Lyndon Crossing
Inspection history, citations, penalties and survey trends for this long-term care facility in Louisville, Kentucky.
- Location
- 1101 Lyndon Lane, Louisville, Kentucky 40222
- CMS Provider Number
- 185165
- Inspections on file
- 29
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 14 (2 serious)
Citation history
Health deficiencies cited at Lyndon Crossing during CMS and state inspections, most recent first.
Medications labeled with a resident's name, a capped syringe, and a glucometer were left unattended on top of a locked medication cart with no staff present. An LPN admitted to leaving the items while attempting to administer medications on time, despite being aware that this violated facility policy. Interviews with nursing staff and leadership confirmed that this action was against policy and unsafe.
A resident with dementia, severe cognitive impairment, and anxiety was care planned to live on a secured memory unit with supervision and structured diversion activities due to elopement risk. In the days before the incident, the resident repeatedly voiced a desire to go home. On the night of the event, an exit alarm sounded, but CNAs and an LPN were occupied providing showers and other care, and although one CNA briefly redirected the resident from the exit door, staff did not ensure ongoing supervision or verify the resident’s whereabouts after silencing the alarm. The resident left the unit and facility without staff knowledge and was later found in a nearby park by community members and law enforcement, while facility staff initially believed the resident was still in her room. Staff interviews confirmed that required supervision and person-centered diversion interventions from the care plan were not implemented at the time.
A cognitively impaired, exit-seeking resident with dementia and severe cognitive deficits, identified as a moderate elopement risk and care planned to reside on a secure memory unit with supervision and diversional activities, was placed in a room adjacent to an alarmed exit door. In the days before the incident, staff documented and observed escalating behaviors, including repeated statements about wanting to go home, pushing on exit doors, packing a suitcase, and being non-redirectable, yet at the time of the event, one LPN and two CNAs on the unit were occupied with other residents. When the exit door alarm sounded, staff briefly checked the courtyard and rooms, turned off the alarm, and returned to their tasks, while a deteriorated wooden gate in the courtyard fence allowed the resident to push through and leave the property. The resident walked to a nearby park and was found by citizens who called 911; law enforcement then notified facility staff, who had been unaware the resident had left, demonstrating a failure to provide adequate supervision and maintain secure egress controls for an identified elopement risk.
Staff were observed inserting food thermometers through plastic wrap covering food items on the tray line, rather than removing the wrap as required by USDA guidelines and facility policy. This practice was confirmed by interviews with the dietary manager, DON, and administrator, who all stated that proper procedure is to remove barriers before temping food to prevent cross contamination and choking hazards.
A facility failed to develop a baseline care plan for a resident at risk for elopement, leading to the resident leaving the facility unsupervised. The resident, with severe cognitive impairment and a history of stroke, was not provided with necessary interventions despite being assessed as at risk. Staff interviews revealed a lack of awareness and communication regarding the resident's elopement risk, contributing to the incident.
The facility failed to provide adequate supervision and safety measures for two residents, leading to significant deficiencies. One resident, at risk for elopement, left the facility unnoticed and was found at a hospital. Another resident, admitted without a smoking or fall risk assessment, experienced multiple falls and was initially allowed to smoke unsupervised. Staff interviews revealed a lack of communication and understanding of the residents' risks and necessary precautions.
The facility failed to provide residents and their guardians with quarterly statements of personal funds accounts, as required by policy. Interviews revealed that residents did not receive these statements unless requested, leading to confusion about account balances. The BOM noted delays due to a change in facility ownership, while the DON and Administrator acknowledged the issue, which violated residents' rights.
The facility failed to provide a safe and comfortable environment due to a lack of hot water in 14 resident rooms, with temperatures as low as 44°F. Residents reported no hot water for over a month, affecting daily activities. Staff were unaware of the issue's extent, and maintenance checks were insufficient. Recent cold weather caused infrastructure issues, leading to high demand on limited shower facilities.
