Wurtland Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Wurtland, Kentucky.
- Location
- 100 Wurtland Avenue, Wurtland, Kentucky 41144
- CMS Provider Number
- 185261
- Inspections on file
- 18
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 3 (3 serious)
Citation history
Health deficiencies cited at Wurtland Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple cardiac and neurologic diagnoses experienced a rapid weight gain of over 17 pounds in less than two weeks, along with shortness of breath and +3 to +4 pitting edema. Facility policy and the resident’s care plan required staff to notify a physician or APRN of weight changes of three pounds in one week and abnormal assessment findings, but nursing staff and the DON documented successive weight increases and respiratory symptoms without evidence of provider notification. The APRN reported not being informed of the repeated weight gains until the day an LPN finally contacted him, obtained orders for diagnostic tests and IM furosemide, and sent the resident to the hospital at the request of a family member who had repeatedly voiced concerns about worsening edema.
A resident with pneumonia, atrial fibrillation, coronary artery disease, and hypertension was admitted with an IV antibiotic infusion and ordered weekly weights. The care plan required staff to monitor for cardiac dysfunction, including edema, and to notify the physician of significant weight changes, consistent with facility policy. Over approximately two weeks, the resident gained more than 17 pounds and developed progressive edema observed by family, but there was no documentation that nurses notified the physician or consistently assessed for edema. Staff interviews confirmed lack of physician notification and incomplete assessment practices, and the APRN reported not being informed of the weight gain until the day of hospital transfer, where the resident was admitted with fluid overload and MI and later expired. Surveyors cited the facility for failing to develop and implement a comprehensive, resident-centered care plan, including resident-specific interventions for continuous IV fluids and timely response to significant weight changes.
A resident admitted for short-term rehab with cardiac and respiratory comorbidities experienced a rapid 17‑pound weight gain over less than two weeks, along with progressive edema, shortness of breath, and increased confusion. Facility policies and the care plan required re‑weighs, assessment, and MD/APRN notification for significant weight changes and signs of cardiac dysfunction, but nursing staff, including the DON and multiple LPNs, did not consistently reassess, document edema and dyspnea in progress notes, or notify a provider as the weight increased from the low 250s to 270 pounds. Family repeatedly voiced concerns about swelling in the resident’s extremities and scrotum, which were initially met only with instructions to continue monitoring, and the APRN later reported not being informed of the rapid weight gain or evolving assessment findings until the day the resident was ultimately sent to the hospital with fluid overload and acute cardiac issues.
The facility failed to implement comprehensive care plans for several residents, leading to unmet medical and personal care needs. A resident with plaque psoriasis did not receive proper shampoo application, while another with pressure ulcers was not repositioned or provided timely incontinence care. A third resident did not receive frequent toileting assistance or oral care, and a fourth had improper artificial eye care. Additionally, a resident's midline dressing was not changed as ordered.
The facility failed to provide timely incontinence and oral care for several residents, leading to feelings of embarrassment and inadequate hygiene. Residents often waited long periods for assistance, resulting in soiled conditions and plaque build-up. Staff interviews indicated that short staffing contributed to these deficiencies.
The facility failed to provide appropriate care for three residents, including incorrect application of medicated shampoo for a resident with a scalp condition, inadequate care for a resident with a prosthetic eye, and failure to change a dressing for a resident with a midline IV as ordered. Staff were not adequately informed or aware of the correct procedures, leading to ongoing issues and discomfort for the residents.
Two residents in an LTC facility developed facility-acquired pressure ulcers due to inadequate care. Despite being identified as at risk, they did not receive timely incontinence care and repositioning, leading to skin breakdown. Staff interviews revealed systemic issues, including understaffing and ineffective implementation of care plans, contributing to the deficiency.
The facility failed to maintain adequate staffing levels, resulting in insufficient care for residents. Observations and interviews revealed that residents did not receive necessary assistance with activities of daily living, such as incontinence and dental care. Additionally, staff failed to provide proper care for residents with specific medical needs, including incorrect application of medicated treatments and failure to change dressings as ordered. The lack of sufficient, competent staff led to the development of facility-acquired pressure ulcers in some residents and inadequate care for those with catheters, resulting in urinary tract infections.
The facility failed to inform and document advance directive information for several residents, as required by policy. Despite verbal discussions claimed by staff, there was no evidence in the records that residents were given the opportunity to formulate or decline advance directives. Incomplete documentation and lack of awareness among staff contributed to this deficiency.
