Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Coventry Operations Ri Llc Dba Respiratory And Reh during CMS and state inspections, most recent first.
The facility failed to complete and document a comprehensive facility-wide assessment for resident care needs during routine operations and emergencies. The 2025 Facility Assessment was signed by former leadership, referenced a missing Staffing and Personnel Worksheet, listed prior admin and DON staff, and contained multiple sections stating no records were found. The facility also could not provide evidence of a plan to maximize recruitment and retention of direct care staff, and the DON acknowledged the assessment did not accurately reflect staffing patterns.
Failure to Protect Resident from Physical Abuse: A resident with dementia and behavioral disturbances pursued another resident, cornered the resident against a door, and held a butter knife to the resident’s neck. Staff separated the residents, and law enforcement was contacted after the resident refused to hand over the knife. The victimized resident had moderately impaired cognition and a history of verbal outbursts, and the DON could not provide evidence that the resident was kept free from physical abuse.
Respiratory Care and Ventilator Order Failures: A ventilator-dependent resident with chronic respiratory failure was transferred for chest pain on a non-rebreather mask instead of with the portable ventilator or BVM, and became unresponsive and died in transit. Staff also failed to verify that a physician’s order and prescribed settings were in place for the resident’s VOCSN ventilator, and another resident was observed on the ventilator without the ordered oxygen setting.
Inaccurate Ventilator Documentation: A resident with Duchenne muscular dystrophy, chronic respiratory failure, and ventilator dependence had records that did not match actual NIV use. The chart showed the nighttime LTV was discontinued and VOCSN was started, but the TAR continued to document the LTV with ordered settings on multiple later dates. The PA said staff should document accurately, and the DON could not provide evidence that the medical record was accurate.
A resident with dementia, COPD, GERD, history of venous thrombosis, and anxiety disorder was discharged home with home care services, but the facility failed to complete the Continuity of Care Discharge/Transfer form. Although a PA documented the need for follow-up with multiple specialists, this information was not included on the discharge form, which also lacked the discharging facility contact, post-discharge physician information, home care agency phone number, "call physician if" instructions, and follow-up appointments. An LPN and social worker involved in the discharge, as well as the PA, acknowledged the form was incomplete, and the DON could not provide evidence that adequate preparation and orientation for a safe, orderly discharge had been documented.
A resident with dementia, muscle weakness, and gait instability who required partial to moderate assistance with bathing was scheduled for weekly showers on an evening shift but had no documented showers on two scheduled dates, with only one shower recorded on the day of discharge. A community complaint reported the resident had noticeably greasy hair and that nursing staff could not identify the last shower date. Record review showed no documentation that showers were offered or refused on the missed dates, and the DON was unable to provide evidence that the resident received a shower before discharge, despite expecting refusals to be documented.
Failure to Prepare Ordered Thickened Liquids Correctly: A resident with dysphagia and a nectar-thick liquid order was observed drinking a thin liquid from a large styrofoam cup, and the LPN confirmed it was not thickened. Staff were unaware of the nectar order or how to prepare it, and the unit cups in use were 16 fl. oz. instead of the 12 fl. oz. size shown on the staff guide, causing the thickening instructions to be applied incorrectly.
The facility failed to complete annual performance reviews for 5 of 5 NAs whose personnel records were reviewed. Record review did not show evidence of required yearly evaluations for multiple NAs, and the DON was unable to provide documentation that the reviews had been completed within the last 12 months.
Failure to act on consultant pharmacist MRR recommendations affected 4 residents. The LTC record showed outstanding recommendations for monitoring high-risk meds, obtaining lab work for statin therapy and other meds, and reviewing a psychotropic order, but provider review and action were delayed until the surveyor brought the issues to the facility’s attention. The DON and other providers acknowledged they had not been aware of the recommendations within the required timeframe.
A resident with hypotension had an order for Midodrine 2.5 mg TID with instructions to hold if SBP was greater than 110. Review of the MAR showed the medication was given multiple times when SBP was above the hold parameter, and an LPN acknowledged the doses were administered when they should not have been; the PA and DON stated they would expect the medication to be held when SBP exceeded 110.
Improper Medication Storage and Labeling: Expired acetaminophen suppositories were found in a med storage room, and multiple med carts contained insulin beyond the open-date timeframe, an unlabeled Solu-Medrol vial, Lorazepam Intensol stored outside refrigeration, an undated Lantus insulin pen, and several discontinued pain and anxiety meds left on the cart. Staff and the DON acknowledged the storage, dating, labeling, and removal issues during observation.
Kitchenette Food Storage and Sanitation Deficiencies: Surveyors found dirty microwaves and multiple expired, undated, or improperly stored food items in several kitchenette refrigerators. An LPN, dietary staff, and the assistant kitchen manager acknowledged the microwaves needed cleaning and the food items were beyond use-by dates, lacked proper dating, or had been stored too long.
Incomplete observation, splint, and G-tube documentation was found for three residents. A resident on 15-minute checks after an altercation had multiple gaps in the observation record, an LPN signed off that another resident’s hand splints were completed even though the splints were not on the resident and were found in a drawer, and a resident with a G-tube had inconsistent flush documentation on the MAR/TAR despite a physician order for 30 mL before and after each feeding.
Infection Control Precautions Not Followed: Staff did not consistently follow EBP and contact/droplet precautions for multiple residents. An RN flushed a resident’s G-tube without the required gown under EBP, and staff caring for residents on RSV precautions entered rooms without the PPE listed on signage, including missing face shields, gowns, and gloves. One resident’s doorway signage was also inaccurate, and the DON could not provide evidence that the infection control practices were maintained.
Missing Required Annual Staff Training: The facility failed to maintain an effective annual education program consistent with its facility assessment. Record review showed that 10 of 11 employees, including LPNs, NAs, MAs, and a respiratory therapist, lacked evidence of completing multiple required trainings such as resident rights, HIPAA, corporate compliance, safe resident handling, emergency preparedness, skin integrity, pain management, dementia, mental health, food safety, nutrition/hydration/dysphagia, communication, culturally competent care, trauma-informed care, and ethics. The Administrator stated he expected all trainings listed in the facility assessment to be completed but could not provide proof of completion.
Inconsistent code status documentation left a resident’s advance directive unclear. A resident with ESRD and dialysis dependence had the EMR banner and a physician order showing DNR/CMO, while the most recent signed MOLST showed CPR/Full Code. The PA confirmed the resident had changed his/her mind about code status, and an LPN stated she would initially rely on the EMR in an emergency, which would have indicated DNR.
A resident with anoxic brain damage and persistent vegetative state developed a new Stage 1 pressure injury to the dorsum of the R foot. Although the care plan and MD orders directed staff to float/offload the heels and feet with pillows at all times, surveyors observed the resident's heels and feet resting directly on the mattress, and the UM acknowledged the order was not being followed.
Failure to Apply Ordered Hand Splints: A resident with anoxic brain damage, persistent vegetative state, impaired ROM, and bilateral hand contractures was ordered to have bilateral hand splints applied after morning care. Surveyors observed the resident without the splints on multiple occasions, with the splints stored in the nightstand drawer, while the TAR was signed as completed. An LPN acknowledged the resident was not wearing the splints and that the treatment had been documented as done.
The facility failed to provide written quarterly accountings of deposits, withdrawals, and balances for 6 residents whose funds were held by the nursing home. Record review did not show evidence of the required statements, and both the RB Office Assistant and the Administrator were unable to produce proof that the quarterly accountings had been provided within the last four quarters.
The facility failed to provide written notice to two residents when their personal needs fund balances reached $200 below the SSI resource limit. A review of the trial balance showed both residents had account balances above the Medicaid eligibility guideline, and the RBO assistant could not provide evidence that the required notices had been issued.
Failure to Provide Requested Medical Records to Resident Representative: A resident’s legal representative requested copies of the resident’s records electronically, but the facility did not provide evidence that the records were sent to the representative or the representative’s lawyer. The MRM said the records were emailed to the facility’s lawyer, while the representative reported multiple calls and emails over several months without receiving the records. The Administrator could not show that the request was fulfilled with the required advance notice.
A resident with a gastrostomy tube did not receive flushes as ordered by the physician, with documentation and staff interviews confirming that prescribed amounts of water were not administered during medication passes and continuous tube feedings. An LPN reported using less water than ordered, and the physician acknowledged the orders were not followed.
A resident with a tracheostomy and full code status was found unresponsive and pulseless. Staff transferred the resident to a bed and initiated CPR without using a backboard, and rescue breaths via Ambu bag were inconsistently provided, with one staff member delivering fewer than the required breaths per minute and later delegating the task. Emergency personnel arrived to find only chest compressions being performed, and the resident was later pronounced dead at the hospital. The facility could not demonstrate that CPR was performed according to basic life support protocols.
A resident with multiple chronic conditions was given Metolazone 5 mg three times daily instead of the prescribed three times a week due to a transcription error by a nurse. This resulted in the resident receiving excessive doses, leading to fatigue, hypotension, and an unwitnessed fall with severe injuries. The error was confirmed by staff interviews and documentation review, and the facility could not demonstrate compliance with medication administration policies.