The facility failed to conduct annual performance reviews for CNAs and did not consistently provide required in-service education. Five CNAs lacked documented evaluations, and three did not meet the annual training requirement. The facility had no staffing policy, and a change in ownership affected documentation. The new Administrator acknowledged the importance of evaluations for feedback and competency assessment.
The facility failed to submit complete and accurate staffing data to CMS for Q3 2024, resulting in no RN hours and insufficient licensed nursing coverage. A change in ownership and software issues led to submission errors, impacting the facility's survey outcome and star rating.
An LTC facility failed to maintain an effective infection control program, as observed in the wound care of two residents. An LPN did not perform hand hygiene or change gloves between dirty and clean tasks, and failed to use barriers for supplies, risking contamination. Interviews with the DON and Wound Care Nurse confirmed these practices did not meet infection control standards.
The facility failed to implement its abuse prohibition policy by not completing required background checks and abuse training for new employees. Several personnel files lacked documentation of criminal background checks, nurse aide abuse registry checks, and Kentucky Adult Caregiver Misconduct Registry (KACMR) checks. Additionally, there was no evidence of abuse training for newly hired staff. Interviews revealed that Human Resources staff were responsible for these checks, which were not consistently completed before employees began work.
A facility failed to report an alleged abuse incident involving a resident with severe cognitive impairment within the required timeframe. CNA 14 witnessed CNA 13 allegedly choking the resident during care, but the report was delayed by 15 hours, hindering prompt investigation. The resident showed no physical signs of abuse, and staff interviews did not substantiate the claim.
A facility failed to develop a comprehensive care plan for a resident using a SoftPro Ambulating AFO boot. The resident, with conditions including hemiplegia and dementia, was unable to self-ambulate due to a broken boot and improper wheelchair footrest positioning. Despite awareness of the broken boot, the care plan was not updated, revealing a lapse in protocol adherence.
The facility failed to ensure proper labeling and storage of medications, with observations of undated, unlabeled, and expired medications in medication and treatment carts. A tube of Silvasorb gel and Diclofenac 1% topical medication were found without proper labeling, and a Cyclobenzaprine pill was found unlabeled in a medication cart. Interviews with staff revealed that the facility's policy did not adequately address documentation of open/expiration dates, and there was an expectation for nursing staff to regularly check and label medications.
Unattended Medications and Syringes Left on Medication Cart
Penalty
Summary
Facility staff failed to store medications and biologicals in a secure manner as required by facility policy and professional standards. During an observation, a medication cart was found unattended and locked, but medications labeled with a resident's name, a capped syringe, and a glucometer with a test strip were left on top of the cart. No staff were present in the area at the time. The facility's policy, reviewed and acknowledged by staff, clearly states that all drugs and biologicals must be stored in locked compartments and not left unattended. Interviews with the LPN involved, the unit manager, a registered nurse, and the Director of Nursing confirmed that leaving medications and syringes unattended on top of the cart was against facility policy and unsafe. The LPN admitted to being aware of the policy but stated he was trying to administer medications on time. Other staff members reiterated that medications and syringes should not be left unattended and that the LPN should have sought assistance if needed.
