Belmont Terrace Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Florence, Kentucky.
- Location
- 7300 Woodspoint Drive, Florence, Kentucky 41042
- CMS Provider Number
- 185090
- Inspections on file
- 24
- Latest survey
- April 24, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Belmont Terrace Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Three residents experienced abuse or neglect when a staff member removed a dependent resident's call light device and failed to report or repair it, and when two residents were involved in a physical altercation after one entered the other's room. Staff did not ensure the call system was functional or provide adequate supervision to prevent resident-to-resident abuse, despite facility policies requiring such protections.
A resident with a history of behavioral and psychiatric issues was transferred to a BH facility after exhibiting combative behavior. The facility did not provide the required written 30-day discharge notice to the State Guardian or the LTC Ombudsman when it decided not to readmit the resident, and failed to communicate its intentions in a timely manner. The lack of notification and communication led to confusion, legal intervention, and the resident remaining at the BH facility longer than necessary.
The facility failed to develop and implement comprehensive person-centered care plans for eight residents, leading to various deficiencies, including pressure ulcers, elopements, inadequate catheter care, and improper G-tube site management. Additionally, concerns about a malfunctioning wheelchair brake were not addressed, posing a risk of falls.
A resident developed a stage 4 pressure ulcer due to the facility's failure to provide adequate care, including timely repositioning and incontinence management. Staff did not consistently assist or remind the resident to off-load pressure, and there was a lack of communication and coordination among the care team.
The facility failed to maintain sufficient nursing staff, resulting in residents experiencing delays in care and inadequate supervision. A resident was admitted to the hospital with saturated briefs and wounds due to insufficient staffing. Interviews with residents and staff confirmed long wait times and rushed care, highlighting the severe impact of inadequate staffing.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, with issues including undated and unlabeled food items, unsanitary conditions in the tray line area, and improper storage of clean dishes. Interviews revealed that facility policies were not being followed, leading to multiple deficiencies.
The facility failed to ensure effective administration and infection control, leading to continued non-compliance in areas such as Resident Rights, Quality of Life, Nursing Services, and Infection Control. Staffing issues and lack of adherence to infection control protocols were observed, with staff failing to disinfect equipment and wear appropriate protective gear. Interviews revealed insufficient training and oversight by the administration.
The facility failed to address systemic failures through the QAPI process, leading to issues in staffing, basic care, and infection control. One resident did not receive a shower for over a week due to low staffing, and another resident's dignity was compromised during care. Additionally, staff did not follow proper hand hygiene and disinfection protocols.
The facility failed to follow proper infection control practices, including hand hygiene, disinfection of shared equipment, and handling of soiled linens, leading to potential cross-contamination and increased infection risk among residents. Staff were observed not adhering to protocols, and interviews revealed gaps in training and compliance.
The facility failed to accommodate the needs and preferences of six residents, including delayed wheelchair repairs, communication barriers for a non-English speaking resident, inaccessible call lights, and unmet personal shopping needs.
The facility failed to ensure a safe, clean, and homelike environment, with strong odors of urine and feces, unclean floors, and a tripping hazard from a loose metal plate. Staff and residents expressed concerns about cleanliness, and interviews revealed a lack of proper maintenance and cleaning documentation.
The facility failed to protect residents from abuse and neglect, including incidents of sexual activity between cognitively impaired residents, verbal abuse by untrained staff, neglect of a resident sent to the hospital in soiled briefs, and resident-to-resident altercations. The facility's lack of proper supervision, training, and consistent care contributed to these deficiencies.
The facility failed to protect residents from misappropriation of their belongings and money, involving six residents. Despite being aware of a resident's repeated thefts, the facility did not take adequate measures to prevent further incidents. The facility's policies on abuse, neglect, and misappropriation were not effectively implemented, and medication carts were not secured, leading to unauthorized access to controlled substances.
The facility failed to maintain a safe environment and provide adequate supervision to prevent accidents for eleven residents. Two residents with cognitive impairments eloped from the facility due to inadequate supervision and an ineffective alarm system. The facility's Elopement Binders were not up-to-date, and staff were desensitized to frequent, loud alarms, leading to delayed responses.
The facility failed to have an effective antibiotic stewardship program, neglecting to monitor and assess antibiotic use for five residents. The facility did not track antibiotic use or report on antibiotic use and resistance to leadership.
The facility failed to educate and offer COVID-19 immunization to two residents and did not maintain proper documentation of vaccination status for a staff member. The interim DON/IP and Administrator acknowledged the lack of complete vaccination records and emphasized the importance of following CDC recommendations and infection control policies.
The facility failed to ensure a dignified existence for two residents by not providing privacy during catheter care and not using dignity bags for their catheters. Staff interviews confirmed the importance of these measures, but they were not consistently implemented.
The facility failed to involve a resident in the care planning process, as required by policy. Despite the resident having no cognitive impairment, there was no documentation of their participation in recent care conferences. Interviews with staff revealed inconsistencies and a lack of clarity in the care conference process.
The facility failed to follow its policy regarding Advance Directives for three residents, resulting in missing signed Advance Directives and lack of documentation that materials were reviewed with residents or their representatives upon admission or quarterly thereafter.
The facility failed to protect a resident from involuntary seclusion. Staff members were observed escorting the resident to his/her room and closing the door tightly, preventing the resident from exiting. The resident, who has severe cognitive impairment, was unable to open the door independently. Staff admitted to not being aware of the policy against this practice, and interviews with various staff members revealed inconsistent understanding and adherence to the facility's policy on involuntary seclusion.
The facility failed to thoroughly investigate allegations of sexual abuse involving two cognitively impaired residents. Despite being found in compromising situations twice, there was no documented evidence of a complete investigation or adequate measures to prevent further incidents. Staff interviews revealed a lack of proper assessment and monitoring of the residents' capacity to consent to sexual activity.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS did not reflect their use of oxygen, despite a physician's order and observation of oxygen use. Another resident's dental care was not assessed, leading to untreated cavities and missed dental appointments.
The facility failed to ensure that a resident who was unable to perform ADLs independently received necessary services for good grooming, personal, and oral hygiene. The resident was observed with soiled clothes, poor dental hygiene, and uncombed hair, and reported not receiving timely assistance for transfers and other care needs. Staff interviews confirmed inconsistencies in care provision and documentation.
The facility failed to provide individualized activities for two residents, leading to dissatisfaction and lack of engagement. One resident described the activities as childlike and simplistic, while another expressed a desire for gardening and outdoor activities. Observations and interviews revealed that the facility did not adhere to its policies on resident rights and activities, and the Activities Director confirmed the lack of a specific policy and a low budget for activities.
The facility failed to ensure proper wound and tube site care for three residents. One resident's sacral wound dressing was not changed as ordered, another resident's J-tube site was not cleaned or dressed properly, and a third resident's G-tube site was excoriated and not covered with a dressing. Interviews and observations confirmed these deficiencies.
A resident with severe cognitive impairment and requiring enteral nutrition experienced significant weight loss due to the facility's failure to follow physician's orders for tube feedings. The tube feeding pump was consistently set to incorrect parameters, and the equipment used for flushing the feeding tube was not maintained properly. Nursing staff and the DON confirmed the orders were not followed, leading to inadequate nutrition and hydration for the resident.
The facility failed to ensure nurse aides demonstrated competency in essential skills, including behavior management, catheter care, and maintaining resident dignity. Observations revealed improper feeding techniques and inadequate hand hygiene practices. Staff reported not receiving training on handling aggressive resident behavior, and management acknowledged gaps in training, especially for agency and travel staff.
An LPN on her first day at the facility administered eight medications prescribed for one resident to another, resulting in a medication error rate of 26.67%. The error occurred due to difficulties in logging into the computer and unfamiliarity with the residents, leading to incorrect resident identification.
A nurse failed to accurately identify residents, resulting in a significant medication error where a resident received another's medications. The error was realized after the surveyor's intervention, and the facility's staff acknowledged the failure to follow proper medication administration protocols.
The facility failed to ensure proper labeling and storage of medications for two residents. A KMA placed medications into unlabeled cups and stored them in a medication cart drawer, contrary to facility policy. The DON confirmed the medications should have been properly labeled and stored.
The facility failed to provide two residents with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs. One resident on a controlled carbohydrate diet received inadequate portions and no alternatives, while another resident did not receive fish as per their religious preference. Interviews revealed a lack of training and adherence to specialized diets and food preferences among dietary staff.
The facility failed to follow dietary orders and provide adequate nutrition for a resident with specific dietary needs due to conditions like end-stage renal disease and Type 2 diabetes. Despite physician-ordered diets, the resident frequently received inadequate portions, and other residents also reported insufficient food servings. Interviews and observations revealed systemic issues in the facility's dietary service.
The facility failed to provide food that was palatable, attractive, and at an appetizing temperature for three residents. Observations and interviews revealed that meals were often served cold, and residents were not consistently offered substitutions. Staff acknowledged issues with food temperature monitoring, and despite changes made by the Administrator, the problem persisted.
The facility failed to provide and document the pneumococcal vaccination for a resident with moderate cognitive impairment and multiple diagnoses, despite following CDC recommendations. The resident did not recall being offered the vaccine, and there was no evidence of vaccination or refusal in the medical record.
Failure to Prevent Abuse and Neglect of Residents
Penalty
Summary
The facility failed to protect residents from abuse and neglect in multiple instances involving three residents. In one case, a resident with functional quadriplegia and total dependence on staff for care reported that a night shift SRNA intentionally removed his call light device from the wall and inserted a plastic object into the port, rendering the call system unusable for the duration of the shift. The resident, who was able to make decisions regarding daily life tasks and communicate his needs, was left without access to the call system until the following day when a day shift SRNA discovered the issue and restored the device. The staff member involved admitted to removing the device due to a malfunction but failed to notify maintenance or the oncoming shift, and no work order was placed for repair. The resident did not experience further incidents with the call device after the event. In another incident, a resident with severe cognitive impairment physically struck another resident who had entered her room, resulting in a nosebleed for the visitor and an ankle injury for the aggressor. Both residents were immediately separated by staff, and the incident was witnessed by staff who responded to the altercation. The resident who was struck was confused but did not show signs of pain or fear, and the aggressor was assessed for injury. Both residents' families and appropriate authorities were notified, and psychosocial monitoring was conducted following the event. The facility placed a stop sign on the aggressor's door to prevent further incidents of wandering into her room. The facility's policies required screening of potential hires for abuse history, background checks, and staff training on abuse prevention and reporting. Despite these policies, the incidents occurred due to staff inaction, such as failing to ensure the call light was functional and not reporting or addressing the malfunction, as well as inadequate supervision that allowed a resident-to-resident altercation to occur. Interviews with staff and administration confirmed the sequence of events and the failure to follow established protocols to prevent abuse and neglect.