Nursing staff failed to demonstrate appropriate competencies in medication management and emergency response, resulting in a significant medication error for a resident and inadequate CPR for another. One resident received an incorrect dosage of Metolazone due to multiple missed verification checks, and staff did not complete required assessments after the error was discovered. Another resident did not receive proper CPR or airway management after being found unresponsive, with staff failing to follow basic life support protocols. Both residents subsequently died.
A resident with hemiplegia, ventilator dependence, and total care needs sustained fractures to the left distal tibia and fibula after a nursing assistant provided incontinence care alone, contrary to the care plan requiring two staff for assistance. The resident rolled out of bed and fell, and the facility could not provide evidence that the care plan was followed.
A resident who was quadriplegic and ventilator-dependent sustained a nasal fracture after an unwitnessed fall from bed when only three NAs were present on the unit, despite facility guidelines requiring more staff. Staff reported being unable to provide adequate supervision due to insufficient staffing, and management was aware of the shortfall but did not adjust assignments or follow their own staffing guidelines.
The facility did not complete or update its facility-wide assessment, resulting in missing documentation and outdated leadership information. A resident experienced two falls and did not receive appropriate care, and concerns were raised about insufficient and unqualified staff. The assessment lacked required supporting records and a current staffing worksheet.
A resident with multiple complex medical conditions sustained a lower leg fracture after a fall and was ordered to have an outpatient orthopedic follow-up. Despite clear documentation and instructions, the facility failed to ensure the resident received the required orthopedic appointment after an initial scheduling attempt was cancelled, resulting in noncompliance with physician orders.
A resident with heart failure, pulmonary hypertension, and chronic kidney disease was readmitted after a hospital stay, and a medication order for Metolazone was incorrectly transcribed by a nurse as three times daily instead of three times a week. The physician reviewed the record but did not identify the error, and the medication reconciliation process was not completed as expected, resulting in the resident receiving the medication in error.
A resident with heart failure, pulmonary hypertension, and chronic kidney disease received Metolazone at a much higher frequency than prescribed due to a transcription error by a nurse, resulting in seven doses being administered over three days instead of the intended two doses. The error was discovered after the resident experienced a fall and was transferred to a hospital, where the resident later passed away. The DON confirmed the medication order was entered incorrectly.
A resident with severe cognitive impairment was mistakenly given another resident's antipsychotic medications by an RN, who failed to properly identify the patient. The error was not communicated to other staff or the resident's family, and the resident was allowed to leave on LOA without monitoring. The assigned LPN did not assess the resident or realize the resident had left, and the provider was not notified until hours later. The resident became unresponsive and required emergency hospitalization and ventilation due to adverse effects from the medication error.
A resident with dementia and multiple comorbidities was mistakenly given another resident's psychiatric medications, including Clozapine and Geodon, by a nurse who failed to properly identify the patient. The error was discovered after the resident became unresponsive while on leave with family, requiring emergency transport, ventilation, and hospitalization for toxic metabolic encephalopathy. The facility did not immediately inform the family or hospital of the medication error, and there was no physician order for the administered drugs.
A resident with multiple health conditions was mistakenly given another resident's antipsychotic medications by an RN. The error was discovered by an LPN, but neither the physician nor the resident's family was promptly notified. The resident's spouse, unaware of the error, took the resident out on LOA, after which the resident became unresponsive and required emergency hospitalization and ventilator support. Staff interviews and record review confirmed the lack of immediate notification.
A resident admitted with multiple pressure ulcers did not receive negative pressure wound therapy as ordered on two occasions, and required wound evaluations were not completed upon admission or weekly as per facility policy. The DON confirmed that documentation and assessments were missing for the specified periods.
The facility failed to provide quarterly financial statements to five residents, as required by regulation. Despite having funds held by the facility, these residents did not receive written accountings of their deposits, withdrawals, and balances. The Business Office Manager and Administrator acknowledged the oversight during interviews.
The facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and the Notice of Medicare Non-Coverage (NOMNC) to residents as required. Two residents did not receive the SNFABN, and two others did not receive the NOMNC in a timely manner, as confirmed by interviews with the Business Office Manager and Administrator.
A resident was inaccurately assessed with a schizophrenia diagnosis in multiple MDS assessments despite lacking supporting documentation. The MDS Coordinator and Physician Assistant could not provide evidence for the diagnosis, and the Administrator acknowledged the error.
A resident with chronic conditions had an active physician's order for daily weights, which were not obtained over several months. Facility staff, including a nurse and dietitian, were unaware of the order, and the DON acknowledged the oversight, indicating a lapse in communication and adherence to medical directives.
A facility failed to act on a pharmacist's recommendations during a Medication Regimen Review for a resident with COPD and pneumonia. Despite repeated recommendations to clarify stop dates for doxycycline and prednisone, the resident continued receiving these medications for an extended period. The DON could not provide evidence of action on these recommendations, and the resident's physician expected the medications to be adjusted as advised.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with MDROs, as observed by surveyors. Staff were seen providing care without wearing gowns, despite signage indicating the need for EBP. This affected residents with conditions like chronic respiratory failure and those with devices such as G-tubes and tracheostomies. Staff interviews revealed confusion and lack of awareness about EBP requirements.
The facility failed to implement an effective antibiotic stewardship program, resulting in two residents receiving antibiotics without proper review or time-out. A resident with severe sepsis was prescribed antibiotics without an end date, and another with pneumonia received doxycycline for an extended period due to lack of communication and review. Interviews with staff confirmed the absence of a systematic approach to antibiotic monitoring.
A resident with dementia was administered Rexulti without the appointed representative's informed consent. The facility's records lacked documentation of communication regarding the medication's risks, benefits, or alternatives, despite policy requirements. The DON acknowledged the expectation for nurses to inform representatives about treatment changes.
A resident with significant ADL needs was neglected in a LTC facility. Despite requiring assistance with grooming, bathing, dressing, and toileting, the resident reported inadequate care from nursing assistants, leading to a delay in incontinence care. Miscommunication among staff and lack of awareness of assignments contributed to the neglect, as the resident did not receive necessary personal hygiene assistance during the observed shift.
A facility failed to communicate critical changes in a resident's condition to the dialysis center, as required by policy. The resident, with ESRD, experienced a GI bleed and a fall, necessitating a change in transfer status. Staff interviews revealed a lack of awareness about the communication policy, resulting in the dialysis center not being informed of these significant events.
A resident was administered unnecessary medications for an extended period due to the facility's failure to follow discharge orders. Despite recommendations from the Pharmacist to clarify stop dates, the resident continued to receive doxycycline and prednisone beyond their intended duration. Interviews revealed a lack of awareness and oversight by the facility's staff.
The facility failed to document all required components of the facility-wide assessment and did not update it when necessary. The 2025 assessment lacked involvement from key participants, with most listed contributors no longer employed. There was no evidence of input from residents or their representatives. The Administrator could not provide evidence of compliance during an interview.
The facility failed to effectively implement its QAPI program, particularly in infection control and antibiotic stewardship. Staff did not adhere to PPE protocols during high-contact care, and there was no evidence of antibiotic time outs for residents. The DON and Administrator could not demonstrate efforts to address these issues.
A resident with dementia and mobility issues experienced multiple falls, but the facility failed to revise the care plan after a fall in February. Despite adding an intervention for frequent checks, there was no evidence of its implementation, leading to another fall in March. Staff interviews confirmed the oversight.
The facility failed to prevent elopement for three residents identified as at risk. A resident with dementia eloped and was found at a convenience store, with no evidence of interventions or care plan updates. Another resident left unsupervised, despite an evaluation highlighting route dangers, and staff were unaware of the risk. A third resident, with severe cognitive impairment, lacked appropriate interventions, and staff were uninformed of the risk. The facility also failed to conduct required elopement drills.
Facility Assessment Not Updated to Reflect Staffing Needs
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine what resources were necessary to care for residents competently during day-to-day operations, including nights and weekends, and during emergencies. Review of a community-reported complaint alleged a severe and persistent staffing shortage at the facility. Review of the 2025 Facility Assessment showed it was signed by the former administrator and former DNS on 3/30/2026, and it referenced a Staffing and Personnel Worksheet that was not found in the attachments. Multiple supporting document sections stated, "No records were found." The assessment also listed previous employees as the administrator and DNS rather than the current administrator and DNS. The facility also failed to provide evidence of a plan to maximize recruitment and retention of direct care staff. During interview, the DNS acknowledged that the Facility Assessment did not accurately reflect the staffing patterns of the facility and could not provide evidence of a recruitment and retention plan for direct care staff.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure that Resident ID #2 remained free from physical abuse when Resident ID #1 physically assaulted the resident by pushing him/her against a door and holding a butter knife to his/her neck. The incident was reported to the Rhode Island Department of Health, and staff immediately separated the two residents. There were no injuries to either resident, and Resident ID #1 refused to hand the butter knife to staff but later gave it to a police officer. Resident ID #1 was then sent to the hospital for further evaluation. Resident ID #1 was admitted in September 2025 with diagnoses including dementia with behavioral disturbances, major depressive disorder, anxiety disorder, adjustment disorder, and alcohol dependence. A care plan noted impaired cognition, verbal and physical behaviors, ineffective coping skills, and poor anger management. Resident ID #2 was admitted in February 2015 with diagnoses including dementia with behavioral disturbances, paranoid schizophrenia, personality disorder, major depressive disorder, and anxiety disorder, and had a BIMS score of 8 out of 15 indicating moderately impaired cognition. A progress note documented that a nurse witnessed Resident ID #2 being pushed by another resident in the hall and intervened, and the DNS stated that Resident ID #1 unexpectedly stood up, pursued Resident ID #2, cornered him/her against a door, and held a butter knife near his/her neck, but could not provide evidence that Resident ID #2 was kept free from physical abuse.
