Citations in Kentucky
Statistics, citations and compliance trends for long-term care facilities in Kentucky.
Statistics for Kentucky (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Kentucky
The facility failed to maintain an effective pest control and sanitation program, resulting in a widespread gnat infestation in common areas, resident halls, the laundry room, medication cart trash, dirty utility room, and the kitchen. Surveyors observed gnats emerging from drains, stagnant mop water with a rancid odor, and extensive moisture, standing water, and organic debris in kitchen drains, cracked floor tiles, and hard-to-reach areas behind equipment. Pest control service reports over several months repeatedly documented unresolved issues such as drain debris, standing water, and debris accumulation, while the pest control provider stated that facility compliance with recommended cleaning and maintenance was inconsistent and many action items remained undone. The Dietary Manager reported ongoing gnat problems and use of a hose-mounted floor sprayer and vinegar in drains, which the pest control representative stated would not remove organic buildup or larvae. Leadership, including the VPO, DON, and Administrator, described expectations for cleaning, pest reporting, and drain use that were not reflected in observed conditions, and two residents reported that gnats were frequently present around them and their food, especially during meals.
A resident with morbid obesity and bilateral foot drop, whose care plan called for two staff for bed mobility and incontinence care, slid off the edge of the bed during perineal care and sustained abrasions and skin discoloration. The resident stated an SRNA rolled them too far while the SRNA was on the opposite side of the bed, and staff interviews confirmed the SRNA performed the care alone instead of waiting for another staff member. The ADON and DON stated the resident should have had two staff assist with the care.
An LPN was observed administering insulin via a pen injector to a resident with diabetes without priming the needle before either dose. The resident had type 2 DM with hyperglycemia and active NovoLog FlexPen orders, but the facility’s competency assessment covered insulin by syringe and did not show training or assessment for insulin pen use. The LPN stated she was not aware priming was required, and the DON and Administrator confirmed the facility had not provided competency training on insulin pens.
A resident admitted for rehab with muscle weakness and unsteadiness had PT and OT care plans and orders for treatment five times per week, but therapy logs showed missed PT/OT sessions on two days with no documented reason. The Director of Rehabilitation confirmed the resident received therapy only three of five days over two consecutive weeks, contrary to the plan of care, and could not explain or document why sessions were missed. The resident and the resident’s representative reported that the resident did not receive therapy as expected, that therapy minutes were insufficient, and that services were not tailored to the resident’s needs, including use of group therapy despite the resident’s stated preference against it.
The facility failed to maintain a safe, clean, and sanitary laundry environment and to properly manage a resident’s clothing. A resident with COPD, heart failure, type 2 DM, and ESRD had most of their clothing lost during a short stay, and the family member who searched for the items described the laundry room as extremely hot, messy, dirty, with clothes everywhere and overflowing trash. Staff interviews confirmed the laundry room had long‑standing issues with excessive heat and clutter. Surveyor observations found floors between and behind washers covered with dirt, a dry flaky substance, loose concrete, and residue on piping and chemical tubing, alongside buckets of corrosive chemicals. Interviews with housekeeping, EVS, a chemical vendor, and maintenance showed that a chemical spill behind the washers had occurred over a year earlier and was never properly cleaned up, with conflicting accounts over whether maintenance or EVS was responsible and no effective system to ensure cleaning behind the machines.
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident with mild cognitive impairment and multiple medical conditions was reported by the resident’s family member. The Administrator was notified of the allegation that someone had smacked the resident across the face, but the initial report to the state survey agency was not submitted until more than three and a half hours later, exceeding the required two-hour timeframe. Facility documentation did not show that law enforcement was notified, despite policy requiring reporting of suspected crimes, and interviews with the SSD, DON, and Administrator confirmed that the expected practice was to report such allegations promptly to the state survey agency and law enforcement when applicable.
