Nhc Healthcare, Glasgow
Inspection history, citations, penalties and survey trends for this long-term care facility in Glasgow, Kentucky.
- Location
- 109 Homewood Boulevard, Glasgow, Kentucky 42141
- CMS Provider Number
- 185093
- Inspections on file
- 18
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Nhc Healthcare, Glasgow during CMS and state inspections, most recent first.
The facility failed to maintain complete and accurate medical records for multiple residents by not consistently documenting controlled substance administration on MARs in accordance with pharmacy policy. Pharmacy audits showed repeated instances where narcotic doses such as Norco, hydrocodone-APAP, and oxycodone were signed out or removed on narcotic records but had no corresponding MAR entries, and in one case, MAR documentation of oxycodone-acetaminophen administration conflicted with a negative urine opiate screen. Several residents with dementia, fractures, chronic pain, and other comorbidities were affected, including both cognitively intact and severely impaired individuals. Staff interviews confirmed that narcotics were expected to be documented on both the narcotic sheet and MAR, but the pharmacist reported ongoing concerns about poor documentation, while the staff educator and DON described uncertainty or lack of clear processes for MAR documentation training and chart audits, and the administrator stated she would have considered such inconsistencies to be medication errors.
The facility failed to maintain a safe, clean, comfortable, and homelike environment when handrails were removed and left with exposed metal wall anchors protruding from the hallway walls where residents used the walls for support. In addition, observations found stained ceiling tiles, an exposed cable wire, a partially disengaged ventilation screen, hoyer slings, medication carts, an unlocked rollator, and an obstructed crash cart in a dining area, while another dining area stored exercise equipment and a wheelchair scale where residents ate. The DON, Administrator, and other staff did not view several of these conditions as safety concerns.
A resident with dementia and a femur fracture, who took pills whole, was involved in an incident where an RN asked an LPN to witness wasting a spilled, crushed narcotic that did not match the resident’s usual medication form. The concern was reported internally to the DON and Administrator and later triggered an internal investigation after an anonymous hotline report and documentation that the RN had administered multiple doses of oxycodone-acetaminophen to the resident. Despite a facility policy requiring all alleged violations of abuse, neglect, misappropriation, or exploitation to be reported to the SSA, leadership, including a Regional Nurse, the DON, and the Administrator, determined the situation did not constitute misappropriation or abuse and did not report it to the SSA, limiting external reporting to the state nursing board.
The facility failed to timely report a suspected misappropriation of narcotic medication involving a cognitively impaired resident. A unit manager raised concerns to the DON after an RN asked an LPN to witness waste of a crushed narcotic, even though the resident reportedly took pills whole. An anonymous complaint was later made to the company hotline about the RN and narcotics, prompting an internal investigation. A regional nurse identified multiple documented doses of oxycodone-acetaminophen given to the resident over several days, and a drug screen ordered by the Medical Director was negative for opiates. Although the DON, ADON, Administrator, and regional staff were aware of these concerns, the allegation of misappropriation was not reported to the State Survey Agency within the required 24-hour timeframe.
The facility failed to thoroughly investigate an allegation of narcotic misappropriation involving a resident with dementia and a history of fracture and anxiety. A UM reported concerns about how a narcotic dose was wasted and noted that one RN appeared to be the only nurse administering the resident’s PRN oxycodone-acetaminophen. An anonymous Values Line complaint and a regional nurse’s review showed repeated narcotic administrations by the same RN over several days, and a pharmacist’s audit identified extensive wasting and frequent PRN use tied to one nurse and select residents. Despite these findings and facility policy requiring investigation of possible abuse or misappropriation, the facility did not conduct or document staff or resident interviews, did not perform a drug screen on the RN, and did not document required notifications to state agencies, resulting in a deficient investigation.
Two residents did not receive care in accordance with professional standards and facility expectations. For one resident with dementia and a femur fracture, an RN documented multiple administrations of oxycodone-acetaminophen on the MAR, but a subsequent urine opiate screen was negative, and the facility concluded the narcotic had not been given despite the documentation. For another resident with a gastrostomy, dysphagia, and prior traumatic brain injury, a CNA reported pausing the TF pump during repositioning, while the unit manager, DON, and LPNs indicated that only licensed nurses were authorized to manage the TF pump and that such tasks were outside CNA scope; the facility also could not produce a TF management policy.
