Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Morgan Health Center during CMS and state inspections, most recent first.
A resident with HF and GERD had persistent nausea, vomiting, mouth sores, weight loss, and abdominal pain, along with abnormal BUN and creatinine results. The NP ordered GI and nephrology referrals and an abdominal US showed bilateral hydronephrosis and a renal cyst, but the consults were not scheduled and staff did not follow up despite ongoing symptoms. The resident was later hospitalized with renal failure.
The facility failed to follow physician orders for post-fall care for three anticoagulated residents who experienced falls. One resident on a blood thinner with a head injury was ordered to be transferred to the ED after a telehealth evaluation, but an LPN did not send the resident, citing instructions to contact a supervisor first and inability to reach that supervisor. For two other residents on anticoagulants, providers ordered intensive neuro checks (every 15 minutes, then every 30 minutes, then hourly, then every 4 hours), but staff instead performed neuro checks only once per shift for 72 hours. The DON and Medical Director acknowledged that the transfer and monitoring orders were not implemented as written.
A resident with multiple comorbidities was admitted with a Stage 2 pressure ulcer and surrounding blisters, but the initial skin assessment lacked measurements and a detailed description. No treatment order was obtained or implemented for six days, and staff interviews confirmed that wound care was not provided during this period.
A resident with hypertension was administered Metoprolol Succinate without documented checks of blood pressure or apical pulse as required by physician orders. Review of MARs and staff interviews confirmed the absence of documentation that these vital signs were obtained prior to medication administration.
A pharmacist did not identify or report missing documentation of blood pressure and apical pulse monitoring before administering an antihypertensive medication to a resident, despite monthly medication regimen reviews and facility policy requiring such oversight. Both the pharmacist and the DON acknowledged the oversight during interviews.
Two residents did not receive timely follow-up for ordered medical appointments, including a GI surgical consult and neurology referral, due to the facility's failure to schedule and document these appointments. Residents and their families had to arrange the appointments themselves after repeated requests to staff, and facility staff were unaware of the appointments' outcomes. The DON and Administrator could not provide evidence of follow-up or scheduling as ordered by providers.
A resident with severely impaired cognition was inappropriately touched by another resident with intact cognition, who had a history of inappropriate behavior. The incident was witnessed by staff, and the facility failed to protect the resident's right to be free from abuse.
A resident with alcoholic cirrhosis had abnormal lab results that were not communicated to a provider, contrary to facility protocol. The resident later showed severe symptoms and was transferred to the hospital, where they were diagnosed with a ruptured intestine and sepsis, and subsequently died. Staff interviews confirmed the expectation for lab results to be reported, but no evidence was found that this occurred.
The facility failed to provide a safe and sanitary environment by not implementing a water management program based on industry standards and the CDC toolkit. Observations revealed that the second and fourth-floor tubs were used as storage and not regularly flushed, with no evidence of a water flow assessment to identify areas where Legionella could grow.
A resident with hemiplegia and an ankle fracture, who requires an interpreter, was not assisted properly with toileting and communication. The NA provided a bedpan instead of helping the resident to the bathroom, leading to frustration and an alleged physical altercation. Both the NA and the nurse failed to use the available communication tools, resulting in a deficiency for the facility.
The facility failed to report an allegation of staff-to-resident sexual abuse to the Rhode Island Department of Health (RIDOH) within the required timeframe. A resident reported that a male staff member inserted their finger in the resident's rectum during care. Despite the Social Services Director reporting the allegation to the Administrator immediately, the Administrator did not report it to RIDOH until approximately four weeks later, after being questioned by a surveyor.
A resident reported an allegation of staff-to-resident sexual abuse during a care conference. Despite the facility's policy requiring thorough investigation and a follow-up report within five business days, the Administrator acknowledged that no thorough investigation was conducted.
