Glenview Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Glasgow, Kentucky.
- Location
- 1002 Glenview Drive, Glasgow, Kentucky 42141
- CMS Provider Number
- 185271
- Inspections on file
- 20
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Glenview Health And Rehabilitation during CMS and state inspections, most recent first.
Two residents alleged that a male CNA physically abused them on separate occasions, including being pushed from a wheelchair to the bathroom floor and being struck in the eye, resulting in pain and bruising. Multiple CNAs, LPNs, and a former social services director reported hearing or witnessing concerning interactions, screams, and subsequent bruising, and several staff stated they informed supervisory or administrative staff. Despite a written policy requiring immediate reporting of all abuse allegations to the Administrator and state agencies and completion of an investigation with results reported within five working days, the DON and Administrator stated they were never informed of these allegations, and staff interviews indicated the incidents were not reported to state agencies or properly investigated.
The facility failed to follow its abuse policy requiring immediate, thorough investigation of alleged abuse for two residents. One resident with severe cognitive impairment and behavioral issues later reported that a male CNA pushed him from his wheelchair to the bathroom floor and bent his arm, causing hand and wrist pain, while staff accounts described the CNA threatening and placing the resident on the floor and multiple staff hearing and discussing the allegation without evidence of a documented abuse investigation. Another resident with Alzheimer’s disease and moderate cognitive impairment developed a black eye and reported that a male CNA hit her in the eye; several CNAs and an LPN stated the resident accused the CNA, observed the emerging bruise, and believed the matter had been reported, while explanations were given that the resident had been rubbing or scratching her eye, yet progress notes and skin assessments did not document the injury and staff reported that no proper abuse investigation was conducted or documented as required.
The facility did not consistently implement or develop comprehensive care plans for several residents requiring orthotic devices, resulting in splints and braces not being applied as ordered and necessary interventions, such as range of motion exercises, being omitted. Additionally, a resident with a history of falls did not have the required brightly colored tape applied to the call light as specified in the care plan. Staff interviews revealed confusion about responsibilities and a lack of policy guidance, contributing to the deficiencies.
A resident with hypertension, Alzheimer's disease, and chronic kidney disease was given Lisinopril multiple times by a CMT despite physician orders to hold the medication if systolic blood pressure was below 150 mm Hg. The CMT and other staff misunderstood the hold parameters, resulting in repeated administration of the medication outside the prescribed guidelines, as confirmed by MAR review and staff interviews.
Three residents with orders for hand splints and ROM did not consistently receive these interventions as prescribed, with splints often left unused and staff unclear about responsibilities for application and documentation. The facility lacked policies for splinting and restorative nursing, and staff interviews revealed confusion and inconsistent practices regarding the provision of care for residents with contractures.
The facility did not ensure that three residents with limited ROM received consistent application of prescribed hand splints or appropriate ROM services. For example, a resident with hemiplegia did not have her splint applied for months, another with contractures had her splint left unused on the bedside table, and a third with dementia was not wearing her splint as ordered. Staff interviews revealed confusion about responsibilities and a lack of a restorative nursing program or clear policy for splint use and ROM care.
The facility did not ensure that call light systems were accessible in all resident bathrooms and bathing areas, with observations showing that cords were only available near toilets and not within reach of showers, and some restrooms lacked functioning call systems entirely. A resident reported concerns about being unable to call for help if a fall occurred in the shower, and staff interviews confirmed that workarounds were used due to the lack of accessible call lights.
The facility failed to include residents and/or their representatives in the care planning process, affecting five residents with varying cognitive impairments. There was no documentation of care conference invitations or explanations for non-participation, as confirmed by interviews and record reviews.
The facility failed to properly label, store, and secure medications, including leaving medication carts unlocked and unattended, not discarding expired medications, and not maintaining proper temperature logs for medication storage. Staff interviews confirmed awareness of these requirements but cited distractions and other duties as reasons for the oversight.
The facility failed to provide food at a palatable temperature and with adequate seasoning, affecting several residents. Observations and interviews revealed that hot foods were served below acceptable temperatures, cold foods were too warm, and the food was often bland. Multiple grievances were filed, but the responses did not address the core issue of food temperature for room service meals.
A facility failed to maintain an infection prevention and control program during wound care for a resident with peripheral vascular disease and skin breakdown. An LPN did not use a barrier for wound supplies, failed to change gloves, and did not perform hand hygiene as required. The Interim DON confirmed the nurse did not follow proper infection control procedures.
