Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Pavilion At Kenton during CMS and state inspections, most recent first.
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.
Insufficient Nursing Staffing and Delayed Resident Care: The facility did not staff according to its Facility Assessment, with fewer nurses and nurse aides than required for the resident census and acuity. Staffing records showed repeated shortages, low aide HPRD, and frequent call-ins and no-shows. Residents and council minutes described delayed call light response, missed or late showers, and late medication administration, while staff reported working short, covering multiple units, and relying on nurses and agency aides to help complete care.
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.
Failure to maintain resident dignity during meals: A number of residents reported being served meals on Styrofoam plates and bowls with plastic silverware for more than three months, and they voiced frustration in the Resident Council meeting. Meal observations confirmed residents in the dining rooms were eating with disposable dishware, while the DON and Administrator said they were unaware of the practice and the Dietary Manager said Styrofoam was only for limited situations such as orders, safety issues, water outages, dishwasher problems, or COVID.
Delayed Resident Mail and Package Delivery: Residents reported they could not send or receive mail, letters, packages, and other materials delivered on Saturdays. Staff confirmed the business office was closed on weekends, weekend mail was held until Monday, and packages delivered to the lobby were not given to residents until the following Monday unless staff had been заранее informed of the delivery.
Grievance Process Not Available or Properly Tracked: The facility failed to make grievance/complaint filing information available to residents and did not maintain a consistent grievance system for prompt resolution. Residents stated they had not seen a grievance form or known where to find one, while the Activities Director said concerns were verbalized to her but not documented on grievance forms or reported to the grievance officer. The Social Services Director, DON, and Administrator gave differing accounts of how grievances were handled, and staff were not consistently using a tracking system.
Failure to Complete Trauma-Informed Care Assessments: The facility did not complete trauma-informed care/PTSD assessments for 5 sampled residents with psychiatric, cognitive, and behavioral health histories. Records showed one resident had PTSD linked to trauma and ongoing nightmares, while others had dementia, psychotic disorders, anxiety, or a documented PTSD diagnosis, yet no assessment identified trauma history, triggers, symptoms, or needed interventions. Interviews with the SSD, DON, residents, and family/POA confirmed the assessments were not completed or were not discussed.
Unattended medication carts were left unlocked on multiple occasions. An RN left one cart in a hallway near residents, an LPN left another cart unlocked while administering meds via G-tube, and another RN left a cart unlocked while stepping away to grab a pen. The facility policy required carts to be kept closed and locked when out of the nurse’s sight, and the DON and Administrator stated carts were expected to be locked when unattended.
Failure to Provide Resident’s Requested Showers: A resident with intact cognition and a care plan for showers twice weekly stated he preferred daily showers, but staff told him he was not allowed to shower and instead gave him bed baths. Shower logs showed showers were documented even though the resident said he had not received one for months, and an STNA admitted one shower entry was false and that the resident only wiped himself off in bed. The DON was unaware of the issue, while the Administrator and Medical Director stated the resident could shower and staff should have followed the care plan.
Failure to Provide Written Transfer/Discharge Notice: The facility did not provide a resident’s representative with written notice of hospital transfers or the reasons for the moves, and the record lacked Transfer/Discharge Notices for either event. The resident had cerebral palsy, malnutrition, and epilepsy, and was rarely or never understood per MDS. Staff stated the family was informed verbally, while the BOM handled bed-hold notices and was unsure who was responsible for the written transfer/discharge notice.
Failure to Provide Individualized and Group Activities: The facility did not provide individualized or group activities that matched residents’ schedules and preferences. Three residents with significant cognitive and physical impairments were observed either in bed or away at school, with no documented follow-up attempts, alternate timing, or meaningful one-to-one engagement. Records and staff interviews showed limited activity participation, inconsistent documentation, and residents remaining in bed without socialization or assistance to attend activities.
Failure to maintain dialysis communication and transfer information. A resident with ESRD received scheduled dialysis and had a care plan and order for a dialysis communication binder, but the facility could not produce evidence of communication with the dialysis center. The DON stated the binder could not be located and the EMR contained no evidence of ongoing exchange of information, despite the facility’s transfer agreement and ESRD policy requiring coordinated communication for resident care.
Failure to provide ordered adaptive eating equipment. A resident with severe cognitive impairment, dysphagia puree diet needs, and dependence for eating was observed being served pureed food on a glass plate instead of in bowls listed on the meal ticket to support self-feeding. The facility policy required adaptive devices for residents who needed them, and staff acknowledged the tray was prepared without following the ticket instructions.
