Lyndon Crossing
Inspection history, citations, penalties and survey trends for this long-term care facility in Louisville, Kentucky.
- Location
- 1101 Lyndon Lane, Louisville, Kentucky 40222
- CMS Provider Number
- 185165
- Inspections on file
- 29
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 14 (2 serious)
Citation history
Health deficiencies cited at Lyndon Crossing during CMS and state inspections, most recent first.
Medications labeled with a resident's name, a capped syringe, and a glucometer were left unattended on top of a locked medication cart with no staff present. An LPN admitted to leaving the items while attempting to administer medications on time, despite being aware that this violated facility policy. Interviews with nursing staff and leadership confirmed that this action was against policy and unsafe.
A resident with dementia, severe cognitive impairment, and anxiety was care planned to live on a secured memory unit with supervision and structured diversion activities due to elopement risk. In the days before the incident, the resident repeatedly voiced a desire to go home. On the night of the event, an exit alarm sounded, but CNAs and an LPN were occupied providing showers and other care, and although one CNA briefly redirected the resident from the exit door, staff did not ensure ongoing supervision or verify the resident’s whereabouts after silencing the alarm. The resident left the unit and facility without staff knowledge and was later found in a nearby park by community members and law enforcement, while facility staff initially believed the resident was still in her room. Staff interviews confirmed that required supervision and person-centered diversion interventions from the care plan were not implemented at the time.
A cognitively impaired, exit-seeking resident with dementia and severe cognitive deficits, identified as a moderate elopement risk and care planned to reside on a secure memory unit with supervision and diversional activities, was placed in a room adjacent to an alarmed exit door. In the days before the incident, staff documented and observed escalating behaviors, including repeated statements about wanting to go home, pushing on exit doors, packing a suitcase, and being non-redirectable, yet at the time of the event, one LPN and two CNAs on the unit were occupied with other residents. When the exit door alarm sounded, staff briefly checked the courtyard and rooms, turned off the alarm, and returned to their tasks, while a deteriorated wooden gate in the courtyard fence allowed the resident to push through and leave the property. The resident walked to a nearby park and was found by citizens who called 911; law enforcement then notified facility staff, who had been unaware the resident had left, demonstrating a failure to provide adequate supervision and maintain secure egress controls for an identified elopement risk.
Staff were observed inserting food thermometers through plastic wrap covering food items on the tray line, rather than removing the wrap as required by USDA guidelines and facility policy. This practice was confirmed by interviews with the dietary manager, DON, and administrator, who all stated that proper procedure is to remove barriers before temping food to prevent cross contamination and choking hazards.
A facility failed to develop a baseline care plan for a resident at risk for elopement, leading to the resident leaving the facility unsupervised. The resident, with severe cognitive impairment and a history of stroke, was not provided with necessary interventions despite being assessed as at risk. Staff interviews revealed a lack of awareness and communication regarding the resident's elopement risk, contributing to the incident.
The facility failed to provide adequate supervision and safety measures for two residents, leading to significant deficiencies. One resident, at risk for elopement, left the facility unnoticed and was found at a hospital. Another resident, admitted without a smoking or fall risk assessment, experienced multiple falls and was initially allowed to smoke unsupervised. Staff interviews revealed a lack of communication and understanding of the residents' risks and necessary precautions.
The facility failed to provide residents and their guardians with quarterly statements of personal funds accounts, as required by policy. Interviews revealed that residents did not receive these statements unless requested, leading to confusion about account balances. The BOM noted delays due to a change in facility ownership, while the DON and Administrator acknowledged the issue, which violated residents' rights.
The facility failed to provide a safe and comfortable environment due to a lack of hot water in 14 resident rooms, with temperatures as low as 44°F. Residents reported no hot water for over a month, affecting daily activities. Staff were unaware of the issue's extent, and maintenance checks were insufficient. Recent cold weather caused infrastructure issues, leading to high demand on limited shower facilities.