Failure to Report Alleged Physical Abuse to State Agencies
Penalty
Summary
The deficiency involves the facility’s failure to report allegations of abuse to state agencies as required by its own policy and federal regulations for two sampled residents. The facility’s abuse policy, reviewed in June 2025, required all alleged violations to be reported immediately, but no later than two hours after the allegation is made when abuse or serious bodily injury is involved, and to report investigation results to the appropriate state agency within five working days. Despite this, multiple staff interviews and record reviews showed that serious allegations involving two residents were not reported to the Administrator or state agencies, and in at least one case staff believed the incident was not investigated. For one resident with severe cognitive impairment, dementia with behavioral disturbance, bipolar disorder, and other conditions, records showed an event report dated mid‑June 2025 describing the resident being "assisted to floor due to behaviors" in the bathroom with no injuries noted. Progress notes over the next days documented complaints of right hand and wrist pain, an x‑ray, and a bruise on the right index finger attributed to a recent fall. In a later interview, the resident stated that a male staff member pushed him out of his wheelchair onto the bathroom floor, bent his arm back, and hurt his hand and wrist, and that he told multiple nurses about the incident. One LPN reported hearing that the resident threw himself on the floor, that a CNA refused to pick him up and told him to get up on his own, and that the resident hurt his hand; this LPN stated she did not think the incident was ever investigated, although she believed the DON and Administrator knew about it. A CNA who was orienting at the time reported witnessing the CNA screaming at the resident, threatening to put him on the floor, and then putting him on the bathroom floor, and stated she reported this to the DON. The former social services director stated the resident told her that the CNA put him on the floor and threw him in bed, hurting his wrist, and that she informed the DON and Administrator. For another resident with Alzheimer’s disease, hearing loss, and a history of falls, documentation from August through October 2025 contained no record of eye bruising. However, multiple staff and the resident described an incident in which the resident had a black eye and alleged that a male CNA hit her in the eye. One CNA stated that the resident told her and another CNA that the CNA had hit her eye, and that dayshift staff said it had been reported to the DON and Administrator; she also stated HR told her to stay out of it. The resident reported that a black male staff member hit her left eye with the back of his hand, causing a large bruise, and that no one later questioned her about it. An LPN reported hearing a scream, seeing the CNA in the hallway, then finding the resident screaming that the CNA hit her in the eye, with bruising beginning; she stated the DON instructed her to chart that the bruising was from the resident rubbing her eye, which she refused to do, and that the incident was not investigated or reported as abuse. Other staff, including another CNA and the former social services director, recalled the resident having a black eye and stating that the CNA hit her, but were told by leadership that the resident had been rubbing or scratching her eye. The current DON and Administrator both stated in interviews that they were never informed of the abuse allegations involving these two residents, despite the facility policy requiring immediate reporting of all alleged abuse and the Administrator’s role as abuse coordinator. The combined record review and interviews demonstrate that, although multiple staff and both residents described events they believed to be physical abuse by the same CNA, these allegations were not reported to the Administrator or state agencies within the required time frames, and in some instances staff believed the incidents were not investigated at all. The facility’s own policy required immediate reporting of all alleged violations, including to state agencies, and mandated that investigation results be reported within five working days, but there was no evidence that the allegations involving these two residents were reported as required.
