Wurtland Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Wurtland, Kentucky.
- Location
- 100 Wurtland Avenue, Wurtland, Kentucky 41144
- CMS Provider Number
- 185261
- Inspections on file
- 18
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 3 (3 serious)
Citation history
Health deficiencies cited at Wurtland Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple cardiac and neurologic diagnoses experienced a rapid weight gain of over 17 pounds in less than two weeks, along with shortness of breath and +3 to +4 pitting edema. Facility policy and the resident’s care plan required staff to notify a physician or APRN of weight changes of three pounds in one week and abnormal assessment findings, but nursing staff and the DON documented successive weight increases and respiratory symptoms without evidence of provider notification. The APRN reported not being informed of the repeated weight gains until the day an LPN finally contacted him, obtained orders for diagnostic tests and IM furosemide, and sent the resident to the hospital at the request of a family member who had repeatedly voiced concerns about worsening edema.
A resident with pneumonia, atrial fibrillation, coronary artery disease, and hypertension was admitted with an IV antibiotic infusion and ordered weekly weights. The care plan required staff to monitor for cardiac dysfunction, including edema, and to notify the physician of significant weight changes, consistent with facility policy. Over approximately two weeks, the resident gained more than 17 pounds and developed progressive edema observed by family, but there was no documentation that nurses notified the physician or consistently assessed for edema. Staff interviews confirmed lack of physician notification and incomplete assessment practices, and the APRN reported not being informed of the weight gain until the day of hospital transfer, where the resident was admitted with fluid overload and MI and later expired. Surveyors cited the facility for failing to develop and implement a comprehensive, resident-centered care plan, including resident-specific interventions for continuous IV fluids and timely response to significant weight changes.
A resident admitted for short-term rehab with cardiac and respiratory comorbidities experienced a rapid 17‑pound weight gain over less than two weeks, along with progressive edema, shortness of breath, and increased confusion. Facility policies and the care plan required re‑weighs, assessment, and MD/APRN notification for significant weight changes and signs of cardiac dysfunction, but nursing staff, including the DON and multiple LPNs, did not consistently reassess, document edema and dyspnea in progress notes, or notify a provider as the weight increased from the low 250s to 270 pounds. Family repeatedly voiced concerns about swelling in the resident’s extremities and scrotum, which were initially met only with instructions to continue monitoring, and the APRN later reported not being informed of the rapid weight gain or evolving assessment findings until the day the resident was ultimately sent to the hospital with fluid overload and acute cardiac issues.
The facility failed to implement comprehensive care plans for several residents, leading to unmet medical and personal care needs. A resident with plaque psoriasis did not receive proper shampoo application, while another with pressure ulcers was not repositioned or provided timely incontinence care. A third resident did not receive frequent toileting assistance or oral care, and a fourth had improper artificial eye care. Additionally, a resident's midline dressing was not changed as ordered.
The facility failed to provide timely incontinence and oral care for several residents, leading to feelings of embarrassment and inadequate hygiene. Residents often waited long periods for assistance, resulting in soiled conditions and plaque build-up. Staff interviews indicated that short staffing contributed to these deficiencies.
The facility failed to provide appropriate care for three residents, including incorrect application of medicated shampoo for a resident with a scalp condition, inadequate care for a resident with a prosthetic eye, and failure to change a dressing for a resident with a midline IV as ordered. Staff were not adequately informed or aware of the correct procedures, leading to ongoing issues and discomfort for the residents.
Two residents in an LTC facility developed facility-acquired pressure ulcers due to inadequate care. Despite being identified as at risk, they did not receive timely incontinence care and repositioning, leading to skin breakdown. Staff interviews revealed systemic issues, including understaffing and ineffective implementation of care plans, contributing to the deficiency.
The facility failed to maintain adequate staffing levels, resulting in insufficient care for residents. Observations and interviews revealed that residents did not receive necessary assistance with activities of daily living, such as incontinence and dental care. Additionally, staff failed to provide proper care for residents with specific medical needs, including incorrect application of medicated treatments and failure to change dressings as ordered. The lack of sufficient, competent staff led to the development of facility-acquired pressure ulcers in some residents and inadequate care for those with catheters, resulting in urinary tract infections.
The facility failed to inform and document advance directive information for several residents, as required by policy. Despite verbal discussions claimed by staff, there was no evidence in the records that residents were given the opportunity to formulate or decline advance directives. Incomplete documentation and lack of awareness among staff contributed to this deficiency.
The facility failed to store insulin at the correct temperature in two medication refrigerators, with temperatures recorded below the recommended range. Observations showed that Refrigerator 1 had a temperature of 26°F and Refrigerator 3 had a temperature of 30°F, both containing various insulin pens. The ADON confirmed that medications stored at these temperatures would freeze and become ineffective. Despite requests, a Medication Storage policy was not provided.
The facility did not follow its infection prevention and control policies, including failing to provide PPE carts outside droplet precaution rooms, leaving precaution room doors open, and not properly cleaning shared equipment such as glucometers and bandage scissors. Staff also failed to date and store food items used for medication administration on ice as required. These actions were not in line with CDC guidelines, manufacturer instructions, or facility policy.
The facility failed to ensure call lights were within reach for three residents, compromising their ability to request assistance. A resident with severe cognitive impairment had an adaptive call light out of reach, while another resident, cognitively intact but needing mobility assistance, was found attempting to get out of bed without access to her call light. A third resident with dementia was also unable to reach his call light. Staff confirmed the expectation for call lights to be accessible, but this was not consistently practiced.
A resident admitted with pressure ulcers did not have these addressed in their baseline care plan within 48 hours, contrary to facility policy. Staff interviews confirmed the presence of pressure ulcers at admission, highlighting a lapse in following procedures to ensure accurate and effective care.
The facility failed to prevent and treat UTIs in two residents with indwelling catheters. One resident's catheter bag was on the floor, and her complaints of UTI symptoms were not promptly addressed, leading to delayed treatment. Another resident's catheter bag was also found on the floor, despite staff being trained on proper catheter care. These deficiencies highlight lapses in adherence to care standards and documentation practices.
A resident with a gastrostomy tube did not receive the prescribed amounts of enteral feed and water flushes, leading to severe dehydration and hypernatremia. The facility's inadequate documentation and communication practices contributed to the deficiency, as nursing staff failed to document changes in the resident's condition and did not communicate with the NP about interruptions in tube feedings. The resident was hospitalized due to these failures.
A resident with a right acetabulum fracture experienced unmanaged pain due to the facility's failure to reorder oxycodone in a timely manner. The resident missed several doses, and staff did not utilize the Emergency Kit or notify the provider about the medication's unavailability. Interviews revealed inconsistent practices in monitoring medication stock, contributing to the deficiency.
Failure to Notify Physician of Significant Weight Gain and Fluid Overload Signs
Penalty
Summary
The deficiency involves the facility’s failure to recognize and notify a physician of a resident’s significant weight gain and associated symptoms, as required by facility policy and the resident’s care plan. The facility’s Weight Monitoring policy required staff to notify the physician of a weight gain or loss of three pounds within one week. The resident was admitted with diagnoses including pneumonia, nontraumatic subdural hemorrhage, primary hypertension, atrial fibrillation, and hypertension, and had a care plan intervention for nurses to weigh the resident as ordered and notify the physician of significant weight changes, documenting abnormal findings and notifying the physician. The physician’s orders included weekly weights. From admission, the resident’s weight increased from 252.8 pounds to 259 pounds within four days, a gain of 6.2 pounds, and then to 267 pounds within nine days, a total gain of 14.2 pounds from admission. These weights were entered by the DON and an LPN, respectively. There was no documentation that the provider was notified of either the 6.2‑pound gain in four days or the 14.2‑pound gain in nine days, despite the facility policy requiring notification for a three‑pound gain in one week. Nursing documentation also showed that the resident had shortness of breath and/or labored breathing with exercise and while lying flat, but there was no documentation that the physician was notified of these abnormal findings, contrary to the resident’s care plan interventions. The resident’s weight continued to increase, reaching 270 pounds 13 days after admission, a total gain of 17.2 pounds. On that date, an LPN documented +3 to +4 pitting edema in all four extremities and shortness of breath, and notified the APRN, obtaining orders for a chest x‑ray, labs, and intramuscular furosemide. The resident was sent to the hospital for evaluation at the request of a family member. Interviews with the family member indicated he observed increasing swelling of the resident’s legs, feet, and scrotum throughout the stay and reported these concerns daily to staff, who told him the edema was not a problem. Interviews with the APRN, Medical Director, DON, and Administrator confirmed that staff were expected to notify a provider of significant weight changes and changes in condition, and that there was no evidence staff had identified the resident’s weight gain as a significant change in condition or notified the APRN or physician of the repeated weight gains prior to the date when the APRN was finally contacted.