The facility failed to operate an effective QAPI system that incorporated pharmacy and controlled substance issues into its quality review and performance improvement activities. Although the QAPI policy assigned the committee responsibility for ongoing systemwide quality improvement, the HIM Director reported that QAPI meetings focused on other topics and did not address controlled substances or known pharmacy issues identified over several months. The DON stated that medication concerns, including internal findings of extra narcotic sheets, were not brought to QAPI and that related checks were not documented. The Administrator acknowledged concern about wasted medications but stated the facility did not track them and that such issues were not presented to QAPI or the Medical Director. The Medical Director confirmed he had not been informed of prior pharmacy audit concerns and believed these discrepancies should have been addressed through QAPI.
Failure to Maintain Resident Dignity During Personal Care: A cognitively intact resident with multiple chronic conditions was left on her bed wearing only a brief after toileting/personal care, with her blanket off and no clothing on, according to the resident, her roommate, and a CNA. The resident said she was cold and upset by the incident, and staff interviews confirmed expectations to provide privacy, complete ADL assistance before leaving the room, and maintain resident dignity.
Failure to review advance directives during care planning: A resident with intact cognition and post-stroke diagnoses was not documented as having advance directives discussed at the quarterly care conference. The SSD, Admission Coordinator, DON, and Administrator each described admission-based discussion or uncertainty about follow-up, while the resident said he did not recall any advance directive discussion and wanted to appoint his brother as POA.
Improper Food Storage and Handling: Food service staff stored dented cans of apple pie filling and mushroom stems in active rotation, left dry goods open to air, and kept an undated hot chocolate container in the pantry. In the refrigerator, leftover tomato soup was left unsealed, door seals had dark discoloration, and flour and sugar bins were stored near a sink and exposed piping with visible droplets on the flour bin lid.
The facility did not deliver mail to residents on Saturdays, as required by their policy. A resident reported this issue during a Resident Council meeting, and it was confirmed by others. The Activities Director stated that mail was not distributed on Saturdays due to a lack of weekend staff. The Administrator acknowledged the lapse and confirmed the activities department's responsibility for mail delivery during weekdays.
The facility failed to comply with food safety standards, as food items were improperly stored and labeled, and dietary staff did not secure hair and beards as required. Observations revealed open, unlabeled, and undated food items in the refrigerator, and staff not wearing proper hair and beard restraints, contrary to facility policies.
Inaccurate and Incomplete Documentation of Controlled Substances on MARs and Narcotic Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records, specifically related to documentation of controlled substance administration on Medication Administration Records (MARs) and Accountability Records (ARs)/Controlled Substance Inventory Records (CSIRs). Facility pharmacy policies required that the individual administering a medication immediately document the dose on the MAR after administration and, for controlled substances, also record the date and time, amount administered, remaining quantity, and initials on the AR, completed after the medication was actually given. Pharmacy audits and record reviews showed repeated discrepancies where narcotic doses were signed out or removed on ARs/CSIRs but not documented as administered on the corresponding MARs, and in one case, MAR documentation of narcotic administration was inconsistent with a negative urine opiate screen. For one resident with Alzheimer’s disease, dementia, and Parkinson’s disease who was cognitively intact per a BIMS score of 14, the pharmacy’s PRN controlled substance audits showed multiple dates on which Norco 5-325 mg doses were documented as removed on the AR, but there was no corresponding documentation of administration on the MAR. These undocumented MAR entries occurred on several consecutive days, indicating that either the administration was not recorded as required or the medication was removed without proper MAR documentation. Another resident with osteomyelitis, Alzheimer’s disease, and dementia, assessed with severe cognitive impairment (BIMS score of 5), had numerous hydrocodone-APAP 5-325 mg doses documented as removed on the AR across multiple dates, yet none of these doses were documented on the corresponding MAR. A third resident admitted with a right femur fracture and additional diagnoses including dementia, hypertension, and anxiety disorder, and assessed with severe cognitive impairment (BIMS score of 6), had MAR entries showing oxycodone-acetaminophen 5-325 mg administered twice daily over several days. However, a urine opiate screen obtained during that period was negative, with a normal reference range of negative, indicating the resident had not received the narcotic pain medication as documented on the MAR for those days. For another resident with mild dementia, a displaced left femur fracture, Type 2 diabetes, and chronic pain, the CSIR for oxycodone 5 mg showed four doses removed during a specified period that were not documented as administered on the MAR. Additional review showed doses removed from stock that were documented on the MAR only later, sometimes hours after removal, and some removed doses were never documented as administered on the MAR. For a fifth resident with an unspecified displaced fracture of the right humerus, unspecified dementia, and hypertensive chronic kidney disease, and who was cognitively intact with a BIMS score of 14, the pharmacy’s PRN controlled substance audit showed multiple Norco 5 mg doses documented as removed on the AR on different dates without corresponding documentation on the MAR. Staff interviews confirmed that facility practice and expectation were that narcotic medications must be signed out on both the narc sheet (AR) and the MAR, and that discrepancies in narcotic counts should be reported to the ADON or DON. The pharmacist reported that PRN and periodic audits comparing narcotic sign-outs to MAR documentation revealed poor documentation, and that these concerns had been shared with the DON. The staff educator was unsure whether anyone specifically educated new hires on MAR documentation or whether chart audits were performed, and the DON acknowledged being made aware of documentation concerns by the pharmacist but stated she had not seen inconsistencies and that the pharmacist’s concerns were not brought to the QAPI committee. The administrator stated she was unaware of the pharmacist’s concern and would have considered inconsistencies between AR and MAR to be medication errors.