The facility failed to store insulin at the correct temperature in two medication refrigerators, with temperatures recorded below the recommended range. Observations showed that Refrigerator 1 had a temperature of 26°F and Refrigerator 3 had a temperature of 30°F, both containing various insulin pens. The ADON confirmed that medications stored at these temperatures would freeze and become ineffective. Despite requests, a Medication Storage policy was not provided.
The facility did not follow its infection prevention and control policies, including failing to provide PPE carts outside droplet precaution rooms, leaving precaution room doors open, and not properly cleaning shared equipment such as glucometers and bandage scissors. Staff also failed to date and store food items used for medication administration on ice as required. These actions were not in line with CDC guidelines, manufacturer instructions, or facility policy.
The facility failed to ensure call lights were within reach for three residents, compromising their ability to request assistance. A resident with severe cognitive impairment had an adaptive call light out of reach, while another resident, cognitively intact but needing mobility assistance, was found attempting to get out of bed without access to her call light. A third resident with dementia was also unable to reach his call light. Staff confirmed the expectation for call lights to be accessible, but this was not consistently practiced.
A resident admitted with pressure ulcers did not have these addressed in their baseline care plan within 48 hours, contrary to facility policy. Staff interviews confirmed the presence of pressure ulcers at admission, highlighting a lapse in following procedures to ensure accurate and effective care.
The facility failed to prevent and treat UTIs in two residents with indwelling catheters. One resident's catheter bag was on the floor, and her complaints of UTI symptoms were not promptly addressed, leading to delayed treatment. Another resident's catheter bag was also found on the floor, despite staff being trained on proper catheter care. These deficiencies highlight lapses in adherence to care standards and documentation practices.
A resident with a gastrostomy tube did not receive the prescribed amounts of enteral feed and water flushes, leading to severe dehydration and hypernatremia. The facility's inadequate documentation and communication practices contributed to the deficiency, as nursing staff failed to document changes in the resident's condition and did not communicate with the NP about interruptions in tube feedings. The resident was hospitalized due to these failures.
A resident with a right acetabulum fracture experienced unmanaged pain due to the facility's failure to reorder oxycodone in a timely manner. The resident missed several doses, and staff did not utilize the Emergency Kit or notify the provider about the medication's unavailability. Interviews revealed inconsistent practices in monitoring medication stock, contributing to the deficiency.
Failure to Notify Physician of Significant Weight Gain and Fluid Overload Signs
Penalty
Summary
The deficiency involves the facility’s failure to recognize and notify a physician of a resident’s significant weight gain and associated symptoms, as required by facility policy and the resident’s care plan. The facility’s Weight Monitoring policy required staff to notify the physician of a weight gain or loss of three pounds within one week. The resident was admitted with diagnoses including pneumonia, nontraumatic subdural hemorrhage, primary hypertension, atrial fibrillation, and hypertension, and had a care plan intervention for nurses to weigh the resident as ordered and notify the physician of significant weight changes, documenting abnormal findings and notifying the physician. The physician’s orders included weekly weights. From admission, the resident’s weight increased from 252.8 pounds to 259 pounds within four days, a gain of 6.2 pounds, and then to 267 pounds within nine days, a total gain of 14.2 pounds from admission. These weights were entered by the DON and an LPN, respectively. There was no documentation that the provider was notified of either the 6.2‑pound gain in four days or the 14.2‑pound gain in nine days, despite the facility policy requiring notification for a three‑pound gain in one week. Nursing documentation also showed that the resident had shortness of breath and/or labored breathing with exercise and while lying flat, but there was no documentation that the physician was notified of these abnormal findings, contrary to the resident’s care plan interventions. The resident’s weight continued to increase, reaching 270 pounds 13 days after admission, a total gain of 17.2 pounds. On that date, an LPN documented +3 to +4 pitting edema in all four extremities and shortness of breath, and notified the APRN, obtaining orders for a chest x‑ray, labs, and intramuscular furosemide. The resident was sent to the hospital for evaluation at the request of a family member. Interviews with the family member indicated he observed increasing swelling of the resident’s legs, feet, and scrotum throughout the stay and reported these concerns daily to staff, who told him the edema was not a problem. Interviews with the APRN, Medical Director, DON, and Administrator confirmed that staff were expected to notify a provider of significant weight changes and changes in condition, and that there was no evidence staff had identified the resident’s weight gain as a significant change in condition or notified the APRN or physician of the repeated weight gains prior to the date when the APRN was finally contacted.
