Madonna Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Villa Hills, Kentucky.
- Location
- 2344 Amsterdam Road, Villa Hills, Kentucky 41017
- CMS Provider Number
- 185241
- Inspections on file
- 19
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Madonna Manor during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as identified by surveyors.
A resident with moderate cognitive impairment was improperly restrained by a Dining Aide who tied a washcloth to the wheel of the resident's wheelchair to prevent wandering. This action was witnessed by a STNA who did not report it. The facility's policy prohibits the use of physical restraints unless medically necessary, and the Administrator confirmed that such restraint is not a standard for quality care.
A resident with dementia fell from her wheelchair after a Dining Aide tied a washcloth to the wheel, witnessed by an STNA who failed to report the incident. The resident, assessed as moderately cognitively impaired, was at risk for falls. The facility's policy required immediate reporting of such incidents, which was not followed, leading to a violation of the abuse policy.
The facility failed to notify the physician of significant changes in the condition of two residents, leading to serious health consequences. One resident experienced a significant change in mental status, which was not reported, resulting in a critical emergency department admission. Another resident developed an unstageable wound that worsened due to delayed notification and treatment. Interviews revealed a lack of adherence to the facility's policy for notifying physicians of changes in residents' conditions.
The facility failed to develop timely baseline care plans for two residents, leading to inadequate care. One resident with an infection and PICC line did not have a care plan addressing these needs, resulting in a transfer to the ED with sepsis. Another resident at risk for pressure injuries developed a severe heel wound due to a lack of interventions in the care plan. Staff interviews revealed confusion about responsibilities for initiating and revising care plans.
A resident with a post-surgical infection did not receive several doses of prescribed antibiotics due to the facility's failure to administer them as ordered. Despite a significant change in the resident's mental status being observed, neither the RN nor the LPN conducted an assessment or notified the physician. The resident's family later found the resident unresponsive and requested an emergency transfer to the hospital, where the resident was admitted with life-threatening conditions.
A resident admitted with post-surgical infection did not receive several doses of prescribed antibiotics, cefepime and metronidazole, as ordered. The resident's family found them unresponsive and febrile, leading to a hospital transfer where they were diagnosed with sepsis and atrial fibrillation. Interviews revealed that the LPN fell behind on medication administration, and there was no formal documentation of medication audits.
A resident at an LTC facility developed an unstageable pressure ulcer due to the facility's failure to implement necessary interventions and conduct regular skin assessments. Despite being at risk, the resident did not receive adequate pressure off-loading measures, and discrepancies in documentation further delayed appropriate care.
The facility failed to maintain an effective infection prevention and control program, as staff did not adhere to PPE protocols and proper cleaning of shared medical equipment. An APRN and RN entered a contact isolation room without wearing gowns and gloves, while an LPN mishandled a contaminated glucometer by not following cleaning protocols. Despite training, staff did not consistently implement infection control practices.
A resident's privacy was compromised when an LPN administered an insulin injection at a dining table in view of other residents, contrary to facility policy. The resident had consented to the procedure to avoid her meal getting cold, but the facility's protocol requires private administration of medical treatments to ensure dignity and privacy.
A facility failed to store medications according to professional standards when a pharmacy delivery tote was left unattended and unsecured on a medication cart. The tote contained various medications, including albuterol, IV fluids, and heparin, and was found in a public area. Interviews with staff confirmed that medications should be stored in locked compartments immediately upon receipt, highlighting a lapse in following facility policy.
A resident in an LTC facility was denied a COVID-19 test despite exhibiting symptoms and a family member's request. The facility's policy allowed for testing upon request, but staff refused, citing no positive cases in the facility. Interviews revealed a lack of adherence to the facility's COVID-19 testing guidelines.
A facility failed to document whether a resident with COPD and Alzheimer's received or refused the influenza vaccine for 2023-2024. Despite policies requiring documentation, the resident's immunization record lacked this information. Interviews with the IP Nurse and DON confirmed that education and consent were provided, but documentation was missing. The Administrator expected records to reflect immunization status.
The facility failed to ensure effective communication with residents' families, leading to distress and concern. Two residents' family members reported being unable to reach the facility due to unanswered calls and full voicemail boxes. Staff interviews revealed systemic issues with the phone system, including a lack of responsibility for checking messages and informing families of updated contact numbers.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified by surveyors based on observations or events that indicated the environment posed risks for accidents and that supervision was insufficient to prevent such incidents. No additional details about specific residents, their medical history, or the exact nature of the hazards or accidents were provided in the report.
