation when a hospice RN recommended more frequent scheduled and PRN Morphine and Ativan for end-of-life comfort. An RN texted these recommendations to the physician, who approved them, but the new orders were never entered on the MAR or implemented. As a result, only the prior, less frequent PRN and TID Lorazepam and PRN Morphine orders remained active, and the last doses of Ativan and Morphine were administered many hours before the resident's death. The physician later stated the nurse should have implemented the hospice recommendations, and the DON acknowledged the resident did not receive the comfort medications as ordered.
A resident on hospice with Alzheimer’s disease, hypertension, and coronary artery disease experienced apnea, tachycardia, pain, and agitation near end of life. Hospice recommended increasing scheduled Morphine and Ativan to Q2H with additional PRN dosing Q1H for breakthrough symptoms, but facility records showed these recommendations were not communicated to the physician or implemented. The MAR reflected the last Morphine and Ativan doses were given many hours before the resident’s death, and there were no nursing progress notes documenting assessment of the resident’s condition during the final hours, despite facility policy requiring communication with hospice, adherence to hospice interventions, and ongoing monitoring. The DON confirmed the resident did not receive medications per hospice recommendations and that ongoing monitoring was not documented.
A resident with hypertension and atrial fibrillation had physician orders for metoprolol and amiodarone that included specific HR parameters requiring the medications to be held when the HR was below 60. Review of MARs showed that metoprolol and amiodarone were documented as administered on multiple occasions despite HRs below the ordered parameters, while metoprolol was also held numerous times for low HR. Staff, including a CMT, an RN, the DON, and the Infection Preventionist, acknowledged that the medications should not have been given when the HR was below the parameters and that CMTs were expected to obtain vital signs and notify nursing when medications were held. Record review showed no evidence that the provider was notified of the repeated held doses, and the provider reported she was unaware of the frequent holds and expected both adherence to parameters and notification when the medications were held.
During a norovirus outbreak, a resident with dementia and GI symptoms was placed on contact precautions with posted signage and a physician’s order requiring gown, gloves, and hand hygiene on room entry and exit. A nursing assistant entered and exited the resident’s room without wearing PPE, did not perform hand hygiene, then accessed a clean linen room and returned to the resident’s room still without PPE. The staff member later acknowledged knowing the resident was on contact precautions for norovirus and that she failed to follow the posted instructions, while facility leadership stated they expected staff to adhere to the contact precaution requirements.
Two residents with wounds did not consistently receive wound care as ordered by the physician, due to delays in transcribing new treatment orders and missed or incorrect treatments. Documentation showed that wound care was not completed on several occasions, and updated orders were not promptly implemented, resulting in residents not receiving necessary wound management.
The facility did not obtain, review, or report ordered lab tests and failed to complete required COVID-19 testing for two newly admitted residents, resulting in delayed care and hospitalization for one resident with a UTI and COVID-19. Staff and leadership confirmed that physician orders were not followed and providers were not notified of abnormal or missing results during a COVID-19 outbreak.
Surveyors found that two newly admitted residents did not have ordered lab tests completed or reported, and COVID-19 testing was not performed as required. One resident with a UTI and a urostomy was not tested for COVID-19 or had lab results reported, leading to hospitalization for UTI and COVID-19. Another resident did not have a UA C&S completed or COVID-19 testing done as ordered, and abnormal lab results were not communicated to a provider. Staff confirmed these lapses during interviews, and the facility was experiencing a COVID-19 outbreak at the time.
A resident with dementia and moderate cognitive impairment reported that a NA grabbed their forearm tightly and attempted to force care, resulting in fear and arm discomfort. The facility did not promptly or thoroughly investigate the allegation, failing to interview involved staff or document the investigation as required by policy.
Two residents in the facility were not provided with respiratory care consistent with professional standards. One resident with COPD was receiving oxygen at a higher flow rate than prescribed, while another resident was receiving oxygen without a documented physician's order. Staff acknowledged these discrepancies, indicating a failure in adhering to proper protocols for oxygen administration.