Failure to Implement Elopement Care Plan and Supervision on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan for a resident assessed as being at risk for elopement. The resident was admitted with dementia with behavioral disturbance, cognitive communication deficit, anxiety, and major depressive disorder, and was placed on a secured memory care unit for safety. An Elopement/Wandering Risk Evaluation identified the resident as a moderate elopement risk, and the comprehensive care plan required that the resident reside on the secured unit with supervision while on the unit. The care plan also included diversion and structured activity interventions such as toileting, walking inside and outside, reorientation strategies with signs and pictures, and use of memory boxes. In the days leading up to the incident, progress notes documented that the resident repeatedly expressed a desire to go home. On the night of the elopement, an alarm sounded on the women’s memory care unit exit door. Staff interviews revealed that CNAs and the LPN on duty were occupied providing showers and care to other residents when the alarm went off. One CNA reported seeing the resident at the exit door and moving her to the dining room but did not know the code to stop the alarm and sought assistance from the LPN. The LPN reported checking the courtyard, stepping outside, and checking resident rooms after the alarm, but staff did not identify that the resident was missing at that time. Another CNA stated that after the alarm was silenced, she returned to showering residents and later noticed the unit was unusually quiet, as the resident was typically loud, but no one was actively looking for the resident. The resident ultimately left the facility unsupervised and without staff knowledge, later being found by citizens in a local park who contacted law enforcement. The sheriff’s officer reported that when he first arrived at the facility and asked staff if the resident was missing, staff stated she was in her room; only after checking the room did they realize she was gone. The resident told the officer and bystanders that she had been held captive and had run away, and she told surveyors she had prayed for an intervention, that both exit doors opened, and that she escaped through a faulty fence slat and ran to the park. She also stated she was very unhappy, did not feel she belonged at the facility, and would leave again if able. Staff interviews confirmed that the care plan interventions requiring supervision on the secured unit and provision of diversional, person-centered activities were not implemented at the time of the elopement because staff were engaged in care of other residents and some staff were unfamiliar with the unit and its procedures.
Removal Plan
- Updated Resident 1 care plan to include increased supervision by staff, implemented q15-minute checks immediately, and completed psychosocial visit/assessment once daily for 3 days
- Completed pain evaluation for Resident 1 (no negative findings)
- Conducted medication and laboratory reviews for Resident 1
- Conducted elopement drills by Maintenance Director to ensure staff comprehension; staff verbally validated understanding
- Completed 100% elopement evaluations on all facility residents by licensed nursing staff
- Reviewed 100% of elopement care plans by MOS Coordinator and Director of Nursing Services
- Completed 100% staff education (including contract staff) on the Elopement policy and procedure by Executive Director, Director of Nursing Services, and department heads; staff verbally validated understanding
- Completed education for Social Services staff and MDS Coordinator on updating resident care plans and implementing interventions; staff verbally validated understanding
- Reviewed all residents’ care plans to ensure elopement risk is reflected on the comprehensive care plan and Kardex
- Implemented requirement that all residents who trigger for 'at-risk' and 'high-risk' will have an elopement care plan
- Revised resident care plans to include residents at risk for elopement
- Reviewed the Elopement Policy by the IDT to include individualized interventions for residents at risk for elopement
- Implemented weekly audits of new admissions for 3 months to ensure elopement risk and interventions are in place and care plan/Kardex updated
- Provided education to nursing staff on updating care plans, elopement evaluation, and Kardex as needed
- Continued staff education plan until complete; no staff (including new hires/contract) may work until educated; staff verbally validated understanding
- Completed elopement risk assessments on all residents by Director of Nursing Services/MOS Coordinator/Therapy Director
- Educated MOS/Social Services on elopement evaluation and implementing individualized interventions (supervision/observation), completing evaluations, following care plan/Kardex, and responding to alarms; staff verbally validated understanding
- Educated 100% of staff on revising care plans after identifying at-risk residents, individualized supervision/observation interventions, completing evaluations, following care plan/Kardex
- MOS Coordinator reviewed all baseline and comprehensive care plans to ensure revisions after identification of at-risk residents per elopement evaluations
- MOS Coordinator reviewed all comprehensive care plans to ensure revisions after identification of at-risk residents per elopement evaluations
- Held an ad-hoc QAPI meeting with leadership/IDT to review the plan and findings
- Forwarded Care Plan and Elopement Assessment audits to the Executive Director for QAPI Committee review monthly for at least 3 months to ensure ongoing compliance
- Held QAPI meetings monthly
