Hartland Park Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Lexington, Kentucky.
- Location
- 1500 Trent Boulevard, Lexington, Kentucky 40515
- CMS Provider Number
- 185197
- Inspections on file
- 24
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Hartland Park Health & Rehabilitation during CMS and state inspections, most recent first.
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 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.
Surveyors found that the facility did not provide or document required written information about Advance Directives for several residents, including those with severe cognitive impairment and those who were cognitively intact. Despite facility policies and staff interviews indicating that Advance Directives should be obtained and reviewed, only Hospitality Guide Acknowledgements were present in the records, with missing or incomplete Advance Directive, Living Will, or POA documentation.
Staff failed to store drugs and biologicals in their original packaging, resulting in unidentified pills being left on a resident's bedside table and loose pills found in two medication carts. A resident with intact cognition was unable to identify pills left in her room, and staff interviews revealed inconsistent adherence to medication administration and disposal policies. Facility leadership confirmed expectations for proper medication handling, but observations showed these were not always met.
Staff failed to consistently follow infection prevention and control practices, including proper hand hygiene, use of PPE, and cleaning of shared equipment. Contaminated linens and trash were improperly handled and stored, and environmental cleanliness was not maintained, with infectious waste observed both inside and outside the facility. These deficiencies affected multiple residents, including those with cognitive impairment and indwelling devices, and had the potential to impact all residents.
Two residents were not treated with dignity and privacy as required. One resident's full urinary catheter bag was left uncovered and visible from the hallway, contrary to the care plan. Another resident received an insulin injection in the hallway from an LPN, with other residents and staff present, and without privacy. Facility leadership confirmed that privacy and dignity should have been maintained in both cases.
A nurse administered a dose of MiraLAX, prescribed to one resident, to another resident when the latter's supply was missing, instead of following facility protocols for medication shortages. Both residents were cognitively intact and had physician orders for MiraLAX. Facility policy prohibits sharing medications between residents, and staff interviews confirmed this expectation.
The facility did not timely update or implement comprehensive, person-centered care plans for multiple residents, including those with indwelling urinary catheters, colostomies, and severe cognitive impairment. Care plans failed to reflect residents' preferences, changes in condition, or ongoing activity participation, despite staff awareness and provision of care.
A resident with severe cognitive impairment and multiple diagnoses received enteral tube feeding without the required head-of-bed elevation, as observed on multiple occasions. Despite facility policy and CDC guidelines mandating a 30-45 degree elevation to prevent complications like aspiration, staff did not consistently maintain this position during feedings.
A resident with severe cognitive impairment and complex medical needs did not consistently receive prescribed Volara System respiratory treatments, with 22 missed doses documented over a month. The missed treatments occurred primarily when the respiratory therapist was not present and nursing staff were responsible. The resident's representative and clinical staff expressed concerns about the impact of these missed treatments, including increased congestion and the need for additional medical evaluation.
Food in a nourishment refrigerator was repeatedly stored at temperatures above the recommended maximum of 41°F, as documented on multiple days. Staff interviews revealed confusion about the correct temperature range and inconsistent monitoring practices. The DON confirmed the standard was not to exceed 41°F, but this was not consistently followed.
Two residents experienced deficiencies in their care plans. One resident did not receive prescribed pain medication for over 21 hours after hospital readmission, despite a care plan to administer medications per orders. Another resident's care plan failed to address non-compliance with a prescribed diet, as family members brought in regular-texture food contrary to the resident's dietary needs. The facility's policy required comprehensive care plans, but these were not fully developed or implemented for the residents.
A resident with femur fractures did not receive timely pain medication due to staff unawareness of available Oxycodone in the emergency medication box. Despite orders for Oxycodone, the resident experienced significant pain for approximately 21 hours. Interviews revealed a lack of communication and adherence to procedures, leading to the deficiency.
The facility failed to document and resolve grievances related to missing personal items for several residents. Despite residents reporting missing items to staff, these grievances were not logged, and the items were neither found nor replaced. Interviews with residents and staff revealed a lack of proper documentation and follow-up, contrary to the facility's policy requiring grievances to be documented and resolved.
A resident with dysphagia was not accurately assessed for a modified texture diet in the MDS, despite physician's orders for a pureed diet. The RD failed to mark the mechanically altered diet section, leading to an inaccurate reflection of the resident's dietary needs. Staff discussions in clinical meetings did not translate into accurate MDS documentation.
