Glen Ridge Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Louisville, Kentucky.
- Location
- 6415 Calm River Way, Louisville, Kentucky 40299
- CMS Provider Number
- 185461
- Inspections on file
- 17
- Latest survey
- June 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Glen Ridge Health Campus during CMS and state inspections, most recent first.
The facility failed to ensure the medication error rate remained below 5%, with errors identified in the administration of medications to two residents. An LPN did not properly measure a powdered laxative for a resident with gastrointestinal issues, and another resident with hypokalemia and hypothyroidism received multiple medications together and without food, contrary to orders and manufacturer instructions. Staff interviews confirmed that medications were not administered according to policy and best practices.
A resident with severe cognitive impairment and multiple medical conditions was subjected to mental abuse when a Certified Resident Care Aide made an inappropriate hand gesture toward the resident. The aide admitted to the action, and staff interviews confirmed the incident, which was determined to be mental abuse under facility policy.
A resident with severe cognitive impairment alleged that a staff member made an inappropriate hand gesture towards them. Although internal notifications were made promptly, the facility failed to submit the required initial abuse report to the State Survey Agency within the mandated two-hour timeframe due to an unsuccessful fax attempt and lack of follow-up, resulting in delayed external reporting.
A resident with multiple respiratory conditions requiring supplemental oxygen was not accurately assessed on the MDS, as the use of oxygen therapy was omitted from Section O0110. Nursing and physician documentation, as well as interviews with the resident and several LPNs, confirmed ongoing nighttime oxygen use since admission, but this was not reflected in the assessment. The MDS Coordinator acknowledged the error, which was not identified during routine audits.
A resident with multiple respiratory conditions was provided supplemental oxygen nightly without a physician's order specifying administration parameters, despite facility policy requiring such an order. Nursing and physician notes referenced oxygen use, and several LPNs and the Director of Health Services confirmed the absence of a formal order for the ongoing oxygen therapy.
A resident with multiple chronic conditions and dementia was found with dry, flaky skin and a buildup of black, dry skin on their feet, indicating a failure to follow the facility's hygiene policies. Staff confirmed the resident's feet had not been washed for an extended period, and the care plan lacked specific interventions for bathing or hygiene.
A resident with severe cognitive impairment fell in the shower due to a loose metal ring on the grab bar, which was not reported or repaired. The fall resulted in a skin tear and hematoma. Staff involved noted the loose grab bar contributed to the fall, and the Director of Plant Operations confirmed the hazard upon inspection.
A resident missed ten doses of routine medications due to the facility's failure to order medications timely after admission. Staff interviews revealed inconsistencies in the process of ordering and receiving medications, and the issue was not escalated to the Director of Health Services or Executive Director in a timely manner.
A resident with severe cognitive impairment and type 2 diabetes had their blood glucose level checked and insulin administered in a common area, violating privacy policies. Both the LPN involved and facility leadership acknowledged that the procedure should have been conducted in a private area.
A resident's grievance about their roommate's disruptive behavior at night was not resolved by the facility. Despite multiple staff members being aware of the issue, the grievance was not documented or addressed effectively, leading to ongoing sleep disturbances for the resident.
The facility failed to implement the bowel protocol for a resident who exceeded 72 hours without a bowel movement on two occasions. Despite the resident's severe cognitive impairment and dependency on staff for toilet use, the required assessments and interventions were not documented or performed. Staff interviews revealed that the EMR system did not flag the issue, and the bowel protocol was not followed as per the facility's policy.