Respiratory Care and Ventilator Order Failures
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a ventilator-dependent resident who had diagnoses including Duchenne muscular dystrophy, dependence on respirator status, and chronic respiratory failure. The resident complained of chest pain and requested transfer to the hospital. Staff documented that the resident was on a nighttime BiPAP/VOCSN setup, but when rescue personnel arrived, the resident was placed on a non-rebreather mask for transport rather than being transported with the portable ventilator or supported with a bag valve mask. The resident became unresponsive during transit, stopped breathing, and had no pulse on arrival at the hospital, where the resident was pronounced dead. The facility’s own transport policy stated that ventilated patients requiring external transport must be assessed by RT prior to departure and that required equipment includes a portable ventilator with a charged battery. Staff interviews showed that the VOCSN ventilator was portable and could have accompanied the resident, and multiple staff acknowledged that a non-rebreather mask was not appropriate for a ventilator-dependent resident. The DNS and other clinical staff stated that if the resident was removed from the ventilator, a bag valve mask should have been used. The Administrator was unable to provide evidence that the facility followed its transport policy for the emergency transfer. The facility also failed to ensure that a physician’s order and prescribed settings were in place for the resident’s VOCSN ventilator after the facility discontinued the prior LTV ventilator and began using the VOCSN at night. Record review showed no physician order or settings for the VOCSN ventilator, yet ventilator check assessments continued and documented that the resident was on the VOCSN as ordered. Staff A, C, D, and E completed ventilator checks without identifying the missing order or settings, despite competency validations showing they were expected to verify complete physician orders and prescribed settings. In addition, the resident did not receive prescribed ventilator settings on the LTV ventilator as ordered, and another resident was observed receiving room air instead of the ordered 3 liters of oxygen on the ventilator.
Inaccurate Ventilator Documentation
Penalty
Summary
The facility failed to maintain complete and accurate resident medical records in accordance with accepted professional standards and practices for one resident receiving non-invasive ventilation. The resident was admitted in March 2026 with diagnoses including Duchenne muscular dystrophy, dependence on respirator status, and chronic respiratory failure. The care plan identified that the resident was ventilator dependent, used mouthpiece ventilation during the day, and used nasal pillows at night, with ventilator checks to be completed every six hours and ventilator use per physician order. Record review showed the resident used three ventilators at the facility between 3/2/2026 and 3/14/2026: Astral for daytime use, LTV for nighttime use, and VOCSN for nighttime use. The physician order for the LTV listed settings of VT 1100, RR 14, PEEP 6, FiO2 21%, and PS 8. Although the facility discontinued the LTV and began using the VOCSN at night beginning on 3/4/2026, the March 2026 Treatment Administration Record continued to document that staff were providing the LTV at the prescribed settings on multiple dates after it had been discontinued. During interview, the PA stated he expected staff to document accurately, and the DON was unable to provide evidence that the facility maintained accurate medical records for the resident.
Incomplete Discharge Documentation and Preparation for Home Transition
Penalty
Summary
The deficiency involves the facility’s failure to provide and document sufficient preparation and orientation for a resident’s safe and orderly discharge home. The resident, admitted in March 2026 with dementia, COPD, GERD, history of venous thrombosis, and anxiety disorder, was discharged with home care services on 4/6/2026. On the day of discharge, a progress note by a physician assistant documented that the resident should follow up with a primary physician, neurologist, gastroenterologist, pulmonologist, vascular physician, and psychologist. However, this follow-up information was not carried over to the Continuity of Care Discharge/Transfer of Patient Form provided to and signed by the resident’s representative. Record review showed that multiple critical sections of the discharge/transfer form were left blank, including the discharging facility contact person/phone number, the physician who would follow the patient after discharge (with name, phone number, and whether the physician was notified), the phone number of the home care agency, the “call physician if” section, and follow-up appointments with phone numbers. Interviews with the physician assistant, an LPN who assisted with the discharge, and the social worker involved in arranging home care confirmed that they expected the form to be completed and could not explain why it was not. The DON was unable to provide evidence that the facility had provided and documented adequate preparation and orientation to ensure a safe and orderly discharge for this resident.
Failure to Provide Scheduled Showers and Document Bathing Care
Penalty
Summary
The facility failed to provide necessary services to maintain grooming and personal hygiene for a resident who required assistance with activities of daily living, specifically bathing. A community complaint submitted to the Rhode Island Department of Health alleged that the resident was observed with noticeably greasy hair and that the nurse could not determine when the resident last received a shower, and further alleged that the resident did not receive a shower until after the family complained. The resident had been admitted in March 2026 with diagnoses including dementia, muscle weakness, difficulty walking, and unsteadiness, and a Discharge MDS assessment documented that the resident required partial to moderate assistance with showering or bathing. Facility task documentation showed that the resident was scheduled to receive a shower every Friday on the 3:00 PM–11:00 PM shift. Review of records from 3/26/2026 through 4/6/2026 revealed no documented showers on the scheduled dates, indicating missed showers on 3/27/2026 and 4/3/2026. A single shower was documented on 4/6/2026 at 12:30 PM, the day of discharge. The clinical record contained no evidence that showers were offered or refused on the missed dates. During an interview, the Director of Nursing Services was unable to provide evidence that the resident had received a shower prior to 4/6/2026 and stated that she would expect refusals to be documented in the record if a shower had been offered and declined.
Failure to Prepare Ordered Thickened Liquids Correctly
Penalty
Summary
The facility failed to ensure that fluids were prepared and served in a form that matched residents’ prescribed dietary needs. Resident ID #21, who was admitted with diagnoses including COPD and dysphagia, had a physician’s order for a mechanical soft diet with nectar thick liquids. A Speech Therapy document noted a FEES in October 2025 that showed aspiration of thin liquids, and the resident continued to work with Speech Therapy four times a week. During observation, the resident was seen with a large white styrofoam cup containing a red liquid that appeared thin, and the resident stated, “I knew it was too thin.” The Unit Manager/LPN acknowledged that the liquid provided was thin and not thickened. The facility also had a breakdown in its system for preparing thickened liquids on the units. A laminated staff guide in the kitchenettes showed that the large styrofoam cup was 12 fl. oz. and required 3 nectar packets, and the thickening agent instructions stated to add 1 packet to 4 fl. oz. of liquid. However, the styrofoam cups in use on 4 of 4 units were actually 16 fl. oz., which would require 4 packets to reach nectar consistency. Staff interviews showed that the NA assigned to the resident was unaware of the nectar order and could not explain how to prepare nectar thick liquids, while the Speech Therapist and NA staff confirmed the cup size discrepancy and the amount of thickener needed. The DON acknowledged that staff should prepare drinks according to the ordered consistency and manufacturer instructions and confirmed that the cups on the units were 16 fl. oz., not 12 fl. oz. as shown on the staff guide.
Missing annual performance evaluations for nurse aides
Penalty
Summary
The facility failed to complete annual performance reviews for 5 of 5 nurse aides whose personnel records were reviewed: Staff I, Staff J, Staff K, Staff L, and Staff M. Record review did not reveal evidence that each of these nurse aides had an annual performance evaluation completed at least once every 12 months. The personnel files reviewed included Staff I, hired 3/15/2000; Staff J, hired 11/11/2013; Staff K, hired 1/21/2025; Staff L, hired 3/29/2001; and Staff M, hired 7/11/2024. During an interview on 4/10/2026 at 11:15 AM, the DON was unable to provide evidence of performance evaluations for these employees that had been completed within the last 12 months.
