Steere House Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Providence, Rhode Island.
- Location
- 100 Borden Street, Providence, Rhode Island 02903
- CMS Provider Number
- 415091
- Inspections on file
- 17
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Steere House Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Improper Thermometer Sanitization During Meal Temperature Checks: A Dietary Cook checked holding temps for multiple lunch items without sanitizing the thermometer probe between foods, including peas, mashed potatoes, and ground broccoli. Before checking baked fish, she dipped the probe in sanitizer but then wiped it with her bare hands before inserting it into the fish. The FSD stated the probe should be sanitized between every food item and wiped with a clean cloth after sanitizing.
A resident with a PICC line and IV antibiotics did not have confirmed catheter tip placement in the SVC before the line was used, and the record showed repeated antibiotic administration without that verification. PICC dressing changes were also documented without required external length and arm circumference measurements, and when the catheter was later charted as migrated 6 cm, the provider was not notified; the DON and physician both stated they expected placement confirmation and notification of migration.
A resident with ESRD and severe cognitive impairment did not have required pre- and post-dialysis weights documented after dialysis trips, and the COC paperwork was missing on return from the dialysis center. Staff also failed to notify the provider of the dialysis center’s recommendation to discontinue calcitriol, and the resident continued receiving the medication despite those recommendations.
Missing Annual Competencies for Direct Care Staff and PICC Line Care: Record review showed the facility did not have evidence that several direct care staff, including an RN, LPN, and NA, completed required annual education and competencies. The facility assessment required competency-based mandatory training upon hire and annually, and the education files for multiple nurses also lacked yearly competencies for PICC line care, including midline/central line dressing changes. The ADON was unable to provide evidence of the required competencies during interview.
A resident with type 2 DM had an order for an HbA1c to support diabetes management, but the lab test was not obtained as ordered. The Infection Preventionist acknowledged the missed test and could not show that the provider was notified or that staff attempted to follow up with the lab, and the DON stated she would have expected the nurse and/or provider to follow up.
The facility failed to provide appropriate ground texture diets for three residents, leading to them being served foods that were not safe for their conditions. A resident with dysphagia was given toasted garlic bread and donut holes, another with acute respiratory failure was served whole grilled cheese sandwiches, and a third with dementia received inappropriate foods like toast and salad. Staff were unaware of dietary requirements, and the Director of Nursing could not provide evidence of compliance with prescribed diets.
The facility failed to store medications properly, with expired drugs found in medication rooms and carts, and a resident with dementia had medications left unattended at their bedside without proper evaluation or physician's order. Staff acknowledged the oversight, and the DON could not explain the lapses.
The facility failed to maintain an effective infection prevention and control program, with deficiencies including a resident with ESBL not on Enhanced Barrier Precautions, improper cleaning of a BIPAP device, and inadequate hand hygiene during meal service. These issues were acknowledged by staff, indicating lapses in infection control practices.
A resident with moderately impaired cognition was physically abused by a roommate with intact cognition, resulting in a significant injury. The facility's investigation confirmed the abuse, but the Director of Nursing and Administrator could not provide evidence that the resident was kept free from harm, indicating a failure in the facility's protective measures.
A resident with cognitive impairment and a history of falls was able to leave the facility unsupervised, resulting in a fall and injuries. The resident's Elopement Risk Evaluation was inaccurately coded, and staff failed to provide necessary supervision, leading to the incident.
A facility failed to develop a comprehensive care plan for a resident diagnosed with a UTI after returning from the hospital. The resident, with mild cognitive impairment and a history of falling, was prescribed Cephalexin. However, no care plan was created for the UTI treatment. Staff interviews confirmed the oversight.
Improper Thermometer Sanitization During Meal Temperature Checks
Penalty
Summary
The facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety when a Dietary Cook obtained food temperatures for the lunch meal without properly sanitizing the thermometer probe between items. During observation in the main kitchen, the cook measured the holding temperature of peas, then moved directly to mashed potatoes without cleaning and sanitizing the probe, and then moved from the mashed potatoes to ground broccoli without cleaning and sanitizing the probe. Before checking baked fish, she dipped the probe in sanitizer but then wiped it with her bare hands before inserting it into the fish. In interview, the cook acknowledged that she did not sanitize the thermometer after each vegetable and should not have used her bare hands to wipe the thermometer before using it on the fish. The Food Service Director stated that the thermometer should be sanitized between every food item and wiped with a clean cloth after sanitizing.
