Belmont Terrace Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Florence, Kentucky.
- Location
- 7300 Woodspoint Drive, Florence, Kentucky 41042
- CMS Provider Number
- 185090
- Inspections on file
- 24
- Latest survey
- April 24, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Belmont Terrace Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Three residents experienced abuse or neglect when a staff member removed a dependent resident's call light device and failed to report or repair it, and when two residents were involved in a physical altercation after one entered the other's room. Staff did not ensure the call system was functional or provide adequate supervision to prevent resident-to-resident abuse, despite facility policies requiring such protections.
A resident with a history of behavioral and psychiatric issues was transferred to a BH facility after exhibiting combative behavior. The facility did not provide the required written 30-day discharge notice to the State Guardian or the LTC Ombudsman when it decided not to readmit the resident, and failed to communicate its intentions in a timely manner. The lack of notification and communication led to confusion, legal intervention, and the resident remaining at the BH facility longer than necessary.
The facility failed to develop and implement comprehensive person-centered care plans for eight residents, leading to various deficiencies, including pressure ulcers, elopements, inadequate catheter care, and improper G-tube site management. Additionally, concerns about a malfunctioning wheelchair brake were not addressed, posing a risk of falls.
A resident developed a stage 4 pressure ulcer due to the facility's failure to provide adequate care, including timely repositioning and incontinence management. Staff did not consistently assist or remind the resident to off-load pressure, and there was a lack of communication and coordination among the care team.
The facility failed to maintain sufficient nursing staff, resulting in residents experiencing delays in care and inadequate supervision. A resident was admitted to the hospital with saturated briefs and wounds due to insufficient staffing. Interviews with residents and staff confirmed long wait times and rushed care, highlighting the severe impact of inadequate staffing.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, with issues including undated and unlabeled food items, unsanitary conditions in the tray line area, and improper storage of clean dishes. Interviews revealed that facility policies were not being followed, leading to multiple deficiencies.
The facility failed to ensure effective administration and infection control, leading to continued non-compliance in areas such as Resident Rights, Quality of Life, Nursing Services, and Infection Control. Staffing issues and lack of adherence to infection control protocols were observed, with staff failing to disinfect equipment and wear appropriate protective gear. Interviews revealed insufficient training and oversight by the administration.
The facility failed to address systemic failures through the QAPI process, leading to issues in staffing, basic care, and infection control. One resident did not receive a shower for over a week due to low staffing, and another resident's dignity was compromised during care. Additionally, staff did not follow proper hand hygiene and disinfection protocols.
The facility failed to follow proper infection control practices, including hand hygiene, disinfection of shared equipment, and handling of soiled linens, leading to potential cross-contamination and increased infection risk among residents. Staff were observed not adhering to protocols, and interviews revealed gaps in training and compliance.
The facility failed to accommodate the needs and preferences of six residents, including delayed wheelchair repairs, communication barriers for a non-English speaking resident, inaccessible call lights, and unmet personal shopping needs.
The facility failed to ensure a safe, clean, and homelike environment, with strong odors of urine and feces, unclean floors, and a tripping hazard from a loose metal plate. Staff and residents expressed concerns about cleanliness, and interviews revealed a lack of proper maintenance and cleaning documentation.
The facility failed to protect residents from abuse and neglect, including incidents of sexual activity between cognitively impaired residents, verbal abuse by untrained staff, neglect of a resident sent to the hospital in soiled briefs, and resident-to-resident altercations. The facility's lack of proper supervision, training, and consistent care contributed to these deficiencies.
The facility failed to protect residents from misappropriation of their belongings and money, involving six residents. Despite being aware of a resident's repeated thefts, the facility did not take adequate measures to prevent further incidents. The facility's policies on abuse, neglect, and misappropriation were not effectively implemented, and medication carts were not secured, leading to unauthorized access to controlled substances.
The facility failed to maintain a safe environment and provide adequate supervision to prevent accidents for eleven residents. Two residents with cognitive impairments eloped from the facility due to inadequate supervision and an ineffective alarm system. The facility's Elopement Binders were not up-to-date, and staff were desensitized to frequent, loud alarms, leading to delayed responses.
The facility failed to ensure nurse aides demonstrated competency in essential skills, including behavior management, catheter care, and maintaining resident dignity. Observations revealed improper feeding techniques and inadequate hand hygiene practices. Staff reported not receiving training on handling aggressive resident behavior, and management acknowledged gaps in training, especially for agency and travel staff.
The facility failed to have an effective antibiotic stewardship program, neglecting to monitor and assess antibiotic use for five residents. The facility did not track antibiotic use or report on antibiotic use and resistance to leadership.
The facility failed to educate and offer COVID-19 immunization to two residents and did not maintain proper documentation of vaccination status for a staff member. The interim DON/IP and Administrator acknowledged the lack of complete vaccination records and emphasized the importance of following CDC recommendations and infection control policies.
The facility failed to ensure a dignified existence for two residents by not providing privacy during catheter care and not using dignity bags for their catheters. Staff interviews confirmed the importance of these measures, but they were not consistently implemented.
The facility failed to involve a resident in the care planning process, as required by policy. Despite the resident having no cognitive impairment, there was no documentation of their participation in recent care conferences. Interviews with staff revealed inconsistencies and a lack of clarity in the care conference process.
The facility failed to follow its policy regarding Advance Directives for three residents, resulting in missing signed Advance Directives and lack of documentation that materials were reviewed with residents or their representatives upon admission or quarterly thereafter.
The facility failed to protect a resident from involuntary seclusion. Staff members were observed escorting the resident to his/her room and closing the door tightly, preventing the resident from exiting. The resident, who has severe cognitive impairment, was unable to open the door independently. Staff admitted to not being aware of the policy against this practice, and interviews with various staff members revealed inconsistent understanding and adherence to the facility's policy on involuntary seclusion.
The facility failed to thoroughly investigate allegations of sexual abuse involving two cognitively impaired residents. Despite being found in compromising situations twice, there was no documented evidence of a complete investigation or adequate measures to prevent further incidents. Staff interviews revealed a lack of proper assessment and monitoring of the residents' capacity to consent to sexual activity.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS did not reflect their use of oxygen, despite a physician's order and observation of oxygen use. Another resident's dental care was not assessed, leading to untreated cavities and missed dental appointments.
The facility failed to ensure that a resident who was unable to perform ADLs independently received necessary services for good grooming, personal, and oral hygiene. The resident was observed with soiled clothes, poor dental hygiene, and uncombed hair, and reported not receiving timely assistance for transfers and other care needs. Staff interviews confirmed inconsistencies in care provision and documentation.
The facility failed to provide individualized activities for two residents, leading to dissatisfaction and lack of engagement. One resident described the activities as childlike and simplistic, while another expressed a desire for gardening and outdoor activities. Observations and interviews revealed that the facility did not adhere to its policies on resident rights and activities, and the Activities Director confirmed the lack of a specific policy and a low budget for activities.
The facility failed to ensure proper wound and tube site care for three residents. One resident's sacral wound dressing was not changed as ordered, another resident's J-tube site was not cleaned or dressed properly, and a third resident's G-tube site was excoriated and not covered with a dressing. Interviews and observations confirmed these deficiencies.
A resident with severe cognitive impairment and requiring enteral nutrition experienced significant weight loss due to the facility's failure to follow physician's orders for tube feedings. The tube feeding pump was consistently set to incorrect parameters, and the equipment used for flushing the feeding tube was not maintained properly. Nursing staff and the DON confirmed the orders were not followed, leading to inadequate nutrition and hydration for the resident.
An LPN on her first day at the facility administered eight medications prescribed for one resident to another, resulting in a medication error rate of 26.67%. The error occurred due to difficulties in logging into the computer and unfamiliarity with the residents, leading to incorrect resident identification.
A nurse failed to accurately identify residents, resulting in a significant medication error where a resident received another's medications. The error was realized after the surveyor's intervention, and the facility's staff acknowledged the failure to follow proper medication administration protocols.
The facility failed to ensure proper labeling and storage of medications for two residents. A KMA placed medications into unlabeled cups and stored them in a medication cart drawer, contrary to facility policy. The DON confirmed the medications should have been properly labeled and stored.
The facility failed to provide two residents with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs. One resident on a controlled carbohydrate diet received inadequate portions and no alternatives, while another resident did not receive fish as per their religious preference. Interviews revealed a lack of training and adherence to specialized diets and food preferences among dietary staff.
The facility failed to follow dietary orders and provide adequate nutrition for a resident with specific dietary needs due to conditions like end-stage renal disease and Type 2 diabetes. Despite physician-ordered diets, the resident frequently received inadequate portions, and other residents also reported insufficient food servings. Interviews and observations revealed systemic issues in the facility's dietary service.
The facility failed to provide food that was palatable, attractive, and at an appetizing temperature for three residents. Observations and interviews revealed that meals were often served cold, and residents were not consistently offered substitutions. Staff acknowledged issues with food temperature monitoring, and despite changes made by the Administrator, the problem persisted.
The facility failed to provide and document the pneumococcal vaccination for a resident with moderate cognitive impairment and multiple diagnoses, despite following CDC recommendations. The resident did not recall being offered the vaccine, and there was no evidence of vaccination or refusal in the medical record.
Failure to Prevent Abuse and Neglect of Residents
Penalty
Summary
The facility failed to protect residents from abuse and neglect in multiple instances involving three residents. In one case, a resident with functional quadriplegia and total dependence on staff for care reported that a night shift SRNA intentionally removed his call light device from the wall and inserted a plastic object into the port, rendering the call system unusable for the duration of the shift. The resident, who was able to make decisions regarding daily life tasks and communicate his needs, was left without access to the call system until the following day when a day shift SRNA discovered the issue and restored the device. The staff member involved admitted to removing the device due to a malfunction but failed to notify maintenance or the oncoming shift, and no work order was placed for repair. The resident did not experience further incidents with the call device after the event. In another incident, a resident with severe cognitive impairment physically struck another resident who had entered her room, resulting in a nosebleed for the visitor and an ankle injury for the aggressor. Both residents were immediately separated by staff, and the incident was witnessed by staff who responded to the altercation. The resident who was struck was confused but did not show signs of pain or fear, and the aggressor was assessed for injury. Both residents' families and appropriate authorities were notified, and psychosocial monitoring was conducted following the event. The facility placed a stop sign on the aggressor's door to prevent further incidents of wandering into her room. The facility's policies required screening of potential hires for abuse history, background checks, and staff training on abuse prevention and reporting. Despite these policies, the incidents occurred due to staff inaction, such as failing to ensure the call light was functional and not reporting or addressing the malfunction, as well as inadequate supervision that allowed a resident-to-resident altercation to occur. Interviews with staff and administration confirmed the sequence of events and the failure to follow established protocols to prevent abuse and neglect.
