Life Care Center Of Morehead
Inspection history, citations, penalties and survey trends for this long-term care facility in Morehead, Kentucky.
- Location
- 933 North Tolliver Road, Morehead, Kentucky 40351
- CMS Provider Number
- 185155
- Inspections on file
- 17
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Life Care Center Of Morehead during CMS and state inspections, most recent first.
A resident admitted with PTSD and other diagnoses had a trauma-informed care assessment showing distressing trauma symptoms, but the comprehensive care plan did not address PTSD or include trauma-informed interventions. Staff interviews confirmed the diagnosis was known, yet the care plan lacked the information needed for nursing, CNA, MDS, SSD, DON, and ED staff to identify needs, triggers, and resident-centered interventions.
A resident admitted with PTSD and a left femur fracture had a BIMS score of 15/15 and a trauma assessment showing distressing symptoms tied to a prior transportation accident, but the comprehensive care plan did not address PTSD or trauma-informed care. The resident declined to discuss triggers, and staff reported they were not aware of specific triggers; the SSD, DON, and ED stated they expected trauma-informed care and monitoring for behavior changes when triggers were not identified.
Staff failed to properly clean and disinfect shared glucometers after blood glucose checks, using incorrect wipes and not following manufacturer instructions, while also neglecting to use appropriate PPE and perform hand hygiene during high-contact care activities for residents on Enhanced Barrier Precautions. Additionally, non-critical equipment such as Hoyer lifts was not cleaned as required, leading to widespread lapses in infection prevention.
Surveyors found that food was not consistently stored or handled according to professional standards, with frozen meat thawed at room temperature, unlabeled and undated food items in refrigerators, and snacks left unrefrigerated on nurse's station counters. Staff and leadership interviews confirmed that personal food was sometimes stored in resident nourishment refrigerators and that food safety policies regarding labeling, dating, and storage were not consistently followed.
A resident who was dependent on staff for bathing received only sporadic and partial hygiene care, as confirmed by chart reviews and interviews. Due to staffing shortages, CNAs were unable to provide regular full showers or bed baths, resulting in the resident feeling unclean and embarrassed. Facility leadership acknowledged the expectation for regular bathing but cited documentation and staffing issues.
A resident receiving enteral nutrition was found with tube feeding solution and water flush dated several days prior, still hanging in the room and not changed according to facility policy or manufacturer guidelines. Nursing staff interviews confirmed the requirement to change solutions and tubing every 24 hours, but there was confusion and lack of awareness about the outdated solution among staff and leadership, resulting in a failure to follow established protocols for tube feeding care.
A resident with end-stage renal disease and on hemodialysis did not have required pre- and post-dialysis communication forms or assessments documented for multiple treatments. Staff interviews confirmed that the process for completing and tracking these forms was not consistently followed, and the necessary documentation was missing from both the paper chart and EMR.
Two residents experienced unmanaged pain due to the facility's failure to administer prescribed pain medications as ordered. One resident with a hip fracture did not receive ordered Oxycodone because the LPN could not access the emergency medication system, resulting in the resident being sent to the ER for pain control. Another resident missed 14 doses of gabapentin for neuropathic pain due to supply and communication issues, leading to increased pain without alternative interventions. Staff and pharmacy interviews confirmed that medication access and refill processes were not effectively followed.
Two residents experienced missed doses of essential medications due to delays in prior authorization, pharmacy communication issues, and inconsistent medication reordering processes. One resident with an autoimmune disorder went several days without a critical muscle-strengthening medication, resulting in observable weakness, while another with neuropathic pain missed multiple doses of gabapentin, leading to increased pain. Staff interviews revealed confusion over pharmacy notifications and emergency medication access, and facility policies for medication management were not consistently followed.