An LPN worked 82 shifts with a suspended license at a facility that lacked a policy on staff licensure. The facility's job description and employee handbook required proof of current licensure, which was not followed. The LPN was terminated after the suspension was discovered, as confirmed by interviews with the facility's administration.
A facility failed to secure a medication cart and properly label medications, leading to potential risks. An unlocked medication cart was found unattended, contrary to policy. Additionally, a resident's medication lacked proper labeling, with the opened date missing, risking administration of expired medication. Staff interviews confirmed the importance of securing carts and following expiration dates to ensure safety and effectiveness.
The facility failed to follow infection control precautions for three residents. A Social Service Assistant and an LPN did not adhere to hand hygiene and equipment disinfection protocols for a resident on enhanced barrier precautions. An RN administered medication to another resident without gloves, and another RN changed a dressing without wearing required protective gear. The facility's infection control policies were not properly implemented, as revealed in interviews with staff and administration.
The facility failed to maintain clear hallways, creating a safety hazard. Observations showed wheelchairs and a linen cart obstructing a hallway, confirmed by staff interviews. The congestion was due to unidentified wheelchairs and frequent use of carts, posing a risk during emergencies.
A resident with severe cognitive impairment did not receive scheduled medications on time due to an LPN being distracted by other residents' needs. The LPN had prematurely signed the MAR, indicating the medications were given, which was against facility policy. The oversight was discovered by a family member, and the medications were administered later by an RN.
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 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 Provide and Document Advance Directive Information and Documentation
Penalty
Summary
The facility failed to provide and document written information to residents and their representatives regarding the right to accept or refuse medical or surgical treatment and to formulate an Advance Directive, as required by federal regulations and the facility's own policies. Multiple residents, including those with severe cognitive impairment and those who were cognitively intact, did not have copies of their Advance Directives, Living Wills, or Power of Attorney (POA) documents present in their electronic medical records (EMR) when requested by surveyors. Instead, the only documentation provided was a Hospitality Guide Acknowledgement, which did not include the required Advance Directive documents. For several residents, such as those with diagnoses of cerebral palsy, epilepsy, dementia, and heart disease, the facility's records showed either a lack of documentation of Advance Directives or incomplete records, such as missing POA or Living Will documents. In some cases, residents or their representatives stated they did not recall receiving written information about Advance Directives or signing related documents. Interviews with facility staff, including the Social Services Director, Director of Medical Records, Director of Nursing, and the Administrator, confirmed that while the facility had processes in place to request Advance Directives during admission and care plan meetings, these processes were not consistently followed or documented. The facility's policies required that residents be informed of their rights regarding Advance Directives upon admission and that staff verify and periodically review these wishes. However, the survey found that for six sampled residents, there was no evidence that the facility provided the necessary written information or obtained and retained the required documentation. This deficiency was identified through interviews, record reviews, and policy reviews, demonstrating a failure to comply with federal and state requirements for Advance Directives.
Failure to Properly Store and Identify Medications
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were stored in their original packaging or containers as required by policy and professional standards. Observations revealed that one resident had five unidentified pills left on her bedside table, and neither the resident nor the nursing staff could identify the medications or their origin. The resident, who had intact cognition and a history of rheumatoid arthritis, hypertension, and anxiety, was unsure about the purpose or duration of the pills' presence. The nurse practitioner acknowledged the resident's autonomy in self-administering medications but also recognized the potential risk if other residents accessed the pills. Additionally, staff interviews confirmed that facility policy required medications to be administered immediately after preparation and that unused doses should be disposed of according to policy. Further observations identified loose, unidentified pills in two medication carts. In one instance, twelve loose pills were found in a medication cart drawer, and the LPN on duty could not account for how they got there, noting that pills sometimes fell out of blister packs. Another observation showed a nurse preparing a resident's medications in advance and storing them in the cart before administration. An additional loose, unidentified tablet was found in a cup in another cart, with a medication aide admitting she did not want to waste the pill and initially considered returning it to the drawer. Facility leadership interviews confirmed expectations that staff verify medication ingestion and waste unused medications appropriately, but these practices were not consistently followed.