Failure to Provide Required Written Notification of Discharge to Guardian and Ombudsman
Penalty
Summary
The facility failed to provide timely and proper written notification to the State Guardian and the Office of the State Long-Term Care Ombudsman regarding its intention to discharge a resident, as required by federal regulations. The resident in question, who had diagnoses including dysphagia, schizophrenia, and bipolar disorder, was transferred to a Behavioral Health (BH) facility following combative and disruptive behavior, including physical aggression and property destruction. Documentation revealed that the facility did not notify the State Guardian or the Ombudsman in writing of the transfer or the subsequent decision not to readmit the resident, nor did it provide a 30-day written notice of discharge as required. The facility's own policies on transfer/discharge and bed hold did not address the required 30-day notice of transfer/discharge. Review of the resident's medical record and facility documentation showed inconsistencies and lack of clarity regarding who was notified, when, and how. The State Guardian and the Ombudsman both reported not receiving the required notifications, and the Guardian only learned of the facility's refusal to readmit the resident through the BH facility's Discharge Planner. Multiple attempts by the Guardian and the Discharge Planner to contact the facility for clarification went unanswered, and the Ombudsman was not informed of the discharge decision until after the fact. Interviews with facility staff, including the Business Office Manager, DON, and Administrator, confirmed that the required notifications were not sent in a timely manner or at all. The Administrator stated that a notice was not sent because the facility did not initially intend to refuse readmission, but later required documentation that the resident was not a danger before considering readmission. The lack of written notice and communication led to legal intervention, with the Guardian seeking a stay of discharge and legal counsel being retained. The Ombudsman and Guardian both confirmed that the facility did not follow required notification procedures, resulting in the resident remaining at the BH facility longer than necessary.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for eight residents, leading to various deficiencies. Resident #3 developed a Stage 4 pressure ulcer due to the facility's failure to include interventions for offloading and keeping the wound bed dry, despite the resident's urostomy/ileostomy frequently leaking. Staff did not remind or assist the resident with repositioning, and the wound care nurse noted that keeping the wound dry was crucial for healing, but this was not adequately addressed in the care plan. Resident #63 and Resident #112 both eloped from the facility, with the facility failing to develop and implement effective interventions to prevent these incidents. Resident #112 also had severe cognitive impairment and was involved in sexual activity with another resident, but the facility did not address the resident's inability to consent to sexual activity in the care plan. Similarly, Resident #101, who engaged in sexual activity with Resident #112, had language barriers that were not adequately addressed, leading to ineffective communication and assessment of the resident's needs. Other deficiencies included the facility's failure to implement care plan interventions for Resident #105's indwelling urinary catheter, leading to the catheter bag dragging on the floor and lack of privacy during catheter care. Resident #126 and Resident #86, both with G-tubes, had excoriated skin around the insertion sites due to the facility's failure to implement proper care plan interventions. Additionally, Resident #71 expressed concerns about a malfunctioning wheelchair brake, but the facility did not develop a care plan intervention to address this issue, posing a risk of falls during transfers.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to provide adequate pressure ulcer prevention and care for Resident #3, who was admitted with no skin breakdown but later developed a stage 4 pressure ulcer. Despite being assessed as at risk for pressure ulcers, the facility did not implement effective interventions to prevent the development of the ulcer. The resident was often found in soiled briefs, and staff failed to encourage or assist with repositioning to off-load pressure from the wound. Additionally, the resident's care plan did not include specific interventions to address the frequent leakage from the resident's urostomy/ileostomy, which contributed to the wound's deterioration. Observations during the survey revealed multiple instances where staff did not notice or address the resident's incontinence, leading to prolonged exposure to moisture and further compromising the wound. The resident was found sitting in a heavily soiled brief with a displaced dressing, and staff failed to remind or assist the resident with repositioning. Interviews with staff indicated a lack of awareness and communication regarding the resident's needs and abilities, such as the ability to perform wheelchair push-ups to off-load pressure. The facility also lacked a mechanism to hold staff accountable for regularly checking and changing the resident's briefs. The facility's failure to provide timely and appropriate care for Resident #3's pressure ulcer was further compounded by inadequate communication and coordination among the care team. The Wound Care Nurse and other staff members acknowledged the need for frequent repositioning and keeping the wound dry, but these interventions were not consistently implemented. The facility did not explore potential solutions, such as consulting with therapy departments for specialized cushions or developing a resident-specific schedule for repositioning, to better accommodate the resident's preferences and promote wound healing.
Inadequate Staffing Leading to Resident Neglect
Penalty
Summary
The facility failed to ensure sufficient numbers of nursing staff, including nurse aides, on a 24-hour basis to provide necessary nursing care for residents in accordance with their care plans. On multiple occasions, the facility was found to have significantly fewer nurse aide hours than required, particularly on weekends and during the night shifts. This resulted in residents experiencing delays in receiving incontinence care and medications, as well as inadequate supervision and assistance with daily activities. For instance, on 03/03/2024, the facility had under 200 nurse aide hours, well below the required 230-260 hours, leading to residents waiting over an hour for call lights to be answered and staff feeling rushed in their duties. Resident #152 was admitted to the hospital on 01/07/2024, wearing two saturated briefs and with wounds on his/her buttocks. The facility's records indicated that staffing on that day was significantly below the required levels, with only 154.5 nurse aide hours documented. Interviews with staff revealed that double briefing was a common practice due to short staffing, which was not condoned by the facility. The resident's condition deteriorated due to insufficient care, highlighting the severe impact of inadequate staffing. Multiple interviews with residents and staff corroborated the findings of insufficient staffing. Residents reported long wait times for assistance, and staff admitted to feeling overwhelmed and unable to provide adequate care. The facility's management acknowledged the staffing issues but failed to provide a clear plan for ensuring sufficient staffing levels. The Director of Nursing and the Administrator both admitted to the challenges in maintaining adequate staffing, particularly during weekends and night shifts, but did not offer a solution to address the deficiencies effectively.
Deficiencies in Food Storage, Preparation, and Cleanliness
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service in the kitchen. During an initial kitchen tour, surveyors observed several issues including undated and unlabeled food items such as thickened orange juice, chicken, dumplings, and sugar cookie dough. Additionally, the tray line area was found to be unsanitary with a mop container filled with brown water, a dirty rag on the garbage can lid, and a dusty light fixture overhead. The pantry also contained undated canned spaghetti and lacked a thermometer, while the supply room had a sticky substance on the floor and a broken vent on the air conditioning unit. Clean dishes were improperly stored upright or sideways without covering, increasing the risk of contamination. These observations were confirmed during a follow-up kitchen tour, where similar issues persisted, including the presence of gnats in the pantry and undated food items. Interviews with the Interim Dietary Manager, Registered Dietician, Interim Director of Nursing, and Administrator revealed that the facility's policies were not being followed, as all agreed that food items should be labeled and dated, and the kitchen should be cleaned daily. The Administrator emphasized the importance of proper labeling to prevent foodborne illnesses and expected the dietary staff to maintain cleanliness and proper hand hygiene. Despite these expectations, the facility failed to adhere to its own policies, resulting in multiple deficiencies in food storage, preparation, and cleanliness.
Facility Fails to Ensure Effective Administration and Infection Control
Penalty
Summary
The facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility did not have an effective process in place to address systemic failures through the Quality Assurance Performance Improvement (QAPI) process. This resulted in continued non-compliance in several areas, including Resident Rights, Quality of Life, Nursing Services, and Infection Control, potentially affecting all 129 current residents. The facility's Plan of Correction (POC) from a previous survey included training all nursing staff on catheter care, hand hygiene, and providing resident care in a dignified manner, as well as conducting regular audits to identify and correct any continued deficient practice. However, the facility failed to implement these measures effectively, as evidenced by the continued deficiencies observed during the survey. On the Daily Staffing Assignment Sheet dated 05/06/2024, the Administrator signed off on a schedule that displayed only 212 hours of State Registered Nurse Aide (SRNA) hours, which did not reflect the true staffing for the night shift due to an SRNA calling in. Interviews with staff revealed that staffing had improved but was still insufficient, particularly during evening hours, leading to decreased supervision of residents with behaviors and some residents missing showers. The Administrator admitted to verifying staffing each day but was unaware of the SRNA call-in on 05/06/2024 and had no evidence of informal interviews with staff regarding workloads. Observations on 05/10/2024 revealed multiple instances of staff failing to follow infection control protocols. An SRNA did not disinfect a mechanical lift after use, and two SRNAs and an LPN did not wear gowns while providing care to a resident on Enhanced Barrier Precautions (EBP). Additionally, an SRNA failed to perform hand hygiene after doffing soiled gloves. Interviews with staff indicated a lack of recall regarding recent training on infection control measures, and the Administrator acknowledged the need for re-education on disinfection protocols. The facility's POC evidence binders failed to identify continued staff noncompliance with regulations related to hand hygiene, disinfection of shared equipment, resident dignity during care, and provision of ADL care.
Systemic Failures in QAPI Process and Basic Care
Penalty
Summary
The facility failed to have an effective process in place to address systemic failures through the Quality Assurance Performance Improvement (QAPI) process. The facility did not effectively track staffing patterns and staff failed to provide basic care, including showers. The Administrator and Director of Nursing (DON) were supposed to review staffing needs and implement corrective actions, but discrepancies in staffing calculations and lack of awareness of staff absences were noted. The Administrator admitted that the staffing sheets were confusing and that the Scheduler did not always comply with directives, leading to incorrect staffing numbers and unawareness of staff absences, which were not identified until the State Survey Agency (SSA) intervened. The facility also failed to ensure residents received Activities of Daily Living (ADL) care, including showers. One resident, admitted with diagnoses including hemiplegia and tracheostomy status, had not received a shower for over a week. The resident indicated that she was due for a shower but believed the facility was short-staffed. The responsible State Registered Nurse Aide (SRNA) confirmed that due to low staffing, she did not have time to give the resident a shower. The resident was observed with greasy hair, indicating a lack of proper hygiene care. Additionally, the facility failed to ensure proper catheter care, hand hygiene, and disinfection of contaminated equipment. One Licensed Practical Nurse (LPN) did not follow proper hand hygiene protocols during catheter care, and another LPN could not recall recent training on catheter care. Another resident was exposed to the hallway and a shared mirror during care, compromising her dignity. Furthermore, an SRNA failed to disinfect a mechanical lift after use. The Director of Nursing (DON) did not respond to multiple attempts for an interview, and the Administrator acknowledged the need for re-education on infection prevention protocols.
