Cambridge Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lexington, Kentucky.
- Location
- 2020 Cambridge Drive, Lexington, Kentucky 40504
- CMS Provider Number
- 185444
- Inspections on file
- 21
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Cambridge Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors identified that the facility failed to follow its own food storage and employee sanitary practices policies, potentially affecting all residents receiving meals. In dry storage and the walk-in freezer, multiple food items, including large containers of mayonnaise and relish, au gratin potatoes, cereal, coffee creamers, frozen peas, and biscuits, were found opened or removed from original packaging without required received or opened dates. A dietary aide was observed preparing food while wearing a bonnet that did not fully restrain her hair, leaving bangs and side hair exposed. The dietary manager, dietary staff, department head, and administrator all acknowledged in interviews that policy requires all food to be dated when received and when opened, and that anyone entering the kitchen must wear hair restraints that fully contain all hair to prevent contamination.
Infection control practices were not followed across the facility. Staff were observed failing to perform hand hygiene before and after resident contact, between room entries, and after handling trays or resident items. A resident with ESBL history was not consistently placed on EBP, with no door signage and staff entering for direct care without gowns; one aide wore gloves but not a gown and did not clean hands when leaving. Surveyors also found dirty utility and shower room sanitation problems, no non-permeable gowns in the laundry area, and a nurse returned a glucometer to storage without cleaning or disinfecting it after a fingerstick.
Surveyors identified that multiple resident rooms and both working shower rooms were not maintained in a safe, clean, and homelike condition, with findings including fecal staining and deposits, mold, visibly soiled shower equipment, dirty floors and baseboards, damaged and exposed drywall, cracked and holed flooring, water-stained and deteriorated ceilings, and corroded PTAC grilles with black grime. A resident reported anxiety and concern for safety due to water damage, floor damage, and rotted baseboards, and another resident and family stated that promised room and bathroom repairs had not occurred after more than a year. Staff interviews showed that while an LPN and a unit manager were aware of the process to enter maintenance requests, they had not recently or consistently done so, and the DON lacked access to track outstanding work orders. The Corporate Director of Plant Operations described use of a maintenance management system and separate task tracking that was not produced to surveyors, and the Administrator acknowledged that repairs were delayed because the facility prioritized maintaining full census rather than creating temporary vacancies to complete needed room repairs.
Medication Storage and Labeling Failures: Multiple medication carts and a medication refrigerator contained loose pills, opened medications without dates, and an expired product. An LPN, KMAs, the UM, the SDC, the DON, and the Administrator all described expectations for dating opened items, discarding loose pills, and keeping carts clean, but surveyors still found undated budesonide, Tubersol, Spiriva, and ProHeal, along with loose tablets and expired Glutose gel.
A resident on Hospice with CKD and HF did not have the CCP updated to include Hospice-oriented goals or interventions for comfort-focused care. The MDS Coordinator stated Hospice status should be reflected in the care plan, and the DON, Administrator, and Medical Director all stated care plans were expected to guide staff in meeting resident needs.
A long-term care facility failed to maintain effective infection control, as evidenced by staff not adhering to PPE protocols, improper handling of isolation linens, and inadequate enforcement of COVID-19 isolation measures. Observations included a resident receiving a nebulizer treatment with the door open, staff not wearing gloves while handling garbage, and residents not wearing masks as required.
A resident with dementia and a history of falls, assessed as a high elopement risk, exited the facility unsupervised after the discontinuation of 15-minute checks without the APRN's knowledge. Despite having a Wander Guard bracelet, the resident managed to leave the facility, and staff failed to respond promptly to the alarm. Interviews revealed that alarms were often ignored, and there was a lack of consistent monitoring of the resident's exit-seeking behavior.
