Royal Middletown Nursing Center
Royal Middletown Nursing Center in Middletown, RI — inspection on November 25, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of a care plan dated 11/19/2025 revealed, the resident had a UTI with interventions including, but not limited to, to obtain and monitor lab results, as ordered.2a.
Record review of the physician's order revealed the following:11/19/2025 to obtain a UA C&S
Record review failed to reveal evidence that the UA C&S was completed.
Additional record review revealed laboratory tests that included a CBC were obtained on 11/14/2025 and resulted the same day; however, the record failed to provide evidence of a physician's order.
Furthermore, the record failed to provide evidence that the abnormal results were reported to a provider, or that the UA C&S was obtained as ordered.2b.
Record review revealed a physician's order dated 11/13/2025 to [Covid-19] Test new admissions or residents who have left the facility for more than 24 hours, regardless of vaccination status, on admission, day 2 and day 4.
Record review failed to reveal evidence that Resident ID #2 was tested for Covid-19 on admission or on day two, as ordered.
Record review revealed the resident tested positive for Covid on 11/21/2025.During a surveyor interview on 11/25/2025 at approximately 11:00 AM with RN, Staff B, she indicated that all new admissions are tested for Covid-19 on admission, day two, and day four, and acknowledged that Resident ID #2 had not been tested on admission or on day two, as ordered.
She could not provide evidence of a physician's order for the labs obtained on 11/14/2025 or that a provider had been notified of the abnormal results.
Additionally, she acknowledged that the UA C&S still had not been obtained, as ordered, and could not provide evidence that the provider had been notified.
During a surveyor interview on 11/25/2025 at 11:21 AM with the Director of Nursing Services, she indicated that she would expect physician's orders to be followed, as ordered, and that labs would be completed and reported to a provider.
She further indicated that the Covid-19 outbreak began on 11/17/2025 and that 19 of 43 residents had tested positive as of 11/24/2025.
During a surveyor interview on 11/25/2025 at approximately 11:45 AM with the Medical Director, she indicated that she would expect to be notified of lab results because she does not review results unless the facility notifies her.
Additionally, she indicated that she would expect physician's orders to be completed, as ordered, and that nurses document when providers are notified.
The facility's failure involved UTI-related laboratory testing and follow-up, that resulted in a delay of care, including the hospitalization of Resident ID #1.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Royal Middletown Nursing Center
193 Forest Avenue Middletown, RI 02842
SUMMARY STATEMENT OF DEFICIENCIES
Review of a care plan dated 11/19/2025 revealed, the resident had a UTI with interventions including, but not limited to, to obtain and monitor lab results, as ordered.2a.
Record review of the physician's order revealed the following:- 11/19/2025 to obtain a UA C&S
Record review failed to reveal evidence that the UA C&S was completed as ordered. 2b.
Record review revealed a physician's order dated 11/13/2025 to [Covid-19] Test new admissions or residents who have left the facility for more than 24 hours, regardless of vaccination status, on admission, day 2 and day 4.
Record review failed to reveal evidence that Resident ID #2 was tested for Covid-19 on admission or on day two, as ordered.
Record review revealed the resident tested positive for Covid on 11/21/2025.During a surveyor interview on 11/25/2025 at approximately 11:00 AM with RN, Staff B, she indicated that all new admissions are tested for Covid-19 on admission, day two, and day four, and acknowledged that Resident ID #2 had not been tested on admission or on day two, as ordered.
Additionally, she acknowledged that the UA C&S still had not been obtained, as ordered, and could not provide evidence that the provider had been notified.
During a surveyor interview on 11/25/2025 at 11:21 AM with the Director of Nursing Services, she indicated that she would expect physician's orders to be followed, and that labs would be completed and reported to a provider.
She further indicated that the Covid-19 outbreak began on 11/17/2025 and that 19 of 43 residents had tested positive as of 11/24/2025.
During a surveyor interview on 11/25/2025 at approximately 11:45 AM with the Medical Director, she indicated that she would expect to be notified of lab results because she does not review results unless the facility notifies her.
Additionally, she indicated that she would expect physician's orders to be completed and that nurses document when providers are notified.
The facility's failure involved UTI-related laboratory testing and follow-up, and failure to obtain Covid-19 testing as ordered, which resulted in a delay of care, including the hospitalization of Resident ID #1 with diagnoses including a UTI and Covid-19.
Facility ID:
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.