The facility failed to conduct annual performance reviews for CNAs and did not consistently provide required in-service education. Five CNAs lacked documented evaluations, and three did not meet the annual training requirement. The facility had no staffing policy, and a change in ownership affected documentation. The new Administrator acknowledged the importance of evaluations for feedback and competency assessment.
The facility failed to submit complete and accurate staffing data to CMS for Q3 2024, resulting in no RN hours and insufficient licensed nursing coverage. A change in ownership and software issues led to submission errors, impacting the facility's survey outcome and star rating.
An LTC facility failed to maintain an effective infection control program, as observed in the wound care of two residents. An LPN did not perform hand hygiene or change gloves between dirty and clean tasks, and failed to use barriers for supplies, risking contamination. Interviews with the DON and Wound Care Nurse confirmed these practices did not meet infection control standards.
The facility failed to implement its abuse prohibition policy by not completing required background checks and abuse training for new employees. Several personnel files lacked documentation of criminal background checks, nurse aide abuse registry checks, and Kentucky Adult Caregiver Misconduct Registry (KACMR) checks. Additionally, there was no evidence of abuse training for newly hired staff. Interviews revealed that Human Resources staff were responsible for these checks, which were not consistently completed before employees began work.
A facility failed to report an alleged abuse incident involving a resident with severe cognitive impairment within the required timeframe. CNA 14 witnessed CNA 13 allegedly choking the resident during care, but the report was delayed by 15 hours, hindering prompt investigation. The resident showed no physical signs of abuse, and staff interviews did not substantiate the claim.
A facility failed to develop a comprehensive care plan for a resident using a SoftPro Ambulating AFO boot. The resident, with conditions including hemiplegia and dementia, was unable to self-ambulate due to a broken boot and improper wheelchair footrest positioning. Despite awareness of the broken boot, the care plan was not updated, revealing a lapse in protocol adherence.
The facility failed to ensure proper labeling and storage of medications, with observations of undated, unlabeled, and expired medications in medication and treatment carts. A tube of Silvasorb gel and Diclofenac 1% topical medication were found without proper labeling, and a Cyclobenzaprine pill was found unlabeled in a medication cart. Interviews with staff revealed that the facility's policy did not adequately address documentation of open/expiration dates, and there was an expectation for nursing staff to regularly check and label medications.
Unattended Medications and Syringes Left on Medication Cart
Penalty
Summary
Facility staff failed to store medications and biologicals in a secure manner as required by facility policy and professional standards. During an observation, a medication cart was found unattended and locked, but medications labeled with a resident's name, a capped syringe, and a glucometer with a test strip were left on top of the cart. No staff were present in the area at the time. The facility's policy, reviewed and acknowledged by staff, clearly states that all drugs and biologicals must be stored in locked compartments and not left unattended. Interviews with the LPN involved, the unit manager, a registered nurse, and the Director of Nursing confirmed that leaving medications and syringes unattended on top of the cart was against facility policy and unsafe. The LPN admitted to being aware of the policy but stated he was trying to administer medications on time. Other staff members reiterated that medications and syringes should not be left unattended and that the LPN should have sought assistance if needed.