Failure to Maintain Effective Pest Control and Sanitary Conditions Resulting in Widespread Gnat Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free of insects and other pests, resulting in a widespread gnat infestation throughout the building. Surveyor observations over two days identified gnats in multiple common areas, including the conference room, resident halls, laundry room, medication cart trash can, and dirty utility room. In the laundry room, gnats were seen emerging from the washing machine discharge drain, and in the dirty utility room, gnats were concentrated around a mop bucket containing stagnant, foul-smelling water. On a resident hall, multiple gnats were observed flying around residents and on surfaces throughout the corridor. Extensive observations in the kitchen revealed multiple environmental and sanitation issues that contributed to the gnat activity. Behind and around the ice machine and juice cart, there was wet dust, dirt, and organic debris such as food crumbs, sugar packets, and trash items, all saturated with moisture. Cracked, loose, and broken floor tiles near the ice machine drain and in the dish room contained food debris lodged within and beneath the damaged tiles, with standing water collected beneath the tiles and pooled around the ice machine drain. Standing water was also observed in the spray room, dish room, along walls, and in corners, with water spread across the kitchen floor after staff used a hose-mounted sprayer to clean the floors. On a subsequent day, the kitchen floor again had visible standing water, and a floor drain contained accumulated debris, paper fragments, and organic material, with a broken drain grate that did not fully cover the drain and exposed additional trapped debris; gnats were present in and near this drain and throughout the kitchen. Review of facility work orders showed only one report of gnats in common areas and nursing units for one month and one report of bugs facility-wide in the following month, despite the widespread activity observed. Service reports from the contracted pest control company over several months documented ongoing, unresolved environmental concerns in the kitchen and adjacent areas, including repeated findings of drain debris, standing water in kitchen and dishwashing areas, debris accumulation, and moisture issues that remained uncorrected by the facility. The pest control representative and pest control account manager both stated that gnats were originating from drains, cracks, and crevices with organic debris and moisture, and that routine cleaning practices were ineffective when debris remained or was pushed into cracks and around drains. They reported that recommendations such as debris removal, proper drain maintenance, and cleaning of hard-to-reach areas were repeatedly communicated and documented, but the facility’s compliance with these recommendations was inconsistent, with many action items left undone and carried over on subsequent service reports. Interviews with staff and leadership further described the facility’s actions and inactions related to pest control and sanitation. The Dietary Manager reported ongoing gnat concerns for multiple weeks, stated that pest control services were provided twice monthly, and that kitchen staff performed routine cleaning weekly and as needed, using a hose-mounted spray system for floors and pouring vinegar down drains between pest control visits. The pest control representative stated that pouring vinegar down drains would not eliminate the infestation and might attract gnats, as it did not remove organic buildup or kill larvae. The pest control account manager identified contributing factors such as debris buildup in cracks and flooring, lack of routine cleaning behind equipment, standing water or improperly maintained mop buckets, inconsistent cleaning practices in non-visible areas, and lack of routine maintenance of drains and traps, and noted that environmental cleaning often improved only after issues became more apparent. The VPO acknowledged gnat activity throughout the building and that pest control reports had identified ongoing debris concerns in the kitchen, but could not clearly describe a process to ensure consistent cleaning of hard-to-reach areas or to verify cleaning effectiveness. The DON and Administrator described expectations for reporting pests, emptying mop buckets, removing trash from medication carts, removing debris before floor cleaning, and not sweeping debris into drains, but these expectations were not reflected in the observed conditions. Two cognitively impaired and intact residents reported that gnats were always present, especially around meal times and food, and that they found them bothersome and undesirable during meals.
Failure to Provide Two-Person Assistance During Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance to prevent a fall for one resident who had diagnoses of morbid obesity, left foot drop, and right foot drop. The resident’s care plan identified a need for two staff members for bed mobility and in-bed care related to bariatric status, and also directed staff to provide two-person assistance for bed mobility and total assistance for incontinence care as the resident allowed. The resident’s MDS indicated intact cognition and that the resident required supervision or touching assistance for rolling left and right in bed. During incontinence care, the resident slid off the edge of the bed to the floor and onto their knees. The acute change in condition assessment documented abrasions and skin discoloration after the incident. In interviews, the resident stated that a staff member rolled them out of bed during incontinence care and that they were able to assist with rolling by using the assist bars on either side of the bed. The resident stated that while rolling to the right side of the bed, they rolled too far and slid off the edge of the bed while the SRNA was standing on the opposite side of the bed. Staff interviews showed that the SRNA provided the incontinence care by herself even though the resident required two-person assistance. The SRNA stated she did not ask another staff member for help because she was used to performing the care alone, and later stated that having another SRNA in the room could have prevented the incident. Other staff, including the ADON and DON, stated the resident should have had two staff members assist with incontinence care. The DON also stated the resident could assist with turning using the bed rails, but the SRNA should have used another staff member and waited for assistance.
