Mansion Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Central Falls, Rhode Island.
- Location
- 104 Clay Street, Central Falls, Rhode Island 02863
- CMS Provider Number
- 415097
- Inspections on file
- 25
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Mansion Nursing And Rehab Center during CMS and state inspections, most recent first.
A Registered Nurse on an overnight shift failed to complete the medication pass and required treatments, monitoring, and documentation for most residents under her care. Record review showed that medication and treatment orders were not carried out for 40 of 48 residents reviewed during that shift, and the only drugs documented as given were Oxycodone, Ritalin, and Lorazepam, with documentation noted as inaccurate. When the missing documentation was discovered by the oncoming shift, the DON and Administrator suspected possible diversion by the agency nurse and were unable to produce evidence that residents received their ordered medications and treatments in accordance with professional standards of practice.
A resident with multiple medical conditions, including a recent fracture, sepsis, and opioid use disorder, was transferred to the hospital after a verbal altercation with staff. The facility did not provide the required written information about its bed-hold policy to the resident or their representative prior to the transfer, as confirmed by record review and staff interviews.
A resident with a history of opioid addiction and other medical conditions did not receive prescribed Methadone for two days due to the medication being unavailable. The DON reported delays in obtaining the medication from the treatment center, and the resident exhibited behavioral changes during this period. The facility could not demonstrate that the resident was kept free from significant medication errors.
The facility did not establish or document actions, measurements, or tracking systems to monitor and improve identified problem areas as required by its QAPI program. Review of records and staff interview confirmed the absence of evidence showing that performance improvement efforts were measured or tracked.
The facility did not ensure that pharmacy recommendations from monthly medication regimen reviews were reviewed or acted upon for four residents with complex psychiatric and medical conditions. Documentation and staff interviews confirmed that recommendations regarding medication changes or discontinuations, especially after incidents like falls, were not addressed as required by facility policy.
A resident with schizoaffective disorder, anxiety disorder, and PTSD did not receive recommended changes to psychiatric medications after a consultation, due to a lack of communication and follow-through among staff. The resident continued to experience increased anxiety and sleep disturbances, and the recommended medication adjustments were not implemented or reviewed by the physician.
A resident with a history of hypertensive heart disease and orthostatic hypotension was given midodrine despite physician orders to hold the medication when systolic BP exceeded 130 mm Hg. MAR review showed the medication was administered multiple times outside of these parameters, and staff interviews confirmed the failure to follow the order.
The facility did not notify or provide a final accounting of personal funds for two residents who died while receiving Medicaid benefits. Funds were still being held by the facility, and there was no evidence that the required notifications or conveyance of funds to the appropriate parties or probate jurisdiction occurred within the mandated timeframe.
Surveyors observed deficiencies in food safety standards, including a pink substance in the ice machine and an expired Hi-Cal supplement in the kitchenette. Both the LPN and Food Service Director acknowledged these issues.
The facility failed to maintain infection control by allowing an ice scoop to sit in stagnant water, risking Legionella growth. Additionally, two residents requiring Enhanced Barrier Precautions (EBP) did not receive proper care, as a Nursing Assistant was observed not wearing a gown during high-contact activities. The Director of Nursing acknowledged these lapses.
The facility failed to properly store and label medications, as observed by surveyors. An LPN acknowledged undated and improperly stored medications, including a tuberculin solution, Lorazepam tablets, and inhalers. Additionally, expired medications were found in the storage room, which the DNS confirmed should have been discarded.
Surveyors identified deficiencies in the facility's environment, including disrepair in the 2nd floor common area and resident rooms. An entertainment center had an uneven surface, and rooms had holes in drywall, chipped paint, and exposed wiring. The Operations Manager and DON acknowledged these issues.
A resident with type II diabetes mellitus experienced significant weight gain, prompting a physician's order for thyroid-related blood tests. However, the facility failed to complete the ordered lab work. A Registered Nurse acknowledged the oversight, and the DON confirmed the expectation for the lab work to be completed, highlighting a failure to meet professional standards of practice.
A resident with COPD was prescribed 2 liters of oxygen per minute, but was observed receiving higher flow rates, up to 3 liters, on multiple occasions. This discrepancy was confirmed by the DON and a nurse during a surveyor interview.
The facility failed to obtain written authorization to manage personal funds for two residents. One resident, admitted in 2011, had a balance of $4,379.42, and another, admitted in 2023, had a balance of $125.00, both without authorization. The Administrator acknowledged this oversight during an interview.
The facility did not provide quarterly financial statements to two residents who had funds held by the facility. Despite having personal needs accounts, these residents did not receive the required written accounting of their deposits, withdrawals, and balances. The Administrator confirmed the oversight during an interview.