Removal Plan
- All current residents were re-weighed and reassessed for change of condition by the Director of Nursing Services, Assistant Director of Nursing Services, and Unit Manager; weights for the last 6 months were reviewed.
- For any significant weight changes identified, nursing assessments were completed by the Director of Nursing Services, Assistant Director of Nursing Services, or Unit Manager with physician or nurse practitioner notification for orders as needed.
- All residents were reassessed and reweighed.
- All residents were reassessed by the Director of Nursing Services, Assistant Director of Nursing Services, and Unit Manager with any changes of condition reported to the Nurse Practitioner and orders obtained.
- Director of Nursing Services was educated by the Regional Nurse Consultant to review weight reports timely related to the weekly Nutritional At Risk meeting.
- All nurses were educated by the Infection Preventionist/Staff Development, Director of Nursing Services, or Assistant Director of Nursing Services regarding the policy on notifying the physician or nurse practitioner of all changes of condition including weight changes; education completion tracked.
- A post-test was administered to all nurses with an expected 100% pass rate; if 100% was not achieved, re-education was provided.
- Director of Nursing Services, Assistant Director of Nursing Services, Infection Preventionist/Staff Development, or Unit Manager will provide education until all nurses complete it.
- Education on notification of changes in condition including weight changes will be added to new-hire nurse orientation.
- An ad hoc QAPI meeting was held with the Executive Director, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and Medical Director to review the alleged deficiency, audit tools, and education regarding notification of changes.
- The Director of Nursing Services, Assistant Director of Nursing, or Unit Manager will audit to ensure all changes in condition including weight changes resulted in physician or nurse practitioner notification.
- Audit results will be forwarded to the QAPI Committee for review and presented by the Director of Nursing.
Failure to Implement Comprehensive Cardiac and Weight Monitoring Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, resident-specific care plan that addressed all identified needs, including monitoring and response to significant weight changes and potential complications from continuous IV fluids. The resident was admitted with diagnoses including pneumonia, nontraumatic subdural hemorrhage, atrial fibrillation, coronary artery disease, and hypertension, and had an IV access for antibiotics. The care plan included an intervention for nurses to weigh the resident as ordered and notify the physician of significant weight changes, and was later updated to identify risk for cardiac dysfunction with instructions to observe for signs such as shortness of breath, cough, abnormal lung sounds, change in mental status, activity intolerance, decreased urine output, edema, dizziness, and weakness, document abnormal findings, and notify the physician. However, the care plan did not include resident-specific interventions related to potential complications from continuously infusing IV fluids. The facility’s own Weight Monitoring policy required staff to notify the physician of a weight gain or loss of three pounds within one week, and the physician’s orders for the resident included weekly weights. The weight records showed that the resident’s weight increased from the admission weight to 259 pounds within four days (a gain of 6.2 pounds), then to 267 pounds within nine days (a gain of 14.2 pounds), and then to 270 pounds within 13 days (a total gain of 17.2 pounds). Despite these significant weight gains, there was no documented evidence that staff implemented the care plan interventions by notifying the physician of the changes between the admission date and the date of the last recorded weight. Interviews with nursing staff indicated that they did not recall notifying the physician about the weight gain, and one LPN acknowledged she did not always directly assess residents for edema, despite the care plan requiring observation for edema as a sign of cardiac dysfunction. A family member reported observing progressive swelling of the resident’s legs, feet, and scrotum during daily visits and stated he felt staff ignored his concerns about the edema. He indicated that he requested the resident be sent to the hospital due to his concerns about the swelling, and that the transfer occurred only after his request. The APRN stated that staff did not notify him of changes in assessment findings, including the resident’s weight gain, until the date the resident was ultimately sent to the hospital. The facility’s leadership, including the DON and Administrator, stated they expected staff to follow care plans, including interventions to notify the physician of significant weight changes and edema, but could not explain why staff failed to implement the care-planned interventions for this resident. The combination of incomplete care planning for continuous IV fluids and failure to implement existing care plan interventions and notification requirements led to the cited deficiency under F656 for not ensuring a comprehensive, resident-centered care plan was developed and implemented. Hospital documentation showed that the resident arrived on the inpatient unit in the evening and was later found unresponsive with pulseless electrical activity and agonal breathing, with a Code Blue initiated and the resident subsequently pronounced expired. The hospital admission diagnoses included fluid overload and myocardial infarction. The surveyors concluded that the facility’s failure to implement the care plan interventions and notify the physician beginning several days prior resulted in a delay in intervention and treatment for the resident, and Immediate Jeopardy was identified related to the deficient practice in comprehensive care planning and implementation.
Removal Plan
- All residents were reassessed and reweighed.
- All residents were reassessed by the Director of Nursing Services, Assistant Director of Nursing Services, and Unit Manager, with any changes of condition reported to the Nurse Practitioner and orders obtained.
- All care plans for residents with congestive heart failure, use of diuretics, and orders for daily or weekly weights were reviewed by the Regional Resident Assessment Specialist to ensure accuracy.
- All nurses were re-educated regarding the care plan policy, including implementation and physician notification with changes of condition, with no nurse working before receiving the education.
- A post-test was given to all nurses with an expected 100% pass rate; if 100% was not achieved, re-education was provided.
- DNS/ADNS/IPSO/Unit Manager will provide education until all nurses complete the education.
- Care plan and notification education will be added to new nurse hire orientation.
- An ADHOC QAPI meeting was held with the Executive Director, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and Medical Director to review the alleged deficiency, audit tools, plan, and education regarding notification of changes.
- The Director of Nursing Services, Assistant Director of Nursing, or Unit Manager will audit to ensure all weight changes resulted in physician or nurse practitioner notification per the care plan.
- Audit results will be forwarded to the QAPI Committee for review and presented by the Director of Nursing.
Failure to Recognize and Act on Rapid Weight Gain and Edema as Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to recognize and respond to a significant change in condition for one resident, including substantial weight gain and edema, in accordance with its own policies and the resident’s care plan. The resident was admitted for short-term rehabilitation following a serious illness with sepsis and a spinal abscess, with hospital diagnoses including atrial fibrillation, coronary artery disease, pneumonia, and stable shortness of breath at discharge. On admission, the facility documented diagnoses of pneumonia, nontraumatic subdural hemorrhage, and primary hypertension, and the MDS reflected atrial fibrillation, hypertension, moderate cognitive impairment (BIMS score of 8/15), IV access, and shortness of breath when lying flat. The care plan directed staff to weigh the resident as ordered, notify the physician of significant weight changes, and, after an update, to observe and document signs and symptoms of cardiac dysfunction such as shortness of breath, abnormal lung sounds, decreased urine output, edema, and changes in mental status, and to notify the physician of abnormal findings. The facility’s policies on Change in Condition and Weight Monitoring required staff to notify the physician or nurse practitioner for abnormal weights and significant changes, to re-weigh residents for weight changes of 3 pounds or more in one day or 5 pounds in one week, and to notify the physician, resident, and representative of such changes. Despite these policies, the resident’s weight increased from an admission weight of 252.8 pounds to 259 pounds within four days, then to 267 pounds within nine days, and to 270 pounds within 13 days, for a total gain of 17.2 pounds. The DON entered the 259‑pound weight and acknowledged later that this represented a clinically significant gain per policy but did not assess the resident or notify the APRN. LPN1 entered the 267‑pound weight but did not document any re‑weigh, assessment, or provider notification related to this gain and could not recall taking any such actions, stating that if she had notified a provider she would have charted it. During this period of rapid weight gain, clinical signs consistent with fluid accumulation were present but not consistently recognized or acted upon as a change in condition. A Health Status Note documented that a family member reported the resident’s right hand swelling, increased confusion from baseline, and complaints of shortness of breath; LPN5 documented these findings and notified the APRN, who ordered continued monitoring only, without further specified parameters. Skilled nursing assessments on two dates documented shortness of breath or labored breathing with exertion and when lying flat, need for supplemental O2 and head-of-bed elevation, and edema in both lower extremities, yet the corresponding progress notes from admission through the date of transfer contained no documentation of edema or shortness of breath and no evidence that staff recognized the weight gain as a significant change in status or notified the physician as required. On the thirteenth day, LPN4 documented +3 to +4 pitting edema in all four extremities, marked scrotal swelling, and shortness of breath after the family member again raised concerns, and EMS later assessed the resident as in acute respiratory distress with crackles/wheezing and pitting edema in all extremities. The APRN and Medical Director both stated they relied on nursing staff to notify them of rapid weight gain and changes in assessment findings, and the DON confirmed she could find no evidence that staff identified the resident’s weight gain as a potential change in condition or notified the APRN after the initial report of arm swelling, leading surveyors to cite the facility under F684 for failing to provide care in accordance with policies, care plan, and professional standards.
