St Antoine Residence
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
and Primapore (a non-adherent dressing) to cover area as s/he is picking at it. Record review failed to reveal evidence that the facility monitored or assessed the lesion/wound to the right temple from 2/10/2025 until 6/28/2025 when it was documented that the resident was picking at the lesion/wound. Record review revealed the following physician orders:6/28/2025- an antibiotic ointment to be applied to the open area on
the right temple cancer lesion and cover with Primapore.7/15/2025- Imiquimod external cream 5% (a topical medication used to treat certain skin conditions, including basal cell carcinoma apply to right temple every other day.9/4/2025- Metronidazole external gel 0.75 % (an antibiotic medication used to treat various infections caused by bacteria and parasites) apply to the right side of head every other day. Record review of the weekly skin checks from 12/13/2024 through 9/7/2025 failed to reveal evidence that the resident had
a right temple wound/lesion. Record review of a nursing progress note dated 9/7/2025 revealed that the resident was sent to the hospital as maggots were found in the right temple wound. The resident was admitted to the hospital with squamous cell carcinoma of right temple with maggots present. Record review of a nursing progress note dated 9/7/2025, authored by Licensed Practical Nurse (LPN), Staff A, indicated that the resident kept picking at the wound. Additionally, the note revealed that Staff A noticed some bloody drainage leaking onto the resident's face and right hand from the wound. When Staff A attempted to clean
the wound and the resident's face, she observed some pulsating worms moving inside of the wound, so s/he was transferred to an acute care hospital. Record review of the hospital admission document dated 9/7/2025 revealed that the resident was transferred to the Emergency Department (ED) with a large right-sided wound on the temple which was infested with many maggots. Additionally, the document revealed that the resident was actively picking at the wound while in the ED. Further, it indicated that the wound was irrigated, and many maggots/fly larvae (eggs from the flies) were removed from it.Further hospital documentation revealed that the family member denied MOHS surgery and thought the lesion was being managed conservatively with ointments and topical creams at the nursing home. The note indicates that initially .the patient had a intact skin barrier with no breakage or infestations. But slowly over the course of the last six months the wound marking started to fall out and a full-blown hollow wound was formed .
Additional review of this paperwork revealed a 3.5-centimeter lesion with necrotic components at right temporal-parietal region adjacent to the ear and the patient will be referred for resection and skin flap advancement by plastic surgery. During a surveyor interview on 9/9/2025 at 1:39 PM and 9/16/2025 at approximately 12:30 PM with Licensed Practical Nurse, Staff A, she revealed the resident has a cancerous lesion which was found during a dermatology consult a few months ago but got worse over time as the resident kept picking at it. Additionally, Staff A disclosed that the resident had a physician's order to apply Aquaphor ointment to the right temple for two weeks from January to February. However, after the treatment ended, the lesion was left untreated until June, when a topical antibiotic was finally started due to
the wound's condition. Further, Staff A revealed on 9/7/2025 she observed maggots in the wound and sent
the resident to the hospital. During surveyor interviews on 9/10/2025 at 9:16 AM and on 9/16/2025 at approximately 3:00 PM with the Director of Nursing Services, she acknowledged that the lesion/wound to
the resident's right temple had become worse. Additionally, she was unable to provide evidence that the wound was treated or assessed from 2/10/2025 until 6/28/2025. Furthermore, she was unable to provide evidence that the weekly skin checks from 12/13/2024 through 9/7/2025 were accurately completely, as the right temple lesion/wound was not assessed on the weekly skin checks.
Event ID:
Facility ID:
If continuation sheet
St Antoine Residence in North Smithfield, RI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in North Smithfield, RI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from St Antoine Residence or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.