Citations in Kentucky
Comprehensive analysis of citations, statistics, 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 adequately monitor and manage the behaviors of two residents with documented behavioral and cognitive issues, leading to a resident-to-resident altercation. One resident with complex behavioral symptoms and unawareness of social norms repeatedly questioned another resident with dementia and behavioral disturbances about staff presence in the kitchen, became upset when ignored, and used an expletive. In response, the second resident admitted to slapping the first resident in the face with an open hand. No staff directly witnessed the interaction or intervened before the slap, despite existing care plans noting behavioral concerns and the need for redirection and reporting of behaviors.
Surveyors found that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses from pens that were not primed according to manufacturer instructions. An LPN and an RN each attached a needle and dialed the ordered insulin dose on insulin pens for two different residents, then proceeded to administer the injections without first priming with 2 units as required. The DHS and interim ED stated that nurses were expected to follow manufacturer guidelines, and another LPN confirmed that pens should be primed before dialing the ordered dose, but there was no specific facility policy on insulin use, contributing to the observed errors.
A resident with schizophrenia, dementia, and a documented history of sexually inappropriate and aggressive behavior repeatedly exhibited impulsive sexual contact, aggression toward staff and other residents, and attempts to enter others’ rooms over several months. Psychiatric notes, behavior notes, and staff reports described ongoing touching of female caregivers, pushing another resident toward her room, and entering residents’ rooms, yet MDS assessments documented no behaviors and the care plan and CNA Kardex did not include behavioral problems, supervision needs, or protective interventions. Another resident with severe cognitive impairment and anxiety, who had not been assessed or documented as able to consent to sexual contact, expressed fear and discomfort about this resident, crying and stating she did not feel safe. An LPN later found the aggressive resident in this resident’s room, positioned over her in bed, holding her hands down and pushing her back while attempting to get on top of her. Afterward, the cognitively impaired resident showed ongoing emotional distress and fear of that man entering her room again. Facility leadership, including the ED, DON, and social services, did not initially identify the event as abuse or report it, asserting without evidence that the severely cognitively impaired resident could consent to being touched, despite facility policy defining sexual abuse as nonconsensual contact and requiring documented capacity assessments.
The facility failed to immediately report multiple allegations and incidents of potential abuse and injuries of unknown origin to external authorities as required by policy and federal regulations. In one incident, an LPN observed a male resident with a history of sexual behaviors physically restraining a severely cognitively impaired female resident in her bed, causing her emotional distress, but leadership told the LPN not to escalate the concern and did not report the allegation to law enforcement or the SSA. Leadership, including the ED, DON, and social services, repeatedly decided that this and other events—such as a resident’s allegation that her roommate pushed her down and several severely cognitively impaired residents found with unexplained bruises to the thigh, knee, face, and upper arm—did not meet their internal definition of abuse and therefore were not reported, despite policy requiring all alleged abuse and injuries of unknown origin to be reported within two hours. The ED and a corporate representative acknowledged that the facility and corporate team would investigate first and determine what constituted abuse before reporting, rather than immediately reporting all allegations as required.
Facility leadership failed to ensure effective administration in care planning, abuse prevention, and mandatory reporting. A resident with schizophrenia had documented escalating aggressive and sexually inappropriate behaviors over several months, but nursing leadership did not identify these behaviors on the MDS, did not trigger the behavioral care area, and did not develop a behavioral care plan until after a serious incident. An LPN later observed this resident physically restraining and attempting to get on top of a severely cognitively impaired female resident in her bed and reported it to the DON and SSD/Assistant ED, but they dismissed the concern, did not classify it as abuse, and believed the cognitively impaired resident could consent to being touched. The ED, acting as abuse coordinator, along with the DON and SSD/Assistant ED, did not report this allegation to state agencies or law enforcement within required time frames, and similar delays or failures occurred with other allegations of resident‑to‑resident abuse and injuries of unknown origin, contributing to an Immediate Jeopardy finding under F835.
The facility failed to conduct and document thorough investigations into multiple alleged abuse incidents and injuries of unknown origin. In several cases, a resident reported being pushed by a roommate, and other residents were found with bruises on the knee, inner and outer thigh, eye/cheek, and upper arm, but required elements such as complete skin assessments and written statements from direct care staff and witnesses were missing. The DON and leadership relied on brief notes and verbal interviews to conclude causes such as self-rubbing, prior aggressive behavior, or injury during a gown change, without obtaining the comprehensive documentation and assessments mandated by the facility’s abuse policy.
Two residents with dementia and moderate cognitive impairment and a third resident with severe cognitive impairment were involved in separate resident-to-resident altercations in which one resident swatted another in the chest during a smoke-break line and, in a later hallway dispute, another resident forcefully hit the same resident’s shoulder. Staff witnesses, including an AA and a CNA, described the contacts as physical abuse based on their training, and leadership, including the DON and Administrator, agreed the incidents met the facility’s definition of physical abuse under its abuse policy.