A resident with end-stage renal disease and moderate cognitive impairment did not receive the prescribed medication Xphozah on multiple occasions, as revealed by a review of the Medication Administration Record. Staff interviews indicated a lack of awareness about the missed doses, and the DON could not provide evidence of administration.
During a survey of the main kitchen, several food items were found improperly stored, including a red liquid in a prep pan without an identifier and stored beyond 7 days, a deli salad without an identifier or date, and frozen protein without an identifier. Additionally, three bags of frozen, sliced orange vegetables were found in clear plastic bags without identifiers or dates. The Food Service Director acknowledged the lack of proper labeling and dating, indicating non-compliance with food safety regulations.
The facility did not implement a water management program based on industry standards and the CDC toolkit for Legionella prevention. The Maintenance Director acknowledged not performing flushing maintenance of unoccupied resident rooms as required, although water temperatures were checked. The water management binder lacked documentation of necessary maintenance activities, indicating non-compliance with CDC Legionella prevention protocols.
A facility failed to ensure a resident's drug regimen was free from unnecessary drugs by not checking vital signs before administering Carvedilol, despite physician's orders to hold the medication if certain parameters were not met. The Director of Nursing Services could not provide evidence that the required checks were performed.
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.
Incomplete hospice documentation and coordination for a resident receiving hospice services
Penalty
Summary
The facility failed to ensure that hospice services met professional standards for one of two residents receiving hospice care, Resident ID #11, who was admitted in March 2026 with a diagnosis including dementia and began hospice services that same month. Review of the electronic and paper medical records did not reveal the most recent hospice plan of care, hospice election form, physician certification and recertification of the terminal illness, names and contact information for hospice personnel involved in care, hospice medication information, or hospice physician and attending physician orders. During interview, an RN acknowledged that the hospice binder was incomplete and stated she was unsure of the frequency of hospice visits and did not know the personnel involved in the resident’s care. The DON was also unable to provide evidence that the facility had the required hospice information.
Failure to Maintain Clean Technique During Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program related to a clean dressing change for Resident ID #40. The resident was readmitted in February 2026 with diagnoses including peripheral vascular disease and cellulitis of the lower limb. A physician’s order directed staff to cleanse open areas on the left lower leg with vashe wound wash, apply xeroform to the wound bed, and wrap with kling, and the facility policy titled, Wound Treatment Management, stated that wound care should be provided using evidence-based treatments in accordance with current standards of practice and physician orders. During surveyor observation on 4/27/2026 at 11:51 AM, Registered Nurse Staff E performed wound care without establishing a clean field. She placed all supplies directly on the resident’s bed next to the left leg wound, removed the dirty dressing, and took off the glove on her left hand, which landed on the wound supplies. Staff E also failed to cleanse her hands between removing a dirty glove and applying a clean glove. In a subsequent interview, Staff E acknowledged that she did not set up a clean field and said she placed the supplies on the resident’s bed because she did not want to mess up the bedside table. She was unable to explain why the dirty glove was placed on clean wound supplies or why hand cleansing was not performed between glove changes. The DNS stated she would expect the nurse to set up a clean field, throw the dirty glove in the trash, and cleanse hands between glove changes.
