Madonna Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Villa Hills, Kentucky.
- Location
- 2344 Amsterdam Road, Villa Hills, Kentucky 41017
- CMS Provider Number
- 185241
- Inspections on file
- 19
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Madonna Manor during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as identified by surveyors.
A resident with moderate cognitive impairment was improperly restrained by a Dining Aide who tied a washcloth to the wheel of the resident's wheelchair to prevent wandering. This action was witnessed by a STNA who did not report it. The facility's policy prohibits the use of physical restraints unless medically necessary, and the Administrator confirmed that such restraint is not a standard for quality care.
A resident with dementia fell from her wheelchair after a Dining Aide tied a washcloth to the wheel, witnessed by an STNA who failed to report the incident. The resident, assessed as moderately cognitively impaired, was at risk for falls. The facility's policy required immediate reporting of such incidents, which was not followed, leading to a violation of the abuse policy.
The facility failed to notify the physician of significant changes in the condition of two residents, leading to serious health consequences. One resident experienced a significant change in mental status, which was not reported, resulting in a critical emergency department admission. Another resident developed an unstageable wound that worsened due to delayed notification and treatment. Interviews revealed a lack of adherence to the facility's policy for notifying physicians of changes in residents' conditions.
The facility failed to develop timely baseline care plans for two residents, leading to inadequate care. One resident with an infection and PICC line did not have a care plan addressing these needs, resulting in a transfer to the ED with sepsis. Another resident at risk for pressure injuries developed a severe heel wound due to a lack of interventions in the care plan. Staff interviews revealed confusion about responsibilities for initiating and revising care plans.
A resident with a post-surgical infection did not receive several doses of prescribed antibiotics due to the facility's failure to administer them as ordered. Despite a significant change in the resident's mental status being observed, neither the RN nor the LPN conducted an assessment or notified the physician. The resident's family later found the resident unresponsive and requested an emergency transfer to the hospital, where the resident was admitted with life-threatening conditions.
A resident admitted with post-surgical infection did not receive several doses of prescribed antibiotics, cefepime and metronidazole, as ordered. The resident's family found them unresponsive and febrile, leading to a hospital transfer where they were diagnosed with sepsis and atrial fibrillation. Interviews revealed that the LPN fell behind on medication administration, and there was no formal documentation of medication audits.
A resident at an LTC facility developed an unstageable pressure ulcer due to the facility's failure to implement necessary interventions and conduct regular skin assessments. Despite being at risk, the resident did not receive adequate pressure off-loading measures, and discrepancies in documentation further delayed appropriate care.
The facility failed to maintain an effective infection prevention and control program, as staff did not adhere to PPE protocols and proper cleaning of shared medical equipment. An APRN and RN entered a contact isolation room without wearing gowns and gloves, while an LPN mishandled a contaminated glucometer by not following cleaning protocols. Despite training, staff did not consistently implement infection control practices.
A resident's privacy was compromised when an LPN administered an insulin injection at a dining table in view of other residents, contrary to facility policy. The resident had consented to the procedure to avoid her meal getting cold, but the facility's protocol requires private administration of medical treatments to ensure dignity and privacy.
A facility failed to store medications according to professional standards when a pharmacy delivery tote was left unattended and unsecured on a medication cart. The tote contained various medications, including albuterol, IV fluids, and heparin, and was found in a public area. Interviews with staff confirmed that medications should be stored in locked compartments immediately upon receipt, highlighting a lapse in following facility policy.
A resident in an LTC facility was denied a COVID-19 test despite exhibiting symptoms and a family member's request. The facility's policy allowed for testing upon request, but staff refused, citing no positive cases in the facility. Interviews revealed a lack of adherence to the facility's COVID-19 testing guidelines.
A facility failed to document whether a resident with COPD and Alzheimer's received or refused the influenza vaccine for 2023-2024. Despite policies requiring documentation, the resident's immunization record lacked this information. Interviews with the IP Nurse and DON confirmed that education and consent were provided, but documentation was missing. The Administrator expected records to reflect immunization status.
The facility failed to ensure effective communication with residents' families, leading to distress and concern. Two residents' family members reported being unable to reach the facility due to unanswered calls and full voicemail boxes. Staff interviews revealed systemic issues with the phone system, including a lack of responsibility for checking messages and informing families of updated contact numbers.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified by surveyors based on observations or events that indicated the environment posed risks for accidents and that supervision was insufficient to prevent such incidents. No additional details about specific residents, their medical history, or the exact nature of the hazards or accidents were provided in the report.