The facility failed to notify residents receiving Medicaid benefits when their account balances approached the SSI resource limit, as required by regulations. Three residents had balances exceeding the threshold, and the Administrator could not provide evidence of written notifications.
The facility breached resident confidentiality by posting past survey results in a public area, which included identifying information of residents from previous surveys. The DON confirmed the availability of these rosters, indicating a failure to protect residents' personal and medical records.
Failure to Administer and Document Medications and Treatments During Overnight Shift
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received treatment and care in accordance with professional standards of practice by not following provider orders for medications and treatments during a specific overnight shift. A facility-reported incident dated 1/14/2026 indicated that during the 11:00 PM to 7:00 AM shift on 1/2/2026, a Registered Nurse (Staff A) did not fulfill assigned nursing responsibilities. Record review showed that medication orders were not administered and treatment orders were not completed for 40 of 48 residents reviewed during that shift, covering the period from 11:00 PM on 1/2/2026 into 7:00 AM on 1/3/2026. Surveyor interviews with the Director of Nursing Services (DNS) and the Administrator on 1/20/2026 revealed that when the oncoming shift identified missing documentation, their initial concern was possible medication diversion by the agency nurse. The only medications documented as administered during the shift were Oxycodone, Ritalin, and Lorazepam, and the DNS and Administrator stated that the nurse’s documentation was inaccurate. They reported that when contacted, the agency nurse refused to return to the facility to complete the documentation. The DNS and Administrator were unable to provide evidence that residents received their ordered medications and treatments in accordance with professional standards of practice during the 11:00 PM to 7:00 AM timeframe in question.
Failure to Provide Bed-Hold Policy Notification Upon Hospital Transfer
Penalty
Summary
The facility failed to provide written information regarding its bed-hold policy to a resident or the resident's representative prior to the resident's transfer to a hospital. According to the facility's own Bed Hold Policy, residents and/or their representatives must be informed of the policy whenever a resident is transferred for hospitalization or therapeutic leave. However, clinical record review and staff interviews confirmed that this requirement was not met for a resident who was transferred to the hospital following a verbal altercation with staff. The resident in question had been admitted with multiple diagnoses, including an intertrochanteric fracture of the left femur with surgical repair, sepsis secondary to cellulitis of the left lower extremity, and was on daily Methadone for opioid use disorder. Despite these complex medical needs, there was no documentation in the clinical record that the resident was offered a bed-hold upon transfer. Both the DON and the Administrator confirmed during interviews that the required notification was not provided.
Failure to Administer Prescribed Methadone Due to Medication Unavailability
Penalty
Summary
A deficiency occurred when a resident admitted with multiple diagnoses, including a left femur fracture with surgical repair and sepsis secondary to cellulitis, did not receive prescribed Methadone for opioid addiction. The resident had physician orders for Methadone 40 mg in the morning and 60 mg in the evening, but the Medication Administration Record (MAR) showed that both doses were missed on two consecutive days. Documentation indicated that the medication was unavailable as the reason for the missed doses. The Director of Nursing (DON) reported that the orders for Methadone were faxed to the substance abuse treatment center after it had closed, and despite multiple calls and messages, the medication did not arrive until the resident's third day at the facility. During this period, the resident exhibited behavioral changes, including verbal aggression, which led to a behavioral health evaluation. The facility was unable to provide evidence that the resident was kept free from significant medication errors, as the resident never received the prescribed Methadone during their stay.
Failure to Measure and Track QAPI Performance
Penalty
Summary
The facility failed to implement and document effective mechanisms for monitoring and evaluating resident care as part of its Quality Assurance and Performance Improvement (QAPI) program. Record review of the facility's QAPI plan for 2024 and 2025 showed no evidence of actions, measurements, or tracking systems to ensure that efforts for improvement in identified problem areas were being made or sustained. During an interview, the Administrator was unable to provide documentation demonstrating that the facility had developed or used any actions, measurements, or tracking systems to monitor performance in these areas. This deficiency was identified through both record review and staff interview.
Failure to Act on Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that irregularities identified by the Clinical Consultant Pharmacist during monthly Medication Regimen Reviews (MRR) were acted upon for four residents. According to facility policy, recommendations from the pharmacist are to be addressed and documented by staff or the prescriber, with the prescriber either accepting and acting upon the suggestion or providing an explanation for disagreement. For each of the four residents reviewed, there was no evidence that pharmacy recommendations were reviewed or acted upon by the provider or facility staff, as required by policy. Specifically, for residents with diagnoses such as dementia, major depressive disorder, anxiety, PTSD, delusional disorder, and bipolar disorder, pharmacy recommendations regarding medication adjustments or discontinuations following incidents such as falls were not documented as reviewed or addressed. Interviews with the Director of Nursing Services confirmed the absence of documentation or evidence that these recommendations were considered or acted upon for the residents in question.
