Golden Crest Nursing Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in North Providence, Rhode Island.
- Location
- 100 Smithfield Road, North Providence, Rhode Island 02904
- CMS Provider Number
- 415029
- Inspections on file
- 33
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Golden Crest Nursing Centre during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease and a femur fracture, who was on a diuretic and had a care plan for altered fluid maintenance, did not receive consistent monitoring and documentation of fluid intake as required. Nursing standards cited in the record indicated a minimum desirable adult intake of 1,500 mL per day, yet EMR review showed missing intake documentation for most shifts over several weeks and recorded intake below 1,500 mL on nearly all days reviewed. Lab results showed an increase in creatinine, noted as a possible sign of dehydration. An LPN and the ADON both acknowledged that staff were expected to monitor and document the resident’s fluid intake in the EMR each shift, but this did not occur as expected.
The facility failed to ensure complete and accurate clinical records for two residents who required extensive staff assistance with ADLs, including personal hygiene and toileting. Despite documented needs such as a left femur fracture with Alzheimer’s disease and paraplegia with staff dependence for care, the NA Point of Care records for a specific day shift contained no entries showing that ADL assistance was provided. A complainant alleged inadequate staffing and lack of assistance for one resident during that shift, and the ADNS acknowledged that NAs did not document the care provided as required by professional documentation standards.
The facility failed to develop and implement individualized care plans for residents, leading to inadequate assistance and care. Residents with specific needs, such as those with multiple sclerosis, dementia, and PTSD, did not have care plans that detailed the necessary level of assistance. Staff relied on verbal communication rather than comprehensive care plans, resulting in inconsistencies in resident care.
A resident with arthritis and muscle weakness was found to have five unopened lidocaine patches in their room without an assessment for self-administration. A physician's order required the application of a lidocaine patch daily, but there was no evidence of an assessment for self-administration. An LPN and the Assistant DON confirmed that the patches should have been stored in the medication cart.
The facility failed to properly store and label medications, as observed during a survey. Expired medications were found on the 2 East Medication Cart, and undated medications were discovered on the 2 [NAME] Medication Cart. Additionally, an undated multidose vial of Aplisol was found in the 2 East Medication Room. Staff acknowledged the oversight, and the DON expected medications to be dated and discarded appropriately.
A facility failed to maintain an infection prevention and control program for a resident using a BIPAP device. The resident, who had sleep apnea and acute respiratory failure, reported that their BIPAP machine was not cleaned by the facility. The manufacturer's instructions require daily cleaning of the device, but the facility did not have an order to clean the equipment, and the Director of Nursing Services could not provide evidence of cleaning.
A resident with GERD refused Famotidine on multiple occasions due to its liquid form, but the facility failed to notify the physician of these refusals. Staff interviews confirmed the lack of communication, and the DON acknowledged the oversight, unable to provide evidence of physician notification.
A resident with a history of Peripheral Artery Disease and bilateral below-knee amputations was observed to have pressure ulcers. During a dressing change, an LPN did not follow physician orders for wound care, soaking a wound for only 2 minutes instead of 10 and failing to apply skin prep. The DON could not provide evidence that treatments were administered as ordered.
A resident with multiple health conditions, including Crohn's disease and chronic osteomyelitis, experienced a significant weight gain of 12.27% over one month, which was not addressed according to facility policy. Despite the requirement for reweights and physician notification, these actions were not taken until identified by a surveyor. Interviews with staff revealed a lack of awareness and action regarding the resident's weight gain.
A pharmacist failed to report medication irregularities for a resident prescribed as-needed Seroquel, an antipsychotic, without a stop date. Despite facility policy requiring monthly reviews and reporting of irregularities, the pharmacist's recommendations were not communicated to the facility, resulting in the resident receiving the medication without the recommended 14-day stop date.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.25% error rate. A resident's Depakote was crushed against packaging instructions, and MiraLAX was not administered but signed off as given. A CMT acknowledged the error, and an RN confirmed the discrepancies.
A resident with multiple health issues, including muscle weakness and failure to thrive, was found unable to reach their call light, which was tied to the bed rail on the opposite side of the bed. This oversight was acknowledged by a nursing assistant and the DON, who confirmed the care plan was not followed.
A resident with significant weight loss and multiple diagnoses did not receive a prescribed nutritional supplement for 5 out of 16 opportunities due to the supplement being on back order. The deficiency was acknowledged by the DON.
The facility failed to ensure that the environment was free from accident hazards for two residents at moderate risk for falls. One resident with dementia was observed trying to get up from a wheelchair without the call light within reach, and another resident with bipolar disorder was in pain and unable to locate the call light. Staff acknowledged that the call lights were not within reach as required.