Infection Control Deficiencies
Penalty
Summary
The facility failed to identify and correct problems related to infection prevention practices for eight sampled residents. Observations revealed that staff did not follow proper hand hygiene protocols, failed to clean and disinfect shared medical equipment, and improperly handled soiled linens. For instance, a Social Services Assistant adjusted call lights for multiple residents without performing hand hygiene between each interaction, and a Hoyer lift used for resident transfers was visibly dirty and not disinfected between uses. Additionally, staff were observed handling soiled linens and contaminated equipment without appropriate personal protective equipment (PPE) or hand hygiene, increasing the risk of cross-contamination and infection spread. Specific incidents included a resident's urinary drainage bag dragging on the floor, which was not addressed by staff, and improper catheter care where washcloths were placed directly in a sink without a basin, potentially introducing bacteria. Another resident's glucose monitoring equipment was not cleaned and disinfected after use, and the nurse failed to perform hand hygiene after administering insulin. These actions were contrary to the facility's infection control policies and CDC guidelines, which emphasize the importance of hand hygiene, proper disinfection of shared equipment, and correct handling of soiled linens to prevent infection. Interviews with staff revealed gaps in training and adherence to infection control protocols. Some staff members were unaware of the correct procedures for cleaning and disinfecting equipment, while others admitted to not following hand hygiene practices consistently. The facility's policies on infection control, cleaning and disinfection of equipment, and catheter care were not being followed, leading to multiple instances of potential cross-contamination and increased risk of infection among residents.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of six residents. Resident #71's wheelchair brake was broken, and the facility did not repair it in a timely manner. The temporary replacement wheelchair also had faulty brakes, causing the resident to feel unsafe during transfers. Despite the resident's concerns and the occupational therapist's daily checks with maintenance, the part for the wheelchair was delayed, and there was no record of follow-up on the order status. The resident's wheelchair was eventually repaired, but the delay placed the resident at risk for falls and injury. Resident #101, a non-English speaking resident with Cantonese as the preferred language, faced significant communication barriers due to the facility's failure to ensure staff were trained and used a Language Line. Multiple staff members, including LPNs and an APRN, documented their inability to communicate effectively with the resident, impacting assessments and care. Despite the facility's policy on language access, there was no evidence that communication tools were used, and staff were unaware of the available interpreter services. Residents #5 and #105 had their call lights out of reach, leaving them unable to request assistance. Observations confirmed that the call lights were either on the bed or the floor, out of the residents' reach. Staff interviews revealed a lack of awareness and adherence to the policy of ensuring call lights were accessible. Additionally, Resident #1 needed new shoes after vomiting on the old pair, and Resident #65 required batteries for hearing aids and desired to go shopping for personal items. The facility's van was out of service, and the activities department was overwhelmed with shopping requests, leading to unmet resident needs.
Facility Fails to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to ensure residents had a safe, clean, comfortable, and homelike environment. Observations revealed a strong odor of urine and feces throughout the facility, particularly in the 100 Hallway. There were water stains on the ceilings, cracked and misshapen ceiling tiles, dirty air intake vents, and unclean floors. A loose and warped metal plate in the 100 Hallway posed a tripping hazard, and clean and dirty items were stored together in the soiled utility room. Additionally, shared bathrooms had strong urine odors and were not clean, and there were visible stains on walls and floors in various areas of the facility. Interviews with staff members indicated that the metal plate in the 100 Hallway had been a known issue since at least mid-February, but it was not reported to maintenance until recently. The Maintenance Assistant confirmed that repairs were made only after being informed a few days prior. Housekeeping staff and directors acknowledged the facility's cleanliness issues, with no daily cleaning logs or documentation of what was cleaned. The Director of Nursing and other staff members admitted that the facility's condition did not constitute a safe, clean, comfortable, homelike environment. Residents and staff expressed concerns about the facility's cleanliness and odors. One resident mentioned that the bathroom could be cleaned more often and better. Social Worker #18 described the facility's potent smell of urine and feces and the dirty condition of the floors. The Housekeeping Director and Regional Housekeeping Director outlined the cleaning procedures but admitted there was no documentation of daily cleaning tasks. The Administrator and Regional Vice President of Operations acknowledged the facility's odors and cleanliness issues, stating that efforts were being made to address them, such as replacing exhaust fans, mattresses, and encouraging residents to shower.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents involving eight residents. Two cognitively impaired residents were observed engaging in sexual activity on two separate occasions, indicating a lack of proper supervision and assessment of their ability to consent. Despite being aware of their cognitive impairments, the facility did not adequately monitor or separate the residents to prevent further incidents. Additionally, there was no documented evidence of psychiatric follow-up for one of the residents involved in the incident, and the care plans lacked specific interventions to address the behaviors observed. A resident was verbally abused by a housekeeping staff member who had not received training on handling residents with aggressive behaviors. The housekeeper threatened to hit the resident after being called a racial slur, demonstrating a lack of appropriate response to the situation. The facility's investigation revealed that the housekeeper had not been provided with any training on abuse prevention or managing residents with behavioral issues. This incident highlights the facility's failure to ensure all staff members are adequately trained to handle such situations. Another resident was sent to the hospital wearing two soiled briefs, indicating neglect in providing appropriate care. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, was found in a neglected state by hospital staff. Interviews with facility staff revealed inconsistencies in the care provided, with some staff members admitting to seeing residents double-briefed due to staffing shortages. The facility's failure to provide consistent and adequate care for this resident resulted in neglect and a decline in the resident's condition. Additionally, there were incidents of resident-to-resident altercations, with one resident scratching another during a verbal argument. The facility's response to these incidents was inadequate, as there was no history of physical aggression between the residents, and the interventions in place were insufficient to prevent such occurrences.
Failure to Protect Residents from Misappropriation of Property
Penalty
Summary
The facility failed to protect residents from the misappropriation of their belongings and money, involving six residents. Resident #127 was identified as responsible for multiple incidents of theft, including taking money from two residents and medications from two others. The facility's policies on abuse, neglect, and misappropriation were not effectively implemented, as evidenced by the repeated incidents involving Resident #127. Despite being aware of Resident #127's behavior, the facility did not take adequate measures to prevent further thefts, such as increasing supervision or providing secure storage for residents' belongings. Resident #127, who was admitted with diagnoses including bipolar disorder and schizophrenia, was assessed as severely cognitively impaired. The resident's care plan included interventions such as increased supervision and behavioral health consultations, but these measures were not sufficient to prevent the thefts. The facility's staff, including LPNs and SRNAs, were aware of Resident #127's behavior but did not consistently monitor or intervene effectively. The facility's administration was also aware of the issue but failed to implement a comprehensive plan to address the resident's behavior and protect other residents. The facility's failure to secure medication carts and properly supervise Resident #127 led to the theft of controlled substances, including Hydrocodone and Gabapentin, from two residents. The facility's policies on medication storage and security were not followed, resulting in unauthorized access to medications. Additionally, the facility did not adequately investigate or report all incidents of theft, as evidenced by the missing iPad and wallet that were not properly documented or addressed. The facility's inaction and lack of effective interventions contributed to an environment where residents' belongings and medications were not safeguarded, leading to multiple incidents of misappropriation.
Failure to Prevent Resident Elopement and Maintain Effective Alarm System
Penalty
Summary
The facility failed to ensure the residents' environment remained free of accident hazards and did not provide adequate supervision to prevent accidents for eleven out of 104 sampled residents. Specifically, the facility did not maintain accurate Elopement Binders with correct or thorough information for ten residents at high risk for elopement. Additionally, the facility did not provide appropriate supervision for two residents to prevent elopement and failed to have an effective alarm system in place for monitoring and supervising wandering and elopement risk residents. One resident, who had a history of dementia and moderate cognitive impairment, eloped from the facility and was found in a nearby shopping mall parking lot. The facility's investigation revealed that the resident exited through a door that did not have a wander guard system, and the regular fire alarm was not heard by staff. The resident's elopement risk assessments were not completed quarterly or upon readmission from the hospital, and the resident's care plan included interventions that were not effectively implemented. Another resident with severe cognitive impairment and a history of exit-seeking behaviors eloped from the facility and was found near a local golf course. The facility's investigation revealed that the resident exited during a smoke break, and the staff member responsible for supervision was unaware of the resident's elopement risk. The facility's alarm system was found to be excessively loud and frequently triggered, causing staff to become desensitized to the alarms and not respond appropriately. The facility's maintenance director acknowledged the issues with the alarm system and the need for adjustments to ensure proper monitoring and supervision of residents at risk for elopement.
Lack of Training and Competency Validation for Nurse Aides
Penalty
Summary
The facility failed to ensure nurse aides demonstrated competency in essential skills and techniques necessary for resident care, as identified through resident assessments and described in the plan of care. Staff interviews revealed a lack of training in behavior management, catheter care, and maintaining resident dignity. One SRNA reported not receiving any training on abuse, neglect, and exploitation despite working at the facility for six months. Observations confirmed that SRNAs were not following proper procedures, such as standing while feeding residents and failing to perform hand hygiene between resident rooms. Specific incidents highlighted the deficiencies, including an SRNA feeding a resident at a rapid pace while standing, which is against the facility's documented procedures. Another SRNA was observed failing to perform hand hygiene when exiting and entering multiple resident rooms. Additionally, an SRNA improperly performed catheter care by placing washcloths directly in the sink and using them to cleanse a resident's catheter. These actions were attributed to a lack of training and competency validation by the facility. The facility also failed to provide adequate training on handling verbally or physically aggressive resident behavior. Multiple staff members, including housekeepers and SRNAs, reported not receiving training on de-escalation techniques or stress management. The Director of Nursing and the Administrator acknowledged the gaps in training, especially for agency and travel staff, who were expected to be ready to work without additional training. The facility's management team had not implemented a comprehensive training and skills validation program, leading to these deficiencies.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to have an effective antibiotic stewardship program to monitor antibiotic use as part of the overall infection prevention and control program. The facility did not incorporate monitoring and assessment of antibiotic use for five of the sampled residents. Additionally, the facility failed to track antibiotic use and report regularly on antibiotic use and resistance to the facility's leadership. Resident #20 was admitted with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and chronic kidney disease. Despite being prescribed Levaquin for pneumonia, there was no evidence of antibiotic monitoring or infection control notes. Similarly, Resident #45, who was admitted with diagnoses including COPD and type 2 diabetes mellitus, was prescribed Cefuroxime for a urinary tract infection, but the facility failed to provide evidence of antibiotic monitoring or infection control notes. Resident #71, admitted with diagnoses including type 2 diabetes mellitus and infection due to a hip prosthesis, was prescribed Levaquin for MSSA bacteremia, but again, there was no evidence of antibiotic monitoring. Resident #97, with diagnoses including type 2 diabetes mellitus and chronic kidney disease, was prescribed Amoxicillin for a urinary tract infection, but the facility failed to provide evidence of antibiotic monitoring. Lastly, Resident #158, admitted with diagnoses including congestive heart failure and end-stage renal disease, was prescribed Cefdinir for pneumonia, but there was no evidence of antibiotic monitoring or infection control notes.