Surveyors identified expired oral and topical medications in five of six medication and treatment carts, with several types of medications found past their expiration dates or lacking clear expiration labeling. Interviews with nursing staff, the DON, and the pharmacist revealed inconsistent and unclear protocols for auditing and removing expired medications, leading to expired drugs remaining accessible. Facility policy required secure storage and timely removal of expired medications, but these procedures were not reliably followed.
The facility did not consistently implement infection prevention and control protocols, including proper use of PPE, hand hygiene, and signage for residents on transmission-based or enhanced barrier precautions. Staff were observed entering rooms and providing care without following required precautions, and meal trays were distributed without appropriate hand hygiene or glove changes. Additionally, improper management of urinary catheter bags was noted, and staff interviews revealed confusion about infection control procedures.
Surveyors found that cold foods were left unrefrigerated for extended periods before meal service, and dietary staff failed to follow proper hand hygiene and glove use protocols, including touching surfaces and returning to food service without changing gloves or washing hands. The main dining room counter was also observed to be inadequately cleaned, with food crumbs and residue present.
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.
Insufficient Nursing Staffing and Inconsistent Coverage
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs and to maintain a licensed nurse in charge on each shift as reflected in its own Facility Assessment and staffing documents. The Facility Assessment approved on 12/10/2025 and again on 03/06/2026 identified staffing needs for an average daily census of 74 as four to five nurses per shift, eight to 10 nurse aides on day shift, and seven to eight nurse aides on night shift. A separate staffing guide used by the DON showed lower staffing expectations, including three nurses per shift and fewer aides, even though the facility census during the 30-day review period ranged from 78 to 81 residents and never fell below 78. Review of staffing records for 02/23/2026 through 03/23/2026 showed the facility consistently fell below the staffing requirements identified in the Facility Assessment. The facility only met its staffing goals for seven day-shift aides on three dates, and the average nurse aide staffing was 1.46 HPRD, below the 2.45 HPRD listed in the Facility Assessment. The lowest nurse aide staffing occurred on 03/16/2026 at 1.07 HPRD. The facility also had 27 residents who required a two-person assist for transfers, including residents using mechanical lifts. Resident council minutes documented repeated concerns about delayed medication administration, long waits for call light response, trouble getting aides to assist with getting residents out of bed or back to bed, missed showers, and late-night medication issues. A grievance was also filed when a family member could not reach the facility by phone and was concerned about a resident’s well-being. Interviews with STNAs described frequent call-ins and no-shows, working with too few aides, nurses sometimes helping and sometimes not, and showers being missed or changed to bed baths when staffing was short. A resident reported waiting 45 minutes for call light response and said long waits happened more often on night shift. The DON acknowledged the staffing guide did not match the Facility Assessment and stated the facility was using agency staff while trying to hire more staff.
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.
Failure to Maintain Resident Dignity During Meals
Penalty
Summary
The facility failed to treat residents with respect and dignity and to care for each resident in a manner and environment that promoted maintenance or enhancement of quality of life for 9 of 15 residents participating in the Resident Council meeting, including R3, R8, R9, R18, R43, R56, R68, R71, and R75. During dinner and lunch observations, residents were served meals on Styrofoam plates and were eating with plastic silverware in the main dining room and rehabilitation dining room. Residents stated they had been eating off Styrofoam plates and using plastic silverware for more than three months and said they were told by staff that residents were throwing away silverware and the budget would not allow the facility to order more silverware. During the Resident Council meeting, the 9 residents expressed concern and frustration about being served meals on Styrofoam plates and bowls and using plastic silverware. The Dietary Manager stated Styrofoam was only to be used for residents with orders, safety issues with utensils, when the water was turned off, when the dishwasher was not working, and for residents with COVID. The DON stated she was not aware residents were eating off Styrofoam plates and bowls or using plastic silverware, and the Administrator stated she was unaware of the issue and had not been notified by dietary that normal plates or silverware were unavailable. The facility policy stated residents should be informed in writing of their rights as residents and the rules and regulations governing their conduct and responsibilities.
