St Antoine Residence
Inspection history, citations, penalties and survey trends for this long-term care facility in North Smithfield, Rhode Island.
- Location
- 10 Rhodes Avenue, North Smithfield, Rhode Island 02896
- CMS Provider Number
- 415106
- Inspections on file
- 29
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at St Antoine Residence during CMS and state inspections, most recent first.
The facility failed to implement and document required antibiotic stewardship "time outs" or day-three reviews for multiple residents receiving antibiotics for conditions such as dementia with suspected infection, diverticulitis, pneumonia, and sepsis. Clinical records for several antibiotic courses, including Doxycycline, Cefpodoxime, Clindamycin, and IV Meropenem, did not contain evidence of a review two to three days after initiation to assess infection status, appropriateness of the antibiotic, or potential de-escalation. The IP reported that antibiotics are discussed verbally in staff meetings but that time outs or reviews are not documented without a physician order, and the DON could not provide documentation that such reviews were completed.
A resident with hemiplegia, partial foot amputation, vascular dementia, and total dependence for transfers experienced multiple incidents while using a stand aid, including sliding to the floor, falling backward, and being lowered to the floor when knees buckled. Despite facility policy requiring post-fall rehab screens, no rehab screens were documented after several of these falls, and the rehab director was unaware of the events and the resident’s non-compliance and knee buckling. Later, rehab formally recommended use of a full-body Hoyer lift with two staff for all transfers, but nursing did not update the care plan or the NA assignment sheet, which continued to direct use of a stand aid, and leadership acknowledged that the resident’s changed transfer status was not clearly communicated to caregivers.
A resident with pneumonia and acute respiratory failure had a physician order for PRN oxygen at 2 L/min, but surveyors repeatedly observed the resident receiving 3 L/min. An RN initially stated there was an order for 3 L/min, but upon review of the EMR acknowledged the order was for 2 L/min, and the Unit Manager also confirmed the discrepancy. Despite the surveyor notifying staff of the incorrect flow rate, the resident continued to receive oxygen at 3 L/min, contrary to facility policy and professional standards requiring adherence to the ordered oxygen flow rate.
A resident with dementia and a history of pre-cancerous scalp lesions developed a cancerous wound on the right temple. After an initial course of topical treatment, the wound was left unassessed and untreated for several months, despite facility policy requiring weekly skin checks. The wound deteriorated, and maggots were eventually discovered, leading to hospital transfer. Staff and DON interviews confirmed the lack of wound monitoring and treatment during this period.
The facility did not update its facility-wide assessment to include wound vac therapy, despite providing this service to a resident with osteomyelitis and other conditions. The assessment failed to reflect the resources and services actually offered, and the Administrator was unable to provide documentation showing that the assessment was revised when wound vac treatment was initiated.
A resident with a surgical wound and a PICC line did not have Enhanced Barrier Precautions (EBP) implemented as required by facility policy. PPE such as gowns and gloves were not available near the room, and staff did not wear gowns during care. Nursing staff and the DON confirmed that EBP should have been in place for this resident.
A resident with advanced dementia and severe cognitive impairment was subjected to physical abuse by staff, including being dragged, forcefully pushed into a chair, and pinned in bed, instead of being redirected as per the care plan. Staff used manual restraint and unreasonable force, causing distress to the resident, and did not follow established interventions for managing resistive behavior.
A facility failed to act on pharmacy recommendations for a resident prescribed Clozapine, leading to a lapse in medication administration. The resident, with Alzheimer's and schizophrenia, did not receive the medication for 11 days due to an error. Despite a pharmacy recommendation for prompt action, the issue was not addressed until the resident was hospitalized for suicidal ideation and self-harm. Staff interviews revealed no system to highlight priority recommendations, risking resident safety.
A resident with Alzheimer's and schizophrenia was readmitted to a facility without proper medication reconciliation, leading to the discontinuation of essential medications like Clozapine and Trazadone. Despite recommendations to continue these medications, they were not updated, resulting in the resident experiencing delusions, paranoia, and self-harm, ultimately requiring hospitalization. The facility's failure to adhere to its medication reconciliation policy was confirmed by staff interviews.