Removal Plan
- Resident #117 was discharged.
- All current residents were re-weighed and reassessed for change of condition by the Director of Nursing Services, Assistant Director of Nursing Services, and Unit Manager, with weights reviewed for the last 6 months.
- For any significant weight changes identified, a nursing assessment was completed by the Director of Nursing Services, Assistant Director of Nursing Services, or Unit Manager with notification of the physician or nurse practitioner for orders as needed.
- All residents were reassessed and reweighed, and any changes of condition were reported to the Nurse Practitioner with orders given.
- All nurses were re-educated by the Infection Preventionist/Staff Development, Director of Nursing Services, or Assistant Director of Nursing Services regarding the policy to notify the physician or nurse practitioner of all significant weight changes and the policy on changes in condition; no nurse worked before receiving the education.
- A post-test was administered to all nurses with an expected 100% pass rate; if 100% was not achieved, re-education was provided.
- The Director of Nursing, Assistant Director of Nursing, Infection Preventionist/Staff Development, or Unit Manager will provide education until all nurses complete it.
- Education on notification of significant weight changes and changes in condition will be added to new-hire orientation for nurses and certified medication technicians.
- An ad hoc QAPI meeting was held with the Executive Director, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and Medical Director to review the alleged deficiency, audit tools, plan, and education regarding notification of changes.
- The Director of Nursing Services, Assistant Director of Nursing, or Unit Manager will audit to ensure all weight changes and head-to-toe resident assessments resulted in physician or nurse practitioner notification when warranted.
- Audit results will be forwarded to the QAPI Committee for review and presented by the Director of Nursing.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to unmet medical and personal care needs. For Resident 80, the care plan included the use of a medicated shampoo for plaque psoriasis, but specific instructions for its application were not provided to the staff. As a result, the shampoo was not left on the scalp for the required duration, leading to continued itching and scalp issues. Additionally, the care plan for skin breakdown risk was not updated with specific interventions for the scalp condition until after the surveyor's intervention. Resident 27's care plan identified the need for regular repositioning and incontinence care to prevent pressure ulcers. However, staff failed to assist with repositioning and did not provide timely incontinence care, as observed during the survey. The facility's staffing issues were highlighted as a contributing factor, with staff unable to follow care plans due to insufficient support. The Assistant Director of Nursing Services acknowledged the lack of audits to verify compliance with care plan interventions. For Resident 52, the care plan required frequent toileting assistance and oral care, but these interventions were not consistently implemented. The resident was found with soaked briefs and reddened skin, indicating inadequate incontinence care. Oral care was also neglected, as staff failed to assist or remind the resident to perform it. The Director of Nursing Services admitted to not verifying the implementation of these care plan interventions. Similar issues were noted for Resident 36, whose care plan lacked specific instructions for cleaning an artificial eye, leading to improper care and infection. Resident 124's care plan included dressing changes for a midline, but these were not performed as ordered, resulting in the dressing remaining unchanged for an extended period.
Deficiencies in Incontinence and Oral Care
Penalty
Summary
The facility failed to provide necessary services to maintain good personal and oral hygiene for six residents, leading to deficiencies in activities of daily living care. Residents expressed feelings of embarrassment and humiliation due to the facility's failure to provide timely incontinence care. Interviews with residents and their family members revealed that residents often waited long periods, sometimes up to four hours, before staff could change them, resulting in residents urinating in their beds and lying in urine for extended periods. Additionally, the facility failed to provide daily oral care for two residents, who had plaque build-up as noted by the dentist. One resident, admitted with diagnoses including a fracture and heart failure, required substantial assistance for toileting hygiene and lower body dressing. The resident reported waiting over four hours to be changed, resulting in soiling of a leg brace. Another resident, with mild cognitive impairment and a pressure ulcer, reported waiting long periods for incontinence care, leading to skin breakdown and embarrassment. Observations confirmed that residents were left in soiled conditions for extended periods, and staff interviews indicated that short staffing contributed to the delays in care. The facility's failure to provide adequate oral care was also noted, with one resident having a bridge of calculus on their teeth and another resident with partial dentition requiring assistance with daily tooth brushing. Observations and interviews revealed that oral care was often neglected due to staff being busy with other tasks. The facility's policies on activities of daily living and oral care were not followed, resulting in inadequate care for the residents.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards and resident preferences for three residents. For one resident with a scalp condition, the facility did not ensure that the medicated shampoo was applied correctly. The shampoo was not left on the scalp for the required three to five minutes, as specified by the manufacturer's instructions. The resident continued to experience itching and discomfort, and there was no documentation of the condition's evaluation or the treatment's effectiveness. The resident had not been seen by a healthcare provider for over a month, and the staff responsible for applying the shampoo were not adequately informed about the correct procedure. Another resident with a prosthetic eye experienced ongoing issues with eye drainage and infection. The facility did not have specific care instructions for the prosthetic eye, and staff were unaware that the eye needed to be removed for proper cleaning. The resident's eye was observed to have green, pus-filled drainage, and staff interviews revealed that this was a persistent problem. Despite the presence of an artificial eye, there were no physician orders for eye care until after the survey began, and the care plan did not include necessary interventions for the prosthetic eye. A third resident with a midline IV access for antibiotic therapy did not receive the required dressing changes as ordered. The dressing was not changed weekly as specified, and observations confirmed that the dressing had not been updated since the resident's admission. Staff interviews indicated a lack of awareness regarding the outdated dressing, and the facility's procedures for ensuring timely dressing changes were not followed. The failure to change the dressing as ordered was not addressed until after the surveyor's intervention.
Inadequate Pressure Ulcer Prevention and Care in LTC Facility
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to the development of facility-acquired pressure ulcers. Resident 27, who was admitted with mild cognitive impairment, osteoarthritis, and depression, was identified as at risk for skin breakdown. Despite being assessed as cognitively intact and requiring assistance with mobility and incontinence care, Resident 27 developed a Stage III pressure ulcer on the right buttock and a deep tissue injury on the left buttock. The facility's records indicated a lack of timely incontinence care and repositioning, contributing to the worsening of the resident's skin condition. Interviews with staff revealed systemic issues, including understaffing and inadequate implementation of care plans. Staff members reported that residents often waited long periods for incontinence care, leading to prolonged exposure to moisture and increased risk of skin breakdown. The facility's interdisciplinary team failed to identify a root cause for the pressure ulcers and did not ensure that necessary interventions, such as timely repositioning and incontinence care, were consistently provided. Resident 10, with a history of multiple sclerosis, vascular dementia, and diabetes, also developed a facility-acquired pressure ulcer. Despite being identified as at risk for pressure ulcers, the resident's care plan was not effectively implemented, resulting in a deep tissue injury on the right hip. Staff interviews highlighted challenges in providing timely care due to high resident-to-staff ratios, with reports of residents being left soiled for extended periods. The facility's recent termination of a wound care service contract further strained the ability of nurses to manage wound care effectively.
Inadequate Staffing Leads to Resident Care Deficiencies
Penalty
Summary
The facility failed to maintain adequate staffing levels, resulting in insufficient care for residents. Observations and interviews revealed that residents did not receive necessary assistance with activities of daily living, such as incontinence and dental care. Additionally, staff failed to provide proper care for residents with specific medical needs, including incorrect application of medicated treatments and failure to change dressings as ordered. The lack of sufficient, competent staff led to the development of facility-acquired pressure ulcers in some residents and inadequate care for those with catheters, resulting in urinary tract infections. The facility's staffing documentation and Payroll Based Journal (PBJ) reports indicated a chronic shortage of State Registered Nurse Aides (SRNAs) and licensed nurses, particularly on weekends and night shifts. This shortage resulted in each SRNA being responsible for an excessive number of residents, often leading to delays in care and unmet needs. Interviews with staff and family members highlighted the impact of these staffing issues, with reports of call lights going unanswered for extended periods and residents being left in soiled clothing or without necessary hygiene care. The facility's internal assessments and policies acknowledged the need for sufficient staffing to meet resident needs, yet the actual staffing levels fell short of these requirements. Staff interviews revealed a high turnover rate and dissatisfaction with the workload, contributing to the ongoing staffing challenges. Despite the facility's stated goals for staffing levels, the actual number of staff on duty frequently did not meet these targets, compromising the quality of care provided to residents.