Resident Restrained with Washcloth in Wheelchair
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by an incident involving a Dining Aide (DA) who tied a washcloth around one wheel of a resident's wheelchair. This action was taken to prevent the resident from wandering around the facility. The resident, identified as having moderate cognitive impairment and a history of dementia, was found on the floor by an Activity Assistant, which led to the discovery of the restraint. The resident, who was admitted to the facility with diagnoses including dementia and cognitive communication deficit, was assessed to be ambulatory and capable of self-propelling in a manual wheelchair. Despite this, the DA's action of tying a washcloth to the wheelchair wheel was witnessed by a State Trained Nurse Aide (STNA), who failed to report the incident. The facility's policy clearly states that residents have the right to be free from physical restraints unless required for medical treatment, and the tying of the washcloth was not in line with this policy. The Administrator was informed of the incident after the resident was found on the floor. An investigation was initiated, revealing that the washcloth was used as a restraint, which is not a standard for quality care. The Administrator confirmed that the use of a washcloth to restrict a resident's movement is considered a form of physical restraint, which is against the facility's policy and residents' rights.
Failure to Implement Abuse Policy Leads to Resident Fall
Penalty
Summary
The facility failed to implement its abuse policy for one of the sampled residents, identified as R15. A Dining Aide (DA1) tied a washcloth around one wheel of R15's wheelchair, which was witnessed by a State Trained Nurse Aide (STNA13) who did not report the incident. This action led to R15 falling from her wheelchair. The facility's policy required staff to immediately report any incidents of abuse, neglect, or mistreatment to the Administrator, who would then report to the appropriate agencies. However, STNA13 did not report the incident, which was a violation of the facility's policy. R15 was admitted to the facility with diagnoses of dementia, cognitive communication deficit, and disorientation. The resident was assessed to be moderately cognitively impaired and used a manual wheelchair for mobility. R15's Comprehensive Care Plan indicated a risk for falls due to impaired mobility and other health conditions. Despite these known risks, the incident occurred when DA1 tied a washcloth to the wheelchair, making it stationary and leading to R15's fall. The incident was discovered when Nurse 8 was called to assess R15, who was found lying on the floor with no physical injuries. During interviews, it was revealed that STNA13 was unsure if the washcloth constituted a restraint and did not report it. The Administrator confirmed that tying a washcloth to a wheelchair to restrict movement was a form of physical restraint and not in line with quality care standards. The failure to report the incident by STNA13 conflicted with the facility's policy on reporting abuse.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in the physical status of two residents, leading to serious health consequences. For one resident, a significant change in mental status was observed by a registered nurse, but the physician was not notified. The resident's condition worsened, and the family eventually found the resident unresponsive and requested emergency medical services. The resident was admitted to the emergency department with altered mental status, sepsis, and atrial fibrillation with rapid ventricular response. In another case, a physical therapist discovered an unstageable wound on a resident's heel, but the nursing staff did not notify the physician immediately. The wound worsened over several days, and the resident experienced pain and difficulty with mobility. The wound care physician was eventually notified and provided new treatment orders, but the delay in notification and treatment likely contributed to the wound's deterioration. Interviews with staff and family members revealed a lack of adherence to the facility's policy for notifying physicians of changes in residents' conditions. The nursing staff failed to assess and document the residents' conditions promptly, and there was a breakdown in communication between the nursing staff and other healthcare providers. This failure to follow established procedures put the residents at risk for serious harm.
Removal Plan
- An Ad Hoc QAPI meeting was held with DON, Medical Director and ED discussing IJ regarding Notification of Changes for Medical Director input.
- Notification of Changes policy was reviewed by the Director of Clinical Risk Management.
- The Director of Clinical Risk Manager provided education for the Director of Nursing, Executive Director and Nurse Managers regarding the Notification of Changes policy.
- The Executive Director, Corporate Clinical Leadership Team, Director of Clinical Risk, DON discussed the Notification of Changes policy and the plan for the abatement.
- Education was provided by Nurse Managers for all nurses and KMAs regarding Notification of Changes policy. Agency nurses were educated prior to their shift by DON/Nurse Managers. 25/28 completed = 93%, 1 nurse on leave will be educated by DON/Nurse Managers prior to her return to work., 2 staff still to complete prior to their next shift.