Failure to Educate and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to educate and offer COVID-19 immunization as required or appropriate for two of five sampled residents. Resident #126, who had severe cognitive impairment and was non-interviewable, was admitted with multiple diagnoses including cerebral infarction and emphysema. There was no documentation that Resident #126 received or was offered the COVID-19 vaccine, nor was there evidence of education provided to the resident or their representative. Similarly, Resident #128, who had moderate cognitive impairment and was their own responsible party, had no documented evidence of receiving or being offered the COVID-19 vaccine, and the resident did not recall being offered any vaccines by the facility. The facility also failed to maintain proper documentation of screening, education, offering, and current COVID-19 vaccination status for staff. Specifically, SRNA #5, who had been employed at the facility for six weeks, stated she was not provided education related to the COVID-19 vaccine and was not offered the vaccine by the facility. The interim DON/IP acknowledged the lack of complete vaccination records for all employees due to missing files or inability to locate them after a change in ownership of the facility. During interviews, the interim DON/IP and the Administrator both stated that the facility followed CDC recommendations for all immunizations and vaccines. However, they were unable to provide documentation showing how the facility tracked immunizations for all residents and staff. The Administrator emphasized the importance of following infection control policies and procedures, including immunizations, to prevent the spread of infection and communicable diseases.
Failure to Ensure Resident Dignity During Catheter Care
Penalty
Summary
The facility failed to ensure a dignified existence for two residents, Resident #105 and Resident #103. Resident #105 was not afforded privacy during catheter care as the SRNA did not close the curtain before performing the procedure. Additionally, Resident #105 was observed without a dignity bag for his/her catheter on multiple occasions. The SRNA admitted to not realizing the importance of closing the curtain and ensuring the dignity bag was in place. The Director of Nursing and the Administrator both confirmed that staff are expected to provide privacy and use dignity bags for catheter care to maintain resident dignity. Resident #103 was also not provided with a dignity bag for his/her catheter, which was observed uncovered and visible from the hallway. The resident expressed that he/she had not been offered a dignity cover but would like to have one. Interviews with various staff members, including SRNAs and LPNs, revealed that they were aware of the importance of using dignity bags but were unsure why Resident #103 did not have one. The Director of Nursing reiterated the importance of maintaining resident privacy and dignity by using dignity bags. The facility's policy on resident rights under federal law, dated 11/28/2016, states that residents have the right to a dignified existence. Despite this policy, the facility failed to provide adequate privacy and dignity for Residents #105 and #103, as evidenced by the lack of privacy during catheter care and the absence of dignity bags for their catheters. Interviews with staff and administration confirmed the expectations for maintaining resident dignity, but these were not met in the observed instances.
Failure to Involve Resident in Care Planning Process
Penalty
Summary
The facility failed to ensure that residents or their representatives were involved in the care planning process, as evidenced by the case of a resident who reported not being involved in their care planning. The facility's policy required that residents and their representatives be part of the care planning process, but there was no documentation of the resident's participation in the most recent care plan meeting. Interviews with social services staff and a review of the resident's chart revealed inconsistencies and a lack of documentation regarding care conferences, indicating that the resident's rights to participate in their care planning were not observed. The resident, who had no cognitive impairment, stated that they were not involved in care conferences. The facility's interdisciplinary attendance log and the resident's chart lacked evidence of recent care conferences, despite notes indicating that care conferences had occurred. Interviews with the Director of Nursing and MDS Coordinators revealed a lack of clarity and consistency in the care conference process, further highlighting the deficiency in ensuring resident participation in care planning. The Administrator acknowledged the oversight in documentation but maintained that the resident had attended the care conference.
Failure to Follow Advance Directive Policy
Penalty
Summary
The facility failed to follow its policy regarding Advance Directives for three residents. Resident #22, who had diagnoses including chronic kidney disease and type 2 diabetes mellitus, did not have a signed Advance Directive in their medical record despite a verbal DNR order. The facility also could not provide documentation that Advance Directive materials were reviewed with the resident upon admission or quarterly thereafter. During an interview, Resident #22 could not recall being asked about formulating an Advance Directive and stated they did not have one. Resident #103, who had diagnoses including congestive heart failure and type 2 diabetes mellitus, also did not have a signed Advance Directive in their medical record. The resident had a state-appointed guardian, and the facility could not provide documentation that Advance Directive materials were reviewed with the resident or their representative upon admission or quarterly thereafter. The Admissions Coordinator and the Regional Director of Business Marketing were unaware of why Resident #103 did not have a signed Advance Directive. Resident #57, who had diagnoses including extrapyramidal and movement disorder and cognitive communication deficit, was assessed to have moderate cognitive impairment. Despite being care planned as having a DNR order, there was no signed Advance Directive in the resident's medical record. The facility failed to produce documentation that Advance Directive materials were reviewed with the resident or their representative upon admission or quarterly thereafter. Interviews with the Social Services Director and the Admissions Coordinator revealed gaps in the process of ensuring residents had signed Advance Directives or were educated about them.
Failure to Protect Resident from Involuntary Seclusion
Penalty
Summary
The facility failed to protect Resident #112 from involuntary seclusion. On multiple occasions, staff members were observed escorting Resident #112 to his/her room and closing the door tightly, preventing the resident from exiting. This occurred despite the resident's severe cognitive impairment and inability to open the door independently. Staff members, including SRNA #26 and SRNA #28, admitted to not being aware that closing the door on a resident who could not open it was not allowed. SRNA #26, a travel nurse aide, stated he had not received any education on this matter since starting at the facility in January 2024. Resident #112, who has diagnoses of dementia with agitation, dysphagia oral phase, and Alzheimer's Disease, was assessed to have severe cognitive impairment with a BIMS score of six out of fifteen. The resident was noted to have no behaviors during the assessment and required varying levels of assistance for daily activities. The facility's care plan for Resident #112 included interventions for exit-seeking behaviors and cognitive loss, such as monitoring the resident's activities, using a security bracelet, and redirecting the resident when near exits or doorways. Despite these interventions, staff frequently escorted the resident back to his/her room and closed the door, which the resident could not open. Interviews with various staff members, including LPN #9, LPN #1, the APRN, the DON, and the Administrator, revealed a lack of consistent understanding and adherence to the facility's policy on involuntary seclusion. LPN #9 and the DON acknowledged that closing the door on a resident who could not open it constituted involuntary seclusion and was a form of abuse. The Administrator confirmed that the resident's door was broken at the time of the observation and was being fixed, but emphasized that the door should not be closed if the resident could not open it independently. The facility's failure to educate staff and enforce policies led to the involuntary seclusion of Resident #112.
Failure to Investigate Allegations of Sexual Abuse
Penalty
Summary
The facility failed to provide a complete and thorough investigation into the allegation of sexual abuse involving two residents, both of whom were severely cognitively impaired. The incident was reported to state agencies, revealing that the residents were found in bed together with their hands down each other's pants and later engaged in a second sexual encounter in the dining room. Despite the severity of the situation, the facility did not document any evidence of an investigation into the first incident, nor did they take adequate measures to prevent further potential abuse while the investigation was in progress. Resident #101, who was non-English speaking and had a BIMS score indicating severe cognitive impairment, was admitted for rehabilitation and later diagnosed with unspecified dementia. The resident's care plan was updated to address sexual behaviors, but there was no documented evidence of psychiatric follow-up after the incident. Similarly, Resident #112, who also had a severe cognitive impairment with a BIMS score of six, was noted to have engaged in sexual touching with Resident #101. The facility's care plan for Resident #112 included interventions such as alerting psychiatric services and room changes, but there was no mention of the incident in the psychiatric follow-up. Interviews with staff revealed a lack of proper assessment and monitoring of the residents' capacity to consent to sexual activity. The Social Services Assistant, who had limited experience in long-term care, was responsible for completing sections of the Minimum Data Set but did not conduct assessments for consent to sexual activity. The Director of Social Services delegated much of her work to the assistant and did not complete any assessments herself. The Director of Nursing stated that the SSA was responsible for gathering information for investigations, but the Administrator admitted that the facility did not have access to all documents from the previous ownership, leading to incomplete investigations.
Inaccurate MDS Assessments and Dental Care Oversight
Penalty
Summary
The facility failed to ensure the MDS assessment accurately reflected the resident's status for two residents. Resident #55's MDS assessment indicated that the resident did not wear oxygen, despite the resident being observed wearing oxygen via nasal cannula at two liters. The resident had a physician's order for oxygen to maintain oxygen saturations greater than 90%. This discrepancy was confirmed through an interview with a registered nurse who stated she regularly changed the oxygen tubing and monitored the oxygen concentrator for the resident. Additionally, the facility failed to assess dental care for Resident #52. The resident, admitted with diagnoses including traumatic brain injury and dementia, had no documentation of being seen by a dentist until nearly five years after admission. The resident's Quarterly MDS indicated no discomfort or difficulty with chewing, yet an observation revealed several oral cavities and the resident reported difficulty chewing and loose teeth. A dental record from a state university healthcare clinic confirmed the resident had cracked and decayed teeth and was referred for oral surgery. The Social Service Director admitted there was no follow-up after the resident missed a scheduled dental appointment.