Failure to Maintain Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple direct observations of staff not adhering to established infection control practices. Staff were observed failing to perform hand hygiene, not wearing appropriate personal protective equipment (PPE) during high-contact care, and improperly handling contaminated linens and trash. For example, a certified nurse aide provided direct care to a resident under enhanced barrier precautions without donning a gown, and several staff members were seen transporting dirty linens and trash through hallways without removing gloves or performing hand hygiene. Additionally, clean and contaminated items were improperly stored, such as respiratory equipment and dentures left to dry on a stained towel in a resident's bathroom, and clean privacy curtains dragged on the floor before being hung. Shared equipment, including gait belts, blood glucose meters, blood pressure cuffs, and mechanical lifts, was not consistently cleaned and disinfected between resident use. An LPN was observed performing a blood sugar fingerstick without following infection control protocols, including failing to clean and disinfect the glucometer according to manufacturer instructions and not performing hand hygiene before or after the procedure. Other staff members admitted to not cleaning equipment between uses unless a resident was on contact precautions, and there was confusion or lack of knowledge regarding proper disinfection procedures and required contact times for cleaning products. Environmental cleanliness and waste management were also deficient. Trash and contaminated linens were left on floors in resident rooms and hallways, and infectious waste was observed scattered around the dumpster area outside the facility. Staff interviews revealed inconsistent understanding and application of infection control policies, despite reported training and competencies. These failures were observed to affect multiple residents, including those with severe cognitive impairment, indwelling devices, and those under enhanced barrier precautions, and had the potential to impact all residents in the facility.
Failure to Maintain Resident Dignity and Privacy During Care
Penalty
Summary
The facility failed to maintain resident dignity and privacy for two residents. In the first instance, a resident with cerebral palsy, epilepsy, and neuromuscular dysfunction of the bladder was observed with an indwelling urinary catheter collection bag that was full of urine and not covered by a dignity bag, as required by the resident's care plan. The collection bag was visible from the hallway, and the unit manager confirmed that dignity covers should be used but was unaware why it was not in place for this resident. In the second instance, a resident with hemiplegia, cerebral infarction, type 2 diabetes, and severe cognitive impairment received an insulin injection in the abdomen from an LPN while seated in her wheelchair next to the medication cart in the hallway. Multiple residents and staff were present and could see the procedure. The LPN acknowledged that privacy was not provided and that the injection should have been administered in the resident's room. Both the DON and the facility administrator confirmed that staff are expected to provide privacy and treat residents with dignity during care.
Misappropriation of Resident Medication by Nursing Staff
Penalty
Summary
A deficiency occurred when a registered nurse (RN) administered MiraLAX, a laxative prescribed to one resident, to another resident. The RN observed that one resident was missing their prescribed MiraLAX and, instead of waiting for the pharmacy to deliver a new supply, used another resident's medication. Both residents were cognitively intact and had physician orders for MiraLAX for constipation, but the medication was specifically prescribed to each individual. Facility policy defined misappropriation as the wrongful use of a resident's belongings or medication without consent and stated that residents have the right to be free from such misappropriation. The RN acknowledged during an interview that medications should not be shared between residents. The Director of Nursing and the Administrator both confirmed that staff are expected to reorder medications through the pharmacy and consult the provider if a medication is missing, rather than borrowing from another resident. The incident was identified through observation, record review, and staff interviews, confirming that the facility failed to protect a resident from the misappropriation of their medication.
Failure to Timely Update and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, as required by policy and regulatory standards. For one resident with an indwelling urinary catheter, the care plan was not updated in a timely manner to reflect the resident's longstanding preference for a leg bag, despite staff being aware of this preference. The care plan was only revised months after the preference was established, and interviews with nursing staff confirmed that the resident had always used a leg bag. Another resident who was readmitted with a colostomy did not have this significant change in condition reflected in the care plan until several months after readmission. Although the resident had a physician's order for ostomy care and staff were providing the necessary care, the care plan was not updated to include the colostomy until it was discovered missing by the MDS nurse. The MDS nurse acknowledged that the omission occurred at the time of readmission and was not caught during daily meetings or by other staff responsible for care plan updates. Additional deficiencies were noted for a resident with severe cognitive impairment and an indwelling urinary catheter, whose care plan was not updated to include the use of a leg bag after the resident repeatedly removed the catheter. The change to a leg bag was made to address this behavior, but the care plan was not revised until much later. Another resident with severe cognitive impairment was not care planned for activities until long after admission, despite ongoing participation in bedside activities and music therapy. Staff interviews confirmed that activities were being provided, but the care plan did not reflect this until it was eventually updated.