Resident Restrained with Washcloth in Wheelchair
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by an incident involving a Dining Aide (DA) who tied a washcloth around one wheel of a resident's wheelchair. This action was taken to prevent the resident from wandering around the facility. The resident, identified as having moderate cognitive impairment and a history of dementia, was found on the floor by an Activity Assistant, which led to the discovery of the restraint. The resident, who was admitted to the facility with diagnoses including dementia and cognitive communication deficit, was assessed to be ambulatory and capable of self-propelling in a manual wheelchair. Despite this, the DA's action of tying a washcloth to the wheelchair wheel was witnessed by a State Trained Nurse Aide (STNA), who failed to report the incident. The facility's policy clearly states that residents have the right to be free from physical restraints unless required for medical treatment, and the tying of the washcloth was not in line with this policy. The Administrator was informed of the incident after the resident was found on the floor. An investigation was initiated, revealing that the washcloth was used as a restraint, which is not a standard for quality care. The Administrator confirmed that the use of a washcloth to restrict a resident's movement is considered a form of physical restraint, which is against the facility's policy and residents' rights.
Failure to Implement Abuse Policy Leads to Resident Fall
Penalty
Summary
The facility failed to implement its abuse policy for one of the sampled residents, identified as R15. A Dining Aide (DA1) tied a washcloth around one wheel of R15's wheelchair, which was witnessed by a State Trained Nurse Aide (STNA13) who did not report the incident. This action led to R15 falling from her wheelchair. The facility's policy required staff to immediately report any incidents of abuse, neglect, or mistreatment to the Administrator, who would then report to the appropriate agencies. However, STNA13 did not report the incident, which was a violation of the facility's policy. R15 was admitted to the facility with diagnoses of dementia, cognitive communication deficit, and disorientation. The resident was assessed to be moderately cognitively impaired and used a manual wheelchair for mobility. R15's Comprehensive Care Plan indicated a risk for falls due to impaired mobility and other health conditions. Despite these known risks, the incident occurred when DA1 tied a washcloth to the wheelchair, making it stationary and leading to R15's fall. The incident was discovered when Nurse 8 was called to assess R15, who was found lying on the floor with no physical injuries. During interviews, it was revealed that STNA13 was unsure if the washcloth constituted a restraint and did not report it. The Administrator confirmed that tying a washcloth to a wheelchair to restrict movement was a form of physical restraint and not in line with quality care standards. The failure to report the incident by STNA13 conflicted with the facility's policy on reporting abuse.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in the physical status of two residents, leading to serious health consequences. For one resident, a significant change in mental status was observed by a registered nurse, but the physician was not notified. The resident's condition worsened, and the family eventually found the resident unresponsive and requested emergency medical services. The resident was admitted to the emergency department with altered mental status, sepsis, and atrial fibrillation with rapid ventricular response. In another case, a physical therapist discovered an unstageable wound on a resident's heel, but the nursing staff did not notify the physician immediately. The wound worsened over several days, and the resident experienced pain and difficulty with mobility. The wound care physician was eventually notified and provided new treatment orders, but the delay in notification and treatment likely contributed to the wound's deterioration. Interviews with staff and family members revealed a lack of adherence to the facility's policy for notifying physicians of changes in residents' conditions. The nursing staff failed to assess and document the residents' conditions promptly, and there was a breakdown in communication between the nursing staff and other healthcare providers. This failure to follow established procedures put the residents at risk for serious harm.
Removal Plan
- An Ad Hoc QAPI meeting was held with DON, Medical Director and ED discussing IJ regarding Notification of Changes for Medical Director input.
- Notification of Changes policy was reviewed by the Director of Clinical Risk Management.
- The Director of Clinical Risk Manager provided education for the Director of Nursing, Executive Director and Nurse Managers regarding the Notification of Changes policy.
- The Executive Director, Corporate Clinical Leadership Team, Director of Clinical Risk, DON discussed the Notification of Changes policy and the plan for the abatement.