Surveyors observed significant cleanliness issues in the kitchen, including dust and grease accumulation on equipment and floors. A dietary cook was found working with exposed food while wearing acrylic nails without gloves. Trash containers were also left uncovered when not in use. The Food Service Director acknowledged these deficiencies.
Two residents at risk for pressure ulcers did not receive the required offloading of heels as per physician orders. One resident with a stroke and severe cognitive impairment had a Deep Tissue Pressure Injury, and another resident with protein calorie malnutrition was at risk for skin breakdown. Observations showed non-compliance with orders, confirmed by LPNs and acknowledged by the DON.
The facility failed to maintain proper infection control practices for residents with wounds, as staff did not change gloves or perform hand hygiene during wound care. Additionally, two residents with pressure injuries were not placed on Enhanced Barrier Precautions (EBP), and staff did not wear protective gowns during care. These deficiencies were acknowledged by staff and the Infection Preventionist.
A facility failed to ensure a Nurse Practitioner provided necessary orders for a resident's care. The resident, with vascular dementia and cerebrovascular disease, showed signs of acute cystitis, but a urine culture and sensitivity order was not provided. The NP acknowledged the oversight, and the Medical Director expected the NP to follow up with the order.
Failure to Implement and Document Antibiotic Stewardship Time-Outs
Penalty
Summary
The deficiency involves the facility’s failure to establish and implement an Infection Prevention and Control Program that includes an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use, specifically the lack of documented antibiotic “time outs” or day-three reviews. For five residents receiving antibiotics, clinical record review did not show evidence that a review was conducted two to three days after antibiotic initiation to determine if a bacterial infection was present, whether the antibiotic, dose, and route were appropriate, or if therapy could be narrowed or shortened. One resident admitted with dementia received Doxycycline 100 mg twice daily for 10 days, and another resident with diverticulitis of the large intestine received Doxycycline 100 mg twice daily for seven days, with no documentation of an antibiotic time out or day-three review for either course. A resident admitted with pneumonia received Cefpodoxime Proxetil 200 mg twice daily for seven days, another resident with dementia received Clindamycin 300 mg three times daily for 10 days, and a resident with sepsis received Meropenem 500 mg IV every 12 hours for six days; in all three cases, records lacked documentation of an antibiotic time out or day-three review. During an interview, the Infection Preventionist stated that antibiotics are discussed verbally at staff meetings but that antibiotic time outs or reviews are not documented unless there is a physician’s order. In a subsequent interview, the Director of Nursing Services was unable to provide evidence that antibiotic time outs or reviews had been completed for these residents.
Failure to Update Transfer Status and Rehab Screening After Multiple Stand-Aid Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate assistive devices and supervision to prevent accidents for a resident who used a stand aid for transfers. The facility’s Falls Prevention & Management policy and post-fall guidelines required submission of rehab screens after falls for residents not on hospice and communication of changes in status to the interdisciplinary team. Resident ID #165, admitted in 2018 with hemiplegia/hemiparesis following cerebrovascular disease, partial traumatic amputation of the left foot, and vascular dementia, was non-ambulatory and dependent on staff for all transfers, with intact cognition per a recent MDS. Progress notes documented multiple stand-aid related incidents: on 10/17/2025 the resident lost balance and slid to the floor; on 10/31/2025 the resident fell backwards from the stand aid; on 11/1/2025 the resident was noted to be non-compliant with instructions while using the stand aid; on 12/29/2025 the resident was lowered to the floor by two NAs during a stand-aid transfer and was described as non-compliant and at high risk for falling; and on 12/30/2025 the resident was again lowered to the floor when knees buckled during a stand-aid transfer in the shower room. Despite these repeated falls and documented concerns, record review did not show that rehab screens were submitted after the falls on 10/31/2025, 11/1/2025, 12/29/2025, and 12/30/2025, contrary to the facility’s fall procedure. The Unit Manager RN stated that rehab screens should be submitted after a fall and that all screens are scanned into the EMR, but no such documentation was found. The Director of Rehabilitation confirmed she could not provide evidence that rehab screens were completed following these falls and reported she was unaware that the resident had fallen from the stand aid, had been non-compliant with instructions, or had experienced knee buckling during transfers with the device. This lack of post-fall rehab screening and communication meant that the rehab department was not informed of the resident’s repeated stand-aid related incidents. Additionally, the facility failed to update and communicate changes in the resident’s transfer status and assistive device needs after a rehab evaluation. Assignment documentation indicated the resident required assistance of 1–2 staff with a stand aid for all transfers, and the fall care plan last revised on 12/30/2025 continued to direct use of a stand aid. After a hospitalization for change in medical status, a rehab evaluation on 1/13/2026 recommended use of a full-body Hoyer lift with two staff for all transfers, documented on a Transfer Status Form signed by OT and PT. The Director of Rehabilitation stated this recommendation was communicated in writing to nursing and that the resident’s whiteboard was updated. However, record review showed the care plan was not revised and the NA assignment sheet was not updated to reflect the new Hoyer lift requirement. The Unit Manager RN acknowledged that the resident’s transfer status had not been updated on the assignment sheet or in the care plan, and the DON acknowledged that rehab screens were not provided after each fall and that the facility failed to clearly communicate the resident’s status to NAs, contributing to ongoing risks during transfers.