Failure to Act on Consultant Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that irregularities identified by the Consultant Pharmacist during monthly Medication Regimen Reviews were acted upon for 4 of 4 residents reviewed with outstanding pharmacy recommendations. The facility policy dated 1/2024 stated that the nursing care center follows up on recommendations to verify appropriate action has been taken and that recommendations should be acted upon within 30 calendar days. Resident ID #6, admitted with diagnoses including chronic diastolic heart failure, schizophrenia, neuropathy, and coronary artery disease, had pharmacy recommendations from a February 2026 review for monitoring related to furosemide, gabapentin, paliperidone, Rexulti, and aspirin. The record did not show that the monitoring recommendations were implemented, and the provider did not sign in agreement until after the surveyor asked the facility to review the MRR document. The DON was unable to provide evidence that the recommendations had been acted upon within 30 days as required by policy. Resident ID #29 had diagnoses including cerebral infarction and hyperlipidemia and was prescribed atorvastatin. Pharmacy recommendations from January 2026 and again in March 2026 called for baseline and annual LFTs and a lipid panel, but the provider did not review and act on them until April 9, 2026. Resident ID #84, admitted with major depressive disorder and anxiety, had a February 2026 pharmacy recommendation to evaluate the diagnosis, behaviors, and usage pattern for trazodone because the psychotropic order could not exceed 14 days, but there was no evidence the recommendation was reviewed and acted upon until it was brought to the facility’s attention by the surveyor. Resident ID #107, admitted with cerebrovascular disease, hypotension, and vitamin D deficiency, had a February 2026 recommendation for routine BMP, CBC, and vitamin D lab work, and the record did not show provider review and action within 30 days until the surveyor identified it on April 9, 2026.
Improper Administration of Midodrine Outside Ordered Blood Pressure Parameters
Penalty
Summary
The facility failed to ensure that one resident's drug regimen was free from unnecessary drugs for Resident ID #13, who was re-admitted with a diagnosis including hypotension. The resident had a physician order dated 2/17/2026 for Midodrine 2.5 mg three times daily for hypotension, with instructions to hold the medication if systolic blood pressure (SBP) was greater than 110. Review of the March and April 2026 MARs showed Midodrine was administered on multiple occasions when the resident's SBP was above the ordered hold parameter, including readings of 112, 114, 116, 118, 119, 120, and 126. During interview, an LPN acknowledged the medication was given when it should not have been, and both the PA and DON stated they would expect Midodrine to be held when the resident's SBP was greater than 110.
Improper Medication Storage and Labeling
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles in the facility’s medication storage areas and medication carts. During observation of the Third-Floor medication storage room, two packets of acetaminophen suppositories 650 mg were found with expiration dates of 3/2026, and Staff P acknowledged the suppositories were expired. The facility policy stated that medications and biologicals are to be stored properly, that medications requiring refrigeration are to be kept in the refrigerator, that insulin vials and pens are to be dated when first opened, and that outdated or discontinued medications are to be immediately removed from stock. During observation of the One North low-side medication cart, Humalog insulin had an open date but was beyond the manufacturer’s 28-day discard timeframe, Solu-Medrol 125 mg lacked a pharmacy label with a resident identifier, and Lorazepam Intensol was stored in the cart despite a manufacturer label indicating refrigeration. On the One North high-side medication cart, Lorazepam Intensol was also found in the cart with a refrigeration instruction. On the One South medication cart, Insulin Lispro had an open date beyond the 28-day discard timeframe, Lantus insulin pen was opened and not dated, Lorazepam Intensol was stored in the cart instead of the refrigerator, and multiple discontinued medications remained on the cart, including morphine sulfate, tramadol, hydrocodone/acetaminophen, alprazolam, and oxycodone. Staff members and the DON acknowledged the expired, undated, unlabeled, improperly stored, and discontinued medications during the observations and interviews.
Kitchenette Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food service safety standards in 3 of 4 kitchenettes. Surveyors observed dirty microwaves in the One North Unit kitchenette and the One South Unit kitchenette, with dried red/orange matter, splatters, and stains on the ceilings and interior walls. Staff acknowledged both microwaves were dirty and needed cleaning. Surveyors also found multiple expired or improperly stored food items in kitchenette refrigerators. In the One North Unit kitchenette, pudding and applesauce cups were past their use-by dates, and a resident-labeled take-out bag had remained in the refrigerator beyond three days. In the One South Unit kitchenette, a peanut butter and jelly sandwich, chef's salad, and several 2 oz. cups of applesauce and pudding were beyond their use-by dates. In the Two South Unit kitchenette, surveyors found a peanut butter and jelly sandwich past its use-by date, two partially consumed containers of Lactaid whole milk with open dates of 3/16 and 3/3, an opened and undated container of hickory smoked ham salad, and an opened container of rice pudding with a sour smell. Staff acknowledged the expired and improperly labeled items and stated they needed to be discarded or dated when opened.
Incomplete Observation, Splint, and G-tube Documentation
Penalty
Summary
Resident ID #9, who was readmitted in January 2026 with dementia with psychotic disturbance, was involved in a physical altercation with another resident on 4/4/2026 and was placed on 15-minute checks every shift until 4/12/2026. Review of the observation records showed incomplete documentation on multiple dates and times, including gaps on 4/5/2026, 4/6/2026, and 4/8/2026. During interview, the LPN/unit manager acknowledged the missing documentation, stated nursing assistants completed the forms, and said it was the nurse’s responsibility to ensure the checks were completed and documented as ordered; she also acknowledged she had worked during one of the shifts when the checks were not ensured. The DNS stated she expected the 15-minute checks to be completed in their entirety as ordered. Resident ID #52, admitted in March 2021 with anoxic brain damage and persistent vegetative state, had a care plan intervention for bilateral hand splints to be placed in the morning and removed at night as tolerated, with a physician’s order to apply the splints after morning care. The April 2026 TAR showed the splints were signed off as completed, but during observation the resident was not wearing them and they were found in the top drawer; the LPN acknowledged signing the TAR as completed when the resident was not wearing the splints. Resident ID #71, readmitted in December 2024 with anoxic brain damage and a G-tube, had a physician’s order to flush the tube with 30 mL of water before feeding and 30 mL after each feeding. The February, March, and April 2026 MAR/TARs showed the order signed as completed each shift, but the documented fluid totals were inconsistent, including 640 mL, 150 mL, and 60 mL. The LPN stated she documented 60 mL because she calculated 30 mL for each flush and was unclear why other staff documented different amounts; the DNS stated she expected staff to clarify the order and document accurately.
Infection Control Precautions Not Followed
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not consistently following Enhanced Barrier Precautions and contact/droplet precautions for residents with ordered isolation measures. Resident #20, admitted with anoxic brain damage and a gastrostomy tube, had signage at the doorway indicating Enhanced Barrier Precautions and requiring gown and glove use for high-contact care activities, including feeding tube care. During observation, an RN flushed the resident’s G-tube without wearing a gown, and the RN acknowledged she had not worn one. The facility also failed to follow contact/droplet precautions for Resident #87, who was on precautions for RSV and had signage directing staff to wear a face shield upon entry. During medication administration, an RN entered the room without a face shield and acknowledged the omission. Later, an NA entered the same resident’s room wearing only a gown and mask, without a face shield and gloves, then exited wearing the same gown, did not perform hand hygiene, removed gloves from a clean PPE bin outside the room, and reentered without a face shield. Resident #41, who was on contact/droplet precautions for RSV, had signage directing staff to wear an N95 respirator, gown, face shield, and gloves upon entry. An NA was observed in the room wearing only a mask and gloves and not wearing a gown or face shield, and acknowledged the omission. Resident #107, who was also on contact/droplet precautions for RSV, had signage posted that incorrectly stated only Contact Precautions. The Infection Preventionist acknowledged the resident was on contact/droplet precautions and that the signage was inaccurate. The DON was unable to provide evidence that infection control practices were maintained by the staff involved.
Missing Required Annual Staff Training
Penalty
Summary
The facility failed to develop, implement, and maintain an effective annual training program for existing staff members consistent with their expected roles and the education requirements listed in the facility assessment. The facility assessment, dated March 2026, stated that Health Stream was used for increased and mandatory education on annual and quarterly bases, and that staff-specific courses and competencies were maintained in Health Stream. The facility’s annual education plan listed required trainings including resident rights and abuse prevention, HIPAA and confidentiality, corporate compliance and ethics, safe resident handling and transfers, emergency preparedness, skin integrity and pressure injury prevention, pain assessment and management, dementia and behaviors, mental health management, food safety and sanitation, nutrition, hydration, and dysphagia care, effective communication, culturally competent care, trauma informed care, and ethics in health care. Record review showed that 10 of 11 employees reviewed did not have evidence of completion of multiple required annual trainings for 2025 to 2026. Staff T, an LPN hired on 9/9/2024, lacked evidence of completing numerous required trainings including resident rights and abuse prevention, corporate compliance and ethics, safe resident handling and transfers, emergency preparedness, skin integrity and pressure injury prevention, pain assessment and management, dementia and behaviors, mental health management, food safety and sanitation, nutrition, hydration, and dysphagia care, effective communication, culturally competent care, trauma informed care, and ethics in health care. Staff Y, an LPN hired on 5/16/2017, lacked evidence of completing corporate compliance and ethics, mental health management, food safety and sanitation, nutrition, hydration, and dysphagia care, effective communication, culturally competent care, trauma informed care, and ethics in health care. Staff GG, a respiratory therapist hired on 1/20/2022, lacked evidence of completing safe resident handling and transfers, skin integrity and pressure injury prevention, pain assessment and management, dementia and behaviors, food safety and sanitation, nutrition, hydration, and dysphagia care, and culturally competent care. Additional record review showed similar missing training documentation for NA Staff K, NA Staff M, NA Staff I, NA Staff J, NA Staff L, MA Staff HH, and MA Staff II. Missing topics included corporate compliance and ethics, safe resident handling and transfers, emergency preparedness, skin integrity and pressure injury prevention, pain management or pain assessment and management, dementia and behaviors, mental health management, food safety and sanitation, nutrition, hydration, and dysphagia care, effective communication, culturally competent care, trauma informed care, ethics in health care, HIPAA and confidentiality, and resident rights and abuse prevention. During interview, the Administrator stated he would expect all trainings outlined in the facility assessment to be completed by staff, but he was unable to provide evidence that the identified staff had received the required annual education and training.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to ensure that a resident’s formulated advance directive would be followed because the paper medical record and the Electronic Medical Record (EMR) contained inconsistent code status information for Resident ID #4. The resident was re-admitted in April 2025 with diagnoses including end stage renal disease and dependence on renal dialysis. The EMR advance directive banner showed DNR/Comfort Measures Only, and a physician order also indicated DNR/CMO. However, the most recent MOLST document, signed by the provider and the resident, indicated that the resident’s code status was to attempt resuscitation/CPR. A provider progress note stated that the resident requested to re-evaluate advance care planning and changed his/her mind from wanting to be DNR to Full Code. During interview, the Unit Manager/LPN stated she would initially refer to the EMR for the resident’s code status in an emergency, which would have indicated DNR, while the PA confirmed that the MOLST dated [DATE] was the resident’s most up to date code status.