- Education was provided by Nurse Managers for all nurses and KMAs regarding Notification of Changes policy. Agency nurses were educated prior to their shift by DON/Nurse Managers. 25/28 completed = 93%, 1 nurse on leave will be educated by DON/Nurse Managers prior to her return to work., 2 staff still to complete prior to their next shift.
- All nurses and KMAs who are hired will be educated by the DON/Nurse Managers regarding the Notification of Changes policy prior to working.
- All progress notes were reviewed by DON/Nurse Manager for changes in condition of identified residents and proper notification of MD and Responsible Party as appropriate.
- Information was given to STNAs, housekeepers and dietary staff regarding what to do when you notice a change in a residents' condition. Information sent by ED via text.
- The 24 hour report sheet and the 24 hour summary in Point Click Care (PCC) will be reviewed by DON/Nurse Manager daily for appropriate notification of changes in the morning Clinical Meeting.
- DON/Nurse Managers administer quizzes to nurses and KMAs regarding Notification of Changes in Condition and report results to QAPI team. If a question is missed, DON/Nurse Managers will educate the nurse immediately and document the education.
- DON reported audit results regarding notification of changes missed at the QAPI meeting and will continue to report audit results and how findings were resolved to QAPI weekly for 4 weeks then every other week until substantial compliance is achieved.
- QAPI meeting was attended by Medical Director, Nurse Practitioner, ED, DON, Diet Tech, Nurse Managers, IP Nurse, Social Worker designee, Director of Facilities, Business Office Manager, MOS nurse, Director of Therapy and Life Enrichment Director. IJ abatement plan audits, results, and follow up were discussed.
- Next QAPI meeting scheduled.
Failure to Implement Timely Baseline Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours for two residents, R2 and R3, which resulted in deficiencies in providing effective and person-centered care. R3 was admitted with an intrathecal pain pump infection and was receiving intravenous antibiotic therapy via a PICC line. However, the facility did not create a baseline care plan addressing R3's infection, antibiotic therapy, PICC line care, or procedures for physician notification in case of a worsening condition. This oversight led to R3 being transferred to the emergency department with an altered mental status, sepsis, and atrial fibrillation with rapid ventricular response. R2 was admitted with a risk for developing pressure injuries, and an unstageable wound on the left heel was identified by the physical therapy staff. Despite this, R2's baseline care plan did not address the existing skin issues or include interventions to prevent further deterioration. The wound worsened significantly over a few days, leading to pain and the need for treatment at another facility. The facility's failure to revise R2's care plan to include necessary interventions for skin breakdown contributed to the resident's decline. Interviews with facility staff revealed a lack of clarity and responsibility regarding the initiation and revision of baseline care plans. LPN1 was unaware of her responsibility to initiate care plans, and the MDS Nurse indicated that care plans were sometimes delayed due to admissions occurring during off-hours. The Interim Director of Nursing and other staff members acknowledged the importance of including health and safety concerns in baseline care plans but could not identify why the care plans for R2 and R3 were incomplete.
Removal Plan
- An Ad Hoc QAPI meeting was held with DON, Medical Director and ED discussing IJ regarding Baseline Care Plans for Medical Director input.
- The Director of Clinical Risk Management educated the DON and Nurse Managers on the Baseline Care Plan Policy.
- The Executive Director, Corporate Clinical Leadership Team, Director of Clinical Risk, DON discussed the Baseline Care Plan policy and the plan for the abatement.
- The Director of Clinical Reimbursement and the MDS nurse audited all baseline care plans for completion and accuracy. If the baseline care plan was missed, comprehensive care plans from admissions have been completed.
- Education was provided by DON/Nurse Managers for all nurses and KMAs regarding the Baseline Care Plan policy. Agency nurses are educated prior to their shift by the DON/Nurse Managers. 100% of nurses educated (1 nurse on leave will be educated prior to returning to work by the DON/Nurse Managers).
- DON/Nurse Managers administer quizzes to nurses and KMAs regarding Baseline Care Plans and report results to the QAPI team weekly. Any nurses/KMAs not receiving a 100% correct will receive 1:1 education provided by the DON/Nurse Managers.
- DON/Nurse Managers will audit Baseline Care Plan daily 7 days per week in morning clinical meetings. 100% Baseline Care Plans have been completed per policy.
- DON/Nurse Managers reported results of the audit of baseline care plans, issues that needed resolution and how resolution was achieved to the QAPI committee and will continue to report to QAPI weekly for 4 weeks and then every other week until substantial compliance is achieved.
