Morgan Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Johnston, Rhode Island.
- Location
- 80 Morgan Avenue, Johnston, Rhode Island 02919
- CMS Provider Number
- 415062
- Inspections on file
- 38
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Morgan Health Center during CMS and state inspections, most recent first.
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 multiple comorbidities was admitted with a Stage 2 pressure ulcer and surrounding blisters, but the initial skin assessment lacked measurements and a detailed description. No treatment order was obtained or implemented for six days, and staff interviews confirmed that wound care was not provided during this period.
A resident with hypertension was administered Metoprolol Succinate without documented checks of blood pressure or apical pulse as required by physician orders. Review of MARs and staff interviews confirmed the absence of documentation that these vital signs were obtained prior to medication administration.
A pharmacist did not identify or report missing documentation of blood pressure and apical pulse monitoring before administering an antihypertensive medication to a resident, despite monthly medication regimen reviews and facility policy requiring such oversight. Both the pharmacist and the DON acknowledged the oversight during interviews.
Two residents did not receive timely follow-up for ordered medical appointments, including a GI surgical consult and neurology referral, due to the facility's failure to schedule and document these appointments. Residents and their families had to arrange the appointments themselves after repeated requests to staff, and facility staff were unaware of the appointments' outcomes. The DON and Administrator could not provide evidence of follow-up or scheduling as ordered by providers.
A resident with severely impaired cognition was inappropriately touched by another resident with intact cognition, who had a history of inappropriate behavior. The incident was witnessed by staff, and the facility failed to protect the resident's right to be free from abuse.
A resident with alcoholic cirrhosis had abnormal lab results that were not communicated to a provider, contrary to facility protocol. The resident later showed severe symptoms and was transferred to the hospital, where they were diagnosed with a ruptured intestine and sepsis, and subsequently died. Staff interviews confirmed the expectation for lab results to be reported, but no evidence was found that this occurred.
The facility failed to provide a safe and sanitary environment by not implementing a water management program based on industry standards and the CDC toolkit. Observations revealed that the second and fourth-floor tubs were used as storage and not regularly flushed, with no evidence of a water flow assessment to identify areas where Legionella could grow.
A resident with hemiplegia and an ankle fracture, who requires an interpreter, was not assisted properly with toileting and communication. The NA provided a bedpan instead of helping the resident to the bathroom, leading to frustration and an alleged physical altercation. Both the NA and the nurse failed to use the available communication tools, resulting in a deficiency for the facility.
The facility failed to report an allegation of staff-to-resident sexual abuse to the Rhode Island Department of Health (RIDOH) within the required timeframe. A resident reported that a male staff member inserted their finger in the resident's rectum during care. Despite the Social Services Director reporting the allegation to the Administrator immediately, the Administrator did not report it to RIDOH until approximately four weeks later, after being questioned by a surveyor.
A resident reported an allegation of staff-to-resident sexual abuse during a care conference. Despite the facility's policy requiring thorough investigation and a follow-up report within five business days, the Administrator acknowledged that no thorough investigation was conducted.
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 Initiate Timely Pressure Ulcer Treatment and Documentation
Penalty
Summary
A resident admitted in November 2025 with a history of laminectomy, diabetes mellitus, and obesity was found to have a Stage 2 pressure ulcer on the coccyx and popped blisters in the same area upon admission. The initial skin assessment documented the presence of these wounds but did not include measurements or a detailed description. There was no evidence that a treatment order for the wounds was obtained or implemented at the time of admission. Review of the clinical record and staff interviews confirmed that the resident's wound was not treated for six days following identification. The admitting nurse acknowledged failing to obtain a treatment order upon admission, and the wound nurse confirmed that standard practice requires a complete assessment and prompt initiation of treatment orders for identified wounds. Documentation did not show that the resident received any wound care from the time the wounds were first identified until six days later.
Failure to Document Vital Signs Prior to Medication Administration
Penalty
Summary
A deficiency was identified when a resident with a diagnosis including hypertension was not provided care in accordance with professional standards and physician's orders. The resident had physician orders for Metoprolol Succinate ER 50 mg daily, with specific instructions to hold the medication if the systolic blood pressure (SBP) was less than 100 or if the apical pulse (AP) was less than 60 (later changed to less than 50). These orders were in effect from late April through early July 2025. Record review of the Medication Administration Records (MAR) for April, May, June, and July 2025 did not show documentation that the resident's blood pressure or apical pulse were checked prior to administering the medication as required. During interviews, both a registered nurse and the Director of Nursing Services confirmed that there was no evidence that these vital signs were obtained before medication administration, as directed by the physician's orders.
