Bourbon Heights Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Paris, Kentucky.
- Location
- 2000 South Main Street, Paris, Kentucky 40361
- CMS Provider Number
- 185283
- Inspections on file
- 20
- Latest survey
- November 22, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Bourbon Heights Nursing Home during CMS and state inspections, most recent first.
The facility failed to maintain an effective QAPI Program, leading to a deficiency in infection prevention and control related to legionellosis. Despite submitting a plan of correction, the facility did not complete necessary actions like a Water Infection Control Risk Assessment and Water Management Plan. Legionella pneumophila was found at uncontrolled levels, and the facility did not implement recommendations from the Division of Epidemiology and Health Planning. Staff interviews revealed a lack of communication and action, with the QAPI Committee waiting for guidance from a Certified Legionella Water Safety Expert.
The facility failed to maintain an effective infection prevention and control program, resulting in Legionella bacteria growth in the water system. Despite recommendations from health authorities, the facility did not implement necessary measures, such as proper documentation and staff training. Staff were observed not following infection control protocols, and communication with residents and families was insufficient. The facility's inadequate response led to ongoing positive Legionella test results.
The facility failed to manage Legionella bacteria growth, leading to a health deficiency. Despite receiving recommendations from the DEHP, the administration did not implement them, resulting in continued uncontrolled growth of Legionella. The IP delayed communication of these recommendations, and the facility lacked a Water Management Plan due to no contractual agreement with a Certified Legionella Water Safety Expert. This led to Immediate Jeopardy being identified.
The facility's Governing Body failed to implement infection control measures for Legionella, leading to Immediate Jeopardy. Despite receiving recommendations from health authorities, the facility did not adequately address the growth of Legionella pneumophila in the water system. The Board of Directors was not fully aware of the severity of the issue, and the Administrator did not review critical recommendations, resulting in ongoing water contamination issues.
A resident experienced an unwitnessed fall and elevated blood pressure, but the RN failed to notify the NP of these changes. The resident's condition worsened, showing lethargy and confusion, which were not documented or communicated to the physician. The family requested hospital evaluation, leading to a TIA diagnosis. The facility's policy for notifying changes in condition was not followed.
A resident with hypertension experienced a fall and subsequent symptoms of elevated blood pressure and headache, but the RN failed to follow the care plan to monitor, document, and report these changes. The resident's condition worsened the following day, leading to a hospital transfer and diagnosis of a transient ischemic attack. The facility did not update the care plan with new interventions, resulting in a deficiency.
A resident with a history of hypertension experienced an unwitnessed fall, followed by prolonged elevated blood pressure and a change in mental status. Despite these symptoms, the RN failed to notify the NP or document the changes, leading to a delay in emergency care. The resident was eventually sent to the hospital after family intervention and diagnosed with a TIA. Interviews revealed inconsistent staff training on stroke symptoms and appropriate response actions.
A facility failed to develop a baseline care plan for a newly admitted resident with Congestive Heart Failure and End Stage Renal Disease requiring hemodialysis. The resident, who had a history of falls, was admitted without a care plan addressing these needs, resulting in multiple falls and hospitalization. Staff interviews revealed confusion about responsibility for completing care plans, contributing to the deficiency.
A resident experienced a fall and was diagnosed with a TIA, but the facility failed to update her care plan to prevent future falls or accommodate her family's request for rest. This oversight led to another fall, resulting in a hip fracture. Staff interviews revealed confusion over who was responsible for updating care plans, contributing to the deficiency.
The facility failed to maintain a safe environment and provide adequate supervision for two residents, leading to falls and significant injuries. One resident fell twice, resulting in a hip fracture and a hospital admission for a transient ischemic attack. Another resident, admitted with a history of falls, was not care planned for fall prevention and fell twice, sustaining a subdural hematoma. The facility did not update care plans or follow fall prevention policies, contributing to these deficiencies.
The facility failed to ensure that licensed nurses and nursing personnel had the necessary competencies to care for residents, as agency staff reported not receiving adequate training or competency assessments. Interviews revealed that agency staff were not tracked for training compliance, and residents expressed dissatisfaction with the care provided. The Interim DON and Administrator acknowledged the challenges posed by the high percentage of agency staff, which hindered continuity of care.
The facility failed to provide showers for residents due to water contamination concerns, despite recommendations to use portable showers. Legionella bacteria were detected in one unit's shower, leading to the closure of all showers. Residents were only offered bed baths, which they found inadequate. The facility did not communicate effectively with residents and families about the situation, resulting in a deficiency in maintaining residents' rights and quality of life.
