Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hartland Park Health & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to maintain an effective pest control and sanitation program, resulting in a widespread gnat infestation in common areas, resident halls, the laundry room, medication cart trash, dirty utility room, and the kitchen. Surveyors observed gnats emerging from drains, stagnant mop water with a rancid odor, and extensive moisture, standing water, and organic debris in kitchen drains, cracked floor tiles, and hard-to-reach areas behind equipment. Pest control service reports over several months repeatedly documented unresolved issues such as drain debris, standing water, and debris accumulation, while the pest control provider stated that facility compliance with recommended cleaning and maintenance was inconsistent and many action items remained undone. The Dietary Manager reported ongoing gnat problems and use of a hose-mounted floor sprayer and vinegar in drains, which the pest control representative stated would not remove organic buildup or larvae. Leadership, including the VPO, DON, and Administrator, described expectations for cleaning, pest reporting, and drain use that were not reflected in observed conditions, and two residents reported that gnats were frequently present around them and their food, especially during meals.
A resident admitted for rehab with muscle weakness and unsteadiness had PT and OT care plans and orders for treatment five times per week, but therapy logs showed missed PT/OT sessions on two days with no documented reason. The Director of Rehabilitation confirmed the resident received therapy only three of five days over two consecutive weeks, contrary to the plan of care, and could not explain or document why sessions were missed. The resident and the resident’s representative reported that the resident did not receive therapy as expected, that therapy minutes were insufficient, and that services were not tailored to the resident’s needs, including use of group therapy despite the resident’s stated preference against it.
A resident with severe cognitive impairment, Parkinson's disease, dysphagia, and esophageal obstruction had repeated food-seeking behaviors that were not timely added to the behavioral care plan. Staff found him eating a granola bar, later observed him with popcorn before coughing and emesis, and later saw him grab food from another resident's tray. Hospital records showed repeated readmissions for vomiting and inability to swallow, and staff interviews confirmed the care plan had not been updated for the behavior.
A resident with severe cognitive impairment, Parkinson’s disease, and esophageal obstruction was on a pureed diet, but the care plan was not updated to address repeated attempts to obtain regular foods. The resident ate a granola bar from an unknown source, shared popcorn from another resident during an activity, and later grabbed pineapple from another resident’s tray. Each event led to coughing, emesis, inability to swallow, or hospitalization for esophageal impaction/obstruction and EGD treatment.
Surveyors found that the facility did not provide or document required written information about Advance Directives for several residents, including those with severe cognitive impairment and those who were cognitively intact. Despite facility policies and staff interviews indicating that Advance Directives should be obtained and reviewed, only Hospitality Guide Acknowledgements were present in the records, with missing or incomplete Advance Directive, Living Will, or POA documentation.
Staff failed to store drugs and biologicals in their original packaging, resulting in unidentified pills being left on a resident's bedside table and loose pills found in two medication carts. A resident with intact cognition was unable to identify pills left in her room, and staff interviews revealed inconsistent adherence to medication administration and disposal policies. Facility leadership confirmed expectations for proper medication handling, but observations showed these were not always met.
Staff failed to consistently follow infection prevention and control practices, including proper hand hygiene, use of PPE, and cleaning of shared equipment. Contaminated linens and trash were improperly handled and stored, and environmental cleanliness was not maintained, with infectious waste observed both inside and outside the facility. These deficiencies affected multiple residents, including those with cognitive impairment and indwelling devices, and had the potential to impact all residents.
Two residents were not treated with dignity and privacy as required. One resident's full urinary catheter bag was left uncovered and visible from the hallway, contrary to the care plan. Another resident received an insulin injection in the hallway from an LPN, with other residents and staff present, and without privacy. Facility leadership confirmed that privacy and dignity should have been maintained in both cases.
A nurse administered a dose of MiraLAX, prescribed to one resident, to another resident when the latter's supply was missing, instead of following facility protocols for medication shortages. Both residents were cognitively intact and had physician orders for MiraLAX. Facility policy prohibits sharing medications between residents, and staff interviews confirmed this expectation.
The facility did not timely update or implement comprehensive, person-centered care plans for multiple residents, including those with indwelling urinary catheters, colostomies, and severe cognitive impairment. Care plans failed to reflect residents' preferences, changes in condition, or ongoing activity participation, despite staff awareness and provision of care.
A resident with severe cognitive impairment and multiple diagnoses received enteral tube feeding without the required head-of-bed elevation, as observed on multiple occasions. Despite facility policy and CDC guidelines mandating a 30-45 degree elevation to prevent complications like aspiration, staff did not consistently maintain this position during feedings.