PICC Line Placement and Monitoring Not Verified
Penalty
Summary
The facility failed to ensure that a resident with a PICC line received treatment and care in accordance with professional standards of practice. The resident was admitted in February 2026 with diagnoses including dementia with severe agitation and bacteremia, and had a PICC line placed after removing the first one. Physician orders directed IV cefazolin and required weekly PICC dressing changes with measurement of the external catheter length and arm circumference. After the PICC was replaced on 2/10/2026, the record did not show that the facility verified correct catheter tip placement in the SVC before using the line, yet the resident received antibiotics on 63 occasions without confirmation that the PICC tip was in the appropriate location. The record also showed that PICC dressing changes were documented without the required measurements. On 2/13/2026, the dressing was changed due to the resident’s complaint of discomfort and itching, but there was no evidence that external catheter length or arm circumference were measured. Later documentation showed a catheter length of 00 cm on 2/21/2026 and 6 cm on 2/28/2026, with an arm circumference of 27 cm, but the record did not show that the provider was notified when the catheter was documented as migrating 6 cm from the initial placement. The resident continued to receive antibiotics 15 more times without confirmation that the PICC tip was in the correct location. During interviews, the DON stated she expected confirmation of catheter placement before antibiotics were given and expected the provider to be notified if the catheter migrated 6 cm; the physician stated she expected the facility to obtain confirmation of placement and external catheter length on admission and said she was not notified of the migration.
Dialysis care documentation and medication communication failures
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care for a resident with end stage renal disease and dependence on renal dialysis. The resident had severe cognitive impairment with a BIMS score of 5 out of 15 and was ordered to receive dialysis every Monday, Wednesday, and Friday. A physician order also required the resident to be weighed before and after dialysis and for the post-dialysis weight to be recorded in the electronic medical record. Record review showed no evidence of pre- and post-dialysis weights documented in the resident’s electronic medical record for two dialysis treatments. The record also did not contain continuity of care documents received back from the dialysis center for those dates, including the required weights. Staff interviews confirmed that on one occasion the resident returned from dialysis without a continuity of care document and the LPN called the dialysis center but did not obtain the weights, and on another occasion the RN stated the resident returned without the document and she was unable to provide evidence that the weights were obtained. The record also showed a physician order for calcitriol three times weekly, while dialysis center progress notes stated the medication should be discontinued because it was being given at the dialysis center and should not be administered by the facility. The record did not show that the provider was notified of these recommendations, and the MAR showed the resident continued to receive calcitriol for weeks after the dialysis center’s recommendations. The resident’s physician and the DON both stated they would have expected staff to obtain the weights from the dialysis center and notify the provider of the dialysis center’s recommendations.
Missing Annual Competencies for Direct Care Staff and PICC Line Care
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide nursing and related services for resident safety and to support residents in attaining or maintaining the highest practicable physical, mental, and psychosocial well-being, as determined by resident assessments and the facility assessment. Based on record review, annual education and competencies were not found for RN Staff C, RN Staff D, LPN Staff E, and NA Staff F, despite the facility assessment stating that competency-based mandatory trainings are required for direct care staff and are completed upon hire and annually. The facility also failed to ensure that staff had the appropriate competencies and skill sets for PICC line care. Record review of the facility assessment showed that the facility provides IV medication administration and PICC line care and dressing changes, but the education and competency files for Staff C, D, E, G, and H did not show yearly competencies, including midline/central line dressing changes. During interview, the ADON was unable to provide evidence that these direct care staff members had completed their yearly competencies according to the facility assessment.
Failure to Obtain Ordered HbA1c Testing
Penalty
Summary
The facility failed to obtain laboratory services to meet the needs of 1 resident with type 2 diabetes mellitus who had a provider plan to check a Hemoglobin A1c level for diabetes management because the resident's last documented HbA1c was 11.5. A physician order was entered to obtain the HbA1c on 2/24/2026, but the laboratory record did not show that the test was obtained as ordered. During interview, the Infection Preventionist acknowledged that the HbA1c was not obtained and could not provide evidence that the provider was notified or that the facility attempted to obtain the ordered bloodwork after the due date. The DON stated she would have expected the nurse and/or provider to follow up with the laboratory to obtain the ordered bloodwork.