The facility failed to conduct a comprehensive assessment to address legionella contamination and did not account for the high volume of agency staffing, which comprised 68% of assignments. The incomplete Infection Control Risk Assessment and insufficient Water Management Plan were noted, while interviews revealed agency staff lacked proper training, affecting continuity of care. Residents expressed dissatisfaction, and the Interim DON and Administrator acknowledged these issues to the board.
The facility failed to ensure adequate staff were trained and certified in CPR, with eight nurses having expired certifications, including two LPNs working as charge nurses. Interviews revealed confusion over responsibility for tracking certifications, with the IP Nurse later assigned this duty. The Interim Administrator expected all nurses to maintain active CPR certifications for resident safety.
The facility failed to ensure residents received food at safe and appetizing temperatures, as multiple residents reported receiving cold meals. Observations showed significant temperature drops from the steam table to the point of service, with conflicting documentation on acceptable temperature ranges. The Dietary Manager and Interim Director of Nursing were unaware of the ongoing complaints, highlighting a need for consistent policy and practice.
A resident did not receive required Medicare non-coverage notices, leading to a failure in informing them of service termination and appeal rights. The facility's Admissions Coordinator was not informed due to a lack of communication, and the Interim Administrator was unfamiliar with the notification process.
A facility failed to provide appropriate dialysis care for a resident with End Stage Renal Disease, lacking ongoing assessments and communication with the dialysis facility. Documentation showed inconsistencies in monitoring the resident's condition, and staff reported insufficient training. The facility's policy required pre and post dialysis assessments, but these were not consistently documented, leading to a deficiency in care.
The facility failed to label opened medications in accordance with professional standards, as observed in one medication cart containing undated medications like Flonase inhalers and nasal sprays. Interviews revealed staff were unaware of the policy requiring opened medications to be dated, despite expectations set by the Interim DON and Administrator.
The facility failed to implement recommended infection control measures for legionella, leading to continued use of potentially contaminated water for hygiene and drinking purposes. Staff were unaware of the water contamination, and residents were not provided with bottled water, despite recommendations from the Local Health Department.
The facility failed to prevent resident-to-resident abuse, as evidenced by multiple incidents where residents struck each other. Despite having policies and interventions in place, the facility did not effectively prevent these altercations, highlighting a deficiency in ensuring residents were free from abuse.
A resident with severe cognitive impairment reported sexual abuse to staff on two separate occasions. The first report was not taken seriously and not reported to administration, while the second report was delayed, violating the facility's policy of immediate reporting within two hours. The delay in reporting hindered the investigation and notification of required agencies.
Failure in Infection Control and Water Management
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) Program, which led to a deficiency in infection prevention and control. The deficiency was evidenced by the facility's inability to establish and maintain an infection prevention and control program (IPCP) to prevent and control the development and transmission of communicable diseases. Specifically, the facility was cited for infection control related to legionellosis and their water management system. Despite submitting a plan of correction to address the deficiency, the facility did not follow through with the necessary actions, such as completing a Water Infection Control Risk Assessment (WICRA) and developing a Water Management Plan (WMP). The facility's failure to implement the plan of correction resulted in the identification of Legionella pneumophila SG1 and SG2-15 at uncontrolled growth levels in the Unit 3 shower, leading to the cessation of showers for all residents. The Division of Epidemiology and Health Planning (DEHP) provided recommendations to mitigate the spread of legionellosis, but the facility did not implement these recommendations. The QAPI Committee meetings lacked documentation supporting the development or implementation of a plan of correction when the facility's water quality did not meet appropriate parameters according to third-party testing results. Interviews with facility staff revealed a lack of communication and action regarding the DEHP's recommendations and the development of a WMP. The Infection Preventionist (IP) and other QAPI Committee members were aware of the recommendations but were waiting for guidance from a Certified Legionella Water Safety Expert (CLWSE) and the local health department. The former Director of Nursing (DON) and Administrator indicated that the QAPI Committee was waiting for the CLWSE to write the WMP and follow up on the DEHP recommendations, leading to delays in addressing the water contamination issue.