A resident with dementia, scoliosis, and impaired mobility had a comprehensive care plan and assignment sheet specifying use of a total mechanical lift with a green sling and two-person assist for all transfers. Despite this, a CNA independently transferred the resident from a wheelchair to a bed without using the lift or a second staff member, causing a full-thickness laceration to the resident’s lower leg from contact with the bed frame that required hospital treatment and suturing. Interviews and record review showed the lift requirement and sling color were clearly documented and accessible to staff, and nursing leadership stated the CNA was aware of these care plan interventions but did not follow them.
A resident with dementia, impaired mobility, and dependence for transfers was care planned and assigned to be transferred with a total mechanical lift, green sling, and assistance of two staff, as documented in the MDS, care plan, device assessment, and assignment sheets. Despite this, a CNA independently transferred the resident from wheelchair to bed without using the mechanical lift, during which the resident’s leg struck the iron bed frame, causing a full-thickness laceration that required hospital evaluation and suturing. Staff interviews confirmed that the resident was known to require a total lift and that assignment sheets clearly indicated the required lift, sling color, and two-person assist.
A resident with dementia, severe cognitive impairment, malnutrition, and a g-tube was placed on hospice and prescribed lorazepam and morphine for end-of-life care. A hospice RN obtained 15 lorazepam 0.5 mg tablets in a brown pill bottle from the pharmacy, which an LPN and an SRNA/KMA counted, documented, and locked in the narcotic drawer after one dose was given, leaving 14 tablets. During a hectic shift change, the oncoming LPN did not count the lorazepam despite being informed it was in a bottle, and the SRNA/KMA later accepted the cart without performing the required narcotic count with the night nurse. When the same LPN later attempted to administer another dose, only nine tablets were present, confirming five missing tablets after a recount, and the discrepancy was reported to the unit manager. The pharmacist verified that 15 tablets had been dispensed, and leadership stated that all narcotics were expected to be counted at each cart handoff, but this did not occur, resulting in unaccounted-for controlled medication.
Failure to Monitor and Manage Resident Behaviors Resulting in Resident-to-Resident Slap
Penalty
Summary
The deficiency involves the facility’s failure to sufficiently monitor and manage resident behaviors that could provoke or result in resident-to-resident altercations, specifically cursing and physical slapping, for two residents. One resident, R118, had a medical history including Parkinson’s disease, schizoaffective disorder bipolar type, anxiety disorder, and borderline intellectual functioning, and was assessed with intact cognition and no documented behaviors on a recent MDS. However, the care plan identified significantly complex behavioral symptoms and noted that staff should firmly redirect the resident when demanding or aggressive behaviors occurred and redirect behaviors due to unawareness of social norms. Another resident, R78, had diagnoses including unspecified dementia with behavioral disturbances, unspecified mood disorder, and depression, and was assessed with moderate cognitive impairment. R78’s care plan noted the resident could be unpleasant and flat related to placement, with interventions for staff to report declines and behaviors to social services. The incident occurred in the dining room when R118 approached R78 to ask if anyone was in the kitchen because she wanted a drink. According to the residents’ statements, R78 did not respond to repeated questions, which upset R118, who then called R78 an expletive. Both residents reported that, in response, R78 slapped R118 in the face with an open hand. There were no staff witnesses to the interaction leading up to the slap, and the activities assistant present in the dining room only heard R118 yell out and then learned from both residents that a slap had occurred. The social services director and LPN staff later obtained consistent statements from both residents that the slap followed the verbal insult. Interviews with staff, including the LPN who led the investigation, the activities assistant, the social services director, the DON, and the administrator, confirmed that staff were not aware of any prior provocation history between the two residents and that no staff member directly observed the altercation. The facility’s own documentation and interviews established that R118 had known behavioral issues requiring redirection and unawareness of social norms, and that R78 had dementia with behavioral disturbances and could be unpleasant, yet the interaction between them in the dining room was not monitored closely enough to prevent or promptly intervene in the escalating exchange. The lack of staff presence and direct supervision at the time of the verbal and physical interaction, despite both residents’ identified behavioral risks, led to a resident-to-resident physical contact incident that constituted the abuse-related deficiency.