Failure to Ensure Timely Follow-Up for Persistent Nausea, Vomiting, and Abnormal Renal Labs
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice when the resident experienced ongoing nausea and vomiting for approximately 21 days and was later transferred and admitted to the hospital with renal failure. The resident had a history that included heart failure and gastro-esophageal reflux, and the care plan included monitoring for nausea and vomiting. The resident was also receiving Ondansetron 4 mg every 6 hours as needed for nausea and vomiting. The record shows that the resident had persistent daily vomiting, mouth sores, weight loss, and left upper quadrant abdominal pain. On 4/16/2026, laboratory testing showed a BUN of 70 mg/dL and creatinine of 3.41 mg/dL. The Nurse Practitioner documented referrals to nephrology and gastrointestinal services and noted that the family wanted the resident sent to the emergency room for an endoscopy, but stated that hospitalization was not needed at that time. The abdominal ultrasound later showed bilateral hydronephrosis and left renal cysts, and additional orders were written for further evaluation. The facility documented that the nephrology and gastrointestinal consults were faxed to the VA hospital, but the appointments were not arranged and the facility remained waiting for a response. Staff interviews confirmed that the referrals were sent and that follow-up on the status of the consults was not completed despite the resident continuing to have nausea and vomiting. The Nurse Practitioner stated she was unaware that an appointment had not been scheduled for the resident.
Failure to Follow Post-Fall Physician Orders for Anticoagulated Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for post-fall care, including hospital transfer and neurological monitoring, for residents on anticoagulant therapy. One resident with atrial fibrillation on Xarelto experienced an unwitnessed fall with a scalp laceration and head lump. The on-call provider, after a telehealth evaluation, ordered transfer to the ED and wrote an order directing that the resident be sent to the hospital. The resident was not transferred as ordered, and an additional order for vital signs and neuro checks every shift for 72 hours after the fall was not completed as ordered on one of the shifts. The LPN caring for this resident stated she did not send the resident to the ED because she had been instructed to call a supervisor before sending residents out, and she was unable to reach the supervisor during the shift. A second resident, also with atrial fibrillation and on Xarelto, had an unwitnessed fall with injury. The on-call provider was notified and ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, then every four hours for an additional 24 hours. A physician’s order reflecting this schedule was scanned into the EMR. However, the neuro checks were not completed as ordered; instead, they were performed only once per shift for 72 hours. The RN who authored the progress note documented the fall and the resident’s anticoagulant use, and later stated she could not remember why she did not transcribe and complete the neuro checks as ordered. A third resident with atrial fibrillation on Apixaban had a non-injury fall after attempting to walk independently. The on-call provider ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, and then every four hours for an additional 24 hours, and this order was scanned into the EMR. The record did not show that these neuro checks were completed as ordered; instead, neuro checks were documented only once per shift for 72 hours. The Medical Director stated he would have expected the first resident to be transferred to the ED as ordered and that the facility should not override a provider’s order. The DON acknowledged that the transfer order and the ordered monitoring for the first resident were not followed as written, and that for the second and third residents, staff performed only once-per-shift neuro checks instead of the more frequent monitoring ordered by the providers.
Failure to Initiate Timely Pressure Ulcer Treatment and Documentation
Penalty
Summary
A resident admitted in November 2025 with a history of laminectomy, diabetes mellitus, and obesity was found to have a Stage 2 pressure ulcer on the coccyx and popped blisters in the same area upon admission. The initial skin assessment documented the presence of these wounds but did not include measurements or a detailed description. There was no evidence that a treatment order for the wounds was obtained or implemented at the time of admission. Review of the clinical record and staff interviews confirmed that the resident's wound was not treated for six days following identification. The admitting nurse acknowledged failing to obtain a treatment order upon admission, and the wound nurse confirmed that standard practice requires a complete assessment and prompt initiation of treatment orders for identified wounds. Documentation did not show that the resident received any wound care from the time the wounds were first identified until six days later.
Failure to Document Vital Signs Prior to Medication Administration
Penalty
Summary
A deficiency was identified when a resident with a diagnosis including hypertension was not provided care in accordance with professional standards and physician's orders. The resident had physician orders for Metoprolol Succinate ER 50 mg daily, with specific instructions to hold the medication if the systolic blood pressure (SBP) was less than 100 or if the apical pulse (AP) was less than 60 (later changed to less than 50). These orders were in effect from late April through early July 2025. Record review of the Medication Administration Records (MAR) for April, May, June, and July 2025 did not show documentation that the resident's blood pressure or apical pulse were checked prior to administering the medication as required. During interviews, both a registered nurse and the Director of Nursing Services confirmed that there was no evidence that these vital signs were obtained before medication administration, as directed by the physician's orders.