Failure to Monitor and Document Hydration for a Resident on Diuretics
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate monitoring and assistance with hydration for a resident with identified fluid maintenance needs. The resident was admitted with a left femur fracture and Alzheimer’s disease and had a care plan problem of altered fluid maintenance related to diuretic use and poor insight into hydration needs. An intervention to monitor the resident’s fluid intake was initiated on 3/19/2026. Fundamentals of Nursing 7th Edition (2011) was cited, indicating that desirable adult fluid intake ranges from 1,500 to 3,500 mL per 24 hours, averaging 2,500 to 2,600 mL per day, and that intake records should be initiated and maintained for patients with real or potential water or electrolyte problems. A community complaint alleged that the facility was short staffed and allowing the resident’s health to decline, including inconsistent assistance with hydration. Clinical record review showed that laboratory results on 4/9/2026 revealed a creatinine level of 1.47 mg/dL, elevated from 1.25 mg/dL on 4/2/2026, with the report noting that elevated creatinine may be a sign of dehydration. Staff interviews confirmed that staff were expected to monitor and document the resident’s fluid intake in the electronic medical record (EMR) every shift. However, EMR review from 3/21/2026 through 4/14/2026 showed missing fluid intake documentation for 53 of 75 shifts and that the resident’s recorded intake did not meet the minimum recommended 1,500 mL per day for 24 of 25 days reviewed. The Assistant Director of Nursing Services stated that she expected staff to document the resident’s fluid intake in the EMR as required, confirming that the facility did not follow its own expectations for monitoring and documenting the resident’s hydration status.
Failure to Accurately Document ADL Assistance in Clinical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for residents in accordance with accepted professional standards, specifically related to documentation of assistance with activities of daily living (ADLs). A community complaint reported to the Rhode Island Department of Health alleged that the facility was short staffed and allowing one resident’s health to decline, including an allegation that there was not enough staff to assist this resident during a specified day shift. Fundamentals of Nursing, Seventh Edition (2011), was cited regarding the requirement that nursing documentation be complete, accurate, current, factual, and organized, and that care not documented is considered not done. Record review showed that one resident, admitted in March 2026 with a left femur fracture and Alzheimer’s disease, had a Comprehensive MDS indicating a need for maximal assistance with personal hygiene and toileting, yet the NA Point of Care History for the referenced day shift contained no documentation that assistance with care was provided. A second resident, admitted in November 2022 with paraplegia and identified on a Quarterly MDS as staff-dependent for personal hygiene and toileting, also had no documented assistance with care on the NA Point of Care History for the same day shift. During interview, the Assistant Director of Nursing Services acknowledged that NAs failed to document in the clinical record the care provided to these two residents during that shift, as required.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans with measurable objectives and timeframes to meet the medical, nursing, mental, and psychosocial needs of residents. This deficiency was identified for five residents, each with specific needs related to their diagnoses and conditions. For instance, one resident with multiple sclerosis and spastic quadriplegia experienced a fall from bed due to inadequate assistance during morning care, highlighting the lack of a focused care plan addressing their ADL needs. Another resident with muscle weakness and dementia required substantial assistance with ADLs, yet their care plan lacked a person-specific approach detailing the level of staff assistance required. Similarly, a resident with PTSD and Parkinson's disease had a care plan that failed to address their specific needs, including a culturally competent and trauma-informed approach for PTSD. The deficiency was further compounded by the facility's reliance on verbal communication among staff to determine the level of assistance needed for residents, rather than utilizing comprehensive care plans. Interviews with staff revealed inconsistencies in the documentation and communication of residents' care needs, with some staff unaware of the care plans or relying on undated and incomplete documents.
Improper Storage of Medications in Resident's Room
Penalty
Summary
The facility failed to store medications in accordance with currently accepted professional principles for a resident who was admitted with diagnoses including arthritis and muscle weakness. A physician's order dated October 1, 2024, prescribed a lidocaine adhesive patch 4% to be applied to the resident's right shoulder every morning and removed at bedtime. However, there was no evidence of an assessment for the resident's self-administration of the medication, which would indicate the resident's safety in storing and administering their medications. During a surveyor observation on November 4, 2024, five unopened lidocaine patches were found in the resident's room. Interviews with an LPN and the Assistant Director of Nursing Services confirmed that the patches should not have been in the resident's room and should have been stored in the medication cart instead.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles, as observed during a survey. On the 2 East Medication Cart, several medications, including Latanoprost Solution, Timolol Maleate Gel Forming Solution, Artificial Tears Ophthalmic Solution, and brimonidine-timolol drops, were found to be expired but not discarded. The Certified Medication Technician, Staff E, acknowledged the oversight during the surveyor's observation. Additionally, the Registered Nurse, Staff D, confirmed that staff should be dating medications when opened and discarding them upon expiration. Further observations on the 2 [NAME] Medication Cart revealed multiple bottles of eye drops, such as Cosopt, Artificial Tears Ophthalmic Solution, Systane Complete PF, and brimonidine-timolol drops, that were opened but undated, leaving their expiration status unknown. Staff F admitted to being unsure of the expiration dates. In the 2 East Medication Room, a multidose vial of Aplisol was found opened and undated, with RN Staff D unable to provide evidence of when it was opened. The Director of Nursing Services expressed that staff are expected to date medications when opened and discard them appropriately.