Improper Food Storage and Inadequate Hair Restraints in Dietary Services
Penalty
Summary
The deficiency involves the facility’s failure to store and prepare food in accordance with its own policies and professional standards for food safety, potentially affecting 106 residents who received food from the kitchen. Surveyors reviewed the facility’s “Food Storage” policy, which required all foods to be covered, dated, and labeled, including dating items removed from shipping containers, and the “Employee Sanitary Practices” policy, which required hair restraints for all food and nutrition services employees. Despite these policies, observations in dry storage and the walk-in freezer revealed multiple food items that were opened or removed from original packaging without any received or opened dates. During an observation of dry storage, surveyors found two unopened 128-ounce jars of mayonnaise and one unopened 128-ounce jar of sweet pickle relish that were out of their original box packaging and undated, a 36-ounce box of au gratin potatoes with no opened date, an opened bag of cereal that was rolled up, unsealed, and undated, and an opened box of 1000 coffee creamers with no received date. In the walk-in freezer, they observed an opened 30-pound bag of frozen sweet peas inside an opened box with no opened date, and an opened case of 210 frozen biscuits with no opened date. The Head of the department acknowledged that received dates were important to calculate use-by dates and confirmed that all items should have been dated. The deficiency also included failures in employee sanitary practices related to hair restraints. Surveyors observed a dietary aide at a food preparation table wearing a hair bonnet that only partially restrained her hair, with bangs and hair on both sides of her face loose. The Dietary Manager stated that the aide should have worn a hairnet under the bonnet to fully restrain her hair and that hairnets were required for anyone entering the kitchen. Multiple dietary staff, including dietary aides and the Head of the department, confirmed in interviews that staff were expected to date delivered and opened food items and that everyone entering the kitchen must wear hair restraints that fully contain all hair, including beards, to prevent contamination. The Administrator also stated his expectation that kitchen staff follow policy for dating stored and opened food items and wear hair restraints with all hair covered.
Infection Control Failures With Hand Hygiene, EBP, Glucometer Disinfection, and Environmental Sanitation
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not following hand hygiene, enhanced barrier precaution, and glucometer disinfection practices, and by allowing contaminated and soiled areas to remain improperly maintained. Surveyors observed multiple staff members entering and exiting resident rooms, providing care, handling trays, and touching resident items without performing hand hygiene before or after contact. The [NAME] Unit Manager failed to perform hand hygiene before entering or after exiting a resident’s room, failed to clean hands after touching a resident’s hearing assistive device, and failed to use hand sanitizer while moving between resident rooms and handling trays. A State Registered Nurse Aide also failed to perform hand hygiene while collecting meal trays from two residents’ rooms. The facility also failed to implement enhanced barrier precautions for a resident with a history of ESBL in urine. The resident had been admitted with stage 5 chronic kidney disease, debility, and ESBL in urine, and the quarterly MDS showed a BIMS score of 15. Although the resident’s care plan had been revised, it did not include EBP goals or interventions related to ESBL. Surveyors observed no isolation signage on the resident’s door, and staff entered the room to provide direct care without wearing gowns. One aide provided care such as repositioning, linen adjustment, and changing an underpad without a gown, and another aide entered the room, donned gloves but not a gown, and exited without performing hand hygiene. Staff interviewed about the resident stated they believed EBP was no longer needed after the urinary catheter was removed, while the Infection Preventionist stated the resident had been colonized with an MDRO and should have remained on EBP. Surveyors also observed environmental and equipment-related infection control failures. In the East Wing dirty utility room, medical supplies including IV poles, oxygen concentrators, suction machines, and a bedside commode were stored with dirty linen and trash. The East Wing shower room contained multiple areas of fecal staining and formed fecal deposits on the floor. In the laundry room, no non-permeable gowns were available for handling contaminated laundry, and debris, dust, lint, trash, and other items were present on the floor near the sink and behind the washing machines. In addition, a nurse tested a resident’s blood glucose and returned the glucometer to the bedside drawer without cleaning or disinfecting it, despite the manufacturer’s instructions requiring disinfection after each use and the facility’s expectation that bleach wipes be used.