Pharmacist Failed to Identify and Report Medication Monitoring Irregularity
Penalty
Summary
A deficiency was identified when a licensed pharmacist failed to report medication irregularities for a resident admitted with hypertension. The resident had physician's orders for Metoprolol Succinate ER 50 mg, with specific instructions to hold the medication if the systolic blood pressure (SBP) was less than 100 or if the apical pulse (AP) was below a certain threshold. Record review showed that, over several months, there was no documentation that the resident's blood pressure or apical pulse were checked prior to administering the medication, as required by the physician's orders. The pharmacist conducted monthly medication regimen reviews on three separate occasions but did not identify or report the lack of required monitoring documentation. Both the pharmacist and the Director of Nursing Services acknowledged during interviews that the irregularity was not identified or reported according to facility policy. This failure to recognize and report the medication administration irregularity constituted the deficiency.
Failure to Schedule and Follow Up on Ordered Medical Appointments
Penalty
Summary
The facility failed to ensure that two residents received necessary care and services related to follow-up medical appointments, as ordered by their providers. One resident, admitted with diagnoses including spinal stenosis and diabetes, had an order for an abdominal ultrasound to rule out a hernia, which was completed and confirmed a small right inguinal hernia. The nurse practitioner subsequently ordered a GI surgical consult, but there was no evidence in the records that this consult was scheduled by the facility. The resident reported having to schedule the GI appointment independently after repeated requests to staff, and attended the appointment, providing paperwork to the nurse. However, staff interviews revealed a lack of awareness about the appointment and its outcome, and the new nurse practitioner was unaware of the need for cardiac clearance for surgery following the GI consult. Another resident, admitted with diabetes and chronic obstructive pulmonary disease, had orders for lab work, a CT scan, MRI, and a neurology referral. While some lab results were faxed as part of the neurology referral process, there was no evidence that the CT or MRI were scheduled, nor that the neurology appointment was arranged by the facility. The resident and their spouse ultimately scheduled the neurology appointment themselves after waiting for months without information from staff. The transport aide indicated that incomplete referral information from nursing staff prevented her from scheduling the neurology appointment, and there was no documentation of follow-up for the required imaging or consults. Interviews with both residents' physicians confirmed that it was their expectation that the facility would have scheduled and followed up on the ordered consults. The Director of Nursing Services and the Administrator were unable to provide evidence that the facility had followed up or scheduled the necessary appointments as ordered by the providers. The records lacked documentation of the appointments and outcomes, indicating a failure in the facility's processes for ensuring residents receive timely and appropriate follow-up care.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving two residents. Resident ID #2 was observed by staff with their hand under the blanket of Resident ID #1, rubbing between their legs and asking if they liked it. This incident was witnessed by staff, and Resident ID #2 quickly moved their hand away when approached. Resident ID #1, the victim, had a BIMS score of 3 out of 15, indicating severely impaired cognition, and was unable to consent to such actions. Resident ID #2, the perpetrator, had a BIMS score of 13 out of 15, indicating intact cognition, and had a history of using inappropriate language towards others. The incident was reported to the Rhode Island Department of Health, and interviews with facility staff, including the Administrator, DON, and MDS Coordinator, confirmed the inappropriate behavior. The MDS Coordinator noted that Resident ID #2 was likely aware of their actions due to their cognitive status, while Resident ID #1's cognitive impairment rendered them unable to consent. The facility's failure to prevent this incident resulted in a deficiency related to the protection of residents from abuse.
Failure to Notify Provider of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify the ordering physician or a provider of laboratory results that were outside of clinical reference ranges for a resident. The resident, who was admitted to the facility with a diagnosis including alcoholic cirrhosis of the liver, had a physician's order for regular blood tests. A lab report revealed abnormal results, including elevated white blood cells and monocytes, and low hemoglobin levels, which were not communicated to a provider. This lack of communication occurred despite the facility's protocol to report lab results to a provider and document any new orders in the progress notes. The resident later exhibited symptoms of trouble breathing, a bloated abdomen, and rectal bleeding, leading to their transfer to the hospital, where they were diagnosed with a ruptured intestine and sepsis, and subsequently died. Interviews with facility staff, including a nurse practitioner and the Director of Nursing Services, confirmed that the lab results should have been reported to another provider in the absence of the primary provider. However, there was no evidence that the lab results were reviewed or acted upon by any provider, contributing to the resident's deteriorating condition.