Failure to Offload Heels for Resident With New Pressure Injury
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for a resident with actual pressure ulcers. The resident was admitted in March 2021 with diagnoses including anoxic brain damage and persistent vegetative state. A nursing progress note dated 4/8/2026 documented a new Stage 1 pressure injury to the dorsum of the right foot. The care plan, last revised on 3/5/2026, identified the resident as at risk for skin breakdown and included interventions to offload and float heels with pillows while in bed. Physician orders included floating heels while in bed and, on 4/8/2026, offloading bilateral heels and feet with pillows at all times, as tolerated, every shift. During surveyor observations on 4/10/2026 at 10:16 AM and 12:16 PM, the resident's heels and feet were resting directly on the mattress. During interview, the Unit Manager acknowledged the resident had a new pressure injury to the right foot, had orders to offload the heels at all times, and that the resident's feet were resting directly on the mattress. The DON stated she would expect staff to follow all physician orders.
Failure to Apply Ordered Hand Splints
Penalty
Summary
The facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM. Resident ID #52 was admitted with diagnoses including anoxic brain damage and persistent vegetative state, and the MDS documented no discernible consciousness, impaired ROM to both upper extremities, and total dependence on staff for ADLs. An OT discharge summary noted contractures in both hands and recommended a splint/brace to both hands after morning care, and a physician order dated 10/13/2022 directed bilateral hand splints to be applied after morning care. The care plan also included bilateral splints to be applied in the morning and removed in the afternoon/evening as tolerated. During multiple surveyor observations from 4/6/2026 through 4/8/2026, the resident did not have the bilateral hand splints on, and the splints were observed in the top drawer of the nightstand. The April 2026 TAR showed the splint order was signed as completed daily from 4/1/2026 through 4/8/2026. During interview, the LPN acknowledged the resident was not wearing the bilateral hand splints and acknowledged signing that the treatment was completed. A new physician order dated 4/9/2026 later changed the instruction to apply the bilateral hand splints after morning care as tolerated in the morning.
Failure to Provide Quarterly Resident Fund Accountings
Penalty
Summary
The facility failed to ensure that each resident with funds deposited with the nursing home was given a written accounting of deposits, withdrawals, and balances at least quarterly for 6 of 6 residents reviewed: Resident ID #s 14, 55, 57, 71, 74, and 86. A facility document titled Resident Fund Management Service balance report as of 4/8/2026 showed that the facility held funds for these residents, but record review did not reveal evidence that quarterly statements were provided to them. During interview, the Regional Business Office Assistant was unable to provide evidence of written accountings for the residents' deposits, withdrawals, and balances at least quarterly, and the Administrator was also unable to provide evidence that quarterly statements had been provided within the last four quarters.
Failure to Notify Residents of Excess Personal Needs Fund Balances
Penalty
Summary
The facility failed to notify residents or resident representatives in writing when Medicaid residents' personal needs fund balances reached $200 less than the SSI resource limit. Record review showed that the applicable Medicaid LTSS accountability procedures require written notice when a resident's account reaches $200 below the $4,000 resource eligibility guideline. A review of the facility's trial balance dated 4/8/2026 showed Resident ID #14 had a balance of $5,522.21 and Resident ID #74 had a balance of $4,118.71. During an interview on 4/8/2026 at 10:19 AM, the Regional Business Office Assistant was unable to provide evidence that either resident had been notified in writing when their account balances reached $200 less than the SSI Medicaid eligibility resource limit.
Failure to Provide Requested Medical Records to Resident Representative
Penalty
Summary
The facility failed to allow a resident’s legal representative to obtain a copy of the resident’s records, including in electronic form, after a formal request was made with advance notice. The resident, identified as Resident ID #120, lived in the facility from September 2025 until passing away there in October 2025. A document titled Consent for the Release of Confidential Health Care Information dated 1/5/2026 showed the family member’s request for the resident’s record, and the request was received by the facility on 1/7/2026 by certified mail. During interview, the Medical Records Manager stated she received the request in January 2026 and sent the records to the facility’s lawyer by email, but she did not know whether the resident’s representative received them. The email thread showed the resident’s electronic medical records were sent to the facility’s lawyer on 2/17/2026, but there was no indication they were then sent to the resident’s representative or the representative’s lawyer. The resident’s representative stated that multiple calls and emails had been made over the prior 3 months requesting the records electronically and that they had not yet been received. The facility’s lawyer did not return the surveyor’s call, and the Administrator was unable to provide evidence that the representative was given a copy of the records with 2 working days advance notice.
Failure to Follow Physician Orders for G-Tube Flushes
Penalty
Summary
The facility failed to meet professional standards of quality by not following physician's orders for gastrostomy tube flushes for a resident with a history of traumatic brain injury, dysphagia, and a gastrostomy tube. Physician orders specified that the feeding tube should be flushed with 30 mL of water before and after each medication pass, at least 15 mL between each medication, and 30 mL prior to feeding, every 4 hours during continuous feeding, and at the end of each feeding. Record review of the Medication Administration Record (MAR) for October revealed that, during medication administration, only 30 mL of water was administered for 91 out of 93 shifts, and during continuous feedings, only 30 mL was administered for 31 out of 33 shifts, with one shift receiving only 22 mL. This documentation did not align with the specific physician orders for flushes. Staff interviews further confirmed the deficiency. An LPN stated that she administered only 15 mL of water before and after medication administration, which did not meet the physician's orders. The physician also acknowledged that the flushes during medication administration and continuous tube feeding were not completed as ordered. These findings were based on a community complaint and subsequent review of records and staff interviews.
Failure to Provide Effective CPR and Basic Life Support
Penalty
Summary
Facility staff failed to provide effective cardiopulmonary resuscitation (CPR) consistent with basic life support protocols to a resident who was found unresponsive, pulseless, and not breathing. The resident, who had a history of acute and chronic respiratory failure with hypoxia and a tracheostomy, was documented as a full code, indicating a desire for all life-saving measures, including CPR. Upon discovery, staff transferred the resident from the toilet to the bed and initiated CPR, with one staff member providing rescue breaths via Ambu bag and another performing chest compressions. An Automated External Defibrillator (AED) was also applied during the resuscitation attempt. Review of documentation and staff interviews revealed that CPR was performed on the bed without the use of a backboard, contrary to best practices for effective chest compressions on soft surfaces. The Director of Nursing Services (DNS) stated that staff should have moved the resident to the floor or used a backboard if CPR was performed on the bed. Additionally, the facility's policy required rescue breaths to be delivered at a rate of 10-12 breaths per minute via Ambu bag for residents with a tracheostomy, but staff interviews and emergency personnel reports indicated that rescue breaths were inconsistently provided, with one staff member admitting to delivering only three breaths per minute and delegating the task to an unidentified staff member at one point. Emergency personnel arrived to find staff performing only chest compressions, with no evidence that rescue breaths or supplemental oxygen were being administered at that time. The resident was subsequently transported to the hospital, where death was pronounced shortly after arrival. The facility was unable to provide evidence that effective CPR, consistent with basic life support protocols and facility policy, was provided throughout the resuscitation effort.
Significant Medication Error Due to Incorrect Transcription of Diuretic Order
Penalty
Summary
A medication error occurred when a resident with a history of heart failure, pulmonary hypertension, and chronic kidney disease was readmitted to the facility with an order for Metolazone 5 mg to be administered three times a week. The order was incorrectly transcribed by a registered nurse to be given three times daily, resulting in the resident receiving seven doses over three days instead of the intended two doses. The facility's policy required medications to be administered according to the prescriber's orders, but this was not followed in this instance. The resident's care plan identified a risk for dehydration related to diuretic medications, with interventions to administer medications as ordered. Progress notes indicated that after the medication error, the resident appeared fatigued and had a low blood pressure reading. Subsequently, the resident was found unresponsive on the floor with significant facial trauma and bleeding, and was transferred to an acute care hospital, where the resident later died. EMS documentation confirmed the resident was not breathing upon their arrival and required resuscitation efforts. Interviews with facility staff, including the nurse who transcribed the order, the DON, and a pharmacist, confirmed the error in transcription and administration of Metolazone. The pharmacist noted that the prescribed frequency was typical and that excessive dosing could lead to adverse effects such as dehydration, lethargy, and hypotension. The facility was unable to provide evidence that it ensured residents were free from significant medication errors, as required by policy.