- Audited and reviewed all monitoring by Executive Director and/or Director of Nursing Services until ongoing compliance is achieved; corrected deficient practices immediately and referred to QAPI Committee for further review and interventions
Failure to Supervise Exit-Seeking Resident Leads to Elopement from Secure Memory Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe, secure environment for a cognitively impaired resident on a memory care unit, resulting in an elopement. The resident was admitted with dementia with behavioral disturbance, cognitive communication deficit, anxiety, and major depressive disorder, and hospital records indicated the need for a secured, locked unit due to impaired safety decisions and poor safety awareness. On admission, the facility’s elopement/wandering risk evaluation scored the resident as a moderate elopement risk, and the admission MDS showed a BIMS score of five, indicating severe cognitive impairment. The resident’s care plan, initiated shortly after admission and later revised, included goals and interventions to maintain safety on the secure unit, including supervision while on the unit and provision of activities of interest with redirection as needed. In the days leading up to the incident, progress notes documented escalating behaviors and clear exit-seeking. Notes from several days before the elopement described the resident as having behavioral issues, constantly stating a desire to go home, yelling out for God to get her out, and repeatedly expressing a desire to leave. Staff interviews further confirmed that the resident frequently packed a suitcase, made statements about wanting to go home, pushed on exit doors, and watched the doors to see if someone would go out. On the day of the elopement, staff reported the resident was antsy, wanted to get out, and was not redirectable, with social services noting that the resident insisted she needed to get to her dying mother. Despite these known behaviors and documented risks, the resident was placed in a room directly catty-corner to an exit door on the secure unit, and there is no indication in the report that enhanced supervision such as 1:1 monitoring was consistently implemented at the time of the incident. On the evening of the elopement, staff on the women’s memory care unit consisted of one LPN and two CNAs for 16 residents, and all three staff members reported being occupied with other resident care tasks when the alarm sounded. One CNA reported hearing the alarm, going to the exit door, seeing another resident in a wheelchair, moving that resident, and, along with the LPN and another CNA, checking the courtyard and not seeing anyone before the LPN turned off the alarm. Another CNA stated she saw the eloping resident at the exit door when the alarm went off, moved her to the dining room, and then returned to provide a shower to another resident, noting that the door did not lock right away and that no one was actively looking for the resident later. The LPN reported responding from the men’s secure unit when the alarm sounded, checking the courtyard and resident rooms per policy, and stated he did not realize the resident was missing until a law enforcement officer arrived and asked about her. The resident was able to exit the building through the alarmed exit door and then leave the courtyard through a deteriorated wooden gate connected to the privacy fence. The maintenance director later acknowledged that the gate’s wood boards were beginning to deteriorate before the incident and that the resident was able to push through the boards and then place them back, securing the gate with empty plant pots on the opposite side, which led staff to believe the gate was secure when checked. The resident reported that on the night she left, both exit doors near her room opened, that the wood gate was faulty and allowed her to get through, and that she ran to a nearby park where she sat on a bench and told a couple about her escape. Concerned citizens at the park called 911, and a sheriff’s officer responded, found the resident, and then went to the facility, where staff initially stated the resident was in her room and were unaware she had left until they checked and found her missing. The officer reported that no staff member told him they were looking for or missing a resident, and the resident herself stated she was unhappy in the facility, did not feel she belonged there, and would leave again if able. The facility’s own elopement and wandering policy stated that residents at risk for elopement were to receive adequate supervision to prevent accidents, that alarms were not a replacement for necessary supervision, and that staff were to respond to alarms in a timely manner. The policy also required a systematic approach to monitoring and managing residents at risk for elopement, including identification and assessment of risk, implementation of interventions to reduce hazards and risks, and monitoring and modifying interventions as needed, with interventions added to the care plan and communicated to appropriate staff. Despite this, staff interviews revealed that at the time of the elopement, all assigned staff were engaged in other resident care tasks, could not provide supervision or diversional activities as outlined in the care plan, and did not recognize or report the resident as missing until notified by law enforcement. The combination of the resident’s known exit-seeking behavior, placement in a room adjacent to an exit door, a defective courtyard gate, and staff being occupied with other tasks when the alarm sounded led to the resident leaving the secure unit and the facility without staff awareness, resulting in the identified deficiency under F689 for failure to ensure adequate supervision and a hazard-free environment.