Removal Plan
- All current residents were re-weighed and reassessed for change of condition by the Director of Nursing Services, Assistant Director of Nursing Services, and Unit Manager; weights for the last 6 months were reviewed.
- For any significant weight changes identified, nursing assessments were completed by the Director of Nursing Services, Assistant Director of Nursing Services, or Unit Manager with physician or nurse practitioner notification for orders as needed.
- All residents were reassessed and reweighed.
- All residents were reassessed by the Director of Nursing Services, Assistant Director of Nursing Services, and Unit Manager with any changes of condition reported to the Nurse Practitioner and orders obtained.
- Director of Nursing Services was educated by the Regional Nurse Consultant to review weight reports timely related to the weekly Nutritional At Risk meeting.
- All nurses were educated by the Infection Preventionist/Staff Development, Director of Nursing Services, or Assistant Director of Nursing Services regarding the policy on notifying the physician or nurse practitioner of all changes of condition including weight changes; education completion tracked.
- A post-test was administered to all nurses with an expected 100% pass rate; if 100% was not achieved, re-education was provided.
- Director of Nursing Services, Assistant Director of Nursing Services, Infection Preventionist/Staff Development, or Unit Manager will provide education until all nurses complete it.
- Education on notification of changes in condition including weight changes will be added to new-hire nurse orientation.
- An ad hoc QAPI meeting was held with the Executive Director, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and Medical Director to review the alleged deficiency, audit tools, and education regarding notification of changes.
- The Director of Nursing Services, Assistant Director of Nursing, or Unit Manager will audit to ensure all changes in condition including weight changes resulted in physician or nurse practitioner notification.
- Audit results will be forwarded to the QAPI Committee for review and presented by the Director of Nursing.
Failure to Implement Comprehensive Cardiac and Weight Monitoring Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, resident-specific care plan that addressed all identified needs, including monitoring and response to significant weight changes and potential complications from continuous IV fluids. The resident was admitted with diagnoses including pneumonia, nontraumatic subdural hemorrhage, atrial fibrillation, coronary artery disease, and hypertension, and had an IV access for antibiotics. The care plan included an intervention for nurses to weigh the resident as ordered and notify the physician of significant weight changes, and was later updated to identify risk for cardiac dysfunction with instructions to observe for signs such as shortness of breath, cough, abnormal lung sounds, change in mental status, activity intolerance, decreased urine output, edema, dizziness, and weakness, document abnormal findings, and notify the physician. However, the care plan did not include resident-specific interventions related to potential complications from continuously infusing IV fluids. The facility’s own Weight Monitoring policy required staff to notify the physician of a weight gain or loss of three pounds within one week, and the physician’s orders for the resident included weekly weights. The weight records showed that the resident’s weight increased from the admission weight to 259 pounds within four days (a gain of 6.2 pounds), then to 267 pounds within nine days (a gain of 14.2 pounds), and then to 270 pounds within 13 days (a total gain of 17.2 pounds). Despite these significant weight gains, there was no documented evidence that staff implemented the care plan interventions by notifying the physician of the changes between the admission date and the date of the last recorded weight. Interviews with nursing staff indicated that they did not recall notifying the physician about the weight gain, and one LPN acknowledged she did not always directly assess residents for edema, despite the care plan requiring observation for edema as a sign of cardiac dysfunction. A family member reported observing progressive swelling of the resident’s legs, feet, and scrotum during daily visits and stated he felt staff ignored his concerns about the edema. He indicated that he requested the resident be sent to the hospital due to his concerns about the swelling, and that the transfer occurred only after his request. The APRN stated that staff did not notify him of changes in assessment findings, including the resident’s weight gain, until the date the resident was ultimately sent to the hospital. The facility’s leadership, including the DON and Administrator, stated they expected staff to follow care plans, including interventions to notify the physician of significant weight changes and edema, but could not explain why staff failed to implement the care-planned interventions for this resident. The combination of incomplete care planning for continuous IV fluids and failure to implement existing care plan interventions and notification requirements led to the cited deficiency under F656 for not ensuring a comprehensive, resident-centered care plan was developed and implemented. Hospital documentation showed that the resident arrived on the inpatient unit in the evening and was later found unresponsive with pulseless electrical activity and agonal breathing, with a Code Blue initiated and the resident subsequently pronounced expired. The hospital admission diagnoses included fluid overload and myocardial infarction. The surveyors concluded that the facility’s failure to implement the care plan interventions and notify the physician beginning several days prior resulted in a delay in intervention and treatment for the resident, and Immediate Jeopardy was identified related to the deficient practice in comprehensive care planning and implementation.