- QAPI meeting was attended by Medical Director, Nurse Practitioner, ED, DON, Diet Tech, Nurse Manager, IP Nurse, Social Worker designee, Director of Facilities, Business Office Manager, MDS nurse, Director of Therapy and Life Enrichment Director. IJ abatement plan audits, results, and follow up were discussed.
- The next QAPI meeting will review Baseline Care Plan completion.
Failure to Administer Medications and Respond to Change in Condition
Penalty
Summary
The facility failed to promptly identify and intervene with a significant change in a resident's condition, leading to a deficiency in providing treatment and care according to professional standards of practice. A resident, identified as R3, was admitted with a post-surgical infection of the intrathecal pain pump and was prescribed a two-week course of intravenous antibiotic therapy via a PICC line. However, the resident missed several doses of the prescribed antibiotics, both intravenous and oral, due to the facility's failure to administer them as ordered. This lapse in medication administration contributed to the resident's deteriorating condition. On a particular morning, a registered nurse observed a significant change in R3's mental status but failed to conduct a thorough assessment or notify the physician. During the shift change, this information was communicated to an LPN, who also did not assess the resident or notify the physician. It was not until the resident's family alerted the staff later that morning that the resident was found to be febrile, unresponsive, and exhibiting tremors. The family requested an emergency transfer to the hospital, where the resident was admitted with life-threatening conditions, including sepsis and atrial fibrillation. The facility's policy required that residents receive care in accordance with professional standards, including timely medication administration and appropriate response to changes in condition. However, the facility failed to adhere to these standards, as evidenced by the lack of documented assessments and the missed doses of antibiotics. The failure to follow established policies and procedures resulted in the resident's hospitalization and critical care admission, highlighting a significant deficiency in the facility's quality of care.
Removal Plan
- An Ad Hoc QAPI meeting was held with DON, Medical Director and ED to discuss quality of care related to Medication Administration, Baseline Care Plans, and Notification of Changes in Resident Condition for Medical Director input.
- Notification of Changes Policy, the Baseline Care Plan Policy and the Medication Administration Policy were reviewed immediately for accuracy by the Director of Clinical Risk Management.
- The Executive Director, Corporate Clinical Team and DON discussed the Notification of Changes in Condition, Medication Administration, and Baseline Care Plan policies and the plan for abatement.
- The Executive Director, Corporate Clinical Team and DON discussed the Provision of Quality Care policy.
- The Director of Clinical Risk Management educated the DON, Nurse Managers and ED regarding Baseline Care Plans, Medication Administration and Notification of Changes in Resident Condition and Provision of Quality Care policies.
- The DON/Nurse Managers provided education for all nurses and KMAs regarding Notification of Changes, Baseline Care Plan, and Medication Administration policies and provisions of the Quality of Care policy prior to their next shift. Agency nurses received education prior to their shift by DON/Nurse Managers. 100% completion of active staff, 1 nurse on leave will be educated by the DON/Nurse Manager prior to returning to work.
- Going forward all newly hired nurses and all agency staff will be educated by the DON/Nurse Managers on the Notification of Changes, Baseline Care Plan, Medication Administration, Provision of Quality Care policies and the Nurse Clinical Binder.
- DON/Nurse Managers completed an audit of all progress notes for changes in condition of identified residents and proper notification of MD and Responsible Party as appropriate.
- STNAs, Housekeepers and Dining staff received information via text regarding: if they notice a change in a residents' condition that they should report it to the nurse immediately.
- Director of Clinical Risk Management/DON audited all missed meds for identified residents using the Medication Administration Audit Report.
- DON notified the Medical Director of results of the Medication Admin Audit report and asked for any new orders. No new orders given. DON notified responsible parties of any current affected residents.
- The Director of Clinical Reimbursement and MDS nurse audited baseline care plans for admissions for completion and accuracy. If incomplete or inaccurate, comprehensive care plans have been completed by the Director of Clinical Reimbursement/MOS nurse.
- In morning clinical meeting- DON/Nurse Managers review 24 hour report sheet and 24 hour summary report in PCC daily for appropriate notification of changes in resident condition. The DON reported results of the audit to the QAPI committee and will continue to report audit results to QAPI weekly for 4 weeks then every other week until substantial compliance is achieved.