Failure to Provide Necessary ADL Support for Resident
Penalty
Summary
The facility failed to ensure that Resident #117, who was unable to perform Activities of Daily Living (ADLs) independently, received the necessary services to maintain good grooming, personal, and oral hygiene. Resident #117, who had diagnoses including hemiplegia, hemiparesis, COPD, and dementia, was assessed to have total dependence on staff for ADLs. Despite this, the resident was observed multiple times with soiled clothes, poor dental hygiene, uncombed hair, and a white crusty substance on the face. The resident also reported not being given a choice when ADLs were performed and not receiving timely assistance for transfers and other care needs. Review of the past three months' shower sheets and documentation revealed inconsistencies in the recorded dates of bathing/showering, indicating that Resident #117 did not receive regular showers or baths as required. Additionally, the resident was not dressed for bed on several occasions, and staff failed to perform basic hygiene tasks such as washing the resident's face, performing oral care, and combing the resident's hair. Interviews with staff members, including SRNAs and an LPN, confirmed that the resident's care was not consistently provided according to the care plan, and refusals of care were not adequately documented or addressed. The Director of Nursing (DON) and the Administrator both stated that staff were expected to follow the care plan and provide comprehensive care for total care residents, including oral care twice daily and two showers or baths per week. However, observations and interviews revealed that these expectations were not met for Resident #117, resulting in the resident's poor hygiene and unmet care needs. The facility's failure to adhere to its policies and procedures for ADL support led to the identified deficiency in care for Resident #117.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to ensure an ongoing program of activities was developed to meet the individual needs of two residents. Resident #55, who had intact cognition, expressed dissatisfaction with the activities provided, describing them as childlike and simplistic. The resident also mentioned that the facility no longer shopped for residents, except for tobacco products, and that there were no outings planned. Despite being care planned for self-directed involvement in meaningful activities, the resident stated that one-on-one activities were never discussed, and the activities staff did not offer to bring items for personal activities such as puzzles, crafts, or books. The resident's room observations confirmed the lack of an activities calendar and the presence of personal books provided by a friend, not the facility. Resident #117, also with intact cognition, was observed multiple times sitting in a wheelchair facing the wall with no activities nearby. The resident stated that attending group activities was too difficult and that the topics were uninteresting. The resident expressed a desire for gardening activities and going outside, which were not provided. The resident also mentioned that activities staff never brought individual activities to the room and that the facility never took residents outside for activities. Interviews with staff revealed that activities were announced over the intercom, and nursing staff would assist residents to activities if needed. However, the Activities Director admitted that the facility's van was broken, and they did not take residents outside the facility for activities. The facility's policies on resident rights and activities were not adhered to, as evidenced by the lack of individualized activities based on comprehensive assessments and care plans. The Activities Director confirmed that the facility did not have a specific policy on activities and that the budget for activities was low. The Administrator stated that it was her expectation for all staff to be well-versed with the policies related to their job duties and to adhere to all facility policies and procedures. However, the observations and interviews indicated that the facility failed to meet the individual needs and preferences of the residents regarding activities.
Failure to Provide Proper Wound and Tube Site Care
Penalty
Summary
The facility failed to ensure Resident #91's sacral wound dressing was changed as ordered by the physician to be completed on every day shift. On 03/01/2024, the Wound Care Nurse changed the dressings on the resident's legs but forgot to return to change the dressing on the sacral wound. The resident confirmed that the sacral dressing had not been changed, and subsequent observations revealed no dressing on the sacral wound. The Treatment Administration Record (TAR) also lacked documentation of the dressing change for the sacral wound on that date. Interviews with the Wound Care Nurse and the Director of Nursing (DON) confirmed the oversight and the need for additional training on double-checking wound care procedures to ensure compliance with physician orders and facility policies. The Administrator emphasized the expectation for all nurses to provide the best possible care for residents, but the deficiency in wound care was evident in this case. The facility also failed to provide appropriate care for Resident #86's jejunostomy tube (J-tube) site. Observations revealed a crusted area with purulent drainage around the J-tube insertion site and no evidence of the ordered gauze dressing. The resident's Treatment Administration Record (TAR) for February 2024 showed no documented evidence of the daily cleaning and dressing application as ordered. An interview with an agency Licensed Practical Nurse (LPN) confirmed that the tube feed insertion site should be cleaned daily and have a gauze dressing in place, but this was not done for Resident #86. Similarly, Resident #126's gastrostomy tube (G-tube) site was observed to be excoriated with a dried dark brown crusted substance and no dressing covering the insertion site. The resident's care plan and physician's orders required daily cleaning and dressing of the G-tube site, but these were not followed. Interviews with the interim and current DONs revealed that all staff, including agency nurses, were expected to be competent in tube feed site care and follow physician orders. However, the observations and lack of documentation indicated a failure to provide the necessary care for Resident #126's G-tube site.
Failure to Follow Enteral Feeding Orders
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, specifically by not following the physician's orders for enteral tube feedings. The resident, who had severe cognitive impairment and required enteral nutrition due to aphasia secondary to a cerebral vascular accident, experienced a significant weight loss over six months. Despite the physician's orders to administer Jevity 1.5 CAL at 60 mL per hour for 16 hours per day with a free water flush of 145 mL every four hours, the tube feeding pump was consistently set to incorrect parameters of 55 mL per hour and 100 mL of water flush every four hours. This discrepancy was observed multiple times over several days, indicating a failure to adhere to the prescribed nutritional regimen. The resident's medical record and care plan indicated the need for specific interventions to ensure proper enteral nutrition, including monitoring the tube feeding formula, cleaning the stoma site, and inspecting for signs of infection. However, observations revealed that the tube feeding pump settings were not adjusted according to the updated physician's orders, and the equipment used for flushing the feeding tube was not maintained properly. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the orders were not followed, and there was a lack of awareness and verification of the updated tube feeding parameters. The failure to follow the physician's orders for enteral feedings was acknowledged by the nursing staff and the DON. The staff responsible for administering the tube feedings did not verify the correct dosage, leading to the resident receiving an incorrect amount of nutrition and hydration. This oversight was further compounded by the use of outdated equipment for flushing the feeding tube. The healthcare provider emphasized the importance of adhering to the prescribed enteral feeding orders to maintain the resident's weight and support wound healing, highlighting the critical nature of this deficiency in the resident's care.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was less than five percent, resulting in a medication error rate of 26.67%. An LPN, who was an agency nurse on her first day at the facility, administered eight medications prescribed for one resident to another resident. The LPN was having difficulties logging into the computer and was not familiar with the residents, leading to the error. The LPN mistakenly identified Resident #63 as Resident #37 and administered medications accordingly, despite the resident's incorrect acknowledgment of the name used by the LPN. The medications administered in error included Benztropine, Ferrous Sulfate, Protonix, Singulair, Celecoxib, and Norco, none of which were prescribed for Resident #63. The LPN realized the mistake after the SSA Surveyor intervened and confirmed the resident's identity. The LPN then reported the incident to the DON and sought guidance on the facility's process for handling medication errors. The DON and APRN were notified, and the APRN issued orders for monitoring Resident #63's vital signs and encouraging fluid intake. Interviews with the DON and the Administrator revealed that agency staff were expected to have established competencies and follow the five rights of medication administration, including verifying the resident's identity using the MAR photo and asking the resident's name. The LPN had received a day of orientation but did not have additional written instructions on facility routines. The incident highlighted a failure in the medication administration process, particularly in verifying resident identity and ensuring proper orientation for agency staff.
Significant Medication Error Due to Resident Misidentification
Penalty
Summary
The facility failed to ensure it was free of significant medication errors for one of the sampled residents. During medication administration, a nurse failed to accurately identify residents in their room, resulting in Resident #63 receiving medications prescribed for Resident #37. The nurse did not directly ask the resident to identify themselves and relied on the room's name placement, which led to the error. The nurse prepared and administered medications labeled for Resident #37 to Resident #63, who later identified themselves correctly to the surveyor. Resident #63, who had diagnoses including chronic obstructive pulmonary disease, epilepsy, and vascular dementia, received medications intended for Resident #37, who had diagnoses including parkinsonism, hepatic failure, and dementia. The medications administered to Resident #63 included Benztropine, Ferrous Sulfate, Protonix, Singulair, Celecoxib, and Norco, which were not prescribed for them. The nurse realized the error after the surveyor's intervention and reported it to the Director of Nursing (DON). Interviews with the DON, other nursing staff, and the Consultant Pharmacist confirmed the medication error and highlighted the lack of proper resident identification practices. The facility's policy required checking the label three times and using two resident identifiers, which were not followed. The error was deemed significant, and the facility's staff acknowledged the failure to adhere to the established medication administration protocols.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure that medications were properly labeled and stored for two residents. On 02/28/2024, a Kentucky Medication Aide (KMA) placed medications for two residents into unlabeled medication cups and stored them in the top drawer of the medication cart. This action was not in accordance with the facility's policy, which requires medications to be stored in their original packaging and labeled with specific information, including the resident's name. The medications included various drugs for conditions such as cardiac dysrhythmias, high blood pressure, diabetes, anxiety, depression, and high cholesterol. During an interview, the KMA admitted that one resident did not want to take their medications after they were placed in the cup, and the other resident was walking in the hall, leading her to store the medications temporarily. The KMA acknowledged that this could have resulted in the medications being given to the wrong resident, potentially causing harm. The Director of Nursing (DON) confirmed that the medications should have been stored according to the facility's policy and properly labeled.
Failure to Provide Adequate and Specialized Diets
Penalty
Summary
The facility failed to provide residents with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs. Resident #58, who had a diagnosis of diabetes mellitus and was on a controlled carbohydrate (CCHO) diet with large portions of vegetables, received inadequate portions and no alternatives for the CCHO diet. The resident's breakfast tray also contained regular syrup instead of diet syrup, and the resident reported not being offered a diabetic diet or alternatives since admission. Additionally, the resident did not consistently receive a bedtime snack to prevent overnight sugar drops, as required for diabetic management. Resident #70, who had a personal preference for fish due to religious reasons, did not receive fish for the supper meal as requested. Instead, the resident received spaghetti with meat sauce, which did not align with their dietary preferences. The resident reported that it was rare to receive fish despite the request, and the kitchen staff confirmed that no fish was available at the time. Interviews with the dietary staff, including the cook, registered dietician (RD), and interim dietary manager (IDM), revealed a lack of training and adherence to specialized diets and food preferences. The cook admitted to using only one size serving scoop, which potentially caused residents to receive incorrect portions. The IDM acknowledged that the dietary staff had not been trained on specialized diets like CCHO and that there was no always available menu to offer alternatives. The interim director of nursing (IDON) and the administrator emphasized the importance of following physician orders and honoring resident preferences, but the facility's practices did not align with these expectations.