Removal Plan
- Review of the IJ Removal Plan
- Approval and submission of the WICRA to the LHD
- Adoption of the WMP
- Compliance monitoring
- Completion of the CDC Prevent LD online course by required staff
- Updates to the WICRA
- Discussion of the WMP
- Infection surveillance for LD
Inadequate Infection Control and Legionella Management
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, leading to the development and transmission of Legionella bacteria within the water system. The facility's water management plan was insufficient, as evidenced by the presence of Legionella pneumophila at uncontrolled growth levels in various units and rooms. Despite receiving recommendations from the Division of Epidemiology and Health Planning (DEHP) and the Local Health Department (LHD), the facility did not implement the necessary measures to control the outbreak, such as proper documentation of water management procedures and ensuring all staff completed the required training. The facility's staff were observed providing care without adhering to proper infection control protocols, such as hand sanitizing and following Enhanced Barrier Precautions. Additionally, there were failures in labeling and storing feeding tubes and handling clean laundry. The facility did not provide adequate bottled water for residents' daily hygiene needs, and staff continued to use potentially contaminated water from faucets for handwashing and oral care. Communication with residents and their families regarding the water contamination was also lacking, leading to confusion and concern among family members. Interviews with staff and family members revealed a lack of transparency and understanding of the situation. Staff were not adequately trained on the infection prevention and control program, and there was no consistent documentation of water flushing procedures. The facility's Director of Maintenance admitted to not having formal training on proper water line flushing, and there was no evidence of a comprehensive water management plan being developed or implemented. The facility's inaction and inadequate response to the Legionella outbreak resulted in ongoing positive test results and a failure to ensure a safe environment for residents and staff.
Removal Plan
- The facility provided an acceptable Immediate Jeopardy Removal Plan, alleging removal of the IJ.
- The State Survey Agency determined the IJ had been removed, with remaining non-compliance at a S/S of an F while the facility develops and implements a Plan of Correction and the facility's Quality Assurance monitors to ensure compliance with systemic changes.
Failure to Implement Legionella Control Measures
Penalty
Summary
The facility failed to effectively manage its resources to prevent and control the growth of Legionella bacteria, leading to a health deficiency. On 05/28/2024, uncontrolled growth levels of Legionella pneumophila Serogroup 1 and Serogroup 2 were identified in the Unit 3 shower. Despite receiving recommendations from the Division of Epidemiology and Health Planning (DEHP) on 07/26/2024 to prevent future outbreaks, the facility's administration did not review or implement these recommendations. Test results continued to show uncontrolled growth of Legionella bacteria in other areas of the facility through 09/18/2024. The facility's administration, including the Administrator and Director of Nursing Services (DON), were informed of the DEHP's findings and recommendations via an email from the Local Health Department (LHD) on 08/05/2024. However, the Infection Preventionist (IP) delayed communicating these recommendations to facility providers until 08/20/2024. The DON and Administrator were unaware of the DEHP's preliminary findings until the State Survey Agency (SSA) Representative brought them to their attention. The facility had not completed or submitted the Water Infection Control Risk Assessment (WICRA) form to the LHD, and the Water Management Plan (WMP) was not developed due to a lack of contractual agreement with a Certified Legionella Water Safety Expert (CLWSE). Interviews with facility staff revealed a lack of communication and responsibility in addressing the Legionella issue. The Interim DON stated that the IP was responsible for implementing infection control guidelines, but the IP did not document enhanced surveillance of possible new Legionella cases. The Administrator assumed the CLWSE was working pro bono to help the facility, but no contractual agreement was established until 10/04/2024. The facility's failure to act on the DEHP's recommendations and effectively manage its water system led to the identification of Immediate Jeopardy on 10/11/2024, which was determined to have existed since 08/05/2024.
