Mt. Sterling Health & Rehab, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Sterling, Kentucky.
- Location
- 125 Sterling Way, Mount Sterling, Kentucky 40353
- CMS Provider Number
- 185242
- Inspections on file
- 22
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Mt. Sterling Health & Rehab, Llc during CMS and state inspections, most recent first.
Failure to Properly Document Advance Directives: The facility did not ensure advance directive rights were properly supported for multiple residents. Several records contained only a general POA instead of documentation for health care decision making, some residents had no Health Care Decision Making form or advance directive on file, and some forms were incomplete or did not match the documents in the chart. The AC stated she reviewed the admission packet and asked about advance directives, while the SSD said the records suggested residents and families were not educated on the purpose and elements of an advance directive.
Expired and undated eye drops were found on multiple med carts, including Wisteria Unit carts 1 and 2 and Lakeview Unit cart 1. Surveyors observed several opened eye drops and an eye ointment for multiple residents that were not dated or were past the usual 28- to 30-day discard timeframe. Staff, including the KMA, Pharmacy Consultant, DON, and ADON, stated eye drops should be dated when opened and checked before administration.
Staff failed to follow infection control practices during resident care and routine tasks. An NA was observed wearing contaminated gloves in the hallway, entering multiple resident rooms without hand hygiene, and not removing PPE inside the room. Another NA passed ice and water by filling cups over the open ice chest and leaving the scoop on top of the ice, while moving between residents without hand hygiene. Leadership stated staff were expected to perform hand hygiene before and after resident contact, after glove removal, and to follow proper PPE and sanitary ice-handling practices.
The facility failed to provide adequate supervision and a hazard-free environment for three residents, resulting in two falls and unsafe medication handling. One resident, cognitively intact but requiring two-person assistance and supervision for toileting, was transferred to the bathroom by a single aide and left alone on the commode, where the resident was later found on the floor. Another resident with severe cognitive impairment and high fall risk, care planned for two-person transfers but without specific supervision interventions for time spent in a common area, sustained an unwitnessed fall from a chair in the TV area, resulting in facial injuries and a nasal fracture. A third resident with severe cognitive impairment, not assessed to self-administer medications, was observed with a cup of crushed medications in pudding left unattended at the bedside, contrary to facility policies requiring direct observation of medication administration and secure storage.
A facility failed to provide ordered respiratory care for two residents with COPD and other medical conditions. One resident was observed without oxygen in place, with tubing out of reach, and the concentrator set above the ordered flow rate; staff did not return to replace the oxygen during the observation. Another resident’s concentrator was observed set below and above the ordered 3 LPM. Facility leaders stated staff were expected to follow physician orders and verify the oxygen flow rate at the prescribed setting.
Incomplete dialysis assessment and communication documentation: A resident receiving hemodialysis had missing pre- and post-dialysis assessments and incomplete dialysis communication forms across multiple treatments. The facility’s records lacked required details such as VS, meal information, nurse contact information, dialysis results, and post-treatment monitoring documentation, and staff interviews confirmed the forms were expected to be completed before transport and reviewed on return.
A resident with severe physical and cognitive impairments was injured during a transfer when two SRNAs failed to extend the legs of a mechanical lift and improperly pulled on the lift pad, causing the device to tilt and strike the resident's head. The incident resulted in a laceration and required emergency medical care. Investigation confirmed the lift was functioning properly and the injury was due to staff not following established safe transfer procedures.
A resident with severe cognitive impairment and multiple medical conditions developed significant bruising on her chest, which was observed by nursing staff and assessed by the DON. However, the resident's family was not notified of the injury until several days after it was first identified, resulting in a delay in communication about the resident's condition.
Multiple lapses in infection prevention and control were observed, including failure to change and date oxygen equipment as required, lack of hand hygiene by staff during meal service and wound care, improper cleaning of shared equipment such as gait belts, and inadequate use of personal protective equipment when handling soiled linens. These actions and inactions were inconsistent with facility policies and contributed to the deficiency.
Two residents did not have complete or properly implemented care plans: one lacked a care plan for a dialysis catheter despite visible signs of redness and dried blood, and another received oxygen at rates above physician orders, with staff failing to consistently check and match oxygen settings to care plans. Staff interviews confirmed gaps in care planning and monitoring for both residents.
A resident with chronic respiratory conditions was observed receiving oxygen at rates higher than the physician-ordered 4 L/min via nasal cannula on multiple occasions. Staff interviews confirmed that the oxygen concentrator was not always set according to orders, and the resident experienced repeated hospitalizations for respiratory issues. Facility policy and leadership expected staff to check and follow oxygen orders, but this was not consistently done.