Failure to Maintain Infection Control for BIPAP Device
Penalty
Summary
The facility failed to maintain an infection prevention and control program for a resident using a Bilevel Positive Airway Pressure (BIPAP) device. The manufacturer's instructions for the BIPAP device, dated July 2017, require that the flexible tube and mask be cleaned before first use and daily thereafter. However, the facility did not follow these instructions for Resident ID #77, who was readmitted in August 2024 with diagnoses including sleep apnea and acute respiratory failure. The resident, who had intact cognition, reported to the surveyor that the facility did not clean their BIPAP machine. A review of the Treatment Administration Record for August and September 2024 showed that the resident had an order to use the BIPAP machine every night, but there was no order to clean the mask and tubing. The Director of Nursing Services confirmed that the facility's policy is to follow the manufacturer's instructions for cleaning the BIPAP equipment, but acknowledged that there was no order to clean the equipment for the resident and could not provide evidence that the machine was cleaned as required.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to meet professional standards of quality for a resident with medication refusals. The resident, who was readmitted to the facility with a diagnosis of gastro-esophageal reflux disease (GERD), had a physician's order for Famotidine, a medication prescribed to treat GERD. The medication was not administered on multiple occasions due to the resident's refusal, specifically on six different dates. Despite these refusals, there was no evidence that the provider was notified about the resident's refusal to take the medication. Interviews with facility staff revealed that the resident often refused the medication because it was in liquid form, although the resident was willing to take pills. Both a Certified Medication Technician and a Licensed Practical Nurse acknowledged that the provider had not been informed of the refusals. The Director of Nursing Services confirmed that the physician should have been notified if a patient was not taking a medication, but he was unable to provide evidence that this notification occurred.
Failure to Follow Wound Care Orders for Resident at Risk for Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident at risk for pressure ulcers, as observed during a survey. The resident, who was admitted in May 2023, has a medical history that includes Peripheral Artery Disease, Peripheral Vascular Disease, and bilateral below-knee amputations. The resident's care plan identified a risk for impaired skin integrity, with existing pressure ulcers on the coccyx, right lower shin, and right lateral knee. Physician orders specified detailed wound care procedures, including the use of Vashe wound cleanser and skin prep application to peri-wounds. During a dressing change observation, it was noted that the LPN, Staff C, did not adhere to the physician's orders. The coccyx wound was soaked with Vashe for only 2 minutes instead of the prescribed 10 minutes, and skin prep was not applied to the peri-wounds as required. Staff C acknowledged the failure to follow the orders during interviews. The Director of Nursing Services could not provide evidence that the treatments were administered as ordered, indicating a lapse in following professional standards of practice for wound care.
Failure to Address Significant Weight Gain in Resident
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, as evidenced by a significant weight gain that was not addressed in accordance with the facility's policy. The resident, who was admitted with conditions including Crohn's disease, rectal abscess, pressure ulcer, and chronic osteomyelitis, experienced a weight gain of 14.4 pounds, or 12.27%, over the course of one month. Despite the facility's policy requiring reweights and notification of the physician if a significant weight discrepancy is noted, there was no evidence that these actions were taken until the issue was identified by a surveyor. Interviews with facility staff, including a registered nurse, the dietitian, and the Director of Nursing Services, revealed a lack of awareness and action regarding the resident's significant weight gain. The registered nurse acknowledged the alarming nature of the weight gain, especially given the resident's fluid restriction, but confirmed that no reweights were obtained and the physician was not notified. The dietitian, who reviews weights weekly, was unaware of the extent of the weight gain and had not reported it to the physician. The Director of Nursing Services also confirmed that he was unaware of the situation until it was brought to his attention by the surveyor.