A resident with severe cognitive impairment and complex medical needs did not consistently receive prescribed Volara System respiratory treatments, with 22 missed doses documented over a month. The missed treatments occurred primarily when the respiratory therapist was not present and nursing staff were responsible. The resident's representative and clinical staff expressed concerns about the impact of these missed treatments, including increased congestion and the need for additional medical evaluation.
Food in a nourishment refrigerator was repeatedly stored at temperatures above the recommended maximum of 41°F, as documented on multiple days. Staff interviews revealed confusion about the correct temperature range and inconsistent monitoring practices. The DON confirmed the standard was not to exceed 41°F, but this was not consistently followed.
Two residents experienced deficiencies in their care plans. One resident did not receive prescribed pain medication for over 21 hours after hospital readmission, despite a care plan to administer medications per orders. Another resident's care plan failed to address non-compliance with a prescribed diet, as family members brought in regular-texture food contrary to the resident's dietary needs. The facility's policy required comprehensive care plans, but these were not fully developed or implemented for the residents.
A resident with femur fractures did not receive timely pain medication due to staff unawareness of available Oxycodone in the emergency medication box. Despite orders for Oxycodone, the resident experienced significant pain for approximately 21 hours. Interviews revealed a lack of communication and adherence to procedures, leading to the deficiency.
The facility failed to document and resolve grievances related to missing personal items for several residents. Despite residents reporting missing items to staff, these grievances were not logged, and the items were neither found nor replaced. Interviews with residents and staff revealed a lack of proper documentation and follow-up, contrary to the facility's policy requiring grievances to be documented and resolved.
A resident with dysphagia was not accurately assessed for a modified texture diet in the MDS, despite physician's orders for a pureed diet. The RD failed to mark the mechanically altered diet section, leading to an inaccurate reflection of the resident's dietary needs. Staff discussions in clinical meetings did not translate into accurate MDS documentation.
An LPN worked 82 shifts with a suspended license at a facility that lacked a policy on staff licensure. The facility's job description and employee handbook required proof of current licensure, which was not followed. The LPN was terminated after the suspension was discovered, as confirmed by interviews with the facility's administration.
A facility failed to secure a medication cart and properly label medications, leading to potential risks. An unlocked medication cart was found unattended, contrary to policy. Additionally, a resident's medication lacked proper labeling, with the opened date missing, risking administration of expired medication. Staff interviews confirmed the importance of securing carts and following expiration dates to ensure safety and effectiveness.
The facility failed to follow infection control precautions for three residents. A Social Service Assistant and an LPN did not adhere to hand hygiene and equipment disinfection protocols for a resident on enhanced barrier precautions. An RN administered medication to another resident without gloves, and another RN changed a dressing without wearing required protective gear. The facility's infection control policies were not properly implemented, as revealed in interviews with staff and administration.
The facility failed to maintain clear hallways, creating a safety hazard. Observations showed wheelchairs and a linen cart obstructing a hallway, confirmed by staff interviews. The congestion was due to unidentified wheelchairs and frequent use of carts, posing a risk during emergencies.
A resident with severe cognitive impairment did not receive scheduled medications on time due to an LPN being distracted by other residents' needs. The LPN had prematurely signed the MAR, indicating the medications were given, which was against facility policy. The oversight was discovered by a family member, and the medications were administered later by an RN.
Failure to Maintain Effective Pest Control and Sanitary Conditions Resulting in Widespread Gnat Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free of insects and other pests, resulting in a widespread gnat infestation throughout the building. Surveyor observations over two days identified gnats in multiple common areas, including the conference room, resident halls, laundry room, medication cart trash can, and dirty utility room. In the laundry room, gnats were seen emerging from the washing machine discharge drain, and in the dirty utility room, gnats were concentrated around a mop bucket containing stagnant, foul-smelling water. On a resident hall, multiple gnats were observed flying around residents and on surfaces throughout the corridor. Extensive observations in the kitchen revealed multiple environmental and sanitation issues that contributed to the gnat activity. Behind and around the ice machine and juice cart, there was wet dust, dirt, and organic debris such as food crumbs, sugar packets, and trash items, all saturated with moisture. Cracked, loose, and broken floor tiles near the ice machine drain and in the dish room contained food debris lodged within and beneath the damaged tiles, with standing water collected beneath the tiles and pooled around the ice machine drain. Standing water was also observed in the spray room, dish room, along walls, and in corners, with water spread across the kitchen floor after staff used a hose-mounted sprayer to clean the floors. On a subsequent day, the kitchen floor again had visible standing water, and a floor drain contained accumulated debris, paper fragments, and organic material, with a broken drain grate that did not fully cover the drain and exposed additional trapped debris; gnats were present in and near this drain and throughout the kitchen. Review of facility work orders showed only one report of gnats in common areas and nursing units for one month and one report of bugs facility-wide in the following month, despite the widespread activity observed. Service reports from the contracted pest control company over several months documented ongoing, unresolved environmental concerns in the kitchen and adjacent areas, including