A facility failed to sustain an effective QAPI program, resulting in a repeat deficiency when staff exited a resident's room on droplet precautions with a used, uncleaned gait belt. Despite prior education and audits, staff did not consistently clean shared equipment between uses, and monitoring of these practices had ceased, leading to ongoing infection control concerns.
The facility failed to properly store and handle medications, biologicals, and vaccines, leading to deficiencies in three medication storage rooms. Vaccines were improperly stored, and refrigerator temperatures were not maintained, affecting medication integrity. Medication carts were left unlocked, and keys were improperly stored, risking unauthorized access. Staff lacked awareness of proper storage practices, and documentation for controlled substances was incomplete.
The facility failed to maintain sanitary food storage conditions in three nourishment unit refrigerators. Ice packs were improperly stored in the Sterling and Bluegrass Unit freezers, and the Lakeview Unit refrigerator lacked a thermometer and temperature log. Staff interviews confirmed the risk of cross-contamination and the absence of required temperature monitoring.
The facility failed to provide appropriate care for residents with limited range of motion (ROM) due to the absence of a restorative nursing program (RNP). Observations and interviews revealed that residents with ROM impairments were not receiving targeted interventions, and staff lacked training and guidance in providing restorative care. The facility's staffing records showed no restorative staff on duty, and the program had not been reinstated since the COVID-19 pandemic.
The facility failed to follow proper infection control practices, including inadequate cleaning of shared medical equipment like glucometers and mechanical lifts, improper storage of supplies, and use of expired disinfecting wipes. Staff did not adhere to hand hygiene protocols, and a medication was administered after contact with a contaminated surface. These deficiencies were observed despite infection control training being provided.
A facility failed to refer a resident for a level II PASARR after a new diagnosis of unspecified psychosis. The resident, initially admitted with metabolic encephalopathy, dementia, and anxiety, was later diagnosed with psychosis but did not have a new PASARR submission. Despite severe cognitive impairment and behavior issues, the facility did not coordinate with the PASARR program as required. The Social Services Director admitted the oversight, and the Administrator expected resubmission after the resident's psychiatric hospitalization.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in care. A resident developed an infection at the gastric tube site due to staff not following physician's orders. Another resident's care plan interventions for skin protection were not consistently applied, resulting in skin tears. Additionally, a resident with diabetes did not have a care plan for podiatry services, leading to untrimmed toenails and potential complications.
A resident with impaired skin integrity was not provided care according to their plan, which included keeping fingernails short and using Geri-sleeves. Observations showed the resident with long nails and no protective sleeves, leading to skin picking and injuries. Staff interviews revealed communication lapses and inconsistent implementation of the care plan.
A resident with diabetes did not receive necessary podiatry services as required by the facility's policy. Despite the resident's long, untrimmed, and thick toenails causing pain, and a request from the resident's daughter, no referral was made for podiatry services. Interviews with staff confirmed the absence of a referral, and the importance of professional foot care for diabetic residents was emphasized by the PCP.
A resident with a gastric tube infection did not receive the prescribed care due to a nurse's failure to apply a bacterial ointment as ordered. The resident, who was dependent on tube feedings and had a severely impaired mental status, was observed to have an infected gastric tube site. Despite physician orders for specific care, the nurse was unaware of these orders, and no root cause analysis was conducted for the infection.
The facility failed to document COVID-19 vaccination education and status for a KMA and a DA, increasing the risk of communicable diseases. The DA's file lacked evidence of vaccine education or offering, while the KMA's file showed a request for religious exemption but no education documentation. Interviews with the IP, DON, and Administrator highlighted the importance of maintaining proper documentation for infection control.
Failure to Properly Document Advance Directives
Penalty
Summary
The facility failed to ensure residents were provided the right to formulate an advance directive for 12 of 19 sampled residents. Review of the facility policy stated the facility would support and facilitate a resident's right to formulate an advance directive, and if requested, provide information about that right. The admission packet included a Health Care Decision Making form asking whether a resident had an advance directive, what type it was, and whether the resident wanted to proceed further with Social Services, but the documentation on file for multiple residents did not meet those requirements. For Resident 1, the responsible party completed the form indicating no advance directive, but the form did not answer whether the resident wanted to proceed further with Social Services. Resident 2 had no Health Care Decision Making form on file, and guardianship documentation did not delineate responsibility for health care decision making. Resident 4, Resident 6, Resident 8, Resident 37, and Resident 60 each had a Health Care Decision Making form indicating an advance directive such as a durable power of attorney for health care, but the records contained only a general power of attorney that did not address health care decision making. Resident 10 had a form indicating a durable power of attorney for health care and no desire to proceed further with Social Services, but no further documentation was on file. Resident 22 had no Health Care Decision Making form, and the general power of attorney on file did not address health care decision making. Resident 38 and Resident 54 had no Health Care Decision Making form and no advance directive on file. Resident 56 had no Health Care Decision Making form, and the emergency guardianship order on file did not address advance directives. During interviews, the Admissions Coordinator stated she reviewed the form on admission and asked about advance directives, but also stated she had limited training with the prior AC. The Social Services Director stated no resident or representative had expressed interest in an advance directive and, after reviewing several records, stated it looked like residents or families were not educated on the purpose and elements of an advance directive. The DON and Administrator stated advance directives were expected to be discussed and followed, and the Administrator stated discrepancies suggested confusion about what constituted an advance directive.