Failure to Maintain Proper Head-of-Bed Elevation During Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral tube feeding was provided with appropriate care to prevent complications such as aspiration. Observations on two separate occasions showed that the resident was lying in bed with tube feeding infusing, but the head of the bed (HOB) was not elevated as required by both facility policy and CDC guidelines. The facility's policy and CDC guidance specify that the HOB should be elevated 30 to 45 degrees for residents receiving enteral feedings, unless medically contraindicated. The resident in question had diagnoses including cerebral palsy, epilepsy, and dysphagia, and was severely cognitively impaired according to the most recent assessment. Interviews with staff, including an LPN, the Infection Preventionist/Staff Development Coordinator, the DON, and the Administrator, confirmed that the expectation was for the HOB to be elevated for residents receiving tube feedings. The LPN stated that the resident experienced pain and yelled out when the HOB was elevated, so she raised it slowly throughout the shift. Despite these statements, observations confirmed that the HOB was not elevated during feedings, which was inconsistent with both policy and professional standards. The deficiency was identified for one resident with a feeding tube, and no evidence was provided that the required positioning was maintained during enteral feeding.
Failure to Consistently Administer Ordered Respiratory Treatments
Penalty
Summary
The facility failed to consistently provide prescribed respiratory treatments for a resident with severe cognitive impairment and multiple medical diagnoses, including dementia, cerebral infarction, and aphasia. The resident was ordered to receive Volara System therapy with sodium chloride inhalation twice daily, as documented in the electronic medical record. However, review of the device's digital therapy log revealed that 22 treatments were missed over a period of approximately one month. The missed treatments included both morning and evening doses, and there was no documentation provided to explain these omissions. The facility was also unable to provide the requested Respiratory Policy to the surveyor during the investigation. Interviews with the resident's Power-of-Attorney, the respiratory therapist, and the nurse practitioner confirmed concerns about inconsistent administration of the respiratory therapy, particularly during evenings and weekends when the respiratory therapist was not present and nursing staff were responsible. The resident's POA reported increased congestion and wheezing when treatments were missed, which led to a chest x-ray being ordered. Both the respiratory therapist and nurse practitioner stated that it was their expectation for nursing staff to follow provider orders to maintain the resident's health and well-being.
Failure to Maintain Safe Food Storage Temperatures in Unit Refrigerator
Penalty
Summary
The facility failed to store food in a safe manner in a nourishment refrigerator on one of its resident units. Review of the refrigerator temperature logs for the unit revealed that, on multiple dates, the recorded temperatures were above the recommended maximum of 41 degrees Fahrenheit, with specific readings of 46, 42, 48, and 46 degrees Fahrenheit on consecutive days. The State Operations Manual defines the 'Danger Zone' as food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit, which can allow the rapid growth of pathogenic microorganisms. Staff interviews indicated uncertainty about the correct temperature range, with some staff believing the acceptable range extended up to 45 or 46 degrees Fahrenheit. The night shift staff were responsible for monitoring and recording refrigerator temperatures, while the unit manager was responsible for ensuring this was done. Interviews with the CNA, LPN/Unit Manager, DON, and Administrator confirmed that staff were expected to monitor and document refrigerator temperatures and report any concerns to supervisors or maintenance. However, the logs showed that the refrigerator was repeatedly above the safe temperature threshold, and there was a lack of clear understanding among staff regarding the correct temperature range. The Director of Nursing clarified that the appropriate refrigerator temperature should not exceed 41 degrees Fahrenheit, but this standard was not consistently met or enforced on the unit.
Deficiencies in Care Plan Implementation for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. Resident 124, who was readmitted from the hospital with fractures in both femurs, did not receive prescribed pain medication for approximately 21 hours after it was ordered. Despite having a care plan that included administering medications per orders, the resident's pain scores indicated significant discomfort, with scores ranging from 5/10 to 8/10 during this period. The medication administration record showed that the resident did not receive the ordered Oxycodone at several documented times when pain was reported. Resident 36's care plan was not adequately developed to address non-compliance with the prescribed diet. The resident, who had dysphagia and major depression, was on a controlled carbohydrate, pureed diet. However, observations and interviews revealed that the resident's family frequently brought in regular-texture food, which was not in compliance with the diet order. The care plan lacked interventions to address this non-compliance and did not include education for the resident or family about the prescribed diet. Interviews with staff and family members confirmed that the resident's dietary needs were not being fully met according to the care plan. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timeframes to meet residents' needs. However, the care plans for both residents were not fully developed or implemented, resulting in unmet medical and dietary needs. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, highlighted the expectation that care plans should be accurate and reflect the residents' current care needs, which was not the case for these two residents.