Removal Plan
- Conduct elopement drills once per shift to ensure staff comprehension of the elopement drill process.
- Complete a 100% audit of door and lock evaluations with no negative findings.
- Complete 100% elopement evaluations.
- Provide 100% staff education (including contract staff) on the Elopement policy/procedure and appropriate resident supervision.
- Initiate an investigation of the incident, including staff interviews and a root cause analysis.
- Repair the defective courtyard gate by facility staff and a licensed contractor.
- Inspect all doors, locks, and gates throughout the facility to ensure proper functioning.
- Add additional interventions to the resident’s care plan: increased supervision, q15-minute checks for 72 hours, and review of medications and labs.
- Adjust the exit door on the Memory Care Unit to prevent delayed egress.
- Review the Elopement Policy by the IDT to include individualized interventions for residents at risk for elopement.
- Audit new admissions weekly for 3 months to ensure elopement risk and interventions are in place.
- Complete elopement risk assessments on all residents.
- Educate MDS/Social Services on completing elopement evaluations, implementing interventions based on findings (including supervision/observation), and the necessity of staff availability and timely alarm response.
- Hold an Ad-Hoc QAPI meeting with leadership/IDT members to review the plan and findings.
- Forward elopement assessment audits to the Executive Director for QAPI Committee review monthly for at least 3 months to ensure ongoing compliance.
- Hold QAPI meetings monthly.
- Correct any deficient practices identified through monitoring immediately and report/review them through the QAPI Committee until ongoing compliance is achieved.
- Complete elopement drills each shift for 1 day and monthly ongoing.
Improper Food Temperature Monitoring Through Plastic Wrap
Penalty
Summary
Surveyors observed that staff failed to follow proper procedures for checking food temperatures during meal service. Specifically, staff were seen inserting food thermometers through the plastic wrap covering food items such as creamed corn, pureed enchilada casserole, and kernel corn on the steam table, rather than removing the plastic wrap before taking temperatures. According to the USDA guidelines and the facility's own policies, thermometers should be inserted directly into the food, avoiding any barriers like plastic wrap, to prevent cross contamination and ensure accurate temperature readings. Interviews with the Interim Dietary Manager, a staff member, the DON, and the Administrator confirmed that the correct procedure is to remove any plastic or foil covering before inserting the thermometer. The DON and Administrator both acknowledged that piercing plastic wrap could introduce a choking or aspiration hazard and that staff are expected to use clean, dry thermometers and inspect them prior to use. The failure to follow these procedures was identified as a deficiency affecting all residents who received food from the kitchen.
Failure to Develop Baseline Care Plan for Elopement Risk
Penalty
Summary
The facility failed to develop a baseline care plan for a resident identified as at risk for elopement upon admission. The resident, who had a history of hemiplegia, hemiparesis following cerebral infarction, epilepsy, aphasia, and chronic congestive heart failure, was admitted to the facility and assessed as at risk for elopement. Despite this assessment, the facility did not create a baseline care plan with necessary interventions to address the resident's risk for elopement, leading to the resident leaving the facility without staff's knowledge. The resident's clinical records indicated severe cognitive impairment, with deficits in short-term memory, delayed recall, orientation, problem-solving, and safety awareness. The facility's policy required that residents at risk for elopement receive adequate supervision and have a person-centered care plan developed within 48 hours of admission. However, the care plan for this resident did not include interventions for wandering or elopement risk, even after the resident had eloped and was found by emergency services with stroke-like symptoms. Interviews with facility staff revealed a lack of communication and understanding regarding the resident's elopement risk. Several staff members, including LPNs and CNAs, were unaware of the resident's risk for elopement and did not receive guidance from management on monitoring the resident. The facility's interdisciplinary care plan team failed to implement a systematic approach to managing the resident's elopement risk, resulting in the resident's unsupervised departure from the facility.