- The Medication Admin Audit Report in PCC is completed daily by DON/Nurse Managers. Missed medications will be reported to the MD and responsible party immediately as per policy by the DON/Nurse Manager. Report audit results to QAPI weekly for 4 weeks then every other week until substantial compliance is achieved.
- Nurse Managers provide daily 1:1 Nurse/KMA coaching to ensure medication administration per MD orders and following the nursing process to assure quality care.
- Audit of baseline care plans will be by the DON/Nurse Managers daily with immediate follow up. 100% compliance has been achieved to date. DON reported results to QAPI committee and will continue to report audit results to QAPI weekly for 4 weeks then every other week until substantial compliance is achieved.
- QAPI meeting was attended by Medical Director, Nurse Practitioner, ED, DON, Diet Tech, Nurse Manager, IP Nurse, Social Worker designee, Director of Facilities, Business Office Manager, MOS nurse, Director of Therapy and Life Enrichment Director. IJ abatement plan audits, results, and follow up were discussed.
- Next QAPI meeting scheduled.
Failure to Administer Antibiotics as Ordered
Penalty
Summary
The facility failed to ensure that a resident, identified as R3, was free from significant medication errors during their stay. R3 was admitted with diagnoses including post laminectomy syndrome and a post-surgical infection of the intrathecal pain pump, requiring intravenous antibiotic therapy. However, the facility did not administer several doses of the prescribed antibiotics, cefepime and metronidazole, as ordered by the physician. Specifically, R3 missed four doses of cefepime and five doses of metronidazole, and some doses were administered outside the scheduled time frame, contrary to the facility's medication administration policy. On one occasion, R3's family found the resident febrile, unresponsive, and exhibiting tremors, prompting them to alert a Licensed Practical Nurse (LPN). The LPN had not administered the 9:00 AM dose of IV antibiotics by the time the family raised concerns. R3 was subsequently transferred to the emergency department, where they were diagnosed with an altered mental status, sepsis, and atrial fibrillation with rapid ventricular response. The resident required critical care and was hospitalized for 12 days. Interviews with facility staff, including the LPN, Advanced Practice Registered Nurse (APRN), Medical Director, and others, revealed expectations that medications should be administered as ordered to prevent infection recurrence and ensure resident safety. However, the LPN admitted to falling behind on medication administration due to a busy day and did not seek assistance. The Interim Director of Nursing (IDON) acknowledged that there was no formal documentation of medication administration audits, which contributed to the oversight in ensuring timely and accurate medication delivery.
Removal Plan
- An Ad Hoc QAPI meeting was held with DON, Medical Director and ED discussed IJ regarding Medication Administration for Medical Director input.
- The Corporate Clinical team, VP of Operations, Executive Director and DON discussed the Medication Administration policy and the plan for abatement.
- The Director of Clinical Risk Management reviewed the Medication Administration policy.
- The Director of Clinical Risk Management educated the DON and Nurse Managers regarding the Medication Administration policy.
- The Director of Clinical Risk Management and the DON audited all missed meds using the Medication Admin Audit Report in PCC and communicated with MD and responsible party as needed.
- The DON/Nurse Managers provided education for all nurses and KMAs regarding Medication Administration policy and the Nurse Clinical Binder. Agency Nurses are educated prior to their shift. 100% complete with 1 nurse on leave who will be educated prior to her return to work.
- Nurses were educated by the DON/Nurse Managers on the Nurse Clinical Binder that includes information on Daily Nurse Expectations, pharmacy cut off times, admission/readmission orders, what to do when a medication is unavailable, what to do when someone admits to the facility, what to do when a resident receives new orders, what to do when sending someone to the hospital, what to do when you receive medications from the pharmacy and Medication Administration Special Considerations. Education was initially completed by the DON at the Monthly All Staff Clinical Meeting. The DON/Nurse Managers started referencing the Nurse Clinical Binder as education on step by step guides for nurses and KMAs.
- DON/Nurse Managers administer quizzes to nurses and KMAs regarding Medication Administration. DON/Nurse Managers follow up with Nurse/KMA if a question is missed and reports results to QAPI team.
- DON/Nurse Manager completes audit using Medication Admin Audit Report in PCC. DON/ Nurse Managers address issues immediately with appropriate nurse or KMA and assures follow up regarding notification policy.