Failure to Provide Appropriate Ground Texture Diets
Penalty
Summary
The facility failed to provide and prepare food in a form designed to meet individual needs for three residents with a physician's order for a ground texture diet. Resident ID #58, who was admitted with dysphagia, was observed being served inappropriate foods such as toasted garlic bread and whole dry donut holes, which were not cut into bite-sized pieces as ordered. Despite the resident's coughing while eating, staff members, including a Certified Medication Technician and a Dietary Aide, were unaware of the specific dietary requirements for a ground diet, leading to the resident being served foods that were not safe for their condition. Resident ID #44, readmitted with acute respiratory failure and end-stage renal disease, was observed eating whole slices of toasted white bread and grilled cheese sandwiches, contrary to the physician's order for a ground texture diet. Staff members, including a Nursing Assistant and an LPN, were unaware that these foods were inappropriate for the resident's dietary needs, indicating a lack of communication and understanding of the dietary orders among the staff. Resident ID #365, admitted with dementia and dysphagia, was served over medium eggs with toasted bread and a garden salad with large pieces of grilled chicken and watermelon with seeds, despite having a ground texture diet order. The resident's son had to prompt the resident to swallow, highlighting the risk posed by the inappropriate food texture. The SLP confirmed that the resident should not have received these foods, and the diet was subsequently downgraded to a pureed texture. The Director of Nursing Services was unable to provide evidence that the residents were served a therapeutic diet as prescribed, demonstrating a systemic failure in adhering to dietary orders.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with accepted professional principles, as observed in one of two medication rooms, two of five medication carts, and at the bedside of a resident. In the third-floor medication room, a bottle of Lorazepam intensol was found expired and not discarded, which was acknowledged by the Licensed Practical Nurse present. On the second-floor medication cart, expired Latanoprost ophthalmic solution and Stye sterile lubricant eye ointment were found, with the Certified Medication Technician confirming they should have been discarded. Additionally, on the third-floor medication cart, Latanoprost and Brimonidine tartrate eye drops were found, with the latter being undated and the technician unable to provide evidence of when it was opened. A resident with dementia and chronic pain was observed with medications left unattended at their bedside, including Asper Cream, vaporizing rub, and a penetrating heat rub. The resident indicated self-application of these medications, but there was no evidence of an evaluation for self-administration or a physician's order for these medications. The Registered Nurse and Director of Nursing Services were unaware of the medications at the resident's bedside and could not explain why the expired medications were not discarded appropriately.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue involved a resident with a Multi-Drug Resistant Organism (MDRO) infection, specifically Extended Spectrum Beta Lactamase (ESBL), who was not placed on Enhanced Barrier Precautions (EBP). Despite the resident's dependency on staff for toileting and frequent incontinence, there was no evidence of isolation measures such as an isolation cart or signage outside the resident's room. The Infection Preventionist acknowledged that the facility did not utilize EBP for ESBL and could not provide evidence of follow-up urine cultures to confirm the resident was no longer positive for ESBL. Another deficiency was noted in the care of a resident using a Bilevel Positive Airway Pressure (BIPAP) device. The facility failed to follow the manufacturer's cleaning instructions for the BIPAP machine, as there was no documentation or physician's order for cleaning the equipment. During an observation, the BIPAP mask was found to have an accumulation of pink and white matter, and staff were unsure of the cleaning process. The Director of Nursing Services revealed that the facility mistakenly believed an outside company was responsible for cleaning the BIPAP machines, but this was not the case. Additionally, improper hand hygiene practices were observed during meal service. A Dietary Aide was seen using the same gloves to handle food and operate a phone, without changing gloves in between tasks. This practice was acknowledged by the Food Service Director, who stated that the staff member should have changed gloves after using the phone and before handling food. These observations highlight the facility's failure to adhere to proper infection control practices, potentially increasing the risk of infection transmission among residents.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents. Resident ID #2 reported being kicked by Resident ID #3 while exiting the bathroom, resulting in a skin tear on the left leg. The facility's investigation confirmed the abuse, with Resident ID #3 admitting to hitting Resident ID #2 with a trash can. Resident ID #2, who has a history of adjustment disorder with anxiety and brain disorders, sustained a wound that required treatment for 31 days. The incident was reported to the Rhode Island Department of Health, and the facility's policy on abuse prohibition was not effectively implemented to prevent this occurrence. Resident ID #3, who has a history of being a difficult roommate and has undergone multiple room changes, was found to have intact cognition with a BIMS score of 14 out of 15. Despite this, Resident ID #3 deliberately inflicted harm on Resident ID #2, who has moderately impaired cognition with a BIMS score of 9 out of 15. The Director of Nursing Services and the Administrator were unable to provide evidence that Resident ID #2 was kept free from physical abuse, highlighting a deficiency in the facility's ability to protect its residents from harm.