Failure to Ensure Competent Nursing Staff Leads to Medication Error and Inadequate Emergency Response
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies to provide safe and effective care for all residents, resulting in significant medication errors and inadequate emergency response. In one instance, a resident with a tracheostomy and full code status was found unresponsive and pulseless. Staff initiated CPR on a bed without a backboard, contrary to best practices, and failed to provide rescue breaths at the correct rate as outlined in both facility policy and basic life support protocols. The respiratory therapist delegated rescue breaths to another staff member and could not recall who took over, and emergency personnel found that only chest compressions were being performed when they arrived. The Director of Nursing and Respiratory Therapy Director both confirmed that staff actions did not meet expected standards for CPR delivery. Another resident, also with full code status and multiple comorbidities including heart failure and chronic kidney disease, was readmitted to the facility with a medication order for Metolazone to be given three times a week. The order was incorrectly transcribed as three times daily, and this error was not identified during multiple required medication reconciliation checks by several nurses and the Assistant Director of Nursing. The pharmacy questioned the order, but the nurse responsible failed to verify it with the provider as instructed. The resident received seven doses of Metolazone in three days, and the error was not caught by the provider during a subsequent review. After the error was discovered, new orders were given, including obtaining orthostatic vital signs, but these were not completed before the resident was found unresponsive on the floor with severe hypotension and subsequently died. Additionally, when the second resident was found unresponsive after a fall, staff failed to properly assess and intervene as the resident's condition deteriorated. Despite the resident being face down, unresponsive, and bleeding, staff did not reposition the resident to assess airway or breathing, nor did they initiate CPR or other life-saving measures as the resident's respiratory rate declined. Staff cited facility policy as the reason for not moving the resident, but both the physician and Director of Nursing stated that staff should have stabilized and repositioned the resident to allow for proper assessment and intervention. These failures in medication management, emergency assessment, and CPR delivery demonstrate a lack of sufficient nursing staff with appropriate skill sets, directly impacting resident safety and well-being.
Failure to Follow Care Plan Results in Resident Fall and Fractures
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan, which required two staff members to assist with incontinence care. Despite this intervention being clearly documented in the care plan, a nursing assistant provided care alone, resulting in the resident rolling out of bed and falling. The incident was witnessed, and the resident subsequently complained of severe pain. The resident involved had significant medical needs, including hemiplegia and hemiparesis following a stroke, dependence on a ventilator, and use of both a tracheostomy and gastrostomy. The resident was assessed as totally dependent on staff for all activities of daily living. As a direct result of the failure to implement the care plan, the resident sustained fractures to the left distal tibia and fibula. The facility was unable to provide evidence that staff followed the care plan as required.
Failure to Maintain Sufficient Staffing Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to maintain sufficient nursing staff to meet the needs of all residents, as evidenced by an incident involving a resident who was quadriplegic, ventilator-dependent, and fully reliant on staff for all care. On the evening in question, the resident experienced an unwitnessed fall from bed resulting in a nasal fracture. Staff interviews and record reviews revealed that only three nursing assistants (NAs) were present on the unit during the shift, despite the facility's own staffing guidelines requiring four to five NAs for that shift. Staff reported being overwhelmed and unable to provide adequate supervision, particularly when multiple staff were occupied with another dependent resident, leaving the rest of the unit unsupervised. Further review showed that the facility's assessment did not specify the average number of staff required to meet resident needs, and management was aware of the staffing shortfall but did not adjust assignments accordingly. The facility was unable to provide evidence that staffing was adjusted based on resident acuity or that their own guidelines were followed. As a result, the resident, who required total assistance, was left without adequate supervision, leading to the fall and injury.
Failure to Complete and Update Facility-Wide Assessment and Staffing Documentation
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. Record review revealed that the facility's assessment, dated March 2025-2026, was incomplete, lacking required supporting documentation and a completed Staffing and Personnel Worksheet. Additionally, the assessment listed a previous employee as the Administrator instead of the current one. During an interview, the current Administrator acknowledged that the assessment was not complete and did not accurately reflect the facility's staffing patterns or leadership. A community complaint reported to the Rhode Island Department of Health alleged that a resident sustained two falls and did not receive appropriate care for their injuries. The complaint also raised concerns about insufficient and unqualified staffing. Review of the facility's documentation confirmed these deficiencies, as multiple sections of the assessment were missing records, and there was no evidence of a current, accurate evaluation of staffing sufficiency or qualifications.
Failure to Ensure Timely Orthopedic Follow-Up After Fracture
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following a stroke, ventilator dependence, tracheostomy, and gastrostomy was admitted to the facility. The resident sustained a witnessed fall while a nursing assistant was changing their brief, resulting in a complaint of severe pain. Subsequent radiology confirmed a fracture of the distal tibia and fibula, and the resident was placed in a splint at the hospital with orders for an outpatient orthopedic follow-up within one week. Multiple progress notes documented the need for orthopedic follow-up, and nursing staff were instructed to arrange the appointment and send x-ray results to the orthopedic provider. Despite these orders and instructions, record review did not reveal evidence that the resident received the required orthopedic follow-up. Staff interviews indicated that an appointment was initially scheduled but was cancelled by the orthopedic office. The transport aide communicated the cancellation to the physician assistant, who believed the facility staff would reschedule, while the physician assistant stated he does not schedule appointments and expected facility staff to do so. This lack of follow-through resulted in the resident not receiving the ordered orthopedic evaluation.
Failure to Reconcile Medication Orders on Readmission Leads to Medication Error
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician completed a medication reconciliation upon a resident's readmission. The resident, who had diagnoses including heart failure, pulmonary hypertension, and chronic kidney disease, was readmitted after a hospital stay for congestive heart failure exacerbation and respiratory distress. Upon readmission, the hospital discharge documentation ordered Metolazone 5 mg to be administered three times a week. However, a registered nurse incorrectly transcribed this order into the facility's record as three times daily. The resident's physician saw the resident after readmission and reviewed the medical record but did not identify the transcription error regarding the Metolazone order. During interviews, the physician stated that he does not reconcile medication orders between the facility's system and the hospital's continuity of care form, considering it the nursing staff's responsibility. The Director of Nursing Services, however, indicated that it is expected for the provider to reconcile these records to ensure accuracy. This failure resulted in the resident receiving Metolazone in error.
Medication Order Transcription Error Led to Over-Administration
Penalty
Summary
A deficiency occurred when a resident's medication order for Metolazone was incorrectly transcribed in the electronic medical record by a registered nurse. The hospital discharge documentation specified that the resident should receive Metolazone 5 mg by mouth three times a week for 30 days. However, the physician's order entered into the facility's system stated the medication should be given three times a day. As a result, the resident received seven doses of Metolazone over three days, rather than the two doses that were actually ordered. The resident involved had recently been readmitted to the facility with diagnoses including heart failure, pulmonary hypertension, and chronic kidney disease. The error was identified after the resident experienced a fall, was transferred to an acute care hospital, and subsequently passed away. The Director of Nursing Services acknowledged during an interview that the medication order was incorrectly transcribed, leading to the administration of Metolazone at a much higher frequency than prescribed.
Failure to Monitor and Notify After Medication Error Leads to Resident Hospitalization
Penalty
Summary
A resident with multiple medical conditions, including dementia, diabetes, bradycardia, and aortic valve stenosis, was admitted to the facility and had significant cognitive impairment, being rarely or never understood and having severely impaired decision-making skills. On the morning in question, a registered nurse administered another resident's medications, including 200 mg of Clozapine and 80 mg of Geodon, to this resident in error. The nurse failed to properly identify the resident, despite the resident wearing a name band, and the error was only recognized after the medications were ingested. Documentation indicates that the resident remained in the dining area for supposed monitoring, but vital signs were not taken in real time, and the note was not entered until the following day. The nurse assigned to the resident did not assess the resident or ensure monitoring, relying on the other nurse's statement that monitoring had occurred. The facility failed to inform additional staff on the unit about the medication error, so no enhanced monitoring was provided. The resident's family, including the spouse who was present in the facility for about an hour after the error, was not informed of the incident. The resident was allowed to leave the facility on a leave of absence (LOA) with the spouse, who signed the resident out following protocol, but was unaware of the medication error. The nurse assigned to the resident did not review the LOA book and was unaware that the resident had left the facility. Other staff, including nursing assistants, were not informed of the need for monitoring and assisted with the LOA process without knowledge of the error. The provider was not notified of the medication error until approximately nine hours after the incident, after the resident had already been transported to the hospital by emergency medical services due to unresponsiveness. Documentation of vital signs in the resident's record was either delayed or used outdated information from a previous month. The medical director confirmed that the resident should not have been allowed to leave the facility and that no interventions or real-time monitoring were implemented following the error. As a result, the resident experienced adverse effects from the medications, required emergency hospitalization, and was placed on a ventilator for treatment of toxic metabolic encephalopathy.