Failure to Implement Water Management Program
Penalty
Summary
The facility failed to provide a safe and sanitary environment to help prevent the transmission of infections related to implementing a water management program based on industry standards and the CDC toolkit. The surveyor's observations, record reviews, and staff interviews revealed that the facility's water management binder lacked evidence of a water flow assessment identifying areas where Legionella could grow and spread. Additionally, the second and fourth-floor tubs were observed being used as storage, and there was no evidence that these tubs were flushed regularly to maintain water quality. During interviews, the Maintenance Director and the Regional Plant Operations Director acknowledged that the tubs were still functioning but could not provide evidence of regular flushing. Further record reviews failed to show monitoring and flushing of infrequently used fixtures, including the second and fourth-floor tubs. The facility was unable to provide evidence of a water flow assessment or a water management program based on industry standards and the CDC toolkit for preventing Legionella growth, as required.
Failure to Treat Resident with Respect and Dignity
Penalty
Summary
The facility failed to treat a resident with respect and dignity, particularly in relation to assistance with toileting and communication. The resident, who was admitted with diagnoses including hemiplegia and an ankle fracture, has intact cognition and requires an interpreter as English is not their primary language. Despite the facility's policy to use translation services and communication boards, these were not utilized during the incident in question. The resident's care plan included specific interventions for communication, but these were not followed by the staff involved. During the night shift, the resident requested assistance to transfer from bed to the bathroom, but the Nursing Assistant (NA) provided a bedpan instead. The resident, recently cleared by physical therapy for transferring out of bed, urinated in the bedpan, which eventually spilled. The resident alleged that the NA became upset and hit them on the leg. The NA admitted to not using the communication board or interpreter services and called for the nurse's assistance due to the resident's frustration. The nurse also failed to use the communication tools and did not inform the NA about the resident's preference for using the bathroom. The Director of Nursing Services (DNS) confirmed that staff should have used the communication tools available to facilitate communication with the resident. The DNS was unable to provide evidence that the resident was treated with respect and dignity during the incident. The failure to use the appropriate communication methods and the alleged physical abuse led to the deficiency noted in the report.
Failure to Report Alleged Sexual Abuse in a Timely Manner
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, as required by state and federal law. Specifically, an allegation of staff-to-resident sexual abuse was reported to the facility in February 2024, but the facility did not report this allegation to the Rhode Island Department of Health (RIDOH) or other officials until approximately four weeks later, after being questioned by a surveyor. The facility's policy mandates that such allegations be reported immediately, but not later than 2 hours after the allegation is made if it involves abuse, or no later than 24 hours if it does not involve abuse and does not result in serious bodily injury. The resident involved, who was admitted to the facility in December 2023 with diagnoses including diabetes, cerebrovascular accident (stroke), and depression, reported that a male staff member inserted their finger in the resident's rectum during care. The resident had a Brief Interview for Mental Status score indicating intact cognition. Despite the Social Services Director reporting the allegation to the Administrator immediately after it was made, the Administrator acknowledged that he did not follow through with the required reporting to RIDOH or other officials until prompted by the surveyor's inquiry, thus failing to comply with the facility's policy and regulatory requirements.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to provide evidence that all alleged violations were thoroughly investigated for a resident who reported an allegation of staff-to-resident sexual abuse. The complaint was submitted to the Rhode Island Department of Health, alleging that the facility did not follow up on the allegation. The facility's policy requires that all reports of resident abuse be thoroughly investigated and a follow-up investigation report be provided within five business days. However, the facility did not adhere to this policy in this case. The resident, who was admitted in December 2023 with diagnoses including diabetes, cerebrovascular accident (stroke), and depression, reported the abuse during a care conference in February 2024. The Social Services Director confirmed that she reported the allegation to the Administrator immediately. The Administrator acknowledged being aware of the allegation but admitted that the facility did not conduct a thorough investigation as required by their policy.
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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.
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Nursing homes near Johnston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedar Crest Nursing Centre Inc | 1.6 mi | ★★★★★ | 2 | 0 |
| Briarcliffe Manor | 2.3 mi | ★★★★★ | 0 | 0 |
| Cherry Hill Manor | 2.4 mi | ★★★★★ | 7 | 0 |
| Elmwood Nursing And Rehabilitation Center | 2.6 mi | ★★★★★ | 14 | 0 |
| Adviniacare Providence Dodge Rehab Center, Llc | 2.7 mi | ★★★★★ | 4 | 0 |
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