Failure to Include PTSD in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with PTSD that included measurable objectives and timeframes to address his medical, nursing, mental, and psychosocial needs. The resident was admitted with diagnoses including a left femur fracture, PTSD, and acute respiratory failure, and his quarterly MDS showed a BIMS score of 15 out of 15, indicating he was cognitively intact. Review of the comprehensive care plan showed that PTSD and trauma-informed care were not addressed, even though PTSD was listed as an active diagnosis in the hospital discharge paperwork and order summary report. A trauma-informed care assessment completed after admission documented that the resident reported personal trauma related to a transportation accident and identified multiple symptoms over the past month, including repeated disturbing dreams, distress when reminded of the event, physical reactions such as heart pounding and sweating, avoidance of memories or feelings, trouble remembering parts of the experience, self-blame or blaming others, and strong negative emotions such as fear, horror, guilt, anger, or shame. During interview, the resident stated he was in the facility for therapy after falling and breaking his leg and said his goal was to return home, but he declined to discuss the trauma event. Staff interviews showed the resident’s PTSD diagnosis and trauma-related needs were known, but not reflected in the care plan. The SRNA stated she relied on report and the Kardex for resident care needs, and the LPN stated she was not aware of specific triggers and that it was important PTSD be listed on the care plan so staff would know how to meet the resident’s needs. The SSD, MDS Coordinator, DON, and ED all stated PTSD should have been included in the care plan and that staff needed to be aware of the diagnosis and any known triggers so the resident could receive resident-centered, trauma-informed care and be monitored for changes in behavior.
Trauma-Informed Care Not Addressed in Care Plan
Penalty
Summary
The facility failed to ensure trauma-informed care was included in the care plan for a resident admitted with a documented diagnosis of PTSD. The resident was admitted with diagnoses including a left femur fracture, PTSD, and acute respiratory failure, and the quarterly MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact and had an active PTSD diagnosis. Review of the comprehensive care plan showed PTSD and trauma-informed care were not addressed, despite the facility policy stating residents with trauma history or PTSD should receive person-centered care planning to identify and lessen triggers that could cause re-traumatization. The resident’s trauma-informed care assessment documented that he reported a personal trauma related to a transportation accident and identified symptoms including repeated disturbing dreams, distress when reminded of the event, physical reactions such as heart pounding and sweating, avoidance of memories, trouble remembering parts of the experience, self-blame, and strong negative feelings. During interview, the resident declined to discuss the trauma further. Staff interviews showed the LPN was not aware of specific triggers, the SSD said the resident declined to discuss triggers, and the DON and ED stated they expected residents with PTSD to receive trauma-informed care and be monitored for changes in behavior when triggers were not identified. No active or standing psychiatric orders were noted in the record.
Failure to Implement Effective Infection Control for Glucometer Use and PPE Compliance
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observations of improper cleaning and disinfection of shared glucometers used for blood glucose monitoring. Staff, including RNs and LPNs, did not follow the manufacturer's instructions for cleaning and disinfecting the glucometers, such as using the correct EPA-approved wipes, performing the required cleaning and disinfection steps, and ensuring the proper dwell time for disinfectant. In several instances, staff used unapproved wipes, did not allow the disinfectant to remain wet for the required time, and failed to use two wipes as instructed. Additionally, glucometers were stored improperly, often in direct contact with each other and without barriers, increasing the risk of cross-contamination. One resident with a bloodborne illness (HIV) was among those receiving fingerstick glucose checks with shared devices. Further deficiencies were observed in the use of Enhanced Barrier Precautions (EBP) and personal protective equipment (PPE) during high-contact care activities. Staff members, including CNAs and nurses, were seen providing direct care to residents on EBP without donning appropriate PPE such as gowns and gloves, despite clear signage and facility policy requirements. In several cases, staff failed to perform hand hygiene before and after glove use, and in some instances, left resident rooms and handled equipment or supplies with contaminated gloves. These lapses occurred with residents who had wounds, indwelling catheters, or multidrug-resistant organism (MDRO) infections, all of whom required strict adherence to infection control protocols. Additionally, the facility did not ensure proper cleaning of non-critical resident care equipment, such as Hoyer lifts. Observations revealed visible contamination on the base of a mechanical lift, and staff interviews confirmed that cleaning after each use was expected but not consistently performed. These failures in infection control practices were identified through direct observation, staff interviews, and review of facility policies and CDC guidelines, and had the potential to affect all residents receiving fingerstick blood glucose checks and those requiring high-contact care.
