Stillwater Assisted Living And Skilled Nursing Com
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenville, Rhode Island.
- Location
- 20 Austin Avenue, Greenville, Rhode Island 02828
- CMS Provider Number
- 415123
- Inspections on file
- 24
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Stillwater Assisted Living And Skilled Nursing Com during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow physician orders for lab monitoring for two residents. One resident with a history of acute pulmonary edema had an order for periodic BNP testing, but the scheduled BNP was not completed as documented on the MAR or elsewhere in the record, despite the resident reporting ongoing leg swelling. Another resident with hypertension had a physician order for a repeat BMP in one week, but there was no evidence in the record that this lab was obtained as ordered. These omissions show that physician-directed lab tests were not carried out as required.
The facility failed to maintain proper food safety standards, with food items stored at incorrect temperatures and lacking a certified Food Safety Manager during meal preparations. Observations revealed food items like salads and sandwiches were not kept at the required cold holding temperatures, and a cook without the necessary certification was responsible for evening meals.
The facility breached residents' privacy by posting a resident's name and weight visibly at their room entrance and failing to close a privacy curtain during a wound dressing change for another resident. The incidents were confirmed by staff interviews and surveyor observations.
A facility failed to conduct necessary laboratory tests for a resident on Atorvastatin, despite a physician's order and pharmacist's recommendation for a lipid panel and hepatic function panel. The DON could not provide evidence that these tests were performed.
A resident readmitted with surgical wounds did not receive proper wound assessment or treatment upon re-admission. The facility's initial skin assessment lacked detailed wound descriptions, and no treatment orders were in place until two days later. Staff interviews confirmed the oversight in wound assessment and treatment inquiry.
A facility failed to follow professional standards for administering IV antibiotics via a PICC line for a resident with MRSA. The resident, receiving Vancomycin, did not have a physician's order for the required 10 ml saline flush before and after medication administration, as per facility policy. Both a nurse and the facility's pharmacist confirmed the absence of this order, highlighting a deficiency in adhering to established protocols.
The facility failed to ensure nursing staff had the necessary competencies to manage a PICC line for a resident with sepsis due to MRSA. Discrepancies in catheter length measurements were noted, with staff unable to accurately measure or explain the process. The Nursing Staff Educator expected staff to use the lines on the catheter for measurement, indicating a lack of competency in PICC line management.
The facility was found to have several deficiencies related to food storage and sanitation in the main kitchen and two kitchenettes. Issues included unlabeled and undated food items in the walk-in freezer, expired food in refrigerators, and improper labeling of food from external sources. Additionally, food-contact surfaces of equipment had encrusted grease and soil accumulations, and equipment such as a microwave contained dried food particles and debris. The facility also did not comply with the Rhode Island Food Code regarding the air gap requirement for the ice machine, posing potential food safety risks. These observations, along with record reviews and staff interviews, indicated systemic issues in maintaining professional standards for food service safety.
A resident with type 2 diabetes mellitus did not receive their prescribed insulin on multiple occasions, and there was no evidence of an order to hold the insulin or notification to the provider. Interviews confirmed the facility's failure to follow professional standards of practice.
A resident with pressure ulcers did not receive necessary treatment as per physician's orders. The resident had an unstageable pressure ulcer on the left posterior calf, which required daily dressing changes. However, the dressing changes were incorrectly scheduled for Monday, Wednesday, and Friday, leading to 9 missed dressing changes. The error was acknowledged by the Infection Preventionist and the Regional Infection Preventionist.
A resident with a history of traumatic subdural hemorrhage and Down syndrome experienced multiple falls due to the facility's failure to use a prescribed gait belt for transfers and ambulation. Despite clear instructions from the Rehabilitation Department, staff did not utilize the gait belt, leading to repeated falls and injuries.
A facility failed to provide appropriate care for a resident with a suprapubic catheter. The resident's drainage bag was repeatedly observed hung above the level of their bladder, contrary to facility policy. Staff acknowledged the improper positioning during interviews.
The facility failed to establish an IPCP that includes an antibiotic stewardship program with protocols and monitoring systems. Two residents were prescribed antibiotics without evidence of urine culture and sensitivity tests to confirm appropriateness. Interviews revealed a lack of processes for reviewing or obtaining necessary diagnostic tests.
Failure to Follow Physician Orders for Laboratory Testing for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received treatment and care in accordance with professional standards of practice by not following physician orders for laboratory testing. For one resident with a history of acute pulmonary edema and intact cognition, the physician ordered a Brain Natriuretic Peptide (BNP) test to be obtained every second Monday in February and August. The February Medication Administration Record showed the BNP was scheduled but not signed off as completed on the specified date, and further record review did not show evidence that the BNP was obtained as ordered. During an interview, the resident reported being given a fluid pill for leg swelling that had not helped, and the Assistant Director of Nursing Services acknowledged that the ordered BNP test was not completed. For a second resident admitted with hypertension, the physician documented a new order in a progress note for a repeat Basic Metabolic Panel (BMP) to be obtained in one week. Record review failed to show that this repeat BMP was completed within the ordered timeframe. In an interview, the Assistant Director of Nursing Services was unable to provide evidence that the repeat BMP had been obtained as ordered. These missed laboratory tests, despite clear physician orders, constitute the failure to provide care and services in accordance with professional standards of quality.