Failure to Administer Timely Pain Medication
Penalty
Summary
The facility failed to administer prescribed pain medications in a timely manner for Resident 124, who was readmitted to the facility with fractures of the right and left femur. Despite having orders for Oxycodone 5 mg every 12 hours as needed and Oxycodone 15 mg every six hours, the resident did not receive the medication until approximately 21 hours after first expressing pain. The resident's pain scores ranged from 5/10 to 8/10 during this period, indicating significant discomfort. Interviews and observations revealed that the facility staff were unaware that the necessary medications were available in the emergency medication box. The Registered Nurse responsible for admitting the resident did not recall the incident or the resident being in extreme pain. The facility's policies allowed for verbal authorization in emergencies, but this was not utilized, and there was a lack of awareness about the availability of Oxycodone in the emergency medication box. The Director of Nursing and Assistant Director of Nursing both stated that they expected nursing staff to administer pain medication when a resident was in pain. However, there was a breakdown in communication and procedure, as the medication was not administered promptly, and the facility's process for handling controlled medications was not effectively followed. The facility's failure to provide timely pain management resulted in prolonged discomfort for the resident.
Failure to Document and Resolve Grievances for Missing Items
Penalty
Summary
The facility failed to document, replace, and resolve grievances related to missing personal items for four residents. These residents reported missing items to staff, but the facility did not log these grievances in the grievance log, nor did they find or replace the missing items. The facility's policy required that grievances be documented and resolved, but this was not adhered to in these cases. Interviews with the residents revealed that they had reported missing items to staff, but no follow-up or resolution was provided. One resident mentioned that her items were never returned from the laundry, leading her to have her laundry done by family members. Another resident reported missing clothing items and stated that no staff member had followed up with her about these grievances. A third resident, who shared a room with her mother, reported multiple missing clothing items and noted that staff no longer allowed residents to search for their missing items in the laundry room. Staff interviews indicated a lack of proper documentation and follow-up on grievances. A CNA mentioned verbally informing the charge nurse about missing items, but there was no formal documentation. The Social Worker, responsible for grievances, stated that items should be replaced if not found, but this was not done. The Director of Nursing and the Administrator both emphasized the importance of documenting grievances and providing resolutions, but this was not reflected in the actions taken by the facility.
Inaccurate Dietary Assessment for Resident
Penalty
Summary
The facility failed to ensure an accurate assessment for one resident, who was on a modified texture diet due to dysphagia. The Quarterly and Annual Minimum Data Set (MDS) assessments did not reflect the resident's need for a mechanically altered diet, despite the resident's admission records and physician's orders indicating a pureed texture diet. The resident, who was cognitively intact, confirmed she had been on pureed food for a long time due to failing a swallowing test at the hospital. Interviews with facility staff, including the Regional Registered Dietitian (RD), MDS Nurse, Director of Nursing (DON), and Administrator, revealed that the RD was responsible for completing the swallow and nutritional status section of the MDS. However, the RD did not mark the mechanically altered diet section, leading to an inaccurate reflection of the resident's dietary needs in the MDS. The MDS Nurse and other staff discussed resident care changes in clinical morning meetings, but the MDS did not accurately reflect these changes in the comprehensive care plan.
LPN Worked with Suspended License
Penalty
Summary
The facility failed to ensure that nursing staff providing resident care was licensed, as evidenced by an LPN working on a suspended license. The LPN performed duties as a licensed nurse in the facility for a period of time while her license was suspended. The facility did not have a policy regarding staff licensure, and it was revealed that the LPN worked 82 shifts during the period her license was suspended. The facility's job description and employee handbook required that licensed employees furnish proof of current registration and licensure, which was not adhered to in this case. Interviews with the facility's administration, including the Administrator, Assistant Administrator, and Director of Nursing, confirmed the oversight. The Administrator acknowledged the importance of maintaining active licenses to ensure compliance and resident safety. The Assistant Administrator confirmed that the LPN was terminated once the facility discovered the suspension. The Director of Nursing emphasized the necessity of valid licenses to ensure staff compliance and up-to-date education hours.