Failure to Provide Required Written Notification of Discharge to Guardian and Ombudsman
Penalty
Summary
The facility failed to provide timely and proper written notification to the State Guardian and the Office of the State Long-Term Care Ombudsman regarding its intention to discharge a resident, as required by federal regulations. The resident in question, who had diagnoses including dysphagia, schizophrenia, and bipolar disorder, was transferred to a Behavioral Health (BH) facility following combative and disruptive behavior, including physical aggression and property destruction. Documentation revealed that the facility did not notify the State Guardian or the Ombudsman in writing of the transfer or the subsequent decision not to readmit the resident, nor did it provide a 30-day written notice of discharge as required. The facility's own policies on transfer/discharge and bed hold did not address the required 30-day notice of transfer/discharge. Review of the resident's medical record and facility documentation showed inconsistencies and lack of clarity regarding who was notified, when, and how. The State Guardian and the Ombudsman both reported not receiving the required notifications, and the Guardian only learned of the facility's refusal to readmit the resident through the BH facility's Discharge Planner. Multiple attempts by the Guardian and the Discharge Planner to contact the facility for clarification went unanswered, and the Ombudsman was not informed of the discharge decision until after the fact. Interviews with facility staff, including the Business Office Manager, DON, and Administrator, confirmed that the required notifications were not sent in a timely manner or at all. The Administrator stated that a notice was not sent because the facility did not initially intend to refuse readmission, but later required documentation that the resident was not a danger before considering readmission. The lack of written notice and communication led to legal intervention, with the Guardian seeking a stay of discharge and legal counsel being retained. The Ombudsman and Guardian both confirmed that the facility did not follow required notification procedures, resulting in the resident remaining at the BH facility longer than necessary.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for eight residents, leading to various deficiencies. Resident #3 developed a Stage 4 pressure ulcer due to the facility's failure to include interventions for offloading and keeping the wound bed dry, despite the resident's urostomy/ileostomy frequently leaking. Staff did not remind or assist the resident with repositioning, and the wound care nurse noted that keeping the wound dry was crucial for healing, but this was not adequately addressed in the care plan. Resident #63 and Resident #112 both eloped from the facility, with the facility failing to develop and implement effective interventions to prevent these incidents. Resident #112 also had severe cognitive impairment and was involved in sexual activity with another resident, but the facility did not address the resident's inability to consent to sexual activity in the care plan. Similarly, Resident #101, who engaged in sexual activity with Resident #112, had language barriers that were not adequately addressed, leading to ineffective communication and assessment of the resident's needs. Other deficiencies included the facility's failure to implement care plan interventions for Resident #105's indwelling urinary catheter, leading to the catheter bag dragging on the floor and lack of privacy during catheter care. Resident #126 and Resident #86, both with G-tubes, had excoriated skin around the insertion sites due to the facility's failure to implement proper care plan interventions. Additionally, Resident #71 expressed concerns about a malfunctioning wheelchair brake, but the facility did not develop a care plan intervention to address this issue, posing a risk of falls during transfers.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to provide adequate pressure ulcer prevention and care for Resident #3, who was admitted with no skin breakdown but later developed a stage 4 pressure ulcer. Despite being assessed as at risk for pressure ulcers, the facility did not implement effective interventions to prevent the development of the ulcer. The resident was often found in soiled briefs, and staff failed to encourage or assist with repositioning to off-load pressure from the wound. Additionally, the resident's care plan did not include specific interventions to address the frequent leakage from the resident's urostomy/ileostomy, which contributed to the wound's deterioration. Observations during the survey revealed multiple instances where staff did not notice or address the resident's incontinence, leading to prolonged exposure to moisture and further compromising the wound. The resident was found sitting in a heavily soiled brief with a displaced dressing, and staff failed to remind or assist the resident with repositioning. Interviews with staff indicated a lack of awareness and communication regarding the resident's needs and abilities, such as the ability to perform wheelchair push-ups to off-load pressure. The facility also lacked a mechanism to hold staff accountable for regularly checking and changing the resident's briefs. The facility's failure to provide timely and appropriate care for Resident #3's pressure ulcer was further compounded by inadequate communication and coordination among the care team. The Wound Care Nurse and other staff members acknowledged the need for frequent repositioning and keeping the wound dry, but these interventions were not consistently implemented. The facility did not explore potential solutions, such as consulting with therapy departments for specialized cushions or developing a resident-specific schedule for repositioning, to better accommodate the resident's preferences and promote wound healing.
Inadequate Staffing Leading to Resident Neglect
Penalty
Summary
The facility failed to ensure sufficient numbers of nursing staff, including nurse aides, on a 24-hour basis to provide necessary nursing care for residents in accordance with their care plans. On multiple occasions, the facility was found to have significantly fewer nurse aide hours than required, particularly on weekends and during the night shifts. This resulted in residents experiencing delays in receiving incontinence care and medications, as well as inadequate supervision and assistance with daily activities. For instance, on 03/03/2024, the facility had under 200 nurse aide hours, well below the required 230-260 hours, leading to residents waiting over an hour for call lights to be answered and staff feeling rushed in their duties. Resident #152 was admitted to the hospital on 01/07/2024, wearing two saturated briefs and with wounds on his/her buttocks. The facility's records indicated that staffing on that day was significantly below the required levels, with only 154.5 nurse aide hours documented. Interviews with staff revealed that double briefing was a common practice due to short staffing, which was not condoned by the facility. The resident's condition deteriorated due to insufficient care, highlighting the severe impact of inadequate staffing. Multiple interviews with residents and staff corroborated the findings of insufficient staffing. Residents reported long wait times for assistance, and staff admitted to feeling overwhelmed and unable to provide adequate care. The facility's management acknowledged the staffing issues but failed to provide a clear plan for ensuring sufficient staffing levels. The Director of Nursing and the Administrator both admitted to the challenges in maintaining adequate staffing, particularly during weekends and night shifts, but did not offer a solution to address the deficiencies effectively.
Deficiencies in Food Storage, Preparation, and Cleanliness
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service in the kitchen. During an initial kitchen tour, surveyors observed several issues including undated and unlabeled food items such as thickened orange juice, chicken, dumplings, and sugar cookie dough. Additionally, the tray line area was found to be unsanitary with a mop container filled with brown water, a dirty rag on the garbage can lid, and a dusty light fixture overhead. The pantry also contained undated canned spaghetti and lacked a thermometer, while the supply room had a sticky substance on the floor and a broken vent on the air conditioning unit. Clean dishes were improperly stored upright or sideways without covering, increasing the risk of contamination. These observations were confirmed during a follow-up kitchen tour, where similar issues persisted, including the presence of gnats in the pantry and undated food items. Interviews with the Interim Dietary Manager, Registered Dietician, Interim Director of Nursing, and Administrator revealed that the facility's policies were not being followed, as all agreed that food items should be labeled and dated, and the kitchen should be cleaned daily. The Administrator emphasized the importance of proper labeling to prevent foodborne illnesses and expected the dietary staff to maintain cleanliness and proper hand hygiene. Despite these expectations, the facility failed to adhere to its own policies, resulting in multiple deficiencies in food storage, preparation, and cleanliness.
Facility Fails to Ensure Effective Administration and Infection Control
Penalty
Summary
The facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility did not have an effective process in place to address systemic failures through the Quality Assurance Performance Improvement (QAPI) process. This resulted in continued non-compliance in several areas, including Resident Rights, Quality of Life, Nursing Services, and Infection Control, potentially affecting all 129 current residents. The facility's Plan of Correction (POC) from a previous survey included training all nursing staff on catheter care, hand hygiene, and providing resident care in a dignified manner, as well as conducting regular audits to identify and correct any continued deficient practice. However, the facility failed to implement these measures effectively, as evidenced by the continued deficiencies observed during the survey. On the Daily Staffing Assignment Sheet dated 05/06/2024, the Administrator signed off on a schedule that displayed only 212 hours of State Registered Nurse Aide (SRNA) hours, which did not reflect the true staffing for the night shift due to an SRNA calling in. Interviews with staff revealed that staffing had improved but was still insufficient, particularly during evening hours, leading to decreased supervision of residents with behaviors and some residents missing showers. The Administrator admitted to verifying staffing each day but was unaware of the SRNA call-in on 05/06/2024 and had no evidence of informal interviews with staff regarding workloads. Observations on 05/10/2024 revealed multiple instances of staff failing to follow infection control protocols. An SRNA did not disinfect a mechanical lift after use, and two SRNAs and an LPN did not wear gowns while providing care to a resident on Enhanced Barrier Precautions (EBP). Additionally, an SRNA failed to perform hand hygiene after doffing soiled gloves. Interviews with staff indicated a lack of recall regarding recent training on infection control measures, and the Administrator acknowledged the need for re-education on disinfection protocols. The facility's POC evidence binders failed to identify continued staff noncompliance with regulations related to hand hygiene, disinfection of shared equipment, resident dignity during care, and provision of ADL care.
Systemic Failures in QAPI Process and Basic Care
Penalty
Summary
The facility failed to have an effective process in place to address systemic failures through the Quality Assurance Performance Improvement (QAPI) process. The facility did not effectively track staffing patterns and staff failed to provide basic care, including showers. The Administrator and Director of Nursing (DON) were supposed to review staffing needs and implement corrective actions, but discrepancies in staffing calculations and lack of awareness of staff absences were noted. The Administrator admitted that the staffing sheets were confusing and that the Scheduler did not always comply with directives, leading to incorrect staffing numbers and unawareness of staff absences, which were not identified until the State Survey Agency (SSA) intervened. The facility also failed to ensure residents received Activities of Daily Living (ADL) care, including showers. One resident, admitted with diagnoses including hemiplegia and tracheostomy status, had not received a shower for over a week. The resident indicated that she was due for a shower but believed the facility was short-staffed. The responsible State Registered Nurse Aide (SRNA) confirmed that due to low staffing, she did not have time to give the resident a shower. The resident was observed with greasy hair, indicating a lack of proper hygiene care. Additionally, the facility failed to ensure proper catheter care, hand hygiene, and disinfection of contaminated equipment. One Licensed Practical Nurse (LPN) did not follow proper hand hygiene protocols during catheter care, and another LPN could not recall recent training on catheter care. Another resident was exposed to the hallway and a shared mirror during care, compromising her dignity. Furthermore, an SRNA failed to disinfect a mechanical lift after use. The Director of Nursing (DON) did not respond to multiple attempts for an interview, and the Administrator acknowledged the need for re-education on infection prevention protocols.
Infection Control Deficiencies
Penalty
Summary
The facility failed to identify and correct problems related to infection prevention practices for eight sampled residents. Observations revealed that staff did not follow proper hand hygiene protocols, failed to clean and disinfect shared medical equipment, and improperly handled soiled linens. For instance, a Social Services Assistant adjusted call lights for multiple residents without performing hand hygiene between each interaction, and a Hoyer lift used for resident transfers was visibly dirty and not disinfected between uses. Additionally, staff were observed handling soiled linens and contaminated equipment without appropriate personal protective equipment (PPE) or hand hygiene, increasing the risk of cross-contamination and infection spread. Specific incidents included a resident's urinary drainage bag dragging on the floor, which was not addressed by staff, and improper catheter care where washcloths were placed directly in a sink without a basin, potentially introducing bacteria. Another resident's glucose monitoring equipment was not cleaned and disinfected after use, and the nurse failed to perform hand hygiene after administering insulin. These actions were contrary to the facility's infection control policies and CDC guidelines, which emphasize the importance of hand hygiene, proper disinfection of shared equipment, and correct handling of soiled linens to prevent infection. Interviews with staff revealed gaps in training and adherence to infection control protocols. Some staff members were unaware of the correct procedures for cleaning and disinfecting equipment, while others admitted to not following hand hygiene practices consistently. The facility's policies on infection control, cleaning and disinfection of equipment, and catheter care were not being followed, leading to multiple instances of potential cross-contamination and increased risk of infection among residents.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of six residents. Resident #71's wheelchair brake was broken, and the facility did not repair it in a timely manner. The temporary replacement wheelchair also had faulty brakes, causing the resident to feel unsafe during transfers. Despite the resident's concerns and the occupational therapist's daily checks with maintenance, the part for the wheelchair was delayed, and there was no record of follow-up on the order status. The resident's wheelchair was eventually repaired, but the delay placed the resident at risk for falls and injury. Resident #101, a non-English speaking resident with Cantonese as the preferred language, faced significant communication barriers due to the facility's failure to ensure staff were trained and used a Language Line. Multiple staff members, including LPNs and an APRN, documented their inability to communicate effectively with the resident, impacting assessments and care. Despite the facility's policy on language access, there was no evidence that communication tools were used, and staff were unaware of the available interpreter services. Residents #5 and #105 had their call lights out of reach, leaving them unable to request assistance. Observations confirmed that the call lights were either on the bed or the floor, out of the residents' reach. Staff interviews revealed a lack of awareness and adherence to the policy of ensuring call lights were accessible. Additionally, Resident #1 needed new shoes after vomiting on the old pair, and Resident #65 required batteries for hearing aids and desired to go shopping for personal items. The facility's van was out of service, and the activities department was overwhelmed with shopping requests, leading to unmet resident needs.
