Mt. Sterling Health & Rehab, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Sterling, Kentucky.
- Location
- 125 Sterling Way, Mount Sterling, Kentucky 40353
- CMS Provider Number
- 185242
- Inspections on file
- 20
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Mt. Sterling Health & Rehab, Llc during CMS and state inspections, most recent first.
The facility failed to provide adequate supervision and a hazard-free environment for three residents, resulting in two falls and unsafe medication handling. One resident, cognitively intact but requiring two-person assistance and supervision for toileting, was transferred to the bathroom by a single aide and left alone on the commode, where the resident was later found on the floor. Another resident with severe cognitive impairment and high fall risk, care planned for two-person transfers but without specific supervision interventions for time spent in a common area, sustained an unwitnessed fall from a chair in the TV area, resulting in facial injuries and a nasal fracture. A third resident with severe cognitive impairment, not assessed to self-administer medications, was observed with a cup of crushed medications in pudding left unattended at the bedside, contrary to facility policies requiring direct observation of medication administration and secure storage.
A resident with severe physical and cognitive impairments was injured during a transfer when two SRNAs failed to extend the legs of a mechanical lift and improperly pulled on the lift pad, causing the device to tilt and strike the resident's head. The incident resulted in a laceration and required emergency medical care. Investigation confirmed the lift was functioning properly and the injury was due to staff not following established safe transfer procedures.
A resident with severe cognitive impairment and multiple medical conditions developed significant bruising on her chest, which was observed by nursing staff and assessed by the DON. However, the resident's family was not notified of the injury until several days after it was first identified, resulting in a delay in communication about the resident's condition.
Multiple lapses in infection prevention and control were observed, including failure to change and date oxygen equipment as required, lack of hand hygiene by staff during meal service and wound care, improper cleaning of shared equipment such as gait belts, and inadequate use of personal protective equipment when handling soiled linens. These actions and inactions were inconsistent with facility policies and contributed to the deficiency.
Two residents did not have complete or properly implemented care plans: one lacked a care plan for a dialysis catheter despite visible signs of redness and dried blood, and another received oxygen at rates above physician orders, with staff failing to consistently check and match oxygen settings to care plans. Staff interviews confirmed gaps in care planning and monitoring for both residents.
A resident with chronic respiratory conditions was observed receiving oxygen at rates higher than the physician-ordered 4 L/min via nasal cannula on multiple occasions. Staff interviews confirmed that the oxygen concentrator was not always set according to orders, and the resident experienced repeated hospitalizations for respiratory issues. Facility policy and leadership expected staff to check and follow oxygen orders, but this was not consistently done.
A facility failed to sustain an effective QAPI program, resulting in a repeat deficiency when staff exited a resident's room on droplet precautions with a used, uncleaned gait belt. Despite prior education and audits, staff did not consistently clean shared equipment between uses, and monitoring of these practices had ceased, leading to ongoing infection control concerns.
The facility failed to properly store and handle medications, biologicals, and vaccines, leading to deficiencies in three medication storage rooms. Vaccines were improperly stored, and refrigerator temperatures were not maintained, affecting medication integrity. Medication carts were left unlocked, and keys were improperly stored, risking unauthorized access. Staff lacked awareness of proper storage practices, and documentation for controlled substances was incomplete.
The facility failed to maintain sanitary food storage conditions in three nourishment unit refrigerators. Ice packs were improperly stored in the Sterling and Bluegrass Unit freezers, and the Lakeview Unit refrigerator lacked a thermometer and temperature log. Staff interviews confirmed the risk of cross-contamination and the absence of required temperature monitoring.
The facility failed to provide appropriate care for residents with limited range of motion (ROM) due to the absence of a restorative nursing program (RNP). Observations and interviews revealed that residents with ROM impairments were not receiving targeted interventions, and staff lacked training and guidance in providing restorative care. The facility's staffing records showed no restorative staff on duty, and the program had not been reinstated since the COVID-19 pandemic.