Expired and Undated Eye Drops Found on Multiple Medication Carts
Penalty
Summary
The facility failed to label drugs and biologicals in accordance with currently accepted professional principles, including the appropriate expiration date when applicable, for 3 of 8 medication carts. Surveyors observed expired and/or undated eye drops in the Wisteria Unit medication cart 1, Wisteria Unit medication cart 2, and the Lakeview Unit medication cart 1. The observations included opened bottles and tubes of eye drops and eye ointment for multiple residents that were either not dated when opened or were past the expected discard timeframe. On the Wisteria Unit medication cart 1, surveyors found three eye drops that were expired and/or undated, including Systane eye drops for one resident, Lumigan eye drops for another resident, and Refresh eye drops that were opened and not dated. On the Wisteria Unit medication cart 2, surveyors found seven expired and/or undated eye drops and eye ointment, including gentamycin eye drops, Systane eye drops, bimatoprost eye drops, tobramycin eye drops, and erythromycin eye ointment for several residents. On the Lakeview Unit medication cart 1, surveyors found one bottle of brimonidine eye drops that had been opened and dated. Staff interviews showed the KMA, Pharmacy Consultant, ADON, DON, and Administrator all acknowledged that eye drops should be dated when opened and generally discarded after about 28 to 30 days, but the observations showed several were not dated or were beyond the expected timeframe.
Failure to Follow Hand Hygiene, PPE, and Ice-Handling Infection Control Practices
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. Review of CDC guidance and the facility’s infection prevention and control policy showed that hand hygiene was required immediately before and after resident care, gloves were not a substitute for hand hygiene, and PPE was to be used and removed according to policy. The policy also stated staff received infection control education and training related to their job duties. During observation, Nurse Aide State Registered 5 was seen exiting one resident’s room wearing gloves and holding a plastic trash bag containing soiled briefs, disposing of the bag in a laundry cart, removing contaminated gloves, and then donning new gloves and entering another resident’s room without performing hand hygiene. He was later observed exiting a resident’s room after transferring the resident with a mechanical lift while still wearing gloves and again not performing hand hygiene. In interview, he stated PPE should be removed inside the resident’s room and hand hygiene should be performed before exiting, but he could not explain why he failed to remove gloves inside the room or perform hand hygiene after resident care and before entering another resident’s room. Another nurse aide was observed passing ice and water to residents by filling cups while holding them over the open ice chest, placing the scoop on top of the ice instead of in its holder, and moving from room to room without performing hand hygiene between resident contacts. The ADON/IP, DON, Administrator, and Medical Director all stated staff were expected to perform hand hygiene before and after resident contact, after removing gloves, and to follow PPE and sanitary ice-handling practices. The observations showed staff did not follow those practices for residents including R11, R18, R38, R113, R122, and R133.