Facility Fails to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to ensure residents had a safe, clean, comfortable, and homelike environment. Observations revealed a strong odor of urine and feces throughout the facility, particularly in the 100 Hallway. There were water stains on the ceilings, cracked and misshapen ceiling tiles, dirty air intake vents, and unclean floors. A loose and warped metal plate in the 100 Hallway posed a tripping hazard, and clean and dirty items were stored together in the soiled utility room. Additionally, shared bathrooms had strong urine odors and were not clean, and there were visible stains on walls and floors in various areas of the facility. Interviews with staff members indicated that the metal plate in the 100 Hallway had been a known issue since at least mid-February, but it was not reported to maintenance until recently. The Maintenance Assistant confirmed that repairs were made only after being informed a few days prior. Housekeeping staff and directors acknowledged the facility's cleanliness issues, with no daily cleaning logs or documentation of what was cleaned. The Director of Nursing and other staff members admitted that the facility's condition did not constitute a safe, clean, comfortable, homelike environment. Residents and staff expressed concerns about the facility's cleanliness and odors. One resident mentioned that the bathroom could be cleaned more often and better. Social Worker #18 described the facility's potent smell of urine and feces and the dirty condition of the floors. The Housekeeping Director and Regional Housekeeping Director outlined the cleaning procedures but admitted there was no documentation of daily cleaning tasks. The Administrator and Regional Vice President of Operations acknowledged the facility's odors and cleanliness issues, stating that efforts were being made to address them, such as replacing exhaust fans, mattresses, and encouraging residents to shower.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents involving eight residents. Two cognitively impaired residents were observed engaging in sexual activity on two separate occasions, indicating a lack of proper supervision and assessment of their ability to consent. Despite being aware of their cognitive impairments, the facility did not adequately monitor or separate the residents to prevent further incidents. Additionally, there was no documented evidence of psychiatric follow-up for one of the residents involved in the incident, and the care plans lacked specific interventions to address the behaviors observed. A resident was verbally abused by a housekeeping staff member who had not received training on handling residents with aggressive behaviors. The housekeeper threatened to hit the resident after being called a racial slur, demonstrating a lack of appropriate response to the situation. The facility's investigation revealed that the housekeeper had not been provided with any training on abuse prevention or managing residents with behavioral issues. This incident highlights the facility's failure to ensure all staff members are adequately trained to handle such situations. Another resident was sent to the hospital wearing two soiled briefs, indicating neglect in providing appropriate care. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, was found in a neglected state by hospital staff. Interviews with facility staff revealed inconsistencies in the care provided, with some staff members admitting to seeing residents double-briefed due to staffing shortages. The facility's failure to provide consistent and adequate care for this resident resulted in neglect and a decline in the resident's condition. Additionally, there were incidents of resident-to-resident altercations, with one resident scratching another during a verbal argument. The facility's response to these incidents was inadequate, as there was no history of physical aggression between the residents, and the interventions in place were insufficient to prevent such occurrences.
Failure to Protect Residents from Misappropriation of Property
Penalty
Summary
The facility failed to protect residents from the misappropriation of their belongings and money, involving six residents. Resident #127 was identified as responsible for multiple incidents of theft, including taking money from two residents and medications from two others. The facility's policies on abuse, neglect, and misappropriation were not effectively implemented, as evidenced by the repeated incidents involving Resident #127. Despite being aware of Resident #127's behavior, the facility did not take adequate measures to prevent further thefts, such as increasing supervision or providing secure storage for residents' belongings. Resident #127, who was admitted with diagnoses including bipolar disorder and schizophrenia, was assessed as severely cognitively impaired. The resident's care plan included interventions such as increased supervision and behavioral health consultations, but these measures were not sufficient to prevent the thefts. The facility's staff, including LPNs and SRNAs, were aware of Resident #127's behavior but did not consistently monitor or intervene effectively. The facility's administration was also aware of the issue but failed to implement a comprehensive plan to address the resident's behavior and protect other residents. The facility's failure to secure medication carts and properly supervise Resident #127 led to the theft of controlled substances, including Hydrocodone and Gabapentin, from two residents. The facility's policies on medication storage and security were not followed, resulting in unauthorized access to medications. Additionally, the facility did not adequately investigate or report all incidents of theft, as evidenced by the missing iPad and wallet that were not properly documented or addressed. The facility's inaction and lack of effective interventions contributed to an environment where residents' belongings and medications were not safeguarded, leading to multiple incidents of misappropriation.
Failure to Prevent Resident Elopement and Maintain Effective Alarm System
Penalty
Summary
The facility failed to ensure the residents' environment remained free of accident hazards and did not provide adequate supervision to prevent accidents for eleven out of 104 sampled residents. Specifically, the facility did not maintain accurate Elopement Binders with correct or thorough information for ten residents at high risk for elopement. Additionally, the facility did not provide appropriate supervision for two residents to prevent elopement and failed to have an effective alarm system in place for monitoring and supervising wandering and elopement risk residents. One resident, who had a history of dementia and moderate cognitive impairment, eloped from the facility and was found in a nearby shopping mall parking lot. The facility's investigation revealed that the resident exited through a door that did not have a wander guard system, and the regular fire alarm was not heard by staff. The resident's elopement risk assessments were not completed quarterly or upon readmission from the hospital, and the resident's care plan included interventions that were not effectively implemented. Another resident with severe cognitive impairment and a history of exit-seeking behaviors eloped from the facility and was found near a local golf course. The facility's investigation revealed that the resident exited during a smoke break, and the staff member responsible for supervision was unaware of the resident's elopement risk. The facility's alarm system was found to be excessively loud and frequently triggered, causing staff to become desensitized to the alarms and not respond appropriately. The facility's maintenance director acknowledged the issues with the alarm system and the need for adjustments to ensure proper monitoring and supervision of residents at risk for elopement.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to have an effective antibiotic stewardship program to monitor antibiotic use as part of the overall infection prevention and control program. The facility did not incorporate monitoring and assessment of antibiotic use for five of the sampled residents. Additionally, the facility failed to track antibiotic use and report regularly on antibiotic use and resistance to the facility's leadership. Resident #20 was admitted with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and chronic kidney disease. Despite being prescribed Levaquin for pneumonia, there was no evidence of antibiotic monitoring or infection control notes. Similarly, Resident #45, who was admitted with diagnoses including COPD and type 2 diabetes mellitus, was prescribed Cefuroxime for a urinary tract infection, but the facility failed to provide evidence of antibiotic monitoring or infection control notes. Resident #71, admitted with diagnoses including type 2 diabetes mellitus and infection due to a hip prosthesis, was prescribed Levaquin for MSSA bacteremia, but again, there was no evidence of antibiotic monitoring. Resident #97, with diagnoses including type 2 diabetes mellitus and chronic kidney disease, was prescribed Amoxicillin for a urinary tract infection, but the facility failed to provide evidence of antibiotic monitoring. Lastly, Resident #158, admitted with diagnoses including congestive heart failure and end-stage renal disease, was prescribed Cefdinir for pneumonia, but there was no evidence of antibiotic monitoring or infection control notes.
Failure to Educate and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to educate and offer COVID-19 immunization as required or appropriate for two of five sampled residents. Resident #126, who had severe cognitive impairment and was non-interviewable, was admitted with multiple diagnoses including cerebral infarction and emphysema. There was no documentation that Resident #126 received or was offered the COVID-19 vaccine, nor was there evidence of education provided to the resident or their representative. Similarly, Resident #128, who had moderate cognitive impairment and was their own responsible party, had no documented evidence of receiving or being offered the COVID-19 vaccine, and the resident did not recall being offered any vaccines by the facility. The facility also failed to maintain proper documentation of screening, education, offering, and current COVID-19 vaccination status for staff. Specifically, SRNA #5, who had been employed at the facility for six weeks, stated she was not provided education related to the COVID-19 vaccine and was not offered the vaccine by the facility. The interim DON/IP acknowledged the lack of complete vaccination records for all employees due to missing files or inability to locate them after a change in ownership of the facility. During interviews, the interim DON/IP and the Administrator both stated that the facility followed CDC recommendations for all immunizations and vaccines. However, they were unable to provide documentation showing how the facility tracked immunizations for all residents and staff. The Administrator emphasized the importance of following infection control policies and procedures, including immunizations, to prevent the spread of infection and communicable diseases.
Failure to Ensure Resident Dignity During Catheter Care
Penalty
Summary
The facility failed to ensure a dignified existence for two residents, Resident #105 and Resident #103. Resident #105 was not afforded privacy during catheter care as the SRNA did not close the curtain before performing the procedure. Additionally, Resident #105 was observed without a dignity bag for his/her catheter on multiple occasions. The SRNA admitted to not realizing the importance of closing the curtain and ensuring the dignity bag was in place. The Director of Nursing and the Administrator both confirmed that staff are expected to provide privacy and use dignity bags for catheter care to maintain resident dignity. Resident #103 was also not provided with a dignity bag for his/her catheter, which was observed uncovered and visible from the hallway. The resident expressed that he/she had not been offered a dignity cover but would like to have one. Interviews with various staff members, including SRNAs and LPNs, revealed that they were aware of the importance of using dignity bags but were unsure why Resident #103 did not have one. The Director of Nursing reiterated the importance of maintaining resident privacy and dignity by using dignity bags. The facility's policy on resident rights under federal law, dated 11/28/2016, states that residents have the right to a dignified existence. Despite this policy, the facility failed to provide adequate privacy and dignity for Residents #105 and #103, as evidenced by the lack of privacy during catheter care and the absence of dignity bags for their catheters. Interviews with staff and administration confirmed the expectations for maintaining resident dignity, but these were not met in the observed instances.