Failure to Store and Handle Food According to Professional Standards
Penalty
Summary
The facility failed to store and handle food in accordance with professional standards and its own policies, as evidenced by multiple observations and staff interviews. Surveyors observed five rolls of frozen ground beef thawing at room temperature in the kitchen, contrary to the facility's policy requiring thawing in the refrigerator or as part of the cooking process. Additionally, a commercially prepared container of sliced meat and a can of soda were found in the reach-in refrigerator without labels or dates. Snacks, including meat sandwiches and milk, were observed left unrefrigerated on the nurse's station counter ahead of scheduled distribution times. Further deficiencies were noted in the storage of nourishment and snacks on the North and South Units. The North Unit nourishment refrigerator contained a box from a fast food restaurant and a lunch box with energy drinks, both unlabeled and undated. The South Unit nourishment refrigerator held a shopping bag with fruit and crackers belonging to a staff member, as well as another bag with apples and chocolate milk, all unlabeled and undated. Staff interviews confirmed that personal food items were sometimes stored in resident nourishment refrigerators, and that snacks were often delivered to nurse's stations and left unrefrigerated for extended periods before distribution. Interviews with dietary and nursing staff, as well as facility leadership, revealed inconsistent adherence to food safety policies regarding labeling, dating, and proper storage of food items. Staff acknowledged that meat was sometimes left to thaw at room temperature and that snacks were delivered and left out on counters rather than being promptly refrigerated. Facility leadership confirmed that only resident items, properly labeled and dated, should be stored in nourishment refrigerators, and that staff food should be kept in designated staff areas.
Failure to Provide Adequate Bathing Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically bathing, for one resident who was dependent on staff for showering and bathing. The resident, admitted with a trimalleolar fracture, difficulty walking, and dysphagia, was cognitively intact and required full assistance for bathing. Review of charting showed that the resident received only a few bed baths over a period of more than a month, with no evidence of regular full showers or complete bed baths as required by facility policy. Interviews with the resident revealed that she mostly received partial bed baths, often limited to washing her face and armpits, and that she felt unclean and embarrassed due to the lack of proper hygiene care. Staff interviews confirmed that due to staffing shortages, aides were often unable to provide full showers or complete bed baths, and care was frequently rushed. The CNAs reported that with only two aides for a hall of 34 residents, many of whom required two-person assistance, they could not consistently provide full hygiene care. The DON acknowledged that residents should receive head-to-toe bed baths and daily wash-ups, but also noted that sometimes showers or baths were not properly documented. The Executive Director stated that residents should receive showers and linen changes as scheduled, but staff were expected to report if they were unable to complete these tasks.
Failure to Change Tube Feeding Solution and Tubing per Policy
Penalty
Summary
The facility failed to provide appropriate care and services to prevent complications related to enteral feeding for a resident who was dependent on tube feeding. The facility's policy and the formula manufacturer's guidelines required that enteral feeding solutions and tubing be changed every 24 hours to prevent bacterial growth and potential infection. However, observation revealed that a tube feeding solution and water flush, both dated several days prior, were still hanging in the resident's room and had not been changed according to policy. The feeding solution and water flush were dated for three days prior to the observation, and neither was connected to the resident at the time. Interviews with nursing staff, including RNs and LPNs, confirmed that the standard practice was to change tube feeding solutions and tubing every 24 hours. Staff acknowledged the importance of this practice to prevent the solution from spoiling and to avoid the risk of infection or food poisoning. Despite this, there was uncertainty among staff regarding the continuation of orders and the timing of solution changes, with some unable to recall when the solution was last changed or why it was still hanging with an outdated date. Further interviews with the Infection Preventionist Nurse and the DON confirmed that the facility's expectation was for tube feeding solutions and sets to be changed every 24 hours, and that failure to do so could result in bacterial growth and resident illness. The DON and other leadership were not aware that the outdated solution was still present in the resident's room, indicating a lapse in monitoring and communication regarding adherence to enteral feeding protocols.