Failure to Implement Infection Control Measures for Legionella
Penalty
Summary
The facility's Governing Body failed to ensure the implementation of policies regarding the management and operation of the facility, specifically in the area of infection control. Immediate Jeopardy was identified due to the facility's failure to control the growth of Legionella pneumophila in the water system, particularly in Unit 3's shower. Despite receiving recommendations from the Division of Epidemiology and Health Planning (DEHP) and the Local Health Department (LHD), the facility did not effectively implement these recommendations to prevent and control legionellosis. The facility's Infection Preventionist (IP), Director of Nursing (DON), and Administrator were informed of the DEHP's recommendations via an email from the LHD. However, the facility did not act on these recommendations, which included developing a comprehensive Water Management Plan (WMP) and conducting adequate water sampling. The facility's water system continued to show detectable levels of legionella, and the necessary elements of a proper WMP were not documented. The facility's Board of Directors (BOD) was not fully aware of the severity of the problem or the specific recommendations from the DEHP until later. Interviews with various stakeholders, including family members, the LHD Director, and the Certified Legionella Water Safety Expert (CLWSE), revealed ongoing issues with water contamination and inadequate response measures. The facility's Administrator and BOD were criticized for not implementing timely water management infection control measures. The Administrator admitted to not reviewing the email attachment containing the DEHP's recommendations, and the BOD was not fully informed of the situation until after receiving a citation from the State Survey Agency.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in the resident's physical status. A resident, identified as R76, experienced an unwitnessed fall and sustained elevated blood pressure readings. Despite these changes, the registered nurse (RN2) did not inform the nurse practitioner (NP) of the continued elevated blood pressure. The resident's condition worsened the following day, with symptoms including lethargy, confusion, and incoherent speech, yet these changes were not documented or communicated to the physician or NP. The resident's family expressed concerns about the resident's condition, prompting RN2 to contact the physician, who then ordered the resident's transfer to the hospital. The resident was diagnosed with a transient ischemic attack (TIA) at the hospital. Interviews with the family, RN2, the Director of Nursing (DON), and the nurse practitioner revealed that the facility's protocol for notifying changes in a resident's condition was not followed. The facility's policy required notifying the physician of any accidents or deterioration in a resident's condition. However, RN2 did not adhere to this policy, failing to communicate the resident's elevated blood pressure and mental status changes. The DON and NP both indicated that the nurse should have sent the resident to the hospital for evaluation due to these changes, highlighting a lapse in following the facility's procedures for ensuring resident safety.
Failure to Implement and Update Care Plan Following Resident's Change in Condition
Penalty
Summary
The facility failed to implement an effective system to ensure that a resident's Comprehensive Care Plan (CCP) interventions were followed when a change in condition occurred. Resident 76, who had a history of hypertension, experienced an unwitnessed fall and subsequently showed signs of elevated blood pressure and a headache. Despite these symptoms, the Registered Nurse (RN) on duty did not adhere to the care plan's directives to monitor, document, and report these changes to the medical provider. On the day following the fall, the resident continued to exhibit elevated blood pressure and a change in mental status, including lethargy and incoherent speech. However, the RN again failed to document these changes or notify the medical provider as required by the care plan. It was only at the family's request that the physician was notified, leading to the resident's transfer to the hospital, where they were diagnosed with a transient ischemic attack. Interviews with facility staff, including the MDS Nurse and the former Director of Nursing (DON), revealed that the resident's care plan was not updated with new interventions following the fall. The facility's policies required that care plans be revised to ensure resident-centered care and safety, but this was not done. The failure to implement and update the care plan as needed resulted in a deficiency under 42 CFR S483.21, Comprehensive Resident Centered Care Plan, F-656, with a Scope and Severity of a J.
Failure to Identify and Intervene in Resident's Change of Condition
Penalty
Summary
The facility failed to promptly identify and intervene for a change in a resident's condition, leading to a deficiency in providing appropriate treatment and care. A resident, who had a history of essential hypertension, metabolic encephalopathy, and general anxiety disorder, experienced an unwitnessed fall. Following the fall, the resident's blood pressure remained elevated, with systolic readings consistently between 180 and 190. Despite these elevated readings, the registered nurse (RN) on duty did not notify the nurse practitioner (NP) about the resident's condition, nor were any additional orders given beyond continued monitoring. The following day, the resident's blood pressure remained elevated, and the resident began exhibiting a change in mental status, including lethargy and incoherent speech. However, these findings were not documented, and the physician was not notified of the resident's change in condition. It was only after the resident's family expressed concern and requested hospital evaluation that the resident was sent to the hospital, where they were diagnosed with a transient ischemic attack (TIA). Interviews with staff revealed a lack of consistent training and understanding of the signs and symptoms of a stroke, as well as the appropriate actions to take in such situations. The facility's failure to ensure timely notification and intervention for the resident's elevated blood pressure and change in mental status resulted in a deficiency under 42 CFR S483.25 Quality of Care, F684, with a scope and severity of a J, indicating Immediate Jeopardy.
Failure to Implement Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a newly admitted resident, identified as R425, which is necessary to provide effective and person-centered care. R425 was admitted with diagnoses including Congestive Heart Failure and End Stage Renal Disease requiring hemodialysis. Despite these significant medical needs, the facility did not create a baseline care plan upon admission to address the resident's hemodialysis requirements and known risk for falls. This omission was identified during a review of the resident's electronic health record, which lacked documentation of an admission assessment and baseline care plan. R425 had a history of falls, including a recent fall prior to admission, and was assessed to be at high risk for falls with a Fall Risk Score of 18.0. Despite this, the baseline care plan addressing fall risk was only developed three days after admission. During this period, R425 experienced multiple falls, one of which resulted in a subdural hematoma and required hospitalization. The facility's failure to implement a timely baseline care plan contributed to these incidents, as the staff lacked guidance on managing the resident's fall risk and hemodialysis needs. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for completing baseline care plans. The MDS Nurse and other nursing staff acknowledged the importance of these plans but admitted to not completing one for R425 upon admission. The Interim DON and Administrator confirmed that baseline care plans were expected to be completed promptly to ensure resident safety, yet this expectation was not met in R425's case, leading to the identified deficiency.