Failure to Implement Hospice-Recommended End-of-Life Comfort Medication Orders
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when hospice-recommended end-of-life comfort medication orders were not implemented. The resident, admitted with diagnoses including Alzheimer's disease, hypertension, and atherosclerotic heart disease, was declining and experiencing increased pain and agitation. A hospice RN assessed the resident in the late afternoon and recommended scheduling Morphine concentrate 5 mg every 2 hours and Ativan (Lorazepam Intensol) 0.5 mg every 2 hours, with PRN orders for both medications every hour for breakthrough pain or agitation. At the time of the resident's death, the MAR still reflected prior orders: Lorazepam Intensol 0.25 ml three times daily, Lorazepam Intensol 0.25 ml every 2 hours PRN for restlessness, and Morphine sulfate 0.25 ml every 2 hours PRN for pain greater than 4, with no evidence that the hospice recommendations had been entered or activated. The RN on duty stated she texted the new hospice recommendations to the resident's physician, and the surveyor verified a text message indicating new hospice recommendations for scheduled and PRN every 1-hour Ativan and Morphine, to which the physician responded "ok." However, the RN could not provide evidence that the orders for scheduled every-2-hour Morphine and Ativan or the hourly PRN orders were ever implemented. The resident's physician indicated that the nurse should have implemented the hospice recommendations after they were approved. MAR review showed the last dose of Ativan was given at 10:00 PM the night before death and the last dose of Morphine at 2:13 PM the previous afternoon, approximately 8 and 16 hours, respectively, before the resident died at 6:17 AM. The DON acknowledged that the resident did not receive Ativan and Morphine as ordered for end-of-life comfort.
Failure to Implement Hospice End-of-Life Recommendations and Monitor Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that hospice services met professional standards and that hospice recommendations were communicated, implemented, and documented for a resident receiving end-of-life care. The resident, admitted in January 2026 with diagnoses including Alzheimer’s disease, hypertension, and atherosclerotic heart disease of the native coronary artery, was on hospice services. A facility policy titled “Coordination of Hospice Services Policy” stated that the facility would communicate with hospice, identify and follow all interventions put into place by hospice and the facility, monitor medications and medical supplies provided by hospice as indicated in the plan of care, and provide ongoing monitoring of resident conditions. On 1/30/2026, hospice documentation showed that during an end-of-life visit between 4:00 PM and 5:00 PM, the hospice RN assessed the resident as having periods of apnea, a racing pulse, increasing pain, and agitation, with any movement causing groaning and grimacing. The hospice RN recommended scheduling Morphine concentrate 5 mg every 2 hours and Ativan concentrate 0.5 mg every 2 hours, with PRN orders for Morphine 5 mg every hour and Ativan 0.5 mg every hour for breakthrough symptoms. Record review revealed that earlier on 1/30/2026 at 11:55 AM, facility staff had spoken with hospice about the resident’s respiratory rate of 30 and restlessness and received a recommendation to increase the frequency of PRN medication from every 4 hours to every 2 hours, which the physician approved. However, further review of the clinical record, including progress notes, physician’s orders, and the MAR, failed to show that the additional hospice recommendations from the late afternoon end-of-life visit were communicated to the physician or implemented. The MAR showed the last dose of Ativan was given at 10:00 PM on 1/30/2026 and the last dose of Morphine at 2:13 PM on 1/30/2026, approximately 8 and 16 hours, respectively, before the resident’s death at 6:17 AM on 1/31/2026. Additionally, there were no nursing progress notes documenting assessment of the resident’s condition between 11:55 AM on 1/30/2026 and the time of death, despite the facility policy requiring ongoing monitoring. During interview, the DON acknowledged that the resident did not receive Morphine and Ativan per hospice recommendations and that there was no evidence of ongoing monitoring of the resident’s condition at end of life.