Inadequate Supervision Leads to Resident Elopement and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent an accident involving a resident who was not initially identified as being at risk for elopement. The resident, who had a history of mild cognitive impairment and falls, was able to independently wheel themselves out of the facility without staff supervision. This led to the resident's wheelchair rolling downhill, resulting in a fall and subsequent injuries, including a bump to the forehead, skin tears, and a hematoma. The resident was admitted to the facility with a diagnosis of mild cognitive impairment and a history of falling. Despite these conditions, the resident had unrestricted access to the second-floor lobby and the main elevator, which led to the main entrance on the first floor. The resident's Elopement Risk Evaluation, completed by a registered nurse, did not deem the resident an elopement risk, although it noted the need for supervision when off the unit. However, the evaluation was not accurately coded according to the RAI manual, and the resident was not adequately supervised when off the unit. On the day of the incident, a nursing assistant observed the resident wheeling themselves out of the facility while on her break. The staff member was distracted by her cell phone and did not intervene until it was too late. The Director of Nursing Services acknowledged that the resident should have been in generally supervised areas but could not explain how the resident managed to exit the unit and the building without proper supervision. This lack of supervision directly contributed to the resident's accident and subsequent injuries.
Failure to Develop Comprehensive Care Plan for UTI
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was being treated for a urinary tract infection (UTI). The resident, who was admitted in March 2022 with mild cognitive impairment and a history of falling, returned from the hospital after a fall and was diagnosed with a UTI. The resident was prescribed Cephalexin, an antibiotic, to be taken every 12 hours for 7 days. However, a review of the records showed no evidence that a care plan was developed and implemented for the UTI. During interviews, both the Minimum Data Set Coordinator and the Director of Nursing Services acknowledged that the care plan should have been updated to include the UTI immediately.
Latest citations in Rhode Island
The facility failed to follow physician orders for post-fall care for three anticoagulated residents who experienced falls. One resident on a blood thinner with a head injury was ordered to be transferred to the ED after a telehealth evaluation, but an LPN did not send the resident, citing instructions to contact a supervisor first and inability to reach that supervisor. For two other residents on anticoagulants, providers ordered intensive neuro checks (every 15 minutes, then every 30 minutes, then hourly, then every 4 hours), but staff instead performed neuro checks only once per shift for 72 hours. The DON and Medical Director acknowledged that the transfer and monitoring orders were not implemented as written.
A resident with intact cognition and psychiatric diagnoses sustained a left eyebrow laceration when another resident with a documented history of escalating aggressive and threatening behaviors struck them with a cane during a hallway dispute. The aggressive resident had multiple prior documented incidents, including verbal threats to kill others, attacking a roommate with a cane over TV volume, throwing objects during activities, and throwing a lunch plate at staff. Despite these events, the care plan was not updated with interventions to address physical aggression toward other residents, and a psychiatric recommendation for PRN trazodone for agitation, anxiety, and insomnia was only implemented as PRN for insomnia. The failure to assess, monitor, and implement effective interventions for the aggressive resident’s behaviors led to the assault and injury and, per the report, placed this and other residents at risk of serious physical and psychosocial harm.
A resident with impulse disorder, mood and anxiety diagnoses, and a history of escalating verbal and physical aggression had multiple documented incidents of threats, object throwing, and assault with a cane. Despite a psychiatric consult recommending PRN trazodone for agitation, anxiety, and insomnia, the provider order listed insomnia only, and the care plan was not updated with specific interventions to address the resident’s physically aggressive behaviors after several documented events. Subsequently, the resident struck another resident with a cane, causing a facial laceration that required wound closure and ongoing treatment.
The facility failed to properly screen and document clearance for a NA with disqualifying criminal history information before hire, as required by its abuse, neglect, and exploitation policy. A BCI check showed disqualifying information, yet the NA was hired, completed orientation, and worked independently based only on verbal disclosure of an old drug-related charge, without written details or verification. Later, a staff member reported witnessing this NA grab a resident’s face and kiss the resident on the lips, and a community complaint alleged inappropriate interactions with the same resident, prompting involvement of local police.
A resident with anxiety disorder and PTSD was unable to attend meals and activities with peers because the facility lost the resident's clothing after it was sent to laundry. The resident was observed in a hospital gown with only a few clothing items in the room, and the record lacked an admission inventory of belongings. The DON/Administrator reported that laundry was handled by an outside vendor without a tracking system or item documentation.