Resident Hospitalized After Receiving Another Resident's Psychiatric Medications
Penalty
Summary
A significant medication error occurred when a registered nurse administered another resident's psychiatric medications, including 200 mg of Clozapine and 80 mg of Geodon, to a resident who was not prescribed these drugs. The nurse failed to properly identify the resident before administration, despite the resident wearing a name band, and relied on verbal confirmation, which was misunderstood. The error was discovered only after the medications had been ingested, when another staff member familiar with the residents identified the mistake. The affected resident had a complex medical history, including type 2 diabetes, dementia, bradycardia, and aortic valve stenosis, and was severely cognitively impaired, rarely understood, and had both short- and long-term memory problems. After receiving the incorrect medications, the resident became unresponsive while on a leave of absence with family, requiring emergency medical services. The resident was found slumped over, with shallow respirations and low blood pressure, necessitating oxygen, intravenous fluids, and mechanical ventilation during transport to the hospital. Hospital records confirmed the resident was treated for toxic metabolic encephalopathy due to accidental overdose of Clozapine. Facility records showed there was no physician's order for Clozapine or Geodon for this resident, and the error was not immediately communicated to the family or the hospital. The Director of Nursing and the Medical Director acknowledged the failure to follow medication administration policy and the lack of proper resident identification. The incident resulted in the resident being at risk for serious harm, injury, impairment, or death, and required hospitalization and intensive medical intervention.
Failure to Immediately Notify Physician and Family After Medication Error
Penalty
Summary
The facility failed to immediately notify a resident's physician and representative after a significant medication error occurred. A registered nurse administered another resident's antipsychotic medications, including Clozaril 200 mg and Geodon 80 mg, to a resident with multiple medical conditions such as type 2 diabetes, dementia, bradycardia, and aortic valve stenosis. The error was identified by another nurse, but neither the resident's physician nor the resident's family was promptly informed of the incident. The resident's spouse was present in the facility visiting the resident after the medication error but was not informed of the incident by staff. The spouse subsequently took the resident out on a leave of absence, during which the resident became unresponsive and required emergency medical services. The family only learned of the medication error when they returned to the facility to obtain documentation for EMS. Interviews with staff confirmed that the nurse responsible for the resident did not notify the physician or the family immediately after discovering the error, waiting instead until after the family returned to the facility. The Director of Nursing and the Administrator were unable to provide evidence that immediate notification had occurred. The resident required emergency transport, hospitalization, and ventilator support as a result of receiving medications not prescribed for them.
Failure to Provide Timely and Consistent Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, as required by professional standards and facility policy. The resident was admitted with multiple pressure ulcers, including a Stage 4 ulcer and unstageable ulcers, and had physician orders for negative pressure wound therapy to be applied every 72 hours. However, documentation did not show that this therapy was administered as ordered on two specific dates. Additionally, the Treatment Administration Record did not reflect that the negative pressure wound therapy was consistently provided according to the physician's instructions. Further review revealed that a complete wound evaluation for one of the resident's pressure ulcers was not performed upon admission, nor were weekly wound assessments consistently documented as required by the facility's policy and the resident's care plan. The first complete evaluation for the left ischial ulcer was not documented until two weeks after admission, and there was no evidence of weekly wound evaluations during a specified week. The Director of Nursing confirmed that these assessments should have been completed and could not provide evidence that they were done as required.
Failure to Provide Quarterly Financial Statements to Residents
Penalty
Summary
The facility failed to provide a written accounting of deposits, withdrawals, and balances at least quarterly for five residents. These residents, identified by their IDs, had funds held by the facility as evidenced by a document titled 'Trial Balance' dated March 18, 2025. However, there was no evidence of quarterly statements being provided to these residents, which is a requirement per the regulation. During interviews with the Business Office Manager and the Administrator, it was acknowledged that the residents had not received the required quarterly statements. The Administrator was unable to provide evidence of compliance with this requirement for the year 2024, confirming the deficiency in the facility's management of residents' personal funds.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to provide proper notice to residents and/or their representatives regarding changes in Medicare coverage, specifically related to the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) of Non-coverage and the Notice of Medicare Non-Coverage (NOMNC). For two residents who were discharged from Medicare Part A services but remained in the facility, there was no evidence that the SNFABN form was issued, as required by Medicare guidelines. These forms are necessary to inform residents when Medicare may not cover certain services, allowing them to make informed decisions about their care and financial responsibilities. Additionally, the facility did not provide the NOMNC in a timely manner for two other residents who were discharged from a Medicare-covered Part A stay with benefit days remaining. The NOMNC is required to be delivered at least two calendar days before the end of Medicare-covered services. Interviews with the Business Office Manager and the Administrator confirmed the lack of evidence for issuing these notices, indicating a failure in the facility's process to comply with Medicare requirements for notifying residents about coverage changes.
Inaccurate Resident Assessment for Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected the resident's status for a resident with a diagnosis of schizophrenia. The resident was admitted to the facility in February 2024 with a diagnosis of bipolar disorder, as documented in the Preadmission Screening and Resident Review (PASRR) from January 2024. However, the resident's Admission MDS assessment did not include schizophrenia as an active diagnosis. Subsequent MDS assessments from May 2024, July 2024, October 2024, and January 2025 incorrectly coded the resident with an active diagnosis of schizophrenia. During interviews, the MDS Coordinator admitted to coding the schizophrenia diagnosis on the January 2025 assessment without supporting documentation. The Physician Assistant claimed to have obtained the schizophrenia diagnosis from facility documentation or a consult but could not provide evidence to support this. The Administrator acknowledged that the MDS assessments included a diagnosis of schizophrenia without any supporting documentation, indicating a failure in maintaining accurate resident assessments.
Failure to Follow Physician's Order for Daily Weights
Penalty
Summary
The facility failed to meet professional standards of quality by not following a physician's order for daily weights for a resident. The resident, who was admitted in February 2022, had diagnoses including chronic obstructive pulmonary disease and type 2 diabetes mellitus with diabetic chronic kidney disease. An active physician's order dated 7/31/2024 required daily morning weights for the resident. However, the record review showed no evidence that these weights were obtained from 7/31/2024 through 3/21/2025. Interviews with facility staff revealed a lack of awareness regarding the physician's order for daily weights. A registered nurse and the dietitian both indicated they were unaware of the order. The Director of Nursing Services acknowledged the existence of the order and expressed that it was his expectation for the weights to have been obtained as ordered. This oversight indicates a failure in communication and adherence to physician directives within the facility.
Failure to Act on Pharmacist's Recommendations for Medication Regimen Review
Penalty
Summary
The facility failed to act upon irregularities identified by the Consultant Pharmacist during the monthly Medication Regimen Review (MRR) for a resident admitted with chronic obstructive pulmonary disease (COPD) and bacterial pneumonia. The resident had physician's orders for prednisone and doxycycline, but the pharmacist recommended clarifying a stop date for doxycycline and a stop date or taper order for prednisone. These recommendations were made on multiple occasions, yet the facility did not act on them. As a result, the resident continued to receive doxycycline twice daily from early January through mid-March, totaling 141 doses, and prednisone once daily for the same period, totaling 71 doses. During interviews, the Director of Nursing Services could not provide evidence that the MRR recommendations were followed, and the resident's physician expressed that the prednisone should have been tapered and the doxycycline stopped as per the pharmacist's recommendations.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for residents with multidrug-resistant organisms (MDRO). The deficiency was identified through surveyor observations, record reviews, and staff interviews, affecting four residents who required EBP due to their medical conditions, including chronic respiratory failure, chronic obstructive pulmonary disease, and the presence of devices such as gastrostomy tubes, tracheostomies, urinary catheters, and central lines. For Resident ID #15, the surveyor observed a respiratory therapist removing a nebulizer treatment from the resident's tracheostomy without wearing a gown, despite signage indicating the need for EBP. Similarly, Resident ID #60 was observed receiving a bed bath from a nursing assistant who did not wear a gown, contrary to the posted EBP requirements. Resident ID #74 was transferred and provided hygiene care by staff who also failed to adhere to the gown-wearing protocol, with staff expressing confusion about the necessity of gowns for these activities. Resident ID #92, who required EBP for a G-tube, tracheostomy, wounds, and a central line, was observed receiving central line care and medication administration without the nurse wearing a gown. Staff interviews revealed a lack of awareness and understanding of the EBP requirements, with some staff unaware of the need to wear gowns for specific care activities. The facility's infection preventionist and director of nursing services confirmed the expectation for staff to follow the posted EBP signage, highlighting a gap in adherence to infection control protocols.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an Infection Prevention and Control Program (IPCP) that includes an antibiotic stewardship program with protocols and a system to monitor antibiotic use. This deficiency was identified for two residents, Resident ID #89 and Resident ID #93, who were prescribed antibiotics without evidence of an antibiotic review or time-out. Resident ID #89 was admitted with severe sepsis and septic shock and was prescribed Levofloxacin and Meropenem-Sodium Chloride Intravenous Solution without an end date or evidence of review. Similarly, Resident ID #93, admitted with bacterial pneumonia, continued to receive doxycycline beyond the recommended duration from the hospital discharge summary, resulting in 141 doses instead of the prescribed 4 doses. The facility's failure to conduct antibiotic reviews or time-outs was confirmed through interviews with the Infection Preventionist, Director of Nursing, and the Administrator, who were unable to provide evidence of such reviews for the residents in question. The Director of Nursing acknowledged the discrepancy in the doxycycline order for Resident ID #93, and the physician was not notified of the hospital discharge summary, leading to the extended administration of the antibiotic. These findings highlight the lack of a systematic approach to antibiotic stewardship within the facility, as required by the Centers for Disease Control and Prevention (CDC) guidelines.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to inform a resident's appointed representative about the administration of Rexulti, an atypical antipsychotic medication, and its associated risks and benefits. The resident, who was diagnosed with dementia with psychotic disturbance and had severe cognitive impairment, was unable to provide consent. Despite the facility's policy requiring informed consent for high-risk treatments, there was no evidence that the representative was informed about the addition of Rexulti or any subsequent dosage changes. The resident was readmitted to the facility with a diagnosis of dementia and began receiving Rexulti in January 2025. The medication was administered in increasing doses without notifying the resident's representative. The facility's records, including progress notes and the Medication Administration Record, failed to show any documentation of communication with the representative regarding the medication's risks, benefits, or alternatives. The Director of Nursing Services acknowledged that the nurse should have discussed the treatment plan changes with the representative and documented it accordingly.