Pharmacist's Failure to Report Medication Irregularities
Penalty
Summary
The deficiency involves a failure by the facility's pharmacist to report medication irregularities for a resident prescribed as-needed antipsychotic medication. The facility policy requires a monthly drug regimen review by a licensed pharmacist, who must report any irregularities to the attending physician, Medical Director, and Director of Nursing Services (DNS). However, for one resident with a history of major depressive disorder, anxiety disorder, post-traumatic stress disorder, and paranoid personality disorder, the pharmacist did not report the absence of a stop date for the antipsychotic medication Seroquel, which was prescribed as needed. The resident was admitted with a physician's order for Seroquel without a stop date, and the pharmacy made recommendations on two occasions, but these were not communicated to the facility. The DNS was unaware of the pharmacist's recommendations until the surveyor's inquiry, indicating a lapse in communication and adherence to the facility's medication regimen review policy. The failure to report and act on the pharmacist's recommendations resulted in the resident receiving the medication without the recommended 14-day stop date, highlighting a deficiency in the facility's medication management process.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6.25% error rate during a medication administration task. This deficiency involved a resident who had physician's orders for Depakote and MiraLAX. During an observation, a Certified Medication Technician failed to administer MiraLAX and crushed a Depakote tablet, despite the packaging instructions indicating not to crush or chew the medication. The technician acknowledged the error when interviewed by the surveyor. Additionally, a Registered Nurse confirmed that the MiraLAX was incorrectly signed off as administered, and acknowledged that the Depakote should not have been crushed.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide person-centered care in accordance with a resident's plan of care, specifically regarding the accessibility of the call light for a resident with multiple health issues. The resident, admitted in April 2024, had diagnoses including adult failure to thrive, paroxysmal atrial fibrillation, and muscle weakness. The care plan dated April 18, 2024, included interventions to prevent falls and injuries, such as ensuring the call light was within reach and reminding the resident to call for assistance as needed. During a surveyor observation on July 15, 2024, the resident was found seated in a wheelchair with the call light tied to the bed rail on the opposite side of the bed, out of sight and reach. The resident expressed feeling trapped and having to yell for help due to the inability to access the call light. A nursing assistant acknowledged the oversight and relocated the call bell within the resident's reach. The Director of Nursing Services also acknowledged that the care plan had not been followed in this instance.
Failure to Administer Nutritional Supplement as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following a physician's order for nutritional supplements. The resident, who was admitted in October 2023 with diagnoses including acquired absence of the right leg below the knee and type II diabetes mellitus, experienced significant weight loss over a month. A physician's order dated 4/23/2024 prescribed 60 milliliters of an oral nutritional supplement twice daily. However, the resident did not receive the supplement for 5 out of 16 opportunities in May 2024 because it was not available in the facility and was on back order. This deficiency was acknowledged by the Director of Nursing Services during a surveyor interview on 5/9/2024.
Failure to Ensure Call Lights Within Reach for Residents at Fall Risk
Penalty
Summary
The facility failed to ensure that the residents' environment remained as free from accident hazards as possible for two residents identified as being at moderate risk for falls. Resident ID #3, who has a history of dementia and falls, was observed attempting to get up from a wheelchair and calling for help, with the call light hanging approximately 8 feet away from the resident. The Registered Nurse acknowledged that the call light was not within the resident's reach, which was a required intervention in the resident's care plan. Similarly, Resident ID #2, who has a history of urinary tract infection and bipolar disorder, was observed lying in bed and experiencing pain. The resident was unable to locate the call light to request pain medication and asked the surveyor to get the nurse. The Licensed Practical Nurse confirmed that the call light was out of the resident's reach, hanging off the bedside rail. The Director of Nursing Services stated that he would expect residents to have their call lights within reach.
Latest citations in Rhode Island
The facility failed to follow physician orders for post-fall care for three anticoagulated residents who experienced falls. One resident on a blood thinner with a head injury was ordered to be transferred to the ED after a telehealth evaluation, but an LPN did not send the resident, citing instructions to contact a supervisor first and inability to reach that supervisor. For two other residents on anticoagulants, providers ordered intensive neuro checks (every 15 minutes, then every 30 minutes, then hourly, then every 4 hours), but staff instead performed neuro checks only once per shift for 72 hours. The DON and Medical Director acknowledged that the transfer and monitoring orders were not implemented as written.
A resident with intact cognition and psychiatric diagnoses sustained a left eyebrow laceration when another resident with a documented history of escalating aggressive and threatening behaviors struck them with a cane during a hallway dispute. The aggressive resident had multiple prior documented incidents, including verbal threats to kill others, attacking a roommate with a cane over TV volume, throwing objects during activities, and throwing a lunch plate at staff. Despite these events, the care plan was not updated with interventions to address physical aggression toward other residents, and a psychiatric recommendation for PRN trazodone for agitation, anxiety, and insomnia was only implemented as PRN for insomnia. The failure to assess, monitor, and implement effective interventions for the aggressive resident’s behaviors led to the assault and injury and, per the report, placed this and other residents at risk of serious physical and psychosocial harm.
A resident with impulse disorder, mood and anxiety diagnoses, and a history of escalating verbal and physical aggression had multiple documented incidents of threats, object throwing, and assault with a cane. Despite a psychiatric consult recommending PRN trazodone for agitation, anxiety, and insomnia, the provider order listed insomnia only, and the care plan was not updated with specific interventions to address the resident’s physically aggressive behaviors after several documented events. Subsequently, the resident struck another resident with a cane, causing a facial laceration that required wound closure and ongoing treatment.