Failure to Provide Adequate Supervision and Safe Medication Handling
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free of accident hazards for three residents, resulting in falls and unsafe medication handling. One resident with lumbar disc degeneration, movement disorder, and cardiomegaly was assessed as cognitively intact but required two-person assistance for transfers and supervision when toileting, and was identified as high risk for falls on the Morse Fall Scale. Despite this, a nurse aide transferred the resident alone to the bathroom commode, left her unsupervised, and instructed her to use the call light when finished. The aide left the bathroom to go to the nurse’s station, and upon returning a short time later, found the resident on the floor beside the commode after the resident had apparently attempted to manage independently. Another resident with acute respiratory failure, dementia, and anxiety was assessed as severely cognitively impaired and at high risk for falls on the Morse Fall Scale. The care plan identified fall risk related to gait and balance and required two staff for transfers between surfaces, but did not include specific interventions for supervision while in a common area or up in a chair. The resident was later found face down on the floor in front of a chair in the TV/common area after an unwitnessed fall from a Broda chair, with documented injuries including a swollen, bleeding nose, a new laceration over the right eyebrow, facial bruising, and right shoulder pain, and was diagnosed with a closed nasal fracture. Staff interviews revealed that some aides and nurses did not consistently review care plans, and one LPN reported not recalling training on assessing residents for fall risk prior to the incident. A third resident with severe cognitive impairment and not assessed to self-administer medications was observed seated in a wheelchair at her bedside table with a medication cup containing multiple crushed medications mixed in pudding and a spoon left unattended in front of her. The Medication Administration Record showed that several oral medications, including antihypertensives, aspirin, vitamin D, stool softener, urinary tract infection prophylaxis, beta-blocker, and acetaminophen, were documented as given that morning by a medication aide. The medication aide stated the unattended cup was from the previous night and admitted she had not removed it when she entered earlier to administer the morning medications. Facility policies required medications to remain under direct observation during administration or be secured, and required staff to observe residents consuming medications, but the unattended medication cup at the bedside demonstrated a failure to follow these policies and to ensure medications were not left accessible or unmonitored.
Incorrect and Inconsistent Oxygen Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who had physician orders for continuous oxygen therapy. One resident was admitted with COPD, chronic respiratory failure with hypercapnia, and myocardial infarction, and had an order for oxygen at 4 LPM via nasal cannula every day and night shift. Another resident was admitted with diagnoses including atrial fibrillation, expressive language disorder, gout, and COPD, and had an order for oxygen at 3 LPM via nasal cannula every day and night shift. Facility policies stated oxygen was to be administered in accordance with physician orders and the prescribed flow rate was to be maintained. For the first resident, observation showed the oxygen concentrator was set at 4.5 LPM instead of the ordered 4.0 LPM. On another observation, the resident was not wearing the nasal cannula, the tubing was on the floor and out of reach, and staff did not return during the observation period to replace the oxygen. The resident stated staff had removed the oxygen during transfer from bed to chair and that he could not adjust the flow due to limited mobility. The resident’s care plan also listed oxygen at 5 LPM via nasal cannula. For the second resident, observation showed the oxygen concentrator was set at 2 LPM on one occasion and 3.5 LPM on another, both different from the ordered 3.0 LPM. The resident was observed wearing the nasal cannula during one observation. Interviews with the ADON/IP, DON, Administrator, and Medical Director confirmed staff were expected to follow physician orders for oxygen therapy and verify the concentrator was set at the prescribed liters per minute.
Incomplete dialysis assessment and communication documentation
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care/services for a resident who required hemodialysis three times weekly. Resident 38 was admitted with diagnoses including dependence on renal dialysis, type 2 diabetes mellitus, and metabolic encephalopathy. The resident’s care plan identified the need for hemodialysis related to renal failure and included a goal to avoid complications from dialysis. The facility’s policy stated that each resident’s care and services would include ongoing assessment and oversight before, during, and after treatments, with monitoring for complications and communication with the dialysis facility. Record review showed incomplete or missing pre- and post-dialysis documentation for multiple treatments in February 2026, including 02/04/2026, 02/05/2026, 02/16/2026, 02/23/2026, and 02/25/2026. The facility also did not provide ongoing assessment and monitoring documentation for January 2026 or March 2026. Several dialysis communication forms had blank sections, including missing vital sign details, meal information, facility nurse contact information, dialysis results, and other required entries. Some forms were prefilled with the nurse’s name and resident information, and staff stated the forms should be completed before the resident left the facility and should reflect the resident’s current condition at the time of transport. The record also included nursing notes and dialysis communication forms that showed incomplete information after dialysis, including missing documentation of the resident’s condition on return and missing dialysis treatment details from the dialysis facility. One form noted the resident should eat before leaving for dialysis because once the fistula was accessed, the resident could not move her right arm, and another noted the resident’s bandage needed to be removed before transport because it prevented access to the site. Interviews with an LPN, the ADON/IP, the DON, the Administrator, and the Medical Director confirmed the facility’s process required complete dialysis communication, review of the form on return, documentation of a nursing note after dialysis, and contact with the dialysis provider if information was missing.