Failure to Maintain Clean, Safe, and Homelike Resident Rooms and Shower Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in multiple resident rooms and shower areas. Surveyors observed that 11 of 25 sampled rooms had significant maintenance and cleanliness issues, including damaged drywall and baseboards, cracked and dented flooring, unpainted drywall patches, wall stains, dirty floors and baseboards, and a PTAC unit with a heavily rusted, corroded grille containing black grime and debris on and within the vent slats. In one room, there was a large dried food stain on the wall, dried food on the bed rail and floor, and dirt and dried material consistent with food residue beneath a fall mat. Another room had extensive brown water staining and deterioration on the ceiling, black discoloration on a bathroom baseboard, a newly replaced raw wood baseboard, and holes and unsecured edges in the linoleum flooring, including by the commode and near a bed. Surveyors also found that both working shower rooms had significant cleanliness problems. The East Unit shower room had multiple areas of fecal staining and several formed fecal deposits on the floor, red mold in the shower area, and a visibly soiled shower chair. The other shower room had mold around the base, faucet, and grab bars, and a dirty floor with dark-stained grout lines. These conditions were observed despite a facility policy titled “Homelike Environment” that required provision of a safe, clean, comfortable, and homelike environment and minimization of institutional characteristics. Maintenance documentation showed periodic entries for cleaning air filters and inspecting condenser coils on PTAC systems, but did not identify which specific units were serviced. Interviews revealed that staff were aware of needed repairs but did not consistently initiate or track maintenance requests. One LPN stated she would enter maintenance requests into the computer portal but had not done so recently. The East Unit manager acknowledged knowing that several rooms needed repairs but had not personally submitted work orders for the damaged rooms on her unit. A resident in a room with water-stained ceilings, cracked areas, a large gash in the bathroom floor, and rotted wood on a baseboard reported having voiced concerns to staff and the Administrator and stated these conditions made her feel anxious and concerned for her safety, including fear of potential mold exposure and that the bathroom floor was a safety hazard. Another resident and family reported they had been told the room floor and bathroom would be refinished and remodeled, but after 14 months had not seen any repairs. The Corporate Director of Plant Operations stated that repairs to walls, ceilings, floors, and baseboards were done when rooms were vacant and that some tasks were tracked outside the electronic system, but the requested separate log of tasks was not provided to surveyors. The DON stated she expected staff to enter repair requests but did not have access to track them and did not believe the disrepair prevented a homelike environment, while the Administrator acknowledged that repairs had not been completed because the facility maintained full census instead of creating vacancies to complete room repairs.
Medication Storage and Labeling Failures
Penalty
Summary
The facility failed to ensure that resident medications and biologicals were stored and labeled according to policy and accepted professional principles. Review of the facility policy showed that medications dispensed by the pharmacy were to remain in labeled containers, multi-dose packaging was to have beyond-use dating per pharmacy protocol, and opened manufacturer containers or vials were to be marked with the date opened. Observation of the East 1 medication cart found R90's budesonide inhalation suspension opened with no opened date, three loose vials in the pouch, and R90's Glutose 15 oral glucose gel with an expired date. The same cart also contained 14 loose pills in the drawers. Observation of the [NAME] 1 medication cart found 17 loose pills. Observation of the East Wing medication refrigerator found an opened vial of Tubersol with no opened date on the bottle or box. Observation of the [NAME] 3 medication cart found seven loose pills, including vitamin D, nifedipine, famotidine, Buspar, sertraline, and sacubitril-valsartan. R58's Spiriva inhaler was opened with no opened date recorded, and a house stock bottle of ProHeal was opened but undated. Staff interviews stated loose pills should be discarded and reported, opened medications should be dated, and medication carts should be kept free of loose pills, but the observations showed these practices were not consistently followed.