A resident with dementia and severely impaired cognition was subjected to repeated non-consensual kissing on the lips by an NA, who entered the resident’s room during care, verbally expressed affection, and then kissed the resident on the mouth on at least two separate occasions witnessed by staff. One staff member delayed reporting the first incident due to fear of the NA. These actions occurred despite a facility policy defining sexual abuse as any non-consensual sexual act and requiring protections of residents’ rights and well-being.
Failure to investigate allegations of resident-to-resident sexual inappropriateness: A resident with dementia and TBI was documented as being inappropriate with another resident, and psych notes later described increased sexually inappropriate behaviors toward other residents. Staff interviews showed the resident had been observed touching others and needing frequent redirection, but the DON, ADON, and Administrator acknowledged the facility did not complete an investigation or recognize the allegation as possible abuse.
A resident with dementia and a hearing deficit did not receive ear care as ordered because the chart lacked the Debrox order and the ear was flushed before the intended Debrox course was completed. In a separate incident, staff witnessed inappropriate kissing of a resident with dementia, but the allegation was not reported to the provider and the care plan was not updated. A third resident’s wound care was also not completed as ordered when an RN used normal saline instead of the prescribed Vashe wound wash.
A resident with migraines and chronic pain did not receive timely pain management after repeatedly reporting a migraine and appearing in visible distress. An NA notified an LPN, an RN said she could not access the med cart, and the resident continued waiting while the LPN was off the unit; the PRN migraine medication was not given until 40 minutes after the first complaint. The DON acknowledged the resident should not have waited that long for pain medication.
A resident missed 6 doses of a prescribed antibiotic, and the MAR did not show that the provider was notified. The RN acknowledged the missed doses and said they should have been reported, while the Medical Director stated she was unaware of the missed doses and would have extended the antibiotic course if informed. The DON also confirmed the missed doses and expected provider notification for any missed antibiotic dose.
Failure to Follow Post-Fall Physician Orders for Anticoagulated Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for post-fall care, including hospital transfer and neurological monitoring, for residents on anticoagulant therapy. One resident with atrial fibrillation on Xarelto experienced an unwitnessed fall with a scalp laceration and head lump. The on-call provider, after a telehealth evaluation, ordered transfer to the ED and wrote an order directing that the resident be sent to the hospital. The resident was not transferred as ordered, and an additional order for vital signs and neuro checks every shift for 72 hours after the fall was not completed as ordered on one of the shifts. The LPN caring for this resident stated she did not send the resident to the ED because she had been instructed to call a supervisor before sending residents out, and she was unable to reach the supervisor during the shift. A second resident, also with atrial fibrillation and on Xarelto, had an unwitnessed fall with injury. The on-call provider was notified and ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, then every four hours for an additional 24 hours. A physician’s order reflecting this schedule was scanned into the EMR. However, the neuro checks were not completed as ordered; instead, they were performed only once per shift for 72 hours. The RN who authored the progress note documented the fall and the resident’s anticoagulant use, and later stated she could not remember why she did not transcribe and complete the neuro checks as ordered. A third resident with atrial fibrillation on Apixaban had a non-injury fall after attempting to walk independently. The on-call provider ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, and then every four hours for an additional 24 hours, and this order was scanned into the EMR. The record did not show that these neuro checks were completed as ordered; instead, neuro checks were documented only once per shift for 72 hours. The Medical Director stated he would have expected the first resident to be transferred to the ED as ordered and that the facility should not override a provider’s order. The DON acknowledged that the transfer order and the ordered monitoring for the first resident were not followed as written, and that for the second and third residents, staff performed only once-per-shift neuro checks instead of the more frequent monitoring ordered by the providers.