The facility failed to follow proper infection control practices, including inadequate cleaning of shared medical equipment like glucometers and mechanical lifts, improper storage of supplies, and use of expired disinfecting wipes. Staff did not adhere to hand hygiene protocols, and a medication was administered after contact with a contaminated surface. These deficiencies were observed despite infection control training being provided.
A facility failed to refer a resident for a level II PASARR after a new diagnosis of unspecified psychosis. The resident, initially admitted with metabolic encephalopathy, dementia, and anxiety, was later diagnosed with psychosis but did not have a new PASARR submission. Despite severe cognitive impairment and behavior issues, the facility did not coordinate with the PASARR program as required. The Social Services Director admitted the oversight, and the Administrator expected resubmission after the resident's psychiatric hospitalization.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in care. A resident developed an infection at the gastric tube site due to staff not following physician's orders. Another resident's care plan interventions for skin protection were not consistently applied, resulting in skin tears. Additionally, a resident with diabetes did not have a care plan for podiatry services, leading to untrimmed toenails and potential complications.
A resident with impaired skin integrity was not provided care according to their plan, which included keeping fingernails short and using Geri-sleeves. Observations showed the resident with long nails and no protective sleeves, leading to skin picking and injuries. Staff interviews revealed communication lapses and inconsistent implementation of the care plan.
A resident with diabetes did not receive necessary podiatry services as required by the facility's policy. Despite the resident's long, untrimmed, and thick toenails causing pain, and a request from the resident's daughter, no referral was made for podiatry services. Interviews with staff confirmed the absence of a referral, and the importance of professional foot care for diabetic residents was emphasized by the PCP.
A resident with a gastric tube infection did not receive the prescribed care due to a nurse's failure to apply a bacterial ointment as ordered. The resident, who was dependent on tube feedings and had a severely impaired mental status, was observed to have an infected gastric tube site. Despite physician orders for specific care, the nurse was unaware of these orders, and no root cause analysis was conducted for the infection.
The facility failed to document COVID-19 vaccination education and status for a KMA and a DA, increasing the risk of communicable diseases. The DA's file lacked evidence of vaccine education or offering, while the KMA's file showed a request for religious exemption but no education documentation. Interviews with the IP, DON, and Administrator highlighted the importance of maintaining proper documentation for infection control.
Failure to Provide Adequate Supervision and Safe Medication Handling
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free of accident hazards for three residents, resulting in falls and unsafe medication handling. One resident with lumbar disc degeneration, movement disorder, and cardiomegaly was assessed as cognitively intact but required two-person assistance for transfers and supervision when toileting, and was identified as high risk for falls on the Morse Fall Scale. Despite this, a nurse aide transferred the resident alone to the bathroom commode, left her unsupervised, and instructed her to use the call light when finished. The aide left the bathroom to go to the nurse’s station, and upon returning a short time later, found the resident on the floor beside the commode after the resident had apparently attempted to manage independently. Another resident with acute respiratory failure, dementia, and anxiety was assessed as severely cognitively impaired and at high risk for falls on the Morse Fall Scale. The care plan identified fall risk related to gait and balance and required two staff for transfers between surfaces, but did not include specific interventions for supervision while in a common area or up in a chair. The resident was later found face down on the floor in front of a chair in the TV/common area after an unwitnessed fall from a Broda chair, with documented injuries including a swollen, bleeding nose, a new laceration over the right eyebrow, facial bruising, and right shoulder pain, and was diagnosed with a closed nasal fracture. Staff interviews revealed that some aides and nurses did not consistently review care plans, and one LPN reported not recalling training on assessing residents for fall risk prior to the incident. A third resident with severe cognitive impairment and not assessed to self-administer medications was observed seated in a wheelchair at her bedside table with a medication cup containing multiple crushed medications mixed in pudding and a spoon left unattended in front of her. The Medication Administration Record showed that several oral medications, including antihypertensives, aspirin, vitamin D, stool softener, urinary tract infection prophylaxis, beta-blocker, and acetaminophen, were documented as given that morning by a medication aide. The medication aide stated the unattended cup was from the previous night and admitted she had not removed it when she entered earlier to administer the morning medications. Facility policies required medications to remain under direct observation during administration or be secured, and required staff to observe residents consuming medications, but the unattended medication cup at the bedside demonstrated a failure to follow these policies and to ensure medications were not left accessible or unmonitored.