Failure to Investigate Abuse Allegations for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and respond to allegations of abuse for two residents, despite having a policy requiring immediate and comprehensive investigations of suspected or reported abuse, neglect, or exploitation. The facility’s abuse policy, reviewed in June 2025, required immediate investigation upon suspicion or report of abuse, including identifying and interviewing all involved persons (alleged victim, alleged perpetrator, witnesses, and others with knowledge) and providing complete documentation of the investigation. Interviews and record review showed that these steps were not carried out as required for the allegations involving two residents. For one resident with severe cognitive impairment, dementia with behavioral disturbance, and a BIMS score of 1, the record showed an event report dated mid‑June 2025 describing the resident as being “assisted to floor due to behaviors” in the bathroom with no injuries noted. Progress notes over the next two days documented complaints of right hand and wrist pain, an x‑ray, and later a bruise on the right index finger attributed to a recent fall. In a later interview, the resident stated that a male staff member pushed him out of his wheelchair onto the bathroom floor, told him he was going to put him back in bed, and bent his arm back, hurting his hand and wrist. The resident reported telling multiple nurses and stated that the staff member no longer came into his room. Multiple staff interviews revealed that staff had heard about the incident, that it was widely discussed among staff, and that some believed it had been reported to the DON and administrator. One CNA who was orienting at the time stated she saw the CNA involved screaming at the resident, threatening to put him on the floor, and then putting him on the floor, and that she reported this to the DON. The former SSD stated the resident told her the CNA put him on the floor and threw him in bed, and that she reported this to the DON and administrator and was later told in a meeting that the resident had lowered himself to the floor. The former DON, however, stated she did not recall any abuse allegation being reported to her, and there was no documentation of a thorough abuse investigation as required by policy. For another resident with Alzheimer’s disease, moderate cognitive impairment (BIMS 9), and a history of falls and muscle weakness, interviews indicated that the resident developed a black eye for which there was no corresponding documentation of bruising or discoloration in progress notes or skin assessments from August through October 2025. A CNA reported that the resident told her and another CNA that a male CNA had hit her in the eye, and that dayshift staff said it had been reported to the DON and administrator; HR allegedly told her to stay out of it. The resident later stated that a black male staff member hit her left eye with the back of his hand on purpose, causing a large bruise, and that no one came to ask her questions about it. An LPN reported hearing a scream, seeing the CNA in the hallway, then entering the resident’s room with the DON, where the resident was screaming that the CNA had hit her eye and a bruise was starting; the LPN stated the DON told her to chart that the bruise was from the resident rubbing her eye, which she refused to do, and that the incident was not investigated. Other staff reported hearing that the resident accused the CNA of hitting her and that explanations were given that she had been rubbing or scratching her eye. The former SSD recalled the resident telling her the CNA hit her in the eye and being later told by the DON that the resident had just been rubbing her eye. The current DON and administrator both stated they were not informed of these abuse allegations and described an abuse investigation process that was not implemented in these cases, and there was no evidence of the comprehensive interviews, assessments, or documentation required by the facility’s abuse policy for these allegations.
Failure to Implement and Develop Comprehensive Care Plans for Orthotic Devices and Fall Prevention
Penalty
Summary
The facility failed to implement and develop comprehensive, person-centered care plans for several residents requiring orthotic devices and for a resident needing a specific fall prevention intervention. For four residents with orders for splints or braces, the care plans either lacked necessary interventions, such as range of motion (ROM) exercises, or the interventions listed were not carried out as specified. Observations revealed that splints and braces were not applied as ordered, and staff interviews confirmed inconsistent application and lack of awareness regarding care plan details. In some cases, splints were found unused in residents' rooms, and staff admitted to not performing required ROM prior to splint application. Additionally, the facility failed to ensure that interventions for fall prevention were implemented as documented in the care plan. One resident, who had experienced multiple falls, had a care plan intervention to apply brightly colored tape to the call light as a visual reminder to request assistance before ambulating. However, repeated observations showed that the call light did not have the required colored tape, and staff interviews confirmed that the intervention was not in place. There was also a lack of clarity among staff regarding responsibility for ensuring that such interventions were implemented and maintained. The facility's policies required that care plans be comprehensive, person-centered, and regularly updated by the interdisciplinary team, with staff notified of their responsibilities. However, interviews with staff, including CNAs, the MDS Coordinator, the DON, and the Administrator, revealed gaps in communication, training, and policy availability. Some staff were unaware of their roles in applying splints or following up on care plan interventions, and the facility lacked specific policies on restorative nursing services and splinting. These deficiencies resulted in residents not receiving care as planned and documented.
Failure to Adhere to Physician-Ordered Blood Pressure Parameters During Medication Administration
Penalty
Summary
A deficiency occurred when a certified medication technician (CMT) administered Lisinopril 20 mg to a resident diagnosed with essential hypertension, Alzheimer's disease, and chronic kidney disease, despite the physician's order to hold the medication if the resident's systolic blood pressure was less than 150 mm Hg. On the observed date, the resident's systolic blood pressure was 132 mm Hg, yet the medication was still given. The CMT later realized the error after reviewing the medication parameters and acknowledged that the medication should not have been administered. The facility's policy required medications to be administered as ordered and for vital signs to be checked and recorded, with medications held if outside prescribed parameters. Further review of the resident's Medication Administration Record (MAR) revealed that Lisinopril had been administered on multiple occasions when the resident's systolic blood pressure was below the ordered threshold of 150 mm Hg. Specifically, in the month of May, the medication was given 21 times despite the highest recorded systolic blood pressure being 136 mm Hg, and in June, it was administered on three occasions with all readings below 150 mm Hg. Interviews with staff indicated a misunderstanding of the hold parameters, with the CMT and nursing leadership referencing more common lower thresholds, rather than the specific order for this resident.