The facility failed to properly screen and document clearance for a NA with disqualifying criminal history information before hire, as required by its abuse, neglect, and exploitation policy. A BCI check showed disqualifying information, yet the NA was hired, completed orientation, and worked independently based only on verbal disclosure of an old drug-related charge, without written details or verification. Later, a staff member reported witnessing this NA grab a resident’s face and kiss the resident on the lips, and a community complaint alleged inappropriate interactions with the same resident, prompting involvement of local police.
A resident with anxiety disorder and PTSD was unable to attend meals and activities with peers because the facility lost the resident's clothing after it was sent to laundry. The resident was observed in a hospital gown with only a few clothing items in the room, and the record lacked an admission inventory of belongings. The DON/Administrator reported that laundry was handled by an outside vendor without a tracking system or item documentation.
A resident with dementia and severely impaired cognition was subjected to repeated non-consensual kissing on the lips by an NA, who entered the resident’s room during care, verbally expressed affection, and then kissed the resident on the mouth on at least two separate occasions witnessed by staff. One staff member delayed reporting the first incident due to fear of the NA. These actions occurred despite a facility policy defining sexual abuse as any non-consensual sexual act and requiring protections of residents’ rights and well-being.
Failure to investigate allegations of resident-to-resident sexual inappropriateness: A resident with dementia and TBI was documented as being inappropriate with another resident, and psych notes later described increased sexually inappropriate behaviors toward other residents. Staff interviews showed the resident had been observed touching others and needing frequent redirection, but the DON, ADON, and Administrator acknowledged the facility did not complete an investigation or recognize the allegation as possible abuse.
A resident with dementia and a hearing deficit did not receive ear care as ordered because the chart lacked the Debrox order and the ear was flushed before the intended Debrox course was completed. In a separate incident, staff witnessed inappropriate kissing of a resident with dementia, but the allegation was not reported to the provider and the care plan was not updated. A third resident’s wound care was also not completed as ordered when an RN used normal saline instead of the prescribed Vashe wound wash.
A resident with migraines and chronic pain did not receive timely pain management after repeatedly reporting a migraine and appearing in visible distress. An NA notified an LPN, an RN said she could not access the med cart, and the resident continued waiting while the LPN was off the unit; the PRN migraine medication was not given until 40 minutes after the first complaint. The DON acknowledged the resident should not have waited that long for pain medication.
A resident missed 6 doses of a prescribed antibiotic, and the MAR did not show that the provider was notified. The RN acknowledged the missed doses and said they should have been reported, while the Medical Director stated she was unaware of the missed doses and would have extended the antibiotic course if informed. The DON also confirmed the missed doses and expected provider notification for any missed antibiotic dose.
Failure to Follow Post-Fall Physician Orders for Anticoagulated Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for post-fall care, including hospital transfer and neurological monitoring, for residents on anticoagulant therapy. One resident with atrial fibrillation on Xarelto experienced an unwitnessed fall with a scalp laceration and head lump. The on-call provider, after a telehealth evaluation, ordered transfer to the ED and wrote an order directing that the resident be sent to the hospital. The resident was not transferred as ordered, and an additional order for vital signs and neuro checks every shift for 72 hours after the fall was not completed as ordered on one of the shifts. The LPN caring for this resident stated she did not send the resident to the ED because she had been instructed to call a supervisor before sending residents out, and she was unable to reach the supervisor during the shift. A second resident, also with atrial fibrillation and on Xarelto, had an unwitnessed fall with injury. The on-call provider was notified and ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, then every four hours for an additional 24 hours. A physician’s order reflecting this schedule was scanned into the EMR. However, the neuro checks were not completed as ordered; instead, they were performed only once per shift for 72 hours. The RN who authored the progress note documented the fall and the resident’s anticoagulant use, and later stated she could not remember why she did not transcribe and complete the neuro checks as ordered. A third resident with atrial fibrillation on Apixaban had a non-injury fall after attempting to walk independently. The on-call provider ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, and then every four hours for an additional 24 hours, and this order was scanned into the EMR. The record did not show that these neuro checks were completed as ordered; instead, neuro checks were documented only once per shift for 72 hours. The Medical Director stated he would have expected the first resident to be transferred to the ED as ordered and that the facility should not override a provider’s order. The DON acknowledged that the transfer order and the ordered monitoring for the first resident were not followed as written, and that for the second and third residents, staff performed only once-per-shift neuro checks instead of the more frequent monitoring ordered by the providers.