Failure to Follow Safe Mechanical Lift Transfer Procedures Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow safe transfer techniques while using a mechanical lift to transfer a resident with significant physical and cognitive impairments. The resident, who had hemiplegia, hemiparesis, dementia, and was dependent in all self-care and mobility, required a mechanical lift with two staff for all transfers. During a transfer from bed to chair, two State Registered Nurse Aides (SRNAs) operated the lift, but did not extend the legs of the device as required for stability. One SRNA pulled on the lift pad to position the resident, causing the lift to become unbalanced and tilt. As a result of the improper use of the mechanical lift, the device's bar struck the resident on the back of the head, causing a laceration and hematoma. The resident required emergency medical attention, including staple closure of the wound and a CT scan to assess for further injury. Documentation and witness statements confirmed that the lift's legs were not extended due to the way the device was positioned under the chair, and that the staff involved did not follow established procedures for safe resident handling and transfer. The facility's investigation found that the incident was not due to equipment malfunction, as maintenance staff confirmed the lift was functioning properly. The incident was attributed to staff not adhering to the facility's policies and procedures for mechanical lift use, specifically the failure to extend the lift's legs and improper handling during the transfer. The staff involved were interviewed, and one was terminated for failure to use proper lifting techniques and non-compliance with training.
Failure to Immediately Notify Family of Resident Injury
Penalty
Summary
The facility failed to immediately notify a resident's representative when an injury was identified. The resident, who had chronic lymphocytic leukemia, chronic kidney disease, and severe cognitive impairment, was found to have significant bruising on her chest by a registered nurse. The nurse observed the bruise on the resident's chest, described its size and color, and noted that the resident often clasped her hands tightly against her chest, which was consistent with the location of the bruising. The Director of Nursing (DON) was notified of the bruising and conducted an assessment, determining that the bruising was likely due to the resident's own actions and her medical condition, which made her prone to bruising. The findings were discussed in a staff meeting, but the DON became ill and left work before a report was initiated. The facility's documentation indicated that the bruising was not reported to the resident's family until several days after it was first observed. The family was only informed after the bruise was already in the process of healing, and the delay in notification was confirmed by both the family and the facility's administrator. The administrator acknowledged that the family was upset about not being contacted promptly when the bruising was discovered. The deficiency centers on the facility's failure to immediately notify the resident's representative of the injury as required.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to establish or maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices involving both staff and residents. For one resident receiving oxygen therapy, the oxygen nasal cannula tubing was found to be in use well past the date it should have been changed, and the humidification water bottle was undated. Review of records confirmed that the tubing was not changed as scheduled, and interviews with staff and administration confirmed that both the tubing and bottle should be changed and dated weekly to prevent infection. During meal service, several State Registered Nurse Aides (SRNAs) were observed not performing hand hygiene between passing lunch trays to residents, and one aide touched a resident's food without gloves or hand hygiene. Staff interviews confirmed that hand hygiene should be performed between each tray delivery, and gloves should be worn when touching food. Additionally, two SRNAs were observed exiting a resident's room on