Failure to Involve Resident in Care Planning Process
Penalty
Summary
The facility failed to ensure that residents or their representatives were involved in the care planning process, as evidenced by the case of a resident who reported not being involved in their care planning. The facility's policy required that residents and their representatives be part of the care planning process, but there was no documentation of the resident's participation in the most recent care plan meeting. Interviews with social services staff and a review of the resident's chart revealed inconsistencies and a lack of documentation regarding care conferences, indicating that the resident's rights to participate in their care planning were not observed. The resident, who had no cognitive impairment, stated that they were not involved in care conferences. The facility's interdisciplinary attendance log and the resident's chart lacked evidence of recent care conferences, despite notes indicating that care conferences had occurred. Interviews with the Director of Nursing and MDS Coordinators revealed a lack of clarity and consistency in the care conference process, further highlighting the deficiency in ensuring resident participation in care planning. The Administrator acknowledged the oversight in documentation but maintained that the resident had attended the care conference.
Failure to Follow Advance Directive Policy
Penalty
Summary
The facility failed to follow its policy regarding Advance Directives for three residents. Resident #22, who had diagnoses including chronic kidney disease and type 2 diabetes mellitus, did not have a signed Advance Directive in their medical record despite a verbal DNR order. The facility also could not provide documentation that Advance Directive materials were reviewed with the resident upon admission or quarterly thereafter. During an interview, Resident #22 could not recall being asked about formulating an Advance Directive and stated they did not have one. Resident #103, who had diagnoses including congestive heart failure and type 2 diabetes mellitus, also did not have a signed Advance Directive in their medical record. The resident had a state-appointed guardian, and the facility could not provide documentation that Advance Directive materials were reviewed with the resident or their representative upon admission or quarterly thereafter. The Admissions Coordinator and the Regional Director of Business Marketing were unaware of why Resident #103 did not have a signed Advance Directive. Resident #57, who had diagnoses including extrapyramidal and movement disorder and cognitive communication deficit, was assessed to have moderate cognitive impairment. Despite being care planned as having a DNR order, there was no signed Advance Directive in the resident's medical record. The facility failed to produce documentation that Advance Directive materials were reviewed with the resident or their representative upon admission or quarterly thereafter. Interviews with the Social Services Director and the Admissions Coordinator revealed gaps in the process of ensuring residents had signed Advance Directives or were educated about them.
Failure to Protect Resident from Involuntary Seclusion
Penalty
Summary
The facility failed to protect Resident #112 from involuntary seclusion. On multiple occasions, staff members were observed escorting Resident #112 to his/her room and closing the door tightly, preventing the resident from exiting. This occurred despite the resident's severe cognitive impairment and inability to open the door independently. Staff members, including SRNA #26 and SRNA #28, admitted to not being aware that closing the door on a resident who could not open it was not allowed. SRNA #26, a travel nurse aide, stated he had not received any education on this matter since starting at the facility in January 2024. Resident #112, who has diagnoses of dementia with agitation, dysphagia oral phase, and Alzheimer's Disease, was assessed to have severe cognitive impairment with a BIMS score of six out of fifteen. The resident was noted to have no behaviors during the assessment and required varying levels of assistance for daily activities. The facility's care plan for Resident #112 included interventions for exit-seeking behaviors and cognitive loss, such as monitoring the resident's activities, using a security bracelet, and redirecting the resident when near exits or doorways. Despite these interventions, staff frequently escorted the resident back to his/her room and closed the door, which the resident could not open. Interviews with various staff members, including LPN #9, LPN #1, the APRN, the DON, and the Administrator, revealed a lack of consistent understanding and adherence to the facility's policy on involuntary seclusion. LPN #9 and the DON acknowledged that closing the door on a resident who could not open it constituted involuntary seclusion and was a form of abuse. The Administrator confirmed that the resident's door was broken at the time of the observation and was being fixed, but emphasized that the door should not be closed if the resident could not open it independently. The facility's failure to educate staff and enforce policies led to the involuntary seclusion of Resident #112.
Failure to Investigate Allegations of Sexual Abuse
Penalty
Summary
The facility failed to provide a complete and thorough investigation into the allegation of sexual abuse involving two residents, both of whom were severely cognitively impaired. The incident was reported to state agencies, revealing that the residents were found in bed together with their hands down each other's pants and later engaged in a second sexual encounter in the dining room. Despite the severity of the situation, the facility did not document any evidence of an investigation into the first incident, nor did they take adequate measures to prevent further potential abuse while the investigation was in progress. Resident #101, who was non-English speaking and had a BIMS score indicating severe cognitive impairment, was admitted for rehabilitation and later diagnosed with unspecified dementia. The resident's care plan was updated to address sexual behaviors, but there was no documented evidence of psychiatric follow-up after the incident. Similarly, Resident #112, who also had a severe cognitive impairment with a BIMS score of six, was noted to have engaged in sexual touching with Resident #101. The facility's care plan for Resident #112 included interventions such as alerting psychiatric services and room changes, but there was no mention of the incident in the psychiatric follow-up. Interviews with staff revealed a lack of proper assessment and monitoring of the residents' capacity to consent to sexual activity. The Social Services Assistant, who had limited experience in long-term care, was responsible for completing sections of the Minimum Data Set but did not conduct assessments for consent to sexual activity. The Director of Social Services delegated much of her work to the assistant and did not complete any assessments herself. The Director of Nursing stated that the SSA was responsible for gathering information for investigations, but the Administrator admitted that the facility did not have access to all documents from the previous ownership, leading to incomplete investigations.
Inaccurate MDS Assessments and Dental Care Oversight
Penalty
Summary
The facility failed to ensure the MDS assessment accurately reflected the resident's status for two residents. Resident #55's MDS assessment indicated that the resident did not wear oxygen, despite the resident being observed wearing oxygen via nasal cannula at two liters. The resident had a physician's order for oxygen to maintain oxygen saturations greater than 90%. This discrepancy was confirmed through an interview with a registered nurse who stated she regularly changed the oxygen tubing and monitored the oxygen concentrator for the resident. Additionally, the facility failed to assess dental care for Resident #52. The resident, admitted with diagnoses including traumatic brain injury and dementia, had no documentation of being seen by a dentist until nearly five years after admission. The resident's Quarterly MDS indicated no discomfort or difficulty with chewing, yet an observation revealed several oral cavities and the resident reported difficulty chewing and loose teeth. A dental record from a state university healthcare clinic confirmed the resident had cracked and decayed teeth and was referred for oral surgery. The Social Service Director admitted there was no follow-up after the resident missed a scheduled dental appointment.
Failure to Provide Necessary ADL Support for Resident
Penalty
Summary
The facility failed to ensure that Resident #117, who was unable to perform Activities of Daily Living (ADLs) independently, received the necessary services to maintain good grooming, personal, and oral hygiene. Resident #117, who had diagnoses including hemiplegia, hemiparesis, COPD, and dementia, was assessed to have total dependence on staff for ADLs. Despite this, the resident was observed multiple times with soiled clothes, poor dental hygiene, uncombed hair, and a white crusty substance on the face. The resident also reported not being given a choice when ADLs were performed and not receiving timely assistance for transfers and other care needs. Review of the past three months' shower sheets and documentation revealed inconsistencies in the recorded dates of bathing/showering, indicating that Resident #117 did not receive regular showers or baths as required. Additionally, the resident was not dressed for bed on several occasions, and staff failed to perform basic hygiene tasks such as washing the resident's face, performing oral care, and combing the resident's hair. Interviews with staff members, including SRNAs and an LPN, confirmed that the resident's care was not consistently provided according to the care plan, and refusals of care were not adequately documented or addressed. The Director of Nursing (DON) and the Administrator both stated that staff were expected to follow the care plan and provide comprehensive care for total care residents, including oral care twice daily and two showers or baths per week. However, observations and interviews revealed that these expectations were not met for Resident #117, resulting in the resident's poor hygiene and unmet care needs. The facility's failure to adhere to its policies and procedures for ADL support led to the identified deficiency in care for Resident #117.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to ensure an ongoing program of activities was developed to meet the individual needs of two residents. Resident #55, who had intact cognition, expressed dissatisfaction with the activities provided, describing them as childlike and simplistic. The resident also mentioned that the facility no longer shopped for residents, except for tobacco products, and that there were no outings planned. Despite being care planned for self-directed involvement in meaningful activities, the resident stated that one-on-one activities were never discussed, and the activities staff did not offer to bring items for personal activities such as puzzles, crafts, or books. The resident's room observations confirmed the lack of an activities calendar and the presence of personal books provided by a friend, not the facility. Resident #117, also with intact cognition, was observed multiple times sitting in a wheelchair facing the wall with no activities nearby. The resident stated that attending group activities was too difficult and that the topics were uninteresting. The resident expressed a desire for gardening activities and going outside, which were not provided. The resident also mentioned that activities staff never brought individual activities to the room and that the facility never took residents outside for activities. Interviews with staff revealed that activities were announced over the intercom, and nursing staff would assist residents to activities if needed. However, the Activities Director admitted that the facility's van was broken, and they did not take residents outside the facility for activities. The facility's policies on resident rights and activities were not adhered to, as evidenced by the lack of individualized activities based on comprehensive assessments and care plans. The Activities Director confirmed that the facility did not have a specific policy on activities and that the budget for activities was low. The Administrator stated that it was her expectation for all staff to be well-versed with the policies related to their job duties and to adhere to all facility policies and procedures. However, the observations and interviews indicated that the facility failed to meet the individual needs and preferences of the residents regarding activities.
Failure to Provide Proper Wound and Tube Site Care
Penalty
Summary
The facility failed to ensure Resident #91's sacral wound dressing was changed as ordered by the physician to be completed on every day shift. On 03/01/2024, the Wound Care Nurse changed the dressings on the resident's legs but forgot to return to change the dressing on the sacral wound. The resident confirmed that the sacral dressing had not been changed, and subsequent observations revealed no dressing on the sacral wound. The Treatment Administration Record (TAR) also lacked documentation of the dressing change for the sacral wound on that date. Interviews with the Wound Care Nurse and the Director of Nursing (DON) confirmed the oversight and the need for additional training on double-checking wound care procedures to ensure compliance with physician orders and facility policies. The Administrator emphasized the expectation for all nurses to provide the best possible care for residents, but the deficiency in wound care was evident in this case. The facility also failed to provide appropriate care for Resident #86's jejunostomy tube (J-tube) site. Observations revealed a crusted area with purulent drainage around the J-tube insertion site and no evidence of the ordered gauze dressing. The resident's Treatment Administration Record (TAR) for February 2024 showed no documented evidence of the daily cleaning and dressing application as ordered. An interview with an agency Licensed Practical Nurse (LPN) confirmed that the tube feed insertion site should be cleaned daily and have a gauze dressing in place, but this was not done for Resident #86. Similarly, Resident #126's gastrostomy tube (G-tube) site was observed to be excoriated with a dried dark brown crusted substance and no dressing covering the insertion site. The resident's care plan and physician's orders required daily cleaning and dressing of the G-tube site, but these were not followed. Interviews with the interim and current DONs revealed that all staff, including agency nurses, were expected to be competent in tube feed site care and follow physician orders. However, the observations and lack of documentation indicated a failure to provide the necessary care for Resident #126's G-tube site.