Failure to Prime Insulin Pens Resulting in Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate at or below 5%, as required, resulting in a calculated error rate of 7.41% (2 errors out of 27 observed medication administration opportunities). Surveyors observed that nursing staff did not follow manufacturer instructions for priming insulin pens before administration. The facility’s general medication administration policy required adherence to the “five rights” and recommended triple-checking these rights, but the Director of Health Services acknowledged there was no facility policy specific to insulin use. The Interim Executive Director and the Director of Health Services both stated that nurses were expected to follow manufacturer guidelines for insulin pen use, including priming. One resident, admitted with type 2 diabetes mellitus with hyperglycemia and ordered insulin aspart U-100 via sliding scale, was observed when an LPN attached a needle to the insulin aspart pen, dialed 10 units, and proceeded toward the resident without priming the pen; the LPN stated she was unaware that priming was required. Another resident, admitted with type 2 diabetes mellitus with ketoacidosis without coma and diabetic neuropathy and ordered Humalog KwikPen insulin 5 units three times daily with meals, was observed when an RN attached a needle, dialed 5 units, and began to administer the dose without priming; the RN acknowledged she was supposed to prime with 2 units. Another LPN and the Director of Health Services both stated that insulin pens should be primed with 2 units before dialing the ordered dose to ensure the full amount is administered, and manufacturer instructions for both NovoLog and Humalog pens specified priming with 2 units before each injection to remove air and ensure proper dosing.
Failure to Address Known Sexual and Aggressive Behaviors Resulting in Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a severely cognitively impaired resident from abuse by another resident despite months of documented sexually inappropriate and aggressive behaviors. The resident identified as the aggressor had schizophrenia, anxiety, depression, and dementia, and psychiatric evaluations as early as mid‑August documented a known history of sexually inappropriate behavior, aggression, psychosis, delusions, paranoia, irritability, and agitation. Staff and psychiatric notes repeatedly described ongoing sexually inappropriate behavior, increased aggression toward staff and other residents, physical contact with other residents, and attempts to enter other residents’ rooms, with redirection often ineffective. Despite this, the facility’s MDS assessments in August and October documented no behavioral symptoms, the behavior care area did not trigger, and the comprehensive care plan did not include a behavioral problem or interventions for these behaviors. Additional facility documentation showed that staff were aware of repeated incidents involving the aggressive resident’s sexually inappropriate contact with staff and targeting of others. Behavioral nursing notes described the resident pushing a female resident down the hallway toward her room, grabbing a CNA’s arm and trying to put his arms around her, and later grabbing CNAs’ legs and buttocks during care. A speech therapist reported that the resident leaned over her and kissed her face in his room. Behavior Review Committee notes in November recorded episodes of touching female caregivers inappropriately and identified triggers, but recommended only reminders, redirection, and encouragement of activities, without evidence of increased supervision, modified staff assignments, or other protective interventions. These behaviors and risks were not incorporated into the resident’s care plan or CNA Kardex, and the DON later acknowledged that behavioral care plans and Kardex entries were not updated and that she had assumed, without verification, that the Unit Manager was doing so. The resident who was abused was severely cognitively impaired with dementia and anxiety disorder and had not been assessed or documented as able to consent to sexual contact, contrary to facility policy. Nursing notes shortly before the incident recorded that this resident and her family were fearful of the aggressive resident, with the resident crying, expressing fear that men were outside her door to harm her, and specifically identifying the aggressive resident as someone who made her feel uncomfortable and scared. On the day of the incident, staff and a family member observed the aggressive resident pacing the hallway, repeatedly standing in his doorway and looking into the cognitively impaired resident’s room. An LPN was alerted that he was attempting to enter the room and then observed him inside, positioned over the resident in bed, holding her hands down with one hand and pushing her shoulder back into the bed with the other while attempting to get on top of her. Afterward, the cognitively impaired resident exhibited ongoing emotional distress, crying, fear of that man coming into her room again, and a desire to leave the facility, with repeated social services and nursing documentation of anxiety, fear of individuals entering her room, and need for frequent reassurance. Despite these events and the facility’s own abuse policy defining sexual abuse as nonconsensual sexual contact and requiring assessment of capacity to consent, the administrative team did not initially treat the incident as abuse. The SSD/Assistant ED and ED stated they believed the severely cognitively impaired resident could consent to being touched and to the male resident entering her room, but they could provide no supporting assessment or documentation. The SSD/Assistant ED described the facility’s practice as gathering information and then deciding as a team whether to report to the state, and reported that the ED, SSD, and DON decided this incident did not need to be reported because they did not feel it met the definition of abuse. The ED, who served as abuse coordinator, stated there had not been recent incidents requiring reporting because the leadership team had not determined that abuse had occurred. The DON similarly stated she had not identified the incident as abuse based on her belief that the severely cognitively impaired resident could consent to being touched. The surveyors determined that the facility failed to promptly recognize, assess, and intervene to address known behaviors and failed to develop and implement a comprehensive behavioral care plan to protect other residents, resulting in abuse and psychosocial harm.