Failure to Provide and Document Advance Directive Information
Penalty
Summary
The facility failed to inform and provide written information to all adult residents concerning their right to accept or refuse medical or surgical treatment and to formulate an advance directive. This deficiency was identified for eight of the thirteen sampled residents reviewed for advance directives. The facility's policy required the Social Services Director (SSD) or Designee to provide this information prior to or upon admission, and to document any existing advance directives in the resident's medical record. However, the review revealed that this process was not consistently followed. For several residents, including those with cognitive impairments and those who were cognitively intact, there was no documented evidence that the opportunity to formulate or decline an advance directive was explained in a manner they understood. In some cases, residents were not asked about advance directives at admission, and existing directives were not requested or documented in the electronic medical record. The admission agreements often contained incomplete Living Will Packets, with only the resident's name and birthdate filled in, and no further documentation of discussions or decisions regarding advance directives. Interviews with facility staff, including the SSD, Director of Nursing Services (DNS), and Executive Director (ED), revealed a lack of awareness and understanding of the requirement to document these discussions and decisions. The SSD stated that verbal discussions were held with residents, but this was not reflected in the records. The ED believed that a signed acknowledgment of receipt of documents was sufficient, despite the absence of completed forms or evidence of informed discussions. This lack of documentation and adherence to policy led to the deficiency identified by the surveyors.
Improper Storage Temperature of Insulin in Medication Refrigerators
Penalty
Summary
The facility failed to store medications at the correct temperature, specifically insulin, in two of four medication refrigerators. Observations revealed that Refrigerator 1 in the Front Hall Medication Room registered a temperature of 26 degrees Fahrenheit, which is below the recommended range of 36 to 46 degrees Fahrenheit. This refrigerator contained various insulin pens, including Lantus, Insulin Glargine, Insulin Degludec, Basaglar, and Novolog. The presence of thick frost in the small freezer section of Refrigerator 1 was also noted. Similarly, Refrigerator 3 in the Back Medication Room registered a temperature of 30 degrees Fahrenheit and contained Admelog, Fiasp, Tresiba, Basaglar, and Lantus insulin pens. Interviews with the Assistant Director of Nursing (ADON) confirmed that medications stored at 26 degrees Fahrenheit would freeze and become ineffective. The ADON indicated that the Maintenance Director needed to adjust or repair the refrigerators and defrost Refrigerator 1, and that the medications needed to be returned to the pharmacy. The Executive Director stated that nurses were responsible for monitoring the medication refrigerator temperatures on both shifts and taking corrective action if temperatures were out of range. Despite requests, a Medication Storage policy was not provided prior to the exit.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement its infection prevention and control program as required, resulting in multiple deficiencies related to the prevention of communicable diseases and infections. Surveyors observed that a room designated for droplet precautions did not have a personal protective equipment (PPE) cart available outside the room, contrary to facility policy and CDC guidelines. Staff interviews confirmed that PPE carts should be present and accessible, but staff were unaware of the missing cart until it was pointed out. Additionally, the door to a droplet precaution room was found open, despite signage and CDC guidance requiring it to remain closed. Staff and leadership interviews revealed a lack of awareness regarding the open door, and a malfunctioning door latch was later identified as the cause. Further observations revealed that staff did not consistently follow proper cleaning and disinfection protocols for shared medical equipment. An LPN was seen cleaning a glucometer with a disinfectant wipe for less than the required dwell time and without performing hand hygiene after glove removal. Another LPN transported contaminated bandage scissors through the hall without using a container, failed to perform hand hygiene before cleaning, and did not allow the disinfectant to remain on the scissors for the required time. Staff interviews indicated knowledge of the correct procedures, but these were not followed in practice. Additional deficiencies were noted in the handling of food items used during medication administration. Opened containers of pudding and applesauce on medication carts were not dated or stored on ice as required. Staff interviews confirmed that food items should be dated when opened, kept on ice during use, and discarded after administration, but these practices were not consistently observed. The facility's infection prevention and control policies, as well as CDC and manufacturer guidelines, were not adhered to in these instances, contributing to the overall deficiency.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation for the needs of three residents by not ensuring their call lights were within reach, which is crucial for their safety and ability to request assistance. Resident 21, who was severely cognitively impaired and dependent on staff for all activities of daily living, had an adaptive call light placed out of reach on a nightstand. Despite staff being informed, no action was taken to rectify the situation. Resident 27, who was cognitively intact but required assistance with mobility, was found attempting to get out of bed without access to her call light, which was tangled in the bed frame. She called out for help, but no staff were present to hear her. Resident 91, who had dementia and mild intellectual disabilities, was also found calling for help with his call light out of reach on a nightstand by the window. Interviews with staff, including the Director of Nursing Services and the Executive Director, confirmed that staff were trained to keep call lights within reach, and it was expected for resident safety. However, the observations indicated a failure to adhere to this practice, compromising the residents' ability to communicate their needs effectively.
Failure to Address Pressure Ulcers in Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, identified as R93, who was admitted with pressure ulcers. The baseline care plan did not address the identification or treatment of these pressure ulcers, which is a requirement according to the facility's policy. The policy mandates that a baseline care plan should include minimum healthcare information necessary for proper care, including interventions for health and safety concerns such as pressure injuries. Despite the presence of pressure ulcers at the time of admission, as confirmed by interviews with the resident and staff, this critical information was omitted from the baseline care plan. Interviews with various staff members, including a State Registered Nurse Aide, a Licensed Practical Nurse, the Assistant Director of Nursing, the MDS Nurse, and the Director of Nursing Services, revealed that the omission was not in line with the facility's procedures. The MDS Nurse and the Director of Nursing Services emphasized the importance of including pressure ulcers in the baseline care plan to ensure accurate and effective care. The failure to include this information in the baseline care plan indicates a lapse in adhering to the facility's policy and professional standards of quality care.
Failure to Prevent and Treat UTIs in Residents with Catheters
Penalty
Summary
The facility failed to provide appropriate care and treatment to prevent and/or treat urinary tract infections (UTIs) for two residents with indwelling urinary catheters. For one resident, the catheter collection bag was observed lying on the floor, and the tubing was not anchored, which is against the facility's policy and CDC guidelines. The resident reported experiencing pain consistent with a UTI and had informed the staff, but no immediate action was taken to assess or address her concerns. The resident's electronic medical record lacked documentation of her complaints, and it was only after the surveyor's intervention that a nurse assessed the resident and initiated appropriate testing and treatment. Another resident with a suprapubic catheter also had their collection bag lying on the floor, unsecured to the wheelchair. This observation was made despite the facility's policy and training that emphasized the importance of securing catheter bags to prevent infections. Interviews with staff revealed that they were aware of the proper catheter care procedures, yet the deficiency occurred, indicating a lapse in adherence to these protocols. The facility's failure to secure catheter bags and promptly address residents' symptoms of UTIs demonstrates a lack of compliance with established care standards. The staff's inaction and inadequate documentation contributed to the delay in recognizing and treating the residents' conditions, potentially increasing the risk of infection and discomfort for the residents involved.
Failure to Prevent Complications from Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident, identified as R62, received appropriate treatment and services to prevent complications from enteral feeding. R62, who was admitted with diagnoses including epilepsy, dysphagia, and intellectual disabilities, was dependent on a gastrostomy tube for nutrition and hydration. Despite physician orders for specific amounts of enteral feed and water flushes, R62 did not receive the prescribed amounts, leading to severe dehydration and hypernatremia, which required hospitalization. The facility's documentation and communication practices were inadequate, contributing to the deficiency. Nursing staff failed to document changes in R62's condition, such as nausea, vomiting, and diarrhea, which led to the interruption of tube feedings. There was also a lack of communication with the nurse practitioner regarding these interruptions and the resident's declining condition. The Director of Nursing Services acknowledged that documentation should have been made when the tube feeding was stopped, and the nurse practitioner should have been notified to ensure proper nutrition. Interviews with facility staff, including the LPN, MDS Nurse, and NP, revealed a lack of consistent documentation and communication regarding R62's condition and care. The Executive Director expected staff to follow the resident's care plan, but the failure to administer treatments as ordered and the lack of documentation and communication led to R62's hospitalization for dehydration, hypernatremia, and a urinary tract infection.
Failure in Timely Pain Management for Resident
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident, identified as R119, who was admitted with a principal diagnosis of right acetabulum fracture with delayed healing, among other conditions. The resident was on a scheduled pain medication regimen, specifically oxycodone, which was not administered as ordered due to a failure in reordering the medication in a timely manner. On multiple occasions, the resident's pain medication was not available, leading to missed doses and unmanaged pain. On April 16, 2024, the resident missed several doses of oxycodone because the medication was not reordered in time, and the facility did not utilize the Emergency Kit to provide the necessary medication. The resident's pain was documented as 7/10 on the pain scale, yet there was no evidence of non-pharmacological interventions being attempted during the time the medication was unavailable. Additionally, the facility staff failed to notify the provider about the unavailability of the medication or request authorization for retrieval from the Emergency Kit. Interviews with staff revealed a lack of consistent practice in monitoring medication stock and reordering procedures. Staff members indicated that they should notify the nurse when medication stock was low, but this process was not effectively followed, resulting in the resident experiencing unmanaged pain. The Director of Nursing Services acknowledged that staff should be aware of declining stock and order medications in time, but this expectation was not met, leading to the deficiency in pain management for the resident.