Failure to Follow Dietary Orders and Provide Adequate Nutrition
Penalty
Summary
The facility failed to follow the menu and provide the required nutritional needs for Resident #50, who had specific dietary requirements due to conditions such as end-stage renal disease and Type 2 diabetes. Despite having a physician-ordered diet that included double protein/meat on non-dialysis days and other specific food items, the resident frequently received inadequate portions. Observations revealed that the resident's meal trays often did not comply with the dietary orders, such as receiving only one serving of protein/meat when double portions were required. Additionally, the resident reported receiving meals that were insufficient in quantity and did not meet their nutritional needs, such as a small salad with spaghetti sauce but no pasta and a breakfast consisting of only a donut and orange juice. Interviews with the resident and other residents corroborated the issue of inadequate food portions. Resident #50 expressed frustration over the lack of protein, especially given their dialysis treatment, which necessitated higher protein intake. The resident provided photographic evidence of meals that did not meet the prescribed dietary requirements. Other residents also reported that the food servings were small and sometimes left them feeling hungry. These observations and interviews highlighted a consistent failure to adhere to the dietary orders and provide adequate nutrition. Interviews with dietary staff and the Dietary Manager revealed that meal tickets were supposed to guide the preparation of trays according to residents' dietary needs. However, despite the Dietary Manager's recent efforts to audit and ensure accuracy, discrepancies persisted. The Director of Nursing and the Administrator acknowledged the expectation that meal tickets should be followed precisely, but the ongoing issues indicated a systemic problem in the facility's dietary service, leading to the deficiency in meeting residents' nutritional needs.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at an appetizing temperature for three residents. Resident #35's supper tray was observed to be cold, and the resident stated that the chicken sandwich did not taste good. Similarly, Resident #113's supper tray was also cold, and the resident complained about the food's taste and portion size, noting that no alternative meal was offered. Resident #66 reported that their food was often cold, and although the kitchen sometimes provided a fresh meal upon request, the resident was reluctant to complain due to staff being busy. Observations confirmed that food temperatures were not within the required range, with hot foods being served at insufficient temperatures and cold foods being too warm. Interviews with staff and residents revealed systemic issues with food service. SRNA #19 confirmed that Resident #66 frequently received cold meals due to being at the end of the hallway, and staff were not allowed to rewarm the food. The Registered Dietician (RD) and Interim Dietary Manager (IDM) acknowledged that food temperatures were not consistently monitored, and the RD highlighted the risk of foodborne illness from improperly heated food. The IDM and Interim Director of Nursing (IDON) both stated that residents should receive meals at appropriate temperatures and that substitutions should be provided if the food was not satisfactory. The Administrator noted that residents had previously complained about cold food served on Styrofoam plates and cups, a practice that was changed upon her arrival. Despite these changes, the issue of cold food persisted, as evidenced by the observations and resident interviews. The Administrator mentioned that staff could use microwaves in dietary rooms to reheat food, but this practice was not consistently followed. The report highlights a failure in the facility's food service operations, leading to residents receiving meals that were not palatable or at the correct temperature.
Failure to Provide and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to provide immunizations as required or appropriate, ensure the resident or the resident's representative had the opportunity to refuse immunizations, and document the resident's or resident representative's education regarding the benefits and potential side effects of immunizations. Specifically, for Resident #128, who was admitted with diagnoses including type 2 diabetes mellitus, atrial fibrillation, cerebral infarction, and respiratory disorders, there was no documented evidence that the resident had received the recommended pneumococcal immunizations or that the resident had declined the vaccination. The resident, who had moderate cognitive impairment, did not recall being offered any vaccines by the facility. Interviews with the Director of Nursing/Infection Preventionist (DON/IP) and the Administrator revealed that the facility followed CDC recommendations for immunizations and expected all residents to receive vaccinations according to these guidelines. However, the DON/IP was unsure why Resident #128 had not received the recommended vaccination. The Administrator stated that the facility's policies should be followed and that the infection prevention program was overseen by the DON/IP, with additional support from a Regional Resource Nurse and a newly appointed Assistant Director of Nursing (ADON) as the new IP. Despite these expectations, the facility failed to ensure proper documentation and administration of the pneumococcal vaccine for Resident #128.
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The facility failed to maintain an effective pest control and sanitation program, resulting in a widespread gnat infestation in common areas, resident halls, the laundry room, medication cart trash, dirty utility room, and the kitchen. Surveyors observed gnats emerging from drains, stagnant mop water with a rancid odor, and extensive moisture, standing water, and organic debris in kitchen drains, cracked floor tiles, and hard-to-reach areas behind equipment. Pest control service reports over several months repeatedly documented unresolved issues such as drain debris, standing water, and debris accumulation, while the pest control provider stated that facility compliance with recommended cleaning and maintenance was inconsistent and many action items remained undone. The Dietary Manager reported ongoing gnat problems and use of a hose-mounted floor sprayer and vinegar in drains, which the pest control representative stated would not remove organic buildup or larvae. Leadership, including the VPO, DON, and Administrator, described expectations for cleaning, pest reporting, and drain use that were not reflected in observed conditions, and two residents reported that gnats were frequently present around them and their food, especially during meals.
A resident with morbid obesity and bilateral foot drop, whose care plan called for two staff for bed mobility and incontinence care, slid off the edge of the bed during perineal care and sustained abrasions and skin discoloration. The resident stated an SRNA rolled them too far while the SRNA was on the opposite side of the bed, and staff interviews confirmed the SRNA performed the care alone instead of waiting for another staff member. The ADON and DON stated the resident should have had two staff assist with the care.
An LPN was observed administering insulin via a pen injector to a resident with diabetes without priming the needle before either dose. The resident had type 2 DM with hyperglycemia and active NovoLog FlexPen orders, but the facility’s competency assessment covered insulin by syringe and did not show training or assessment for insulin pen use. The LPN stated she was not aware priming was required, and the DON and Administrator confirmed the facility had not provided competency training on insulin pens.
A resident admitted for rehab with muscle weakness and unsteadiness had PT and OT care plans and orders for treatment five times per week, but therapy logs showed missed PT/OT sessions on two days with no documented reason. The Director of Rehabilitation confirmed the resident received therapy only three of five days over two consecutive weeks, contrary to the plan of care, and could not explain or document why sessions were missed. The resident and the resident’s representative reported that the resident did not receive therapy as expected, that therapy minutes were insufficient, and that services were not tailored to the resident’s needs, including use of group therapy despite the resident’s stated preference against it.
The facility failed to maintain a safe, clean, and sanitary laundry environment and to properly manage a resident’s clothing. A resident with COPD, heart failure, type 2 DM, and ESRD had most of their clothing lost during a short stay, and the family member who searched for the items described the laundry room as extremely hot, messy, dirty, with clothes everywhere and overflowing trash. Staff interviews confirmed the laundry room had long‑standing issues with excessive heat and clutter. Surveyor observations found floors between and behind washers covered with dirt, a dry flaky substance, loose concrete, and residue on piping and chemical tubing, alongside buckets of corrosive chemicals. Interviews with housekeeping, EVS, a chemical vendor, and maintenance showed that a chemical spill behind the washers had occurred over a year earlier and was never properly cleaned up, with conflicting accounts over whether maintenance or EVS was responsible and no effective system to ensure cleaning behind the machines.
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident with mild cognitive impairment and multiple medical conditions was reported by the resident’s family member. The Administrator was notified of the allegation that someone had smacked the resident across the face, but the initial report to the state survey agency was not submitted until more than three and a half hours later, exceeding the required two-hour timeframe. Facility documentation did not show that law enforcement was notified, despite policy requiring reporting of suspected crimes, and interviews with the SSD, DON, and Administrator confirmed that the expected practice was to report such allegations promptly to the state survey agency and law enforcement when applicable.
Two residents reported serious allegations—one of missing money and identification and another of being slapped by a staff member—but the facility failed to conduct comprehensive investigations as required by its abuse policy. In the misappropriation case, a cognitively intact resident named a specific staff member by first name, and the schedule showed an SRNA with that name worked during the alleged timeframe, yet that SRNA was never interviewed or asked for a statement, and the DON acknowledged not knowing the investigative process. In the physical abuse case, a resident with mild cognitive impairment reported being slapped and told a family member that a manager over the office was responsible, but the facility obtained statements only from some floor staff, did not interview office staff, did not obtain statements from all staff who worked the relevant shifts, and limited resident interviews and skin assessments to one hall. These actions and omissions resulted in incomplete investigations of both abuse-related allegations.
A resident with dementia, osteoporosis, a right artificial hip, and severe cognitive impairment was care planned as dependent for bed mobility, toileting, and transfers, with an intervention requiring two staff for assistance. Despite this, an SRNA, who knew the resident was a two-person assist, began perineal care alone and rolled the resident onto the side, causing the resident to roll out of bed and fall. An LPN obtained stat x-rays that showed a displaced right femoral shaft fracture, and the resident was sent to the hospital, where surgery was performed and the resident later died on a hospice unit. Staff interviews confirmed that the two-person assist requirement had been in place for years and that the failure to follow the care plan led to the incident.
A resident with dementia, osteoporosis, and a right artificial hip joint, assessed as severely cognitively impaired and dependent for bed mobility, toileting, and transfers, had a care plan and Kardex requiring a two-person assist for these ADLs. An SRNA, despite knowing this requirement, began perineal care alone and rolled the resident onto her side, causing the resident to roll out of bed onto the floor. The incident report and IDT identified the root cause as failure to follow the Kardex, with contributing factors including the resident’s weakness and history of falls. An LPN and unit manager found the resident on the floor, obtained stat x-rays that revealed a displaced right femoral shaft fracture, and the resident was sent to the hospital, where imaging confirmed a comminuted, moderately displaced femoral fracture and an ORIF procedure was performed. Staff interviews confirmed that the resident had long required a two-person assist and that only one staff member was present at the time of the incident, and also revealed that nurses and managers had not routinely spot checked SRNAs for adherence to the care plan/Kardex prior to the event.
A resident with intact cognition and multiple comorbidities developed fever and abnormal urinalysis results consistent with a UTI, for which an NP ordered a single 3 g dose of Fosfomycin. The MAR showed the antibiotic order and later an entry placing it on hold due to unavailability from pharmacy, without a corresponding provider order or documentation explaining the delay or who was contacted. The medication was not administered until four days after the original order, during which time the resident reported going without treatment and later required ED transfer, where a complicated UTI was diagnosed and treated with IM Rocephin and Toradol.