Pharmacist Failed to Identify and Report Medication Monitoring Irregularity
Penalty
Summary
A deficiency was identified when a licensed pharmacist failed to report medication irregularities for a resident admitted with hypertension. The resident had physician's orders for Metoprolol Succinate ER 50 mg, with specific instructions to hold the medication if the systolic blood pressure (SBP) was less than 100 or if the apical pulse (AP) was below a certain threshold. Record review showed that, over several months, there was no documentation that the resident's blood pressure or apical pulse were checked prior to administering the medication, as required by the physician's orders. The pharmacist conducted monthly medication regimen reviews on three separate occasions but did not identify or report the lack of required monitoring documentation. Both the pharmacist and the Director of Nursing Services acknowledged during interviews that the irregularity was not identified or reported according to facility policy. This failure to recognize and report the medication administration irregularity constituted the deficiency.
Failure to Schedule and Follow Up on Ordered Medical Appointments
Penalty
Summary
The facility failed to ensure that two residents received necessary care and services related to follow-up medical appointments, as ordered by their providers. One resident, admitted with diagnoses including spinal stenosis and diabetes, had an order for an abdominal ultrasound to rule out a hernia, which was completed and confirmed a small right inguinal hernia. The nurse practitioner subsequently ordered a GI surgical consult, but there was no evidence in the records that this consult was scheduled by the facility. The resident reported having to schedule the GI appointment independently after repeated requests to staff, and attended the appointment, providing paperwork to the nurse. However, staff interviews revealed a lack of awareness about the appointment and its outcome, and the new nurse practitioner was unaware of the need for cardiac clearance for surgery following the GI consult. Another resident, admitted with diabetes and chronic obstructive pulmonary disease, had orders for lab work, a CT scan, MRI, and a neurology referral. While some lab results were faxed as part of the neurology referral process, there was no evidence that the CT or MRI were scheduled, nor that the neurology appointment was arranged by the facility. The resident and their spouse ultimately scheduled the neurology appointment themselves after waiting for months without information from staff. The transport aide indicated that incomplete referral information from nursing staff prevented her from scheduling the neurology appointment, and there was no documentation of follow-up for the required imaging or consults. Interviews with both residents' physicians confirmed that it was their expectation that the facility would have scheduled and followed up on the ordered consults. The Director of Nursing Services and the Administrator were unable to provide evidence that the facility had followed up or scheduled the necessary appointments as ordered by the providers. The records lacked documentation of the appointments and outcomes, indicating a failure in the facility's processes for ensuring residents receive timely and appropriate follow-up care.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving two residents. Resident ID #2 was observed by staff with their hand under the blanket of Resident ID #1, rubbing between their legs and asking if they liked it. This incident was witnessed by staff, and Resident ID #2 quickly moved their hand away when approached. Resident ID #1, the victim, had a BIMS score of 3 out of 15, indicating severely impaired cognition, and was unable to consent to such actions. Resident ID #2, the perpetrator, had a BIMS score of 13 out of 15, indicating intact cognition, and had a history of using inappropriate language towards others. The incident was reported to the Rhode Island Department of Health, and interviews with facility staff, including the Administrator, DON, and MDS Coordinator, confirmed the inappropriate behavior. The MDS Coordinator noted that Resident ID #2 was likely aware of their actions due to their cognitive status, while Resident ID #1's cognitive impairment rendered them unable to consent. The facility's failure to prevent this incident resulted in a deficiency related to the protection of residents from abuse.
Failure to Notify Provider of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify the ordering physician or a provider of laboratory results that were outside of clinical reference ranges for a resident. The resident, who was admitted to the facility with a diagnosis including alcoholic cirrhosis of the liver, had a physician's order for regular blood tests. A lab report revealed abnormal results, including elevated white blood cells and monocytes, and low hemoglobin levels, which were not communicated to a provider. This lack of communication occurred despite the facility's protocol to report lab results to a provider and document any new orders in the progress notes. The resident later exhibited symptoms of trouble breathing, a bloated abdomen, and rectal bleeding, leading to their transfer to the hospital, where they were diagnosed with a ruptured intestine and sepsis, and subsequently died. Interviews with facility staff, including a nurse practitioner and the Director of Nursing Services, confirmed that the lab results should have been reported to another provider in the absence of the primary provider. However, there was no evidence that the lab results were reviewed or acted upon by any provider, contributing to the resident's deteriorating condition.