Failure to Update Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to review and revise the comprehensive care plan (CCP) for a resident, identified as R76, following a significant change in her condition. R76 experienced a fall and was subsequently diagnosed with a transient ischemic attack (TIA) at the hospital. Upon her return to the facility, her family requested that she remain in her room to rest. However, the staff did not update the CCP to include interventions to prevent future falls or to incorporate the family's request. This oversight led to R76 sustaining another fall, resulting in a hip fracture. The facility's policy required that care plans be reviewed and revised as necessary to reflect any changes in a resident's care needs. Despite this, R76's CCP was not updated after her initial fall and hospitalization. Interviews with staff revealed a lack of clarity regarding who was responsible for updating care plans, with some staff believing only the MDS Nurse had access to make changes. This miscommunication contributed to the failure to implement necessary interventions for R76's safety. The deficiency was further compounded by the facility's failure to adhere to its own policies regarding care plan updates. The MDS Nurse and other staff members acknowledged that the CCP should have been revised to include new interventions following R76's fall and hospitalization. The lack of timely updates to the care plan resulted in inadequate monitoring and care for R76, ultimately leading to her second fall and subsequent decline in health.
Failure to Prevent Falls and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for Resident 76, who experienced two falls resulting in significant injuries. Initially, the resident fell while ambulating from the bathroom to the bed, leading to a hospital admission for a transient ischemic attack. Upon returning to the facility, the resident was taken to an activity against the family's request for rest, left unsupervised, and subsequently fell from a wheelchair, sustaining a hip fracture. The facility did not update the resident's care plan with new interventions after the first fall, and incident reports for the falls were missing. Another resident, Resident 425, was admitted to the facility with a history of falls and was not care planned for fall prevention upon admission. The resident fell twice shortly after admission, sustaining a subdural hematoma and an abrasion. The facility's baseline care plan for the resident was not implemented in a timely manner, and the original care plan could not be located. Interviews with staff revealed a lack of adherence to the facility's fall prevention policies. The facility's policies required fall risk assessments and care plans to be implemented based on residents' fall risks. However, these protocols were not followed for both residents, leading to preventable accidents and injuries. The facility's failure to maintain a safe environment and provide adequate supervision and assistive devices contributed to the deficiencies identified in the report.
Deficiency in Staff Competency and Training
Penalty
Summary
The facility failed to ensure that licensed nurses and other nursing personnel had the necessary knowledge, competencies, and skill sets to provide care and respond to each resident's individualized needs as identified in their assessments and care plans. Agency staff reported not receiving training or education prior to being assigned to residents' care. The facility's policy on resident rights emphasized the need for reasonable accommodation of resident needs and preferences, but the facility assessment tool did not account for agency staffing in terms of training, assessment, and competency. Interviews with various staff members, including the Schedule Coordinator and agency nurses, revealed significant gaps in training and competency assessments for agency staff. The Schedule Coordinator mentioned that agency staff were not allowed to provide care if their online training was not current, but there was no tracking of agency staff competencies by the facility. Agency staff were reportedly trained by their agencies through computerized programs, but upon arrival at the facility, they did not receive additional training or competency assessments. Several agency nurses and aides expressed concerns about not receiving any training or skills check-offs from the facility, and some felt overwhelmed due to the lack of familiarity with residents' needs and preferences. Residents also expressed dissatisfaction with the care provided by agency staff, noting that they had to instruct the staff on what to do. The Interim DON and Interim Administrator acknowledged the challenges posed by the high percentage of agency staff, which accounted for 68% of the facility's staffing. They noted that this reliance on agency staff hindered continuity of care and presented issues with ensuring that residents consistently knew who would be taking care of them. The facility's board of directors was informed of these concerns, highlighting the significant staffing issues and the impact on resident care.