- All nurses and KMAs who are hired will be educated by the DON/Nurse Managers regarding the Notification of Changes policy prior to working.
- All progress notes were reviewed by DON/Nurse Manager for changes in condition of identified residents and proper notification of MD and Responsible Party as appropriate.
- Information was given to STNAs, housekeepers and dietary staff regarding what to do when you notice a change in a residents' condition. Information sent by ED via text.
- The 24 hour report sheet and the 24 hour summary in Point Click Care (PCC) will be reviewed by DON/Nurse Manager daily for appropriate notification of changes in the morning Clinical Meeting.
- DON/Nurse Managers administer quizzes to nurses and KMAs regarding Notification of Changes in Condition and report results to QAPI team. If a question is missed, DON/Nurse Managers will educate the nurse immediately and document the education.
- DON reported audit results regarding notification of changes missed at the QAPI meeting and will continue to report audit results and how findings were resolved to QAPI weekly for 4 weeks then every other week until substantial compliance is achieved.
- QAPI meeting was attended by Medical Director, Nurse Practitioner, ED, DON, Diet Tech, Nurse Managers, IP Nurse, Social Worker designee, Director of Facilities, Business Office Manager, MOS nurse, Director of Therapy and Life Enrichment Director. IJ abatement plan audits, results, and follow up were discussed.
- Next QAPI meeting scheduled.
Failure to Implement Timely Baseline Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours for two residents, R2 and R3, which resulted in deficiencies in providing effective and person-centered care. R3 was admitted with an intrathecal pain pump infection and was receiving intravenous antibiotic therapy via a PICC line. However, the facility did not create a baseline care plan addressing R3's infection, antibiotic therapy, PICC line care, or procedures for physician notification in case of a worsening condition. This oversight led to R3 being transferred to the emergency department with an altered mental status, sepsis, and atrial fibrillation with rapid ventricular response. R2 was admitted with a risk for developing pressure injuries, and an unstageable wound on the left heel was identified by the physical therapy staff. Despite this, R2's baseline care plan did not address the existing skin issues or include interventions to prevent further deterioration. The wound worsened significantly over a few days, leading to pain and the need for treatment at another facility. The facility's failure to revise R2's care plan to include necessary interventions for skin breakdown contributed to the resident's decline. Interviews with facility staff revealed a lack of clarity and responsibility regarding the initiation and revision of baseline care plans. LPN1 was unaware of her responsibility to initiate care plans, and the MDS Nurse indicated that care plans were sometimes delayed due to admissions occurring during off-hours. The Interim Director of Nursing and other staff members acknowledged the importance of including health and safety concerns in baseline care plans but could not identify why the care plans for R2 and R3 were incomplete.
Removal Plan
- An Ad Hoc QAPI meeting was held with DON, Medical Director and ED discussing IJ regarding Baseline Care Plans for Medical Director input.
- The Director of Clinical Risk Management educated the DON and Nurse Managers on the Baseline Care Plan Policy.
- The Executive Director, Corporate Clinical Leadership Team, Director of Clinical Risk, DON discussed the Baseline Care Plan policy and the plan for the abatement.
- The Director of Clinical Reimbursement and the MDS nurse audited all baseline care plans for completion and accuracy. If the baseline care plan was missed, comprehensive care plans from admissions have been completed.
- Education was provided by DON/Nurse Managers for all nurses and KMAs regarding the Baseline Care Plan policy. Agency nurses are educated prior to their shift by the DON/Nurse Managers. 100% of nurses educated (1 nurse on leave will be educated prior to returning to work by the DON/Nurse Managers).
- DON/Nurse Managers administer quizzes to nurses and KMAs regarding Baseline Care Plans and report results to the QAPI team weekly. Any nurses/KMAs not receiving a 100% correct will receive 1:1 education provided by the DON/Nurse Managers.
- DON/Nurse Managers will audit Baseline Care Plan daily 7 days per week in morning clinical meetings. 100% Baseline Care Plans have been completed per policy.
- DON/Nurse Managers reported results of the audit of baseline care plans, issues that needed resolution and how resolution was achieved to the QAPI committee and will continue to report to QAPI weekly for 4 weeks and then every other week until substantial compliance is achieved.
