The resident, identified only as Resident ID #1, entered the facility in November 2025 with multiple health conditions including a history of UTIs and COVID-19. A physician ordered laboratory tests on November 10, but staff never completed them.
Four days later, on November 14, a urine culture came back positive for infection. Nobody looked at the results.
The infection preventionist told federal inspectors that facility staff didn't view the November 14 lab results until November 17 — the same day they rushed the resident to the hospital for shortness of breath, blood in the urostomy, and complications with a drainage tube. The resident remained hospitalized as of November 24.
"A provider was not notified of the results and interventions were not put into place," the infection preventionist acknowledged during the November 25 inspection.
The delayed response occurred during a facility-wide COVID outbreak that began November 17 and infected 19 of 43 residents by November 24. Yet staff had also failed to test Resident ID #1 for COVID at all during their stay, despite written policies requiring tests on admission, day two, and day four.
Registered Nurse Staff A confirmed the facility's COVID testing failures during an interview with inspectors. She acknowledged that "every resident should be tested for Covid on admission, on day two, and on day four" but admitted Resident ID #1 "had not been tested for Covid-19 at all while admitted to the facility."
A second resident, ID #2, experienced similar lapses in care. Admitted in November with a history of UTIs and muscle weakness, this resident had a care plan dated November 19 that specifically called for obtaining and monitoring lab results as ordered.
On November 19, a physician ordered a urine culture for Resident ID #2. Staff never completed it.
Records show the facility obtained other blood work for this resident on November 14 without any physician's order. The abnormal results were never reported to a provider. Like the first resident, Resident ID #2 was never tested for COVID on admission or day two as required. The resident tested positive for COVID on November 21.
During interviews, multiple staff members confirmed the systematic failures. Registered Nurse Staff B told inspectors that "all new admissions are tested for Covid-19 on admission, day two, and day four" but acknowledged Resident ID #2 had not been tested on admission or day two. She could not provide evidence of a physician's order for the November 14 blood work or proof that anyone had notified a provider about the abnormal results.
The Director of Nursing Services said she "would expect physician's orders to be followed, as ordered, and that labs would be completed and reported to a provider." She confirmed the COVID outbreak began November 17 and that nearly half the facility's residents had tested positive within a week.
The Medical Director explained she relies entirely on facility staff to alert her to lab results. "She would expect to be notified of lab results because she does not review results unless the facility notifies her," according to the inspection report. She said she expected physician's orders to be completed as ordered and that "nurses document when providers are notified."
Federal inspectors found that Royal Middletown's failures created a cascade of missed opportunities. The facility had clear protocols for COVID testing during outbreaks. Staff knew about the November 17 outbreak start date. Yet they admitted residents during this period without following their own testing requirements.
The UTI-related failures compounded the COVID oversights. Resident ID #1's November 10 lab orders went unfilled for four days. When different tests finally came back positive for infection on November 14, they sat unreviewed until November 17. By then, the resident was experiencing blood in their urostomy and required emergency hospitalization.
For Resident ID #2, the pattern repeated. A November 19 physician's order for urine testing remained unfulfilled as of the November 25 inspection. Meanwhile, unauthorized blood work from November 14 showed abnormal results that no provider ever saw.
The inspection report notes that the facility's failures "resulted in a delay of care, including the hospitalization of Resident ID #1." Federal inspectors classified the violations as causing "actual harm" to residents.
Staff acknowledged during interviews that they understood the requirements but simply hadn't followed them. The infection preventionist confirmed she knew about the COVID testing protocols. The registered nurses confirmed they understood lab results needed physician review. The Director of Nursing confirmed physician orders should be followed.
Yet across multiple residents and multiple weeks, the same basic breakdowns occurred repeatedly.
Resident ID #1 remained hospitalized with complications that included UTI and COVID as of November 24, nearly two weeks after entering Royal Middletown for what should have been routine care. The resident's November 10 lab orders, which might have caught the UTI early, were never completed at all.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Royal Middletown Nursing Center from 2025-11-25 including all violations, facility responses, and corrective action plans.