Failure to Follow Medication Hold Parameters and Notify Provider for Low Heart Rate
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice related to administration of blood pressure and antiarrhythmic medications with ordered parameters. The resident was admitted with diagnoses including hypertension and atrial fibrillation and had a care plan addressing hypertension, with interventions to administer antihypertensive medications as ordered and obtain vital signs as ordered. Physician orders dated 12/7/2025 directed that metoprolol 100 mg twice daily be held for systolic blood pressure less than 110 or heart rate (HR) less than 60, and that amiodarone 200 mg once daily be held for HR less than 60. Review of the December 2025 and January 2026 MARs showed multiple instances where metoprolol and amiodarone were documented as administered despite HRs below the ordered parameters. Specifically, metoprolol was documented as given on several dates when the resident’s HR ranged from 48 to 58, all below the hold parameter of HR less than 60. Amiodarone was also documented as administered on one date when the HR was 58, below the ordered parameter. At the same time, the MAR showed that metoprolol was held on numerous occasions in both December and January due to low HR, indicating repeated occurrences where the resident’s HR was below the ordered threshold. Staff interviews confirmed that CMTs were expected to obtain vital signs prior to administering metoprolol or amiodarone and to hold the medications and notify the nurse if vital signs were outside the ordered parameters. The CMT and RN acknowledged that, based on the documented HRs, the medications should not have been administered on the identified dates. The DON and Infection Preventionist also acknowledged that the medications were documented as administered when the HR was below the parameters. Record review did not show evidence that the provider was notified of the multiple held doses of metoprolol due to low HR, and the provider stated she was unaware that the medication was being held often and would have expected notification when the medications were held, as well as adherence to the ordered parameters.
Failure to Follow Contact Precautions During Norovirus Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program during a norovirus outbreak, specifically by not following transmission-based contact precautions for a resident on isolation. A community complaint reported that residents had norovirus, and the facility’s own policies required contact precautions, including use of appropriate PPE such as gowns and gloves, for residents with symptoms consistent with norovirus gastroenteritis. The facility’s Norovirus Prevention and Control policy directed that symptomatic residents be placed on Contact Precautions, ideally in single rooms or cohorted, and that these precautions continue for at least 48 hours after symptom resolution. The Infection Preventionist reported that a resident positive for norovirus had been admitted and that multiple residents subsequently developed GI symptoms, with 21 residents identified as having nausea, vomiting, or diarrhea and placed on contact precautions per RIDOH and Medical Director direction. Resident ID #4, who had dementia and had been readmitted to the facility in November 2025, had a physician’s order for contact precautions due to GI symptoms, and contact precaution signage was posted outside the resident’s room instructing staff to perform hand hygiene and wear a gown and gloves upon entry. During surveyor observation, a nursing assistant (Staff C) entered and exited this resident’s room without wearing a gown or gloves and failed to perform hand hygiene upon exit. Staff C then entered a clean linen storage room, handled clean linens, and re-entered the resident’s room still without appropriate PPE. In a subsequent interview, Staff C acknowledged awareness that the resident was on contact precautions for norovirus, recognized the posted signage, and admitted not following the required PPE and hand hygiene practices. Both the Infection Preventionist and the Administrator stated they expected staff to follow the posted contact precaution signage and wear appropriate PPE when entering the resident’s room.
Failure to Provide Wound Care as Ordered for Two Residents
Penalty
Summary
The facility failed to ensure that two residents with wounds received necessary treatment and services consistent with professional standards of practice. For one resident admitted with multiple wounds, including to the right ankle, buttock, thigh, and abdomen, there were several instances where wound care orders from the wound physician were not transcribed in a timely manner, resulting in incorrect or missed treatments. Specifically, wound treatments for the right buttock and abdomen were not updated according to new physician orders, leading to the resident receiving outdated treatments for several days. Additionally, documentation failed to show that certain wound treatments were completed as ordered on specific dates, and one wound treatment order for the right thigh was not transcribed or administered for 13 consecutive days. Another resident with a coccyx wound also experienced lapses in wound care management. The care plan required specific wound treatments and follow-up with the wound physician, but the treatment administration record did not show evidence that wound care was completed as ordered on multiple dates. When the wound physician updated the treatment order to a new regimen, the order was not transcribed until two days later, resulting in the resident receiving the incorrect treatment. There was also a missed wound treatment on the morning following the transcription of the new order. Interviews with the wound physician and the facility administrator confirmed that wound care orders were expected to be transcribed and treatments completed as ordered. However, the facility was unable to provide evidence that these processes were consistently followed, resulting in residents not receiving wound care in accordance with physician orders and professional standards of practice.