repeated findings of drain debris, standing water in kitchen and dishwashing areas, debris accumulation, and moisture issues that remained uncorrected by the facility. The pest control representative and pest control account manager both stated that gnats were originating from drains, cracks, and crevices with organic debris and moisture, and that routine cleaning practices were ineffective when debris remained or was pushed into cracks and around drains. They reported that recommendations such as debris removal, proper drain maintenance, and cleaning of hard-to-reach areas were repeatedly communicated and documented, but the facility’s compliance with these recommendations was inconsistent, with many action items left undone and carried over on subsequent service reports. Interviews with staff and leadership further described the facility’s actions and inactions related to pest control and sanitation. The Dietary Manager reported ongoing gnat concerns for multiple weeks, stated that pest control services were provided twice monthly, and that kitchen staff performed routine cleaning weekly and as needed, using a hose-mounted spray system for floors and pouring vinegar down drains between pest control visits. The pest control representative stated that pouring vinegar down drains would not eliminate the infestation and might attract gnats, as it did not remove organic buildup or kill larvae. The pest control account manager identified contributing factors such as debris buildup in cracks and flooring, lack of routine cleaning behind equipment, standing water or improperly maintained mop buckets, inconsistent cleaning practices in non-visible areas, and lack of routine maintenance of drains and traps, and noted that environmental cleaning often improved only after issues became more apparent. The VPO acknowledged gnat activity throughout the building and that pest control reports had identified ongoing debris concerns in the kitchen, but could not clearly describe a process to ensure consistent cleaning of hard-to-reach areas or to verify cleaning effectiveness. The DON and Administrator described expectations for reporting pests, emptying mop buckets, removing trash from medication carts, removing debris before floor cleaning, and not sweeping debris into drains, but these expectations were not reflected in the observed conditions. Two cognitively impaired and intact residents reported that gnats were always present, especially around meal times and food, and that they found them bothersome and undesirable during meals.
Failure to Provide Ordered PT/OT and Document Missed Therapy Sessions
Penalty
Summary
The facility failed to provide specialized rehabilitative services as ordered for one resident admitted for rehabilitation with diagnoses of muscle weakness and unsteadiness on feet. The resident’s care plan, initiated shortly after admission, identified a rehabilitation focus with skilled PT and OT interventions, and physician orders specified PT and OT to evaluate and treat. The OT plan of care called for treatment five times per week for 60 days, and the PT plan of care called for treatment five times per week for 30 days. Review of the Service Log Matrix showed that the resident did not receive individual PT or OT on two specified dates, despite the plan of care requiring therapy five days per week. The Director of Rehabilitation confirmed that the resident missed PT/OT on those two dates, that the plan of care was for five days a week, and that the resident only received PT/OT three out of five days for two consecutive weeks. The resident and the resident’s representative reported concerns that the resident was not receiving the allotted amount of therapy time and that therapy was not tailored to the resident’s specific needs. The representative stated the resident was weaker upon discharge than at admission and that the family sought transfer to another facility for PT after expressing concerns without improvement. The resident reported not receiving any PT during the first week, receiving PT only after questioning staff, and that when PT was provided it lasted 30–40 minutes and included group therapy that was counted as PT despite the resident’s preference against group therapy. The Director of Rehabilitation stated she did not know why therapy was missed on the two identified dates and that no reasons were documented, although such reasons were typically recorded. The DON stated her understanding that if therapy was missed, staff should attempt to reschedule so that residents did not miss needed therapy, and the current Administrator stated her expectation that residents receive the therapy they are supposed to receive to reach their maximum potential.
Failure to Update Behavioral Care Plan for Food-Seeking Resident
Penalty
Summary
The facility failed to develop a resident-centered behavioral care plan for one resident with severe cognitive impairment and multiple swallowing-related diagnoses. The resident had Parkinson's disease, esophageal obstruction, chronic dysphagia, chronic esophageal strictures, and GERD, and his quarterly MDS showed a BIMS score of 0 out of 15. The comprehensive care plan already identified behaviors including rejected care and services, refused meals, hallucinations, false allegations, anxiety, irritability, anger, picking at skin, and wrapping rubber bands around a stump, with a goal that the resident's behaviors not bother other residents. The care plan interventions were not updated to address the resident's current food-seeking behaviors after repeated incidents. The record showed that on one occasion the resident was found eating a granola bar in bed and told the nurse, "I have my connections." On another occasion, activities staff observed the resident with popcorn during a movie in the dining room; when staff approached, he started coughing, then had emesis and could not swallow water. On a later occasion, the resident grabbed pineapple from another resident's tray in the joint dining room while staff were preparing to move him to his assisted table. Hospital discharge summaries showed the resident was readmitted after each incident with vomiting and inability to swallow liquids. The summaries documented esophageal obstruction, chronic dysphagia, chronic esophageal strictures, and GERD, and one EGD removed food from the upper esophagus and included esophageal dilation. Interviews with staff showed the care plan was not updated timely for the resident's food-seeking behavior, and staff on the unit were not aware of specific care plan information about the behavior or that he was grabbing regular food from other residents' trays.