Unsafe and Unhomelike Environment in Hallways and Dining Areas
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when hallway handrails were removed for painting and left unreplaced, exposing metal wall anchors protruding about two inches from the wall at a height of about 33 inches. Observations showed residents using the hallway walls to propel wheelchairs and to balance while walking in the same area where the anchors were exposed. The maintenance staff person stated he would reinstall the handrail after the surveyor pointed out the exposed anchors, but he did not see how they would be harmful. The DON and Administrator both stated they did not view the exposed anchors as a safety issue and compared them to door handles. The dining and lounge areas also contained multiple environmental issues. In station 2, observations revealed discolored ceiling tiles with stains, handprints, and fingerprints, an exposed cable wire suspended from the ceiling to the lower outer wall, a ventilation screen door not fully engaged into the ceiling, hoyer sling pads hung against the wall, medication carts left in the dining room, and an unlocked rollator walker left in the dining area. A crash cart was later observed obstructed by equipment and not easily accessible in the event of a medical emergency. Staff stated the cable wire, ventilation cover, and storage of items in the dining area were known conditions, and the LPN said the medication carts were usually stored there and the hoyer slings and wheelchairs had always been stored there. In station 4 restorative dining, observations over several days showed two exercise machines, cornhole gaming activity, and a wheelchair scale stored along the perimeter of the dining room while residents ate there. The Unit Manager acknowledged the exercise machines could be stored elsewhere, and the wheelchair scale was used by only one resident. The DON stated she had no concerns with the exposed wall mounts or the exercise equipment in the dining area, though she expected crash carts to be easily accessible. The Administrator stated daily rounds and maintenance logbooks were used to monitor the environment and said she did not see harm in the exposed wall mounts or the stored equipment.
Failure to Report Alleged Narcotic Diversion to State Survey Agency
Penalty
Summary
The facility failed to implement its written policy to ensure abuse allegations were reported to the State Survey Agency (SSA) as required by Federal and State law for one resident. The facility’s policy, revised 02/01/2023, required that any patient event reported be considered an allegation of abuse, neglect, misappropriation of property, or exploitation, and that all alleged violations be reported immediately, or within 24 hours if not involving abuse with serious bodily injury, to the Administrator. The policy further required that all alleged violations be reported to other officials, including the SSA, in accordance with State law and Federal regulations. Despite this, the incident involving a concern about possible narcotic diversion for one resident was not reported to the SSA. The resident involved was admitted with a fracture of the head of the right femur, dementia, and anxiety disorder, and had a BIMS score of 6/15, indicating severe cognitive impairment. On 11/04/2025, the Station 3 Unit Manager reported to the DON a concern that an RN had wasted a narcotic medication for this resident, witnessed by an LPN, in a manner inconsistent with the resident’s known practice of taking pills whole; the wasted medication was described as a spilled crushed medication. The DON notified the Administrator of the concern on 11/05/2025. On 11/10/2025, the DON was informed by a Regional Nurse that an anonymous call had been made to the company’s Values Line regarding the RN and narcotics, prompting an internal investigation involving the DON, ADON, RN, and Administrator. Further review showed that on three consecutive days later in November, the RN documented administering six doses of the resident’s oxycodone-acetaminophen 5-325 mg, leading to notification of the Medical Director and an order for a drug screen for the resident. Interviews revealed that Regional Nurse 1 considered reporting to be “extremely situational” and stated that the incident did not meet misappropriation criteria and therefore was not reported to the SSA, though it was reported to the state nursing board. The DON stated she believed the situation had been handled correctly and did not view the concern as a reasonable suspicion until a negative drug screen result was obtained, characterizing it as one nurse complaining about another. The Administrator stated she believed there had been no abuse and that the only required reporting was to the nursing board, demonstrating that the facility did not follow its own policy requiring reporting of all alleged violations to the SSA.