Insulin Pen Competency Not Demonstrated
Penalty
Summary
Licensed nursing staff were not shown to have the competencies and skill set necessary to administer insulin via an insulin injector pen for one LPN observed caring for a resident with diabetes. Review of the LPN’s competency assessment showed the DON assessed insulin administration by syringe, but it did not indicate assessment of insulin pen injector use, even though the competency document stated staff should have access to manufacturer instructions for all insulin delivery systems before use. The manufacturer’s instructions for NovoLog FlexPen required priming the pen before injection to avoid injecting air and ensure proper dosing. The resident involved was admitted with a diagnosis of type 2 diabetes mellitus with hyperglycemia and had active orders for NovoLog FlexPen, including a sliding scale order and a separate order for 16 units before meals. During observed medication administration, the LPN checked the resident’s blood glucose, which was 409, then administered 16 units of NovoLog FlexPen without priming the pen needle. After contacting the physician, the LPN later returned and administered 10 units from the sliding scale order, again without priming the insulin needle. The LPN stated she was not aware the pen needle needed to be primed and was unsure whether she had education on insulin pen injectors. The DON stated competency training covered insulin administration by syringe but not insulin pen injectors, and the Administrator stated the facility had not provided competency training related to insulin pens.
Failure to Provide Ordered PT/OT and Document Missed Therapy Sessions
Penalty
Summary
The facility failed to provide specialized rehabilitative services as ordered for one resident admitted for rehabilitation with diagnoses of muscle weakness and unsteadiness on feet. The resident’s care plan, initiated shortly after admission, identified a rehabilitation focus with skilled PT and OT interventions, and physician orders specified PT and OT to evaluate and treat. The OT plan of care called for treatment five times per week for 60 days, and the PT plan of care called for treatment five times per week for 30 days. Review of the Service Log Matrix showed that the resident did not receive individual PT or OT on two specified dates, despite the plan of care requiring therapy five days per week. The Director of Rehabilitation confirmed that the resident missed PT/OT on those two dates, that the plan of care was for five days a week, and that the resident only received PT/OT three out of five days for two consecutive weeks. The resident and the resident’s representative reported concerns that the resident was not receiving the allotted amount of therapy time and that therapy was not tailored to the resident’s specific needs. The representative stated the resident was weaker upon discharge than at admission and that the family sought transfer to another facility for PT after expressing concerns without improvement. The resident reported not receiving any PT during the first week, receiving PT only after questioning staff, and that when PT was provided it lasted 30–40 minutes and included group therapy that was counted as PT despite the resident’s preference against group therapy. The Director of Rehabilitation stated she did not know why therapy was missed on the two identified dates and that no reasons were documented, although such reasons were typically recorded. The DON stated her understanding that if therapy was missed, staff should attempt to reschedule so that residents did not miss needed therapy, and the current Administrator stated her expectation that residents receive the therapy they are supposed to receive to reach their maximum potential.