Failure to Implement Elopement Care Plan and Supervision on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan for a resident assessed as being at risk for elopement. The resident was admitted with dementia with behavioral disturbance, cognitive communication deficit, anxiety, and major depressive disorder, and was placed on a secured memory care unit for safety. An Elopement/Wandering Risk Evaluation identified the resident as a moderate elopement risk, and the comprehensive care plan required that the resident reside on the secured unit with supervision while on the unit. The care plan also included diversion and structured activity interventions such as toileting, walking inside and outside, reorientation strategies with signs and pictures, and use of memory boxes. In the days leading up to the incident, progress notes documented that the resident repeatedly expressed a desire to go home. On the night of the elopement, an alarm sounded on the women’s memory care unit exit door. Staff interviews revealed that CNAs and the LPN on duty were occupied providing showers and care to other residents when the alarm went off. One CNA reported seeing the resident at the exit door and moving her to the dining room but did not know the code to stop the alarm and sought assistance from the LPN. The LPN reported checking the courtyard, stepping outside, and checking resident rooms after the alarm, but staff did not identify that the resident was missing at that time. Another CNA stated that after the alarm was silenced, she returned to showering residents and later noticed the unit was unusually quiet, as the resident was typically loud, but no one was actively looking for the resident. The resident ultimately left the facility unsupervised and without staff knowledge, later being found by citizens in a local park who contacted law enforcement. The sheriff’s officer reported that when he first arrived at the facility and asked staff if the resident was missing, staff stated she was in her room; only after checking the room did they realize she was gone. The resident told the officer and bystanders that she had been held captive and had run away, and she told surveyors she had prayed for an intervention, that both exit doors opened, and that she escaped through a faulty fence slat and ran to the park. She also stated she was very unhappy, did not feel she belonged at the facility, and would leave again if able. Staff interviews confirmed that the care plan interventions requiring supervision on the secured unit and provision of diversional, person-centered activities were not implemented at the time of the elopement because staff were engaged in care of other residents and some staff were unfamiliar with the unit and its procedures.
Removal Plan
- Updated Resident 1 care plan to include increased supervision by staff, implemented q15-minute checks immediately, and completed psychosocial visit/assessment once daily for 3 days
- Completed pain evaluation for Resident 1 (no negative findings)
- Conducted medication and laboratory reviews for Resident 1
- Conducted elopement drills by Maintenance Director to ensure staff comprehension; staff verbally validated understanding
- Completed 100% elopement evaluations on all facility residents by licensed nursing staff
- Reviewed 100% of elopement care plans by MOS Coordinator and Director of Nursing Services
- Completed 100% staff education (including contract staff) on the Elopement policy and procedure by Executive Director, Director of Nursing Services, and department heads; staff verbally validated understanding
- Completed education for Social Services staff and MDS Coordinator on updating resident care plans and implementing interventions; staff verbally validated understanding
- Reviewed all residents’ care plans to ensure elopement risk is reflected on the comprehensive care plan and Kardex
- Implemented requirement that all residents who trigger for 'at-risk' and 'high-risk' will have an elopement care plan
- Revised resident care plans to include residents at risk for elopement
- Reviewed the Elopement Policy by the IDT to include individualized interventions for residents at risk for elopement
- Implemented weekly audits of new admissions for 3 months to ensure elopement risk and interventions are in place and care plan/Kardex updated
- Provided education to nursing staff on updating care plans, elopement evaluation, and Kardex as needed
- Continued staff education plan until complete; no staff (including new hires/contract) may work until educated; staff verbally validated understanding
- Completed elopement risk assessments on all residents by Director of Nursing Services/MOS Coordinator/Therapy Director
- Educated MOS/Social Services on elopement evaluation and implementing individualized interventions (supervision/observation), completing evaluations, following care plan/Kardex, and responding to alarms; staff verbally validated understanding
- Educated 100% of staff on revising care plans after identifying at-risk residents, individualized supervision/observation interventions, completing evaluations, following care plan/Kardex
- MOS Coordinator reviewed all baseline and comprehensive care plans to ensure revisions after identification of at-risk residents per elopement evaluations
- MOS Coordinator reviewed all comprehensive care plans to ensure revisions after identification of at-risk residents per elopement evaluations
- Held an ad-hoc QAPI meeting with leadership/IDT to review the plan and findings
- Forwarded Care Plan and Elopement Assessment audits to the Executive Director for QAPI Committee review monthly for at least 3 months to ensure ongoing compliance
- Held QAPI meetings monthly