Food Safety and Certification Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by surveyor observations and staff interviews. During a lunch meal tray service, it was observed that certain food items, such as bean salad and turkey salad sandwiches, were not maintained at the required cold holding temperature of 41°F or below. Further inspection of the walk-in refrigerator revealed additional food items, including turkey salad and egg salad, also stored at temperatures above the required limit. The Food Service Director (FSD) and the cook acknowledged these discrepancies and discarded the improperly stored food items. A follow-up visit revealed a similar issue with chicken salad, which was also stored at an inappropriate temperature. Additionally, the facility did not ensure the presence of a certified food protection manager during all meal preparation times. The surveyor found that a cook responsible for preparing and serving evening meals did not possess the necessary Food Safety Manager certification. The kitchen staff schedule confirmed that this uncertified cook was the only one working during several evening meal services. The FSD was unable to provide evidence of a certified Food Safety Manager being present during these times, as required by the Rhode Island Food Code.
Privacy Breaches in Resident Care
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical information, as evidenced by two separate incidents. In the first incident, a resident's name and weight were visibly posted at the entrance of their room, which was accessible to anyone passing by in the hallway. This was observed by surveyors on multiple occasions, and the Assistant Director of Nursing Services confirmed the visibility of the information during an interview. In the second incident, a registered nurse did not ensure privacy during a wound dressing change for a resident with a stage 3 pressure ulcer on the left heel. The nurse failed to close the privacy curtain between the resident and their roommate, leaving the resident exposed during the medical procedure. The Director of Nursing Services later stated that staff are expected to provide privacy for residents, indicating a lapse in adherence to the facility's privacy policy.
Failure to Monitor Atorvastatin Therapy with Required Lab Tests
Penalty
Summary
The facility failed to ensure that a resident receiving Atorvastatin, a medication prescribed to treat high cholesterol, received appropriate monitoring through laboratory tests as per professional standards of practice. A pharmacist recommended an annual lipid panel and hepatic function panel to monitor the therapeutic effects and potential side effects of Atorvastatin. The provider agreed to this recommendation, and a physician's order was issued to obtain these laboratory tests. However, a review of the records revealed no evidence that the lipid panel and hepatic function panel were conducted as ordered. During an interview, the Director of Nursing Services was unable to provide documentation that these tests were obtained.
Failure to Assess and Treat Resident's Surgical Wounds
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, who was readmitted to the facility with a history of a right ankle fracture and surgical wounds, did not have their wounds assessed or described in detail upon re-admission. The facility's Admission Skin assessment, completed by a registered nurse, did not include an assessment or description of the surgical wounds, and the admission nursing progress note failed to document any wound assessment or treatment implementation. Additionally, there was no evidence of a treatment order for the resident's right lower extremity wounds from the time of admission until two days later. The Director of Nursing Services later documented the presence of multiple wounds on the resident's right lower extremity and a pressure wound on the right heel. During interviews, staff acknowledged the failure to assess the wounds upon re-admission and the lack of inquiry about treatment orders, which contributed to the deficiency.
Failure to Follow PICC Line Protocol for IV Antibiotic Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice in the administration of intravenous (IV) fluids for a resident receiving antibiotics via a peripherally inserted central catheter (PICC) line. The resident, admitted in March 2025 with a diagnosis of sepsis due to methicillin-resistant Staphylococcus aureus (MRSA), had a PICC line placed on March 6, 2025, and was receiving Vancomycin intravenously every 12 hours. However, the facility did not have a physician's order for a 10 ml saline flush before and after administering the Vancomycin, as required by the facility's pharmacy policy. During interviews, both a registered nurse and the facility's contracted pharmacist confirmed the absence of the necessary saline flush order. The pharmacist further indicated that a 10 ml saline flush should be administered before and after medication administration via the PICC line, as well as an additional flush on shifts when the antibiotic is not administered. This oversight in following the established protocol for PICC line maintenance and medication administration led to the identified deficiency.
Inadequate PICC Line Management by Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to manage a peripherally inserted central catheter (PICC) for a resident diagnosed with sepsis due to methicillin-resistant Staphylococcus aureus (MRSA). The resident was admitted with a PICC line, and discrepancies in the external catheter length measurements were noted. Initially, the external catheter length was recorded as 0 cm, but a subsequent measurement by RN Staff D during a dressing change showed an 8 cm length. Staff D later acknowledged an error in his initial measurement and admitted to not reviewing previous measurements before documenting the new one. Further interviews with other nursing staff, including RN Staff C and RN Staff A, revealed that they were unable to accurately explain how to measure the external catheter length of a PICC line. The Nursing Staff Educator, Staff E, indicated that the external portion of a PICC line has small lines for measurement, which staff are expected to use. This deficiency highlights a lack of competency among the nursing staff in managing PICC lines, which is critical for ensuring resident safety.