Care plan lacked Hospice interventions for a resident on Hospice
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 60 that included measurable objectives and timeframes to meet the resident’s medical, nursing, mental, and psychosocial needs. Review of the resident’s records showed an active order on 01/21/2026 for Hospice care with a life expectancy of less than six months related to chronic kidney disease and heart failure, but the comprehensive care plan revised on 01/27/2026 did not include Hospice-oriented goals or interventions to support end-of-life care. The resident was admitted to the facility on 08/07/2023 with diagnoses including stage 5 chronic kidney disease, debility, and atrial fibrillation, and the quarterly MDS dated 02/05/2026 showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. During interview, the resident stated she had been in and out of Hospice services and had recently resumed Hospice care, but she had not noticed any additional attention or changes in care since resuming Hospice and could not recall when Hospice staff last visited. The MDS Coordinator stated that when a resident was placed on Hospice services, the care plan should be addressed to ensure comfort-focused interventions were implemented and that Hospice status should be communicated so staff could prioritize comfort; she acknowledged the issue and stated Hospice services should have been added to the care plan. The DON, Administrator, and Medical Director each stated that care plans were expected to direct staff in meeting resident needs and be followed as written.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations and interviews. One incident involved a State Registered Nurse Aide (SRNA) entering an Enhanced Barrier Precautions (EBP) room without donning the required personal protective equipment (PPE). The SRNA admitted to changing a resident's linens without wearing a gown and gloves, despite having received training on EBP protocols. The resident in question had a history of methicillin-resistant Staphylococcus aureus infection and was under EBP orders due to a wound, which had since resolved. Another deficiency was observed when a garbage bag full of dirty linens from a droplet precaution isolation room was left on the floor in the hallway. Staff interviews revealed that linens from isolation rooms should be bagged and taken directly to the dirty utility room, where they are placed in blue biohazard bags to prevent cross-contamination. The housekeeping supervisor confirmed that the protocol was not followed, which could lead to the spread of infection. Additional issues included residents with COVID-19 not adhering to isolation protocols. One resident was observed sitting in a doorway without a mask, while another was receiving a nebulizer treatment with the door and privacy curtain open, contrary to CDC guidelines. Staff interviews indicated a lack of enforcement of mask-wearing and room confinement for COVID-19 positive residents. Furthermore, a housekeeper was seen removing garbage bags without wearing gloves or practicing hand hygiene, and an SRNA improperly donned and doffed PPE, failing to cover their clothing fully and not performing hand hygiene after handling contaminated items.
Failure to Supervise High-Risk Resident Leads to Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring for a resident who exhibited wandering behaviors and was assessed at risk for elopement. The resident, diagnosed with dementia and a history of falls, was ordered to be on 15-minute checks by an Advanced Practice Nurse Practitioner (APRN) due to high elopement risk. However, the order for these checks was discontinued without the APRN's knowledge, leading to the resident exiting the facility unsupervised and unescorted. The resident was found approximately 60 to 70 feet from the facility, near a two-lane road, after an alarm sounded but was not responded to in a timely manner by the staff. The facility's policy required an Elopement Risk Assessment to be completed on admission, quarterly, and whenever there was a significant change in the resident's status. The resident's assessments indicated a high risk for elopement, and interventions such as 15-minute checks and a Wander Guard bracelet were put in place. Despite these measures, the resident managed to leave the facility, highlighting a failure in the system to ensure the resident's safety. Interviews with staff revealed that alarms were frequently ignored, and there was a lack of immediate response to the alarm that signaled the resident's exit. Interviews with various staff members, including the Unit Manager, Housekeeper, Registered Nurse, and others, indicated a general awareness of the resident's wandering behavior and confusion. However, there was a lack of consistent monitoring and response to the resident's exit-seeking behavior. The Director of Nursing (DON) and the acting interim Administrator acknowledged the expectation for staff to respond immediately to alarms and provide supervision, but this was not effectively implemented, resulting in the resident's unsupervised exit from the facility.
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.
Two residents reported serious allegations—one of missing money and identification and another of being slapped by a staff member—but the facility failed to conduct comprehensive investigations as required by its abuse policy. In the misappropriation case, a cognitively intact resident named a specific staff member by first name, and the schedule showed an SRNA with that name worked during the alleged timeframe, yet that SRNA was never interviewed or asked for a statement, and the DON acknowledged not knowing the investigative process. In the physical abuse case, a resident with mild cognitive impairment reported being slapped and told a family member that a manager over the office was responsible, but the facility obtained statements only from some floor staff, did not interview office staff, did not obtain statements from all staff who worked the relevant shifts, and limited resident interviews and skin assessments to one hall. These actions and omissions resulted in incomplete investigations of both abuse-related allegations.
A resident with dementia, osteoporosis, a right artificial hip, and severe cognitive impairment was care planned as dependent for bed mobility, toileting, and transfers, with an intervention requiring two staff for assistance. Despite this, an SRNA, who knew the resident was a two-person assist, began perineal care alone and rolled the resident onto the side, causing the resident to roll out of bed and fall. An LPN obtained stat x-rays that showed a displaced right femoral shaft fracture, and the resident was sent to the hospital, where surgery was performed and the resident later died on a hospice unit. Staff interviews confirmed that the two-person assist requirement had been in place for years and that the failure to follow the care plan led to the incident.