A resident with multiple chronic conditions had excessively long toenails due to the facility's failure to provide necessary foot care. Despite being dependent on staff for personal hygiene, the resident's care plan did not address toenail care, and the facility lacked a policy for it. Observations and interviews revealed that the issue was not reported or addressed, and the resident had not received podiatry services since admission.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy, resulting in a calculated error rate of 15.38% with 4 errors out of 26 opportunities. This deficiency was identified through observation, interviews, and record reviews, and involved two residents during the medication administration task. The facility's policy required medications to be administered as prescribed, following the five rights of medication administration, and within specified timeframes. For one resident with a history of gastrointestinal hemorrhage and constipation, a medication error occurred when an LPN administered polyethylene glycol 3350 powder without properly measuring the dose using the provided measurement lines in the bottle cap, as required by manufacturer instructions and facility policy. The LPN admitted to not knowing the correct method for measuring the medication, and interviews with other nursing staff and the Director of Health Services confirmed that the medication should be measured accurately using the cap's internal lines and checked at eye level. Another resident, admitted with hypokalemia and hypothyroidism, received multiple medications, including levothyroxine, calcium carbonate, ferrous gluconate, and potassium chloride, all administered together in one cup and without food, despite specific orders and manufacturer instructions. Levothyroxine was supposed to be given on an empty stomach and separately from calcium and iron supplements, while potassium chloride was to be given with food. The LPN confirmed that the medications were not administered according to these requirements, and this was corroborated by interviews with other nursing staff, the Director of Health Services, and the facility pharmacist.
Failure to Protect Resident from Mental Abuse by Staff
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of seven out of 15, was admitted with multiple diagnoses including emphysema, acute respiratory failure with hypoxia, acute kidney failure, and acute on chronic diastolic heart failure. The facility's policy defined mental/emotional abuse as conduct that could cause humiliation, intimidation, fear, shame, agitation, or degradation. Despite this policy, a Certified Resident Care Aide (CRCA) directed an inappropriate hand gesture (middle finger) toward the resident in response to the resident's behaviors. The incident was reported by the resident to the nurse on duty, and the CRCA admitted to making the gesture. Witness statements and interviews with staff confirmed the CRCA's actions and acknowledgment that the gesture could be perceived as abuse. The Director of Health Services classified the gesture as mental abuse, consistent with facility policy. The deficiency centers on the failure to protect the resident from mental abuse perpetrated by a staff member.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to submit an initial report of an allegation of staff-to-resident abuse to the State Survey Agency (SSA) within the required two-hour timeframe for one resident. According to facility policy, all alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made if the event involves abuse or results in serious bodily injury. In this case, a resident with severe cognitive impairment, as indicated by a BIMS score of 7 out of 15, reported that a Certified Resident Care Aide (CRCA) made an inappropriate hand gesture towards them. The incident was reported to the Assistant Director of Health Services (ADHS), who then notified the Director of Health Services (DHS) and the Executive Director (ED) in a timely manner. Despite prompt internal notification, the facility did not submit the initial report to the SSA within the required two-hour window. The report was first attempted via fax, but the transmission failed because it was sent to a telephone number instead of a fax line. The ED was unaware that the fax had not been successfully transmitted. The report was eventually submitted via email, but this occurred more than two hours after the initial allegation was made. Interviews with staff confirmed awareness of the reporting requirements, but the delay was due to the unsuccessful fax attempt and lack of follow-up to ensure receipt by the SSA.
Inaccurate MDS Assessment for Oxygen Therapy
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for one resident with multiple respiratory diagnoses, including pulmonary embolism, acute respiratory failure with hypoxia, pulmonary fibrosis, pulmonary hypertension, and atelectasis. The resident was admitted with a history of hypoxia and required supplemental oxygen, as documented in both nursing and physician progress notes, as well as through interviews with the resident and multiple LPNs who confirmed the use of nighttime oxygen since admission. Despite this, the MDS assessment did not reflect the use of supplemental oxygen under Section O0110, Special Treatments, Procedures, and Programs. Review of the resident's active orders showed a directive for nursing to manage oxygen administration in coordination with the physician, but there was no specific physician order detailing when or at what flow rate the oxygen should be administered. The MDS Coordinator acknowledged that the omission of oxygen therapy on the MDS was an error that should have been identified during routine audits. The Director of Health Services and the Executive Director both stated their expectations for accurate and thorough completion of MDS assessments, but the deficiency was not detected prior to the survey.
Failure to Obtain Physician's Order for Supplemental Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order for supplemental oxygen use for one resident who was admitted with multiple respiratory diagnoses, including pulmonary embolism, acute respiratory failure with hypoxia, atelectasis, pulmonary fibrosis, and pulmonary hypertension. The facility's standard operating procedure required verification of a physician's order prior to administering oxygen. Despite this, the resident was provided with supplemental oxygen nightly since admission, as documented in nursing progress notes and confirmed by staff interviews. The care plan directed staff to administer oxygen per physician's order, but no specific order for oxygen administration or flow rate was found in the resident's active orders. Multiple staff members, including LPNs and the Director of Health Services, acknowledged that a physician's order was necessary for supplemental oxygen administration and confirmed that the resident had been using oxygen at night without such an order. Nursing and physician progress notes referenced the resident's use of oxygen, but did not specify the required parameters or provide a formal order. The deficiency was identified through interviews, record reviews, and review of facility procedures, all of which confirmed the lack of a required physician's order for the ongoing administration of supplemental oxygen to the resident.