droplet precautions with a used, uncleaned gait belt, which was then placed in a pocket without being disinfected. Staff interviews revealed inconsistent practices regarding cleaning gait belts between resident use, despite facility policy requiring disinfection after each use. Further deficiencies were observed during wound care, where an LPN failed to perform hand hygiene between glove changes and did not change gloves between treating different wound sites on a resident. The LPN acknowledged the lapse and cited the absence of hand sanitizer in the room as a contributing factor. In the laundry area, staff were observed handling soiled linens without wearing gowns, contrary to facility policy. Interviews with environmental and laundry supervisors indicated a lack of awareness of the policy requirements for personal protective equipment when handling dirty laundry.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two residents. For one resident with end stage renal disease, heart failure, and diabetes, the care plan did not include any interventions or monitoring instructions for a dialysis catheter, despite the presence of a port in the upper right chest. Observations revealed redness and dried blood at the catheter site, and staff interviews confirmed that the only action being taken was monitoring for infection, with no formal care plan in place for the catheter. For another resident with chronic respiratory failure, COPD, and heart failure, the care plan included an intervention for continuous oxygen therapy at a specified rate per physician's orders. However, observations on multiple occasions showed that the oxygen concentrator was set above the ordered rate. Staff interviews revealed that the resident often removed her oxygen or refused to use her bipap, and that hospitalizations frequently occurred due to exacerbations of her conditions. Staff acknowledged that the oxygen settings were not always checked against the care plan and physician's orders each shift, and that incorrect oxygen administration could lead to increased carbon dioxide levels and lethargy. The facility's own policies require comprehensive, person-centered care plans with measurable objectives and timeframes for all identified needs, as well as notification of staff when interventions are added or changed. Despite this, the care plans for these two residents did not address all assessed needs or ensure that interventions were consistently implemented as ordered.
Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident requiring continuous oxygen therapy. Observations revealed that the resident's oxygen concentrator was set above the physician-ordered rate on two separate occasions: once at 5 liters per minute and once at 4.5 liters per minute, while the physician's order specified continuous administration at 4 liters per minute via nasal cannula. The facility's policy required oxygen to be administered according to physician orders, except in emergencies, but there was no documentation of an emergency or a corresponding physician order change at the time of the observed discrepancies. The resident in question had a history of acute on chronic diastolic heart failure, chronic respiratory failure with hypercapnia, and COPD, and was assessed as needing continuous oxygen therapy. Interviews with staff indicated that the resident often removed her oxygen or refused to wear her bipap device, which was intended to help manage her carbon dioxide levels. Staff reported that they would reapply the oxygen and educate the resident, but also acknowledged that the oxygen concentrator was sometimes set above the ordered rate, which could contribute to increased carbon dioxide levels and subsequent hospitalizations for the resident. Further interviews with the medical director, DON, and administrator confirmed that staff were expected to check oxygen settings against physician orders at least each shift, and that deviations from the ordered rate could negatively impact residents with COPD. Despite these expectations, the observed discrepancies in oxygen administration were not addressed in a timely manner, and the resident experienced repeated hospitalizations related to improper oxygenation.