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The facility failed to maintain a safe, clean, and well‑maintained environment as required by its own policy, with surveyors observing loose kitchen handrails, damaged doors and wood paneling, exposed concrete and stained flooring in resident rooms and bathrooms, bubbling and chipped paint, rusted door frames, water‑stained ceiling tiles, scuffed walls and baseboards, damaged tiles, and deteriorated outdoor structures such as a raised garden bed. Additional issues included a broken cabinet and taped wall corner guard in shower rooms, an unsecured wall clock, a missing floor tile, dried paint splatter, rusted heating/cooling units with chipped paint, and a pool table with a missing corner guard. A resident reported a heating/air unit in her room with a missing bottom panel exposing dust and debris. Staff interviews revealed that some items had been broken for years, concerns about the safety of the handrails had not resulted in repairs, housekeeping did not consistently log issues for maintenance, and there was no formal system to track and ensure completion of maintenance work orders, as acknowledged by the DON, the Maintenance Director, and the Administrator.
The facility failed to ensure food and beverages were served at safe and appetizing temperatures, as required by its Food Preparation and Service policy. Multiple test tray assessments documented hot items such as meats, vegetables, and starches being served within the temperature danger zone, and cold items such as desserts, milk, juice, and sandwiches above the required cold-holding temperature. A resident with DM2, major depressive disorder, and anxiety, who was cognitively intact, reported receiving cold food all the time, and residents in a Resident Council meeting also reported cold food at mealtimes. During a test tray observation, surveyors found hot entrée and vegetable items to be room temperature or cold and beverages warm. Despite these findings, dietary leadership and the RD stated that hot food was always hot and that temperatures taken during audits were accurate, while the DON and Administrator expressed expectations that hot food be hot and cold food be cold.
Surveyors found that nourishment refrigerators and freezers on several units were soiled with dried food debris, and multiple opened grape jelly containers were left undated and unrefrigerated despite labeling that required refrigeration after opening. Facility policies required refrigerators and freezers to be kept clean, free of debris, and that refrigerated or frozen foods be covered, labeled, and dated. Staff interviews showed that Dietary was responsible for cleaning nourishment refrigerators, that refrigerators were cleaned on a set schedule with spills expected to be wiped up by staff, and that opened jelly should have been dated and refrigerated. These practices had the potential to affect all current residents.
The facility failed to maintain a safe, clean, and homelike environment and to ensure adequate supplies for resident care. Over several months, grievances and Resident Council minutes documented repeated concerns about lack of needed supplies, use of wrong-size briefs, and the prolonged closure of a small dining room. Multiple STNAs reported frequent shortages of briefs, linens, washcloths, peri-care products, and other supplies, sometimes leading staff to cut towels into washcloths and to use ill-fitting brief sizes for residents. Environmental observations revealed inaccessible and damaged dining areas with buckled and broken floor tiles, missing and stained ceiling tiles, and a resident bathroom with uneven flooring, persistent staining, a cracked shower light cover containing a dead insect, and a soap dispenser installed above a non-functional outlet. Additional rooms and hallways had exposed wall cracks, sagging ceiling tiles, lifting and separating floor tiles, and buckled flooring attributed to leaks, while maintenance and housekeeping leaders acknowledged awareness of many of these issues but had not ensured timely correction.
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, and staff did not consistently follow existing care plan interventions. Several residents with PEG tubes, a dialysis catheter, and a colostomy either lacked appropriate EBP care plan focuses at admission or did not have EBP practices implemented as written, including missing door signage and failure to follow tube-feeding protocols. In addition, two residents with PTSD and other mental health diagnoses had active PTSD documented in assessments and psychiatric notes, but their care plans did not address PTSD-related triggers, symptoms, or trauma-informed interventions, despite staff acknowledging these omissions and the importance of accurate, complete care planning.
A deficiency was cited after surveyors found that multiple residents receiving enteral nutrition did not receive care consistent with facility policy, physician orders, or manufacturer guidance. Tube feeding bags were often hung without dates or times, tubing connectors were left uncapped between uses, and pumps and IV poles were visibly soiled with dried formula. A resident with a G-tube and severe cognitive impairment twice developed abdominal wall cellulitis identified by an adult day care center, with no prior documentation of infection signs by facility staff despite orders to monitor the site each shift. Other residents had medications administered via PEG or G-tubes without verification of tube placement, feedings started late or allowed to run past ordered stop times, and feeding systems spiked and primed hours before use with open, uncovered connectors. Staff interviews confirmed that protective caps were not supplied, that they were behind on tasks, and that they were aware these practices could introduce contamination, leading to the cited deficiency in enteral feeding management.
The facility failed to implement and maintain effective infection prevention and control practices, including missing Enhanced Barrier Precautions (EBP) signage for multiple residents with devices such as feeding tubes, colostomies, dialysis catheters, and indwelling urinary catheters, despite care plans and orders indicating EBP. Several residents receiving tube feedings had bottles and tubing hanging without dates or times and without protective end caps when not in use, contrary to staff statements that feedings should be dated, timed, and properly capped. Staff also did not consistently disinfect shared equipment and surfaces between residents, including a medication cart used for blood glucose checks, a blood pressure cuff used on more than one resident, and a mechanical lift that was returned to the hallway without cleaning after use, despite facility expectations and policies requiring cleaning between each resident.
The facility failed to maintain an effective pest control program, as gnats, roaches, mice, and other pests were repeatedly observed and reported in resident rooms, bathrooms, dining areas, and the kitchen. Surveyors noted gnats around urine-filled urinals on a bedside table, in the kitchen near an open freezer, and on dirty dishware in a unit dining room, as well as a cracked bathroom light fixture containing a dead moth. Exterior doors near the kitchen, courtyard, and parking lot were repeatedly propped open with objects, contrary to expectations stated by the DON, Dietary Manager, and Maintenance Director, allowing pests to enter. A resident reported seeing a mouse and cockroaches in his room, with a mouse glue trap observed there, while another resident reported a mouse in her window and mouse droppings in both the window and on a meal tray. STNAs described ongoing problems with gnats and large roaches and stated that routine pest control spraying and glue traps had not resolved the issues.
A resident with COPD, chronic pain, and pneumonia was placed on palliative and hospice care and ordered oral morphine concentrate for end-of-life pain management. The NP intended a dose of 0.25 ml of 100 mg/5 ml morphine (5 mg), but an LPN entered the order in the EMR as 20 mg/5 ml at 0.25 ml (1 mg), creating a concentration discrepancy. Pharmacy dispensed 100 mg/5 ml morphine labeled to give 0.25 ml (5 mg), yet staff did not detect the mismatch between the EMR and the bottle. A hospice nurse, relying on the incorrect 20 mg/5 ml EMR order, obtained a new order to increase the dose to 1.25 ml to equal 5 mg and documented this on a hospice visit record. A CMT then administered the 100 mg/5 ml concentrate at 0.25 ml once and 1.25 ml three times, each 1.25 ml dose equaling 25 mg instead of 5 mg. Despite concerns from the UM and ADON about the unusually high 1.25 ml dose, clarification was delayed, and the resident was later pronounced dead. Interviews and policies showed staff were expected to follow the five rights of medication administration and reconcile labels with EMR orders, but multiple failures to verify the correct concentration and dose led to repeated morphine overdoses and a significant medication error.
A resident on hospice with COPD and chronic pain received morphine concentrate after a verbal order from an NP was incorrectly entered by an LPN as a lower‑strength solution. A hospice nurse later increased the volume of the morphine dose based on the incorrect concentration in the electronic order rather than the pharmacy order or medication label, resulting in administration of doses five times higher than intended on multiple occasions. The resident died later that day, and hospice staff, the coroner, and police became involved, with police confirming concerns about excessive dosing and seizing the morphine. Despite a facility policy requiring prompt reporting of abuse allegations and any reasonable suspicion of a crime to state agencies, the DON and Administrator did not report the incident, with the Administrator stating she relied on police to make the report.