Failure to Follow Physician Order for Oxygen Flow Rate
Penalty
Summary
The deficiency involves the facility’s failure to provide oxygen therapy in accordance with physician orders and professional standards of practice for one resident using supplemental oxygen. Facility policy and Lippincott Nursing Procedure require a practitioner’s order for oxygen therapy and that the oxygen flow rate be set at the amount specified in the order, with documentation of the rate of flow. The resident, admitted with diagnoses including pneumonia and acute respiratory failure, had a physician’s order dated 12/13/2025 for oxygen at 2 liters per minute as needed. Despite this, surveyor observations on multiple dates and times showed the resident receiving oxygen at 3 liters per minute instead of the ordered 2 liters per minute. During an observation and interview, an RN stated that the resident was receiving oxygen at 3 liters per minute and asserted there was an order for 3 liters per minute. Upon review of the electronic medical record at the surveyor’s request, the RN acknowledged that the actual order was for 2 liters per minute. The Unit Manager also acknowledged that the order indicated 2 liters, not 3 liters, as observed. Later the same day, after the facility had been informed by the surveyor that the oxygen flow rate was incorrect, the resident was again observed receiving 3 liters per minute. The Director of Nursing Services stated she would have expected the resident to receive oxygen at 2 liters per minute, as ordered.
Failure to Monitor and Treat Resident's Cancerous Lesion Resulting in Maggot Infestation
Penalty
Summary
A resident with dementia and severe cognitive impairment was admitted to the facility with multiple pre-cancerous lesions on the scalp, including one on the right temple. Dermatology consultations identified the need for follow-up and, eventually, a MOHS procedure after a biopsy confirmed squamous cell carcinoma. Despite initial treatment with Aquaphor ointment as ordered, documentation shows that after this course ended, the lesion was left untreated for several months, from February to late June, with no evidence of ongoing assessment or monitoring of the wound during this period. The facility's policy required weekly skin checks and documentation of any wounds, but records failed to show that the right temple lesion was assessed or documented in weekly skin checks from December through early September. During this time, the resident's family declined further dermatology appointments and requested in-house wound care, but there was no evidence of consistent wound assessment or treatment until the wound's condition worsened. Orders for topical antibiotics and other treatments were only initiated after a significant lapse in care. The deficiency culminated when staff discovered maggots in the resident's right temple wound, prompting transfer to an acute care hospital. Hospital records confirmed a large, necrotic wound with maggot infestation, and interviews with facility staff and the DON acknowledged the lack of wound assessment and treatment for several months. The failure to monitor, assess, and treat the resident's wound in accordance with professional standards led to the development of a severe wound with maggot infestation.
Failure to Update Facility Assessment for Wound Vac Therapy
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. Record review showed that the facility's assessment, dated 1/30/2025, listed several special treatments and conditions but did not include wound vac therapy, which was a service provided to at least one resident. The assessment also did not reflect updates or modifications when new services, such as wound vac treatment, were introduced. A resident was admitted with multiple diagnoses, including osteomyelitis and was receiving wound vac therapy to the left foot. The facility's documentation did not show that wound vac treatment was considered in their resource planning or assessment. During an interview, the Administrator confirmed that not all services listed in the assessment were actually provided and could not provide evidence that the assessment was updated to include wound vac therapy during the resident's admission.