Removal Plan
- All residents were reassessed and reweighed.
- All residents were reassessed by the Director of Nursing Services, Assistant Director of Nursing Services, and Unit Manager, with any changes of condition reported to the Nurse Practitioner and orders obtained.
- All care plans for residents with congestive heart failure, use of diuretics, and orders for daily or weekly weights were reviewed by the Regional Resident Assessment Specialist to ensure accuracy.
- All nurses were re-educated regarding the care plan policy, including implementation and physician notification with changes of condition, with no nurse working before receiving the education.
- A post-test was given to all nurses with an expected 100% pass rate; if 100% was not achieved, re-education was provided.
- DNS/ADNS/IPSO/Unit Manager will provide education until all nurses complete the education.
- Care plan and notification education will be added to new nurse hire orientation.
- An ADHOC QAPI meeting was held with the Executive Director, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and Medical Director to review the alleged deficiency, audit tools, plan, and education regarding notification of changes.
- The Director of Nursing Services, Assistant Director of Nursing, or Unit Manager will audit to ensure all weight changes resulted in physician or nurse practitioner notification per the care plan.
- Audit results will be forwarded to the QAPI Committee for review and presented by the Director of Nursing.
Failure to Recognize and Act on Rapid Weight Gain and Edema as Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to recognize and respond to a significant change in condition for one resident, including substantial weight gain and edema, in accordance with its own policies and the resident’s care plan. The resident was admitted for short-term rehabilitation following a serious illness with sepsis and a spinal abscess, with hospital diagnoses including atrial fibrillation, coronary artery disease, pneumonia, and stable shortness of breath at discharge. On admission, the facility documented diagnoses of pneumonia, nontraumatic subdural hemorrhage, and primary hypertension, and the MDS reflected atrial fibrillation, hypertension, moderate cognitive impairment (BIMS score of 8/15), IV access, and shortness of breath when lying flat. The care plan directed staff to weigh the resident as ordered, notify the physician of significant weight changes, and, after an update, to observe and document signs and symptoms of cardiac dysfunction such as shortness of breath, abnormal lung sounds, decreased urine output, edema, and changes in mental status, and to notify the physician of abnormal findings. The facility’s policies on Change in Condition and Weight Monitoring required staff to notify the physician or nurse practitioner for abnormal weights and significant changes, to re-weigh residents for weight changes of 3 pounds or more in one day or 5 pounds in one week, and to notify the physician, resident, and representative of such changes. Despite these policies, the resident’s weight increased from an admission weight of 252.8 pounds to 259 pounds within four days, then to 267 pounds within nine days, and to 270 pounds within 13 days, for a total gain of 17.2 pounds. The DON entered the 259‑pound weight and acknowledged later that this represented a clinically significant gain per policy but did not assess the resident or notify the APRN. LPN1 entered the 267‑pound weight but did not document any re‑weigh, assessment, or provider notification related to this gain and could not recall taking any such actions, stating that if she had notified a provider she would have charted it. During this period of rapid weight gain, clinical signs consistent with fluid accumulation were present but not consistently recognized or acted upon as a change in condition. A Health Status Note documented that a family member reported the resident’s right hand swelling, increased confusion from baseline, and complaints of shortness of breath; LPN5 documented these findings and notified the APRN, who ordered continued monitoring only, without further specified parameters. Skilled nursing assessments on two dates documented shortness of breath or labored breathing with exertion and when lying flat, need for supplemental O2 and head-of-bed elevation, and edema in both lower extremities, yet the corresponding progress notes from admission through the date of transfer contained no documentation of edema or shortness of breath and no evidence that staff recognized the weight gain as a significant change in status or notified the physician as required. On the thirteenth day, LPN4 documented +3 to +4 pitting edema in all four extremities, marked scrotal swelling, and shortness of breath after the family member again raised concerns, and EMS later assessed the resident as in acute respiratory distress with crackles/wheezing and pitting edema in all extremities. The APRN and Medical Director both stated they relied on nursing staff to notify them of rapid weight gain and changes in assessment findings, and the DON confirmed she could find no evidence that staff identified the resident’s weight gain as a potential change in condition or notified the APRN after the initial report of arm swelling, leading surveyors to cite the facility under F684 for failing to provide care in accordance with policies, care plan, and professional standards.
Removal Plan
- Resident #117 was discharged.