Failure to Maintain Resident Hygiene
Penalty
Summary
The facility failed to assist a resident with activities of daily living (ADL) care, specifically in maintaining proper hygiene for their feet. Observation revealed that the resident's feet were dry with a buildup of black, dry, and flaky skin between and under the toes, as well as callused skin on the right heel. The facility's policy on pressure prevention, which includes moisturizing the skin and keeping it clean and dry, was not followed. The resident, who had chronic kidney disease, heart failure, chronic respiratory failure, COPD, and dementia, was dependent on staff for personal hygiene and bathing. However, the care plan did not include specific interventions for bathing or hygiene, despite the resident being at risk for skin breakdown due to reduced mobility. During multiple observations and interviews, it was confirmed that the resident's feet had not been washed for an extended period. Certified Resident Care Assistants and a Registered Nurse noted the buildup of dried skin and the lack of cleanliness. The Director of Health Services and the Medical Director both acknowledged that the resident's feet should not have been left in such a condition. The Executive Director also stated that residents should be presentable at all times and expected their feet to be washed and kept clean.
Failure to Address Maintenance Issue Leads to Resident Fall
Penalty
Summary
The facility failed to identify and implement appropriate safety interventions for a resident with severe cognitive impairment, leading to a fall in the shower. The resident, who was dependent on staff for bathing, slipped while being assisted by a Certified Occupational Therapy Assistant (COTA) and a Certified Resident Care Associate (CRCA). The fall was attributed to a loose metal ring on the grab bar in the shower, which startled the resident and caused a loss of balance, resulting in a skin tear and hematoma. Interviews with the staff involved revealed that the loose grab bar cover was not reported prior to the incident. The COTA and CRCA assisting the resident during the fall both noted that the loose part of the grab bar contributed to the resident's fall. The Director of Plant Operations confirmed that no work orders had been submitted for the grab bar, and upon inspection, found the circular screw cover to be improperly applied and sharp, posing a hazard. The Director of Health Services and the Executive Director were unaware of the loose grab bar cover until after the incident. The DHS acknowledged that the grab bar fitting was not properly applied and agreed that it posed a safety risk. The Executive Director emphasized the expectation that maintenance issues should be reported and repaired promptly to ensure resident safety.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident #209, who was admitted on 09/25/2023. The resident's medications were not ordered from the pharmacy until the following day, resulting in the resident missing ten doses of routine medications on 09/26/2023. The facility's policy required that emergency or stat medications be available within four hours, but this was not adhered to in this case. Resident #209 had multiple diagnoses, including pneumonia, acute and chronic respiratory failure with hypoxia, sarcoidosis of the lung, acute pulmonary edema, diabetes, hypercholesterolemia, nonrheumatic aortic stenosis, and asthma. The resident was assessed to be cognitively intact with a BIMS score of 14 out of 15. The missed medications included atorvastatin, furosemide, hydrocodone-acetaminophen, ipratropium-albuterol, levothyroxine, losartan, metformin, and potassium chloride. Interviews with various staff members, including RNs and LPNs, revealed inconsistencies in the process of ordering and receiving medications. Some staff members mentioned that medications should arrive within a few hours if ordered stat, while others noted that medications could be pulled from the facility's emergency drug kit. However, in this case, the medications were not available, and the Director of Health Services and Executive Director were not aware of the issue until after the fact.
Failure to Ensure Resident Privacy During Medical Procedure
Penalty
Summary
The facility failed to ensure personal privacy for a resident with severe cognitive impairment and type 2 diabetes. The resident's blood glucose level was checked, and insulin was administered in the resident's abdomen while seated at a table in a common area with five other residents. This action was observed by surveyors and confirmed by the Licensed Practical Nurse (LPN) involved, who acknowledged that the procedure should have been conducted in the resident's room to ensure privacy. The Director of Health Services and the Executive Director both stated that they expected staff to provide treatments such as insulin injections in a private area to respect residents' dignity and privacy. The facility's policy on Resident Rights Guidelines, which emphasizes the importance of treating residents with dignity and respect, was not followed in this instance, leading to the deficiency noted in the report.