Failure to Document Pre- and Post-Dialysis Assessments and Communication
Penalty
Summary
The facility failed to provide required pre- and post-dialysis communication documentation for one resident who was dependent on renal dialysis. According to the facility's policy, staff were to complete a Pre/Post Dialysis Communication Form for each dialysis session, which included pre- and post-dialysis assessments, medication checks, and documentation of meals sent with the resident. The form was to be sent with the resident to the dialysis center and returned to the facility for inclusion in the medical record. Review of the resident's records revealed that for eight dialysis treatments over a specified period, there was no evidence in either the hard copy chart or the electronic medical record that the required forms or assessments were completed or maintained. Interviews with staff, including RNs, LPNs, medical records personnel, the DON, and the Executive Director, confirmed that the process for completing and tracking the Pre/Post Dialysis Communication Form was not consistently followed. Staff acknowledged the importance of the form for monitoring the resident's condition but indicated that forms were often not completed, not returned from the dialysis center, or not properly filed. The resident involved was cognitively intact and had a history of diabetes, chronic kidney disease stage 5, and dependence on hemodialysis. Despite the facility's policy and care plan requirements, the necessary documentation and assessments were not performed or recorded for the resident's dialysis treatments.
Failure to Provide Effective Pain Management for Two Residents
Penalty
Summary
The facility failed to provide effective pain management for two residents who required such services. One resident was admitted following a right hip fracture and had a physician order for Oxycodone 30 mg every 6 hours as needed for pain. Upon admission, the resident began experiencing significant pain, but the ordered pain medication was not administered because the nurse on duty did not have access to the emergency medication system, which required two nurses with codes. The resident was instead given acetaminophen, which did not adequately control the pain, and ultimately had to be sent to the emergency room for pain evaluation after repeatedly requesting pain relief and expressing distress. Another resident, admitted with chronic conditions including diabetes and neuropathy, was assessed as being at risk for pain and was prescribed gabapentin 300 mg three times daily for leg pain. The facility failed to administer 14 doses of gabapentin over several days due to a lapse in medication supply, despite staff being aware that the medication was running low and attempting to contact the pharmacy and physician. During this period, the resident did not receive any additional pain medication and reported increased pain, describing a shooting sensation down her leg. No nonpharmacologic interventions were offered to alleviate her discomfort. Interviews with staff and pharmacy representatives confirmed that the emergency medication system contained the necessary medications, but access issues and communication failures prevented timely administration. The facility's processes for medication refills and emergency access were not effectively implemented, resulting in residents experiencing unmanaged pain and missed doses of prescribed medications.
Failure to Provide Timely Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of its residents, resulting in missed doses of critical medications for two residents. One resident, admitted with a rare autoimmune disorder, type 2 diabetes, and carcinoma-in-situ of the lung, experienced multiple missed doses of Pyridostigmine Bromide ER, a medication essential for muscle strength. The missed doses were due to issues with prior authorization (PA) requirements, pharmacy communication lapses, and delays in medication delivery. Documentation showed that the resident went several days without the medication, leading to observable physical weakness and concern expressed by the resident. Staff interviews revealed confusion and inconsistent processes regarding PA notifications, ordering, and communication with the pharmacy, with changes in the pharmacy's notification system contributing to the problem. Another resident, with chronic kidney disease and neuropathic pain, missed 14 doses of gabapentin over several weeks. Despite staff attempts to reorder the medication and communicate with both the physician and pharmacy, the medication was not refilled in a timely manner. The resident reported increased pain and discomfort during the period without medication. Staff interviews indicated that the medication was not available in the emergency medication system, although the contracted pharmacy later stated it was. The facility's processes for medication reordering and emergency access were inconsistently followed, and communication barriers with the new pharmacy further delayed medication delivery. Review of facility policies confirmed that procedures were in place for reordering, administering, and documenting medications, but these were not effectively implemented. Staff described multiple methods for reordering medications, including electronic health records, fax, and manual logs, but there was no consistent or reliable system to ensure timely medication delivery, especially when prior authorizations were required. The facility's failure to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals resulted in unmet pharmaceutical needs for the residents involved.
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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