Failure to monitor repeated access to non-approved foods
Penalty
Summary
The facility failed to monitor and provide ongoing assessment of whether care approaches were meeting the needs and behaviors of a resident with severe cognitive impairment and a pureed diet. The resident had diagnoses including Parkinson’s disease and esophageal obstruction, and the quarterly MDS assessed a BIMS score of 0 out of 15. The resident’s comprehensive care plan addressed behaviors such as rejected care and services, refused meals, hallucinations, false allegations, anxiety, irritability, anger, picking at skin, and wrapping rubber bands around a stump, but it was not updated to address the resident’s repeated attempts to obtain and eat regular foods that were not allowed on the ordered pureed diet. On 08/09/2025, the resident obtained and began eating a granola bar from an unknown source while in bed. The RN removed the granola bar, told the resident it was not appropriate for the ordered diet, and notified the NP and the POA. Later that day, the resident developed blood around the gastrostomy tube site and was sent to the ER. The hospital discharge summary documented food impaction of the esophagus, esophageal stenosis, dementia, Parkinson’s disease, esophageal stent, and PEG tube replacement, and stated the CT scan showed impaction of the esophageal stricture reportedly due to access to granola bars not included in the prescribed diet. On 09/19/2025, during an activity in the dining room, another resident shared popcorn with the resident. Staff observed the resident with popcorn, and he began coughing. He was taken to the nurses’ station, had emesis, could not swallow water, and was sent to the ER. The hospital discharge summary documented admission for esophageal stricture and an EGD with dilation of the stricture, and the resident returned to the facility tolerating a pureed diet. On 10/16/2025, the resident grabbed pineapple from another resident’s tray in the dining room. He later returned to the hospital with vomiting and inability to swallow liquids, and the discharge summary documented esophageal obstruction, chronic dysphagia, chronic esophageal strictures, GERD, and EGD with removal of food from the upper esophagus and dilation of the esophagus.
Failure to Provide and Document Advance Directive Information and Documentation
Penalty
Summary
The facility failed to provide and document written information to residents and their representatives regarding the right to accept or refuse medical or surgical treatment and to formulate an Advance Directive, as required by federal regulations and the facility's own policies. Multiple residents, including those with severe cognitive impairment and those who were cognitively intact, did not have copies of their Advance Directives, Living Wills, or Power of Attorney (POA) documents present in their electronic medical records (EMR) when requested by surveyors. Instead, the only documentation provided was a Hospitality Guide Acknowledgement, which did not include the required Advance Directive documents. For several residents, such as those with diagnoses of cerebral palsy, epilepsy, dementia, and heart disease, the facility's records showed either a lack of documentation of Advance Directives or incomplete records, such as missing POA or Living Will documents. In some cases, residents or their representatives stated they did not recall receiving written information about Advance Directives or signing related documents. Interviews with facility staff, including the Social Services Director, Director of Medical Records, Director of Nursing, and the Administrator, confirmed that while the facility had processes in place to request Advance Directives during admission and care plan meetings, these processes were not consistently followed or documented. The facility's policies required that residents be informed of their rights regarding Advance Directives upon admission and that staff verify and periodically review these wishes. However, the survey found that for six sampled residents, there was no evidence that the facility provided the necessary written information or obtained and retained the required documentation. This deficiency was identified through interviews, record reviews, and policy reviews, demonstrating a failure to comply with federal and state requirements for Advance Directives.
Failure to Properly Store and Identify Medications
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were stored in their original packaging or containers as required by policy and professional standards. Observations revealed that one resident had five unidentified pills left on her bedside table, and neither the resident nor the nursing staff could identify the medications or their origin. The resident, who had intact cognition and a history of rheumatoid arthritis, hypertension, and anxiety, was unsure about the purpose or duration of the pills' presence. The nurse practitioner acknowledged the resident's autonomy in self-administering medications but also recognized the potential risk if other residents accessed the pills. Additionally, staff interviews confirmed that facility policy required medications to be administered immediately after preparation and that unused doses should be disposed of according to policy. Further observations identified loose, unidentified pills in two medication carts. In one instance, twelve loose pills were found in a medication cart drawer, and the LPN on duty could not account for how they got there, noting that pills sometimes fell out of blister packs. Another observation showed a nurse preparing a resident's medications in advance and storing them in the cart before administration. An additional loose, unidentified tablet was found in a cup in another cart, with a medication aide admitting she did not want to waste the pill and initially considered returning it to the drawer. Facility leadership interviews confirmed expectations that staff verify medication ingestion and waste unused medications appropriately, but these practices were not consistently followed.