Failure to Provide Showers Due to Water Contamination
Penalty
Summary
The facility failed to treat residents with respect and dignity by not providing showers for an extended period due to water contamination concerns. Legionella bacteria were detected in the Unit 2 shower, leading to the closure of all showers in the facility. Despite recommendations from an independent water systems company and a certified water safety expert to use portable showers, the facility declined to implement this temporary solution. The facility also did not reopen the showers on Units 1 and 3, which tested negative for legionella, until a month later, leaving residents without access to showers and only offering bed baths. Interviews with residents and their families revealed dissatisfaction and a lack of communication from the facility regarding the water contamination issue. Residents expressed that bed baths did not make them feel completely clean, and families were not informed about the situation until they inquired directly. The facility's policies stated that residents had the right to a dignified existence and to receive care in an environment that promoted their quality of life, which was not upheld in this situation. Staff interviews indicated confusion and a lack of clear communication regarding the use of showers. The facility's Infection Preventionist and Director of Nursing were unsure why showers on Units 1 and 3 were not used despite being safe. The facility awaited confirmation from the Local Health Department and other authorities, but the decision to keep showers closed was ultimately the facility's responsibility. The failure to provide adequate bathing facilities and communicate effectively with residents and families led to a deficiency in maintaining residents' rights and quality of life.
Deficiencies in Facility Assessment and Agency Staffing
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for addressing ongoing legionella bacterial contamination in its water system. The Infection Control Risk Assessment section of the Facility Assessment Tool was incomplete, and the facility leadership did not address or include legionella when it was first discovered. The facility's Water Management Plan was deemed insufficient by the State's Division of Epidemiology and Health Planning, and the facility did not update its assessment to reflect the ongoing issues with legionella contamination. Additionally, the facility did not account for the high volume of agency staffing in its assessment, which was crucial for evaluating the resident population and identifying essential resources for care provision. Agency staffing comprised 68% of the facility's 24-hour staffing assignments, yet the assessment only addressed direct care providers such as RNs, LPNs, and SRNAs. Interviews revealed that agency staff often lacked proper training and orientation, leading to concerns about continuity of care and familiarity with residents' needs and preferences. Interviews with facility staff, including the Interim DON and Interim Administrator, highlighted the lack of systems in place to ensure proper administration and the challenges posed by the reliance on agency staff. Residents expressed dissatisfaction with the care provided by agency staff, noting that they often had to instruct them on their needs. The Interim DON and Administrator acknowledged the issues with agency staffing and presented their concerns to the facility's board of directors, emphasizing the need for continuity of care for residents.
Deficiency in CPR Certification Management
Penalty
Summary
The facility failed to ensure that an adequate number of staff were properly trained and certified in Cardiopulmonary Resuscitation (CPR) for Healthcare Providers, which is essential for providing basic life support until emergency medical services arrive. The review of the facility's policy revealed that all licensed nurses and Kentucky Medication Aides (KMAs) were required to obtain a Basic Life Support (BLS) CPR certification from an accredited licensing agency. However, it was found that eight nurses had expired CPR certifications, including two Licensed Practical Nurses (LPNs) who were working as charge nurses on a specific date. Interviews with various staff members, including a Registered Nurse (RN), the Infection Preventionist (IP) Nurse, and the Quality Assurance (QA) Nurse, highlighted a lack of clarity and responsibility regarding the tracking and renewal of CPR certifications. The IP Nurse, who provided CPR classes, stated it was not her duty to monitor certification expirations. The Scheduler/Staff Coordinator assumed the IP Nurse was responsible for full-time staff certifications, while she managed agency staff certifications. The Interim Director of Nursing (DON) later confirmed that the IP Nurse would now be responsible for tracking CPR certifications and expiration dates. The Interim Administrator expressed the expectation that all nurses maintain active CPR certifications for resident safety.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that residents received food and drinks at a palatable, attractive, and safe temperature. This deficiency was identified for five of nine sampled residents. During a resident council meeting, multiple residents expressed concerns about their food being served cold. Observations during a lunch meal revealed that the beef and noodle entree and vegetable medley were not at an appetizing and acceptable temperature. The facility's policy indicated that hot foods should be served at temperatures over 140 degrees Fahrenheit, but conflicting documentation showed varying acceptable temperature ranges. The issue was further highlighted during a Resident Group meeting where several residents complained about consistently receiving cold food. Observations of the food service process showed significant temperature drops from the steam table to the point of service. For instance, the beef entree, initially at 192 degrees Fahrenheit, was served at 125 degrees Fahrenheit. The Dietary Manager acknowledged the temperature drop but was uncertain about the cause, suggesting that frequent opening and closing of the food cart might be a factor. Interviews with the Dietary Manager and Interim Director of Nursing revealed a lack of awareness and consistency in addressing the residents' complaints. The Dietary Manager mentioned that the concerns were reported to the dietician, who did not note any issues with food temperatures. The Interim Director of Nursing and Interim Administrator, both new to the facility, were unaware of the ongoing complaints. The report highlighted the need for consistent policy and practice to ensure food is served at acceptable temperatures to meet residents' satisfaction.