Failure to Follow Enteral Feeding Orders
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, specifically by not following the physician's orders for enteral tube feedings. The resident, who had severe cognitive impairment and required enteral nutrition due to aphasia secondary to a cerebral vascular accident, experienced a significant weight loss over six months. Despite the physician's orders to administer Jevity 1.5 CAL at 60 mL per hour for 16 hours per day with a free water flush of 145 mL every four hours, the tube feeding pump was consistently set to incorrect parameters of 55 mL per hour and 100 mL of water flush every four hours. This discrepancy was observed multiple times over several days, indicating a failure to adhere to the prescribed nutritional regimen. The resident's medical record and care plan indicated the need for specific interventions to ensure proper enteral nutrition, including monitoring the tube feeding formula, cleaning the stoma site, and inspecting for signs of infection. However, observations revealed that the tube feeding pump settings were not adjusted according to the updated physician's orders, and the equipment used for flushing the feeding tube was not maintained properly. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the orders were not followed, and there was a lack of awareness and verification of the updated tube feeding parameters. The failure to follow the physician's orders for enteral feedings was acknowledged by the nursing staff and the DON. The staff responsible for administering the tube feedings did not verify the correct dosage, leading to the resident receiving an incorrect amount of nutrition and hydration. This oversight was further compounded by the use of outdated equipment for flushing the feeding tube. The healthcare provider emphasized the importance of adhering to the prescribed enteral feeding orders to maintain the resident's weight and support wound healing, highlighting the critical nature of this deficiency in the resident's care.
Lack of Training and Competency Validation for Nurse Aides
Penalty
Summary
The facility failed to ensure nurse aides demonstrated competency in essential skills and techniques necessary for resident care, as identified through resident assessments and described in the plan of care. Staff interviews revealed a lack of training in behavior management, catheter care, and maintaining resident dignity. One SRNA reported not receiving any training on abuse, neglect, and exploitation despite working at the facility for six months. Observations confirmed that SRNAs were not following proper procedures, such as standing while feeding residents and failing to perform hand hygiene between resident rooms. Specific incidents highlighted the deficiencies, including an SRNA feeding a resident at a rapid pace while standing, which is against the facility's documented procedures. Another SRNA was observed failing to perform hand hygiene when exiting and entering multiple resident rooms. Additionally, an SRNA improperly performed catheter care by placing washcloths directly in the sink and using them to cleanse a resident's catheter. These actions were attributed to a lack of training and competency validation by the facility. The facility also failed to provide adequate training on handling verbally or physically aggressive resident behavior. Multiple staff members, including housekeepers and SRNAs, reported not receiving training on de-escalation techniques or stress management. The Director of Nursing and the Administrator acknowledged the gaps in training, especially for agency and travel staff, who were expected to be ready to work without additional training. The facility's management team had not implemented a comprehensive training and skills validation program, leading to these deficiencies.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was less than five percent, resulting in a medication error rate of 26.67%. An LPN, who was an agency nurse on her first day at the facility, administered eight medications prescribed for one resident to another resident. The LPN was having difficulties logging into the computer and was not familiar with the residents, leading to the error. The LPN mistakenly identified Resident #63 as Resident #37 and administered medications accordingly, despite the resident's incorrect acknowledgment of the name used by the LPN. The medications administered in error included Benztropine, Ferrous Sulfate, Protonix, Singulair, Celecoxib, and Norco, none of which were prescribed for Resident #63. The LPN realized the mistake after the SSA Surveyor intervened and confirmed the resident's identity. The LPN then reported the incident to the DON and sought guidance on the facility's process for handling medication errors. The DON and APRN were notified, and the APRN issued orders for monitoring Resident #63's vital signs and encouraging fluid intake. Interviews with the DON and the Administrator revealed that agency staff were expected to have established competencies and follow the five rights of medication administration, including verifying the resident's identity using the MAR photo and asking the resident's name. The LPN had received a day of orientation but did not have additional written instructions on facility routines. The incident highlighted a failure in the medication administration process, particularly in verifying resident identity and ensuring proper orientation for agency staff.
Significant Medication Error Due to Resident Misidentification
Penalty
Summary
The facility failed to ensure it was free of significant medication errors for one of the sampled residents. During medication administration, a nurse failed to accurately identify residents in their room, resulting in Resident #63 receiving medications prescribed for Resident #37. The nurse did not directly ask the resident to identify themselves and relied on the room's name placement, which led to the error. The nurse prepared and administered medications labeled for Resident #37 to Resident #63, who later identified themselves correctly to the surveyor. Resident #63, who had diagnoses including chronic obstructive pulmonary disease, epilepsy, and vascular dementia, received medications intended for Resident #37, who had diagnoses including parkinsonism, hepatic failure, and dementia. The medications administered to Resident #63 included Benztropine, Ferrous Sulfate, Protonix, Singulair, Celecoxib, and Norco, which were not prescribed for them. The nurse realized the error after the surveyor's intervention and reported it to the Director of Nursing (DON). Interviews with the DON, other nursing staff, and the Consultant Pharmacist confirmed the medication error and highlighted the lack of proper resident identification practices. The facility's policy required checking the label three times and using two resident identifiers, which were not followed. The error was deemed significant, and the facility's staff acknowledged the failure to adhere to the established medication administration protocols.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure that medications were properly labeled and stored for two residents. On 02/28/2024, a Kentucky Medication Aide (KMA) placed medications for two residents into unlabeled medication cups and stored them in the top drawer of the medication cart. This action was not in accordance with the facility's policy, which requires medications to be stored in their original packaging and labeled with specific information, including the resident's name. The medications included various drugs for conditions such as cardiac dysrhythmias, high blood pressure, diabetes, anxiety, depression, and high cholesterol. During an interview, the KMA admitted that one resident did not want to take their medications after they were placed in the cup, and the other resident was walking in the hall, leading her to store the medications temporarily. The KMA acknowledged that this could have resulted in the medications being given to the wrong resident, potentially causing harm. The Director of Nursing (DON) confirmed that the medications should have been stored according to the facility's policy and properly labeled.
Failure to Provide Adequate and Specialized Diets
Penalty
Summary
The facility failed to provide residents with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs. Resident #58, who had a diagnosis of diabetes mellitus and was on a controlled carbohydrate (CCHO) diet with large portions of vegetables, received inadequate portions and no alternatives for the CCHO diet. The resident's breakfast tray also contained regular syrup instead of diet syrup, and the resident reported not being offered a diabetic diet or alternatives since admission. Additionally, the resident did not consistently receive a bedtime snack to prevent overnight sugar drops, as required for diabetic management. Resident #70, who had a personal preference for fish due to religious reasons, did not receive fish for the supper meal as requested. Instead, the resident received spaghetti with meat sauce, which did not align with their dietary preferences. The resident reported that it was rare to receive fish despite the request, and the kitchen staff confirmed that no fish was available at the time. Interviews with the dietary staff, including the cook, registered dietician (RD), and interim dietary manager (IDM), revealed a lack of training and adherence to specialized diets and food preferences. The cook admitted to using only one size serving scoop, which potentially caused residents to receive incorrect portions. The IDM acknowledged that the dietary staff had not been trained on specialized diets like CCHO and that there was no always available menu to offer alternatives. The interim director of nursing (IDON) and the administrator emphasized the importance of following physician orders and honoring resident preferences, but the facility's practices did not align with these expectations.
Failure to Follow Dietary Orders and Provide Adequate Nutrition
Penalty
Summary
The facility failed to follow the menu and provide the required nutritional needs for Resident #50, who had specific dietary requirements due to conditions such as end-stage renal disease and Type 2 diabetes. Despite having a physician-ordered diet that included double protein/meat on non-dialysis days and other specific food items, the resident frequently received inadequate portions. Observations revealed that the resident's meal trays often did not comply with the dietary orders, such as receiving only one serving of protein/meat when double portions were required. Additionally, the resident reported receiving meals that were insufficient in quantity and did not meet their nutritional needs, such as a small salad with spaghetti sauce but no pasta and a breakfast consisting of only a donut and orange juice. Interviews with the resident and other residents corroborated the issue of inadequate food portions. Resident #50 expressed frustration over the lack of protein, especially given their dialysis treatment, which necessitated higher protein intake. The resident provided photographic evidence of meals that did not meet the prescribed dietary requirements. Other residents also reported that the food servings were small and sometimes left them feeling hungry. These observations and interviews highlighted a consistent failure to adhere to the dietary orders and provide adequate nutrition. Interviews with dietary staff and the Dietary Manager revealed that meal tickets were supposed to guide the preparation of trays according to residents' dietary needs. However, despite the Dietary Manager's recent efforts to audit and ensure accuracy, discrepancies persisted. The Director of Nursing and the Administrator acknowledged the expectation that meal tickets should be followed precisely, but the ongoing issues indicated a systemic problem in the facility's dietary service, leading to the deficiency in meeting residents' nutritional needs.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at an appetizing temperature for three residents. Resident #35's supper tray was observed to be cold, and the resident stated that the chicken sandwich did not taste good. Similarly, Resident #113's supper tray was also cold, and the resident complained about the food's taste and portion size, noting that no alternative meal was offered. Resident #66 reported that their food was often cold, and although the kitchen sometimes provided a fresh meal upon request, the resident was reluctant to complain due to staff being busy. Observations confirmed that food temperatures were not within the required range, with hot foods being served at insufficient temperatures and cold foods being too warm. Interviews with staff and residents revealed systemic issues with food service. SRNA #19 confirmed that Resident #66 frequently received cold meals due to being at the end of the hallway, and staff were not allowed to rewarm the food. The Registered Dietician (RD) and Interim Dietary Manager (IDM) acknowledged that food temperatures were not consistently monitored, and the RD highlighted the risk of foodborne illness from improperly heated food. The IDM and Interim Director of Nursing (IDON) both stated that residents should receive meals at appropriate temperatures and that substitutions should be provided if the food was not satisfactory. The Administrator noted that residents had previously complained about cold food served on Styrofoam plates and cups, a practice that was changed upon her arrival. Despite these changes, the issue of cold food persisted, as evidenced by the observations and resident interviews. The Administrator mentioned that staff could use microwaves in dietary rooms to reheat food, but this practice was not consistently followed. The report highlights a failure in the facility's food service operations, leading to residents receiving meals that were not palatable or at the correct temperature.
Failure to Provide and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to provide immunizations as required or appropriate, ensure the resident or the resident's representative had the opportunity to refuse immunizations, and document the resident's or resident representative's education regarding the benefits and potential side effects of immunizations. Specifically, for Resident #128, who was admitted with diagnoses including type 2 diabetes mellitus, atrial fibrillation, cerebral infarction, and respiratory disorders, there was no documented evidence that the resident had received the recommended pneumococcal immunizations or that the resident had declined the vaccination. The resident, who had moderate cognitive impairment, did not recall being offered any vaccines by the facility. Interviews with the Director of Nursing/Infection Preventionist (DON/IP) and the Administrator revealed that the facility followed CDC recommendations for immunizations and expected all residents to receive vaccinations according to these guidelines. However, the DON/IP was unsure why Resident #128 had not received the recommended vaccination. The Administrator stated that the facility's policies should be followed and that the infection prevention program was overseen by the DON/IP, with additional support from a Regional Resource Nurse and a newly appointed Assistant Director of Nursing (ADON) as the new IP. Despite these expectations, the facility failed to ensure proper documentation and administration of the pneumococcal vaccine for Resident #128.