Failure to Maintain Safe, Clean, and Well-Maintained Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and well‑maintained environment as required by its “Home-like Environment” policy, which states residents have a right to a safe, clean, and homelike setting. Surveyors observed multiple unresolved maintenance and housekeeping issues throughout the building and grounds. These included loose and insecure handrails leading into the kitchen, a damaged kitchen entry door with scratches and a missing piece, damaged and chipped wood paneling at the nurses’ station, and multiple areas of damaged flooring in resident rooms where heating/cooling units had been removed, exposing concrete and stained flooring around toilets and sinks. Additional observations included bubbling and chipping wall paint, rusted door frames, discolored and water‑stained ceiling tiles, and scuffed walls and baseboards in hallways and the dining room. Further observations showed environmental issues in resident-use and common areas, including a water hose lying in flowerbeds at the facility entrance, a Styrofoam cup on the ground outside a resident’s window, scratched glass doors to the smoking area, damaged floor tiles at the exit to the smoking area, a cabinet in a resident shower room with a missing handle, and a wall corner guard held in place with multiple strips of tape. Another shower room had a wall clock not mounted properly, resting on cloth hooks. Additional findings included a missing floor tile in a resident room exposing concrete, dried paint splatter at entries to several resident rooms, rust and chipped paint on a heating/cooling unit and adjacent exit door, a pool table in the dining room with a missing corner guard and exposed edges, and a raised garden bed with structural deterioration and a failing, rotted base partially detached and laying on the ground. Interviews confirmed that these conditions had been ongoing and not consistently addressed through the facility’s maintenance processes. A resident reported that the heating/air unit in her room was missing the bottom part, exposing dust and debris on the floor, and stated she would clean it herself if able. A CNA reported the broken cabinet in the shower room had been in that condition for many years and that repairs were not consistently completed after being reported via logbooks. The Housekeeping Manager acknowledged awareness of scuff marks on walls and baseboards but had not entered them into the maintenance logbook. The Dietary Manager stated she had concerns about the safety of the kitchen handrails, which she believed could pose a fall risk, and that maintenance had not repaired them. The Maintenance Director stated there were no outstanding work orders in the logbook, acknowledged that monthly painting had not been done for March, and noted the damaged raised garden bed had not been repaired or removed. The DON and Administrator both acknowledged there was no formal system to track and ensure completion of maintenance work orders, and the Administrator was aware of the unsecured kitchen handrails but was not aware if repairs had ever been completed.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to provide food and drink at safe and appetizing temperatures in accordance with its own Food Preparation and Service policy. The policy, dated 2001, defined the temperature danger zone as above 41°F and below 135°F, and required potentially hazardous foods to be maintained at or below 41°F or at or above 135°F. Multiple Providence Pavilion Test Tray Assessment documents for various meals showed hot foods such as baked ravioli, baked chicken, rice pilaf, carrots, rosemary chicken, mushroom rice, au gratin cauliflower, broccoli, mashed potatoes, beef stroganoff, and carrots being served at temperatures between 118°F and 132°F, which were within the policy’s stated danger zone. Cold items such as apple bar, milk, cold ham and cheese sandwich, pudding, juice, and lemonade were recorded at temperatures between 42°F and 61°F, also within the danger zone. During a test tray observation, surveyors tasted the beef stroganoff, broccoli, and lemonade and described them as room temperature, cold, and warm, respectively. Resident feedback corroborated these findings. One resident, admitted with diagnoses including type 2 diabetes mellitus, major depressive disorder, and anxiety, and assessed as cognitively intact with a BIMS score of 14/15, stated she received cold food all the time. Residents attending a Resident Council meeting also reported receiving cold food at mealtimes. Despite these reports and documented tray temperatures in the danger zone, the Dietary Manager stated she preferred hot food served at 130°F and reported that steam tables were turned on one-half hour before meal service. The RD reported that she conducted sanitation walkthroughs and test trays and stated that hot food was always hot and that recorded temperatures showed this, and further indicated that department heads passed trays and took temperatures during test tray audits. The DON and Administrator both stated their expectations that residents receive food at proper temperatures, with hot food hot and cold food cold, but the documented observations and resident interviews showed that this was not consistently occurring.
Improper Food Storage and Unsanitary Nourishment Refrigerators
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards and its own policies for food safety. Surveyors observed that nourishment refrigerators and freezers on multiple units, including the Honor, Pavilion, and Purpose Units, were soiled with dried food debris on shelves and throughout the compartments. On the Honor Unit, an opened grape jelly container was found sitting on top of the refrigerator, undated and not stored inside the refrigerator, despite the product label directing refrigeration after opening. In the kitchen, two additional opened and undated grape jelly containers were observed left out of the refrigerator. Review of facility policies from 2001 showed that refrigerators and freezers were to be kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis, and that all foods stored in the refrigerator or freezer were to be covered, labeled, and dated with a use-by date. Staff interviews further clarified practices and expectations related to the deficiency. A state tested nurse aide stated that Dietary was responsible for cleaning the unit nourishment refrigerators. The Dietary Manager reported that nourishment refrigerators were cleaned twice weekly and that any spills should be cleaned up by staff, and acknowledged that the jelly was kept out to make peanut butter and jelly sandwiches, but should have been dated when opened and kept refrigerated. The DON stated her expectation that nourishment refrigerators be clean, and the Administrator stated her expectation that staff wipe up any spills and maintain the cleanliness of nourishment and resident refrigerators. The deficient practices had the potential to affect all 80 current residents.
Failure to Maintain Safe, Clean, and Homelike Environment and Adequate Care Supplies
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with a safe, clean, comfortable, and homelike environment, including adequate supplies for daily care. The facility’s own policy on a homelike environment requires a safe, clean, comfortable setting that emphasizes residents’ independence and personal needs and preferences. Review of grievance logs and Resident Council minutes over several months showed repeated resident concerns about not having needed supplies and the prolonged inaccessibility of the small dining room. Grievances documented that residents lacked needed supplies and that the small dining room remained unusable, while Resident Council minutes reflected residents’ desire for the small dining room to be usable by Thanksgiving and ongoing concerns about not receiving needed supplies and aides using the wrong size briefs. Multiple staff interviews confirmed ongoing supply shortages affecting resident care. One STNA reported that the facility frequently did not have enough supplies, including hand sanitizers, soaps, clean linens, and briefs, and that this had been an issue for a few months. She stated that when briefs ran out, staff reported to nursing, who contacted central supply, and if unavailable, the Administrator was called to purchase supplies locally. Another STNA reported housekeeping budget cuts and stated the facility had run out of washcloths and disposable bed pads, leading staff to cut up towels to use as washcloths for peri-care. She also reported that a previous central supply staff member told STNAs the facility budgeted briefs to be changed once every six hours, which she felt was not sufficient for some residents, and that residents sometimes had to use larger or smaller brief sizes and complained about this. A third STNA stated the facility ran out of supplies on the unit, sometimes leaving no linens for night shift, and that peri-care supplies and specific brief sizes sometimes ran low, requiring use of different sizes. Environmental observations and staff interviews showed multiple areas of the building that were not maintained in a safe, clean, or homelike condition. The small dining/activity room off the main hall was observed with tables and chairs blocking entryways and a wavy, buckled wood-grain tile floor, and the room remained inaccessible to residents. In the Honor dining room, surveyors observed a large section of broken and mismatched wood-grain tiles with gaps between them and a missing ceiling tile. The bathroom in one resident room had an uneven floor, staining on the raised toilet seat, rust-colored stains running from a soap dispenser down past a non-functional wall outlet and onto the baseboard, and a cracked shower light cover containing a dead moth. The Housekeeping Manager acknowledged the staining had been present for two to three months, that attempts to remove it were unsuccessful, that the bathroom was not homelike, and that the floor needed to be replaced. Additional structural issues were observed in resident areas and common spaces. In another resident room, the wall with the window had an exposed crack with visible sheetrock, and ceiling tiles above the door included one missing tile and six stained and sagging tiles; an LPN stated there had been a leak and that maintenance was aware, but no repairs had been made. The Maintenance Director stated the leak was caused by the HVAC system and that repairs had not yet been completed. In the Providence hallway, blue border floor tiles were lifting and separating along the length of the hallway, with large scuff marks and dull, soiled center tiles; the Housekeeping Manager stated staff could not strip and wax the floor due to the tile’s condition, and the Regional Maintenance Director stated the facility was in the process of obtaining quotes to replace the floor. In another resident room, the floor appeared buckled and wavy, which the Maintenance Director attributed to a water leak in a wall coil assist located in the ceiling, and he stated there were plans to repair the flooring in multiple rooms. Interviews with maintenance and management staff showed awareness of many of these environmental issues but also revealed gaps in monitoring and timely correction. The Maintenance Assistant reported doing monthly room rounds for lights, extension cords, plugs, and handrails but was unaware of the bathroom issues in the identified room and had not noticed the damaged tiles in the Honor dining room or how long the small dining room had been closed. The Maintenance Director stated the small dining room floor damage was due to a water leak from an ice machine and believed it occurred months earlier, and he acknowledged that the non-live outlet in the bathroom would need to be removed and covered. The Housekeeping Manager stated she was aware of damaged and ill-fitting tiles in the Honor dining room and that floors in several areas, including the small dining room, needed replacement. The DON and Administrator both stated their expectations that the facility be kept clean, safe, and homelike, with all spaces utilized for residents and floors kept even, clean, dry, and free from clutter, but the observed conditions and staff reports demonstrated that these expectations were not being met.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for multiple residents, and failure of staff to follow existing care plan interventions. For two residents with PEG tubes and one resident with a dialysis catheter, the facility did not fully develop care plans at admission to reflect their diagnoses and required Enhanced Barrier Precautions (EBP). One resident was admitted with a PEG tube in August 2025, but EBP related to the PEG tube was not added to the care plan until March 2026, and there was no EBP signage on the door during observation. Another resident admitted with end stage renal disease and a dialysis catheter had no care plan focus for the dialysis catheter or EBP, despite having an order for EBP and being admitted with the catheter; there was also no EBP signage observed on the door. For a resident with diverticulitis and colostomy status, the care plan did include EBP, and there were orders for EBP and colostomy care every shift; however, there was no EBP signage on the door, and the MDS nurse stated she had been told that residents with colostomies did not require EBP, even though EBP remained on the care plan and staff were expected to follow care plan interventions. Another resident with cerebral palsy, epilepsy, and gastrostomy status had a care plan directing staff to check PEG tube placement and gastric contents/residual volume prior to medication administration per facility protocol, but observation showed an LPN administering medications via the PEG tube without checking for placement before pushing the medication. Two residents with PTSD diagnoses did not have their mental health needs fully addressed in their care plans. One resident admitted in 2023 with PTSD and other mental health diagnoses had a quarterly MDS showing a mood severity score of 18, with difficulty sleeping, little interest in activities, and feeling depressed or hopeless nearly every day, and psychiatry notes documented PTSD and schizoaffective disorder related to past trauma and ongoing nightmares; however, the care plan contained no focus for PTSD. Another resident admitted in 2016 with PTSD and borderline personality disorder had an active PTSD diagnosis on the MDS, but the comprehensive care plan did not address PTSD, including triggers, symptoms, or trauma-informed interventions. The Social Services Director, MDS nurse, DON, and Administrator all acknowledged that the PTSD diagnosis and related care plan focus had been overlooked and that care plans were expected to be fully developed and implemented so staff would know how to properly care for residents.