A resident with dementia, osteoporosis, and a right artificial hip joint, assessed as severely cognitively impaired and dependent for bed mobility, toileting, and transfers, had a care plan and Kardex requiring a two-person assist for these ADLs. An SRNA, despite knowing this requirement, began perineal care alone and rolled the resident onto her side, causing the resident to roll out of bed onto the floor. The incident report and IDT identified the root cause as failure to follow the Kardex, with contributing factors including the resident’s weakness and history of falls. An LPN and unit manager found the resident on the floor, obtained stat x-rays that revealed a displaced right femoral shaft fracture, and the resident was sent to the hospital, where imaging confirmed a comminuted, moderately displaced femoral fracture and an ORIF procedure was performed. Staff interviews confirmed that the resident had long required a two-person assist and that only one staff member was present at the time of the incident, and also revealed that nurses and managers had not routinely spot checked SRNAs for adherence to the care plan/Kardex prior to the event.
A resident with intact cognition and multiple comorbidities developed fever and abnormal urinalysis results consistent with a UTI, for which an NP ordered a single 3 g dose of Fosfomycin. The MAR showed the antibiotic order and later an entry placing it on hold due to unavailability from pharmacy, without a corresponding provider order or documentation explaining the delay or who was contacted. The medication was not administered until four days after the original order, during which time the resident reported going without treatment and later required ED transfer, where a complicated UTI was diagnosed and treated with IM Rocephin and Toradol.
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.
Failure to Conduct Comprehensive Abuse and Misappropriation Investigations
Penalty
Summary
The deficiency involves the facility’s failure to conduct prompt, comprehensive investigations into allegations of abuse and misappropriation of resident property, contrary to its Abuse Prohibition Standard of Practice policy. That policy required the administrator or designee to oversee internal investigations of all alleged violations of abuse, neglect, exploitation, misappropriation of resident property, and injuries of unknown origin, including interviews of all involved persons and others who might have knowledge of the allegations. For one resident, the facility did not interview the staff member specifically named by the resident as the alleged perpetrator of misappropriation, despite documentation showing that a staff member with that first name was scheduled and worked during the timeframe of the alleged incident. For another resident, the facility did not obtain statements from all staff who worked during the relevant shifts and did not interview or obtain statements from office staff, even though the allegation involved a manager in an office area. One resident, admitted with diagnoses including aftercare following removal of a knee joint prosthesis, generalized anxiety disorder, and major depressive disorder, had a BIMS score of 13 indicating intact cognition, but was also care planned for progressive decline in intellectual functioning, memory deficits, and anxiety with agitation. This resident reported that $350, a driver’s license, and an insurance card were missing from their wallet or purse and identified by first name the person they believed took the items. The facility’s initial and final reports to the state survey agency documented the allegation and noted that no cash was recorded on the admission inventory and that no staff by the alleged name worked on the day the allegation was reported. However, the facility’s monthly schedule showed that an SRNA with the same first name as the alleged perpetrator was scheduled and worked the evening and night shift spanning the date of the alleged incident. The investigation packet contained 20 staff statements, but no statement from this SRNA or from any staff member with the alleged first name. The SSD stated she obtained statements from everyone who worked that day and did not interview the SRNA because she believed the SRNA did not work that day, while the SRNA later confirmed she had worked that shift, knew the resident, and was never asked for a statement. The DON acknowledged she did not interview the SRNA, was unaware of the investigative process, and did not know if there was a process for investigating such allegations, and the Administrator, who was the Abuse Coordinator, confirmed that the SRNA was not interviewed despite the resident naming a staff member with that first name. Another resident, admitted with diagnoses including anemia, difficulty in walking, dislocation of an internal right hip prosthesis, muscle weakness, and other symbolic dysfunctions, had a BIMS score of 10 indicating mild cognitive impairment and was care planned for impaired cognition and psychosocial adjustment