Failure to Complete and Report Lab Tests and COVID-19 Testing for New Admissions
Penalty
Summary
The facility failed to obtain, review, and report laboratory tests as ordered, and did not complete required COVID-19 testing for two newly admitted residents. For one resident with a history of urinary tract infection (UTI) and neuromuscular bladder dysfunction, the facility did not report positive urinalysis and culture results to a provider or implement interventions, despite care plan instructions to monitor and report abnormal lab values. This resident was also not tested for COVID-19 on admission, day two, or day four, as required by physician order and facility policy, even though the resident had signed a COVID-19 testing consent form. The same resident was later transferred to the hospital with symptoms including shortness of breath, cough, and blood in the urostomy and nephrostomy tube, and was diagnosed with both a UTI and COVID-19. Staff interviews confirmed that the required COVID-19 testing was not performed and that the positive UTI lab results were not communicated to a provider or acted upon prior to hospitalization. The Infection Preventionist acknowledged that the lab results were not reviewed until the day the resident was sent to the hospital, and that no provider notification or intervention occurred. A second resident, also newly admitted with a history of UTIs and muscle weakness, had a physician's order for urinalysis and culture that was not completed, and COVID-19 testing on admission and day two was not performed as ordered. This resident later tested positive for COVID-19. Staff and leadership interviews confirmed that physician orders for lab tests and COVID-19 testing were not followed, and that providers were not notified of outstanding or abnormal results. The facility was experiencing a COVID-19 outbreak at the time, with a significant number of residents testing positive.
Failure to Complete and Report Laboratory and COVID-19 Testing Orders for New Admissions
Penalty
Summary
Surveyor observation, record review, and staff interviews revealed that the facility failed to obtain, review, and report laboratory tests as ordered, notify providers of abnormal or missing test results, and complete ordered COVID-19 testing for two of three newly admitted residents reviewed. For one resident with a history of urinary tract infection (UTI) and neuromuscular bladder dysfunction, physician orders for a complete blood count (CBC) and complete metabolic panel (CMP) were not transcribed or completed as ordered. Additionally, a urinalysis with culture and sensitivity (UA C&S) was obtained, but the positive results were not reported to a provider, and no interventions were implemented. The resident was not tested for COVID-19 on admission, day two, or day four, despite signed consent and physician orders. The resident was later hospitalized with a UTI and COVID-19 after presenting with shortness of breath, cough, and blood in the urostomy and nephrostomy tube. A second resident, also with a history of UTIs, had a physician order for a UA C&S that was not completed. Laboratory tests, including a CBC, were obtained without a corresponding physician order, and abnormal results were not reported to a provider. This resident also was not tested for COVID-19 on admission or day two as ordered, and subsequently tested positive for COVID-19. Staff interviews confirmed that required laboratory tests and COVID-19 testing were not completed as ordered, and that abnormal results were not communicated to providers. The facility was experiencing a COVID-19 outbreak at the time of the survey, with multiple residents testing positive. Staff, including registered nurses, the infection preventionist, the DON, and the medical director, acknowledged that physician orders were not followed, laboratory results were not reviewed or reported, and COVID-19 testing protocols were not adhered to for new admissions. These failures resulted in delays in care and contributed to the hospitalization of at least one resident.