Repeat Deficiency in QAPI and Infection Control for Shared Equipment
Penalty
Summary
The facility failed to maintain an effective, comprehensive, and data-driven Quality Assurance Performance Improvement (QAPI) program, as evidenced by a repeat deficiency related to infection control practices. Specifically, during an observation, two State Registered Nurse Aides (SRNAs) provided care to a resident on droplet precautions and exited the room with a used, uncleaned gait belt placed in one SRNA's pocket. This occurred despite previous survey findings of similar issues with equipment not being cleaned between resident use and the facility's implementation of a plan of correction that included staff education and audits. Interviews with staff confirmed that gait belts were expected to be cleaned with disinfectant wipes after each use, and that proper cleaning and storage were necessary to prevent infection transmission. The Infection Prevention Nurse and DON acknowledged prior education and monitoring efforts, but the DON stated that audits of equipment cleaning and hand hygiene were no longer being performed. The Administrator reported that quality assurance meetings were held daily and that oversight of QAPI was maintained, but the repeat deficiency indicated that the QAPI process was not effective in sustaining compliance with infection control standards.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and handling of drugs, biologicals, and vaccines, leading to multiple deficiencies in medication management. Observations revealed that medications were improperly stored in three out of four medication storage rooms, affecting nine residents. Specifically, influenza vaccines were found stored in the door of medication refrigerators, contrary to CDC guidelines, which could compromise their efficacy. Additionally, the temperature of the Sterling Unit's medication refrigerator was not maintained within the recommended range, reaching 50 degrees Fahrenheit, which could affect the integrity of the stored medications. Further deficiencies were noted in the management of medication carts and storage rooms. Medications for a discharged resident were not removed from the cart as per facility policy, and medication carts were found unlocked and unattended in the Bluegrass Unit. Keys to medication storage areas were improperly stored in an unattended nurse's station, posing a risk of unauthorized access. The facility also failed to maintain proper documentation for controlled substances, as evidenced by unsigned verification sheets at shift changes. The facility's staff demonstrated a lack of awareness and adherence to professional standards for medication storage. Insulin pens and other medications were not stored in their original packaging, were undated, and were not discarded according to product instructions, increasing the risk of cross-contamination and reduced efficacy. Interviews with staff revealed gaps in knowledge regarding proper storage practices and the importance of maintaining medication efficacy and resident safety. The facility's policies on medication storage and handling were not consistently followed, contributing to the observed deficiencies.
Improper Food Storage and Lack of Temperature Monitoring
Penalty
Summary
The facility failed to store food under sanitary conditions in three of four nourishment unit refrigerators. Observations during the survey revealed that ice packs were stored in the freezer doors of the Sterling and Bluegrass Unit nourishment refrigerators. Additionally, the Lakeview Unit nourishment refrigerator lacked a thermometer and a temperature log for April 2024. The facility's policy required that temperatures be checked and logged at least twice per day, with thermometers placed inside each cooler/freezer and calibrated weekly. The policy also specified that refrigerator storage must be maintained at or below 41 degrees Fahrenheit, and frozen storage at or below -4 degrees Fahrenheit. Interviews with staff, including LPNs, the Director of Rehabilitation, the DON, and the Administrator, confirmed the importance of monitoring refrigerator temperatures and the potential for cross-contamination from storing ice packs with food items. The LPNs indicated that the therapy department had previously used ice packs for rehabilitation, but the Director of Rehabilitation clarified that therapy had not used ice packs in about two years. The DON and Administrator both acknowledged that ice packs should not be stored in the nourishment refrigerators, and there should be a thermometer and temperature log to ensure proper food storage conditions.
Lack of Restorative Nursing Program for Residents with Limited ROM
Penalty
Summary
The facility failed to provide appropriate treatment and services to residents with limited range of motion (ROM), as evidenced by the lack of a restorative nursing program (RNP) for three residents. The facility's policy on Restorative Nursing Programs outlined the need for maintenance and restorative services to maintain or improve residents' abilities, but the facility did not have an active RNP. Observations and interviews revealed that residents with ROM impairments were not receiving targeted interventions to address their limitations, and staff were not adequately trained or guided in providing restorative care. Resident 1 was observed in her room with functional limitations in both upper extremities, but was not receiving therapy or restorative care. Similarly, Resident 37 had limitations in one lower extremity and was unaware of any staff interventions to assist with her ROM. Resident 79 had impairments in both upper and lower extremities and was not receiving therapy due to insurance denials. Staff interviews indicated that ROM exercises were only performed during activities of daily living (ADLs), without specific guidance or a structured program. The facility's staffing records showed no restorative staff on duty, and interviews with various staff members, including the Director of Nursing and the Administrator, confirmed the absence of a restorative program. The facility had previously employed restorative aides, but the program had not been reinstated since the COVID-19 pandemic. The lack of a structured RNP and trained staff resulted in residents not receiving the necessary care to maintain or improve their ROM, leading to the identified deficiency.