- All current residents were re-weighed and reassessed for change of condition by the Director of Nursing Services, Assistant Director of Nursing Services, and Unit Manager, with weights reviewed for the last 6 months.
- For any significant weight changes identified, a nursing assessment was completed by the Director of Nursing Services, Assistant Director of Nursing Services, or Unit Manager with notification of the physician or nurse practitioner for orders as needed.
- All residents were reassessed and reweighed, and any changes of condition were reported to the Nurse Practitioner with orders given.
- All nurses were re-educated by the Infection Preventionist/Staff Development, Director of Nursing Services, or Assistant Director of Nursing Services regarding the policy to notify the physician or nurse practitioner of all significant weight changes and the policy on changes in condition; no nurse worked before receiving the education.
- A post-test was administered to all nurses with an expected 100% pass rate; if 100% was not achieved, re-education was provided.
- The Director of Nursing, Assistant Director of Nursing, Infection Preventionist/Staff Development, or Unit Manager will provide education until all nurses complete it.
- Education on notification of significant weight changes and changes in condition will be added to new-hire orientation for nurses and certified medication technicians.
- An ad hoc QAPI meeting was held with the Executive Director, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and Medical Director to review the alleged deficiency, audit tools, plan, and education regarding notification of changes.
- The Director of Nursing Services, Assistant Director of Nursing, or Unit Manager will audit to ensure all weight changes and head-to-toe resident assessments resulted in physician or nurse practitioner notification when warranted.
- Audit results will be forwarded to the QAPI Committee for review and presented by the Director of Nursing.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to unmet medical and personal care needs. For Resident 80, the care plan included the use of a medicated shampoo for plaque psoriasis, but specific instructions for its application were not provided to the staff. As a result, the shampoo was not left on the scalp for the required duration, leading to continued itching and scalp issues. Additionally, the care plan for skin breakdown risk was not updated with specific interventions for the scalp condition until after the surveyor's intervention. Resident 27's care plan identified the need for regular repositioning and incontinence care to prevent pressure ulcers. However, staff failed to assist with repositioning and did not provide timely incontinence care, as observed during the survey. The facility's staffing issues were highlighted as a contributing factor, with staff unable to follow care plans due to insufficient support. The Assistant Director of Nursing Services acknowledged the lack of audits to verify compliance with care plan interventions. For Resident 52, the care plan required frequent toileting assistance and oral care, but these interventions were not consistently implemented. The resident was found with soaked briefs and reddened skin, indicating inadequate incontinence care. Oral care was also neglected, as staff failed to assist or remind the resident to perform it. The Director of Nursing Services admitted to not verifying the implementation of these care plan interventions. Similar issues were noted for Resident 36, whose care plan lacked specific instructions for cleaning an artificial eye, leading to improper care and infection. Resident 124's care plan included dressing changes for a midline, but these were not performed as ordered, resulting in the dressing remaining unchanged for an extended period.
Deficiencies in Incontinence and Oral Care
Penalty
Summary
The facility failed to provide necessary services to maintain good personal and oral hygiene for six residents, leading to deficiencies in activities of daily living care. Residents expressed feelings of embarrassment and humiliation due to the facility's failure to provide timely incontinence care. Interviews with residents and their family members revealed that residents often waited long periods, sometimes up to four hours, before staff could change them, resulting in residents urinating in their beds and lying in urine for extended periods. Additionally, the facility failed to provide daily oral care for two residents, who had plaque build-up as noted by the dentist. One resident, admitted with diagnoses including a fracture and heart failure, required substantial assistance for toileting hygiene and lower body dressing. The resident reported waiting over four hours to be changed, resulting in soiling of a leg brace. Another resident, with mild cognitive impairment and a pressure ulcer, reported waiting long periods for incontinence care, leading to skin breakdown and embarrassment. Observations confirmed that residents were left in soiled conditions for extended periods, and staff interviews indicated that short staffing contributed to the delays in care. The facility's failure to provide adequate oral care was also noted, with one resident having a bridge of calculus on their teeth and another resident with partial dentition requiring assistance with daily tooth brushing. Observations and interviews revealed that oral care was often neglected due to staff being busy with other tasks. The facility's policies on activities of daily living and oral care were not followed, resulting in inadequate care for the residents.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards and resident preferences for three residents. For one resident with a scalp condition, the facility did not ensure that the medicated shampoo was applied correctly. The shampoo was not left on the scalp for the required three to five minutes, as specified by the manufacturer's instructions. The resident continued to experience itching and discomfort, and there was no documentation of the condition's evaluation or the treatment's effectiveness. The resident had not been seen by a healthcare provider for over a month, and the staff responsible for applying the shampoo were not adequately informed about the correct procedure. Another resident with a prosthetic eye experienced ongoing issues with eye drainage and infection. The facility did not have specific care instructions for the prosthetic eye, and staff were unaware that the eye needed to be removed for proper cleaning. The resident's eye was observed to have green, pus-filled drainage, and staff interviews revealed that this was a persistent problem. Despite the presence of an artificial eye, there were no physician orders for eye care until after the survey began, and the care plan did not include necessary interventions for the prosthetic eye. A third resident with a midline IV access for antibiotic therapy did not receive the required dressing changes as ordered. The dressing was not changed weekly as specified, and observations confirmed that the dressing had not been updated since the resident's admission. Staff interviews indicated a lack of awareness regarding the outdated dressing, and the facility's procedures for ensuring timely dressing changes were not followed. The failure to change the dressing as ordered was not addressed until after the surveyor's intervention.