Removal Plan
- The facility provided an acceptable IJ Removal Plan, alleging removal of the IJ.
Inadequate Supervision and Safety Measures for Residents
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for two residents, leading to significant deficiencies. One resident, admitted with a history of cognitive impairments and assessed as at risk for elopement, was not provided with a care plan addressing this risk. Consequently, the resident left the facility without staff knowledge and was found the next day at a local hospital. The facility's policy required a systematic approach to monitor and manage residents at risk for elopement, which was not effectively implemented in this case. Another resident was admitted without a smoking safety assessment or fall risk assessment, despite having a history of cerebral infarction and requiring assistance with transfers. This resident experienced multiple falls, one resulting in an ankle injury, and was allowed to smoke unsupervised initially. The facility's failure to conduct timely assessments and implement appropriate interventions contributed to the resident's falls and potential safety hazards. Interviews with staff revealed a lack of communication and understanding regarding the residents' risks and the necessary precautions. Staff were unaware of the residents' elopement and fall risks, and there was confusion about the facility's policies and procedures. The facility's inadequate response to these risks and the absence of documented interventions in the care plans highlight the deficiencies in ensuring resident safety and supervision.
Removal Plan
- Implemented a systematic approach for monitoring and managing residents at risk for elopement.
- Conducted a thorough search for R401 and ensured all exit doors, door alarms, and windows were functioning properly.
- Changed door codes to prevent unauthorized exits.
- Placed R401 on one-to-one supervision upon return to the facility.
- Reviewed and revised the facility's policy on elopements and wandering residents.
- Ensured all staff were aware of residents at risk for elopement and the necessary interventions.
- Conducted staff training on the importance of monitoring residents at risk for elopement and the procedures to follow if a resident is missing.
- Implemented a baseline care plan for each resident, including interventions to address safety concerns such as elopement.
Failure to Provide Quarterly Personal Funds Statements
Penalty
Summary
The facility failed to provide residents and/or their guardians with quarterly statements of their personal funds accounts, as required by their policy. This deficiency was identified for five residents who were sampled for personal funds accounts. The facility's policy mandates that individual financial records should be available to residents through quarterly statements and upon request. However, interviews with residents and their representatives revealed that they did not receive these statements unless specifically requested, and in some cases, they had to visit the facility to obtain them. This lack of communication led to confusion about account balances and payments. The Business Office Manager (BOM) acknowledged the issue, noting that the facility was acquired by another company, which delayed the transfer of resident funds accounts. The Director of Nursing (DON) was unaware of the issue and confirmed that not providing quarterly statements violated residents' rights. The Administrator admitted that there were issues with residents receiving their statements, although she claimed that the problem had been resolved since her hire date. Despite these claims, the deficiency persisted, affecting the residents' ability to manage their personal funds effectively.
Facility Fails to Provide Hot Water in Resident Rooms
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the lack of hot water in 14 out of 19 resident rooms. Observations revealed that the water in these rooms remained cold even after running for several minutes, with temperatures recorded as low as 44 degrees Fahrenheit. This issue persisted despite the facility's policy requiring a safe and comfortable environment, and residents reported having no hot water for over a month, impacting their daily living activities such as washing hair. Interviews with residents and staff highlighted the ongoing nature of the problem. Several residents expressed frustration over the lack of hot water, with some stating they had informed the facility's new owner and the Ombudsman about the issue. Staff interviews revealed a lack of awareness and communication regarding the problem, with maintenance personnel unaware of the cold water issue in specific rooms and shower areas. The Maintenance Director admitted to only checking water temperatures in one room per hallway weekly, which may have contributed to the oversight. The facility's infrastructure issues were exacerbated by recent extreme cold temperatures, which caused pipes to burst and ceilings to cave in. This led to a high demand for the limited functional shower facilities, with 72 residents relying on a single shower room at times. The Director of Nursing acknowledged the intermittent hot water supply and the strain on available shower facilities, while the Administrator was unaware of the extent of the cold water issue until recently. Renovations were ongoing, affecting multiple shower rooms, which further complicated the situation.