Failure to Immediately Report Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to immediately report multiple allegations and incidents of potential abuse, including injuries of unknown origin, to external authorities such as law enforcement and the State Survey Agency (SSA), as required by federal regulations and the facility’s own Abuse Reporting and Prevention policy. The policy required all staff to immediately report any observation, suspicion, or information related to possible abuse to facility leadership, and required the Executive Director (ED) or designee to report all alleged abuse to state agencies within two hours. Abuse was defined broadly to include physical, mental, and sexual abuse, neglect, involuntary seclusion, and mistreatment, including abuse perpetrated by other residents. The policy also specified that any willful act in a resident‑to‑resident physical altercation that resulted in physical injury, mental anguish, and/or pain was reportable. One key incident occurred when an LPN observed a male resident with a history of sexual behaviors physically restraining a severely cognitively impaired female resident in her bed. The LPN saw the male resident positioned over the female resident, holding her hands down with one hand and pushing her left shoulder back into the bed with the other while attempting to get on top of her. The LPN reported this to the Social Services Director/Assistant ED and the DON, but was told the situation was speculation and not to “make a mountain out of a molehill.” Facility documentation and SSA records showed no evidence that this allegation was reported to law enforcement or the SSA. The SSD/Assistant ED, ED, and DON later stated they had decided the incident did not need to be reported because they did not believe it met the definition of abuse and believed the severely cognitively impaired resident could consent to being touched, although they could provide no evidence to support this belief. The ED, who was the abuse coordinator, acknowledged the policy required reporting within two hours if abuse was suspected but stated that recent incidents, including this one, had not been reported because leadership did not determine that abuse had occurred. Additional unreported events included a resident’s allegation that her roommate pushed her to the floor, which was reported by a laundry aide to nursing staff but not reported to the SSA. Several residents with severe cognitive impairment were found with bruises or injuries of unknown origin: one resident had dark purple bruising to the inner thigh extending to the knee and a small outer thigh bruise without an identified cause; another had a pale yellow bruise to the outer knee with no clear link to a prior incident where she had hit her hand, not her knee; another had a bruise to the right eye/cheek area; and another had a bruise to the left upper arm. In each of these cases, the DON documented awareness of the injuries and conducted some level of internal review or investigation, but there was no evidence in facility or SSA records that these injuries of unknown origin were immediately reported to the SSA at the time they were first identified. The SSD/Assistant ED stated that she, the ED, and the DON reviewed these incidents and decided they did not need to be reported because they did not feel they met the definition of abuse. The DON also stated she was not aware she was supposed to report allegations or suspicions of alleged abuse immediately to state agencies, and the ED confirmed that the facility’s practice was to investigate and substantiate incidents before reporting, contrary to policy and federal requirements that all alleged violations, including injuries of unknown origin, be reported immediately. The surveyors determined that this pattern of failing to immediately report allegations and incidents of potential abuse, including the witnessed incident of a resident physically restraining another resident in bed and multiple injuries of unknown origin, constituted noncompliance with 42 CFR §483.12 (F609 – Freedom from Abuse, Neglect, and Exploitation). The failure to report the 01/05/2026 incident involving the male and female residents was identified as Immediate Jeopardy at scope and severity J and also constituted Substandard Quality of Care under 42 CFR §483.12. The facility’s leadership, including the ED, DON, SSD/Assistant ED, and a corporate representative, acknowledged that they often decided internally, sometimes with corporate input, whether an occurrence met their definition of abuse before reporting, and that in these cases they had concluded the events were not reportable, despite policy and regulatory requirements to immediately report all allegations and injuries of unknown origin.
Failure in Administration, Care Planning, Abuse Prevention, and Reporting
Penalty
Summary
The deficiency involves the facility’s failure to administer operations effectively to meet residents’ needs in the areas of care planning, protection from abuse, and immediate reporting of alleged abuse. The facility admitted a resident with schizophrenia who, according to multiple psychiatric evaluations and behavioral nursing notes beginning in mid‑August 2025, exhibited escalating aggressive and sexually inappropriate behaviors and was identified as being at risk for sexually acting out. Despite this documented pattern of behavior during the look‑back period for the resident’s annual MDS assessment dated late August 2025, the facility did not identify behavioral symptoms toward others on the MDS, and the behavioral care area did not trigger for care planning. The comprehensive care plan created from that assessment did not include a problem or interventions related to behaviors, and no behavioral care plan was developed until January 9, 2026, after a serious incident had already occurred. During this period without a behavioral care plan, the resident continued to display aggressive behavior, mood instability, irritability, and psychotic symptoms, as documented in subsequent psychiatric evaluations, behavioral notes, and Behavior Review Committee documentation through November 2025. The Unit Manager later confirmed that the resident did not have a behavioral care plan prior to the January 5, 2026 incident and stated that both she and the DON should have been updating the care plan but did not. The Unit Manager reported that the DON had asked her not to document resident behaviors and that when she did document them, the documentation was changed, which contributed to the absence of a behavioral care plan. The DON acknowledged that behavioral care plans were expected to be reviewed and revised when incidents were reported, that it was important to have a behavioral care plan in place so staff would be aware of behavioral risks, and that the resident’s behaviors were not documented in the Kardex. The DON stated she assumed the Unit Manager was updating the care plan and Kardex but did not review them and did not know how