Failure to Implement Enhanced Barrier Precautions for Resident with Wound and Indwelling Device
Penalty
Summary
The facility failed to follow its own Enhanced Barrier Precautions (EBP) policy and standard infection control practices for a resident with a surgical wound and an indwelling medical device. According to the facility's EBP policy, residents with wounds or indwelling medical devices require a physician order for EBP, and personal protective equipment (PPE) such as gowns and gloves should be immediately available near or outside the resident's room. Additionally, a trash can should be positioned inside the room near the exit for discarding PPE prior to leaving. Record review showed that the resident was readmitted with osteomyelitis, enterococcus infection, a surgical wound, and a peripherally inserted central catheter (PICC) for intravenous antibiotics, but there was no physician order for EBP as required by policy. Surveyor observations revealed that gowns and gloves were not immediately available near or outside the resident's room, and a trash can for discarding PPE was not positioned as required. The resident reported that staff did not wear gowns when providing personal care. Interviews with nursing staff and the Director of Nursing confirmed that EBP should have been in place for the resident due to the presence of wounds and a PICC line, but these precautions were not implemented.
Failure to Protect Resident from Abuse through Improper Physical Restraint
Penalty
Summary
A resident with diagnoses including dementia and anxiety disorder, and severely impaired cognition as indicated by a Brief Interview for Mental Status score of 0 out of 15, was involved in an incident where staff failed to protect the resident from abuse. The resident, who was known to be at risk for self-care deficits and had care plan interventions to redirect and reapproach if resistive, became agitated and combative, attempting to enter another resident's room. Staff responded by physically escorting the resident to the common area and later to the resident's room. Multiple staff members, including a registered nurse and a licensed practical nurse, were observed by other staff to use excessive force and physical restraint on the resident. Witness accounts described the resident being dragged down the hallway by the arm and walker, forcefully pushed into a chair, and later thrown into bed and pinned down by the chest and head. Staff were also reported to have made statements indicating a punitive approach, and did not follow the care plan interventions of redirection and calm re-approach. The resident was visibly distressed and attempted to resist, including spitting and kicking at staff. The facility's own investigation, as well as staff interviews, substantiated that the actions taken by the staff constituted abuse, including the use of manual physical restraint and unreasonable confinement. The Director of Nursing confirmed that the staff did not follow expected procedures, such as monitoring the resident from a distance or leaving the resident alone once safe, and acknowledged that the resident was abused during the incident. The survey team concluded that the actions taken by staff resulted in a deficiency related to the failure to protect the resident from abuse.
Failure to Act on Pharmacy Recommendations for Clozapine
Penalty
Summary
The facility failed to develop and maintain policies and procedures to act on pharmacy-identified irregularities marked as Clinical Priority for a resident using Clozapine, an atypical antipsychotic medication. The resident, who had diagnoses including Alzheimer's disease and schizophrenia, was readmitted to the facility with a medication order for Clozapine to be administered for 30 days. However, the medication was discontinued after 30 days due to an error, and the resident did not receive the medication for 11 days. A pharmacy consultation report dated 1/28/2025 recommended a prompt response to continue the medication, but the recommendation was not signed by the Nurse Practitioner until 2/3/2025, the same day the resident was transferred to the hospital. The resident exhibited suicidal ideation, medication refusal, and self-injurious behaviors, leading to hospitalization. Interviews with staff revealed that there was no system in place to highlight priority recommendations requiring prompt responses, and the Director of Nursing Services confirmed that pharmacy recommendations marked as Clinical Priority should have been reviewed within 24 hours. The facility's lack of a system to ensure prompt action on pharmacy reports placed residents at risk for serious harm.