Delayed Resident Mail and Package Delivery
Penalty
Summary
The facility failed to have a system in place for residents to send and receive mail and to receive letters, packages, and other materials delivered to the facility on Saturdays for 15 of 15 residents participating in the Resident Council meeting. During the meeting, residents including R3, R8, R9, R13, R15, R18, R37, R39, R43, R56, R66, R68, R71, R75, and R106 expressed concern and frustration that they could not send mail or receive items delivered to the facility on Saturdays. R9, R37, and R43 stated they had Amazon packages and grocery deliveries that they did not receive on Saturdays because the packages were not given to them upon delivery. Interviews with facility staff showed the business office was closed on Saturdays and Sundays, and weekend mail was not distributed to residents until Monday. The Receptionist stated weekend mail was left on her desk or placed in department mailboxes, and the Business Office Manager confirmed weekend mail was distributed to residents the following Monday. She also stated packages delivered to the lobby sat ત્યાં until Monday unless residents had informed staff in advance of a scheduled delivery. The Activities Director stated residents received mail and packages on Mondays if delivered on Saturdays, while the Social Services Director, DON, and Administrator were unaware that mail and packages were not being delivered to residents on weekends.
Grievance Process Not Available or Properly Tracked
Penalty
Summary
The facility failed to have information on how to file a grievance or complaint available to residents and failed to establish a grievance system to ensure the prompt resolution of all grievances. Review of the facility’s policies showed that residents and their representatives had the right to file grievances orally or in writing, and that the Administrator and staff were to make prompt efforts to resolve them. However, during the Resident Council meeting, residents stated they had expressed concerns to department heads but had never seen a grievance form and did not know where one was located. During interviews, the Activities Director stated residents came to her to verbalize grievances, but she did not use a grievance form, was not sure where the forms were located, and did not report concerns to the grievance officer. She also stated department heads attended resident council meetings, but documentation or grievance forms were not completed for a tracking system. The Social Services Director stated he completed a grievance form and began an investigation when a resident approached him, but he was not sure all staff were educated on completing grievance forms or ensuring grievances were brought to him. The DON stated that if staff did not complete a grievance form, the Social Services Director had no way of knowing a grievance had been reported, and the Administrator stated department heads wrote concerns on paper instead of using grievance forms, although grievance forms were available and the Social Services Director was the grievance compliance officer.
Failure to Complete Trauma-Informed Care Assessments
Penalty
Summary
The facility failed to perform a trauma-informed care assessment for 5 of 5 sampled residents with trauma-related or behavioral health histories, including residents with PTSD, anxiety, schizophrenia, dementia, delusions, and other psychiatric diagnoses. The facility’s policy stated that services would be provided or arranged in the Comprehensive Care Plan and that they would be trauma informed. The Social Services Director job description stated the SSD was responsible for identifying and promoting individualized, non-pharmacological approaches to care, ensuring residents with mental illness or psychosocial difficulties had access to appropriate treatment and resources, and interviewing residents to obtain social history. For one resident with diagnoses including adjustment disorder, schizoaffective disorder, and PTSD, the record showed a history of trauma beginning in the teen years, ongoing nightmares related to abuse, and care plan interventions focused on psychosocial well-being and calming approaches. For another resident with dementia, behavioral disturbance, psychotic disorder, and delusions, no PTSD assessment had been performed, and the spouse stated she had never been asked about trauma history and did not know how to contact the Social Worker. For a third resident with paranoid schizophrenia, major depressive disorder, developmental disorder, and anxiety, the EMR also showed no PTSD assessment, and the POA/friend stated she was unaware of any PTSD diagnosis or traumatic experiences and did not know whether it had ever been discussed. For the remaining residents, one had dementia, stroke, and anxiety with no PTSD assessment performed, and the resident stated he could not recall any traumatic experiences or military service. Another resident had a documented PTSD diagnosis, borderline personality disorder, anxiety disorder, and major depressive disorder, but the CCP did not address PTSD or trauma-informed care and the facility failed to complete an assessment identifying triggers, symptoms, or needed interventions. The SSD stated he had not completed the assessment because he did not know he was supposed to, and staff interviews confirmed the assessment was expected to support resident-centered care and avoid retraumatization. The DON and Administrator stated accurate and timely assessment was expected and that failure to do so could result in the resident not receiving appropriate care and unnecessary adverse outcomes.