- QAPI meeting was attended by Medical Director, Nurse Practitioner, ED, DON, Diet Tech, Nurse Manager, IP Nurse, Social Worker designee, Director of Facilities, Business Office Manager, MDS nurse, Director of Therapy and Life Enrichment Director. IJ abatement plan audits, results, and follow up were discussed.
- The next QAPI meeting will review Baseline Care Plan completion.
Failure to Administer Medications and Respond to Change in Condition
Penalty
Summary
The facility failed to promptly identify and intervene with a significant change in a resident's condition, leading to a deficiency in providing treatment and care according to professional standards of practice. A resident, identified as R3, was admitted with a post-surgical infection of the intrathecal pain pump and was prescribed a two-week course of intravenous antibiotic therapy via a PICC line. However, the resident missed several doses of the prescribed antibiotics, both intravenous and oral, due to the facility's failure to administer them as ordered. This lapse in medication administration contributed to the resident's deteriorating condition. On a particular morning, a registered nurse observed a significant change in R3's mental status but failed to conduct a thorough assessment or notify the physician. During the shift change, this information was communicated to an LPN, who also did not assess the resident or notify the physician. It was not until the resident's family alerted the staff later that morning that the resident was found to be febrile, unresponsive, and exhibiting tremors. The family requested an emergency transfer to the hospital, where the resident was admitted with life-threatening conditions, including sepsis and atrial fibrillation. The facility's policy required that residents receive care in accordance with professional standards, including timely medication administration and appropriate response to changes in condition. However, the facility failed to adhere to these standards, as evidenced by the lack of documented assessments and the missed doses of antibiotics. The failure to follow established policies and procedures resulted in the resident's hospitalization and critical care admission, highlighting a significant deficiency in the facility's quality of care.
Removal Plan
- An Ad Hoc QAPI meeting was held with DON, Medical Director and ED to discuss quality of care related to Medication Administration, Baseline Care Plans, and Notification of Changes in Resident Condition for Medical Director input.
- Notification of Changes Policy, the Baseline Care Plan Policy and the Medication Administration Policy were reviewed immediately for accuracy by the Director of Clinical Risk Management.
- The Executive Director, Corporate Clinical Team and DON discussed the Notification of Changes in Condition, Medication Administration, and Baseline Care Plan policies and the plan for abatement.
- The Executive Director, Corporate Clinical Team and DON discussed the Provision of Quality Care policy.
- The Director of Clinical Risk Management educated the DON, Nurse Managers and ED regarding Baseline Care Plans, Medication Administration and Notification of Changes in Resident Condition and Provision of Quality Care policies.
- The DON/Nurse Managers provided education for all nurses and KMAs regarding Notification of Changes, Baseline Care Plan, and Medication Administration policies and provisions of the Quality of Care policy prior to their next shift. Agency nurses received education prior to their shift by DON/Nurse Managers. 100% completion of active staff, 1 nurse on leave will be educated by the DON/Nurse Manager prior to returning to work.
- Going forward all newly hired nurses and all agency staff will be educated by the DON/Nurse Managers on the Notification of Changes, Baseline Care Plan, Medication Administration, Provision of Quality Care policies and the Nurse Clinical Binder.
- DON/Nurse Managers completed an audit of all progress notes for changes in condition of identified residents and proper notification of MD and Responsible Party as appropriate.
- STNAs, Housekeepers and Dining staff received information via text regarding: if they notice a change in a residents' condition that they should report it to the nurse immediately.
- Director of Clinical Risk Management/DON audited all missed meds for identified residents using the Medication Administration Audit Report.
- DON notified the Medical Director of results of the Medication Admin Audit report and asked for any new orders. No new orders given. DON notified responsible parties of any current affected residents.
- The Director of Clinical Reimbursement and MDS nurse audited baseline care plans for admissions for completion and accuracy. If incomplete or inaccurate, comprehensive care plans have been completed by the Director of Clinical Reimbursement/MOS nurse.
- In morning clinical meeting- DON/Nurse Managers review 24 hour report sheet and 24 hour summary report in PCC daily for appropriate notification of changes in resident condition. The DON reported results of the audit to the QAPI committee and will continue to report audit results to QAPI weekly for 4 weeks then every other week until substantial compliance is achieved.