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The facility failed to maintain a safe, clean, and well‑maintained environment as required by its own policy, with surveyors observing loose kitchen handrails, damaged doors and wood paneling, exposed concrete and stained flooring in resident rooms and bathrooms, bubbling and chipped paint, rusted door frames, water‑stained ceiling tiles, scuffed walls and baseboards, damaged tiles, and deteriorated outdoor structures such as a raised garden bed. Additional issues included a broken cabinet and taped wall corner guard in shower rooms, an unsecured wall clock, a missing floor tile, dried paint splatter, rusted heating/cooling units with chipped paint, and a pool table with a missing corner guard. A resident reported a heating/air unit in her room with a missing bottom panel exposing dust and debris. Staff interviews revealed that some items had been broken for years, concerns about the safety of the handrails had not resulted in repairs, housekeeping did not consistently log issues for maintenance, and there was no formal system to track and ensure completion of maintenance work orders, as acknowledged by the DON, the Maintenance Director, and the Administrator.
The facility failed to ensure food and beverages were served at safe and appetizing temperatures, as required by its Food Preparation and Service policy. Multiple test tray assessments documented hot items such as meats, vegetables, and starches being served within the temperature danger zone, and cold items such as desserts, milk, juice, and sandwiches above the required cold-holding temperature. A resident with DM2, major depressive disorder, and anxiety, who was cognitively intact, reported receiving cold food all the time, and residents in a Resident Council meeting also reported cold food at mealtimes. During a test tray observation, surveyors found hot entrée and vegetable items to be room temperature or cold and beverages warm. Despite these findings, dietary leadership and the RD stated that hot food was always hot and that temperatures taken during audits were accurate, while the DON and Administrator expressed expectations that hot food be hot and cold food be cold.
Surveyors found that nourishment refrigerators and freezers on several units were soiled with dried food debris, and multiple opened grape jelly containers were left undated and unrefrigerated despite labeling that required refrigeration after opening. Facility policies required refrigerators and freezers to be kept clean, free of debris, and that refrigerated or frozen foods be covered, labeled, and dated. Staff interviews showed that Dietary was responsible for cleaning nourishment refrigerators, that refrigerators were cleaned on a set schedule with spills expected to be wiped up by staff, and that opened jelly should have been dated and refrigerated. These practices had the potential to affect all current residents.
The facility failed to maintain a safe, clean, and homelike environment and to ensure adequate supplies for resident care. Over several months, grievances and Resident Council minutes documented repeated concerns about lack of needed supplies, use of wrong-size briefs, and the prolonged closure of a small dining room. Multiple STNAs reported frequent shortages of briefs, linens, washcloths, peri-care products, and other supplies, sometimes leading staff to cut towels into washcloths and to use ill-fitting brief sizes for residents. Environmental observations revealed inaccessible and damaged dining areas with buckled and broken floor tiles, missing and stained ceiling tiles, and a resident bathroom with uneven flooring, persistent staining, a cracked shower light cover containing a dead insect, and a soap dispenser installed above a non-functional outlet. Additional rooms and hallways had exposed wall cracks, sagging ceiling tiles, lifting and separating floor tiles, and buckled flooring attributed to leaks, while maintenance and housekeeping leaders acknowledged awareness of many of these issues but had not ensured timely correction.
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, and staff did not consistently follow existing care plan interventions. Several residents with PEG tubes, a dialysis catheter, and a colostomy either lacked appropriate EBP care plan focuses at admission or did not have EBP practices implemented as written, including missing door signage and failure to follow tube-feeding protocols. In addition, two residents with PTSD and other mental health diagnoses had active PTSD documented in assessments and psychiatric notes, but their care plans did not address PTSD-related triggers, symptoms, or trauma-informed interventions, despite staff acknowledging these omissions and the importance of accurate, complete care planning.
A deficiency was cited after surveyors found that multiple residents receiving enteral nutrition did not receive care consistent with facility policy, physician orders, or manufacturer guidance. Tube feeding bags were often hung without dates or times, tubing connectors were left uncapped between uses, and pumps and IV poles were visibly soiled with dried formula. A resident with a G-tube and severe cognitive impairment twice developed abdominal wall cellulitis identified by an adult day care center, with no prior documentation of infection signs by facility staff despite orders to monitor the site each shift. Other residents had medications administered via PEG or G-tubes without verification of tube placement, feedings started late or allowed to run past ordered stop times, and feeding systems spiked and primed hours before use with open, uncovered connectors. Staff interviews confirmed that protective caps were not supplied, that they were behind on tasks, and that they were aware these practices could introduce contamination, leading to the cited deficiency in enteral feeding management.
The facility failed to implement and maintain effective infection prevention and control practices, including missing Enhanced Barrier Precautions (EBP) signage for multiple residents with devices such as feeding tubes, colostomies, dialysis catheters, and indwelling urinary catheters, despite care plans and orders indicating EBP. Several residents receiving tube feedings had bottles and tubing hanging without dates or times and without protective end caps when not in use, contrary to staff statements that feedings should be dated, timed, and properly capped. Staff also did not consistently disinfect shared equipment and surfaces between residents, including a medication cart used for blood glucose checks, a blood pressure cuff used on more than one resident, and a mechanical lift that was returned to the hallway without cleaning after use, despite facility expectations and policies requiring cleaning between each resident.
The facility failed to maintain an effective pest control program, as gnats, roaches, mice, and other pests were repeatedly observed and reported in resident rooms, bathrooms, dining areas, and the kitchen. Surveyors noted gnats around urine-filled urinals on a bedside table, in the kitchen near an open freezer, and on dirty dishware in a unit dining room, as well as a cracked bathroom light fixture containing a dead moth. Exterior doors near the kitchen, courtyard, and parking lot were repeatedly propped open with objects, contrary to expectations stated by the DON, Dietary Manager, and Maintenance Director, allowing pests to enter. A resident reported seeing a mouse and cockroaches in his room, with a mouse glue trap observed there, while another resident reported a mouse in her window and mouse droppings in both the window and on a meal tray. STNAs described ongoing problems with gnats and large roaches and stated that routine pest control spraying and glue traps had not resolved the issues.
A resident with COPD, chronic pain, and pneumonia was placed on palliative and hospice care and ordered oral morphine concentrate for end-of-life pain management. The NP intended a dose of 0.25 ml of 100 mg/5 ml morphine (5 mg), but an LPN entered the order in the EMR as 20 mg/5 ml at 0.25 ml (1 mg), creating a concentration discrepancy. Pharmacy dispensed 100 mg/5 ml morphine labeled to give 0.25 ml (5 mg), yet staff did not detect the mismatch between the EMR and the bottle. A hospice nurse, relying on the incorrect 20 mg/5 ml EMR order, obtained a new order to increase the dose to 1.25 ml to equal 5 mg and documented this on a hospice visit record. A CMT then administered the 100 mg/5 ml concentrate at 0.25 ml once and 1.25 ml three times, each 1.25 ml dose equaling 25 mg instead of 5 mg. Despite concerns from the UM and ADON about the unusually high 1.25 ml dose, clarification was delayed, and the resident was later pronounced dead. Interviews and policies showed staff were expected to follow the five rights of medication administration and reconcile labels with EMR orders, but multiple failures to verify the correct concentration and dose led to repeated morphine overdoses and a significant medication error.
A resident on hospice with COPD and chronic pain received morphine concentrate after a verbal order from an NP was incorrectly entered by an LPN as a lower‑strength solution. A hospice nurse later increased the volume of the morphine dose based on the incorrect concentration in the electronic order rather than the pharmacy order or medication label, resulting in administration of doses five times higher than intended on multiple occasions. The resident died later that day, and hospice staff, the coroner, and police became involved, with police confirming concerns about excessive dosing and seizing the morphine. Despite a facility policy requiring prompt reporting of abuse allegations and any reasonable suspicion of a crime to state agencies, the DON and Administrator did not report the incident, with the Administrator stating she relied on police to make the report.
Failure to Maintain Safe, Clean, and Well-Maintained Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and well‑maintained environment as required by its “Home-like Environment” policy, which states residents have a right to a safe, clean, and homelike setting. Surveyors observed multiple unresolved maintenance and housekeeping issues throughout the building and grounds. These included loose and insecure handrails leading into the kitchen, a damaged kitchen entry door with scratches and a missing piece, damaged and chipped wood paneling at the nurses’ station, and multiple areas of damaged flooring in resident rooms where heating/cooling units had been removed, exposing concrete and stained flooring around toilets and sinks. Additional observations included bubbling and chipping wall paint, rusted door frames, discolored and water‑stained ceiling tiles, and scuffed walls and baseboards in hallways and the dining room. Further observations showed environmental issues in resident-use and common areas, including a water hose lying in flowerbeds at the facility entrance, a Styrofoam cup on the ground outside a resident’s window, scratched glass doors to the smoking area, damaged floor tiles at the exit to the smoking area, a cabinet in a resident shower room with a missing handle, and a wall corner guard held in place with multiple strips of tape. Another shower room had a wall clock not mounted properly, resting on cloth hooks. Additional findings included a missing floor tile in a resident room exposing concrete, dried paint splatter at entries to several resident rooms, rust and chipped paint on a heating/cooling unit and adjacent exit door, a pool table in the dining room with a missing corner guard and exposed edges, and a raised garden bed with structural deterioration and a failing, rotted base partially detached and laying on the ground. Interviews confirmed that these conditions had been ongoing and not consistently addressed through the facility’s maintenance processes. A resident reported that the heating/air unit in her room was missing the bottom part, exposing dust and debris on the floor, and stated she would clean it herself if able. A CNA reported the broken cabinet in the shower room had been in that condition for many years and that repairs were not consistently completed after being reported via logbooks. The Housekeeping Manager acknowledged awareness of scuff marks on walls and baseboards but had not entered them into the maintenance logbook. The Dietary Manager stated she had concerns about the safety of the kitchen handrails, which she believed could pose a fall risk, and that maintenance had not repaired them. The Maintenance Director stated there were no outstanding work orders in the logbook, acknowledged that monthly painting had not been done for March, and noted the damaged raised garden bed had not been repaired or removed. The DON and Administrator both acknowledged there was no formal system to track and ensure completion of maintenance work orders, and the Administrator was aware of the unsecured kitchen handrails but was not aware if repairs had ever been completed.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to provide food and drink at safe and appetizing temperatures in accordance with its own Food Preparation and Service policy. The policy, dated 2001, defined the temperature danger zone as above 41°F and below 135°F, and required potentially hazardous foods to be maintained at or below 41°F or at or above 135°F. Multiple Providence Pavilion Test Tray Assessment documents for various meals showed hot foods such as baked ravioli, baked chicken, rice pilaf, carrots, rosemary chicken, mushroom rice, au gratin cauliflower, broccoli, mashed potatoes, beef stroganoff, and carrots being served at temperatures between 118°F and 132°F, which were within the policy’s stated danger zone. Cold items such as apple bar, milk, cold ham and cheese sandwich, pudding, juice, and lemonade were recorded at temperatures between 42°F and 61°F, also within the danger zone. During a test tray observation, surveyors tasted the beef stroganoff, broccoli, and lemonade and described them as room temperature, cold, and warm, respectively. Resident feedback corroborated these findings. One resident, admitted with diagnoses including type 2 diabetes mellitus, major depressive disorder, and anxiety, and assessed as cognitively intact with a BIMS score of 14/15, stated she received cold food all the time. Residents attending a Resident Council meeting also reported receiving cold food at mealtimes. Despite these reports and documented tray temperatures in the danger zone, the Dietary Manager stated she preferred hot food served at 130°F and reported that steam tables were turned on one-half hour before meal service. The RD reported that she conducted sanitation walkthroughs and test trays and stated that hot food was always hot and that recorded temperatures showed this, and further indicated that department heads passed trays and took temperatures during test tray audits. The DON and Administrator both stated their expectations that residents receive food at proper temperatures, with hot food hot and cold food cold, but the documented observations and resident interviews showed that this was not consistently occurring.