Failure to Manage Escalating Aggression Leading to Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident, Resident ID #1, from abuse by another resident with a known history of escalating aggression, Resident ID #2. Resident ID #1 was admitted in October 2025 with diagnoses including paranoid schizophrenia and adjustment disorder with mixed anxiety and depressed mood, and had a BIMS score of 14/15, indicating intact cognition. On 4/27/2026, progress notes documented that Resident ID #1 was on the receiving end of a physical altercation with another resident and was found with a deep bleeding abrasion to the left eyebrow. A subsequent nursing note described a new laceration to the left eyebrow measuring 0.5 cm by 2.0 cm by 0.1 cm, related to a resident-to-resident incident, for which wound closure strips were applied. Resident ID #1 requested police involvement and a police report, and refused transfer to the hospital for sutures. Resident ID #2 had been admitted in December 2024 with multiple psychiatric and behavioral diagnoses, including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed a BIMS score of 13/15 and documented both physical and verbal behaviors during the look-back period. Progress notes over several months recorded a pattern of escalating aggressive and threatening behaviors: on 9/13/2025, Resident ID #2 threatened to slit another resident’s throat and made additional threats toward staff; on 11/7/2025, the resident was involved in a verbal dispute with raised voice, name-calling, and verbal threats; on 12/28/2025, after another resident struck Resident ID #2 with a helmet, Resident ID #2 was overheard threatening to kill that resident if touched again. On 2/21/2026, the on-call provider documented that Resident ID #2 attacked a roommate with a cane over TV volume and required ER transfer for psychiatric evaluation. Subsequent notes on 3/9/2026 and 4/10/2026 described the resident throwing poker chips on the floor, yelling and swearing at staff and residents, and throwing a lunch plate across the nurses’ station at a nursing assistant due to dissatisfaction with portion size. Despite this documented pattern, the care plan for Resident ID #2, dated 1/16/2025, only indicated a behavior problem of being verbally aggressive toward staff with resident-to-resident altercations on 12/28/2025, 2/21/2026, and 4/27/2026, and record review failed to show added interventions to mitigate the risk of physical aggression toward other residents after the 2/21/2026 cane attack and the object-throwing incidents on 3/9/2026 and 4/10/2026. A psychiatric evaluation on 4/23/2026 recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order entered on 4/24/2026 specified trazodone 25 mg twice daily as needed only for insomnia, and record review did not show that agitation and anxiety were included as indications for use. During interviews, the RNP and the DON stated it was their expectation that agitation and anxiety would have been included in the trazodone order, and the DON was unable to provide evidence that the care plan had been updated with interventions to address Resident ID #2’s physically aggressive behaviors documented on 2/21/2026, 3/9/2026, and 4/10/2026. On 4/27/2026, the DON documented that Resident ID #2 was ambulating down the hall toward his/her room while Resident ID #1 was walking in the opposite direction, and the two residents began a verbal dispute. Before staff could intervene, Resident ID #2 used his/her cane to make contact with Resident ID #1, resulting in the eyebrow laceration that required steri-strips and ongoing wound treatment. A police incident report recorded that Resident ID #1 stated being struck with a walking cane, wanted to press charges, and that Resident ID #2 admitted to striking Resident ID #1, leading to an arrest on one count of felony assault with a dangerous weapon. The facility’s failure to assess, monitor, and implement effective interventions for Resident ID #2’s known and escalating aggressive behaviors, including failure to update the care plan after prior incidents and failure to fully implement psychiatric recommendations, resulted in this resident-to-resident altercation and injury, and the report states that this failure placed Resident ID #1 and other residents at risk of serious physical and psychosocial harm.
Failure to Implement Psychiatric Recommendations and Update Behavior Care Plan Leading to Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health services and care planning for a resident with a documented history of psychiatric conditions and aggressive behaviors. The resident was admitted in December 2024 with diagnoses including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed intact cognition with a BIMS score of 13/15 and documented physical and verbal behaviors during the look-back period. Over time, multiple behavioral incidents were recorded, including threats to slit another resident’s throat during a smoking session, verbal disputes with name-calling and threats, and a statement to another resident that if touched again the resident would be killed. Further documentation showed escalating behaviors, including an incident where the resident attacked a roommate with a cane over television volume and required ER transfer for psychiatric evaluation, throwing poker chips and yelling when not winning at Bingo, causing the roommate to avoid the shared bathroom due to inappropriate comments and frustration over the light being turned on at night, and throwing a lunch plate across the nurses’ station at a nursing assistant over portion size. The care plan, initiated in January 2025 for verbal aggression and resident-to-resident altercations, did not contain added interventions to address the resident’s physically aggressive behaviors toward others after the incidents on 2/21/2026, 3/9/2026, and 4/10/2026. The DNS later could not provide evidence that the care plan had been updated with interventions to mitigate the risk of these physically aggressive behaviors or to guide staff in ensuring the safety of other residents. On 4/23/2026, a psychiatric evaluation recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order dated 4/24/2026 implemented trazodone 25 mg twice daily as needed for insomnia only, and the record lacked evidence that agitation and anxiety were included as indications for use as recommended by the consulting psychiatrist. Both the RNP and the DNS stated it was their expectation that the trazodone order would have included agitation and anxiety. Following this incomplete implementation of the psychiatric recommendation and the lack of updated behavioral interventions in the care plan, a resident-to-resident altercation occurred on 4/27/2026 in which the resident struck another resident with a cane, causing a laceration to the left eyebrow that required closure with steri-strips and ongoing wound treatment.