Failure to Implement Psychiatric Medication Recommendations for Resident with Mental Health Diagnoses
Penalty
Summary
A resident with diagnoses including schizoaffective disorder, anxiety disorder, and PTSD was admitted to the facility and later reported increased anxiety and sleep disturbances. The resident underwent a psychiatric consultation, which resulted in recommendations to adjust current medications and initiate a new medication to address nightmares and anxiety. The psychiatric consultation document containing these recommendations was sent to the facility, but there was no evidence that the physician was made aware of the recommendations or that the medication changes were implemented. Interviews with the resident revealed ongoing symptoms and repeated requests for medication changes, which were not addressed. Staff interviews indicated a lack of communication and follow-through regarding the psychiatric recommendations, with the responsible nurse not reviewing or acting on the recommendations and the DON acknowledging that the recommendations had not been reviewed or implemented by the physician, even eight days after the consultation. This failure resulted in the resident not receiving necessary behavioral health care and services as required.
Failure to Hold Medication per Blood Pressure Parameters
Penalty
Summary
A resident with hypertensive heart disease and orthostatic hypotension was admitted to the facility and prescribed midodrine 10 mg three times daily, with specific instructions to hold the medication if the systolic blood pressure exceeded 130 mm Hg. Review of the Medication Administration Records for June and July 2025 showed that the resident received midodrine on multiple occasions when their systolic blood pressure was above the ordered threshold, contrary to the physician's instructions. During interviews, a registered nurse confirmed that the medication was administered despite the parameters, and the Director of Nursing Services was unable to provide evidence that the medication was held as ordered.
Failure to Notify and Convey Resident Funds After Death
Penalty
Summary
The facility failed to notify the appropriate individuals or probate jurisdiction of the personal funds held for two residents who received Medicaid benefits and expired while residing at the facility. Record review showed that the facility was holding funds for both residents at the time of their deaths, but was unable to provide evidence of the amount of funds being held. Additionally, there was no documentation that the facility conveyed the residents' funds or provided a final accounting of those funds within 30 days of the residents' deaths, as required by state law. During an interview, the Administrator confirmed that the funds were still being held and that no evidence of notification or final accounting could be provided.
Deficiencies in Food Safety Standards Observed
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as observed during a survey. An inspection of the ice machine revealed an accumulation of a pink substance on the bottommost edge of the ice dispenser shield, which was easily removable with a paper towel. This observation was confirmed by a Licensed Practical Nurse, who acknowledged the presence of the substance. Additionally, the Food Service Director also confirmed the accumulation of the pink substance within the ice machine. Further inspection of the kitchenette revealed an opened bottle of Hi-Cal oral supplement dated 5/7/2024, which was approximately three-quarters full. According to the product information guide, once opened, the supplement should be labeled with the time and date, refrigerated, covered, and used within 48 hours. The LPN acknowledged that the Hi-Cal supplement was past its use-by date and should have been discarded. The Food Service Director also confirmed that the Hi-Cal supplement should have been discarded.
Infection Control and EBP Failures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by surveyor observations and staff interviews. During an inspection of the nourishment area, an ice scoop was found submerged in approximately 2 inches of stagnant water in its designated container. This was acknowledged by both a Licensed Practical Nurse and the Food Service Director, who confirmed that the ice scoop should not be in standing water. This oversight in water management could potentially lead to the growth of Legionella and other waterborne pathogens, posing a risk to the residents and staff. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) for two residents. Resident ID #20, who was readmitted with dementia and a wound on the right great toe, had signage indicating the need for gown and glove use during high-contact activities. However, a Nursing Assistant was observed changing the resident's linens without wearing a gown. Similarly, Resident ID #26, with a diagnosis of schizoaffective disorder, required EBP during personal hygiene and toileting assistance. The same Nursing Assistant was observed not wearing a gown while providing these services. The Director of Nursing Services acknowledged the failure to follow EBP protocols for these residents.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with accepted professional principles, as observed during a survey. In the medication refrigerator, a bottle of tuberculin purified protein derivative solution was found opened and undated, which was acknowledged by the LPN present. Additionally, a medication cart contained a packet of Lorazepam tablets with a discontinue date that had passed, and the LPN confirmed that the medication should have been removed. Furthermore, two inhalers on another medication cart were opened and undated, contrary to manufacturer instructions, which was also acknowledged by the LPN. In the medication storage room, several expired medications were found, including bottles of Vitamin E, Mucus relief tablets, and Fish oil capsules. The Director of Nursing Services acknowledged that these medications were expired and should have been discarded. During a follow-up interview, the DNS could not provide evidence that the medications were stored appropriately as required.