Unattended Medication Carts Left Unlocked
Penalty
Summary
The facility failed to ensure that medications were stored securely and remained inaccessible to unauthorized individuals when 3 of 4 medication carts observed were left unlocked and unattended. The facility policy titled, Administering Medications, revised April 2019, stated medications were to be administered in a safe manner, medication carts were to be kept closed and locked when out of sight of the nurse, and medications were not to be accessible to residents or others. On 03/22/2026, RN1 left Medication Cart 1 in the hallway outside a resident's room with the drawers facing the residents' common area near the nurses' desk while she entered the room to obtain a blood pressure; the cart was unlocked, unattended, and out of her view. Later that day, LPN1 left Medication Cart 2 unlocked and unattended while entering a resident's room to administer medications via gastrostomy tube, and the cart was out of view. On 03/25/2026, RN3 left Medication Cart 3 unattended and unlocked while going around the corner to grab a pen, and the cart was out of view. RN1, LPN1, and RN3 each acknowledged the carts should have been locked when unattended, and the DON and Administrator stated nurses were expected to lock medication carts when unattended to prevent resident access.
Failure to Provide Resident’s Requested Showers
Penalty
Summary
Reasonably accommodating resident needs and preferences was not provided for one sampled resident, who was admitted with diagnoses including generalized atherosclerosis, hypothyroidism, and major depressive disorder and had a BIMS score of 15, indicating little, if any, cognitive impairment. The resident’s care plan dated 03/17/2026 stated he could shower two times a week and as necessary with extensive assistance. During interview, the resident stated his personal preference for daily cleansing was to shower, but facility staff told him he was not allowed to shower and instead gave him bed baths. Review of the shower logs from January 1, 2026 through March 25, 2026 showed staff documented the resident as receiving showers, but the resident stated he had not been given a shower since December 2025. An STNA stated she documented that the resident had taken a shower on 03/24/2026, but acknowledged that was false documentation and that she did not give him a shower that day; she said he only wiped himself off from his bed with no assistance. The DON stated she was unaware the resident had not been taking showers and said staff had been telling him since December 2025 that he was not allowed to shower. The Administrator stated that if the resident was care planned for showers, it was his right to have a shower and staff should provide one on scheduled days and at his request. The Medical Director stated the resident could shower and that staff should have followed the care plan.
Failure to Provide Written Transfer/Discharge Notice
Penalty
Summary
The facility failed to notify the resident and the resident’s representative in writing of the transfer or discharge and the reasons for the move, including the required appeal information, for one sampled resident. The facility policy titled Transfer or Discharge, Facility-Initiated, revised October 2022, required written notification to the resident and representative with the specific reason for transfer or discharge, the effective date, the destination, and an explanation of appeal rights and how to obtain assistance with the appeal process. Resident 46 was admitted with diagnoses of cerebral palsy, malnutrition, and epilepsy, and the quarterly MDS indicated the resident’s BIMS score was undetermined because the resident was rarely or never understood. The record showed hospital paid leaves on 12/31/2025 and 02/12/2026, but the EMR did not contain a Transfer/Discharge Notice sent to the resident’s representative for either transfer. During interviews, the Regional Nurse stated the facility did not provide the representative with a written reason for transfer and only informed them verbally, while the BOM stated she handled bed-hold notices and was unsure who was responsible for the transfer/discharge reason notice. The BOM also stated a bed-hold notice was mailed for the first hospital leave but not for the second because the resident was only gone for a few hours.