Infection Control Deficiencies in Equipment Cleaning and Storage
Penalty
Summary
The facility failed to adhere to infection prevention and control practices, as evidenced by multiple observations of staff not following proper procedures for cleaning and disinfecting shared medical equipment. Specifically, staff did not clean the glucometer before and after use according to the manufacturer's instructions, and hand hygiene was not performed appropriately. This was observed with two residents, where the glucometer was placed on surfaces without barriers, and the required dwell time for disinfectant wipes was not followed. Additionally, staff failed to clean and disinfect a mechanical lift after use on two residents, storing it in a public area without proper sanitation. This oversight was acknowledged by the staff involved, who admitted to not following the correct procedures for cleaning shared equipment. Furthermore, the facility's clean linen storage room was found to have residents' supplies stored directly on the floor, and the portable vital sign machine was visibly dirty, indicating a lack of routine cleaning and maintenance. The facility also failed to dispose of expired disinfecting wipes, which were used for cleaning glucometers, and a medication was administered to a resident after it had come into contact with a contaminated surface. Interviews with staff, including the ADON/IP and the DON, revealed that while infection control training was provided, there were lapses in adherence to the facility's policies and CDC guidelines. The facility's leadership expressed expectations for staff to follow infection control protocols, but the observations indicated a need for improved compliance.
Failure to Resubmit PASARR for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to refer a resident for a level II pre-admission screening and resident review (PASARR) after the resident was diagnosed with a newly evident, serious mental illness. The resident, admitted on March 10, 2023, with diagnoses including metabolic encephalopathy, dementia with agitation, and anxiety disorder, was later diagnosed with unspecified psychosis on February 21, 2024. Despite this new diagnosis, the facility did not provide documented evidence of a new PASARR submission. The facility's policy required coordination with the PASARR program to ensure appropriate care for individuals with mental disorders, including prompt referral for a level II review following an inpatient psychiatric admission. The resident's care plan, initially addressing behavior problems such as yelling at other residents, was updated after an altercation with another resident. The resident had been assessed with severe cognitive impairment and was free of aggressive behavior during the look-back period. However, following a psychiatric hospitalization, the resident exhibited hallucinations, delusions, and other disruptive behaviors. The Social Services Director acknowledged the failure to resubmit PASARR information, stating it was not on her radar, while the Administrator expected resubmission following the resident's increased behaviors and psychiatric stay.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, leading to deficiencies in their care. For Resident 100, the care plan included specific interventions for gastric tube site care, as ordered by the physician. However, staff did not follow these orders, resulting in an infection at the site. Observations revealed that the staff did not apply the prescribed betadine and antibiotic ointment, and interviews indicated a lack of awareness of the specific orders among the staff. Resident 23's care plan included interventions to protect the resident's skin, such as keeping fingernails trimmed and using Geri-sleeves. Despite these interventions, observations showed that the resident had long fingernails with blood-like material underneath and was not wearing protective sleeves, leading to skin tears. Interviews with staff revealed that the interventions were not consistently implemented, and the administrator was unaware of the resident's skin-picking behavior. For Resident 11, the facility did not develop a care plan that included podiatry services, despite the resident's diabetes diagnosis, which necessitates professional foot care. Observations showed that the resident had long, untrimmed toenails, and interviews with the resident and their family indicated that a podiatry referral had been requested but not acted upon. The Director of Nursing confirmed the absence of a podiatry referral and acknowledged the potential complications of not providing professional foot care for diabetic residents.
Failure to Implement Care Plan for Resident with Skin Integrity Issues
Penalty
Summary
The facility failed to provide quality care according to the resident's plan of care for a resident with impaired skin integrity. The resident, who was severely cognitively impaired and had a history of skin picking, was observed with long fingernails and without protective Geri-sleeves, contrary to the care plan. The resident's care plan included interventions such as keeping fingernails short and using Geri-sleeves to protect the skin, but these were not consistently implemented. Observations revealed the resident picking at his skin, resulting in bleeding and scabbed-over skin tears, with long nails that had a bloody substance under them. Interviews with staff, including a nurse aide, LPN, unit manager, DON, and the administrator, revealed a lack of adherence to the care plan and communication lapses. The nurse aide acknowledged the resident's behavior and the need for nail care but failed to inform the night shift staff. The LPN and unit manager were aware of the resident's needs but did not ensure consistent implementation of the care plan. The DON and administrator were not familiar with the specific details of the resident's care plan or the skin-picking behavior, indicating a gap in oversight and communication within the facility.