Failure to Maintain Safe, Timely, and Sanitary Enteral Feeding Practices
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services to prevent complications related to enteral nutrition for six residents with feeding tubes. Surveyors found that tube feeding systems were frequently hung without being dated or timed, and tubing connector tips were left uncapped between uses, despite facility policy and manufacturer guidance requiring protection of components that contact formula. Multiple residents had feeding containers spiked and primed but not infusing, with the open ends of tubing left exposed and no protective caps available. Staff interviews confirmed that caps were not provided by the facility, and nurses acknowledged that uncovered connectors could introduce germs and place residents at risk for infection. For one resident with a gastrostomy tube and severe cognitive impairment, the care plan and orders required monitoring the G-tube site for infection every shift and checking tube placement and gastric residuals. The resident was sent twice from an adult day care center to the Emergency Department and diagnosed with abdominal wall cellulitis on both occasions, after the day care staff identified abnormal G-tube findings, including leakage and inability to flush the tube. The facility’s clinical record contained no documentation that staff had identified or recorded signs or symptoms of infection before the resident left for day care on either occasion, and the Physician Assistant reported she had not been notified of excessive leakage that could contribute to recurrent cellulitis. During observation, this resident’s G-tube site was reddened with yellowish-green drainage, the feeding container had been spiked the previous day and was being reused, the connector was left uncovered, and the pump and IV pole had dried formula residue. Other residents with PEG or G-tubes also experienced deficiencies in enteral feeding management. Several residents had tube feedings hanging and infusing without dates or times on the bags, and tubing sets were observed primed and hanging with open, uncapped ends. One resident received medications via PEG tube without the nurse checking tube placement beforehand, despite a care plan intervention to check placement and gastric contents per protocol. Another resident’s feeding was labeled to start later in the day but was already spiked and primed hours in advance, with the connector left uncovered and the pump and IV pole soiled with dried feeding residue. For a resident ordered to receive tube feeding from late afternoon to early morning, the feeding was started approximately two hours late and then observed still infusing well past the ordered stop time; the resident was later found in bed with a large amount of emesis on the gown and linens, and the LPN stated she had been running behind and had not turned off the feeding. Throughout these observations, the DON, PA, RD, and product representative all confirmed that connectors should be covered, feedings should follow ordered schedules, and systems should not remain hanging beyond recommended timeframes, but the facility’s practices did not align with these expectations. Across multiple days of observation, the surveyors repeatedly noted that enteral feeding pumps and IV poles for several residents were coated with dried feeding residue on the exterior surfaces, along the poles, and at the bases, indicating that equipment used for tube feeding was not maintained in a clean and sanitary condition. Facility policies on enteral nutrition and G-tube site care required staff to monitor for signs of infection, maintain cleanliness of the tube site, assess for redness, swelling, pain, or drainage, and report signs of infection to a supervisor and physician. The policies also emphasized confirming tube placement prior to initiating feedings to reduce aspiration risk and recognizing complications such as aspiration, tube misplacement, skin breakdown, and gastrointestinal symptoms. Despite these written policies and the manufacturer’s guidance on closed versus open systems, hang times, labeling, and handling to prevent contamination, staff actions and inactions—including failure to document and report abnormal G-tube findings, failure to verify tube placement before medication administration, failure to adhere to ordered feeding schedules, and failure to keep connectors capped and equipment clean—led to the cited deficiency for all six residents receiving enteral nutrition.
Failure to Implement Effective Infection Prevention and Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program, as evidenced by multiple observations of noncompliance with policies, CDC guidance, and basic infection control practices. Surveyors observed that residents on Enhanced Barrier Precautions (EBP) did not have required signage posted on their room doors, despite care plans and orders indicating the need for EBP. Residents with devices such as a PEG tube, colostomy, dialysis catheter, and indwelling urinary catheter were under EBP, but their rooms lacked appropriate signage. Staff interviews confirmed that EBP should have been initiated and care planned upon admission for these residents and that signage should have been posted, but this was not done or was delayed. The deficiency also includes improper management of enteral nutrition systems for several residents receiving tube feedings. Surveyors observed tube feeding bottles and tubing hanging on poles without dates or times indicating when they were opened or hung, and with tubing primed but without protective end caps when not in use. Staff, including LPNs and the PA, acknowledged that tube feedings should be dated and timed, that they are only good for a limited period once hung, and that the absence of end caps could allow germs or bacteria to be introduced into the feeding system. The DON and Administrator stated their expectations that tube feedings be dated, timed, and capped, and that undated or uncapped systems should be replaced, but the observed practice did not align with these expectations. Additional deficiencies were identified in the cleaning and disinfection of shared equipment and surfaces between resident use. A nurse performing blood glucose checks placed used supplies and a glucometer on the medication cart surface, cleaned the glucometer, but did not disinfect the cart surface before preparing supplies for another resident on the same surface. Another nurse used a blood pressure cuff on two different residents without cleaning it between uses, stating she normally would use disinfectant wipes but forgot and did not have wipes in her cart. In a separate incident, staff used a mechanical lift to transfer a resident back to bed and then placed the lift in the hallway without cleaning it after use. Staff and leadership interviews confirmed that shared equipment and surfaces should be disinfected between residents to prevent cross-contamination, but this was not consistently done. Collectively, these observations show that the facility did not follow its own infection prevention and control policies related to EBP implementation and signage, safe handling of tube feedings, and cleaning and disinfection of shared equipment and surfaces. The facility’s policies required surveillance of staff adherence to infection control practices, proper use of standard precautions, and cleaning and reprocessing of reusable equipment between residents, but surveyors found repeated instances where these requirements were not met for multiple sampled residents.