Failure to Notify Resident of Medicare Coverage Changes
Penalty
Summary
The facility failed to notify a resident of changes to services covered by Medicare and/or Medicaid in a timely manner. Specifically, one resident, identified as R38, did not receive the required documentation, including the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) and the Notice of Medicare Non-Coverage (NOMNC). This oversight occurred despite the resident receiving therapeutic services under Medicare Part A, with the last covered day being 10/25/2024. The facility's documentation did not show evidence that these forms were issued to the resident or their representative, which is necessary for informing them of the end date of services and their right to appeal. Interviews with facility staff revealed a breakdown in communication and process. The Admissions Coordinator (AC) was not informed or included in the notification process, as she did not receive the necessary email alerts. The Interim Director of Nursing (DON) and Interim Administrator both acknowledged the importance of these forms for ensuring residents or their families are aware of service terminations and can appeal if needed. However, the Interim Administrator, who was new to the facility, was not familiar with the existing process for beneficiary notification, indicating a lack of established procedures or training for staff involved in this process.
Deficiency in Dialysis Care and Communication
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident, identified as R425, who required such services. The deficiency was identified through interviews, record reviews, and policy reviews, revealing that the facility did not conduct ongoing assessments of R425's condition and failed to monitor for complications before and after dialysis treatments. Additionally, there was a lack of documented evidence of communication and collaboration with the dialysis facility regarding R425's care and services. R425 was admitted to the facility with diagnoses including Congestive Heart Failure and End Stage Renal Disease requiring Hemodialysis. The facility's policy required pre and post dialysis assessments, including monitoring the thrill and bruit of the dialysis shunt/fistula. However, the facility's documentation showed only four dialysis communication forms, with no evidence of post dialysis assessments. The resident's care plan included interventions for checking the arteriovenous fistula, but there was no consistent documentation of these assessments. Interviews with facility staff, including LPNs, RNs, and the MDS Nurse, revealed inconsistencies in completing dialysis communication forms and reassessments. Staff reported a lack of training provided by the facility, and the QA Nurse admitted to not providing education or training to staff. The Interim Director of Nursing and Interim Administrator acknowledged the lack of communication between the dialysis clinics and the facility and stated that a new process was being developed to address these issues.
Failure to Label Opened Medications
Penalty
Summary
The facility failed to ensure that all drugs used were labeled in accordance with professional standards. During an observation, it was found that one of the four medication carts contained opened and undated medications, including Flonase inhalers, Ipratropium Bromide nasal spray, Milk of Magnesia, Geri-Tussin, Keppra, and Guaifenosorb. The facility's policy required that once a medication package is opened, the date should be recorded on the primary medication container to adhere to manufacturer guidelines regarding expiration dates. Interviews with staff revealed a lack of awareness and adherence to the facility's medication labeling policy. A Kentucky Medication Aide was unaware that medication containers needed to be dated. An LPN acknowledged that medications should be dated when opened to prevent usage past expiration, and any undated opened medication should be discarded and reordered. The Interim DON and Administrator both stated that it was their expectation for staff to date opened medications to ensure resident safety, indicating a gap between policy and practice among staff members.
Failure to Implement Infection Control Measures for Legionella
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, leading to the development and transmission of communicable diseases and infections. Specifically, the facility did not implement the state's Division of Epidemiology and Health Planning's recommendation to use faucet filters or bottled water to prevent the spread of a water-borne infection with legionella. Staff interviews revealed that they were unaware of water contamination concerns and continued to use the sink faucets in residents' rooms for brushing teeth, hygiene, drinking water, and hand hygiene for staff. The facility's Infection Preventionist (IP) was informed by the Local Health Department (LHD) about a PRN employee diagnosed with Legionnaires' Disease. Despite this, the facility only provided bed baths instead of showers and did not take further recommended actions such as installing faucet filters or providing bottled water. The IP communicated the recommendations to the Administrator, but no immediate action was taken. Staff continued to use potentially contaminated water for various hygiene purposes, and residents were not provided with bottled water. Interviews with staff, including State Registered Nurse Aides (SRNAs) and the Director of Maintenance (DOM), revealed concerns about water quality and a lack of communication from the administration regarding the water contamination. The facility's Director of Nursing (DON) and Administrator were aware of the legionella presence but did not inform staff, residents, or families about the water issue. The facility's failure to follow the health department's recommendations and properly manage the water contamination led to a serious risk of infection for residents and staff.