Failure to Provide Podiatry Services for Diabetic Resident
Penalty
Summary
The facility failed to provide podiatry services for a resident, identified as R11, who was admitted with diagnoses including type 2 diabetes, essential hypertension, and atherosclerosis. The facility's policy required that residents with complicating disease processes be referred to qualified professionals for foot care, but no such referral was made for R11. Observations revealed that R11's toenails were long, untrimmed, and thick, and the resident reported experiencing pain when his toes touched the footboard of the bed. Despite a request from R11's daughter for podiatry services about a month prior, there was no record of a referral or podiatry services being provided since R11's admission. Interviews with facility staff, including the Social Worker, Director of Nursing, and the Administrator, confirmed the absence of a podiatry referral for R11. The Social Worker was unable to locate any referral for podiatry services, and the Director of Nursing acknowledged that with R11's diabetes diagnosis, professional podiatry care was necessary to prevent complications. The Administrator stated that the facility had an auxiliary service company for podiatry needs, but the process to set up appointments was not followed. The Primary Care Provider emphasized the importance of foot health, especially for diabetic residents, and noted that a podiatrist should evaluate any nail deformities.
Failure to Follow Physician's Orders for Gastric Tube Care
Penalty
Summary
The facility failed to prevent complications of enteral feeding for a resident, identified as R100, who was dependent on tube feedings. The resident was admitted with conditions including hemiplegia, dysphagia, and dysarthria, and had a severely impaired mental status. The facility's policy required interventions to prevent complications of enteral feedings, including cleaning the insertion site to prevent or resolve skin irritation and local infection. Despite this, a nurse failed to apply a bacterial ointment to R100's infected gastric tube insertion site as ordered by the physician. Observations revealed that the nurse cleaned the site with soap and water, rinsed it with sterile water, and applied a split gauze, but did not apply the prescribed betadine and antibiotic ointment. The physician had ordered specific care for the gastric tube site, including the application of Muciprocin ointment and oral antibiotics for infection control. However, the nurse was unaware of these specific orders. Interviews with the primary care physician, unit manager, director of nursing, and administrator revealed expectations for staff to follow physician's orders and facility policy, but there was no evidence of a root cause analysis being conducted for the infection. The director of nursing had not observed staff performing site care, and the administrator noted the lack of an interdisciplinary team investigation into the cause of the infection.
Failure to Document COVID-19 Vaccination Education and Status
Penalty
Summary
The facility failed to maintain proper documentation of COVID-19 vaccination education, offering, and status for two of three sampled staff members, specifically a Kentucky Medication Aide (KMA) and a Dietary Aide (DA). The review of the DA's employee file showed no evidence of receiving or being offered the COVID-19 vaccine, nor any documentation of education about the vaccine's benefits, risks, and potential side effects. The New Hire Checklist indicated that the DA refused all vaccinations, but there was no further documentation to support this. The DA was unavailable for an interview to provide additional information. Similarly, the KMA's file lacked documentation of vaccine education, although the KMA had requested a religious exemption. During an interview, the KMA confirmed not receiving education or an offer for the vaccine from the facility. The Infection Preventionist (IP) acknowledged incomplete vaccination records and emphasized the importance of educating staff and maintaining documentation. The Director of Nursing (DON) and the Administrator both highlighted the necessity of knowing staff vaccination status and maintaining proper documentation as part of the facility's infection control program.
Latest citations in Kentucky
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