Failure to Maintain Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple direct observations of staff not adhering to established infection control practices. Staff were observed failing to perform hand hygiene, not wearing appropriate personal protective equipment (PPE) during high-contact care, and improperly handling contaminated linens and trash. For example, a certified nurse aide provided direct care to a resident under enhanced barrier precautions without donning a gown, and several staff members were seen transporting dirty linens and trash through hallways without removing gloves or performing hand hygiene. Additionally, clean and contaminated items were improperly stored, such as respiratory equipment and dentures left to dry on a stained towel in a resident's bathroom, and clean privacy curtains dragged on the floor before being hung. Shared equipment, including gait belts, blood glucose meters, blood pressure cuffs, and mechanical lifts, was not consistently cleaned and disinfected between resident use. An LPN was observed performing a blood sugar fingerstick without following infection control protocols, including failing to clean and disinfect the glucometer according to manufacturer instructions and not performing hand hygiene before or after the procedure. Other staff members admitted to not cleaning equipment between uses unless a resident was on contact precautions, and there was confusion or lack of knowledge regarding proper disinfection procedures and required contact times for cleaning products. Environmental cleanliness and waste management were also deficient. Trash and contaminated linens were left on floors in resident rooms and hallways, and infectious waste was observed scattered around the dumpster area outside the facility. Staff interviews revealed inconsistent understanding and application of infection control policies, despite reported training and competencies. These failures were observed to affect multiple residents, including those with severe cognitive impairment, indwelling devices, and those under enhanced barrier precautions, and had the potential to impact all residents in the facility.
Failure to Maintain Resident Dignity and Privacy During Care
Penalty
Summary
The facility failed to maintain resident dignity and privacy for two residents. In the first instance, a resident with cerebral palsy, epilepsy, and neuromuscular dysfunction of the bladder was observed with an indwelling urinary catheter collection bag that was full of urine and not covered by a dignity bag, as required by the resident's care plan. The collection bag was visible from the hallway, and the unit manager confirmed that dignity covers should be used but was unaware why it was not in place for this resident. In the second instance, a resident with hemiplegia, cerebral infarction, type 2 diabetes, and severe cognitive impairment received an insulin injection in the abdomen from an LPN while seated in her wheelchair next to the medication cart in the hallway. Multiple residents and staff were present and could see the procedure. The LPN acknowledged that privacy was not provided and that the injection should have been administered in the resident's room. Both the DON and the facility administrator confirmed that staff are expected to provide privacy and treat residents with dignity during care.
Misappropriation of Resident Medication by Nursing Staff
Penalty
Summary
A deficiency occurred when a registered nurse (RN) administered MiraLAX, a laxative prescribed to one resident, to another resident. The RN observed that one resident was missing their prescribed MiraLAX and, instead of waiting for the pharmacy to deliver a new supply, used another resident's medication. Both residents were cognitively intact and had physician orders for MiraLAX for constipation, but the medication was specifically prescribed to each individual. Facility policy defined misappropriation as the wrongful use of a resident's belongings or medication without consent and stated that residents have the right to be free from such misappropriation. The RN acknowledged during an interview that medications should not be shared between residents. The Director of Nursing and the Administrator both confirmed that staff are expected to reorder medications through the pharmacy and consult the provider if a medication is missing, rather than borrowing from another resident. The incident was identified through observation, record review, and staff interviews, confirming that the facility failed to protect a resident from the misappropriation of their medication.
Failure to Timely Update and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, as required by policy and regulatory standards. For one resident with an indwelling urinary catheter, the care plan was not updated in a timely manner to reflect the resident's longstanding preference for a leg bag, despite staff being aware of this preference. The care plan was only revised months after the preference was established, and interviews with nursing staff confirmed that the resident had always used a leg bag. Another resident who was readmitted with a colostomy did not have this significant change in condition reflected in the care plan until several months after readmission. Although the resident had a physician's order for ostomy care and staff were providing the necessary care, the care plan was not updated to include the colostomy until it was discovered missing by the MDS nurse. The MDS nurse acknowledged that the omission occurred at the time of readmission and was not caught during daily meetings or by other staff responsible for care plan updates. Additional deficiencies were noted for a resident with severe cognitive impairment and an indwelling urinary catheter, whose care plan was not updated to include the use of a leg bag after the resident repeatedly removed the catheter. The change to a leg bag was made to address this behavior, but the care plan was not revised until much later. Another resident with severe cognitive impairment was not care planned for activities until long after admission, despite ongoing participation in bedside activities and music therapy. Staff interviews confirmed that activities were being provided, but the care plan did not reflect this until it was eventually updated.