Failure to Maintain Clean, Safe Laundry Environment and Proper Handling of Resident Clothing
Penalty
Summary
The facility failed to ensure a safe, clean, sanitary, and comfortable environment in the laundry area as required by its Safe and Homelike Environment and Resident Rights policies. The policies stated that the physical layout should not pose a safety risk and that a sanitary environment must be maintained, including proper cleaning and storage of resident care equipment and items used for activities of daily living. Despite these policies, observations on 04/17/2026 showed the floor between and behind the washing machines covered and caked with dirt, a dry flaky substance, loose concrete, and residue on piping and chemical tubing, while multiple buckets of corrosive laundry chemicals and detergents were present in the same area. A resident’s family member reported that during the resident’s four‑day stay, most of the resident’s clothing was lost, and when she was allowed into the laundry room to search for the items, she found the room extremely hot, messy, with clothes everywhere, dirty conditions, and overflowing trash. The resident involved had significant medical diagnoses including COPD, acute on chronic systolic heart failure, type 2 diabetes mellitus, and end‑stage renal disease. A SRNA corroborated that the laundry room had always been hot, especially in summer, and that the room had long been somewhat messy with clothes, worsening over the past couple of years. Interviews with housekeeping, environmental services, the chemical supplier, and maintenance staff revealed that a chemical spill behind the washing machines had occurred well over a year earlier when ports at the back of the machines became clogged, causing chemicals to leak onto the floor. The chemical representative stated he cleaned the ports and moved tubing, and an EVS staff member told him maintenance would clean up the spill, but it was never done. Housekeeping reported that maintenance told them to clean up the spill themselves, while the Maintenance Director stated that EVS was responsible for cleaning the washing machines and that he had not observed leaks during his tenure. The dried, flaky substance and damaged concrete remained in place until it was later cleaned and repaired, and there was no documented system in place to ensure regular cleaning behind the washers, despite the presence of paper checklists for other tasks such as lint trap cleaning.
Failure to Timely Report Alleged Physical Abuse to State Agency and Law Enforcement
Penalty
Summary
The facility failed to report an allegation of physical abuse to the state survey agency and law enforcement within the required two-hour timeframe. Facility policy titled “Abuse Prohibition Standard of Practice,” last reviewed 03/2026, required that alleged violations be reported immediately to the Administrator or designee and to the state survey agency, adult protective services, and other required agencies, including law enforcement when applicable, within specific time frames. The policy also required the Administrator or designee to report suspicion of a crime to local law enforcement authorities. Resident 94, admitted on 06/19/2025, had a medical history including anemia, difficulty in walking, dislocation of an internal right hip prosthesis, muscle weakness, and other symbolic dysfunctions. An admission MDS with an ARD of 06/24/2025 showed a BIMS score of 10, indicating mild cognitive impairment, and the care plan documented impaired cognition and psychosocial adjustment difficulties related to anemia. On 07/01/2025, the facility generated an Initial Report indicating that a family member reported the resident had stated someone smacked them across the face the previous day after lunch or dinner. The Administrator was notified of this allegation at 9:45 AM. An email from the Administrator to the state survey agency showed the initial report was sent at 1:41 PM, more than three and a half hours after the Administrator was notified, exceeding the two-hour reporting requirement. The Initial Report did not indicate that local law enforcement was notified. During interviews, the SSD, DON, and Administrator all acknowledged that allegations of abuse should be reported to the state survey agency within two hours, and the Administrator stated that their process was to notify law enforcement when a resident requested or when there was a chance a law had been broken, but she did not follow the appropriate process in this case.
Find your facility
Search by name to see its inspection history, citations and penalties — and how to prepare for the next survey.
Get alerted when Immediate Jeopardy citations hit in Kentucky — free
You're all set
Compliance trends in Kentucky
Data through Mar 2026Comparisons below measure the most recent period Apr 2025 – Mar 2026 against the prior period Apr 2024 – Mar 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in Kentucky
- Re-educated all nurses on policies requiring physician/nurse practitioner notification for significant weight changes and changes in condition, and prevented nurses from working until education was completed (J - F0684 - KY) (J - F0580 - KY)
- Administered post-tests after nurse education with a required 100% pass rate and provided re-education as needed (J - F0684 - KY) (J - F0580 - KY)
- Added education on notification of significant weight changes/changes in condition to new-hire orientation for nurses (and certified medication technicians where specified) (J - F0684 - KY) (J - F0580 - KY)
- Educated the Director of Nursing Services to review weight reports timely related to the weekly Nutritional At Risk meeting (J - F0580 - KY)
- Implemented ongoing audits to verify weight changes and resident assessments resulted in physician/nurse practitioner notification when warranted, with results forwarded to QAPI for review and presented by the Director of Nursing (J - F0684 - KY) (J - F0580 - KY)
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 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.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.