Failure to Provide Individualized and Group Activities
Penalty
Summary
The facility failed to provide individualized and group activities that reflected residents’ schedules, choices, and rights, and failed to offer activities at times convenient to the residents, including evenings, holidays, and weekends. Observations across multiple days showed three sampled residents were either away at school for the entire day until about 4:30 PM or remained in bed, with no observation of one-to-one activities and no observation of these residents in group activity areas for socialization or participation. Review of the facility’s activity policy stated that activity programs were to include individual, small group, and large group activities designed to meet resident needs and interests and to be offered at convenient times. For one resident with cerebral palsy, aphasia, and profound intellectual disabilities, the record showed a care plan that included one-to-one contact and participation in an outsourced school program on Mondays, Wednesdays, and Fridays. The resident’s quarterly MDS indicated full dependence for mobility and use of a manual wheelchair for staff-assisted transportation. The guardian stated social interaction would be beneficial. Activity documentation showed one-to-one attempts, but the entries repeatedly noted the resident was not in the building or was sleeping, with no evidence of follow-up attempts, rescheduling, or alternative individualized activities. Documentation also showed the resident was unavailable due to school on several occasions, and no further efforts were documented to accommodate the resident’s schedule or needs. For another resident with autistic disorder, unspecified intellectual disabilities, and a severe impairment in daily decision making, the record showed one-to-one activity documentation with multiple entries stating the resident was unavailable because of school, getting changed, or not in the room, without follow-up attempts at alternate times. Observations showed the resident lying in bed for extended periods with no staff interaction or activity engagement, and no evidence of group activity participation. The guardian reported the resident was consistently observed in bed during visits. Staff interviews confirmed the resident was not being assisted out of bed for activities, that activity staff did not assist the resident to get up, and that the resident remained in bed on non-school days. For a third resident with cerebral palsy, epilepsy, dysphagia, and quadriplegia, the activity roster identified the resident for one-to-one activities, but the participation log and one-to-one records showed limited documented interactions and several attempts when the resident was asleep or at school. The Activity Director stated staff were expected to provide one-to-one activities and to attempt them at different times if the resident was unavailable, but also stated that when residents returned from school later in the day, further attempts were not documented. The DON and Administrator stated residents should be assisted to attend activities and should not remain in bed without meaningful interaction, and that activities were expected to be available during the day, evenings, weekends, and holidays.
Failure to Maintain Dialysis Communication and Transfer Information
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care/services for a resident who required dialysis, and it was unable to provide evidence of communication with the dialysis center. The resident was admitted with ESRD, COPD, and cognitive communication deficit, and the quarterly MDS indicated a BIMS score of 15 out of 15 with dialysis services received. The resident had an order for dialysis on Monday, Wednesday, and Friday with a 10:30 AM pickup time, and an additional order to ensure the resident had a dialysis communication binder to take to and from dialysis appointments. A comprehensive care plan for dialysis was initiated, and the facility policy stated residents with ESRD would be cared for according to recognized standards of care and that assessments between the facility and the contracted ESRD facility would include all aspects of how the resident’s care would be managed. Review of the EMR revealed no evidence of communication between the facility and the ESRD/dialysis center. The facility’s Nursing Home Dialysis Transfer Agreement stated the facility would ensure appropriate medical, social, administrative, and other information accompanied residents at transfer and would provide interchange of information necessary for resident care. During interview, the DON stated the dialysis communication binder could not be located, believed the resident may have kept it, and said the facility was uncertain what happened to it because the resident frequently went to the hospital from dialysis. She also stated the facility was unable to locate any evidence of communication with the dialysis center and expected paperwork to be exchanged for continuity of care and patient safety. The Administrator stated she was unaware of the failure to provide evidence of ongoing communication with the dialysis center and expected dialysis documentation to be completed for each appointment.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment and utensils that matched a resident’s individual needs during meals. R4 had diagnoses including major depressive disorder, severe protein-calorie malnutrition, and need for assistance with personal care. His MDS showed a BIMS score of 3 out of 15, severe cognitive deficit, coughing and choking at meals or when taking medications, a mechanically altered diet, impairment of functional range of motion in the upper and lower extremities, and dependence on staff for eating. His care plan stated he could hold a cup, feed himself, and eat finger foods independently after set up, and his meal ticket indicated that food was to be served in bowls for self-feeding. During dinner observation, R4 was served three types of pureed food on a glass plate instead of in bowls, while he sat in a recliner, slumped over, and ate ice cream with a spoon and his fingers. The facility’s policy stated adaptive devices would be provided for residents who needed or requested them and that assistance would be provided so residents could use and benefit from them. The cook stated she prepared the tray and knew he was supposed to have bowls, but missed the direction on the ticket. The DON stated kitchen staff were responsible for reading the meal ticket, ensuring the appropriate adaptive equipment was available, and providing it to residents who needed it, and the Administrator stated residents were expected to receive all necessary adaptive equipment to promote independence with ADLs.