Facility Environment Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment for residents, staff, and the public, as observed by surveyors on three of six units. On the 2nd floor common area, an entertainment center was found with scattered chip marks and pieces of wood lifting, creating an uneven surface. The Operations Manager acknowledged the disrepair. In a resident room on the [NAME] 1 Unit, three holes in the drywall and chipped paint over the resident's bed were observed. In another room on the Annex 1 Unit, exposed wiring from a call light system box and chipped paint behind the resident's bed and recliner were noted. The Director of Nursing Services acknowledged these findings and indicated the need for repairs.
Failure to Follow Physician's Order for Bloodwork
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice by not following a physician's order for a resident with significant weight gain. The resident, who was admitted with a diagnosis including type II diabetes mellitus, had a Minimum Data Set assessment indicating intact cognition. A Registered Dietician recommended bloodwork to check the resident's thyroid panel due to continued significant weight gain. A physician's order was issued for specific thyroid-related blood tests, including T-3 total, T-3 Uptake, and TSH, to diagnose potential thyroid conditions. However, a review of the records did not reveal any evidence that the ordered lab work was completed. During interviews, a Registered Nurse acknowledged that the physician's order was not followed, and the lab work was not conducted as ordered. The Director of Nursing Services also confirmed that she would have expected the lab work to be completed according to the physician's order, indicating a lapse in following professional standards of practice within the facility.
Failure to Adhere to Oxygen Administration Orders
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident with Chronic Obstructive Pulmonary Disease (COPD). The resident was readmitted to the facility with a physician's order to receive oxygen at 2 liters per minute via a nasal cannula every shift. However, surveyor observations revealed that the resident was receiving oxygen at higher flow rates than prescribed. On multiple occasions, the resident was observed receiving 3 liters of oxygen, and on one occasion, 2.5 liters. During an observation in the presence of the Director of Nursing Services and a Registered Nurse, it was confirmed that the resident was receiving 3 liters of oxygen instead of the ordered 2 liters. Both the Director of Nursing Services and the Registered Nurse acknowledged this discrepancy during a surveyor interview.
Failure to Obtain Written Authorization for Managing Residents' Funds
Penalty
Summary
The facility failed to obtain written authorization to manage personal funds for two residents. Resident ID #10, admitted in September 2011, had a personal needs account balance of $4,379.42 as of June 10, 2024, without having authorized the facility to hold these funds, as indicated by the absence of an authorization document dated September 9, 2011. Similarly, Resident ID #38, admitted in November 2023, had a personal needs account balance of $125.00 as of May 14, 2024, without providing written authorization for the facility to manage their funds, as shown by the lack of an authorization document dated November 7, 2023. During an interview on July 5, 2024, the Administrator acknowledged the absence of written authorization for holding the funds of these two residents. This oversight indicates a failure in the facility's process for managing residents' financial affairs, as required by regulations.
Failure to Provide Quarterly Financial Statements to Residents
Penalty
Summary
The facility failed to provide a written accounting of deposits, withdrawals, and balances at least quarterly for two residents. Resident ID #3, admitted in May 2023, had funds held by the facility, but there was no evidence of quarterly statements being completed and provided. Similarly, Resident ID #38, admitted in November 2023, also had funds held by the facility without any quarterly statements being issued. During an interview, the Administrator acknowledged that these residents had not received the required written accounting of their personal funds as per the regulation.
Failure to Notify Residents of Medicaid Eligibility Risk
Penalty
Summary
The facility failed to notify residents or their representatives who receive Medicaid benefits when their account balances reached $200 less than the Social Security Income (SSI) resource limit. This deficiency was identified for three residents whose personal needs funds were managed by the facility. Specifically, Resident ID #10 had a balance of $4,370.42, Resident ID #16 had a balance of $4,549.22, and Resident ID #17 had a balance of $4,186.66. According to Title 210-Executive Office of Health and Human Services, Chapter 50-Medicaid Long-Term Services and Supports (LTSS), the facility is required to notify residents in writing when their balance approaches the SSI Medicaid eligibility resource limit of $4,000. During an interview, the Administrator was unable to provide evidence that these notifications were made, resulting in a failure to comply with the regulatory requirement.
Breach of Resident Confidentiality in Survey Results Posting
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical records, as evidenced by the posting of past survey results in a public area. During a surveyor observation in the main hallway, a Survey Results envelope was found containing copies of previous survey rosters with identifying information of residents. These rosters included resident IDs from surveys conducted on various dates, specifically 10/4/2019, 4/15/2021, 6/16/2022, and 7/21/2023. The Director of Nursing Services confirmed that these resident rosters were accessible with the Survey Results, indicating a breach of privacy and confidentiality for the residents involved.
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.
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