Failure to Provide Ordered Splinting and ROM Care for Multiple Residents
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for three residents who required range of motion (ROM) and orthotic devices. The facility did not have policies for splinting/orthotic devices or for Restorative Nursing Services, as confirmed by the Administrator. Staff interviews revealed a lack of clarity regarding responsibility for applying splints and performing ROM, with some staff unaware of which residents required these interventions or how to document them. One resident with hemiplegia and hemiparesis had a physician order for a resting hand splint to be applied daily, but reported that the splint had not been applied for about four months and that ROM was not performed prior to application, causing discomfort. Another resident with dementia and contractures had a splint order, but repeated observations showed the splint was left unused on the bedside table over several days. A third resident with dementia and contractures also had a physician order for a hand splint, but was repeatedly observed without the splint in place, and staff documentation showed inconsistent application. Interviews with CNAs, a CMT, and the Director of Rehabilitation indicated confusion about who was responsible for applying splints and performing ROM, with some staff stating that there was no restorative nursing program and that ROM was only provided during ADL care. The DON and Administrator acknowledged the lack of a restorative program and emphasized the expectation to follow physician orders, but confirmed that residents were not consistently receiving the ordered care.
Failure to Provide Consistent Range of Motion Care and Splint Application
Penalty
Summary
The facility failed to ensure that residents with limited range of motion (ROM) received appropriate treatment and services to prevent further decline in ROM for three residents. For one resident with hemiplegia and hemiparesis, staff did not consistently apply the prescribed resting hand splint as ordered by the physician. The resident reported that the splint had not been applied for approximately four months, and when it was applied, no ROM exercises were performed beforehand. The resident also experienced discomfort when the splint was first put on, and staff had to search for the splint in the closet, indicating a lack of routine and consistent care. Another resident with Alzheimer's disease and contractures had physician orders for both therapy evaluation and the application of a hand grip splint. Observations revealed that the splint was not being applied as ordered, as it was seen lying unused on the bedside table during multiple checks. Occupational therapy had recommended consistent use of the splint to maintain function, but there was no evidence of a restorative nursing program or consistent staff follow-through to ensure the splint was used as directed. A third resident with dementia and contractures also had orders for a resting hand splint and passive ROM exercises. Observations showed the splint was not being worn and was found in a chair in the resident's room. Interviews with staff revealed confusion about responsibilities for applying splints and a lack of restorative nursing services in the facility. Staff were unclear about which residents required splints, and there was no established policy or program to ensure the consistent application of splints or provision of ROM exercises, despite physician orders and therapy recommendations.
Inaccessible Call Light Systems in Resident Bathrooms and Bathing Areas
Penalty
Summary
The facility failed to provide an accessible and functioning call system in each resident's bathroom and bathing area, as required by its own policy. Observations revealed that in multiple private bathrooms, the call light cord was installed only near the toilet and did not extend to the shower area, leaving a significant distance between the shower and the call light. In one resident and staff accessible restroom, the call light system was present but lacked a pull cord, rendering it inoperable. Additionally, the therapy gym restroom had no call light system installed at all. These deficiencies were confirmed through direct observation and interviews with staff and residents. A resident expressed concern that the call light cord did not reach the shower, noting that if someone fell while showering, they would be unable to call for help. Staff interviews indicated that CNAs would remain in the room during showers due to the call light limitations, and the ADON stated she would stand outside the bathroom door if a resident showered independently without access to a call light. The DON and Administrator acknowledged the issue, with the Administrator stating she would further investigate. The facility's failure to ensure accessible call systems in all toileting and bathing areas directly contravened its policy and left residents without a reliable means to summon assistance in these areas.