Failure to Properly Screen and Clear NA with Disqualifying Criminal History
Penalty
Summary
The facility failed to ensure that a prospective employee was properly screened and cleared for a history of abuse, neglect, exploitation, or misappropriation of resident property before hire. A nursing assistant, identified as Staff A, was hired on 11/18/2025 and was working independently as a NA. Prior to hire, a Bureau of Criminal Identification (BCI) check dated 11/6/2025 showed that Staff A had disqualifying information under federal and state law. Surveyor review after discovery of the positive BCI revealed that Staff A had an extensive criminal history. Despite this, the facility proceeded with the hire and allowed Staff A to complete orientation and work independently without obtaining or maintaining documentation specifying the nature of the disqualifying information, contrary to the facility’s Abuse, Neglect and Exploitation Policy, which requires screening and documentation of proof that such screening occurred. Subsequently, a facility-reported incident submitted on 4/17/2026 documented that a staff member reported witnessing Staff A grab a resident’s face and kiss the resident on the lips. A community-reported complaint submitted on 4/22/2026 alleged inappropriate interactions between the same NA and the same resident, and included a local police incident report indicating the resident’s family intended to pursue charges related to the incident. During interviews, the Human Resource Director stated that Staff A had disclosed disqualifying information related to a prior drug-related charge from about ten years earlier, but acknowledged there was no documentation specifying the nature of the disqualifying information and that this was known only by word of mouth. The Administrator stated she was aware that the BCI contained disqualifying information and that she exercised her own judgment in proceeding with the hire, and further acknowledged she did not receive documentation detailing the disqualifying information until it was brought to her attention by the surveyor.
Failure to Maintain Resident Clothing and Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when the resident was unable to attend meals and activities with other residents because of a lack of appropriate clothing. The resident was admitted in May 2025 with diagnoses including anxiety disorder and post-traumatic stress disorder, and a care plan revised on 8/25/2025 described the resident as highly social and willing to participate in a variety of activities, with an intervention to provide reminders of scheduled events. During observation on 4/29/2026, the resident was found in the room wearing a hospital gown while other residents were in the dining room for lunch. Only one pair of pants and two T-shirts were observed in the room. The resident stated that the facility lost all of the resident's clothing, including shirts, pants, shorts, and socks, after they were sent to laundry services several months earlier and were never returned. The resident reported that the Administrator was told about the missing clothing, but no follow-up occurred and the clothing was neither located nor replaced. The record did not contain an admission inventory list of the resident's belongings, and the Administrator stated that laundry was handled by an outsourced company without a tracking system or documentation identifying which items belonged to which resident.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse when a nursing assistant (NA) was observed kissing the resident on the lips on more than one occasion. The resident, identified as having dementia and a Brief Interview for Mental Status (BIMS) score of 0/15 indicating severely impaired cognition, had been admitted in March 2026. On one occasion, a Certified Medication Technician (CMT) reported that while she was assisting the resident with breakfast, the NA entered the room, verbally expressed affection for the resident, made a kissing noise, leaned forward, and kissed the resident on the lips. This incident made the CMT uncomfortable, and she later discussed it with another NA. A separate staff member, another NA, reported that two days earlier she had observed the same NA enter the resident’s room while morning care was being provided, ask the resident if they remembered her, state that she loved the resident, then lean toward the resident, make a kissing sound, and kiss the resident on the mouth with full lip-to-lip contact. This second NA did not report the incident at the time because she was fearful of the NA involved and only came forward after learning of the later incident. The facility’s abuse, neglect, and exploitation policy defined sexual abuse as a non-consensual sexual act of any type with a resident and required protections for each resident’s health, welfare, and rights, as well as screening of potential employees for a history of abuse. Despite this policy, the resident with severely impaired cognition was subjected to repeated non-consensual kissing by the NA.