Inadequate Pressure Ulcer Prevention and Care in LTC Facility
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to the development of facility-acquired pressure ulcers. Resident 27, who was admitted with mild cognitive impairment, osteoarthritis, and depression, was identified as at risk for skin breakdown. Despite being assessed as cognitively intact and requiring assistance with mobility and incontinence care, Resident 27 developed a Stage III pressure ulcer on the right buttock and a deep tissue injury on the left buttock. The facility's records indicated a lack of timely incontinence care and repositioning, contributing to the worsening of the resident's skin condition. Interviews with staff revealed systemic issues, including understaffing and inadequate implementation of care plans. Staff members reported that residents often waited long periods for incontinence care, leading to prolonged exposure to moisture and increased risk of skin breakdown. The facility's interdisciplinary team failed to identify a root cause for the pressure ulcers and did not ensure that necessary interventions, such as timely repositioning and incontinence care, were consistently provided. Resident 10, with a history of multiple sclerosis, vascular dementia, and diabetes, also developed a facility-acquired pressure ulcer. Despite being identified as at risk for pressure ulcers, the resident's care plan was not effectively implemented, resulting in a deep tissue injury on the right hip. Staff interviews highlighted challenges in providing timely care due to high resident-to-staff ratios, with reports of residents being left soiled for extended periods. The facility's recent termination of a wound care service contract further strained the ability of nurses to manage wound care effectively.
Inadequate Staffing Leads to Resident Care Deficiencies
Penalty
Summary
The facility failed to maintain adequate staffing levels, resulting in insufficient care for residents. Observations and interviews revealed that residents did not receive necessary assistance with activities of daily living, such as incontinence and dental care. Additionally, staff failed to provide proper care for residents with specific medical needs, including incorrect application of medicated treatments and failure to change dressings as ordered. The lack of sufficient, competent staff led to the development of facility-acquired pressure ulcers in some residents and inadequate care for those with catheters, resulting in urinary tract infections. The facility's staffing documentation and Payroll Based Journal (PBJ) reports indicated a chronic shortage of State Registered Nurse Aides (SRNAs) and licensed nurses, particularly on weekends and night shifts. This shortage resulted in each SRNA being responsible for an excessive number of residents, often leading to delays in care and unmet needs. Interviews with staff and family members highlighted the impact of these staffing issues, with reports of call lights going unanswered for extended periods and residents being left in soiled clothing or without necessary hygiene care. The facility's internal assessments and policies acknowledged the need for sufficient staffing to meet resident needs, yet the actual staffing levels fell short of these requirements. Staff interviews revealed a high turnover rate and dissatisfaction with the workload, contributing to the ongoing staffing challenges. Despite the facility's stated goals for staffing levels, the actual number of staff on duty frequently did not meet these targets, compromising the quality of care provided to residents.