Failure to Resolve Resident Grievance
Penalty
Summary
The facility failed to ensure the resolution of a grievance for a resident who was unable to sleep at night due to their roommate's yelling and screaming. Despite the resident's repeated complaints to various staff members, including the Executive Director (ED), no effective measures were taken to address the issue. The resident's concerns were not documented in the facility's complaint log, and the grievance process was not completed as required by the facility's policy. Staff members, including Registered Nurses (RNs) and Licensed Practical Nurses (LPNs), acknowledged being aware of the resident's complaints but did not take appropriate action to resolve the issue or follow the grievance process. The ED attempted to address the problem by providing earplugs, which were ineffective, and no further interventions were attempted. The Director of Health Services (DHS) and other staff members failed to document or escalate the resident's concerns properly, resulting in the resident continuing to experience sleep disturbances. The facility's failure to follow its grievance policy and ensure prompt resolution of the resident's complaint led to the deficiency identified in the report.
Failure to Implement Bowel Protocol for Resident
Penalty
Summary
The facility failed to implement the bowel protocol in accordance with physician's orders for Resident #213, who exceeded 72 hours without a bowel movement (BM) on two separate occasions. The facility's policy required the initiation of an Ineffective Bowel Pattern Event and specific interventions, including the administration of natural laxatives, Milk of Magnesia (MOM), Dulcolax suppository, and Fleets enema, if no BM occurred within specified timeframes. However, there was no documented evidence that these steps were taken during the periods from 01/05/2024 to 01/10/2024 and from 01/19/2024 to 01/26/2024, when Resident #213 went without a BM for five and seven days, respectively. Resident #213, who had severe cognitive impairment and was dependent on staff for toilet use, was admitted to the facility with diagnoses including unspecified constipation, chronic pancreatitis, severe dementia, and gastroesophageal reflux disease (GERD). The resident's care plan included monitoring for signs of constipation and notifying the physician as needed. Despite these measures, the facility did not follow the bowel protocol when the resident exceeded 72 hours without a BM, and there was no documentation of the required assessments or interventions. Interviews with facility staff, including Licensed Practical Nurses (LPNs) and the Medical Director, revealed that the facility's electronic medical record (EMR) system did not flag when a resident had no BM for three days, requiring nurses to manually check the vital sign section. Staff acknowledged that the bowel protocol should have been initiated and the Medical Director notified when Resident #213 went without a BM for extended periods. The Director of Health Services (DHS) also confirmed that the bowel protocol was not followed and that the BM report, which was previously posted for staff review, had not been posted for about a year.
Failure to Provide Necessary Foot Care
Penalty
Summary
The facility failed to provide necessary foot care for a resident, leading to a deficiency. The resident, who had diagnoses including unspecified dementia, chronic respiratory failure with hypoxia, chronic kidney disease with heart failure, and COPD, was observed with toenails extending half an inch to one inch beyond the tips of their toes. The resident was dependent on staff for personal hygiene and had not expressed any rejection of care. Despite this, there were no documented interventions addressing toenail care in the resident's care plan, and the facility did not have a policy for toenail care. Multiple observations and interviews revealed that the resident's toenails were excessively long and had not been trimmed. Certified Resident Care Assistants (CRCAs) and a Registered Nurse (RN) confirmed the need for toenail care but stated that the issue had not been reported or addressed. The Director of Health Services (DHS) and the Director of Social Services (DSS) were responsible for coordinating podiatry services, but the resident had not received any podiatry care since admission. The podiatrist's visits were infrequent, and recent cancellations had further delayed care. The Medical Director stated that the facility should have arranged for the resident's toenails to be trimmed by an outside source. The DSS confirmed that podiatry services had not been discussed with the resident, and the podiatry provider confirmed that the resident had never been seen. This lack of coordination and communication led to the resident's toenails becoming excessively long, resulting in the deficiency noted in the report.
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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