Failure to Implement Water Management Program
Penalty
Summary
The facility failed to provide a safe and sanitary environment to help prevent the transmission of infections related to implementing a water management program based on industry standards and the CDC toolkit. The surveyor's observations, record reviews, and staff interviews revealed that the facility's water management binder lacked evidence of a water flow assessment identifying areas where Legionella could grow and spread. Additionally, the second and fourth-floor tubs were observed being used as storage, and there was no evidence that these tubs were flushed regularly to maintain water quality. During interviews, the Maintenance Director and the Regional Plant Operations Director acknowledged that the tubs were still functioning but could not provide evidence of regular flushing. Further record reviews failed to show monitoring and flushing of infrequently used fixtures, including the second and fourth-floor tubs. The facility was unable to provide evidence of a water flow assessment or a water management program based on industry standards and the CDC toolkit for preventing Legionella growth, as required.
Failure to Treat Resident with Respect and Dignity
Penalty
Summary
The facility failed to treat a resident with respect and dignity, particularly in relation to assistance with toileting and communication. The resident, who was admitted with diagnoses including hemiplegia and an ankle fracture, has intact cognition and requires an interpreter as English is not their primary language. Despite the facility's policy to use translation services and communication boards, these were not utilized during the incident in question. The resident's care plan included specific interventions for communication, but these were not followed by the staff involved. During the night shift, the resident requested assistance to transfer from bed to the bathroom, but the Nursing Assistant (NA) provided a bedpan instead. The resident, recently cleared by physical therapy for transferring out of bed, urinated in the bedpan, which eventually spilled. The resident alleged that the NA became upset and hit them on the leg. The NA admitted to not using the communication board or interpreter services and called for the nurse's assistance due to the resident's frustration. The nurse also failed to use the communication tools and did not inform the NA about the resident's preference for using the bathroom. The Director of Nursing Services (DNS) confirmed that staff should have used the communication tools available to facilitate communication with the resident. The DNS was unable to provide evidence that the resident was treated with respect and dignity during the incident. The failure to use the appropriate communication methods and the alleged physical abuse led to the deficiency noted in the report.
Failure to Report Alleged Sexual Abuse in a Timely Manner
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, as required by state and federal law. Specifically, an allegation of staff-to-resident sexual abuse was reported to the facility in February 2024, but the facility did not report this allegation to the Rhode Island Department of Health (RIDOH) or other officials until approximately four weeks later, after being questioned by a surveyor. The facility's policy mandates that such allegations be reported immediately, but not later than 2 hours after the allegation is made if it involves abuse, or no later than 24 hours if it does not involve abuse and does not result in serious bodily injury. The resident involved, who was admitted to the facility in December 2023 with diagnoses including diabetes, cerebrovascular accident (stroke), and depression, reported that a male staff member inserted their finger in the resident's rectum during care. The resident had a Brief Interview for Mental Status score indicating intact cognition. Despite the Social Services Director reporting the allegation to the Administrator immediately after it was made, the Administrator acknowledged that he did not follow through with the required reporting to RIDOH or other officials until prompted by the surveyor's inquiry, thus failing to comply with the facility's policy and regulatory requirements.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to provide evidence that all alleged violations were thoroughly investigated for a resident who reported an allegation of staff-to-resident sexual abuse. The complaint was submitted to the Rhode Island Department of Health, alleging that the facility did not follow up on the allegation. The facility's policy requires that all reports of resident abuse be thoroughly investigated and a follow-up investigation report be provided within five business days. However, the facility did not adhere to this policy in this case. The resident, who was admitted in December 2023 with diagnoses including diabetes, cerebrovascular accident (stroke), and depression, reported the abuse during a care conference in February 2024. The Social Services Director confirmed that she reported the allegation to the Administrator immediately. The Administrator acknowledged being aware of the allegation but admitted that the facility did not conduct a thorough investigation as required by their policy.
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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