Failure to Maintain Effective Pest Control and Sanitary Conditions Resulting in Widespread Gnat Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free of insects and other pests, resulting in a widespread gnat infestation throughout the building. Surveyor observations over two days identified gnats in multiple common areas, including the conference room, resident halls, laundry room, medication cart trash can, and dirty utility room. In the laundry room, gnats were seen emerging from the washing machine discharge drain, and in the dirty utility room, gnats were concentrated around a mop bucket containing stagnant, foul-smelling water. On a resident hall, multiple gnats were observed flying around residents and on surfaces throughout the corridor. Extensive observations in the kitchen revealed multiple environmental and sanitation issues that contributed to the gnat activity. Behind and around the ice machine and juice cart, there was wet dust, dirt, and organic debris such as food crumbs, sugar packets, and trash items, all saturated with moisture. Cracked, loose, and broken floor tiles near the ice machine drain and in the dish room contained food debris lodged within and beneath the damaged tiles, with standing water collected beneath the tiles and pooled around the ice machine drain. Standing water was also observed in the spray room, dish room, along walls, and in corners, with water spread across the kitchen floor after staff used a hose-mounted sprayer to clean the floors. On a subsequent day, the kitchen floor again had visible standing water, and a floor drain contained accumulated debris, paper fragments, and organic material, with a broken drain grate that did not fully cover the drain and exposed additional trapped debris; gnats were present in and near this drain and throughout the kitchen. Review of facility work orders showed only one report of gnats in common areas and nursing units for one month and one report of bugs facility-wide in the following month, despite the widespread activity observed. Service reports from the contracted pest control company over several months documented ongoing, unresolved environmental concerns in the kitchen and adjacent areas, including repeated findings of drain debris, standing water in kitchen and dishwashing areas, debris accumulation, and moisture issues that remained uncorrected by the facility. The pest control representative and pest control account manager both stated that gnats were originating from drains, cracks, and crevices with organic debris and moisture, and that routine cleaning practices were ineffective when debris remained or was pushed into cracks and around drains. They reported that recommendations such as debris removal, proper drain maintenance, and cleaning of hard-to-reach areas were repeatedly communicated and documented, but the facility’s compliance with these recommendations was inconsistent, with many action items left undone and carried over on subsequent service reports. Interviews with staff and leadership further described the facility’s actions and inactions related to pest control and sanitation. The Dietary Manager reported ongoing gnat concerns for multiple weeks, stated that pest control services were provided twice monthly, and that kitchen staff performed routine cleaning weekly and as needed, using a hose-mounted spray system for floors and pouring vinegar down drains between pest control visits. The pest control representative stated that pouring vinegar down drains would not eliminate the infestation and might attract gnats, as it did not remove organic buildup or kill larvae. The pest control account manager identified contributing factors such as debris buildup in cracks and flooring, lack of routine cleaning behind equipment, standing water or improperly maintained mop buckets, inconsistent cleaning practices in non-visible areas, and lack of routine maintenance of drains and traps, and noted that environmental cleaning often improved only after issues became more apparent. The VPO acknowledged gnat activity throughout the building and that pest control reports had identified ongoing debris concerns in the kitchen, but could not clearly describe a process to ensure consistent cleaning of hard-to-reach areas or to verify cleaning effectiveness. The DON and Administrator described expectations for reporting pests, emptying mop buckets, removing trash from medication carts, removing debris before floor cleaning, and not sweeping debris into drains, but these expectations were not reflected in the observed conditions. Two cognitively impaired and intact residents reported that gnats were always present, especially around meal times and food, and that they found them bothersome and undesirable during meals.
Failure to Provide Two-Person Assistance During Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance to prevent a fall for one resident who had diagnoses of morbid obesity, left foot drop, and right foot drop. The resident’s care plan identified a need for two staff members for bed mobility and in-bed care related to bariatric status, and also directed staff to provide two-person assistance for bed mobility and total assistance for incontinence care as the resident allowed. The resident’s MDS indicated intact cognition and that the resident required supervision or touching assistance for rolling left and right in bed. During incontinence care, the resident slid off the edge of the bed to the floor and onto their knees. The acute change in condition assessment documented abrasions and skin discoloration after the incident. In interviews, the resident stated that a staff member rolled them out of bed during incontinence care and that they were able to assist with rolling by using the assist bars on either side of the bed. The resident stated that while rolling to the right side of the bed, they rolled too far and slid off the edge of the bed while the SRNA was standing on the opposite side of the bed. Staff interviews showed that the SRNA provided the incontinence care by herself even though the resident required two-person assistance. The SRNA stated she did not ask another staff member for help because she was used to performing the care alone, and later stated that having another SRNA in the room could have prevented the incident. Other staff, including the ADON and DON, stated the resident should have had two staff members assist with incontinence care. The DON also stated the resident could assist with turning using the bed rails, but the SRNA should have used another staff member and waited for assistance.
Insulin Pen Competency Not Demonstrated
Penalty
Summary
Licensed nursing staff were not shown to have the competencies and skill set necessary to administer insulin via an insulin injector pen for one LPN observed caring for a resident with diabetes. Review of the LPN’s competency assessment showed the DON assessed insulin administration by syringe, but it did not indicate assessment of insulin pen injector use, even though the competency document stated staff should have access to manufacturer instructions for all insulin delivery systems before use. The manufacturer’s instructions for NovoLog FlexPen required priming the pen before injection to avoid injecting air and ensure proper dosing. The resident involved was admitted with a diagnosis of type 2 diabetes mellitus with hyperglycemia and had active orders for NovoLog FlexPen, including a sliding scale order and a separate order for 16 units before meals. During observed medication administration, the LPN checked the resident’s blood glucose, which was 409, then administered 16 units of NovoLog FlexPen without priming the pen needle. After contacting the physician, the LPN later returned and administered 10 units from the sliding scale order, again without priming the insulin needle. The LPN stated she was not aware the pen needle needed to be primed and was unsure whether she had education on insulin pen injectors. The DON stated competency training covered insulin administration by syringe but not insulin pen injectors, and the Administrator stated the facility had not provided competency training related to insulin pens.
Failure to Provide Ordered PT/OT and Document Missed Therapy Sessions
Penalty
Summary
The facility failed to provide specialized rehabilitative services as ordered for one resident admitted for rehabilitation with diagnoses of muscle weakness and unsteadiness on feet. The resident’s care plan, initiated shortly after admission, identified a rehabilitation focus with skilled PT and OT interventions, and physician orders specified PT and OT to evaluate and treat. The OT plan of care called for treatment five times per week for 60 days, and the PT plan of care called for treatment five times per week for 30 days. Review of the Service Log Matrix showed that the resident did not receive individual PT or OT on two specified dates, despite the plan of care requiring therapy five days per week. The Director of Rehabilitation confirmed that the resident missed PT/OT on those two dates, that the plan of care was for five days a week, and that the resident only received PT/OT three out of five days for two consecutive weeks. The resident and the resident’s representative reported concerns that the resident was not receiving the allotted amount of therapy time and that therapy was not tailored to the resident’s specific needs. The representative stated the resident was weaker upon discharge than at admission and that the family sought transfer to another facility for PT after expressing concerns without improvement. The resident reported not receiving any PT during the first week, receiving PT only after questioning staff, and that when PT was provided it lasted 30–40 minutes and included group therapy that was counted as PT despite the resident’s preference against group therapy. The Director of Rehabilitation stated she did not know why therapy was missed on the two identified dates and that no reasons were documented, although such reasons were typically recorded. The DON stated her understanding that if therapy was missed, staff should attempt to reschedule so that residents did not miss needed therapy, and the current Administrator stated her expectation that residents receive the therapy they are supposed to receive to reach their maximum potential.
Failure to Maintain Clean, Safe Laundry Environment and Proper Handling of Resident Clothing
Penalty
Summary
The facility failed to ensure a safe, clean, sanitary, and comfortable environment in the laundry area as required by its Safe and Homelike Environment and Resident Rights policies. The policies stated that the physical layout should not pose a safety risk and that a sanitary environment must be maintained, including proper cleaning and storage of resident care equipment and items used for activities of daily living. Despite these policies, observations on 04/17/2026 showed the floor between and behind the washing machines covered and caked with dirt, a dry flaky substance, loose concrete, and residue on piping and chemical tubing, while multiple buckets of corrosive laundry chemicals and detergents were present in the same area. A resident’s family member reported that during the resident’s four‑day stay, most of the resident’s clothing was lost, and when she was allowed into the laundry room to search for the items, she found the room extremely hot, messy, with clothes everywhere, dirty conditions, and overflowing trash. The resident involved had significant medical diagnoses including COPD, acute on chronic systolic heart failure, type 2 diabetes mellitus, and end‑stage renal disease. A SRNA corroborated that the laundry room had always been hot, especially in summer, and that the room had long been somewhat messy with clothes, worsening over the past couple of years. Interviews with housekeeping, environmental services, the chemical supplier, and maintenance staff revealed that a chemical spill behind the washing machines had occurred well over a year earlier when ports at the back of the machines became clogged, causing chemicals to leak onto the floor. The chemical representative stated he cleaned the ports and moved tubing, and an EVS staff member told him maintenance would clean up the spill, but it was never done. Housekeeping reported that maintenance told them to clean up the spill themselves, while the Maintenance Director stated that EVS was responsible for cleaning the washing machines and that he had not observed leaks during his tenure. The dried, flaky substance and damaged concrete remained in place until it was later cleaned and repaired, and there was no documented system in place to ensure regular cleaning behind the washers, despite the presence of paper checklists for other tasks such as lint trap cleaning.
Failure to Timely Report Alleged Physical Abuse to State Agency and Law Enforcement
Penalty
Summary
The facility failed to report an allegation of physical abuse to the state survey agency and law enforcement within the required two-hour timeframe. Facility policy titled “Abuse Prohibition Standard of Practice,” last reviewed 03/2026, required that alleged violations be reported immediately to the Administrator or designee and to the state survey agency, adult protective services, and other required agencies, including law enforcement when applicable, within specific time frames. The policy also required the Administrator or designee to report suspicion of a crime to local law enforcement authorities. Resident 94, admitted on 06/19/2025, had a medical history including anemia, difficulty in walking, dislocation of an internal right hip prosthesis, muscle weakness, and other symbolic dysfunctions. An admission MDS with an ARD of 06/24/2025 showed a BIMS score of 10, indicating mild cognitive impairment, and the care plan documented impaired cognition and psychosocial adjustment difficulties related to anemia. On 07/01/2025, the facility generated an Initial Report indicating that a family member reported the resident had stated someone smacked them across the face the previous day after lunch or dinner. The Administrator was notified of this allegation at 9:45 AM. An email from the Administrator to the state survey agency showed the initial report was sent at 1:41 PM, more than three and a half hours after the Administrator was notified, exceeding the two-hour reporting requirement. The Initial Report did not indicate that local law enforcement was notified. During interviews, the SSD, DON, and Administrator all acknowledged that allegations of abuse should be reported to the state survey agency within two hours, and the Administrator stated that their process was to notify law enforcement when a resident requested or when there was a chance a law had been broken, but she did not follow the appropriate process in this case.