Failure to Manage Escalating Aggression Leading to Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident, Resident ID #1, from abuse by another resident with a known history of escalating aggression, Resident ID #2. Resident ID #1 was admitted in October 2025 with diagnoses including paranoid schizophrenia and adjustment disorder with mixed anxiety and depressed mood, and had a BIMS score of 14/15, indicating intact cognition. On 4/27/2026, progress notes documented that Resident ID #1 was on the receiving end of a physical altercation with another resident and was found with a deep bleeding abrasion to the left eyebrow. A subsequent nursing note described a new laceration to the left eyebrow measuring 0.5 cm by 2.0 cm by 0.1 cm, related to a resident-to-resident incident, for which wound closure strips were applied. Resident ID #1 requested police involvement and a police report, and refused transfer to the hospital for sutures. Resident ID #2 had been admitted in December 2024 with multiple psychiatric and behavioral diagnoses, including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed a BIMS score of 13/15 and documented both physical and verbal behaviors during the look-back period. Progress notes over several months recorded a pattern of escalating aggressive and threatening behaviors: on 9/13/2025, Resident ID #2 threatened to slit another resident’s throat and made additional threats toward staff; on 11/7/2025, the resident was involved in a verbal dispute with raised voice, name-calling, and verbal threats; on 12/28/2025, after another resident struck Resident ID #2 with a helmet, Resident ID #2 was overheard threatening to kill that resident if touched again. On 2/21/2026, the on-call provider documented that Resident ID #2 attacked a roommate with a cane over TV volume and required ER transfer for psychiatric evaluation. Subsequent notes on 3/9/2026 and 4/10/2026 described the resident throwing poker chips on the floor, yelling and swearing at staff and residents, and throwing a lunch plate across the nurses’ station at a nursing assistant due to dissatisfaction with portion size. Despite this documented pattern, the care plan for Resident ID #2, dated 1/16/2025, only indicated a behavior problem of being verbally aggressive toward staff with resident-to-resident altercations on 12/28/2025, 2/21/2026, and 4/27/2026, and record review failed to show added interventions to mitigate the risk of physical aggression toward other residents after the 2/21/2026 cane attack and the object-throwing incidents on 3/9/2026 and 4/10/2026. A psychiatric evaluation on 4/23/2026 recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order entered on 4/24/2026 specified trazodone 25 mg twice daily as needed only for insomnia, and record review did not show that agitation and anxiety were included as indications for use. During interviews, the RNP and the DON stated it was their expectation that agitation and anxiety would have been included in the trazodone order, and the DON was unable to provide evidence that the care plan had been updated with interventions to address Resident ID #2’s physically aggressive behaviors documented on 2/21/2026, 3/9/2026, and 4/10/2026. On 4/27/2026, the DON documented that Resident ID #2 was ambulating down the hall toward his/her room while Resident ID #1 was walking in the opposite direction, and the two residents began a verbal dispute. Before staff could intervene, Resident ID #2 used his/her cane to make contact with Resident ID #1, resulting in the eyebrow laceration that required steri-strips and ongoing wound treatment. A police incident report recorded that Resident ID #1 stated being struck with a walking cane, wanted to press charges, and that Resident ID #2 admitted to striking Resident ID #1, leading to an arrest on one count of felony assault with a dangerous weapon. The facility’s failure to assess, monitor, and implement effective interventions for Resident ID #2’s known and escalating aggressive behaviors, including failure to update the care plan after prior incidents and failure to fully implement psychiatric recommendations, resulted in this resident-to-resident altercation and injury, and the report states that this failure placed Resident ID #1 and other residents at risk of serious physical and psychosocial harm.
Failure to Implement Psychiatric Recommendations and Update Behavior Care Plan Leading to Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health services and care planning for a resident with a documented history of psychiatric conditions and aggressive behaviors. The resident was admitted in December 2024 with diagnoses including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed intact cognition with a BIMS score of 13/15 and documented physical and verbal behaviors during the look-back period. Over time, multiple behavioral incidents were recorded, including threats to slit another resident’s throat during a smoking session, verbal disputes with name-calling and threats, and a statement to another resident that if touched again the resident would be killed. Further documentation showed escalating behaviors, including an incident where the resident attacked a roommate with a cane over television volume and required ER transfer for psychiatric evaluation, throwing poker chips and yelling when not winning at Bingo, causing the roommate to avoid the shared bathroom due to inappropriate comments and frustration over the light being turned on at night, and throwing a lunch plate across the nurses’ station at a nursing assistant over portion size. The care plan, initiated in January 2025 for verbal aggression and resident-to-resident altercations, did not contain added interventions to address the resident’s physically aggressive behaviors toward others after the incidents on 2/21/2026, 3/9/2026, and 4/10/2026. The DNS later could not provide evidence that the care plan had been updated with interventions to mitigate the risk of these physically aggressive behaviors or to guide staff in ensuring the safety of other residents. On 4/23/2026, a psychiatric evaluation recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order dated 4/24/2026 implemented trazodone 25 mg twice daily as needed for insomnia only, and the record lacked evidence that agitation and anxiety were included as indications for use as recommended by the consulting psychiatrist. Both the RNP and the DNS stated it was their expectation that the trazodone order would have included agitation and anxiety. Following this incomplete implementation of the psychiatric recommendation and the lack of updated behavioral interventions in the care plan, a resident-to-resident altercation occurred on 4/27/2026 in which the resident struck another resident with a cane, causing a laceration to the left eyebrow that required closure with steri-strips and ongoing wound treatment.