difficulties. This resident’s family member reported that the resident said someone smacked them across the face after a meal, and a typed SSD statement documented that the family member reported the resident said the manager over the office smacked them. The facility’s final report stated that the resident reported being slapped in a hall after a meal, could not identify the meal or describe the individual, and said they reported the incident to an employee in the back office. The investigation packet included 17 staff statements from floor staff (SRNAs, LPNs, and RNs) but no statements from any office staff, despite the allegation involving a manager over the office and a report to an employee in the back office. Daily staffing guides showed that 34 different floor staff worked during the two 12-hour shifts on the day of the alleged incident and the following day shift, yet statements were not obtained from multiple identified RNs, LPNs, SRNAs, and KMAs who worked those shifts. The facility conducted skin assessments and interviews only for residents on the hall where the resident resided and did not complete resident interviews or skin assessments for residents on other halls. In interviews, multiple staff who had worked during the relevant timeframe stated they were never asked about any resident being slapped or asked to provide statements. The DON stated that her role in abuse investigations was to perform skin assessments and obtain staff statements, believed that therapy and office staff had been interviewed, and did not review surveillance cameras, while the Administrator stated they narrowed the investigation and did not review cameras because they only showed hallways and not the back hallway where offices and therapy areas were located. Overall, for both residents, the facility did not follow its own policy requirement that investigations be prompt, comprehensive, and include interviews of all involved persons and others who might have knowledge of the allegations. In the misappropriation case, the named SRNA who worked during the alleged timeframe was not interviewed or asked for a statement, and the DON acknowledged lack of familiarity with the investigative process. In the physical abuse case, the facility did not obtain statements from all staff who worked during the relevant shifts, did not interview office staff despite the allegation involving an office manager and a report to a back office employee, and limited resident assessments and interviews to one hall, without extending them to other halls where potential witnesses or victims might have been located. These omissions in investigative steps led to incomplete investigations of the reported allegations of abuse and misappropriation of property for the two residents.
Failure to Follow Two-Person Assist Care Plan Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan for a resident who required extensive assistance with activities of daily living (ADLs). The facility’s policy required development and implementation of care plans with measurable objectives and time frames to meet residents’ medical, nursing, mental, and psychosocial needs. The resident was admitted with osteoporosis, a right artificial hip joint, and dementia, and was assessed on a quarterly MDS as severely cognitively impaired, rarely or never understood, and dependent for bed mobility, toileting, and transfers. The resident’s care plan/kardex identified an ADL problem and included an intervention requiring two staff to assist with bed mobility, toileting, and transfers. On the day of the incident, a state registered nurse aide (SRNA) began providing perineal care to the resident and rolled the resident onto her left side without waiting for a second staff member, despite knowing the resident was care planned as a two-person assist. When the SRNA rolled the resident, the resident rolled out of bed and fell to the floor on her right side. The incident report documented that the root cause of the fall was the resident being rolled too far over, causing her to roll out of bed. Staff interviews confirmed that the resident had been a two-person assist for years and that there had been no changes to the care plan on the day of the incident. Following the fall, an LPN assessed the resident, notified the nurse practitioner, and obtained stat x-rays, which revealed a right femoral diaphyseal fracture with complete displacement and foreshortening, and an orthopedic consult was recommended. Hospital imaging later confirmed a comminuted and moderately displaced mid to distal right femoral shaft fracture, and the surgical team repaired the resident’s hip. Hospital documentation showed that the resident subsequently died while on the hospital’s hospice unit. Interviews with the SRNA, LPN, unit manager, infection preventionist/acting DON, and the administrator consistently indicated that staff were trained to follow the care plan/kardex and that the resident’s two-person assist requirement was known, but in this incident the care plan intervention was not followed.