Failure to Maintain Effective Pest Control and Environmental Practices
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and rodents, despite having a pest control contract and invoices showing routine service. Surveyors observed gnats in multiple areas of the facility on several days, including around urinals in a resident room, in the kitchen near an open double reach-in freezer, and on dishware in a unit dining room sink and tray. A cracked overhead bathroom light fixture in another room contained a large dead moth. Staff and residents reported seeing gnats, roaches, and mice in the facility, and invoices confirmed that pest control services were being provided for various pests including mice, rats, spiders, water bugs, silverfish, and roaches. Multiple observations showed that exterior doors were repeatedly propped open, allowing pests to enter the building. The kitchen delivery and emergency door was held open with a milk crate, creating a gap between the doors, and the kitchen back door was again observed held open with a milk crate on another day. Two side doors leading to the courtyard and toward the kitchen were observed open with wind blowing into the building, and a side door facing the parking lot was held open with two chairs, despite posted signs instructing that the door not be used. The Director of Maintenance, Dietary Manager, and DON each stated that these doors were expected to remain closed except during specific uses, and acknowledged that open doors allowed pests to enter and potentially contaminate food. Residents and staff provided additional accounts of pest activity. One resident reported seeing a mouse come from under a chair in his room, as well as cockroaches on the walls disappearing into ceiling tiles and gnats; a mouse glue trap was observed behind a chair in that room, and the resident stated he had reported the issue and pest control had sprayed. Another resident reported finding a mouse between the screen and window in her room, later seeing mouse droppings in the window, and receiving a meal tray with mouse droppings. STNAs reported seeing large roaches in hallways, ongoing problems with flies and gnats in dining rooms, and complaints from residents and families about gnats, while also stating that pest control spraying did not seem effective. The DON acknowledged that one resident did not like staff touching his belongings, which contributed to urinals with urine being left on a bedside table with gnats flying around them, and stated the facility should be kept clean and as nice as possible for residents.
Fatal Morphine Overdose Due to Unreconciled Concentration and Dose Errors
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when staff administered multiple overdoses of concentrated oral morphine. The resident had COPD, chronic pain, osteoarthritis, and was placed on palliative care, later transitioning to hospice after a decline that included pneumonia, decreased oxygen saturation, shallow breathing, and lethargy. On the morning of the incident, the facility NP gave a verbal order for morphine concentrate 100 mg/5 ml at 0.25 ml (5 mg) every hour as needed, and also sent a written order to the pharmacy for this concentration and dose. However, when the LPN entered the order into the electronic medical record, she documented morphine 20 mg/5 ml with a dose of 0.25 ml (1 mg), creating a discrepancy between the NP’s intended concentration and the order recorded in the system. The pharmacy dispensed morphine sulfate 100 mg/5 ml concentrate with label directions to give 0.25 ml (5 mg) every hour as needed, consistent with the NP’s written order. When the medication arrived, the receiving LPN stated she compared the bottle to the pharmacy order and the computer but did not identify any difference between the 100 mg/5 ml label and the 20 mg/5 ml order in the EMR. Later, a hospice nurse arrived, reviewed the MAR that showed morphine 20 mg/5 ml at 0.25 ml (1 mg), and observed the first dose of 0.25 ml being administered by a CMT. Seeing continued discomfort, the hospice nurse obtained a verbal order from the hospice physician to increase the dose to 1.25 ml to equal 5 mg, basing this calculation on the 20 mg/5 ml concentration shown in the Physician Order Report and not on the actual 100 mg/5 ml concentration on the bottle or the NP’s written pharmacy order. Following the hospice nurse’s written order on the Nursing Home Visit Record to increase the dose to 1.25 ml, the CMT administered the concentrated morphine 100 mg/5 ml at 0.25 ml once and then at 1.25 ml on three subsequent occasions that afternoon, each 1.25 ml dose equaling 25 mg instead of the intended 5 mg. The CMT reported that she questioned the 1.25 ml dose because she had never given that much before, but proceeded after the hospice nurse confirmed it was correct based on the MAR. The Unit Manager and ADON both expressed concern about the 1.25 ml dose and recognized it seemed like a large amount, but clarification with hospice was delayed until late in the day. The pharmacy later confirmed that, based on the 100 mg/5 ml concentration delivered, the resident received 25 mg instead of 5 mg on three administrations within approximately three hours, a fivefold overdose each time. The resident was pronounced dead that evening, and law enforcement and the coroner were notified after hospice staff and facility staff identified a potential morphine overdose and documented that three doses had been given at five times the ordered concentration. Interviews with multiple RNs, the DON, Medical Director, and Administrator confirmed that facility expectations and policies required staff to perform the five rights of medication administration, visually compare the medication label to the EMR order and narcotic sheet, and seek clarification from the provider or pharmacy if any discrepancy or concern arose. Despite these policies, staff involved in ordering, receiving, verifying, and administering the morphine did not reconcile the differing concentrations (20 mg/5 ml vs. 100 mg/5 ml) between the EMR, the hospice documentation, and the pharmacy label. The hospice nurse based the dose increase solely on the EMR order, the receiving LPN did not detect the mismatch between the EMR and the bottle, and the CMT and nursing leadership did not stop administration or obtain timely clarification when the 1.25 ml dose appeared unusually high. These combined actions and inactions resulted in repeated administration of morphine at five times the intended dose and constituted a significant medication error. The facility’s own policies on medication administration, physician orders, and medication labeling required nurses to question inappropriate doses, verify label accuracy, and consult the provider or pharmacy when directions changed or appeared inconsistent. Staff interviews indicated that these expectations were known, including the need to reconcile the drug in hand with the EMR order and narcotic record before administration. Nonetheless, the morphine order was incorrectly entered into the EMR, the discrepancy between the EMR and the pharmacy label was not recognized at receipt or prior to administration, and the hospice nurse’s dose adjustment was calculated from the incorrect EMR concentration rather than the actual bottle concentration. The failure of multiple staff members to follow established verification processes and to resolve evident concerns about the dose led directly to the resident receiving three excessive doses of morphine concentrate and underpinned the cited deficiency for significant medication errors under 42 CFR 483.45 (F760).
Failure to Report Suspected Abuse/Neglect and Medication Error Involving Morphine Overdose
Penalty
Summary
The deficiency involves the facility’s failure to report an alleged violation involving potential abuse/neglect and a reasonable suspicion of a crime to state agencies as required by facility policy and regulation. The facility’s Abuse, Neglect and Misappropriation of Property policy required that any abuse allegation be reported to the state within two hours and that any reasonable suspicion of a crime with serious bodily injury be reported to the state and police. For one resident, R1, who had diagnoses including COPD, chronic pain, and osteoarthritis and who was placed on hospice care at family request, there was a medication error involving morphine dosing on the day of the resident’s death. Despite this event and subsequent involvement of law enforcement and the coroner, the facility Administrator and DON did not report the incident to the state agencies, with the Administrator stating she relied on the police to report it. On the morning of 03/12/2026, the facility NP gave a verbal order for morphine concentrate 0.25 ml every hour as needed, which she clarified as morphine concentrate 100 mg/5 ml, 0.25 ml (5 mg) every hour as needed, and she placed a written order to the pharmacy accordingly. LPN1, however, documented the order in the Physician Order Report as morphine 20 mg/5 ml, 0.25 ml (1 mg) as needed for pain. Later, a hospice nurse (HN1) wrote a hand‑written Nursing Home Visit Record increasing the morphine dose to 1.25 ml to equal 5 mg as needed, basing this on the 20 mg/5 ml concentration shown in the Physician Order Report and not on the NP’s written order to the pharmacy or the actual medication label, which both indicated 100 mg/5 ml. The morphine supplied for R1 was morphine sulfate 100 mg/5 ml concentrate, labeled to give 0.25 ml (5 mg) every hour as needed, and the Controlled Drug Record showed that on 03/12/2026, R1 received 0.25 ml at 11:30 AM and 1.25 ml at 1:46 PM, 3:11 PM, and 4:49 PM, meaning the resident was administered five times the ordered dose on three occasions. During this period, the UM and ADON expressed concern about the increased morphine dose of 1.25 ml, with the ADON instructing the UM to call hospice for clarification because the amount seemed like a lot. The UM reported she did not obtain clarification until later in the shift, and hospice documentation reflected a call at 5:10 PM questioning the order. R1 was pronounced dead at 5:53 PM that day. After the death, hospice staff raised concerns about the amount of morphine administered, reported difficulty obtaining the narcotic log, and one hospice nurse (HN2) stated she was told that the prior hospice paperwork had been shredded. The coroner and police became involved; the police retrieved the morphine, reviewed medications, and had a recorded call from the UM acknowledging that three doses had been given at five times the ordered amount. When interviewed, the DON stated that incidents to be reported to OIG would include any type of abuse and that such allegations should be brought to the Administrator, but she believed the incident was reported by police. The Administrator confirmed she did not report the allegations regarding R1 to state agencies because she knew the police were going to report the incident, even though the Medical Director acknowledged that the incident probably should have been reported. The facility’s failure, therefore, centered on not reporting the alleged violation involving potential abuse/neglect and a reasonable suspicion of a crime related to the morphine dosing error and resident death, despite clear internal policy requiring timely reporting to state agencies and, when applicable, to law enforcement. The report documents that the facility relied on law enforcement to make any required report instead of submitting its own report to the state agencies. This omission occurred in the context of conflicting morphine orders, administration of doses higher than intended based on the actual concentration, concerns raised by hospice staff and facility leadership, and subsequent involvement of the coroner and police.
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