Failure to Properly Screen and Clear NA with Disqualifying Criminal History
Penalty
Summary
The facility failed to ensure that a prospective employee was properly screened and cleared for a history of abuse, neglect, exploitation, or misappropriation of resident property before hire. A nursing assistant, identified as Staff A, was hired on 11/18/2025 and was working independently as a NA. Prior to hire, a Bureau of Criminal Identification (BCI) check dated 11/6/2025 showed that Staff A had disqualifying information under federal and state law. Surveyor review after discovery of the positive BCI revealed that Staff A had an extensive criminal history. Despite this, the facility proceeded with the hire and allowed Staff A to complete orientation and work independently without obtaining or maintaining documentation specifying the nature of the disqualifying information, contrary to the facility’s Abuse, Neglect and Exploitation Policy, which requires screening and documentation of proof that such screening occurred. Subsequently, a facility-reported incident submitted on 4/17/2026 documented that a staff member reported witnessing Staff A grab a resident’s face and kiss the resident on the lips. A community-reported complaint submitted on 4/22/2026 alleged inappropriate interactions between the same NA and the same resident, and included a local police incident report indicating the resident’s family intended to pursue charges related to the incident. During interviews, the Human Resource Director stated that Staff A had disclosed disqualifying information related to a prior drug-related charge from about ten years earlier, but acknowledged there was no documentation specifying the nature of the disqualifying information and that this was known only by word of mouth. The Administrator stated she was aware that the BCI contained disqualifying information and that she exercised her own judgment in proceeding with the hire, and further acknowledged she did not receive documentation detailing the disqualifying information until it was brought to her attention by the surveyor.
Failure to Maintain Resident Clothing and Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when the resident was unable to attend meals and activities with other residents because of a lack of appropriate clothing. The resident was admitted in May 2025 with diagnoses including anxiety disorder and post-traumatic stress disorder, and a care plan revised on 8/25/2025 described the resident as highly social and willing to participate in a variety of activities, with an intervention to provide reminders of scheduled events. During observation on 4/29/2026, the resident was found in the room wearing a hospital gown while other residents were in the dining room for lunch. Only one pair of pants and two T-shirts were observed in the room. The resident stated that the facility lost all of the resident's clothing, including shirts, pants, shorts, and socks, after they were sent to laundry services several months earlier and were never returned. The resident reported that the Administrator was told about the missing clothing, but no follow-up occurred and the clothing was neither located nor replaced. The record did not contain an admission inventory list of the resident's belongings, and the Administrator stated that laundry was handled by an outsourced company without a tracking system or documentation identifying which items belonged to which resident.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse when a nursing assistant (NA) was observed kissing the resident on the lips on more than one occasion. The resident, identified as having dementia and a Brief Interview for Mental Status (BIMS) score of 0/15 indicating severely impaired cognition, had been admitted in March 2026. On one occasion, a Certified Medication Technician (CMT) reported that while she was assisting the resident with breakfast, the NA entered the room, verbally expressed affection for the resident, made a kissing noise, leaned forward, and kissed the resident on the lips. This incident made the CMT uncomfortable, and she later discussed it with another NA. A separate staff member, another NA, reported that two days earlier she had observed the same NA enter the resident’s room while morning care was being provided, ask the resident if they remembered her, state that she loved the resident, then lean toward the resident, make a kissing sound, and kiss the resident on the mouth with full lip-to-lip contact. This second NA did not report the incident at the time because she was fearful of the NA involved and only came forward after learning of the later incident. The facility’s abuse, neglect, and exploitation policy defined sexual abuse as a non-consensual sexual act of any type with a resident and required protections for each resident’s health, welfare, and rights, as well as screening of potential employees for a history of abuse. Despite this policy, the resident with severely impaired cognition was subjected to repeated non-consensual kissing by the NA.
Failure to Investigate Allegations of Resident-to-Resident Sexual Inappropriateness
Penalty
Summary
The facility failed to ensure that allegations made by residents were recognized as possible abuse by staff and that all allegations were investigated for Resident ID #41, who was admitted with diagnoses including dementia and traumatic brain injury. A facility policy titled, Abuse, Neglect and Exploitation, stated that an immediate investigation is warranted when suspicion of abuse, neglect, exploitation, or reports of abuse, neglect, or exploitation occur. A progress note written by an RN documented that a resident reported Resident ID #41 was being inappropriate with another resident. Subsequent records included psychiatric evaluations stating the resident was being seen due to increased sexually inappropriate behaviors toward other residents and that sexual impulses may present an unsafe environment for other patients in the facility. Staff interviews revealed that Resident ID #41 had been observed touching other residents' shoulders and hands and required frequent redirection. The RN who documented the incident stated the behavior involved an attempted hug without contact and that both residents were separated and assessed, while the ADON and DON acknowledged they were unaware of the behavior or that the facility had not investigated the allegations. The Administrator also acknowledged that an investigation had not been completed to determine what sexually inappropriate behavior had occurred and that staff did not identify the allegation as possible abuse or investigate it immediately.