the resident lacked a behavioral care plan until four days after the incident and two days after the state survey agency began its investigation. On January 5, 2026, an LPN entered the room of a severely cognitively impaired female resident and observed the male resident positioned over her, with one leg on the bed, holding her hands down with one hand and pushing her back into the bed with the other while attempting to get on top of her. The LPN reported this to the SSD/Assistant ED and the DON and was told the situation was speculation and not to make a mountain out of a molehill. Subsequent documentation for the female resident, including behavior notes, a psychiatric evaluation, and social services notes, showed that after the incident she was very upset and crying, fearful, uncomfortable, did not want to remain at the facility, and exhibited increased anxiety and worsening emotional symptoms. The SSD/Assistant ED stated that she, the ED, and the DON decided the witnessed incident did not meet the definition of abuse and believed that the severely cognitively impaired resident could consent to being touched. The ED, who served as the abuse coordinator, similarly stated that she, the DON, and SSD/Assistant ED had not determined that abuse had occurred and believed the cognitively impaired resident could consent to the male resident coming into her room and touching her, but could provide no evidence to support this belief. The DON also stated she did not identify the incident as abuse because she believed the severely cognitively impaired resident could consent to being touched. The facility also failed to immediately report this allegation of abuse and other allegations or injuries of unknown origin as required. The LPN’s report of the January 5, 2026 incident to the DON and SSD/Assistant ED was not reported to outside agencies, including law enforcement or the state survey agency. The SSD/Assistant ED stated that facility practice was to gather information, discuss as a team, and then decide whether to report to the Office of Inspector General, and that the leadership team decided the incident did not need to be reported because they did not feel it met the definition of abuse, again citing the belief that the cognitively impaired resident could consent. The ED acknowledged that policy required suspected abuse to be reported within two hours but stated they decided the incident was not reportable for the same reason. The DON initially expressed uncertainty about whether the incident should have been reported and, after reviewing the Abuse and Reporting Policy, stated that a leadership member should have reported it and confirmed that incidents involving alleged sexual misconduct between residents should be reported. Further review of facility investigations showed additional failures to immediately report allegations of abuse or injuries of unknown origin that did not rise to the level of immediate jeopardy. These included resident‑to‑resident abuse on December 26, 2025, and injuries of unknown origin for several residents on dates in 2025 and early 2026. The DON stated she was not aware she was supposed to report allegations or suspicions of alleged abuse immediately to state agencies. The ED stated there had not been any recent incidents requiring reporting and that she, the SSD/Assistant ED, and the DON made decisions not to report incidents, and that she often reached out to corporate for direction. A corporate Director of Clinical Reimbursement confirmed that allegations of abuse should be reported within two hours but was aware the facility would investigate first before reporting, and indicated that in the case of the incident between the two residents, corporate determined it was not a reportable allegation and characterized it as “just touching.” These combined failures in care planning, abuse prevention, and mandatory reporting led surveyors to identify immediate jeopardy under 42 CFR §483.70 (F835).
Failure to Thoroughly Investigate Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough investigations into multiple allegations of abuse and injuries of unknown origin, as required by its Abuse Reporting and Prevention policy. The policy, reviewed in July 2025, required that any report of abuse or injury of undetermined origin trigger a full investigation by the Executive Director (ED) or designee, including immediate resident examination for injury, obtaining written statements from all persons with knowledge of the incident, and conducting pertinent interviews with residents, staff on duty, and others present. Surveyors found that these steps were not consistently followed for several residents with alleged abuse or unexplained injuries. In one case, a laundry aide found a resident on the floor between the bed and recliner; the resident stated her roommate had pushed her, and the aide reported this to the nurse. A notepad “investigation” by the DON documented the allegation, the roommate’s denial, and a staff reenactment concluding the event could not have occurred as described, but there was no written statement from the laundry aide and no evidence of skin assessments for either resident. Another resident was found with a pale yellow bruise on the left outer knee; the DON’s handwritten note linked this to an incident 10 days earlier when the resident was aggressive and hit her hand on a table, with RN documentation that the resident had been kicking her legs but without witnessing contact with any object. There were no witness statements, no interviews with other staff who had provided care around the time of the injury, and no documented skin assessment, yet the cause of the bruise was attributed to the earlier incident without sufficient supporting facts or exploration of other possible causes. Additional residents with injuries of unknown origin also lacked thorough investigations. One resident was noted by an LPN to have dark purple bruising on the inner left thigh down to the knee and a small bruise on the outer thigh, with the resident unable to state the cause; the incident report contained no skin assessment and no staff statements. Another resident had a bruise to the right eye/cheek area; the DON’s notepad entry stated staff interviews were conducted and concluded the resident caused it by rubbing his face, but there were no written witness statements or complete skin assessment documented. A further resident with contractures was reported to have a bruise on the left upper arm; the DON documented staff interviews and concluded the bruise occurred during a gown change with no suspicion of abuse, yet there were no written statements from direct care staff and no evidence of a skin assessment. Interviews with the SSD/Assistant ED, ED, and DON confirmed that investigations were based on interviews and team discussion, and the DON stated that once they determined how injuries happened, they did not pursue further investigation, despite the lack of documentation required by facility policy.