- The Medication Admin Audit Report in PCC is completed daily by DON/Nurse Managers. Missed medications will be reported to the MD and responsible party immediately as per policy by the DON/Nurse Manager. Report audit results to QAPI weekly for 4 weeks then every other week until substantial compliance is achieved.
- Nurse Managers provide daily 1:1 Nurse/KMA coaching to ensure medication administration per MD orders and following the nursing process to assure quality care.
- Audit of baseline care plans will be by the DON/Nurse Managers daily with immediate follow up. 100% compliance has been achieved to date. DON reported results to QAPI committee and will continue to report audit results to QAPI weekly for 4 weeks then every other week until substantial compliance is achieved.
- QAPI meeting was attended by Medical Director, Nurse Practitioner, ED, DON, Diet Tech, Nurse Manager, IP Nurse, Social Worker designee, Director of Facilities, Business Office Manager, MOS nurse, Director of Therapy and Life Enrichment Director. IJ abatement plan audits, results, and follow up were discussed.
- Next QAPI meeting scheduled.
Failure to Administer Antibiotics as Ordered
Penalty
Summary
The facility failed to ensure that a resident, identified as R3, was free from significant medication errors during their stay. R3 was admitted with diagnoses including post laminectomy syndrome and a post-surgical infection of the intrathecal pain pump, requiring intravenous antibiotic therapy. However, the facility did not administer several doses of the prescribed antibiotics, cefepime and metronidazole, as ordered by the physician. Specifically, R3 missed four doses of cefepime and five doses of metronidazole, and some doses were administered outside the scheduled time frame, contrary to the facility's medication administration policy. On one occasion, R3's family found the resident febrile, unresponsive, and exhibiting tremors, prompting them to alert a Licensed Practical Nurse (LPN). The LPN had not administered the 9:00 AM dose of IV antibiotics by the time the family raised concerns. R3 was subsequently transferred to the emergency department, where they were diagnosed with an altered mental status, sepsis, and atrial fibrillation with rapid ventricular response. The resident required critical care and was hospitalized for 12 days. Interviews with facility staff, including the LPN, Advanced Practice Registered Nurse (APRN), Medical Director, and others, revealed expectations that medications should be administered as ordered to prevent infection recurrence and ensure resident safety. However, the LPN admitted to falling behind on medication administration due to a busy day and did not seek assistance. The Interim Director of Nursing (IDON) acknowledged that there was no formal documentation of medication administration audits, which contributed to the oversight in ensuring timely and accurate medication delivery.
Removal Plan
- An Ad Hoc QAPI meeting was held with DON, Medical Director and ED discussed IJ regarding Medication Administration for Medical Director input.
- The Corporate Clinical team, VP of Operations, Executive Director and DON discussed the Medication Administration policy and the plan for abatement.
- The Director of Clinical Risk Management reviewed the Medication Administration policy.
- The Director of Clinical Risk Management educated the DON and Nurse Managers regarding the Medication Administration policy.
- The Director of Clinical Risk Management and the DON audited all missed meds using the Medication Admin Audit Report in PCC and communicated with MD and responsible party as needed.
- The DON/Nurse Managers provided education for all nurses and KMAs regarding Medication Administration policy and the Nurse Clinical Binder. Agency Nurses are educated prior to their shift. 100% complete with 1 nurse on leave who will be educated prior to her return to work.
- Nurses were educated by the DON/Nurse Managers on the Nurse Clinical Binder that includes information on Daily Nurse Expectations, pharmacy cut off times, admission/readmission orders, what to do when a medication is unavailable, what to do when someone admits to the facility, what to do when a resident receives new orders, what to do when sending someone to the hospital, what to do when you receive medications from the pharmacy and Medication Administration Special Considerations. Education was initially completed by the DON at the Monthly All Staff Clinical Meeting. The DON/Nurse Managers started referencing the Nurse Clinical Binder as education on step by step guides for nurses and KMAs.
- DON/Nurse Managers administer quizzes to nurses and KMAs regarding Medication Administration. DON/Nurse Managers follow up with Nurse/KMA if a question is missed and reports results to QAPI team.
- DON/Nurse Manager completes audit using Medication Admin Audit Report in PCC. DON/ Nurse Managers address issues immediately with appropriate nurse or KMA and assures follow up regarding notification policy.