- Nurse Managers provided 1:1 Nurse/KMA coaching to ensure medication administration per MD orders.
- DON/Nurse Managers compare the hospital discharge summary to the MD orders in PCC for all new admissions, to assure accuracy and timeliness of medication administration. Results of the audits will be reported to the QAPI committee until substantial compliance is achieved.
- DON/Nurse Manager reported results of audits, follow up, and trends to QAPI committee and will continue to report data to QAPI until we are in substantial compliance.
- QAPI meeting was attended by Medical Director, Nurse Practitioner, ED, DON, Diet Tech, Nurse Manager, IP Nurse, Social Worker designee, Director of Facilities, Business Office Manager, MDS nurse, Director of Therapy and Life Enrichment Director. IP abatement plan audits, results, and follow up were discussed.
- The next QAPI meeting is scheduled.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate pressure ulcer prevention and care for a resident, identified as R2, who was admitted with a history of idiopathic hydrocephalus, peripheral vascular disease, and atherosclerosis with ulceration. Upon admission, R2 was assessed as being at risk for pressure ulcer development, yet the facility did not implement necessary interventions to prevent pressure ulcers or manage existing ones. Despite having a baseline care plan that included some interventions, the facility did not ensure the use of pressure off-loading boots or off-load the wound while the resident was in bed or a wheelchair. The deficiency was further compounded by the facility's failure to conduct regular skin assessments as ordered. Although there was an order for weekly skin assessments, only one was documented during R2's stay. The facility's records also showed discrepancies in the documentation of R2's skin condition, with some notes indicating intact skin while others noted skin breakdown. The nursing staff did not update the treatment administration record or baseline care plan to reflect the necessary interventions for R2's pressure ulcer care, despite recommendations from the Advanced Practice Registered Nurse and the Physical Therapy staff. Interviews with staff and family members revealed a lack of communication and adherence to care protocols. The family expressed concerns that their requests for pressure off-loading were not honored, and the former Director of Nursing could not recall critical details about the timeline of the wound's development and treatment. The Infection Preventionist/Wound Care Nurse and the Wound Care Physician were not informed promptly about the wound, leading to delays in appropriate treatment. This lack of timely intervention and documentation contributed to the development of an unstageable pressure ulcer on R2's left heel, which was not present upon admission.
Infection Control Deficiencies in PPE Use and Equipment Cleaning
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to proper infection control protocols. In one instance, a resident under contact isolation precautions was visited by an Advanced Practice Registered Nurse (APRN) and a Registered Nurse (RN) who both failed to wear the required personal protective equipment (PPE) such as gowns and gloves. The APRN was observed sitting on the resident's unmade bed, which she later acknowledged was inappropriate and could facilitate the spread of infection. Both the APRN and RN admitted to knowing the facility's policy on PPE use but did not adhere to it during their interactions with the resident. Another deficiency was observed with a Licensed Practical Nurse (LPN) who mishandled a contaminated glucometer after performing a blood glucose fingerstick on a resident. The LPN was seen carrying the glucometer without gloves and placing it on a medication cart without a protective barrier. Despite being aware of the correct cleaning protocol, the LPN failed to clean the glucometer immediately and did not follow the manufacturer's instructions for the required dwell time for disinfection. This lapse in protocol was repeated on a separate occasion, indicating a pattern of non-compliance with infection control procedures. Interviews with the Infection Preventionist/Wound Care Nurse (IP/WCN) and the Interim Director of Nursing (IDON) revealed that staff had received training on infection prevention and control practices, including the use of PPE and cleaning protocols. However, there was no documentation of staff audits to ensure compliance with these practices. The Executive Director also expressed the expectation that staff adhere to the facility's infection control policies to prevent the spread of infection, yet the observed deficiencies indicate a failure to consistently implement these protocols.
Failure to Ensure Resident Privacy During Medical Procedure
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident, identified as R8, during a medical procedure. On 12/18/2024, an LPN administered an insulin injection to R8 at a dining table in the presence of other residents. R8, who was cognitively intact with a BIMS score of 15, had consented to receive the injection at the table to avoid her meal getting cold. However, this action was against the facility's policy, which mandates that medical treatments be conducted privately to respect residents' rights to privacy and dignity. The LPN admitted to not providing privacy during the procedure and acknowledged that she did not consult other residents about their comfort with the situation. The interim Director of Nursing and the Executive Director both confirmed that the facility's protocol requires medication administration to occur privately, regardless of resident consent, to maintain dignity and privacy. The Director of Clinical Risk Management stated that the facility adheres to CMS nursing care standards, emphasizing the importance of following established policies to ensure appropriate care.