Failure to Prevent Resident-to-Resident Physical Abuse Incidents
Penalty
Summary
The facility failed to protect residents from physical abuse during two resident-to-resident altercations involving residents with dementia and moderate to severe cognitive impairment. Facility policy on Abuse, Neglect and Exploitation, last reviewed in 06/2025, defined abuse as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and specified that physical abuse includes hitting, slapping, punching, biting, and kicking, and can include certain resident-to-resident altercations. Despite this policy, two separate incidents occurred in which residents made physical contact with other residents in a manner that staff and leadership later characterized as physical abuse. In the first incident, on 10/02/2025, a resident with dementia and agitation, and a BIMS score of 9/15 indicating moderate cognitive impairment, was waiting for a smoke break when another resident with Alzheimer’s disease and a BIMS score of 11/15 backed a wheelchair into the first resident. The first resident then reached out with an upper extremity, swatted, and made contact with the other resident’s chest. An Activities Assistant who witnessed the event reported that the resident placed a hand on the other resident’s shoulder as if to signal her to stop backing up, but based on her training and experience, she considered what she witnessed to be physical abuse. The DON, who was not present at the time, later stated she felt the incident rose to the level of physical abuse, and the Administrator stated she expected residents to be free of abuse and kept safe. In the second incident, on 10/27/2025, the same resident with dementia and agitation, who had a care plan problem statement initiated on 10/02/2025 for episodes of increased aggressive behavior toward others, was involved in a verbal disagreement in the center hallway with another resident diagnosed with dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and who had a BIMS score of 3/15 indicating severe cognitive impairment. A CNA heard yelling, rounded the corner, and witnessed the second resident forcefully hit the first resident in the left shoulder, after which the first resident yelled, “Don’t you [expletive] hit me.” The CNA stated that, based on her abuse training, she considered the action to be physical abuse. The DON also stated she felt this incident rose to the level of physical abuse, and reiterated her expectation that residents be free from abuse and feel safe in the facility.
Failure to Follow Care Plan Transfer Requirements Resulting in Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan for a resident whose assessment and care plan required use of a mechanical total lift with a green sling and assistance of two staff for all transfers. The resident was admitted with diagnoses including unspecified dementia, scoliosis, and overactive bladder, and had a BIMS score indicating moderate cognitive impairment. The comprehensive care plan, initiated shortly after admission and later updated, identified a self-care deficit and risk for decline related to impaired mobility, with interventions specifying assistance with ADLs, two-person assist, and use of appropriate equipment. On 02/25/2025, the care plan and device assessment were updated to require a total lift with green sling and two-person assist for transfers, including transfers to the tub, and this requirement was also reflected on the resident’s assignment sheet. Despite these documented requirements, on 04/09/2025 a CNA transferred the resident from wheelchair to bed without using the mechanical lift and without a second staff member. During this transfer, the resident sustained a full-thickness vertical laceration to the right lower leg that extended to the bone, reportedly caused by contact with the iron bed frame. The injury required control of bleeding at the facility and subsequent evaluation and treatment at a local hospital, where the diagnosis of leg laceration was confirmed and sutures were placed. Hospital discharge instructions included daily warm soapy washes, antibiotic ointment, elevation to prevent swelling, optional light compression, and suture removal after 10 days. Interviews and record reviews confirmed that the requirement for a total lift with green sling and two-person assist was clearly communicated and available to staff. The assignment sheet listed the need for a lift with two-person assist and the specific sling color, and other CNAs stated that such information is routinely provided on assignment sheets and can also be verified in the electronic care plan or care guide. The MDS nurse stated that care plans are developed to ensure staff follow standards of care based on resident needs, and the DON and nursing staff confirmed that it was their expectation that staff follow care plan interventions. The DON and Interim Executive Director indicated that the CNA who performed the transfer was aware of the lift and two-person assist requirement but chose to transfer the resident independently without the mechanical lift, leading to the resident’s injury.