Failure to Investigate Allegations of Resident-to-Resident Sexual Inappropriateness
Penalty
Summary
The facility failed to ensure that allegations made by residents were recognized as possible abuse by staff and that all allegations were investigated for Resident ID #41, who was admitted with diagnoses including dementia and traumatic brain injury. A facility policy titled, Abuse, Neglect and Exploitation, stated that an immediate investigation is warranted when suspicion of abuse, neglect, exploitation, or reports of abuse, neglect, or exploitation occur. A progress note written by an RN documented that a resident reported Resident ID #41 was being inappropriate with another resident. Subsequent records included psychiatric evaluations stating the resident was being seen due to increased sexually inappropriate behaviors toward other residents and that sexual impulses may present an unsafe environment for other patients in the facility. Staff interviews revealed that Resident ID #41 had been observed touching other residents' shoulders and hands and required frequent redirection. The RN who documented the incident stated the behavior involved an attempted hug without contact and that both residents were separated and assessed, while the ADON and DON acknowledged they were unaware of the behavior or that the facility had not investigated the allegations. The Administrator also acknowledged that an investigation had not been completed to determine what sexually inappropriate behavior had occurred and that staff did not identify the allegation as possible abuse or investigate it immediately.
Failure to Follow Orders, Report Abuse, and Perform Ordered Wound Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for a resident with dementia and anxiety disorder who had a hearing deficit and complained of right ear wax buildup. The medical record showed an order for Debrox ear drops and a separate order to flush the right ear with warm water two times a day following Debrox usage for 5 days, but the record did not include a physician order for the Debrox solution. The April 2026 MAR showed the resident’s right ear was flushed six times, and the resident stated that the right ear still felt blocked. The RN acknowledged flushing the ear and was unaware whether Debrox had been given, while the DON stated the order had been entered incorrectly and that the ear should not have been flushed before Debrox administration. The NP stated the intended order was for Debrox twice daily for five days before irrigation and that she would not have ordered daily ear flushing. The facility also failed to report an allegation of abuse and failed to update the care plan for a resident with dementia after staff reported inappropriate interactions with a nursing assistant. A community complaint and police incident report indicated the family wanted to press charges, and the Administrator and DON confirmed that staff had reported witnessing the nursing assistant kiss the resident on two occasions. The record did not show that the allegation was reported to the provider, and the comprehensive care plan was not updated to reflect the allegation or any interventions related to the incident. The NP stated she was unaware of the incident and would have expected to be notified, and the ADNS acknowledged that the provider had not been notified and the care plan had not been updated. The facility further failed to follow a wound care order for a resident readmitted with peripheral vascular disease and cellulitis of the lower limb. The physician ordered cleansing open areas on the left lower leg with Vashe wound wash, applying xeroform to the wound bed, and wrapping with kling. During observation, the RN performing wound care did not use Vashe wash and instead cleansed the wound with normal saline. The RN acknowledged using normal saline rather than the ordered cleanser, and the DON stated she would expect the nurse to follow the wound orders as written.
Delayed Pain Medication for Resident with Migraine
Penalty
Summary
Safe, appropriate pain management was not provided for Resident ID #17, who was admitted with diagnoses including migraines and chronic pain. The resident’s care plan dated 4/20/2026 included a goal for the resident to verbalize adequate pain relief and an intervention to respond immediately to any complaint of pain. The physician ordered Butalbital-APAP-Caffeine 50-300-40 mg, 1 capsule every 12 hours as needed for migraine pain. On 4/29/2026 at 10:30 AM, the resident was observed in the hallway complaining of a migraine, moaning in pain, and holding his/her head. At 10:34 AM, an NA reported to an LPN that the resident wanted pain medication, and at 10:37 AM the resident continued to complain of migraine pain and told an RN about the pain, but the RN stated she did not have keys to the medication cart and could not get any pain medication. The resident continued to complain of severe head pain, returned to the room to lie down at 10:40 AM, and the LPN was still off the unit at 10:42 AM. The resident was not assessed when the LPN returned, and the medication was not administered until 11:10 AM, 40 minutes after the initial complaint. The resident later reported pain rated 7 out of 10, and the DON acknowledged that a resident should not wait 40 minutes for pain medication.
Missed Antibiotic Doses Not Reported to Provider
Penalty
Summary
The facility failed to ensure that Resident ID #17 was free from significant medication errors when the resident missed 6 doses of a prescribed antibiotic. The resident was admitted in April 2026 with diagnoses including surgical aftercare and complication of surgical and medical care, and had a physician order dated 4/3/2026 for Cefadroxil 500 mg by mouth twice daily for 14 days. Review of the April 2026 MAR showed missed doses on 4/3 at 8:00 PM, 4/6 at 8:00 PM, 4/11 at 8:00 PM, 4/12 at 8:00 AM, 4/14 at 8:00 PM, and 4/17 at 8:00 AM. The record did not show that the provider was notified of the missed antibiotic doses. During interview, the RN acknowledged the 6 missed doses and stated they should have been reported to the provider. The Medical Director stated she was unaware of the missed doses and said she would have extended the antibiotic course if she had known. The DON also acknowledged the missed doses and stated she would expect the provider to be informed if a resident misses any dose of an antibiotic.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