- Nurse Managers provided 1:1 Nurse/KMA coaching to ensure medication administration per MD orders.
- DON/Nurse Managers compare the hospital discharge summary to the MD orders in PCC for all new admissions, to assure accuracy and timeliness of medication administration. Results of the audits will be reported to the QAPI committee until substantial compliance is achieved.
- DON/Nurse Manager reported results of audits, follow up, and trends to QAPI committee and will continue to report data to QAPI until we are in substantial compliance.
- QAPI meeting was attended by Medical Director, Nurse Practitioner, ED, DON, Diet Tech, Nurse Manager, IP Nurse, Social Worker designee, Director of Facilities, Business Office Manager, MDS nurse, Director of Therapy and Life Enrichment Director. IP abatement plan audits, results, and follow up were discussed.
- The next QAPI meeting is scheduled.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate pressure ulcer prevention and care for a resident, identified as R2, who was admitted with a history of idiopathic hydrocephalus, peripheral vascular disease, and atherosclerosis with ulceration. Upon admission, R2 was assessed as being at risk for pressure ulcer development, yet the facility did not implement necessary interventions to prevent pressure ulcers or manage existing ones. Despite having a baseline care plan that included some interventions, the facility did not ensure the use of pressure off-loading boots or off-load the wound while the resident was in bed or a wheelchair. The deficiency was further compounded by the facility's failure to conduct regular skin assessments as ordered. Although there was an order for weekly skin assessments, only one was documented during R2's stay. The facility's records also showed discrepancies in the documentation of R2's skin condition, with some notes indicating intact skin while others noted skin breakdown. The nursing staff did not update the treatment administration record or baseline care plan to reflect the necessary interventions for R2's pressure ulcer care, despite recommendations from the Advanced Practice Registered Nurse and the Physical Therapy staff. Interviews with staff and family members revealed a lack of communication and adherence to care protocols. The family expressed concerns that their requests for pressure off-loading were not honored, and the former Director of Nursing could not recall critical details about the timeline of the wound's development and treatment. The Infection Preventionist/Wound Care Nurse and the Wound Care Physician were not informed promptly about the wound, leading to delays in appropriate treatment. This lack of timely intervention and documentation contributed to the development of an unstageable pressure ulcer on R2's left heel, which was not present upon admission.
Infection Control Deficiencies in PPE Use and Equipment Cleaning
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to proper infection control protocols. In one instance, a resident under contact isolation precautions was visited by an Advanced Practice Registered Nurse (APRN) and a Registered Nurse (RN) who both failed to wear the required personal protective equipment (PPE) such as gowns and gloves. The APRN was observed sitting on the resident's unmade bed, which she later acknowledged was inappropriate and could facilitate the spread of infection. Both the APRN and RN admitted to knowing the facility's policy on PPE use but did not adhere to it during their interactions with the resident. Another deficiency was observed with a Licensed Practical Nurse (LPN) who mishandled a contaminated glucometer after performing a blood glucose fingerstick on a resident. The LPN was seen carrying the glucometer without gloves and placing it on a medication cart without a protective barrier. Despite being aware of the correct cleaning protocol, the LPN failed to clean the glucometer immediately and did not follow the manufacturer's instructions for the required dwell time for disinfection. This lapse in protocol was repeated on a separate occasion, indicating a pattern of non-compliance with infection control procedures. Interviews with the Infection Preventionist/Wound Care Nurse (IP/WCN) and the Interim Director of Nursing (IDON) revealed that staff had received training on infection prevention and control practices, including the use of PPE and cleaning protocols. However, there was no documentation of staff audits to ensure compliance with these practices. The Executive Director also expressed the expectation that staff adhere to the facility's infection control policies to prevent the spread of infection, yet the observed deficiencies indicate a failure to consistently implement these protocols.
Failure to Ensure Resident Privacy During Medical Procedure
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident, identified as R8, during a medical procedure. On 12/18/2024, an LPN administered an insulin injection to R8 at a dining table in the presence of other residents. R8, who was cognitively intact with a BIMS score of 15, had consented to receive the injection at the table to avoid her meal getting cold. However, this action was against the facility's policy, which mandates that medical treatments be conducted privately to respect residents' rights to privacy and dignity. The LPN admitted to not providing privacy during the procedure and acknowledged that she did not consult other residents about their comfort with the situation. The interim Director of Nursing and the Executive Director both confirmed that the facility's protocol requires medication administration to occur privately, regardless of resident consent, to maintain dignity and privacy. The Director of Clinical Risk Management stated that the facility adheres to CMS nursing care standards, emphasizing the importance of following established policies to ensure appropriate care.