Failure to Use Required Mechanical Lift Resulting in Resident Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate supervision and required assistive devices to prevent accidents during transfers. Facility policy on Accidents and Supervision required that residents’ environments remain as free of accident hazards as possible and that each resident receive adequate supervision and assistive devices, including implementation and monitoring of specific interventions to reduce risk. The Interim Executive Director stated the facility did not have a policy on the use of mechanical lifts. The resident at issue, R37, had diagnoses including unspecified dementia, scoliosis, and overactive bladder, and was assessed with a BIMS score of 11/15, indicating moderate cognitive impairment. The resident was dependent for chair/bed-to-chair transfers and used a wheelchair. R37’s comprehensive care plan, initiated shortly after admission, identified a self-care deficit and risk for decline related to impaired mobility, with interventions including assistance with ADLs and assistance of two staff. On 02/25/2025, the care plan was updated to specify that the resident required a total lift with a green sling and assistance of two staff for transfers, and the Comprehensive Device Assessment documented the use of a wheelchair, total lift with green sling, and side rails for positioning, including use of the green sling for tub transfers. The current assignment sheet also indicated that the resident required a lift with two-person assist and a green sling. Staff interviews confirmed that assignment sheets listed the level of assistance and sling color for residents who used lifts, and that R37 was known to require a total lift for transfers. Despite these assessments and care plan directives, on 04/09/2025 CNA10 transferred R37 from wheelchair to bed alone and without using the required mechanical lift. During this transfer, the resident sustained a vertical, full-thickness laceration to the right lower leg, which RN5 observed to have been caused by the iron bed frame. The injury required control of bleeding, physician notification, and transfer to the hospital emergency department, where the diagnosis was a leg laceration requiring sutures and wound care instructions. R37 later stated that staff usually used a mechanical lift to get her out of bed and that she remembered getting a big cut on her leg when an aide tried to move her without the lift. The facility’s internal investigation concluded that, despite recent documented training on use of the mechanical lift, CNA10 did not follow the care plan and did not use the mechanical lift as required, resulting in the resident’s leg laceration.
Failure to Account for Controlled Medication Resulting in Missing Lorazepam Tablets
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property by not ensuring proper accountability of controlled medications. Facility policies required that controlled substances be counted at each shift change by two licensed nurses, with any discrepancies reported to the DON, and that a physical inventory of all controlled medications be conducted and documented at each shift change. The Abuse Prevention policy defined misappropriation of resident property as the wrongful use of a resident’s belongings without consent. For one resident with severe cognitive impairment (BIMS score of 0), admitted with moderate protein-calorie malnutrition, dementia, adult failure to thrive, and receiving medications via g-tube, hospice was consulted and lorazepam and morphine were ordered for end-of-life comfort care. According to the record and interviews, a hospice RN obtained 15 lorazepam 0.5 mg tablets from the contracted pharmacy in a brown pill bottle for the resident. An LPN and an SRNA/KMA counted 15 tablets, created a narcotic count sheet, and locked the bottle in the narcotic drawer of the medication cart. The LPN administered one dose of lorazepam via g-tube later that day, leaving 14 tablets. The SRNA/KMA reported that the evening was hectic due to a call-in and stated that at shift change, she informed the oncoming LPN that the lorazepam was in a bottle rather than a blister pack, but the oncoming LPN closed the drawer without counting the pills. The SRNA/KMA further stated that the following morning she failed to count the lorazepam bottle with the night shift nurse before accepting the cart keys, despite knowing facility policy required this. Later that day, when the LPN went to administer another dose of lorazepam to the resident, only nine tablets were found in the bottle instead of the expected 14, indicating five missing tablets. The LPN and SRNA/KMA recounted and confirmed the discrepancy, then attempted to locate the DON and, when unsuccessful, reported the missing tablets to the unit manager RN. The pharmacist confirmed that 15 lorazepam tablets had been dispensed in a brown bottle to the hospice RN. The responding police officer reported being contacted by the Administrator and noted that key staff had been sent home or were unavailable, and that no police report had yet been filed at the time of interview. The DON and Administrator both stated they expected all narcotics to be thoroughly counted at cart acceptance regardless of container type, but the required counts and documentation were not consistently performed, resulting in unaccounted-for controlled medication for the resident.