Food Storage and Sanitation Deficiencies Identified in Main Kitchen and Kitchenettes
Penalty
Summary
The facility failed to ensure that food was stored and distributed in accordance with professional standards for food service safety in the main kitchen and two kitchenettes observed. The deficiencies included unlabeled and undated food items in the walk-in freezer, expired food items in refrigerators, and improper labeling of food brought from external sources. Additionally, food-contact surfaces of equipment were found to have encrusted grease deposits and other soil accumulations, indicating a lack of proper cleaning and maintenance practices. The report also highlighted issues with the cleanliness of equipment, such as a microwave with dried food particles and debris. Furthermore, the facility was found to be non-compliant with the Rhode Island Food Code regarding the air gap requirement for the ice machine in the main kitchen. The absence of an adequate air gap and the overflowing drain posed potential risks to food safety and sanitation. The observations made during the survey, along with record reviews and staff interviews, revealed a pattern of deficiencies in food storage, labeling, cleanliness, and equipment maintenance across the main kitchen and kitchenettes, indicating a systemic failure in ensuring compliance with professional standards for food service safety.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Resident ID #65, who was admitted with diagnoses including type 2 diabetes mellitus and a urinary tract infection, had a care plan indicating an increased risk for hypo/hyperglycemia with an intervention to administer medication as ordered. However, the Medication Administration Report revealed that the resident's insulin was not administered on four specific dates between March and April 2024, without any evidence of an order to hold the insulin or notification to the provider. Interviews with the Nurse Practitioner and the Assistant Director of Nursing Services confirmed that the facility did not notify the provider or administer the insulin as per the physician's order.
Failure to Provide Necessary Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice. The resident, who was readmitted in February 2024 with diagnoses including pressure-induced deep tissue damage and a Methicillin Resistant Staphylococcus Aureus infection, had a physician's order dated 3/26/2024 for daily dressing changes on an unstageable pressure ulcer on the left posterior calf. However, the Medication Administration Records for March and April 2024 indicated that the dressing changes were scheduled for Monday, Wednesday, and Friday instead of daily, resulting in 9 missed dressing changes. During an interview on 4/10/2024, the Infection Preventionist and the Regional Infection Preventionist acknowledged that the wound order was transcribed incorrectly.
Failure to Use Assistive Devices for Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident received appropriate assistive devices to prevent accidents. The resident, who was admitted with diagnoses including traumatic subdural hemorrhage and Down syndrome, experienced multiple falls. These incidents occurred on various dates, including falls on 2/4/2024, 2/24/2024, 3/17/2024, and 3/23/2024. The resident's care plan included an order for safe patient handling, which required the use of a gait belt for transfers and ambulation. However, surveyor observations on 4/9/2024 revealed that staff did not use a gait belt during ambulation and transfers with the resident, despite this requirement being communicated in multiple ways by the Rehabilitation Department. Interviews with the Director of Rehabilitation and a Physical Therapist confirmed that the expectation was for staff to use a gait belt for all transfers and ambulation when assisting the resident. The Physical Therapist was unable to explain why the staff did not utilize the gait belt during the observed instances. This failure to use the prescribed assistive device contributed to the resident's repeated falls and subsequent injuries, including a readmission to the hospital for an acute subdural hematoma.
Improper Positioning of Suprapubic Catheter Drainage Bag
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a suprapubic catheter. The resident, admitted in February 2024 with diagnoses including obstructive and reflux uropathy and chronic kidney disease stage 3, was observed multiple times on 4/10/2024 with their drainage bag hung on the back of their wheelchair near their shoulders, above the level of their bladder. This was contrary to the facility's policy, which states that the drainage bag should be kept below the resident's waist/bladder. During interviews, both a registered nurse and the infection preventionists acknowledged that the drainage bag was improperly positioned and should be moved below the resident's waist/bladder.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an Infection Prevention and Control Program (IPCP) that includes an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. This deficiency was identified for two residents. Resident ID #124 was admitted with diagnoses including a urinary tract infection and vascular dementia. The resident was prescribed Macrobid, but there was no evidence of a urine culture and sensitivity test to determine if the antibiotic was appropriate. Similarly, Resident ID #129 was admitted with diagnoses including a urinary tract infection and cough and was prescribed cefuroxime axetil. Again, there was no evidence of a urine culture and sensitivity test to confirm the appropriateness of the antibiotic. Interviews with the Nurse Practitioner and Infection Preventionist revealed that the facility lacked a process for reviewing or obtaining laboratory or diagnostic testing to determine if the prescribed antibiotics were still indicated or if adjustments were needed. The Nurse Practitioner stated that staff should call the hospital for results or repeat cultures in-house if no sensitivities are available. The Infection Preventionist was unable to provide evidence of such a process, highlighting a gap in the facility's antibiotic stewardship program.
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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