- Audited and reviewed all monitoring by Executive Director and/or Director of Nursing Services until ongoing compliance is achieved; corrected deficient practices immediately and referred to QAPI Committee for further review and interventions
Failure to Supervise Exit-Seeking Resident Leads to Elopement from Secure Memory Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe, secure environment for a cognitively impaired resident on a memory care unit, resulting in an elopement. The resident was admitted with dementia with behavioral disturbance, cognitive communication deficit, anxiety, and major depressive disorder, and hospital records indicated the need for a secured, locked unit due to impaired safety decisions and poor safety awareness. On admission, the facility’s elopement/wandering risk evaluation scored the resident as a moderate elopement risk, and the admission MDS showed a BIMS score of five, indicating severe cognitive impairment. The resident’s care plan, initiated shortly after admission and later revised, included goals and interventions to maintain safety on the secure unit, including supervision while on the unit and provision of activities of interest with redirection as needed. In the days leading up to the incident, progress notes documented escalating behaviors and clear exit-seeking. Notes from several days before the elopement described the resident as having behavioral issues, constantly stating a desire to go home, yelling out for God to get her out, and repeatedly expressing a desire to leave. Staff interviews further confirmed that the resident frequently packed a suitcase, made statements about wanting to go home, pushed on exit doors, and watched the doors to see if someone would go out. On the day of the elopement, staff reported the resident was antsy, wanted to get out, and was not redirectable, with social services noting that the resident insisted she needed to get to her dying mother. Despite these known behaviors and documented risks, the resident was placed in a room directly catty-corner to an exit door on the secure unit, and there is no indication in the report that enhanced supervision such as 1:1 monitoring was consistently implemented at the time of the incident. On the evening of the elopement, staff on the women’s memory care unit consisted of one LPN and two CNAs for 16 residents, and all three staff members reported being occupied with other resident care tasks when the alarm sounded. One CNA reported hearing the alarm, going to the exit door, seeing another resident in a wheelchair, moving that resident, and, along with the LPN and another CNA, checking the courtyard and not seeing anyone before the LPN turned off the alarm. Another CNA stated she saw the eloping resident at the exit door when the alarm went off, moved her to the dining room, and then returned to provide a shower to another resident, noting that the door did not lock right away and that no one was actively looking for the resident later. The LPN reported responding from the men’s secure unit when the alarm sounded, checking the courtyard and resident rooms per policy, and stated he did not realize the resident was missing until a law enforcement officer arrived and asked about her. The resident was able to exit the building through the alarmed exit door and then leave the courtyard through a deteriorated wooden gate connected to the privacy fence. The maintenance director later acknowledged that the gate’s wood boards were beginning to deteriorate before the incident and that the resident was able to push through the boards and then place them back, securing the gate with empty plant pots on the opposite side, which led staff to believe the gate was secure when checked. The resident reported that on the night she left, both exit doors near her room opened, that the wood gate was faulty and allowed her to get through, and that she ran to a nearby park where she sat on a bench and told a couple about her escape. Concerned citizens at the park called 911, and a sheriff’s officer responded, found the resident, and then went to the facility, where staff initially stated the resident was in her room and were unaware she had left until they checked and found her missing. The officer reported that no staff member told him they were looking for or missing a resident, and the resident herself stated she was unhappy in the facility, did not feel she belonged there, and would leave again if able. The facility’s own elopement and wandering policy stated that residents at risk for elopement were to receive adequate supervision to prevent accidents, that alarms were not a replacement for necessary supervision, and that staff were to respond to alarms in a timely manner. The policy also required a systematic approach to monitoring and managing residents at risk for elopement, including identification and assessment of risk, implementation of interventions to reduce hazards and risks, and monitoring and modifying interventions as needed, with interventions added to the care plan and communicated to appropriate staff. Despite this, staff interviews revealed that at the time of the elopement, all assigned staff were engaged in other resident care tasks, could not provide supervision or diversional activities as outlined in the care plan, and did not recognize or report the resident as missing until notified by law enforcement. The combination of the resident’s known exit-seeking behavior, placement in a room adjacent to an exit door, a defective courtyard gate, and staff being occupied with other tasks when the alarm sounded led to the resident leaving the secure unit and the facility without staff awareness, resulting in the identified deficiency under F689 for failure to ensure adequate supervision and a hazard-free environment.