Failure to Provide and Document Advance Directive Information
Penalty
Summary
The facility failed to inform and provide written information to all adult residents concerning their right to accept or refuse medical or surgical treatment and to formulate an advance directive. This deficiency was identified for eight of the thirteen sampled residents reviewed for advance directives. The facility's policy required the Social Services Director (SSD) or Designee to provide this information prior to or upon admission, and to document any existing advance directives in the resident's medical record. However, the review revealed that this process was not consistently followed. For several residents, including those with cognitive impairments and those who were cognitively intact, there was no documented evidence that the opportunity to formulate or decline an advance directive was explained in a manner they understood. In some cases, residents were not asked about advance directives at admission, and existing directives were not requested or documented in the electronic medical record. The admission agreements often contained incomplete Living Will Packets, with only the resident's name and birthdate filled in, and no further documentation of discussions or decisions regarding advance directives. Interviews with facility staff, including the SSD, Director of Nursing Services (DNS), and Executive Director (ED), revealed a lack of awareness and understanding of the requirement to document these discussions and decisions. The SSD stated that verbal discussions were held with residents, but this was not reflected in the records. The ED believed that a signed acknowledgment of receipt of documents was sufficient, despite the absence of completed forms or evidence of informed discussions. This lack of documentation and adherence to policy led to the deficiency identified by the surveyors.
Improper Storage Temperature of Insulin in Medication Refrigerators
Penalty
Summary
The facility failed to store medications at the correct temperature, specifically insulin, in two of four medication refrigerators. Observations revealed that Refrigerator 1 in the Front Hall Medication Room registered a temperature of 26 degrees Fahrenheit, which is below the recommended range of 36 to 46 degrees Fahrenheit. This refrigerator contained various insulin pens, including Lantus, Insulin Glargine, Insulin Degludec, Basaglar, and Novolog. The presence of thick frost in the small freezer section of Refrigerator 1 was also noted. Similarly, Refrigerator 3 in the Back Medication Room registered a temperature of 30 degrees Fahrenheit and contained Admelog, Fiasp, Tresiba, Basaglar, and Lantus insulin pens. Interviews with the Assistant Director of Nursing (ADON) confirmed that medications stored at 26 degrees Fahrenheit would freeze and become ineffective. The ADON indicated that the Maintenance Director needed to adjust or repair the refrigerators and defrost Refrigerator 1, and that the medications needed to be returned to the pharmacy. The Executive Director stated that nurses were responsible for monitoring the medication refrigerator temperatures on both shifts and taking corrective action if temperatures were out of range. Despite requests, a Medication Storage policy was not provided prior to the exit.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement its infection prevention and control program as required, resulting in multiple deficiencies related to the prevention of communicable diseases and infections. Surveyors observed that a room designated for droplet precautions did not have a personal protective equipment (PPE) cart available outside the room, contrary to facility policy and CDC guidelines. Staff interviews confirmed that PPE carts should be present and accessible, but staff were unaware of the missing cart until it was pointed out. Additionally, the door to a droplet precaution room was found open, despite signage and CDC guidance requiring it to remain closed. Staff and leadership interviews revealed a lack of awareness regarding the open door, and a malfunctioning door latch was later identified as the cause. Further observations revealed that staff did not consistently follow proper cleaning and disinfection protocols for shared medical equipment. An LPN was seen cleaning a glucometer with a disinfectant wipe for less than the required dwell time and without performing hand hygiene after glove removal. Another LPN transported contaminated bandage scissors through the hall without using a container, failed to perform hand hygiene before cleaning, and did not allow the disinfectant to remain on the scissors for the required time. Staff interviews indicated knowledge of the correct procedures, but these were not followed in practice. Additional deficiencies were noted in the handling of food items used during medication administration. Opened containers of pudding and applesauce on medication carts were not dated or stored on ice as required. Staff interviews confirmed that food items should be dated when opened, kept on ice during use, and discarded after administration, but these practices were not consistently observed. The facility's infection prevention and control policies, as well as CDC and manufacturer guidelines, were not adhered to in these instances, contributing to the overall deficiency.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation for the needs of three residents by not ensuring their call lights were within reach, which is crucial for their safety and ability to request assistance. Resident 21, who was severely cognitively impaired and dependent on staff for all activities of daily living, had an adaptive call light placed out of reach on a nightstand. Despite staff being informed, no action was taken to rectify the situation. Resident 27, who was cognitively intact but required assistance with mobility, was found attempting to get out of bed without access to her call light, which was tangled in the bed frame. She called out for help, but no staff were present to hear her. Resident 91, who had dementia and mild intellectual disabilities, was also found calling for help with his call light out of reach on a nightstand by the window. Interviews with staff, including the Director of Nursing Services and the Executive Director, confirmed that staff were trained to keep call lights within reach, and it was expected for resident safety. However, the observations indicated a failure to adhere to this practice, compromising the residents' ability to communicate their needs effectively.