Removal Plan
- The facility's Administrator, Director of Nursing (DON), Infection Preventionist (IP), and Plant Maintenance Director (PMD) participated in a conference call with representatives from the state's Department of Public Health (DPH), Division of Epidemiology and Health Planning's (DEHP), Local Health Department (LHD), and the independent water systems company to determine an appropriate plan to move forward.
- An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the Medical Director, the Administrator, and the DON to discuss the findings and plan for removal of the Immediate Jeopardy. The Quality Assurance Performance Improvement (QAPI) Committee would meet monthly to review compliance and adjust as deemed necessary by the QAPI Committee to maintain compliance for recommendations and further follow-up regarding the plan of correction.
- The DON, IP, and the Minimum Data Set (MDS) Nurse would educate staff on Legionnaires' Disease. Staff must complete all education and post-testing before being allowed to work. The DON, IP, and MDS Nurse would educate agency staff before they worked assigned shifts. A post-test was given, requiring a minimum score of 100 percent. Those who did not receive a score of 100 percent were re-educated and tested again until they achieved a score of 100 percent. Any staff members not receiving education would be provided with the education before working their next shift. The DON was responsible for tracking all education to ensure all facility and agency staff were educated before working.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse, as evidenced by multiple incidents involving resident-to-resident physical altercations. On 06/04/2023, a staff member witnessed Resident 3 strike Resident 4 on the right side while shouting, 'I told you to move.' Both residents were seated in their wheelchairs in the hallway outside their shared room. Despite the facility's policy prohibiting physical abuse, the incident report and subsequent psychiatric consult revealed that Resident 3 had severe cognitive impairment and had been treated for a urinary tract infection, which may have contributed to the behavior. The facility's interventions included separating the residents and placing them on 15-minute checks, but the incident highlighted a failure to prevent the altercation initially. On 09/05/2023, Resident 4 struck Resident 5 on the cheek while they were conversing in the lobby. The receptionist witnessed the incident and reported that the residents were laughing and getting along before the altercation. Both residents were placed on 15-minute checks, and a psychiatric consult was conducted for Resident 5, who had moderate cognitive impairment. The facility's care plan for Resident 4 included monitoring for behavior changes and psychiatric services, but the incident indicated a lapse in preventing resident-to-resident abuse. On 10/24/2023, Resident 6 struck Resident 3 on the neck while trying to enter their shared room. A staff member witnessed the incident and reported that Resident 6 wanted to go into the room, but Resident 3 was in the way. Both residents were separated, and neither sustained injuries. Resident 6, who had severe cognitive impairment, was placed on behavior monitoring and received a psychiatric consult. Despite these measures, the facility's failure to prevent the altercation demonstrated a deficiency in ensuring residents were free from abuse.
Failure to Immediately Report Alleged Abuse
Penalty
Summary
The facility failed to immediately report an alleged incident of sexual abuse involving a resident with severe cognitive impairment. The resident, who had diagnoses including dementia and cerebral atherosclerosis, reported the abuse to staff on two separate occasions. The first report was made on 03/19/2024 at 2:48 AM to an SRNA, who then informed an LPN. The LPN did not report the incident to the administration, believing the resident was confused. The second report was made on 03/20/2024 at 1:15 PM to another SRNA, who then informed another LPN. This time, the incident was reported to the Director of Nursing (DON) and other relevant personnel at 2:00 PM, and subsequently to the State Survey Agency (SSA) at 4:29 PM, well beyond the required two-hour reporting window. Interviews with staff revealed that the initial report of abuse was not taken seriously due to the resident's cognitive impairment and confusion. The LPN who received the first report did not follow the facility's policy of immediate reporting, which mandates that any alleged abuse be reported to the administration within two hours. The second report was handled more appropriately, but still did not meet the immediate reporting requirement. The facility's policy, dated 11/2016, clearly states that all alleged violations involving abuse must be reported immediately to the Administrator or designee, who would then notify the appropriate state agencies. The delay in reporting was confirmed through interviews with various staff members, including the DON, SSD, and the Administrator. The DON emphasized the importance of immediate reporting for evidence preservation, while the Administrator acknowledged that delays in reporting hinder the activation of investigations and notification of required agencies. The facility's failure to adhere to its own policy and regulatory requirements resulted in a significant delay in addressing the resident's allegations of abuse, potentially compromising the investigation and any subsequent actions.
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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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