Removal Plan
- Conduct elopement drills once per shift to ensure staff comprehension of the elopement drill process.
- Complete a 100% audit of door and lock evaluations with no negative findings.
- Complete 100% elopement evaluations.
- Provide 100% staff education (including contract staff) on the Elopement policy/procedure and appropriate resident supervision.
- Initiate an investigation of the incident, including staff interviews and a root cause analysis.
- Repair the defective courtyard gate by facility staff and a licensed contractor.
- Inspect all doors, locks, and gates throughout the facility to ensure proper functioning.
- Add additional interventions to the resident’s care plan: increased supervision, q15-minute checks for 72 hours, and review of medications and labs.
- Adjust the exit door on the Memory Care Unit to prevent delayed egress.
- Review the Elopement Policy by the IDT to include individualized interventions for residents at risk for elopement.
- Audit new admissions weekly for 3 months to ensure elopement risk and interventions are in place.
- Complete elopement risk assessments on all residents.
- Educate MDS/Social Services on completing elopement evaluations, implementing interventions based on findings (including supervision/observation), and the necessity of staff availability and timely alarm response.
- Hold an Ad-Hoc QAPI meeting with leadership/IDT members to review the plan and findings.
- Forward elopement assessment audits to the Executive Director for QAPI Committee review monthly for at least 3 months to ensure ongoing compliance.
- Hold QAPI meetings monthly.
- Correct any deficient practices identified through monitoring immediately and report/review them through the QAPI Committee until ongoing compliance is achieved.
- Complete elopement drills each shift for 1 day and monthly ongoing.
Improper Food Temperature Monitoring Through Plastic Wrap
Penalty
Summary
Surveyors observed that staff failed to follow proper procedures for checking food temperatures during meal service. Specifically, staff were seen inserting food thermometers through the plastic wrap covering food items such as creamed corn, pureed enchilada casserole, and kernel corn on the steam table, rather than removing the plastic wrap before taking temperatures. According to the USDA guidelines and the facility's own policies, thermometers should be inserted directly into the food, avoiding any barriers like plastic wrap, to prevent cross contamination and ensure accurate temperature readings. Interviews with the Interim Dietary Manager, a staff member, the DON, and the Administrator confirmed that the correct procedure is to remove any plastic or foil covering before inserting the thermometer. The DON and Administrator both acknowledged that piercing plastic wrap could introduce a choking or aspiration hazard and that staff are expected to use clean, dry thermometers and inspect them prior to use. The failure to follow these procedures was identified as a deficiency affecting all residents who received food from the kitchen.
Failure to Develop Baseline Care Plan for Elopement Risk
Penalty
Summary
The facility failed to develop a baseline care plan for a resident identified as at risk for elopement upon admission. The resident, who had a history of hemiplegia, hemiparesis following cerebral infarction, epilepsy, aphasia, and chronic congestive heart failure, was admitted to the facility and assessed as at risk for elopement. Despite this assessment, the facility did not create a baseline care plan with necessary interventions to address the resident's risk for elopement, leading to the resident leaving the facility without staff's knowledge. The resident's clinical records indicated severe cognitive impairment, with deficits in short-term memory, delayed recall, orientation, problem-solving, and safety awareness. The facility's policy required that residents at risk for elopement receive adequate supervision and have a person-centered care plan developed within 48 hours of admission. However, the care plan for this resident did not include interventions for wandering or elopement risk, even after the resident had eloped and was found by emergency services with stroke-like symptoms. Interviews with facility staff revealed a lack of communication and understanding regarding the resident's elopement risk. Several staff members, including LPNs and CNAs, were unaware of the resident's risk for elopement and did not receive guidance from management on monitoring the resident. The facility's interdisciplinary care plan team failed to implement a systematic approach to managing the resident's elopement risk, resulting in the resident's unsupervised departure from the facility.