Improper Food Storage and Unsanitary Nourishment Refrigerators
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards and its own policies for food safety. Surveyors observed that nourishment refrigerators and freezers on multiple units, including the Honor, Pavilion, and Purpose Units, were soiled with dried food debris on shelves and throughout the compartments. On the Honor Unit, an opened grape jelly container was found sitting on top of the refrigerator, undated and not stored inside the refrigerator, despite the product label directing refrigeration after opening. In the kitchen, two additional opened and undated grape jelly containers were observed left out of the refrigerator. Review of facility policies from 2001 showed that refrigerators and freezers were to be kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis, and that all foods stored in the refrigerator or freezer were to be covered, labeled, and dated with a use-by date. Staff interviews further clarified practices and expectations related to the deficiency. A state tested nurse aide stated that Dietary was responsible for cleaning the unit nourishment refrigerators. The Dietary Manager reported that nourishment refrigerators were cleaned twice weekly and that any spills should be cleaned up by staff, and acknowledged that the jelly was kept out to make peanut butter and jelly sandwiches, but should have been dated when opened and kept refrigerated. The DON stated her expectation that nourishment refrigerators be clean, and the Administrator stated her expectation that staff wipe up any spills and maintain the cleanliness of nourishment and resident refrigerators. The deficient practices had the potential to affect all 80 current residents.
Failure to Maintain Safe, Clean, and Homelike Environment and Adequate Care Supplies
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with a safe, clean, comfortable, and homelike environment, including adequate supplies for daily care. The facility’s own policy on a homelike environment requires a safe, clean, comfortable setting that emphasizes residents’ independence and personal needs and preferences. Review of grievance logs and Resident Council minutes over several months showed repeated resident concerns about not having needed supplies and the prolonged inaccessibility of the small dining room. Grievances documented that residents lacked needed supplies and that the small dining room remained unusable, while Resident Council minutes reflected residents’ desire for the small dining room to be usable by Thanksgiving and ongoing concerns about not receiving needed supplies and aides using the wrong size briefs. Multiple staff interviews confirmed ongoing supply shortages affecting resident care. One STNA reported that the facility frequently did not have enough supplies, including hand sanitizers, soaps, clean linens, and briefs, and that this had been an issue for a few months. She stated that when briefs ran out, staff reported to nursing, who contacted central supply, and if unavailable, the Administrator was called to purchase supplies locally. Another STNA reported housekeeping budget cuts and stated the facility had run out of washcloths and disposable bed pads, leading staff to cut up towels to use as washcloths for peri-care. She also reported that a previous central supply staff member told STNAs the facility budgeted briefs to be changed once every six hours, which she felt was not sufficient for some residents, and that residents sometimes had to use larger or smaller brief sizes and complained about this. A third STNA stated the facility ran out of supplies on the unit, sometimes leaving no linens for night shift, and that peri-care supplies and specific brief sizes sometimes ran low, requiring use of different sizes. Environmental observations and staff interviews showed multiple areas of the building that were not maintained in a safe, clean, or homelike condition. The small dining/activity room off the main hall was observed with tables and chairs blocking entryways and a wavy, buckled wood-grain tile floor, and the room remained inaccessible to residents. In the Honor dining room, surveyors observed a large section of broken and mismatched wood-grain tiles with gaps between them and a missing ceiling tile. The bathroom in one resident room had an uneven floor, staining on the raised toilet seat, rust-colored stains running from a soap dispenser down past a non-functional wall outlet and onto the baseboard, and a cracked shower light cover containing a dead moth. The Housekeeping Manager acknowledged the staining had been present for two to three months, that attempts to remove it were unsuccessful, that the bathroom was not homelike, and that the floor needed to be replaced. Additional structural issues were observed in resident areas and common spaces. In another resident room, the wall with the window had an exposed crack with visible sheetrock, and ceiling tiles above the door included one missing tile and six stained and sagging tiles; an LPN stated there had been a leak and that maintenance was aware, but no repairs had been made. The Maintenance Director stated the leak was caused by the HVAC system and that repairs had not yet been completed. In the Providence hallway, blue border floor tiles were lifting and separating along the length of the hallway, with large scuff marks and dull, soiled center tiles; the Housekeeping Manager stated staff could not strip and wax the floor due to the tile’s condition, and the Regional Maintenance Director stated the facility was in the process of obtaining quotes to replace the floor. In another resident room, the floor appeared buckled and wavy, which the Maintenance Director attributed to a water leak in a wall coil assist located in the ceiling, and he stated there were plans to repair the flooring in multiple rooms. Interviews with maintenance and management staff showed awareness of many of these environmental issues but also revealed gaps in monitoring and timely correction. The Maintenance Assistant reported doing monthly room rounds for lights, extension cords, plugs, and handrails but was unaware of the bathroom issues in the identified room and had not noticed the damaged tiles in the Honor dining room or how long the small dining room had been closed. The Maintenance Director stated the small dining room floor damage was due to a water leak from an ice machine and believed it occurred months earlier, and he acknowledged that the non-live outlet in the bathroom would need to be removed and covered. The Housekeeping Manager stated she was aware of damaged and ill-fitting tiles in the Honor dining room and that floors in several areas, including the small dining room, needed replacement. The DON and Administrator both stated their expectations that the facility be kept clean, safe, and homelike, with all spaces utilized for residents and floors kept even, clean, dry, and free from clutter, but the observed conditions and staff reports demonstrated that these expectations were not being met.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for multiple residents, and failure of staff to follow existing care plan interventions. For two residents with PEG tubes and one resident with a dialysis catheter, the facility did not fully develop care plans at admission to reflect their diagnoses and required Enhanced Barrier Precautions (EBP). One resident was admitted with a PEG tube in August 2025, but EBP related to the PEG tube was not added to the care plan until March 2026, and there was no EBP signage on the door during observation. Another resident admitted with end stage renal disease and a dialysis catheter had no care plan focus for the dialysis catheter or EBP, despite having an order for EBP and being admitted with the catheter; there was also no EBP signage observed on the door. For a resident with diverticulitis and colostomy status, the care plan did include EBP, and there were orders for EBP and colostomy care every shift; however, there was no EBP signage on the door, and the MDS nurse stated she had been told that residents with colostomies did not require EBP, even though EBP remained on the care plan and staff were expected to follow care plan interventions. Another resident with cerebral palsy, epilepsy, and gastrostomy status had a care plan directing staff to check PEG tube placement and gastric contents/residual volume prior to medication administration per facility protocol, but observation showed an LPN administering medications via the PEG tube without checking for placement before pushing the medication. Two residents with PTSD diagnoses did not have their mental health needs fully addressed in their care plans. One resident admitted in 2023 with PTSD and other mental health diagnoses had a quarterly MDS showing a mood severity score of 18, with difficulty sleeping, little interest in activities, and feeling depressed or hopeless nearly every day, and psychiatry notes documented PTSD and schizoaffective disorder related to past trauma and ongoing nightmares; however, the care plan contained no focus for PTSD. Another resident admitted in 2016 with PTSD and borderline personality disorder had an active PTSD diagnosis on the MDS, but the comprehensive care plan did not address PTSD, including triggers, symptoms, or trauma-informed interventions. The Social Services Director, MDS nurse, DON, and Administrator all acknowledged that the PTSD diagnosis and related care plan focus had been overlooked and that care plans were expected to be fully developed and implemented so staff would know how to properly care for residents.
Failure to Maintain Safe, Timely, and Sanitary Enteral Feeding Practices
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services to prevent complications related to enteral nutrition for six residents with feeding tubes. Surveyors found that tube feeding systems were frequently hung without being dated or timed, and tubing connector tips were left uncapped between uses, despite facility policy and manufacturer guidance requiring protection of components that contact formula. Multiple residents had feeding containers spiked and primed but not infusing, with the open ends of tubing left exposed and no protective caps available. Staff interviews confirmed that caps were not provided by the facility, and nurses acknowledged that uncovered connectors could introduce germs and place residents at risk for infection. For one resident with a gastrostomy tube and severe cognitive impairment, the care plan and orders required monitoring the G-tube site for infection every shift and checking tube placement and gastric residuals. The resident was sent twice from an adult day care center to the Emergency Department and diagnosed with abdominal wall cellulitis on both occasions, after the day care staff identified abnormal G-tube findings, including leakage and inability to flush the tube. The facility’s clinical record contained no documentation that staff had identified or recorded signs or symptoms of infection before the resident left for day care on either occasion, and the Physician Assistant reported she had not been notified of excessive leakage that could contribute to recurrent cellulitis. During observation, this resident’s G-tube site was reddened with yellowish-green drainage, the feeding container had been spiked the previous day and was being reused, the connector was left uncovered, and the pump and IV pole had dried formula residue. Other residents with PEG or G-tubes also experienced deficiencies in enteral feeding management. Several residents had tube feedings hanging and infusing without dates or times on the bags, and tubing sets were observed primed and hanging with open, uncapped ends. One resident received medications via PEG tube without the nurse checking tube placement beforehand, despite a care plan intervention to check placement and gastric contents per protocol. Another resident’s feeding was labeled to start later in the day but was already spiked and primed hours in advance, with the connector left uncovered and the pump and IV pole soiled with dried feeding residue. For a resident ordered to receive tube feeding from late afternoon to early morning, the feeding was started approximately two hours late and then observed still infusing well past the ordered stop time; the resident was later found in bed with a large amount of emesis on the gown and linens, and the LPN stated she had been running behind and had not turned off the feeding. Throughout these observations, the DON, PA, RD, and product representative all confirmed that connectors should be covered, feedings should follow ordered schedules, and systems should not remain hanging beyond recommended timeframes, but the facility’s practices did not align with these expectations. Across multiple days of observation, the surveyors repeatedly noted that enteral feeding pumps and IV poles for several residents were coated with dried feeding residue on the exterior surfaces, along the poles, and at the bases, indicating that equipment used for tube feeding was not maintained in a clean and sanitary condition. Facility policies on enteral nutrition and G-tube site care required staff to monitor for signs of infection, maintain cleanliness of the tube site, assess for redness, swelling, pain, or drainage, and report signs of infection to a supervisor and physician. The policies also emphasized confirming tube placement prior to initiating feedings to reduce aspiration risk and recognizing complications such as aspiration, tube misplacement, skin breakdown, and gastrointestinal symptoms. Despite these written policies and the manufacturer’s guidance on closed versus open systems, hang times, labeling, and handling to prevent contamination, staff actions and inactions—including failure to document and report abnormal G-tube findings, failure to verify tube placement before medication administration, failure to adhere to ordered feeding schedules, and failure to keep connectors capped and equipment clean—led to the cited deficiency for all six residents receiving enteral nutrition.