Failure to Maintain Proper Head-of-Bed Elevation During Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral tube feeding was provided with appropriate care to prevent complications such as aspiration. Observations on two separate occasions showed that the resident was lying in bed with tube feeding infusing, but the head of the bed (HOB) was not elevated as required by both facility policy and CDC guidelines. The facility's policy and CDC guidance specify that the HOB should be elevated 30 to 45 degrees for residents receiving enteral feedings, unless medically contraindicated. The resident in question had diagnoses including cerebral palsy, epilepsy, and dysphagia, and was severely cognitively impaired according to the most recent assessment. Interviews with staff, including an LPN, the Infection Preventionist/Staff Development Coordinator, the DON, and the Administrator, confirmed that the expectation was for the HOB to be elevated for residents receiving tube feedings. The LPN stated that the resident experienced pain and yelled out when the HOB was elevated, so she raised it slowly throughout the shift. Despite these statements, observations confirmed that the HOB was not elevated during feedings, which was inconsistent with both policy and professional standards. The deficiency was identified for one resident with a feeding tube, and no evidence was provided that the required positioning was maintained during enteral feeding.
Failure to Consistently Administer Ordered Respiratory Treatments
Penalty
Summary
The facility failed to consistently provide prescribed respiratory treatments for a resident with severe cognitive impairment and multiple medical diagnoses, including dementia, cerebral infarction, and aphasia. The resident was ordered to receive Volara System therapy with sodium chloride inhalation twice daily, as documented in the electronic medical record. However, review of the device's digital therapy log revealed that 22 treatments were missed over a period of approximately one month. The missed treatments included both morning and evening doses, and there was no documentation provided to explain these omissions. The facility was also unable to provide the requested Respiratory Policy to the surveyor during the investigation. Interviews with the resident's Power-of-Attorney, the respiratory therapist, and the nurse practitioner confirmed concerns about inconsistent administration of the respiratory therapy, particularly during evenings and weekends when the respiratory therapist was not present and nursing staff were responsible. The resident's POA reported increased congestion and wheezing when treatments were missed, which led to a chest x-ray being ordered. Both the respiratory therapist and nurse practitioner stated that it was their expectation for nursing staff to follow provider orders to maintain the resident's health and well-being.
Failure to Maintain Safe Food Storage Temperatures in Unit Refrigerator
Penalty
Summary
The facility failed to store food in a safe manner in a nourishment refrigerator on one of its resident units. Review of the refrigerator temperature logs for the unit revealed that, on multiple dates, the recorded temperatures were above the recommended maximum of 41 degrees Fahrenheit, with specific readings of 46, 42, 48, and 46 degrees Fahrenheit on consecutive days. The State Operations Manual defines the 'Danger Zone' as food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit, which can allow the rapid growth of pathogenic microorganisms. Staff interviews indicated uncertainty about the correct temperature range, with some staff believing the acceptable range extended up to 45 or 46 degrees Fahrenheit. The night shift staff were responsible for monitoring and recording refrigerator temperatures, while the unit manager was responsible for ensuring this was done. Interviews with the CNA, LPN/Unit Manager, DON, and Administrator confirmed that staff were expected to monitor and document refrigerator temperatures and report any concerns to supervisors or maintenance. However, the logs showed that the refrigerator was repeatedly above the safe temperature threshold, and there was a lack of clear understanding among staff regarding the correct temperature range. The Director of Nursing clarified that the appropriate refrigerator temperature should not exceed 41 degrees Fahrenheit, but this standard was not consistently met or enforced on the unit.
Deficiencies in Care Plan Implementation for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. Resident 124, who was readmitted from the hospital with fractures in both femurs, did not receive prescribed pain medication for approximately 21 hours after it was ordered. Despite having a care plan that included administering medications per orders, the resident's pain scores indicated significant discomfort, with scores ranging from 5/10 to 8/10 during this period. The medication administration record showed that the resident did not receive the ordered Oxycodone at several documented times when pain was reported. Resident 36's care plan was not adequately developed to address non-compliance with the prescribed diet. The resident, who had dysphagia and major depression, was on a controlled carbohydrate, pureed diet. However, observations and interviews revealed that the resident's family frequently brought in regular-texture food, which was not in compliance with the diet order. The care plan lacked interventions to address this non-compliance and did not include education for the resident or family about the prescribed diet. Interviews with staff and family members confirmed that the resident's dietary needs were not being fully met according to the care plan. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timeframes to meet residents' needs. However, the care plans for both residents were not fully developed or implemented, resulting in unmet medical and dietary needs. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, highlighted the expectation that care plans should be accurate and reflect the residents' current care needs, which was not the case for these two residents.