Removal Plan
- The facility provided an acceptable IJ Removal Plan, alleging removal of the IJ.
Inadequate Supervision and Safety Measures for Residents
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for two residents, leading to significant deficiencies. One resident, admitted with a history of cognitive impairments and assessed as at risk for elopement, was not provided with a care plan addressing this risk. Consequently, the resident left the facility without staff knowledge and was found the next day at a local hospital. The facility's policy required a systematic approach to monitor and manage residents at risk for elopement, which was not effectively implemented in this case. Another resident was admitted without a smoking safety assessment or fall risk assessment, despite having a history of cerebral infarction and requiring assistance with transfers. This resident experienced multiple falls, one resulting in an ankle injury, and was allowed to smoke unsupervised initially. The facility's failure to conduct timely assessments and implement appropriate interventions contributed to the resident's falls and potential safety hazards. Interviews with staff revealed a lack of communication and understanding regarding the residents' risks and the necessary precautions. Staff were unaware of the residents' elopement and fall risks, and there was confusion about the facility's policies and procedures. The facility's inadequate response to these risks and the absence of documented interventions in the care plans highlight the deficiencies in ensuring resident safety and supervision.
Removal Plan
- Implemented a systematic approach for monitoring and managing residents at risk for elopement.
- Conducted a thorough search for R401 and ensured all exit doors, door alarms, and windows were functioning properly.
- Changed door codes to prevent unauthorized exits.
- Placed R401 on one-to-one supervision upon return to the facility.
- Reviewed and revised the facility's policy on elopements and wandering residents.
- Ensured all staff were aware of residents at risk for elopement and the necessary interventions.
- Conducted staff training on the importance of monitoring residents at risk for elopement and the procedures to follow if a resident is missing.
- Implemented a baseline care plan for each resident, including interventions to address safety concerns such as elopement.
Failure to Provide Quarterly Personal Funds Statements
Penalty
Summary
The facility failed to provide residents and/or their guardians with quarterly statements of their personal funds accounts, as required by their policy. This deficiency was identified for five residents who were sampled for personal funds accounts. The facility's policy mandates that individual financial records should be available to residents through quarterly statements and upon request. However, interviews with residents and their representatives revealed that they did not receive these statements unless specifically requested, and in some cases, they had to visit the facility to obtain them. This lack of communication led to confusion about account balances and payments. The Business Office Manager (BOM) acknowledged the issue, noting that the facility was acquired by another company, which delayed the transfer of resident funds accounts. The Director of Nursing (DON) was unaware of the issue and confirmed that not providing quarterly statements violated residents' rights. The Administrator admitted that there were issues with residents receiving their statements, although she claimed that the problem had been resolved since her hire date. Despite these claims, the deficiency persisted, affecting the residents' ability to manage their personal funds effectively.
Facility Fails to Provide Hot Water in Resident Rooms
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the lack of hot water in 14 out of 19 resident rooms. Observations revealed that the water in these rooms remained cold even after running for several minutes, with temperatures recorded as low as 44 degrees Fahrenheit. This issue persisted despite the facility's policy requiring a safe and comfortable environment, and residents reported having no hot water for over a month, impacting their daily living activities such as washing hair. Interviews with residents and staff highlighted the ongoing nature of the problem. Several residents expressed frustration over the lack of hot water, with some stating they had informed the facility's new owner and the Ombudsman about the issue. Staff interviews revealed a lack of awareness and communication regarding the problem, with maintenance personnel unaware of the cold water issue in specific rooms and shower areas. The Maintenance Director admitted to only checking water temperatures in one room per hallway weekly, which may have contributed to the oversight. The facility's infrastructure issues were exacerbated by recent extreme cold temperatures, which caused pipes to burst and ceilings to cave in. This led to a high demand for the limited functional shower facilities, with 72 residents relying on a single shower room at times. The Director of Nursing acknowledged the intermittent hot water supply and the strain on available shower facilities, while the Administrator was unaware of the extent of the cold water issue until recently. Renovations were ongoing, affecting multiple shower rooms, which further complicated the situation.