Failure to Investigate Alleged Physical Abuse
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of physical abuse involving a resident with dementia, anxiety, and depression who was moderately cognitively impaired and required moderate assistance for activities of daily living. The incident, reported to the Rhode Island Department of Health, involved a Nursing Assistant (NA) allegedly grabbing the resident's right forearm tightly and insisting the resident be washed, despite the resident's refusal, and attempting to pull the resident out of a wheelchair. The resident appeared frightened and reported discomfort in the right arm following the incident. Record review and staff interviews revealed that the facility did not conduct timely or comprehensive interviews with the implicated NA or other staff members, nor did they document a thorough investigation as required by facility policy. The Director of Nursing Services (DNS) acknowledged being aware of the incident and the NA's unusual behavior but did not initiate interviews or collect statements until prompted by the surveyor. The only written statement from the NA was obtained during the survey, and no further documentation of an investigation was provided.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents using oxygen. Resident ID #1, who has chronic obstructive pulmonary disease (COPD) and is dependent on supplemental oxygen, was observed receiving oxygen at a higher flow rate than prescribed. The physician's order specified an oxygen flow rate of 1.5 liters per minute, but observations on two occasions showed the resident receiving between 3.5 and 4 liters per minute. The resident confirmed that only nursing staff adjust the oxygen flow rate. A registered nurse acknowledged the discrepancy and adjusted the flow rate to the correct level. Resident ID #4, who was readmitted with diagnoses including stroke and anxiety, was receiving oxygen without a documented physician's order specifying the frequency, flow rate, and method of delivery. Observations showed the resident receiving oxygen at 2 liters per minute continuously since readmission. Staff confirmed the absence of a proper order for the oxygen administration. The Interim Director of Nursing Services and the residents' physician both expressed expectations that proper orders should be in place for oxygen administration, highlighting the facility's failure to adhere to professional standards of practice.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident received medication in accordance with professional standards of practice, specifically failing to administer Xphozah as prescribed. The resident, who has a history of brain damage, dementia, and end-stage renal disease, was readmitted to the facility with a physician's order for dialysis three times a week and a prescription for Xphozah to manage elevated phosphorus levels. Despite a physician's order obtained on 9/26/2024 for Xphozah to be administered twice daily, the Medication Administration Record for October 2024 showed that the medication was not given on several specified dates. Interviews with facility staff revealed a lack of awareness regarding the missed doses. A Medication Technician confirmed the resident's dialysis schedule and noted that the resident eats breakfast before leaving for dialysis. However, the Registered Nurse was unaware of the missed doses, and the Director of Nursing Services could not provide evidence that the medication was administered as ordered. The resident, who has moderate cognitive impairment, expressed uncertainty about the medications they were supposed to take, indicating a reliance on staff for medication management.
Improper Food Storage Practices Identified in Main Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards of food service safety in the main kitchen, as observed during a survey. Specifically, during an initial tour of the main kitchen, several food items were found to be improperly stored. These included a red liquid in a prep pan dated 3/31 without an identifier and stored beyond 7 days, a deli salad without an identifier or date, and frozen protein dated 4/3/24 without an identifier. Additionally, three bags of frozen, sliced orange vegetables were found in clear plastic bags without an identifier or date in a white reach-in freezer in the back room. The Food Service Director acknowledged during a surveyor interview that the mentioned foods were not labeled with their identifiers, and some were without dates. The director also acknowledged that the tomato soup should have been discarded. These observations indicate a lack of compliance with food safety regulations regarding proper labeling and storage of food items in the facility's main kitchen.
Deficiency in Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to implement a water management program based on industry standards and the CDC toolkit for Legionella prevention. The Maintenance Director admitted to not conducting flushing maintenance of unoccupied resident rooms as required, despite checking water temperatures. The facility's water management binder lacked evidence of necessary maintenance activities, indicating a gap in compliance with Legionella prevention protocols outlined by the CDC.
Failure to Monitor Vital Signs Before Administering Carvedilol
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs. Specifically, for one resident, there was a physician's order for Carvedilol with parameters to hold the medication if the heart rate was below 60 or systolic blood pressure was below 100. However, record reviews revealed that from March 1, 2024, through March 31, 2024, and from April 1, 2024, through April 9, 2024, the medication was administered without evidence of checking the resident's blood pressure or heart rate prior to administration. During an interview, the Director of Nursing Services could not provide evidence that these vital signs were being checked as required.
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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