Expired Medications Found in Multiple Medication Carts Due to Inconsistent Auditing
Penalty
Summary
Surveyors found that the facility failed to ensure proper storage and timely removal of expired oral and topical medications in 5 out of 6 medication and treatment carts. Observations revealed multiple expired medications, including ibuprofen, acetaminophen, midodrine, loperamide, ondansetron, multivitamins, magnesium citrate, naloxone, olanzapine, pantoprazole, Almacone, polyethylene glycol, Refresh eye drops, vitamin D3, Milk of Magnesia, Tylenol, Senna, nitroglycerin, Prostat, ketoconazole cream, and Minerin Cream. Some medications were found without clear expiration dates, and in some cases, pharmacy stickers and commercial bottle dates did not match. Interviews with nursing staff indicated inconsistent practices regarding the auditing and removal of expired medications. Some nurses stated that expired medications should be discarded and that audits were expected to be performed, typically by night shift staff, but there was no clear assignment or protocol for regular audits. Staff also reported that medications not used within 30 to 60 days should prompt a call to the physician, but there was no evidence of a systematic process to ensure this occurred. The facility's policy required medications to be stored securely and for staff to maintain storage areas in a clean and safe manner, with expired or discontinued medications to be returned or destroyed per pharmacy instructions. The pharmacist reported conducting monthly spot checks and removing medications within 30 days of expiration, but these checks were not comprehensive. The DON and Administrator both expected regular audits by nursing staff and managers, but interviews revealed that these expectations were not consistently met, resulting in expired medications remaining accessible in medication carts.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observations and interviews involving five residents. Staff did not consistently follow established protocols for transmission-based precautions (TBP), enhanced barrier precautions (EBP), and standard hand hygiene practices. For example, signage indicating required precautions was missing or inconsistently posted for residents with active orders for TBP or EBP, and staff were observed entering rooms or providing care without donning appropriate personal protective equipment (PPE) such as gowns and gloves. In one case, a resident with MRSA and pressure ulcers did not have TBP signage posted as ordered, and staff could not explain the omission. Another resident with orders for EBP due to multiple risk factors was cared for by a nurse who wore gloves but not a gown, contrary to policy and posted instructions. Staff also failed to adhere to hand hygiene and PPE protocols during routine activities such as meal tray distribution. Several nurse aides were observed passing lunch trays to residents, including those on EBP or TBP, without performing hand hygiene between residents or changing gloves, and in some cases, wearing the same gloves throughout the process. One aide stated she wore gloves for personal preference and did not change them due to time constraints, while another began assisting a resident in contact isolation without performing hand hygiene or donning PPE, despite signage and available supplies. These lapses occurred even though facility policy and posted signage required hand hygiene and PPE use in these situations. Additional deficiencies included improper management of urinary catheter bags, with one resident's catheter bag observed resting on the floor, contrary to infection control policy. Staff interviews confirmed awareness that catheter bags should not touch the floor to prevent infection, but the issue was attributed to the bed being in a low position. The facility's infection preventionist and nursing leadership acknowledged responsibility for ensuring proper signage, PPE use, and adherence to infection control protocols, but were unable to account for the observed lapses. Staff interviews revealed inconsistent understanding of when and how to implement precautions, with some staff unaware that contact precautions constituted isolation or unsure of the correct procedures.
Failure to Store and Handle Food Safely; Inadequate Hand Hygiene in Dietary Services
Penalty
Summary
Surveyors observed that the facility failed to store and handle food in accordance with professional standards and its own policies. During multiple observations in the kitchen, pre-plated cold foods such as juice, tossed salads, and cheese plates were left unrefrigerated on tray carts for extended periods before meal service. The Certified Dietary Manager (CDM) confirmed that these items were set up well in advance and only placed in refrigeration shortly before mealtime, contrary to the facility's policy and food safety guidelines requiring cold foods to be held at 41°F or less. Additionally, the main dining room counter was repeatedly found with food crumbs and a dried brown substance in the hand sink, indicating inadequate cleaning practices. Dietary staff were also observed failing to follow proper hand hygiene and glove use protocols. Staff members wore gloves while serving food but touched various surfaces, such as cabinet handles and the nurse's desk, without changing gloves or washing hands between tasks. The CDM, DON/Infection Control, and Administrator all acknowledged that these actions did not meet facility expectations or infection control standards, as outlined in the facility's hand hygiene policy. No specific residents were identified as being directly affected in the report.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 886 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Covington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rosedale Green | 1.8 mi | ★★★★★ | 0 | 0 |
| Highlandspring Of Ft Thomas | 1.9 mi | ★★★★★ | 3 | 0 |
| St Elizabeth Ft Thomas Snf | 2 mi | ★★★★★ | 0 | 0 |
| Carmel Manor | 3.2 mi | ★★★★★ | 15 | 0 |
| Madonna Manor | 4.5 mi | ★★★★★ | 10 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.