Failure to Follow Two-Person Assist Care Plan Resulting in Fall and Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance during care, resulting in a fall with fracture for one resident. The resident was admitted with osteoporosis, a right artificial hip joint, and dementia, and was assessed on the Quarterly MDS as severely cognitively impaired and rarely/never understood. The MDS further documented the resident as dependent for bed mobility, toileting, and transfers. The resident’s care plan, as reflected on the Kardex, identified an Activities of Daily Living (ADL) problem and included an intervention requiring two staff to assist with bed mobility, toileting, and transfers. On the day of the incident, an SRNA began providing perineal care to the resident alone, despite knowing the resident required a two-person assist. The SRNA rolled the resident onto her left side, which caused the resident to roll out of bed on her right side onto the floor next to the other bed in the room. The incident report documented that the root cause was the resident being rolled too far over during care, and the IDT determined that the SRNA failed to follow the resident’s Kardex. At the time of the incident, the resident had predisposing physiological factors of weakness and situational factors including a history of falls. Following the fall, an LPN and the unit manager responded to the room and found the resident lying on her right side on the floor, with no apparent distress or obvious injury initially observed. The LPN documented notification of the NP and family and obtained orders for x-rays of the right shoulder, hip, and knee. Mobile x-ray results showed a right femoral diaphyseal fracture with complete displacement and foreshortening, and an orthopedic consult was recommended. The resident was subsequently sent to the hospital, where imaging confirmed a comminuted, moderately displaced mid to distal right femoral shaft fracture, and an ORIF procedure with plate and screw fixation was performed. The resident later expired in the hospital’s hospice unit. Interviews with the SRNA, LPN, another SRNA, the unit manager, the acting DON/IP nurse, and the administrator consistently confirmed that the resident had long been a two-person assist and that only one staff member was present providing care at the time of the incident, contrary to the care plan and Kardex. Staff interviews further revealed that, prior to the incident, nurses and unit managers did not routinely spot check SRNAs to ensure they were following the care plan/Kardex when providing care. The SRNA involved acknowledged she had been trained during orientation to follow the care plan/Kardex and admitted she did not follow it in this case, stating she started care alone while expecting her partner to join later. The LPN, another SRNA, the unit manager, the acting DON/IP nurse, and the administrator all stated that the resident’s care plan and Kardex required two staff for bed mobility and related ADLs and that there had been no change to this requirement on the day of the incident. The administrator and acting DON/IP nurse both stated it was their expectation that staff follow the care plans and Kardex when providing care, and the administrator confirmed that only one staff member was present when the incident occurred.
Delayed Administration of Ordered Antibiotic for UTI
Penalty
Summary
The deficiency involves the facility’s failure to provide timely pharmaceutical services and administer an ordered antibiotic for a resident with a suspected urinary tract infection (UTI). The resident, who had intact cognition and diagnoses including arthropathic psoriasis and morbid obesity, was care planned for elimination deficits with interventions such as PRN straight catheterization for urinalysis and monitoring for UTI signs and symptoms. On one occasion, the resident developed a fever of 102°F, and a urinalysis showed significant abnormalities, including 3+ leukocytes, 3+ bacteria, and red blood cells too numerous to count. Based on these findings, the nurse practitioner ordered a single 3 g dose of Fosfomycin to treat the UTI while awaiting culture results. The medication order for Fosfomycin was entered with a start date of the day after the follow-up note, but the drug was not administered as ordered. The MAR showed that the Fosfomycin was to be given one time by mouth for UTI, and a subsequent entry documented that the medication was on hold because it was not available from the pharmacy. There was no documented physician order to hold the medication, and no progress note was found explaining the delay, who was contacted, or what actions were taken when the medication was reportedly unavailable. The Fosfomycin was ultimately documented as administered four days after the original order date, indicating a significant delay in treatment. Interviews and record reviews further clarified the circumstances leading to the deficiency. The infection preventionist stated that the facility followed McGeer criteria for antibiotic use and that the urinalysis did not meet those criteria, but he was not aware of this specific incident. The DON stated she did not know why the Fosfomycin was not given as ordered, noted that this medication was commonly used and readily available from the pharmacy, and confirmed it was not stocked in the emergency medication supply. The DON also stated her expectation that medications be received timely from the pharmacy and administered to residents, and that any delay in antibiotics could possibly lead to sepsis and pain. The resident reported having gone without treatment for approximately three weeks after developing a UTI, stated she never received the originally ordered one-time antibiotic dose, and later required transfer to the emergency department where she was diagnosed with a complicated UTI and treated with IM Rocephin and Toradol for pain.
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