Failure to Address Pressure Ulcers in Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, identified as R93, who was admitted with pressure ulcers. The baseline care plan did not address the identification or treatment of these pressure ulcers, which is a requirement according to the facility's policy. The policy mandates that a baseline care plan should include minimum healthcare information necessary for proper care, including interventions for health and safety concerns such as pressure injuries. Despite the presence of pressure ulcers at the time of admission, as confirmed by interviews with the resident and staff, this critical information was omitted from the baseline care plan. Interviews with various staff members, including a State Registered Nurse Aide, a Licensed Practical Nurse, the Assistant Director of Nursing, the MDS Nurse, and the Director of Nursing Services, revealed that the omission was not in line with the facility's procedures. The MDS Nurse and the Director of Nursing Services emphasized the importance of including pressure ulcers in the baseline care plan to ensure accurate and effective care. The failure to include this information in the baseline care plan indicates a lapse in adhering to the facility's policy and professional standards of quality care.
Failure to Prevent and Treat UTIs in Residents with Catheters
Penalty
Summary
The facility failed to provide appropriate care and treatment to prevent and/or treat urinary tract infections (UTIs) for two residents with indwelling urinary catheters. For one resident, the catheter collection bag was observed lying on the floor, and the tubing was not anchored, which is against the facility's policy and CDC guidelines. The resident reported experiencing pain consistent with a UTI and had informed the staff, but no immediate action was taken to assess or address her concerns. The resident's electronic medical record lacked documentation of her complaints, and it was only after the surveyor's intervention that a nurse assessed the resident and initiated appropriate testing and treatment. Another resident with a suprapubic catheter also had their collection bag lying on the floor, unsecured to the wheelchair. This observation was made despite the facility's policy and training that emphasized the importance of securing catheter bags to prevent infections. Interviews with staff revealed that they were aware of the proper catheter care procedures, yet the deficiency occurred, indicating a lapse in adherence to these protocols. The facility's failure to secure catheter bags and promptly address residents' symptoms of UTIs demonstrates a lack of compliance with established care standards. The staff's inaction and inadequate documentation contributed to the delay in recognizing and treating the residents' conditions, potentially increasing the risk of infection and discomfort for the residents involved.
Failure to Prevent Complications from Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident, identified as R62, received appropriate treatment and services to prevent complications from enteral feeding. R62, who was admitted with diagnoses including epilepsy, dysphagia, and intellectual disabilities, was dependent on a gastrostomy tube for nutrition and hydration. Despite physician orders for specific amounts of enteral feed and water flushes, R62 did not receive the prescribed amounts, leading to severe dehydration and hypernatremia, which required hospitalization. The facility's documentation and communication practices were inadequate, contributing to the deficiency. Nursing staff failed to document changes in R62's condition, such as nausea, vomiting, and diarrhea, which led to the interruption of tube feedings. There was also a lack of communication with the nurse practitioner regarding these interruptions and the resident's declining condition. The Director of Nursing Services acknowledged that documentation should have been made when the tube feeding was stopped, and the nurse practitioner should have been notified to ensure proper nutrition. Interviews with facility staff, including the LPN, MDS Nurse, and NP, revealed a lack of consistent documentation and communication regarding R62's condition and care. The Executive Director expected staff to follow the resident's care plan, but the failure to administer treatments as ordered and the lack of documentation and communication led to R62's hospitalization for dehydration, hypernatremia, and a urinary tract infection.
Failure in Timely Pain Management for Resident
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident, identified as R119, who was admitted with a principal diagnosis of right acetabulum fracture with delayed healing, among other conditions. The resident was on a scheduled pain medication regimen, specifically oxycodone, which was not administered as ordered due to a failure in reordering the medication in a timely manner. On multiple occasions, the resident's pain medication was not available, leading to missed doses and unmanaged pain. On April 16, 2024, the resident missed several doses of oxycodone because the medication was not reordered in time, and the facility did not utilize the Emergency Kit to provide the necessary medication. The resident's pain was documented as 7/10 on the pain scale, yet there was no evidence of non-pharmacological interventions being attempted during the time the medication was unavailable. Additionally, the facility staff failed to notify the provider about the unavailability of the medication or request authorization for retrieval from the Emergency Kit. Interviews with staff revealed a lack of consistent practice in monitoring medication stock and reordering procedures. Staff members indicated that they should notify the nurse when medication stock was low, but this process was not effectively followed, resulting in the resident experiencing unmanaged pain. The Director of Nursing Services acknowledged that staff should be aware of declining stock and order medications in time, but this expectation was not met, leading to the deficiency in pain management for the resident.
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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