Some of the Latest Corrective Actions taken by Facilities in Kentucky
- Implemented ongoing monthly elopement drills to reinforce staff comprehension of the elopement drill process (J - F0689 - KY)
- Implemented weekly audits of new admissions for 3 months to ensure elopement risk and interventions were in place (J - F0689 - KY)
- Implemented monthly QAPI meetings to provide ongoing oversight of elopement prevention compliance (J - F0689 - KY)
- Implemented monthly QAPI Committee review of elopement assessment audit results (forwarded to the Executive Director) for at least 3 months to ensure ongoing compliance (J - F0689 - KY)
Failure to Supervise Exit-Seeking Resident Leads to Elopement from Secure Memory Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe, secure environment for a cognitively impaired resident on a memory care unit, resulting in an elopement. The resident was admitted with dementia with behavioral disturbance, cognitive communication deficit, anxiety, and major depressive disorder, and hospital records indicated the need for a secured, locked unit due to impaired safety decisions and poor safety awareness. On admission, the facility’s elopement/wandering risk evaluation scored the resident as a moderate elopement risk, and the admission MDS showed a BIMS score of five, indicating severe cognitive impairment. The resident’s care plan, initiated shortly after admission and later revised, included goals and interventions to maintain safety on the secure unit, including supervision while on the unit and provision of activities of interest with redirection as needed. In the days leading up to the incident, progress notes documented escalating behaviors and clear exit-seeking. Notes from several days before the elopement described the resident as having behavioral issues, constantly stating a desire to go home, yelling out for God to get her out, and repeatedly expressing a desire to leave. Staff interviews further confirmed that the resident frequently packed a suitcase, made statements about wanting to go home, pushed on exit doors, and watched the doors to see if someone would go out. On the day of the elopement, staff reported the resident was antsy, wanted to get out, and was not redirectable, with social services noting that the resident insisted she needed to get to her dying mother. Despite these known behaviors and documented risks, the resident was placed in a room directly catty-corner to an exit door on the secure unit, and there is no indication in the report that enhanced supervision such as 1:1 monitoring was consistently implemented at the time of the incident. On the evening of the elopement, staff on the women’s memory care unit consisted of one LPN and two CNAs for 16 residents, and all three staff members reported being occupied with other resident care tasks when the alarm sounded. One CNA reported hearing the alarm, going to the exit door, seeing another resident in a wheelchair, moving that resident, and, along with the LPN and another CNA, checking the courtyard and not seeing anyone before the LPN turned off the alarm. Another CNA stated she saw the eloping resident at the exit door when the alarm went off, moved her to the dining room, and then returned to provide a shower to another resident, noting that the door did not lock right away and that no one was actively looking for the resident later. The LPN reported responding from the men’s secure unit when the alarm sounded, checking the courtyard and resident rooms per policy, and stated he did not realize the resident was missing until a law enforcement officer arrived and asked about her. The resident was able to exit the building through the alarmed exit door and then leave the courtyard through a deteriorated wooden gate connected to the privacy fence. The maintenance director later acknowledged that the gate’s wood boards were beginning to deteriorate before the incident and that the resident was able to push through the boards and then place them back, securing the gate with empty plant pots on the opposite side, which led staff to believe the gate was secure when checked. The resident reported that on the night she left, both exit doors near her room opened, that the wood gate was faulty and allowed her to get through, and that she ran to a nearby park where she sat on a bench and told a couple about her escape. Concerned citizens at the park called 911, and a sheriff’s officer responded, found the resident, and then went to the facility, where staff initially stated the resident was in her room and were unaware she had left until they checked and found her missing. The officer reported that no staff member told him they were looking for or missing a resident, and the resident herself stated she was unhappy in the facility, did not feel she belonged there, and would leave again if able. The facility’s own elopement and wandering policy stated that residents at risk for elopement were to receive adequate supervision to prevent accidents, that alarms were not a replacement for necessary supervision, and that staff were to respond to alarms in a timely manner. The policy also required a systematic approach to monitoring and managing residents at risk for elopement, including identification and assessment of risk, implementation of interventions to reduce hazards and risks, and monitoring and modifying interventions as needed, with interventions added to the care plan and communicated to appropriate staff. Despite this, staff interviews revealed that at the time of the elopement, all assigned staff were engaged in other resident care tasks, could not provide supervision or diversional activities as outlined in the care plan, and did not recognize or report the resident as missing until notified by law enforcement. The combination of the resident’s known exit-seeking behavior, placement in a room adjacent to an exit door, a defective courtyard gate, and staff being occupied with other tasks when the alarm sounded led to the resident leaving the secure unit and the facility without staff awareness, resulting in the identified deficiency under F689 for failure to ensure adequate supervision and a hazard-free environment.
Removal Plan
- Conduct elopement drills once per shift to ensure staff comprehension of the elopement drill process.
- Complete a 100% audit of door and lock evaluations with no negative findings.
- Complete 100% elopement evaluations.
- Provide 100% staff education (including contract staff) on the Elopement policy/procedure and appropriate resident supervision.
- Initiate an investigation of the incident, including staff interviews and a root cause analysis.
- Repair the defective courtyard gate by facility staff and a licensed contractor.
- Inspect all doors, locks, and gates throughout the facility to ensure proper functioning.
- Add additional interventions to the resident’s care plan: increased supervision, q15-minute checks for 72 hours, and review of medications and labs.
- Adjust the exit door on the Memory Care Unit to prevent delayed egress.
- Review the Elopement Policy by the IDT to include individualized interventions for residents at risk for elopement.
- Audit new admissions weekly for 3 months to ensure elopement risk and interventions are in place.
- Complete elopement risk assessments on all residents.
- Educate MDS/Social Services on completing elopement evaluations, implementing interventions based on findings (including supervision/observation), and the necessity of staff availability and timely alarm response.
- Hold an Ad-Hoc QAPI meeting with leadership/IDT members to review the plan and findings.
- Forward elopement assessment audits to the Executive Director for QAPI Committee review monthly for at least 3 months to ensure ongoing compliance.
- Hold QAPI meetings monthly.
- Correct any deficient practices identified through monitoring immediately and report/review them through the QAPI Committee until ongoing compliance is achieved.
- Complete elopement drills each shift for 1 day and monthly ongoing.
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