Failure to Follow Orders, Report Abuse, and Perform Ordered Wound Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for a resident with dementia and anxiety disorder who had a hearing deficit and complained of right ear wax buildup. The medical record showed an order for Debrox ear drops and a separate order to flush the right ear with warm water two times a day following Debrox usage for 5 days, but the record did not include a physician order for the Debrox solution. The April 2026 MAR showed the resident’s right ear was flushed six times, and the resident stated that the right ear still felt blocked. The RN acknowledged flushing the ear and was unaware whether Debrox had been given, while the DON stated the order had been entered incorrectly and that the ear should not have been flushed before Debrox administration. The NP stated the intended order was for Debrox twice daily for five days before irrigation and that she would not have ordered daily ear flushing. The facility also failed to report an allegation of abuse and failed to update the care plan for a resident with dementia after staff reported inappropriate interactions with a nursing assistant. A community complaint and police incident report indicated the family wanted to press charges, and the Administrator and DON confirmed that staff had reported witnessing the nursing assistant kiss the resident on two occasions. The record did not show that the allegation was reported to the provider, and the comprehensive care plan was not updated to reflect the allegation or any interventions related to the incident. The NP stated she was unaware of the incident and would have expected to be notified, and the ADNS acknowledged that the provider had not been notified and the care plan had not been updated. The facility further failed to follow a wound care order for a resident readmitted with peripheral vascular disease and cellulitis of the lower limb. The physician ordered cleansing open areas on the left lower leg with Vashe wound wash, applying xeroform to the wound bed, and wrapping with kling. During observation, the RN performing wound care did not use Vashe wash and instead cleansed the wound with normal saline. The RN acknowledged using normal saline rather than the ordered cleanser, and the DON stated she would expect the nurse to follow the wound orders as written.
Delayed Pain Medication for Resident with Migraine
Penalty
Summary
Safe, appropriate pain management was not provided for Resident ID #17, who was admitted with diagnoses including migraines and chronic pain. The resident’s care plan dated 4/20/2026 included a goal for the resident to verbalize adequate pain relief and an intervention to respond immediately to any complaint of pain. The physician ordered Butalbital-APAP-Caffeine 50-300-40 mg, 1 capsule every 12 hours as needed for migraine pain. On 4/29/2026 at 10:30 AM, the resident was observed in the hallway complaining of a migraine, moaning in pain, and holding his/her head. At 10:34 AM, an NA reported to an LPN that the resident wanted pain medication, and at 10:37 AM the resident continued to complain of migraine pain and told an RN about the pain, but the RN stated she did not have keys to the medication cart and could not get any pain medication. The resident continued to complain of severe head pain, returned to the room to lie down at 10:40 AM, and the LPN was still off the unit at 10:42 AM. The resident was not assessed when the LPN returned, and the medication was not administered until 11:10 AM, 40 minutes after the initial complaint. The resident later reported pain rated 7 out of 10, and the DON acknowledged that a resident should not wait 40 minutes for pain medication.
Missed Antibiotic Doses Not Reported to Provider
Penalty
Summary
The facility failed to ensure that Resident ID #17 was free from significant medication errors when the resident missed 6 doses of a prescribed antibiotic. The resident was admitted in April 2026 with diagnoses including surgical aftercare and complication of surgical and medical care, and had a physician order dated 4/3/2026 for Cefadroxil 500 mg by mouth twice daily for 14 days. Review of the April 2026 MAR showed missed doses on 4/3 at 8:00 PM, 4/6 at 8:00 PM, 4/11 at 8:00 PM, 4/12 at 8:00 AM, 4/14 at 8:00 PM, and 4/17 at 8:00 AM. The record did not show that the provider was notified of the missed antibiotic doses. During interview, the RN acknowledged the 6 missed doses and stated they should have been reported to the provider. The Medical Director stated she was unaware of the missed doses and said she would have extended the antibiotic course if she had known. The DON also acknowledged the missed doses and stated she would expect the provider to be informed if a resident misses any dose of an antibiotic.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