Neglect in ADL Care for Resident
Penalty
Summary
The facility failed to protect a resident, identified as Resident ID #452, from neglect concerning their activities of daily living (ADLs). The resident, who was admitted with conditions including anxiety, recurrent depressive disorders, and a urinary tract infection, required significant assistance with ADLs such as grooming, bathing, dressing, toileting, and transfers. Despite these needs, the resident reported that nursing assistants did not provide the necessary care, and only therapists attended to them. On the day of the survey, the resident was observed in a hospital gown, expressing discomfort due to a rash and the need for incontinence care, which was delayed by approximately 48 minutes after the initial call for assistance. The surveyor's observations and interviews revealed a breakdown in communication and responsibility among the staff. Nursing assistants, Staff A and Staff B, indicated they could not transfer the resident without therapy's assistance, although the physical therapist, Staff C, later clarified that no such restriction existed. Additionally, the resident's assigned nursing assistant, Staff E, was unaware of their assignment and did not provide the necessary ADL care, mistakenly believing it was completed by a therapist. This confusion resulted in the resident not receiving assistance with personal hygiene, washing, or dressing during the observed shift. The Director of Nursing Services acknowledged that the nursing assistants should have transferred the resident to provide incontinence care and that all residents should receive necessary ADL assistance, which should be documented. The failure to provide timely and adequate care, as well as the lack of proper documentation and communication among staff, contributed to the neglect of the resident's needs, as highlighted by the surveyor's findings.
Failure to Communicate Critical Changes to Dialysis Center
Penalty
Summary
The facility failed to ensure proper communication with the dialysis center for a resident with end-stage renal disease (ESRD) who required dialysis services. The resident, who was readmitted to the facility with a diagnosis of ESRD, attended dialysis three times a week. Despite the facility's policy requiring communication with the dialysis center regarding changes in the resident's condition, there was no evidence that the dialysis center was informed of the resident's gastrointestinal (GI) bleed or a witnessed fall. The resident had a history of GI bleeds requiring emergency room visits and transfusions, and a recent fall necessitated a change in transfer status to require a Hoyer lift. Interviews with facility staff revealed a lack of awareness regarding the policy to notify the dialysis center of significant changes in the resident's condition. A registered nurse and the Director of Nursing Services both acknowledged the failure to communicate these critical changes, including the GI bleed and fall, to the dialysis center. This oversight indicates a breakdown in the facility's communication processes, as the necessary updates were not included in the dialysis communication binder or records, contrary to the facility's established policy.
Failure to Discontinue Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, as evidenced by the administration of medications beyond their intended duration. A resident was admitted with diagnoses including chronic obstructive pulmonary disease (COPD) and bacterial pneumonia. Upon admission, the Continuity of Care Discharge/Transfer of Patient Form indicated that prednisone and doxycycline were to be discontinued shortly after admission. However, the facility continued to administer doxycycline twice daily from January 7, 2025, through March 19, 2025, totaling 141 doses, and prednisone once daily from January 8, 2025, through March 19, 2025, totaling 71 doses. The Pharmacist had recommended clarifying stop dates for both medications on multiple occasions, but these recommendations were not acted upon. Interviews with the Director of Nursing Services and the Physician Assistant revealed a lack of awareness and oversight regarding the stop dates for these medications. The resident's Physician also expressed that the facility should have followed the orders to discontinue the medications as per the discharge summary. This oversight resulted in the resident receiving unnecessary medications for an extended period.
Facility-Wide Assessment Documentation Deficiency
Penalty
Summary
The facility failed to document all required components of the facility-wide assessment and did not review or update the assessment when changes necessitating substantial modifications occurred. The assessment document for 2025 was undated and unsigned, lacking evidence of active involvement from key participants such as the governing body, Medical Director, Administrator, and Director of Nursing Services (DNS). Of the 13 management staff listed as contributors, 11 were no longer employed at the facility. Additionally, there was no evidence that the facility solicited or considered input from residents, resident representatives, and family members. During an interview, the Administrator could not provide evidence that the facility included all required components or completed necessary changes to the assessment.
Deficiency in QAPI Implementation for Infection Control and Antibiotic Stewardship
Penalty
Summary
The facility failed to implement and maintain an effective Quality Assurance and Performance Improvement (QAPI) program, specifically in the areas of infection control and antibiotic stewardship. The QAPI plan, which was supposed to monitor hand hygiene and personal protective equipment (PPE) compliance, lacked evidence of implementation, tracking, and performance measurement. During surveyor observations, staff were noted to breach infection control practices by not wearing gowns during high-contact care activities for residents under enhanced barrier precautions (EBP). Additionally, the facility's QAPI plan for antibiotic stewardship was not effectively implemented, as there was no evidence of tracking or performance measurement. Record reviews for several residents showed that antibiotic time outs were not completed. During an interview, the Director of Nursing Services and the Administrator could not provide evidence of attempts to address the concerns related to EBP and antibiotic stewardship, indicating a lack of corrective action in these areas.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to implement and revise a care plan for a resident identified as being at risk for falls. The resident, who was readmitted to the facility with diagnoses including dementia, difficulty walking, and unsteadiness on feet, experienced multiple unwitnessed falls. On January 5, 2025, the resident sustained a fall and an intervention was added to the care plan to place a bedside mat on the floor. However, after a subsequent fall on February 11, 2025, where the resident attempted to get out of bed unassisted and sustained injuries, the care plan was not revised with new interventions. Further review revealed that on February 12, 2025, the resident was found sitting on the mat next to the bed, leading to an intervention on February 13, 2025, to implement frequent checks when the resident is in bed. Despite this, the resident experienced another fall on March 20, 2025. Interviews with staff, including a Registered Nurse and the Director of Nursing Services, confirmed that the care plan was not updated after the February 11 fall and that there was no evidence that the intervention for frequent checks was implemented.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision to prevent elopement for three residents identified as at risk. Resident ID #1, with a history of dementia and moderate cognitive impairment, eloped from the facility and was found at a local convenience store. Despite being identified as an elopement risk, there was no evidence of interventions or updates to the care plan following a fall outside the facility. The Director of Nursing Services acknowledged the lack of evidence for interventions or staff education on the resident's elopement risk. Resident ID #4, also with dementia and moderate cognitive impairment, was able to leave the facility unsupervised and was found at a convenience store. An occupational therapy evaluation highlighted the dangers of the resident's route, yet there was no update to the care plan to address these concerns. The resident was observed outside the facility unattended, and staff were unaware of the resident's elopement risk, indicating a failure in communication and supervision. Resident ID #2, with severe cognitive impairment, was identified as an elopement risk but lacked appropriate interventions. Staff were unaware of the resident's risk status, and there was no evidence of implemented interventions. The facility also failed to conduct the required elopement drills, as per their policy, further demonstrating a lack of preparedness and oversight in managing residents at risk of elopement.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 602 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Coventry
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alpine Nursing Home Inc | 3.8 mi | ★★★★★ | 8 | 0 |
| Riverview Healthcare Community | 4.7 mi | ★★★★★ | 14 | 2 |
| West View Nursing Home, Inc | 4.7 mi | ★★★★★ | 9 | 2 |
| Cra-mar Meadows | 5.5 mi | — | 0 | 0 |
| Kent Regency Center | 6.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.