Failure to Include Residents and Representatives in Care Planning
Penalty
Summary
The facility failed to include the resident and/or the resident's representative in the care planning process. This deficiency was identified through interviews, record reviews, and policy reviews, which revealed that the facility did not invite the residents or their representatives to care plan conferences, nor did they document an explanation in the medical records when participation was not practicable. This failure affected five residents out of a sample of twenty-five, all of whom had varying degrees of cognitive impairment and required involvement from their representatives in care planning decisions. For Resident 45, who was severely cognitively impaired, there was no documentation of care conference notes or invitations extended to the resident's Power of Attorney (POA). The POA confirmed not being invited to any care plan meetings and was unaware of the resident's care areas. Similarly, Resident 15, who had moderate cognitive impairment, showed no evidence of being invited to care plan meetings in the progress notes. Resident 48, with severe cognitive impairment, also had no documentation of care plan meeting invitations extended to their responsible party, who confirmed not receiving any invitations. Resident 43, with severe cognitive impairment, and Resident 10, who was cognitively intact, both had no evidence in their records of being invited to care plan meetings. Interviews with the MDS Coordinator and Social Services Director (SSD) revealed that the SSD was responsible for inviting families and documenting attendance, but this was not being done. The interim Director of Nursing and the Administrator confirmed that care plan conferences should be documented and that families or POAs should be invited, but this was not consistently happening as per the facility's policy and regulatory requirements.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure all drugs and biological agents were properly labeled, stored, and secured in accordance with accepted professional principles. On multiple occasions, medication carts were left unlocked and unattended by Certified Medication Technicians (CMTs) and Licensed Practical Nurses (LPNs). This included instances where the medication cart was out of the line of sight of the staff, posing a risk of unauthorized access to medications. Interviews with the staff confirmed that they were aware of the requirement to lock the carts but failed to do so, citing distractions and other duties as reasons for the oversight. The facility also failed to discard expired medications as per their policy. Observations revealed expired medications in both the east and west side medication carts and storage rooms. These included benzonatate capsules, acetaminophen, ondansetron, and an opened vial of Tubersol, among others. Interviews with the LPNs and the Interim Director of Nursing (IDON) indicated a lack of consistent practice in checking and discarding expired medications. The staff acknowledged that expired medications might not be as effective and could pose a risk to residents. Additionally, the facility did not maintain proper temperature logs for medication storage. The west medication storage room had a combined refrigerator/freezer unit with thermometers but lacked a temperature log for the refrigerator. The existing log for the freezer documented temperatures that were not within the acceptable range. Interviews with the LPNs and the IDON revealed uncertainty about the correct temperature ranges and the procedures to follow if temperatures were out of range. The pharmacist recommended discarding the entire stock in the west side refrigerator due to the lack of confirmation of correct temperatures.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to provide food that was at a palatable temperature and flavorful, affecting three of twenty-five sampled residents and potentially impacting 34 residents who prefer to eat in their rooms. Observations revealed that hot foods were below the acceptable temperature levels, while cold foods and beverages were above the acceptable temperatures at the point of service. Residents reported that the food was bland, lacked seasoning, and was often served cold. Grievance logs indicated multiple complaints about the food temperature, with responses suggesting residents eat in the dining room instead of addressing the temperature issues for room service meals. During a tray line observation, it was noted that hot foods were plated on room temperature plates and placed in a non-temperature-controlled cart. A test tray confirmed that the food was not at the required temperatures, with hot foods being only warm and cold items being too warm. Interviews with the Interim Director of Nursing and the Administrator acknowledged the issues with food services and the need for the kitchen to follow guidelines for maintaining food temperature. The facility's failure to ensure food was served at appropriate temperatures and with adequate seasoning led to dissatisfaction among residents and multiple grievances.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for one resident reviewed for wounds. During wound care, an LPN did not use a barrier to lay out wound supplies and failed to change gloves or perform hand hygiene when indicated. The LPN placed treatment supplies directly on the resident's bed without a barrier, donned gloves without performing hand hygiene, and did not change gloves after removing the soiled dressing before proceeding with the wound care. This was confirmed by the LPN during an interview, where she acknowledged the mistakes made during the procedure. The resident involved had been admitted with diagnoses including peripheral vascular disease and skin breakdown. The current treatment order for the resident's right heel wound required specific steps to be followed, including cleansing the wound with normal saline and applying Polymem Pink. However, the LPN did not adhere to the facility's infection control policies and procedures, as confirmed by the Interim Director of Nursing/Infection Preventionist, who stated that the nurse should have changed gloves and washed hands before applying the clean dressing.
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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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