Failure to Implement Effective Infection Prevention and Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program, as evidenced by multiple observations of noncompliance with policies, CDC guidance, and basic infection control practices. Surveyors observed that residents on Enhanced Barrier Precautions (EBP) did not have required signage posted on their room doors, despite care plans and orders indicating the need for EBP. Residents with devices such as a PEG tube, colostomy, dialysis catheter, and indwelling urinary catheter were under EBP, but their rooms lacked appropriate signage. Staff interviews confirmed that EBP should have been initiated and care planned upon admission for these residents and that signage should have been posted, but this was not done or was delayed. The deficiency also includes improper management of enteral nutrition systems for several residents receiving tube feedings. Surveyors observed tube feeding bottles and tubing hanging on poles without dates or times indicating when they were opened or hung, and with tubing primed but without protective end caps when not in use. Staff, including LPNs and the PA, acknowledged that tube feedings should be dated and timed, that they are only good for a limited period once hung, and that the absence of end caps could allow germs or bacteria to be introduced into the feeding system. The DON and Administrator stated their expectations that tube feedings be dated, timed, and capped, and that undated or uncapped systems should be replaced, but the observed practice did not align with these expectations. Additional deficiencies were identified in the cleaning and disinfection of shared equipment and surfaces between resident use. A nurse performing blood glucose checks placed used supplies and a glucometer on the medication cart surface, cleaned the glucometer, but did not disinfect the cart surface before preparing supplies for another resident on the same surface. Another nurse used a blood pressure cuff on two different residents without cleaning it between uses, stating she normally would use disinfectant wipes but forgot and did not have wipes in her cart. In a separate incident, staff used a mechanical lift to transfer a resident back to bed and then placed the lift in the hallway without cleaning it after use. Staff and leadership interviews confirmed that shared equipment and surfaces should be disinfected between residents to prevent cross-contamination, but this was not consistently done. Collectively, these observations show that the facility did not follow its own infection prevention and control policies related to EBP implementation and signage, safe handling of tube feedings, and cleaning and disinfection of shared equipment and surfaces. The facility’s policies required surveillance of staff adherence to infection control practices, proper use of standard precautions, and cleaning and reprocessing of reusable equipment between residents, but surveyors found repeated instances where these requirements were not met for multiple sampled residents.
Failure to Maintain Effective Pest Control and Environmental Practices
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and rodents, despite having a pest control contract and invoices showing routine service. Surveyors observed gnats in multiple areas of the facility on several days, including around urinals in a resident room, in the kitchen near an open double reach-in freezer, and on dishware in a unit dining room sink and tray. A cracked overhead bathroom light fixture in another room contained a large dead moth. Staff and residents reported seeing gnats, roaches, and mice in the facility, and invoices confirmed that pest control services were being provided for various pests including mice, rats, spiders, water bugs, silverfish, and roaches. Multiple observations showed that exterior doors were repeatedly propped open, allowing pests to enter the building. The kitchen delivery and emergency door was held open with a milk crate, creating a gap between the doors, and the kitchen back door was again observed held open with a milk crate on another day. Two side doors leading to the courtyard and toward the kitchen were observed open with wind blowing into the building, and a side door facing the parking lot was held open with two chairs, despite posted signs instructing that the door not be used. The Director of Maintenance, Dietary Manager, and DON each stated that these doors were expected to remain closed except during specific uses, and acknowledged that open doors allowed pests to enter and potentially contaminate food. Residents and staff provided additional accounts of pest activity. One resident reported seeing a mouse come from under a chair in his room, as well as cockroaches on the walls disappearing into ceiling tiles and gnats; a mouse glue trap was observed behind a chair in that room, and the resident stated he had reported the issue and pest control had sprayed. Another resident reported finding a mouse between the screen and window in her room, later seeing mouse droppings in the window, and receiving a meal tray with mouse droppings. STNAs reported seeing large roaches in hallways, ongoing problems with flies and gnats in dining rooms, and complaints from residents and families about gnats, while also stating that pest control spraying did not seem effective. The DON acknowledged that one resident did not like staff touching his belongings, which contributed to urinals with urine being left on a bedside table with gnats flying around them, and stated the facility should be kept clean and as nice as possible for residents.
Fatal Morphine Overdose Due to Unreconciled Concentration and Dose Errors
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when staff administered multiple overdoses of concentrated oral morphine. The resident had COPD, chronic pain, osteoarthritis, and was placed on palliative care, later transitioning to hospice after a decline that included pneumonia, decreased oxygen saturation, shallow breathing, and lethargy. On the morning of the incident, the facility NP gave a verbal order for morphine concentrate 100 mg/5 ml at 0.25 ml (5 mg) every hour as needed, and also sent a written order to the pharmacy for this concentration and dose. However, when the LPN entered the order into the electronic medical record, she documented morphine 20 mg/5 ml with a dose of 0.25 ml (1 mg), creating a discrepancy between the NP’s intended concentration and the order recorded in the system. The pharmacy dispensed morphine sulfate 100 mg/5 ml concentrate with label directions to give 0.25 ml (5 mg) every hour as needed, consistent with the NP’s written order. When the medication arrived, the receiving LPN stated she compared the bottle to the pharmacy order and the computer but did not identify any difference between the 100 mg/5 ml label and the 20 mg/5 ml order in the EMR. Later, a hospice nurse arrived, reviewed the MAR that showed morphine 20 mg/5 ml at 0.25 ml (1 mg), and observed the first dose of 0.25 ml being administered by a CMT. Seeing continued discomfort, the hospice nurse obtained a verbal order from the hospice physician to increase the dose to 1.25 ml to equal 5 mg, basing this calculation on the 20 mg/5 ml concentration shown in the Physician Order Report and not on the actual 100 mg/5 ml concentration on the bottle or the NP’s written pharmacy order. Following the hospice nurse’s written order on the Nursing Home Visit Record to increase the dose to 1.25 ml, the CMT administered the concentrated morphine 100 mg/5 ml at 0.25 ml once and then at 1.25 ml on three subsequent occasions that afternoon, each 1.25 ml dose equaling 25 mg instead of the intended 5 mg. The CMT reported that she questioned the 1.25 ml dose because she had never given that much before, but proceeded after the hospice nurse confirmed it was correct based on the MAR. The Unit Manager and ADON both expressed concern about the 1.25 ml dose and recognized it seemed like a large amount, but clarification with hospice was delayed until late in the day. The pharmacy later confirmed that, based on the 100 mg/5 ml concentration delivered, the resident received 25 mg instead of 5 mg on three administrations within approximately three hours, a fivefold overdose each time. The resident was pronounced dead that evening, and law enforcement and the coroner were notified after hospice staff and facility staff identified a potential morphine overdose and documented that three doses had been given at five times the ordered concentration. Interviews with multiple RNs, the DON, Medical Director, and Administrator confirmed that facility expectations and policies required staff to perform the five rights of medication administration, visually compare the medication label to the EMR order and narcotic sheet, and seek clarification from the provider or pharmacy if any discrepancy or concern arose. Despite these policies, staff involved in ordering, receiving, verifying, and administering the morphine did not reconcile the differing concentrations (20 mg/5 ml vs. 100 mg/5 ml) between the EMR, the hospice documentation, and the pharmacy label. The hospice nurse based the dose increase solely on the EMR order, the receiving LPN did not detect the mismatch between the EMR and the bottle, and the CMT and nursing leadership did not stop administration or obtain timely clarification when the 1.25 ml dose appeared unusually high. These combined actions and inactions resulted in repeated administration of morphine at five times the intended dose and constituted a significant medication error. The facility’s own policies on medication administration, physician orders, and medication labeling required nurses to question inappropriate doses, verify label accuracy, and consult the provider or pharmacy when directions changed or appeared inconsistent. Staff interviews indicated that these expectations were known, including the need to reconcile the drug in hand with the EMR order and narcotic record before administration. Nonetheless, the morphine order was incorrectly entered into the EMR, the discrepancy between the EMR and the pharmacy label was not recognized at receipt or prior to administration, and the hospice nurse’s dose adjustment was calculated from the incorrect EMR concentration rather than the actual bottle concentration. The failure of multiple staff members to follow established verification processes and to resolve evident concerns about the dose led directly to the resident receiving three excessive doses of morphine concentrate and underpinned the cited deficiency for significant medication errors under 42 CFR 483.45 (F760).
Failure to Report Suspected Abuse/Neglect and Medication Error Involving Morphine Overdose
Penalty
Summary
The deficiency involves the facility’s failure to report an alleged violation involving potential abuse/neglect and a reasonable suspicion of a crime to state agencies as required by facility policy and regulation. The facility’s Abuse, Neglect and Misappropriation of Property policy required that any abuse allegation be reported to the state within two hours and that any reasonable suspicion of a crime with serious bodily injury be reported to the state and police. For one resident, R1, who had diagnoses including COPD, chronic pain, and osteoarthritis and who was placed on hospice care at family request, there was a medication error involving morphine dosing on the day of the resident’s death. Despite this event and subsequent involvement of law enforcement and the coroner, the facility Administrator and DON did not report the incident to the state agencies, with the Administrator stating she relied on the police to report it. On the morning of 03/12/2026, the facility NP gave a verbal order for morphine concentrate 0.25 ml every hour as needed, which she clarified as morphine concentrate 100 mg/5 ml, 0.25 ml (5 mg) every hour as needed, and she placed a written order to the pharmacy accordingly. LPN1, however, documented the order in the Physician Order Report as morphine 20 mg/5 ml, 0.25 ml (1 mg) as needed for pain. Later, a hospice nurse (HN1) wrote a hand‑written Nursing Home Visit Record increasing the morphine dose to 1.25 ml to equal 5 mg as needed, basing this on the 20 mg/5 ml concentration shown in the Physician Order Report and not on the NP’s written order to the pharmacy or the actual medication label, which both indicated 100 mg/5 ml. The morphine supplied for R1 was morphine sulfate 100 mg/5 ml concentrate, labeled to give 0.25 ml (5 mg) every hour as needed, and the Controlled Drug Record showed that on 03/12/2026, R1 received 0.25 ml at 11:30 AM and 1.25 ml at 1:46 PM, 3:11 PM, and 4:49 PM, meaning the resident was administered five times the ordered dose on three occasions. During this period, the UM and ADON expressed concern about the increased morphine dose of 1.25 ml, with the ADON instructing the UM to call hospice for clarification because the amount seemed like a lot. The UM reported she did not obtain clarification until later in the shift, and hospice documentation reflected a call at 5:10 PM questioning the order. R1 was pronounced dead at 5:53 PM that day. After the death, hospice staff raised concerns about the amount of morphine administered, reported difficulty obtaining the narcotic log, and one hospice nurse (HN2) stated she was told that the prior hospice paperwork had been shredded. The coroner and police became involved; the police retrieved the morphine, reviewed medications, and had a recorded call from the UM acknowledging that three doses had been given at five times the ordered amount. When interviewed, the DON stated that incidents to be reported to OIG would include any type of abuse and that such allegations should be brought to the Administrator, but she believed the incident was reported by police. The Administrator confirmed she did not report the allegations regarding R1 to state agencies because she knew the police were going to report the incident, even though the Medical Director acknowledged that the incident probably should have been reported. The facility’s failure, therefore, centered on not reporting the alleged violation involving potential abuse/neglect and a reasonable suspicion of a crime related to the morphine dosing error and resident death, despite clear internal policy requiring timely reporting to state agencies and, when applicable, to law enforcement. The report documents that the facility relied on law enforcement to make any required report instead of submitting its own report to the state agencies. This omission occurred in the context of conflicting morphine orders, administration of doses higher than intended based on the actual concentration, concerns raised by hospice staff and facility leadership, and subsequent involvement of the coroner and police.
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