Deficiency in CNA Performance Reviews and Training
Penalty
Summary
The facility failed to conduct performance reviews for all Certified Nursing Assistants (CNAs) at least once every 12 months, as required. This deficiency was identified for five CNAs whose personnel records were reviewed. Specifically, CNAs #2, #18, #20, #31, and #32 did not have documented performance evaluations within the previous 12 months. Additionally, the facility did not provide evidence of regular in-service education based on the outcomes of these reviews for CNAs #18, #31, and #32. The facility's policy required CNAs to attend a minimum of 12 hours of continuing education annually, but this requirement was not consistently met, as evidenced by the varying hours of training documented in the personnel files. The facility's Executive Director admitted that there was no staffing policy in place, and staffing was based on the facility's assessment. The President of Regional Clinical Operations acknowledged that the facility had undergone a change in ownership, which affected the availability of training and performance evaluation documentation. The new Administrator, who was still acclimating to her role, recognized the importance of performance evaluations in providing feedback and assessing competencies, skills, and knowledge. However, the lack of completed evaluations meant that staff could not benefit from this feedback, potentially impacting their performance and the quality of care provided.
Failure to Submit Accurate Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the third quarter of 2024. This failure resulted in no registered nurse (RN) hours being reported and a lack of licensed nursing coverage for 24 hours a day on four or more days within the quarter, specifically in August and September 2024. The facility's Payroll Based Journal (PBJ) report indicated excessively low weekend staffing and no RN hours during this period. Despite requests, the facility could not provide verification that the staffing data for the third quarter had been successfully submitted to CMS. Interviews revealed that the President of Finance (VPF) was responsible for submitting the payroll data and acknowledged an error in the submission process due to a change in ownership and software transition. The VPF attempted to submit the data on October 14, 2024, but received an error message the following day, indicating the data was not submitted. The Administrator, new to her position during the ownership change, was aware of the software error and understood the importance of timely data submission, as the failure affected the facility's survey outcome and star rating.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper wound care practices observed for two residents, R20 and R67. During wound care for R20, an LPN did not perform hand hygiene when transitioning from dirty to clean tasks, such as after removing a dressing and before opening sterile items. The LPN also failed to place a barrier on the table before placing supplies, and her gown came into contact with open dressings, potentially contaminating the wound. These actions were contrary to the facility's policies on hand hygiene and enhanced barrier precautions. For R67, the LPN similarly neglected to perform hand hygiene and change gloves between dirty and clean tasks during wound care. The LPN placed supplies on an unclean table without a barrier and retrieved a dropped dressing from the floor without discarding it. Additionally, the LPN did not change gloves or wash hands after touching non-sterile items, such as the bed controls and tube feed pump, before handling wound care supplies. These practices were inconsistent with the facility's infection control policies and could lead to contamination and infection. Interviews with the Director of Nursing, Wound Care Nurse/Staff Development Coordinator, and the Wound Doctor confirmed that the observed practices did not meet the expected standards for infection control. They emphasized the importance of hand hygiene, glove changes, and the use of barriers to prevent contamination during wound care. The failure to adhere to these protocols for both residents highlights a significant deficiency in the facility's infection prevention and control program.