Failure to Follow Safe Mechanical Lift Transfer Procedures Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow safe transfer techniques while using a mechanical lift to transfer a resident with significant physical and cognitive impairments. The resident, who had hemiplegia, hemiparesis, dementia, and was dependent in all self-care and mobility, required a mechanical lift with two staff for all transfers. During a transfer from bed to chair, two State Registered Nurse Aides (SRNAs) operated the lift, but did not extend the legs of the device as required for stability. One SRNA pulled on the lift pad to position the resident, causing the lift to become unbalanced and tilt. As a result of the improper use of the mechanical lift, the device's bar struck the resident on the back of the head, causing a laceration and hematoma. The resident required emergency medical attention, including staple closure of the wound and a CT scan to assess for further injury. Documentation and witness statements confirmed that the lift's legs were not extended due to the way the device was positioned under the chair, and that the staff involved did not follow established procedures for safe resident handling and transfer. The facility's investigation found that the incident was not due to equipment malfunction, as maintenance staff confirmed the lift was functioning properly. The incident was attributed to staff not adhering to the facility's policies and procedures for mechanical lift use, specifically the failure to extend the lift's legs and improper handling during the transfer. The staff involved were interviewed, and one was terminated for failure to use proper lifting techniques and non-compliance with training.
Failure to Immediately Notify Family of Resident Injury
Penalty
Summary
The facility failed to immediately notify a resident's representative when an injury was identified. The resident, who had chronic lymphocytic leukemia, chronic kidney disease, and severe cognitive impairment, was found to have significant bruising on her chest by a registered nurse. The nurse observed the bruise on the resident's chest, described its size and color, and noted that the resident often clasped her hands tightly against her chest, which was consistent with the location of the bruising. The Director of Nursing (DON) was notified of the bruising and conducted an assessment, determining that the bruising was likely due to the resident's own actions and her medical condition, which made her prone to bruising. The findings were discussed in a staff meeting, but the DON became ill and left work before a report was initiated. The facility's documentation indicated that the bruising was not reported to the resident's family until several days after it was first observed. The family was only informed after the bruise was already in the process of healing, and the delay in notification was confirmed by both the family and the facility's administrator. The administrator acknowledged that the family was upset about not being contacted promptly when the bruising was discovered. The deficiency centers on the facility's failure to immediately notify the resident's representative of the injury as required.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to establish or maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices involving both staff and residents. For one resident receiving oxygen therapy, the oxygen nasal cannula tubing was found to be in use well past the date it should have been changed, and the humidification water bottle was undated. Review of records confirmed that the tubing was not changed as scheduled, and interviews with staff and administration confirmed that both the tubing and bottle should be changed and dated weekly to prevent infection. During meal service, several State Registered Nurse Aides (SRNAs) were observed not performing hand hygiene between passing lunch trays to residents, and one aide touched a resident's food without gloves or hand hygiene. Staff interviews confirmed that hand hygiene should be performed between each tray delivery, and gloves should be worn when touching food. Additionally, two SRNAs were observed exiting a resident's room on droplet precautions with a used, uncleaned gait belt, which was then placed in a pocket without being disinfected. Staff interviews revealed inconsistent practices regarding cleaning gait belts between resident use, despite facility policy requiring disinfection after each use. Further deficiencies were observed during wound care, where an LPN failed to perform hand hygiene between glove changes and did not change gloves between treating different wound sites on a resident. The LPN acknowledged the lapse and cited the absence of hand sanitizer in the room as a contributing factor. In the laundry area, staff were observed handling soiled linens without wearing gowns, contrary to facility policy. Interviews with environmental and laundry supervisors indicated a lack of awareness of the policy requirements for personal protective equipment when handling dirty laundry.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two residents. For one resident with end stage renal disease, heart failure, and diabetes, the care plan did not include any interventions or monitoring instructions for a dialysis catheter, despite the presence of a port in the upper right chest. Observations revealed redness and dried blood at the catheter site, and staff interviews confirmed that the only action being taken was monitoring for infection, with no formal care plan in place for the catheter. For another resident with chronic respiratory failure, COPD, and heart failure, the care plan included an intervention for continuous oxygen therapy at a specified rate per physician's orders. However, observations on multiple occasions showed that the oxygen concentrator was set above the ordered rate. Staff interviews revealed that the resident often removed her oxygen or refused to use her bipap, and that hospitalizations frequently occurred due to exacerbations of her conditions. Staff acknowledged that the oxygen settings were not always checked against the care plan and physician's orders each shift, and that incorrect oxygen administration could lead to increased carbon dioxide levels and lethargy. The facility's own policies require comprehensive, person-centered care plans with measurable objectives and timeframes for all identified needs, as well as notification of staff when interventions are added or changed. Despite this, the care plans for these two residents did not address all assessed needs or ensure that interventions were consistently implemented as ordered.
Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident requiring continuous oxygen therapy. Observations revealed that the resident's oxygen concentrator was set above the physician-ordered rate on two separate occasions: once at 5 liters per minute and once at 4.5 liters per minute, while the physician's order specified continuous administration at 4 liters per minute via nasal cannula. The facility's policy required oxygen to be administered according to physician orders, except in emergencies, but there was no documentation of an emergency or a corresponding physician order change at the time of the observed discrepancies. The resident in question had a history of acute on chronic diastolic heart failure, chronic respiratory failure with hypercapnia, and COPD, and was assessed as needing continuous oxygen therapy. Interviews with staff indicated that the resident often removed her oxygen or refused to wear her bipap device, which was intended to help manage her carbon dioxide levels. Staff reported that they would reapply the oxygen and educate the resident, but also acknowledged that the oxygen concentrator was sometimes set above the ordered rate, which could contribute to increased carbon dioxide levels and subsequent hospitalizations for the resident. Further interviews with the medical director, DON, and administrator confirmed that staff were expected to check oxygen settings against physician orders at least each shift, and that deviations from the ordered rate could negatively impact residents with COPD. Despite these expectations, the observed discrepancies in oxygen administration were not addressed in a timely manner, and the resident experienced repeated hospitalizations related to improper oxygenation.
Repeat Deficiency in QAPI and Infection Control for Shared Equipment
Penalty
Summary
The facility failed to maintain an effective, comprehensive, and data-driven Quality Assurance Performance Improvement (QAPI) program, as evidenced by a repeat deficiency related to infection control practices. Specifically, during an observation, two State Registered Nurse Aides (SRNAs) provided care to a resident on droplet precautions and exited the room with a used, uncleaned gait belt placed in one SRNA's pocket. This occurred despite previous survey findings of similar issues with equipment not being cleaned between resident use and the facility's implementation of a plan of correction that included staff education and audits. Interviews with staff confirmed that gait belts were expected to be cleaned with disinfectant wipes after each use, and that proper cleaning and storage were necessary to prevent infection transmission. The Infection Prevention Nurse and DON acknowledged prior education and monitoring efforts, but the DON stated that audits of equipment cleaning and hand hygiene were no longer being performed. The Administrator reported that quality assurance meetings were held daily and that oversight of QAPI was maintained, but the repeat deficiency indicated that the QAPI process was not effective in sustaining compliance with infection control standards.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and handling of drugs, biologicals, and vaccines, leading to multiple deficiencies in medication management. Observations revealed that medications were improperly stored in three out of four medication storage rooms, affecting nine residents. Specifically, influenza vaccines were found stored in the door of medication refrigerators, contrary to CDC guidelines, which could compromise their efficacy. Additionally, the temperature of the Sterling Unit's medication refrigerator was not maintained within the recommended range, reaching 50 degrees Fahrenheit, which could affect the integrity of the stored medications. Further deficiencies were noted in the management of medication carts and storage rooms. Medications for a discharged resident were not removed from the cart as per facility policy, and medication carts were found unlocked and unattended in the Bluegrass Unit. Keys to medication storage areas were improperly stored in an unattended nurse's station, posing a risk of unauthorized access. The facility also failed to maintain proper documentation for controlled substances, as evidenced by unsigned verification sheets at shift changes. The facility's staff demonstrated a lack of awareness and adherence to professional standards for medication storage. Insulin pens and other medications were not stored in their original packaging, were undated, and were not discarded according to product instructions, increasing the risk of cross-contamination and reduced efficacy. Interviews with staff revealed gaps in knowledge regarding proper storage practices and the importance of maintaining medication efficacy and resident safety. The facility's policies on medication storage and handling were not consistently followed, contributing to the observed deficiencies.
Improper Food Storage and Lack of Temperature Monitoring
Penalty
Summary
The facility failed to store food under sanitary conditions in three of four nourishment unit refrigerators. Observations during the survey revealed that ice packs were stored in the freezer doors of the Sterling and Bluegrass Unit nourishment refrigerators. Additionally, the Lakeview Unit nourishment refrigerator lacked a thermometer and a temperature log for April 2024. The facility's policy required that temperatures be checked and logged at least twice per day, with thermometers placed inside each cooler/freezer and calibrated weekly. The policy also specified that refrigerator storage must be maintained at or below 41 degrees Fahrenheit, and frozen storage at or below -4 degrees Fahrenheit. Interviews with staff, including LPNs, the Director of Rehabilitation, the DON, and the Administrator, confirmed the importance of monitoring refrigerator temperatures and the potential for cross-contamination from storing ice packs with food items. The LPNs indicated that the therapy department had previously used ice packs for rehabilitation, but the Director of Rehabilitation clarified that therapy had not used ice packs in about two years. The DON and Administrator both acknowledged that ice packs should not be stored in the nourishment refrigerators, and there should be a thermometer and temperature log to ensure proper food storage conditions.