Failure to Conduct Medication Reconciliation Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that Resident ID #1 was free from significant medication errors, as evidenced by the lack of medication reconciliation upon the resident's readmission from the hospital. The resident, who had diagnoses including Alzheimer's disease and schizophrenia, was readmitted with specific medication orders, including Clozapine and Trazadone. However, the facility did not complete a medication reconciliation to compare the hospital's medication orders with those prior to hospitalization, as required by their policy. The error was compounded when the facility transcribed the hospital's 30-day medication orders without clinical justification, leading to the discontinuation of essential medications like Clozapine and Trazadone. Despite a psychiatric practitioner's recommendation and a nurse practitioner's agreement to continue these medications, the orders were not updated, resulting in the resident not receiving the necessary medications. This oversight was identified only after the resident exhibited increased delusions and paranoia, prompting a medication review. The resident's condition deteriorated, leading to suicidal ideation, hallucinations, and self-injurious behavior, necessitating a hospital admission. Interviews with the Nurse Practitioner and Director of Nursing Services confirmed the transcription error and the failure to conduct a medication reconciliation. The facility's actions resulted in the resident's transfer to an acute hospital for a month-long treatment, highlighting the significant medication error and its impact on the resident's health.
Food Safety and Cleanliness Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in the main kitchen, as observed by surveyors. There was a significant accumulation of dust and grease on various kitchen surfaces, including the hood system, stove, flat top griddle, and convection oven. Additionally, the floor behind kitchen equipment was found to be dirty with dust and debris. These observations were made on multiple occasions, indicating a persistent issue with cleanliness and maintenance in the kitchen area. Furthermore, a dietary cook was observed working with exposed food while wearing acrylic nails and not using gloves, which is against the Rhode Island Food Code. Additionally, trash containers in the kitchen were left uncovered when not in use, contrary to the requirements of the food code. The Food Service Director acknowledged these deficiencies during an interview, confirming the need for cleaning and adherence to food safety protocols.
Failure to Offload Heels for Residents at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received the necessary treatment and services to promote healing and prevent new ulcers from developing. Resident ID #153, who was readmitted with a stroke and severe cognitive impairment, had a physician's order to offload heels at all times due to a Deep Tissue Pressure Injury on the left heel. However, surveyor observations on multiple dates revealed that the resident's heels were not offloaded as ordered. An LPN acknowledged the failure to follow the physician's order during an interview. Similarly, Resident ID #38, admitted with protein calorie malnutrition and at risk for pressure injuries, had a physician's order to offload both heels every shift. Surveyor observations on several dates showed that the resident's heels were not offloaded as required. An LPN confirmed the non-compliance during an interview, and the Director of Nursing Services expressed an expectation for staff to adhere to the physician's orders.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. Three residents with wound care needs were not provided with proper infection control measures. For Resident ID #77, the LPN did not change gloves or perform hand hygiene between cleaning the wound and applying a collagen dressing, which was acknowledged by the staff member. Similarly, for Resident ID #153, the same LPN failed to change gloves and perform hand hygiene between cleaning the wound and applying betadine. Resident ID #162 also experienced inadequate infection control practices. During a dressing change, the LPN placed a soiled dressing on the resident's bed, used a finger instead of an applicator to apply medication, and did not change gloves or perform hand hygiene before touching various items in the room. These actions were acknowledged by the staff member and the Director of Nursing Services, who expected adherence to infection control guidelines. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with pressure injuries. Resident ID #77 and Resident ID #146, both with open wounds, were not placed on EBP, and staff failed to wear protective gowns during wound care. The Infection Preventionist confirmed that these residents should have been on EBP, indicating a lack of awareness and adherence to infection control policies among staff.
Failure to Provide Necessary Physician Orders for Resident Care
Penalty
Summary
The facility failed to ensure that a Nurse Practitioner provided necessary orders for a resident's immediate care. The resident, who was admitted in October 2023, had diagnoses including vascular dementia and cerebrovascular disease. A progress note dated October 21, 2024, authored by the Nurse Practitioner, documented a late entry for October 17, 2024, indicating that the resident had abnormal weight gain, increased edema, and hypotension. A bladder scan revealed urine retention, leading to the insertion of a Foley catheter. However, a urine sample was not sent to the lab for culture and sensitivity as ordered, despite the resident showing signs of acute cystitis, such as slurred speech and disorientation. The physician's orders did not include an order for a urine culture and sensitivity. During interviews, a Licensed Practical Nurse stated she was unaware of the need for a urine culture and sensitivity. The Nurse Practitioner acknowledged failing to provide the necessary order for the urine culture and sensitivity before or on October 17, 2024, when the resident's condition changed. The Medical Director expressed that he expected the Nurse Practitioner to follow up and provide the order for the urine culture and sensitivity.
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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