Failure to Implement Abuse Prohibition Policy
Penalty
Summary
The facility failed to implement its abuse prohibition policy by not verifying and maintaining documentation of screening and training for new employees. Specifically, the facility did not complete the required criminal background checks, nurse aide abuse registry checks, and Kentucky Adult Caregiver Misconduct Registry (KACMR) checks for 9 out of 12 personnel files reviewed. These checks were either completed after the employees' hire dates or not documented at all. Additionally, there was no evidence that newly hired staff received the mandatory abuse training at the beginning of their employment. The personnel files reviewed revealed several instances where the required checks and training were not completed. For example, Registered Nurses (RNs) and Certified Nursing Assistants (CNAs) had their background checks and registry checks completed after their hire dates, and there was no documentation of abuse training. In some cases, such as with CNA24 and CNA19, there was no evidence of any checks or training being completed. The former administrator's file also lacked documentation of a nurse aide abuse registry check and abuse training. Interviews with the Administrator and the Regional President of Talent and Acquisition highlighted that the Human Resources staff were responsible for completing these pre-employment checks. The Administrator expected these checks to be completed before new employees entered the facility to prevent potential harm to residents. However, the checks were not consistently completed, and the facility's current owners, who took over on September 1, 2024, were not aware of the background checks for employees hired before that date.
Delayed Reporting of Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe, as outlined in their policy. Certified Nursing Assistant (CNA) 14 witnessed CNA 13 allegedly choking Resident 79 during a care incident. This event occurred at approximately 5:20 AM, but the report was not made to the administration until 8:37 PM, resulting in a delay of about 15 hours. This delay hindered the facility's ability to promptly investigate the alleged abuse. Resident 79, who has severe cognitive impairment due to dementia, was reportedly combative during care, which led to the alleged incident. The resident was later assessed and showed no physical signs of abuse, such as bruising or changes in voice. The facility's policy mandates immediate reporting of abuse allegations, but this was not adhered to, as the report was significantly delayed. Interviews with staff revealed that CNA 14 delayed reporting the incident, and there was no corroborating evidence from other staff or physical signs on the resident to substantiate the abuse claim. The Interim Administrator and Director of Nursing confirmed the expectation for immediate reporting of such incidents, which was not met in this case, leading to a deficiency in the facility's handling of the situation.
Failure to Develop Comprehensive Care Plan for AFO Boot
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as R22, who was wearing a SoftPro Ambulating ankle foot orthoses (AFO) boot. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, cerebral infarction, and dementia, was assessed as cognitively intact. Despite this, the care plan did not address the use of the AFO boot, which was necessary for the resident's mobility and safety. Observations revealed that the resident could not self-ambulate in his wheelchair due to a broken AFO boot, and his foot was dragging on the floor because the wheelchair footrest was not elevated. Interviews with the Director of Nursing (DON) and the Minimum Data Set Coordinator (MDSC) revealed a lack of awareness and assumption that the care plan for the AFO boot was in place. The DON acknowledged the boot was broken and had ordered a replacement but was unaware that the care plan was not updated. The MDSC stated that care plans should be completed promptly, and the Administrator emphasized the importance of updating care plans within 24 hours of admission. Despite these protocols, the care plan for the AFO boot was not developed, indicating a lapse in the facility's adherence to its own guidelines and federal requirements.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled in accordance with professional standards, as evidenced by observations of undated, opened, unlabeled, and expired medications in one of five medication carts and one of two treatment carts. Specifically, a tube of Silvasorb gel with an expiration date of July 2024 was found without a label or identifier, and a tube of Diclofenac 1% topical medication was found without an open date or storage bag for a resident. Additionally, a pill of Cyclobenzaprine 5 mg was found separated from its pack and unlabeled in the medication cart for the B hall. Interviews with nursing staff revealed that the pharmacy inspects the carts monthly, but the facility's policy did not adequately address the documentation of open/expiration dates or the labeling of medications. Interviews with the Unit Manager, Staff Development, and the Director of Nursing (DON) highlighted the expectation that expired medications should not be present in the carts and that medications should be labeled with open dates and resident identifiers. The Unit Manager stated that nursing staff were responsible for weekly and monthly checks of the medication and treatment carts, while the DON emphasized the importance of checking expiration dates daily. The Administrator reiterated the expectation that medications should not be in the carts without personal containers and identifiers, and that loose medications must be destroyed. The lack of proper labeling and storage of medications poses a risk of medication errors, as noted by the staff development personnel.
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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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