Failure to Administer Timely Pain Medication
Penalty
Summary
The facility failed to administer prescribed pain medications in a timely manner for Resident 124, who was readmitted to the facility with fractures of the right and left femur. Despite having orders for Oxycodone 5 mg every 12 hours as needed and Oxycodone 15 mg every six hours, the resident did not receive the medication until approximately 21 hours after first expressing pain. The resident's pain scores ranged from 5/10 to 8/10 during this period, indicating significant discomfort. Interviews and observations revealed that the facility staff were unaware that the necessary medications were available in the emergency medication box. The Registered Nurse responsible for admitting the resident did not recall the incident or the resident being in extreme pain. The facility's policies allowed for verbal authorization in emergencies, but this was not utilized, and there was a lack of awareness about the availability of Oxycodone in the emergency medication box. The Director of Nursing and Assistant Director of Nursing both stated that they expected nursing staff to administer pain medication when a resident was in pain. However, there was a breakdown in communication and procedure, as the medication was not administered promptly, and the facility's process for handling controlled medications was not effectively followed. The facility's failure to provide timely pain management resulted in prolonged discomfort for the resident.
Failure to Document and Resolve Grievances for Missing Items
Penalty
Summary
The facility failed to document, replace, and resolve grievances related to missing personal items for four residents. These residents reported missing items to staff, but the facility did not log these grievances in the grievance log, nor did they find or replace the missing items. The facility's policy required that grievances be documented and resolved, but this was not adhered to in these cases. Interviews with the residents revealed that they had reported missing items to staff, but no follow-up or resolution was provided. One resident mentioned that her items were never returned from the laundry, leading her to have her laundry done by family members. Another resident reported missing clothing items and stated that no staff member had followed up with her about these grievances. A third resident, who shared a room with her mother, reported multiple missing clothing items and noted that staff no longer allowed residents to search for their missing items in the laundry room. Staff interviews indicated a lack of proper documentation and follow-up on grievances. A CNA mentioned verbally informing the charge nurse about missing items, but there was no formal documentation. The Social Worker, responsible for grievances, stated that items should be replaced if not found, but this was not done. The Director of Nursing and the Administrator both emphasized the importance of documenting grievances and providing resolutions, but this was not reflected in the actions taken by the facility.
Inaccurate Dietary Assessment for Resident
Penalty
Summary
The facility failed to ensure an accurate assessment for one resident, who was on a modified texture diet due to dysphagia. The Quarterly and Annual Minimum Data Set (MDS) assessments did not reflect the resident's need for a mechanically altered diet, despite the resident's admission records and physician's orders indicating a pureed texture diet. The resident, who was cognitively intact, confirmed she had been on pureed food for a long time due to failing a swallowing test at the hospital. Interviews with facility staff, including the Regional Registered Dietitian (RD), MDS Nurse, Director of Nursing (DON), and Administrator, revealed that the RD was responsible for completing the swallow and nutritional status section of the MDS. However, the RD did not mark the mechanically altered diet section, leading to an inaccurate reflection of the resident's dietary needs in the MDS. The MDS Nurse and other staff discussed resident care changes in clinical morning meetings, but the MDS did not accurately reflect these changes in the comprehensive care plan.
LPN Worked with Suspended License
Penalty
Summary
The facility failed to ensure that nursing staff providing resident care was licensed, as evidenced by an LPN working on a suspended license. The LPN performed duties as a licensed nurse in the facility for a period of time while her license was suspended. The facility did not have a policy regarding staff licensure, and it was revealed that the LPN worked 82 shifts during the period her license was suspended. The facility's job description and employee handbook required that licensed employees furnish proof of current registration and licensure, which was not adhered to in this case. Interviews with the facility's administration, including the Administrator, Assistant Administrator, and Director of Nursing, confirmed the oversight. The Administrator acknowledged the importance of maintaining active licenses to ensure compliance and resident safety. The Assistant Administrator confirmed that the LPN was terminated once the facility discovered the suspension. The Director of Nursing emphasized the necessity of valid licenses to ensure staff compliance and up-to-date education hours.