Deficiency in CNA Performance Reviews and Training
Penalty
Summary
The facility failed to conduct performance reviews for all Certified Nursing Assistants (CNAs) at least once every 12 months, as required. This deficiency was identified for five CNAs whose personnel records were reviewed. Specifically, CNAs #2, #18, #20, #31, and #32 did not have documented performance evaluations within the previous 12 months. Additionally, the facility did not provide evidence of regular in-service education based on the outcomes of these reviews for CNAs #18, #31, and #32. The facility's policy required CNAs to attend a minimum of 12 hours of continuing education annually, but this requirement was not consistently met, as evidenced by the varying hours of training documented in the personnel files. The facility's Executive Director admitted that there was no staffing policy in place, and staffing was based on the facility's assessment. The President of Regional Clinical Operations acknowledged that the facility had undergone a change in ownership, which affected the availability of training and performance evaluation documentation. The new Administrator, who was still acclimating to her role, recognized the importance of performance evaluations in providing feedback and assessing competencies, skills, and knowledge. However, the lack of completed evaluations meant that staff could not benefit from this feedback, potentially impacting their performance and the quality of care provided.
Failure to Submit Accurate Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the third quarter of 2024. This failure resulted in no registered nurse (RN) hours being reported and a lack of licensed nursing coverage for 24 hours a day on four or more days within the quarter, specifically in August and September 2024. The facility's Payroll Based Journal (PBJ) report indicated excessively low weekend staffing and no RN hours during this period. Despite requests, the facility could not provide verification that the staffing data for the third quarter had been successfully submitted to CMS. Interviews revealed that the President of Finance (VPF) was responsible for submitting the payroll data and acknowledged an error in the submission process due to a change in ownership and software transition. The VPF attempted to submit the data on October 14, 2024, but received an error message the following day, indicating the data was not submitted. The Administrator, new to her position during the ownership change, was aware of the software error and understood the importance of timely data submission, as the failure affected the facility's survey outcome and star rating.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper wound care practices observed for two residents, R20 and R67. During wound care for R20, an LPN did not perform hand hygiene when transitioning from dirty to clean tasks, such as after removing a dressing and before opening sterile items. The LPN also failed to place a barrier on the table before placing supplies, and her gown came into contact with open dressings, potentially contaminating the wound. These actions were contrary to the facility's policies on hand hygiene and enhanced barrier precautions. For R67, the LPN similarly neglected to perform hand hygiene and change gloves between dirty and clean tasks during wound care. The LPN placed supplies on an unclean table without a barrier and retrieved a dropped dressing from the floor without discarding it. Additionally, the LPN did not change gloves or wash hands after touching non-sterile items, such as the bed controls and tube feed pump, before handling wound care supplies. These practices were inconsistent with the facility's infection control policies and could lead to contamination and infection. Interviews with the Director of Nursing, Wound Care Nurse/Staff Development Coordinator, and the Wound Doctor confirmed that the observed practices did not meet the expected standards for infection control. They emphasized the importance of hand hygiene, glove changes, and the use of barriers to prevent contamination during wound care. The failure to adhere to these protocols for both residents highlights a significant deficiency in the facility's infection prevention and control program.