Lack of Restorative Nursing Program for Residents with Limited ROM
Penalty
Summary
The facility failed to provide appropriate treatment and services to residents with limited range of motion (ROM), as evidenced by the lack of a restorative nursing program (RNP) for three residents. The facility's policy on Restorative Nursing Programs outlined the need for maintenance and restorative services to maintain or improve residents' abilities, but the facility did not have an active RNP. Observations and interviews revealed that residents with ROM impairments were not receiving targeted interventions to address their limitations, and staff were not adequately trained or guided in providing restorative care. Resident 1 was observed in her room with functional limitations in both upper extremities, but was not receiving therapy or restorative care. Similarly, Resident 37 had limitations in one lower extremity and was unaware of any staff interventions to assist with her ROM. Resident 79 had impairments in both upper and lower extremities and was not receiving therapy due to insurance denials. Staff interviews indicated that ROM exercises were only performed during activities of daily living (ADLs), without specific guidance or a structured program. The facility's staffing records showed no restorative staff on duty, and interviews with various staff members, including the Director of Nursing and the Administrator, confirmed the absence of a restorative program. The facility had previously employed restorative aides, but the program had not been reinstated since the COVID-19 pandemic. The lack of a structured RNP and trained staff resulted in residents not receiving the necessary care to maintain or improve their ROM, leading to the identified deficiency.
Infection Control Deficiencies in Equipment Cleaning and Storage
Penalty
Summary
The facility failed to adhere to infection prevention and control practices, as evidenced by multiple observations of staff not following proper procedures for cleaning and disinfecting shared medical equipment. Specifically, staff did not clean the glucometer before and after use according to the manufacturer's instructions, and hand hygiene was not performed appropriately. This was observed with two residents, where the glucometer was placed on surfaces without barriers, and the required dwell time for disinfectant wipes was not followed. Additionally, staff failed to clean and disinfect a mechanical lift after use on two residents, storing it in a public area without proper sanitation. This oversight was acknowledged by the staff involved, who admitted to not following the correct procedures for cleaning shared equipment. Furthermore, the facility's clean linen storage room was found to have residents' supplies stored directly on the floor, and the portable vital sign machine was visibly dirty, indicating a lack of routine cleaning and maintenance. The facility also failed to dispose of expired disinfecting wipes, which were used for cleaning glucometers, and a medication was administered to a resident after it had come into contact with a contaminated surface. Interviews with staff, including the ADON/IP and the DON, revealed that while infection control training was provided, there were lapses in adherence to the facility's policies and CDC guidelines. The facility's leadership expressed expectations for staff to follow infection control protocols, but the observations indicated a need for improved compliance.
Failure to Resubmit PASARR for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to refer a resident for a level II pre-admission screening and resident review (PASARR) after the resident was diagnosed with a newly evident, serious mental illness. The resident, admitted on March 10, 2023, with diagnoses including metabolic encephalopathy, dementia with agitation, and anxiety disorder, was later diagnosed with unspecified psychosis on February 21, 2024. Despite this new diagnosis, the facility did not provide documented evidence of a new PASARR submission. The facility's policy required coordination with the PASARR program to ensure appropriate care for individuals with mental disorders, including prompt referral for a level II review following an inpatient psychiatric admission. The resident's care plan, initially addressing behavior problems such as yelling at other residents, was updated after an altercation with another resident. The resident had been assessed with severe cognitive impairment and was free of aggressive behavior during the look-back period. However, following a psychiatric hospitalization, the resident exhibited hallucinations, delusions, and other disruptive behaviors. The Social Services Director acknowledged the failure to resubmit PASARR information, stating it was not on her radar, while the Administrator expected resubmission following the resident's increased behaviors and psychiatric stay.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, leading to deficiencies in their care. For Resident 100, the care plan included specific interventions for gastric tube site care, as ordered by the physician. However, staff did not follow these orders, resulting in an infection at the site. Observations revealed that the staff did not apply the prescribed betadine and antibiotic ointment, and interviews indicated a lack of awareness of the specific orders among the staff. Resident 23's care plan included interventions to protect the resident's skin, such as keeping fingernails trimmed and using Geri-sleeves. Despite these interventions, observations showed that the resident had long fingernails with blood-like material underneath and was not wearing protective sleeves, leading to skin tears. Interviews with staff revealed that the interventions were not consistently implemented, and the administrator was unaware of the resident's skin-picking behavior. For Resident 11, the facility did not develop a care plan that included podiatry services, despite the resident's diabetes diagnosis, which necessitates professional foot care. Observations showed that the resident had long, untrimmed toenails, and interviews with the resident and their family indicated that a podiatry referral had been requested but not acted upon. The Director of Nursing confirmed the absence of a podiatry referral and acknowledged the potential complications of not providing professional foot care for diabetic residents.