Failure to Conduct Comprehensive Abuse and Misappropriation Investigations
Penalty
Summary
The deficiency involves the facility’s failure to conduct prompt, comprehensive investigations into allegations of abuse and misappropriation of resident property, contrary to its Abuse Prohibition Standard of Practice policy. That policy required the administrator or designee to oversee internal investigations of all alleged violations of abuse, neglect, exploitation, misappropriation of resident property, and injuries of unknown origin, including interviews of all involved persons and others who might have knowledge of the allegations. For one resident, the facility did not interview the staff member specifically named by the resident as the alleged perpetrator of misappropriation, despite documentation showing that a staff member with that first name was scheduled and worked during the timeframe of the alleged incident. For another resident, the facility did not obtain statements from all staff who worked during the relevant shifts and did not interview or obtain statements from office staff, even though the allegation involved a manager in an office area. One resident, admitted with diagnoses including aftercare following removal of a knee joint prosthesis, generalized anxiety disorder, and major depressive disorder, had a BIMS score of 13 indicating intact cognition, but was also care planned for progressive decline in intellectual functioning, memory deficits, and anxiety with agitation. This resident reported that $350, a driver’s license, and an insurance card were missing from their wallet or purse and identified by first name the person they believed took the items. The facility’s initial and final reports to the state survey agency documented the allegation and noted that no cash was recorded on the admission inventory and that no staff by the alleged name worked on the day the allegation was reported. However, the facility’s monthly schedule showed that an SRNA with the same first name as the alleged perpetrator was scheduled and worked the evening and night shift spanning the date of the alleged incident. The investigation packet contained 20 staff statements, but no statement from this SRNA or from any staff member with the alleged first name. The SSD stated she obtained statements from everyone who worked that day and did not interview the SRNA because she believed the SRNA did not work that day, while the SRNA later confirmed she had worked that shift, knew the resident, and was never asked for a statement. The DON acknowledged she did not interview the SRNA, was unaware of the investigative process, and did not know if there was a process for investigating such allegations, and the Administrator, who was the Abuse Coordinator, confirmed that the SRNA was not interviewed despite the resident naming a staff member with that first name. Another resident, admitted with diagnoses including anemia, difficulty in walking, dislocation of an internal right hip prosthesis, muscle weakness, and other symbolic dysfunctions, had a BIMS score of 10 indicating mild cognitive impairment and was care planned for impaired cognition and psychosocial adjustment difficulties. This resident’s family member reported that the resident said someone smacked them across the face after a meal, and a typed SSD statement documented that the family member reported the resident said the manager over the office smacked them. The facility’s final report stated that the resident reported being slapped in a hall after a meal, could not identify the meal or describe the individual, and said they reported the incident to an employee in the back office. The investigation packet included 17 staff statements from floor staff (SRNAs, LPNs, and RNs) but no statements from any office staff, despite the allegation involving a manager over the office and a report to an employee in the back office. Daily staffing guides showed that 34 different floor staff worked during the two 12-hour shifts on the day of the alleged incident and the following day shift, yet statements were not obtained from multiple identified RNs, LPNs, SRNAs, and KMAs who worked those shifts. The facility conducted skin assessments and interviews only for residents on the hall where the resident resided and did not complete resident interviews or skin assessments for residents on other halls. In interviews, multiple staff who had worked during the relevant timeframe stated they were never asked about any resident being slapped or asked to provide statements. The DON stated that her role in abuse investigations was to perform skin assessments and obtain staff statements, believed that therapy and office staff had been interviewed, and did not review surveillance cameras, while the Administrator stated they narrowed the investigation and did not review cameras because they only showed hallways and not the back hallway where offices and therapy areas were located. Overall, for both residents, the facility did not follow its own policy requirement that investigations be prompt, comprehensive, and include interviews of all involved persons and others who might have knowledge of the allegations. In the misappropriation case, the named SRNA who worked during the alleged timeframe was not interviewed or asked for a statement, and the DON acknowledged lack of familiarity with the investigative process. In the physical abuse case, the facility did not obtain statements from all staff who worked during the relevant shifts, did not interview office staff despite the allegation involving an office manager and a report to a back office employee, and limited resident assessments and interviews to one hall, without extending them to other halls where potential witnesses or victims might have been located. These omissions in investigative steps led to incomplete investigations of the reported allegations of abuse and misappropriation of property for the two residents.
Failure to Follow Two-Person Assist Care Plan Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan for a resident who required extensive assistance with activities of daily living (ADLs). The facility’s policy required development and implementation of care plans with measurable objectives and time frames to meet residents’ medical, nursing, mental, and psychosocial needs. The resident was admitted with osteoporosis, a right artificial hip joint, and dementia, and was assessed on a quarterly MDS as severely cognitively impaired, rarely or never understood, and dependent for bed mobility, toileting, and transfers. The resident’s care plan/kardex identified an ADL problem and included an intervention requiring two staff to assist with bed mobility, toileting, and transfers. On the day of the incident, a state registered nurse aide (SRNA) began providing perineal care to the resident and rolled the resident onto her left side without waiting for a second staff member, despite knowing the resident was care planned as a two-person assist. When the SRNA rolled the resident, the resident rolled out of bed and fell to the floor on her right side. The incident report documented that the root cause of the fall was the resident being rolled too far over, causing her to roll out of bed. Staff interviews confirmed that the resident had been a two-person assist for years and that there had been no changes to the care plan on the day of the incident. Following the fall, an LPN assessed the resident, notified the nurse practitioner, and obtained stat x-rays, which revealed a right femoral diaphyseal fracture with complete displacement and foreshortening, and an orthopedic consult was recommended. Hospital imaging later confirmed a comminuted and moderately displaced mid to distal right femoral shaft fracture, and the surgical team repaired the resident’s hip. Hospital documentation showed that the resident subsequently died while on the hospital’s hospice unit. Interviews with the SRNA, LPN, unit manager, infection preventionist/acting DON, and the administrator consistently indicated that staff were trained to follow the care plan/kardex and that the resident’s two-person assist requirement was known, but in this incident the care plan intervention was not followed.
Failure to Follow Two-Person Assist Care Plan Resulting in Fall and Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance during care, resulting in a fall with fracture for one resident. The resident was admitted with osteoporosis, a right artificial hip joint, and dementia, and was assessed on the Quarterly MDS as severely cognitively impaired and rarely/never understood. The MDS further documented the resident as dependent for bed mobility, toileting, and transfers. The resident’s care plan, as reflected on the Kardex, identified an Activities of Daily Living (ADL) problem and included an intervention requiring two staff to assist with bed mobility, toileting, and transfers. On the day of the incident, an SRNA began providing perineal care to the resident alone, despite knowing the resident required a two-person assist. The SRNA rolled the resident onto her left side, which caused the resident to roll out of bed on her right side onto the floor next to the other bed in the room. The incident report documented that the root cause was the resident being rolled too far over during care, and the IDT determined that the SRNA failed to follow the resident’s Kardex. At the time of the incident, the resident had predisposing physiological factors of weakness and situational factors including a history of falls. Following the fall, an LPN and the unit manager responded to the room and found the resident lying on her right side on the floor, with no apparent distress or obvious injury initially observed. The LPN documented notification of the NP and family and obtained orders for x-rays of the right shoulder, hip, and knee. Mobile x-ray results showed a right femoral diaphyseal fracture with complete displacement and foreshortening, and an orthopedic consult was recommended. The resident was subsequently sent to the hospital, where imaging confirmed a comminuted, moderately displaced mid to distal right femoral shaft fracture, and an ORIF procedure with plate and screw fixation was performed. The resident later expired in the hospital’s hospice unit. Interviews with the SRNA, LPN, another SRNA, the unit manager, the acting DON/IP nurse, and the administrator consistently confirmed that the resident had long been a two-person assist and that only one staff member was present providing care at the time of the incident, contrary to the care plan and Kardex. Staff interviews further revealed that, prior to the incident, nurses and unit managers did not routinely spot check SRNAs to ensure they were following the care plan/Kardex when providing care. The SRNA involved acknowledged she had been trained during orientation to follow the care plan/Kardex and admitted she did not follow it in this case, stating she started care alone while expecting her partner to join later. The LPN, another SRNA, the unit manager, the acting DON/IP nurse, and the administrator all stated that the resident’s care plan and Kardex required two staff for bed mobility and related ADLs and that there had been no change to this requirement on the day of the incident. The administrator and acting DON/IP nurse both stated it was their expectation that staff follow the care plans and Kardex when providing care, and the administrator confirmed that only one staff member was present when the incident occurred.
Delayed Administration of Ordered Antibiotic for UTI
Penalty
Summary
The deficiency involves the facility’s failure to provide timely pharmaceutical services and administer an ordered antibiotic for a resident with a suspected urinary tract infection (UTI). The resident, who had intact cognition and diagnoses including arthropathic psoriasis and morbid obesity, was care planned for elimination deficits with interventions such as PRN straight catheterization for urinalysis and monitoring for UTI signs and symptoms. On one occasion, the resident developed a fever of 102°F, and a urinalysis showed significant abnormalities, including 3+ leukocytes, 3+ bacteria, and red blood cells too numerous to count. Based on these findings, the nurse practitioner ordered a single 3 g dose of Fosfomycin to treat the UTI while awaiting culture results. The medication order for Fosfomycin was entered with a start date of the day after the follow-up note, but the drug was not administered as ordered. The MAR showed that the Fosfomycin was to be given one time by mouth for UTI, and a subsequent entry documented that the medication was on hold because it was not available from the pharmacy. There was no documented physician order to hold the medication, and no progress note was found explaining the delay, who was contacted, or what actions were taken when the medication was reportedly unavailable. The Fosfomycin was ultimately documented as administered four days after the original order date, indicating a significant delay in treatment. Interviews and record reviews further clarified the circumstances leading to the deficiency. The infection preventionist stated that the facility followed McGeer criteria for antibiotic use and that the urinalysis did not meet those criteria, but he was not aware of this specific incident. The DON stated she did not know why the Fosfomycin was not given as ordered, noted that this medication was commonly used and readily available from the pharmacy, and confirmed it was not stocked in the emergency medication supply. The DON also stated her expectation that medications be received timely from the pharmacy and administered to residents, and that any delay in antibiotics could possibly lead to sepsis and pain. The resident reported having gone without treatment for approximately three weeks after developing a UTI, stated she never received the originally ordered one-time antibiotic dose, and later required transfer to the emergency department where she was diagnosed with a complicated UTI and treated with IM Rocephin and Toradol for pain.
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