Failure to Implement Abuse Prohibition Policy
Penalty
Summary
The facility failed to implement its abuse prohibition policy by not verifying and maintaining documentation of screening and training for new employees. Specifically, the facility did not complete the required criminal background checks, nurse aide abuse registry checks, and Kentucky Adult Caregiver Misconduct Registry (KACMR) checks for 9 out of 12 personnel files reviewed. These checks were either completed after the employees' hire dates or not documented at all. Additionally, there was no evidence that newly hired staff received the mandatory abuse training at the beginning of their employment. The personnel files reviewed revealed several instances where the required checks and training were not completed. For example, Registered Nurses (RNs) and Certified Nursing Assistants (CNAs) had their background checks and registry checks completed after their hire dates, and there was no documentation of abuse training. In some cases, such as with CNA24 and CNA19, there was no evidence of any checks or training being completed. The former administrator's file also lacked documentation of a nurse aide abuse registry check and abuse training. Interviews with the Administrator and the Regional President of Talent and Acquisition highlighted that the Human Resources staff were responsible for completing these pre-employment checks. The Administrator expected these checks to be completed before new employees entered the facility to prevent potential harm to residents. However, the checks were not consistently completed, and the facility's current owners, who took over on September 1, 2024, were not aware of the background checks for employees hired before that date.
Delayed Reporting of Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe, as outlined in their policy. Certified Nursing Assistant (CNA) 14 witnessed CNA 13 allegedly choking Resident 79 during a care incident. This event occurred at approximately 5:20 AM, but the report was not made to the administration until 8:37 PM, resulting in a delay of about 15 hours. This delay hindered the facility's ability to promptly investigate the alleged abuse. Resident 79, who has severe cognitive impairment due to dementia, was reportedly combative during care, which led to the alleged incident. The resident was later assessed and showed no physical signs of abuse, such as bruising or changes in voice. The facility's policy mandates immediate reporting of abuse allegations, but this was not adhered to, as the report was significantly delayed. Interviews with staff revealed that CNA 14 delayed reporting the incident, and there was no corroborating evidence from other staff or physical signs on the resident to substantiate the abuse claim. The Interim Administrator and Director of Nursing confirmed the expectation for immediate reporting of such incidents, which was not met in this case, leading to a deficiency in the facility's handling of the situation.
Failure to Develop Comprehensive Care Plan for AFO Boot
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as R22, who was wearing a SoftPro Ambulating ankle foot orthoses (AFO) boot. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, cerebral infarction, and dementia, was assessed as cognitively intact. Despite this, the care plan did not address the use of the AFO boot, which was necessary for the resident's mobility and safety. Observations revealed that the resident could not self-ambulate in his wheelchair due to a broken AFO boot, and his foot was dragging on the floor because the wheelchair footrest was not elevated. Interviews with the Director of Nursing (DON) and the Minimum Data Set Coordinator (MDSC) revealed a lack of awareness and assumption that the care plan for the AFO boot was in place. The DON acknowledged the boot was broken and had ordered a replacement but was unaware that the care plan was not updated. The MDSC stated that care plans should be completed promptly, and the Administrator emphasized the importance of updating care plans within 24 hours of admission. Despite these protocols, the care plan for the AFO boot was not developed, indicating a lapse in the facility's adherence to its own guidelines and federal requirements.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled in accordance with professional standards, as evidenced by observations of undated, opened, unlabeled, and expired medications in one of five medication carts and one of two treatment carts. Specifically, a tube of Silvasorb gel with an expiration date of July 2024 was found without a label or identifier, and a tube of Diclofenac 1% topical medication was found without an open date or storage bag for a resident. Additionally, a pill of Cyclobenzaprine 5 mg was found separated from its pack and unlabeled in the medication cart for the B hall. Interviews with nursing staff revealed that the pharmacy inspects the carts monthly, but the facility's policy did not adequately address the documentation of open/expiration dates or the labeling of medications. Interviews with the Unit Manager, Staff Development, and the Director of Nursing (DON) highlighted the expectation that expired medications should not be present in the carts and that medications should be labeled with open dates and resident identifiers. The Unit Manager stated that nursing staff were responsible for weekly and monthly checks of the medication and treatment carts, while the DON emphasized the importance of checking expiration dates daily. The Administrator reiterated the expectation that medications should not be in the carts without personal containers and identifiers, and that loose medications must be destroyed. The lack of proper labeling and storage of medications poses a risk of medication errors, as noted by the staff development personnel.
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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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