Failure to Implement Care Plan for Resident with Skin Integrity Issues
Penalty
Summary
The facility failed to provide quality care according to the resident's plan of care for a resident with impaired skin integrity. The resident, who was severely cognitively impaired and had a history of skin picking, was observed with long fingernails and without protective Geri-sleeves, contrary to the care plan. The resident's care plan included interventions such as keeping fingernails short and using Geri-sleeves to protect the skin, but these were not consistently implemented. Observations revealed the resident picking at his skin, resulting in bleeding and scabbed-over skin tears, with long nails that had a bloody substance under them. Interviews with staff, including a nurse aide, LPN, unit manager, DON, and the administrator, revealed a lack of adherence to the care plan and communication lapses. The nurse aide acknowledged the resident's behavior and the need for nail care but failed to inform the night shift staff. The LPN and unit manager were aware of the resident's needs but did not ensure consistent implementation of the care plan. The DON and administrator were not familiar with the specific details of the resident's care plan or the skin-picking behavior, indicating a gap in oversight and communication within the facility.
Failure to Provide Podiatry Services for Diabetic Resident
Penalty
Summary
The facility failed to provide podiatry services for a resident, identified as R11, who was admitted with diagnoses including type 2 diabetes, essential hypertension, and atherosclerosis. The facility's policy required that residents with complicating disease processes be referred to qualified professionals for foot care, but no such referral was made for R11. Observations revealed that R11's toenails were long, untrimmed, and thick, and the resident reported experiencing pain when his toes touched the footboard of the bed. Despite a request from R11's daughter for podiatry services about a month prior, there was no record of a referral or podiatry services being provided since R11's admission. Interviews with facility staff, including the Social Worker, Director of Nursing, and the Administrator, confirmed the absence of a podiatry referral for R11. The Social Worker was unable to locate any referral for podiatry services, and the Director of Nursing acknowledged that with R11's diabetes diagnosis, professional podiatry care was necessary to prevent complications. The Administrator stated that the facility had an auxiliary service company for podiatry needs, but the process to set up appointments was not followed. The Primary Care Provider emphasized the importance of foot health, especially for diabetic residents, and noted that a podiatrist should evaluate any nail deformities.
Failure to Follow Physician's Orders for Gastric Tube Care
Penalty
Summary
The facility failed to prevent complications of enteral feeding for a resident, identified as R100, who was dependent on tube feedings. The resident was admitted with conditions including hemiplegia, dysphagia, and dysarthria, and had a severely impaired mental status. The facility's policy required interventions to prevent complications of enteral feedings, including cleaning the insertion site to prevent or resolve skin irritation and local infection. Despite this, a nurse failed to apply a bacterial ointment to R100's infected gastric tube insertion site as ordered by the physician. Observations revealed that the nurse cleaned the site with soap and water, rinsed it with sterile water, and applied a split gauze, but did not apply the prescribed betadine and antibiotic ointment. The physician had ordered specific care for the gastric tube site, including the application of Muciprocin ointment and oral antibiotics for infection control. However, the nurse was unaware of these specific orders. Interviews with the primary care physician, unit manager, director of nursing, and administrator revealed expectations for staff to follow physician's orders and facility policy, but there was no evidence of a root cause analysis being conducted for the infection. The director of nursing had not observed staff performing site care, and the administrator noted the lack of an interdisciplinary team investigation into the cause of the infection.
Failure to Document COVID-19 Vaccination Education and Status
Penalty
Summary
The facility failed to maintain proper documentation of COVID-19 vaccination education, offering, and status for two of three sampled staff members, specifically a Kentucky Medication Aide (KMA) and a Dietary Aide (DA). The review of the DA's employee file showed no evidence of receiving or being offered the COVID-19 vaccine, nor any documentation of education about the vaccine's benefits, risks, and potential side effects. The New Hire Checklist indicated that the DA refused all vaccinations, but there was no further documentation to support this. The DA was unavailable for an interview to provide additional information. Similarly, the KMA's file lacked documentation of vaccine education, although the KMA had requested a religious exemption. During an interview, the KMA confirmed not receiving education or an offer for the vaccine from the facility. The Infection Preventionist (IP) acknowledged incomplete vaccination records and emphasized the importance of educating staff and maintaining documentation. The Director of Nursing (DON) and the Administrator both highlighted the necessity of knowing staff vaccination status and maintaining proper documentation as part of the facility's infection control program.
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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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