Unattended Pharmacy Delivery Tote Leads to Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored according to professional standards, as evidenced by an incident involving an unattended and unsecured pharmacy delivery tote. During an observation, a medication cart in Household B Hall was found with an opened pharmacy delivery tote containing various medications, including albuterol inhalation solution packets, IV fluid bags, heparin flush injections, and IV ceftriaxone bags. The tote was left unattended in a public area where residents and staff were passing by, contrary to the facility's policy that requires medications to be stored in locked compartments accessible only to authorized personnel. Interviews with facility staff, including an LPN, an RN, the Interim Director of Nursing, and the Executive Director, confirmed that the medications should have been stored in the medication room or the designated medication cart immediately upon receipt from the pharmacy. The LPN admitted to leaving the tote unattended while administering medication to a resident, and both the RN and the Interim Director of Nursing acknowledged the potential safety risks posed by leaving medications unsecured. The Executive Director emphasized the expectation that staff adhere to the facility's policy to ensure the safe and appropriate care of residents.
Failure to Administer COVID-19 Test Upon Request
Penalty
Summary
The facility failed to ensure that a resident, identified as R10, was informed of and able to participate in their treatment, specifically regarding COVID-19 testing. Despite the facility's policy allowing residents to request COVID-19 tests, staff refused to administer a test to R10 when requested by the resident's family member. The facility's policy stated that anyone with even mild symptoms should receive a viral test, but staff denied the request, claiming there were no positive COVID cases in the facility. This refusal occurred despite R10 exhibiting symptoms such as a slight cough and runny nose. Interviews with family members and staff revealed that the facility did not follow its own policies regarding COVID-19 testing. The Infection Preventionist Nurse and the Director of Nursing both stated that residents could request a COVID test at any time and that there was no reason to deny such a request. However, the family member's request for a test was not fulfilled, and there was no documentation of COVID testing or results in R10's records. This incident highlights a failure in communication and adherence to established protocols, resulting in the resident not receiving the requested COVID-19 test.
Deficiency in Documenting Influenza Immunization
Penalty
Summary
The facility failed to ensure that a resident's medical record included documentation indicating whether the resident received or refused the influenza immunization for the 2023-2024 season. This deficiency was identified for one of the five sampled residents, who was admitted with chronic obstructive pulmonary disease (COPD) and Alzheimer's disease. The resident's immunization record lacked evidence of the administration or refusal of the influenza vaccine, despite the facility's policy requiring such documentation. Interviews with the Infection Preventionist (IP) Nurse and the Director of Nursing (DON) revealed that residents were provided with educational information about vaccines and that consent was obtained before administration. However, the documentation of this process was missing in the resident's chart. The Administrator confirmed the expectation that medical records should reflect either the administration or refusal of immunizations, in line with the facility's infection prevention guidelines.
Communication Failures in Resident Care
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, particularly in maintaining communication with family members. Two residents, R7 and R10, were involved in incidents where their family members were unable to reach the facility via telephone. R7's family member reported multiple unsuccessful attempts to contact the facility to check on the resident's condition after a COVID diagnosis, only to find out later that the facility had changed its phone numbers without notifying them. Similarly, R10's family member experienced difficulties reaching the facility, leading to concerns about the resident's well-being. Interviews with staff revealed systemic issues with the facility's phone system. The DON and other staff members acknowledged that calls were often not answered, went straight to voicemail, or were not returned due to full mailboxes. The facility's policy allowed for calls to be forwarded to staff cell phones after hours, but there was no designated person responsible for checking and returning messages. This lack of communication was further compounded by the fact that family members were not informed of updated contact numbers, leading to confusion and distress. The facility's failure to maintain effective communication channels was evident during the surveyor's attempt to contact the facility, which also resulted in a full voicemail box. Interviews with the receptionist and other staff highlighted a lack of clarity and responsibility in handling incoming calls, especially after hours. The administrator confirmed that the facility had sent updated phone numbers to residents and families, but the ongoing communication issues suggested that this information was not effectively disseminated or utilized.
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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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