Medication Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper labeling of medications, as evidenced by an unlocked and unattended medication cart on the Memory Care Unit. During an observation, it was noted that the medication cart was left unlocked, which was against the facility's policy that mandates all medication carts be locked when not in use. Interviews with staff, including a registered nurse and the unit manager, confirmed the importance of keeping medication carts locked to prevent unauthorized access by residents, visitors, or other staff. Additionally, the facility did not adhere to professional standards for labeling medications, specifically concerning expiration dates. A resident, who was admitted with diagnoses including deep vein thrombosis, diabetes, and pre-glaucoma, was prescribed latanoprost ophthalmic solution. The medication was observed to be improperly labeled, with the opened date missing on the container, despite the pharmacy's instructions that the medication was good for 42 days after opening. This oversight meant the medication was potentially expired when administered, as the opened date was only noted on the box, which could be separated from the container. Interviews with nursing staff and the unit manager highlighted the importance of following expiration dates and ensuring medications are labeled correctly to maintain their effectiveness. The pharmacist confirmed the potency of the medication decreases after the expiration date, although it does not cause adverse effects. The Director of Nursing and the Administrator reiterated the facility's policy and expectations regarding medication security and labeling, emphasizing the need for compliance to ensure resident safety and effective medication administration.
Infection Control Precautions Not Followed for Residents
Penalty
Summary
The facility failed to adhere to infection control precautions for three residents on infection control precautions. In the case of Resident 124, a Social Service Assistant (SSA) entered the resident's room, which was under enhanced barrier and contact precautions, without following proper hand hygiene protocols. The SSA picked up a clipboard, placed it on the sink, removed her gloves, and left the room without washing her hands or cleaning the clipboard. Additionally, a Licensed Practical Nurse (LPN) provided wound care to the same resident, removed her protective equipment, and placed an eye shield on the sink. She washed her hands but did not disinfect the top of the treatment cart after placing the eye shield on it. For Resident 71, a Registered Nurse (RN) administered medication without wearing gloves, despite the resident being on enhanced barrier precautions. The RN handled the medications with bare hands and expressed nervousness during the interview, acknowledging the potential for transferring infectious organisms due to not wearing gloves. Resident 12 was also on enhanced barrier precautions, but an RN changed the resident's dressing without wearing a gown or gloves, contrary to the signage requirements. The RN believed that gowns were only necessary for certain procedures. Interviews with the Director of Nursing and the Infection Preventionist revealed that staff were expected to follow enhanced barrier precautions, but no issues had been identified in their audits. The Administrator was unaware of any infection control issues, although these were discussed in monthly Quality Assurance Performance Improvement meetings.
Crowded Hallways Create Safety Hazard
Penalty
Summary
The facility failed to maintain a safe environment for residents, staff, and the public in one of its resident care units. An observation revealed that the hallway in the [NAME] Hall was crowded with four wheelchairs folded up against the handrail on one side and a linen cart on the opposite side. This congestion was noted to create a safety issue, particularly in emergencies, as it hindered residents' ability to maneuver through the hallway. Interviews with staff, including a Registered Nurse, the Unit Manager, the Director of Nursing, and the Administrator, confirmed that the hallways were frequently crowded with various carts and equipment. The Unit Manager explained that the wheelchairs were left in the hallway because they had been washed and lacked identification, making it unclear where they should be stored. The Director of Nursing and the Administrator both emphasized the importance of keeping hallways clear for safety, especially during mealtimes when additional tray carts were present.
Medication Administration Lapse for a Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as R114, who did not receive scheduled medications on a specific date. The facility's policy required staff to observe the resident's consumption of medications and sign the Medication Administration Record (MAR) only after administration. However, on the day in question, a Licensed Practical Nurse (LPN) was distracted by other residents' needs and forgot to administer R114's medications, despite having already signed the MAR indicating they were given. This oversight was discovered when a family member reported the issue to a Registered Nurse (RN), who then administered the medications later than scheduled. R114, who had severe cognitive impairment and multiple diagnoses including unspecified dementia and type 2 diabetes mellitus, was supposed to receive several medications, including Metformin and Protonix, at 6:00 PM. The RN confirmed with the LPN that the medications were not given and subsequently administered them at 7:35 PM. The Director of Nursing (DON) confirmed that the medications were administered late and emphasized that the facility's policy was not followed, as medications should not be signed out until they are actually administered. The incident highlighted a lapse in adherence to medication administration protocols, leading to a delay in the resident receiving necessary medications.
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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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