Unattended Pharmacy Delivery Tote Leads to Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored according to professional standards, as evidenced by an incident involving an unattended and unsecured pharmacy delivery tote. During an observation, a medication cart in Household B Hall was found with an opened pharmacy delivery tote containing various medications, including albuterol inhalation solution packets, IV fluid bags, heparin flush injections, and IV ceftriaxone bags. The tote was left unattended in a public area where residents and staff were passing by, contrary to the facility's policy that requires medications to be stored in locked compartments accessible only to authorized personnel. Interviews with facility staff, including an LPN, an RN, the Interim Director of Nursing, and the Executive Director, confirmed that the medications should have been stored in the medication room or the designated medication cart immediately upon receipt from the pharmacy. The LPN admitted to leaving the tote unattended while administering medication to a resident, and both the RN and the Interim Director of Nursing acknowledged the potential safety risks posed by leaving medications unsecured. The Executive Director emphasized the expectation that staff adhere to the facility's policy to ensure the safe and appropriate care of residents.
Failure to Administer COVID-19 Test Upon Request
Penalty
Summary
The facility failed to ensure that a resident, identified as R10, was informed of and able to participate in their treatment, specifically regarding COVID-19 testing. Despite the facility's policy allowing residents to request COVID-19 tests, staff refused to administer a test to R10 when requested by the resident's family member. The facility's policy stated that anyone with even mild symptoms should receive a viral test, but staff denied the request, claiming there were no positive COVID cases in the facility. This refusal occurred despite R10 exhibiting symptoms such as a slight cough and runny nose. Interviews with family members and staff revealed that the facility did not follow its own policies regarding COVID-19 testing. The Infection Preventionist Nurse and the Director of Nursing both stated that residents could request a COVID test at any time and that there was no reason to deny such a request. However, the family member's request for a test was not fulfilled, and there was no documentation of COVID testing or results in R10's records. This incident highlights a failure in communication and adherence to established protocols, resulting in the resident not receiving the requested COVID-19 test.
Deficiency in Documenting Influenza Immunization
Penalty
Summary
The facility failed to ensure that a resident's medical record included documentation indicating whether the resident received or refused the influenza immunization for the 2023-2024 season. This deficiency was identified for one of the five sampled residents, who was admitted with chronic obstructive pulmonary disease (COPD) and Alzheimer's disease. The resident's immunization record lacked evidence of the administration or refusal of the influenza vaccine, despite the facility's policy requiring such documentation. Interviews with the Infection Preventionist (IP) Nurse and the Director of Nursing (DON) revealed that residents were provided with educational information about vaccines and that consent was obtained before administration. However, the documentation of this process was missing in the resident's chart. The Administrator confirmed the expectation that medical records should reflect either the administration or refusal of immunizations, in line with the facility's infection prevention guidelines.
Communication Failures in Resident Care
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, particularly in maintaining communication with family members. Two residents, R7 and R10, were involved in incidents where their family members were unable to reach the facility via telephone. R7's family member reported multiple unsuccessful attempts to contact the facility to check on the resident's condition after a COVID diagnosis, only to find out later that the facility had changed its phone numbers without notifying them. Similarly, R10's family member experienced difficulties reaching the facility, leading to concerns about the resident's well-being. Interviews with staff revealed systemic issues with the facility's phone system. The DON and other staff members acknowledged that calls were often not answered, went straight to voicemail, or were not returned due to full mailboxes. The facility's policy allowed for calls to be forwarded to staff cell phones after hours, but there was no designated person responsible for checking and returning messages. This lack of communication was further compounded by the fact that family members were not informed of updated contact numbers, leading to confusion and distress. The facility's failure to maintain effective communication channels was evident during the surveyor's attempt to contact the facility, which also resulted in a full voicemail box. Interviews with the receptionist and other staff highlighted a lack of clarity and responsibility in handling incoming calls, especially after hours. The administrator confirmed that the facility had sent updated phone numbers to residents and families, but the ongoing communication issues suggested that this information was not effectively disseminated or utilized.
Latest citations in Kentucky
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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