Medication Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper labeling of medications, as evidenced by an unlocked and unattended medication cart on the Memory Care Unit. During an observation, it was noted that the medication cart was left unlocked, which was against the facility's policy that mandates all medication carts be locked when not in use. Interviews with staff, including a registered nurse and the unit manager, confirmed the importance of keeping medication carts locked to prevent unauthorized access by residents, visitors, or other staff. Additionally, the facility did not adhere to professional standards for labeling medications, specifically concerning expiration dates. A resident, who was admitted with diagnoses including deep vein thrombosis, diabetes, and pre-glaucoma, was prescribed latanoprost ophthalmic solution. The medication was observed to be improperly labeled, with the opened date missing on the container, despite the pharmacy's instructions that the medication was good for 42 days after opening. This oversight meant the medication was potentially expired when administered, as the opened date was only noted on the box, which could be separated from the container. Interviews with nursing staff and the unit manager highlighted the importance of following expiration dates and ensuring medications are labeled correctly to maintain their effectiveness. The pharmacist confirmed the potency of the medication decreases after the expiration date, although it does not cause adverse effects. The Director of Nursing and the Administrator reiterated the facility's policy and expectations regarding medication security and labeling, emphasizing the need for compliance to ensure resident safety and effective medication administration.
Infection Control Precautions Not Followed for Residents
Penalty
Summary
The facility failed to adhere to infection control precautions for three residents on infection control precautions. In the case of Resident 124, a Social Service Assistant (SSA) entered the resident's room, which was under enhanced barrier and contact precautions, without following proper hand hygiene protocols. The SSA picked up a clipboard, placed it on the sink, removed her gloves, and left the room without washing her hands or cleaning the clipboard. Additionally, a Licensed Practical Nurse (LPN) provided wound care to the same resident, removed her protective equipment, and placed an eye shield on the sink. She washed her hands but did not disinfect the top of the treatment cart after placing the eye shield on it. For Resident 71, a Registered Nurse (RN) administered medication without wearing gloves, despite the resident being on enhanced barrier precautions. The RN handled the medications with bare hands and expressed nervousness during the interview, acknowledging the potential for transferring infectious organisms due to not wearing gloves. Resident 12 was also on enhanced barrier precautions, but an RN changed the resident's dressing without wearing a gown or gloves, contrary to the signage requirements. The RN believed that gowns were only necessary for certain procedures. Interviews with the Director of Nursing and the Infection Preventionist revealed that staff were expected to follow enhanced barrier precautions, but no issues had been identified in their audits. The Administrator was unaware of any infection control issues, although these were discussed in monthly Quality Assurance Performance Improvement meetings.
Crowded Hallways Create Safety Hazard
Penalty
Summary
The facility failed to maintain a safe environment for residents, staff, and the public in one of its resident care units. An observation revealed that the hallway in the [NAME] Hall was crowded with four wheelchairs folded up against the handrail on one side and a linen cart on the opposite side. This congestion was noted to create a safety issue, particularly in emergencies, as it hindered residents' ability to maneuver through the hallway. Interviews with staff, including a Registered Nurse, the Unit Manager, the Director of Nursing, and the Administrator, confirmed that the hallways were frequently crowded with various carts and equipment. The Unit Manager explained that the wheelchairs were left in the hallway because they had been washed and lacked identification, making it unclear where they should be stored. The Director of Nursing and the Administrator both emphasized the importance of keeping hallways clear for safety, especially during mealtimes when additional tray carts were present.
Medication Administration Lapse for a Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as R114, who did not receive scheduled medications on a specific date. The facility's policy required staff to observe the resident's consumption of medications and sign the Medication Administration Record (MAR) only after administration. However, on the day in question, a Licensed Practical Nurse (LPN) was distracted by other residents' needs and forgot to administer R114's medications, despite having already signed the MAR indicating they were given. This oversight was discovered when a family member reported the issue to a Registered Nurse (RN), who then administered the medications later than scheduled. R114, who had severe cognitive impairment and multiple diagnoses including unspecified dementia and type 2 diabetes mellitus, was supposed to receive several medications, including Metformin and Protonix, at 6:00 PM. The RN confirmed with the LPN that the medications were not given and subsequently administered them at 7:35 PM. The Director of Nursing (DON) confirmed that the medications were administered late and emphasized that the facility's policy was not followed, as medications should not be signed out until they are actually administered. The incident highlighted a lapse in adherence to medication administration protocols, leading to a delay in the resident receiving necessary medications.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lexington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bluegrass Care & Rehabilitation Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Sayre Christian Village Nursing Home | 1.6 mi | ★★★★★ | 0 | 0 |
| Mayfair Manor | 2.4 mi | ★★★★★ | 7 | 0 |
| The Willows At Fritz Farm | 2.9 mi | ★★★★★ | 3 | 0 |
| Lexington Premier Nursing & Rehab | 3.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.