Failure to Timely Report Suspected Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to report a suspected misappropriation of a resident’s narcotic medication to the State Survey Agency within 24 hours as required by its own policy and federal and state regulations. The facility’s policy defined any event reported by a resident as an allegation of abuse, neglect, misappropriation of property, or exploitation, and specified that misappropriation included the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent. The policy further required that all alleged violations involving misappropriation of resident property be reported immediately, or no later than 24 hours, to the Administrator and to other officials, including the State Survey Agency, and that investigative files be maintained as working documents of the Quality Improvement Committee. Despite these requirements, the facility did not report the allegation involving suspected diversion of narcotic medication for one resident to the State Survey Agency within the required timeframe. The resident involved was admitted with anxiety disorder, a right femur head fracture, and dementia, and had a BIMS score of 6/15, indicating severe cognitive impairment. An internal handwritten investigation document showed that on 11/04/2025 the Station 3 Unit Manager reported to the DON a concern about wasting a narcotic medication for this resident: the waste was witnessed by an LPN and an RN, but the concern was that the resident took pills whole while the waste presented for witnessing was a spilled crushed medication. On 11/05/2025 the DON informed the Administrator, and on 11/10/2025 an anonymous call was made to the company’s Values Line about the concern. A regional nurse later notified the DON that an anonymous Values Line call had been received regarding the RN and narcotics, prompting an internal investigation. Documentation from a regional nurse showed that over three days the RN documented administering six doses of oxycodone-acetaminophen to the resident, and a drug screen ordered by the Medical Director for the resident was negative for opiates. These events were known to the DON, ADON, Administrator, and others, but there is no indication that the suspected misappropriation was reported to the State Survey Agency within 24 hours as required.
Failure to Thoroughly Investigate Alleged Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation and possible diversion of narcotic medications for one resident. Facility policy required that all events reported as possible abuse, neglect, or misappropriation of resident property be investigated, and when in doubt, an investigation should be conducted. The resident involved had been admitted with a right femur head fracture, anxiety disorder, and dementia, and was assessed as having severely impaired cognition with a Brief Interview for Mental Status score of 6 out of 15. An initial concern arose when the Station 3 Unit Manager reported to the DON that a nurse had requested a witness for wasting a crushed medication for this resident, even though the resident took pills whole, and the Unit Manager also noted that one nurse appeared to be the only one administering the resident’s narcotic pain medication. Subsequently, an anonymous call was made to the company’s Values Line regarding concerns about a specific RN and narcotics, which was relayed to the DON and regional nursing staff. Documentation from a regional nurse showed that on three consecutive days, the same RN documented administering multiple doses of the resident’s PRN oxycodone-acetaminophen. The Medical Director was notified and an order for a drug screen for the resident was obtained. The Pharmacist, at the DON’s request, audited narcotic sheets on the cart and identified a pattern of significant wasting and frequent PRN use involving one particular nurse and select residents, and she reported these concerns to the DON. Despite these concerns and the facility’s own policy, the facility’s investigation was limited and lacked key components. The Administrator stated that the facility viewed the initial concern as a matter between employees and did not want to accuse someone without proof, and that review of MARs, narcotic sheets, and additional rounding had not raised red flags in their view. No staff interviews were conducted, and there was no documented evidence that residents were interviewed as part of the investigation. The Administrator also stated that a drug screen was not conducted on the implicated RN, and the facility’s documentation did not show that all required state agencies were notified. The survey found no documented evidence that a thorough investigation, consistent with policy and reporting requirements, was performed in response to the suspicion of narcotic misappropriation for this resident.
Failure to Administer Ordered Narcotic and Improper Delegation of Tube Feeding Management
Penalty
Summary
The facility failed to ensure that one resident received ordered narcotic pain medication as documented, and that another resident’s tube feeding (TF) was managed only by qualified staff, in accordance with professional standards and facility policy. For one resident with dementia, a right femur head fracture, and anxiety disorder, the MAR showed that a schedule II narcotic (oxycodone-acetaminophen 5-325 mg) was documented as administered six times over three consecutive days by the same RN. Facility pharmacy policy required medications to be administered as prescribed, documented immediately after administration on the MAR, and the MAR reviewed at the end of each pass to ensure doses were given and recorded. However, a urine opiate screen performed shortly after these documented administrations was negative for opiates, and facility documentation concluded that the resident had no oxycodone in her system despite the RN’s MAR entries indicating administration. The lab technician confirmed the test was sensitive for synthetic opiates, including oxycodone, and stated that if the medication had been given as documented, the test would have been positive. The Medical Director, when informed of the negative drug screen, concluded the resident had not received the narcotic medication as ordered. The facility also failed to ensure that TF management for another resident was performed only by licensed nurses, consistent with standards of practice and regulatory requirements. The facility could not produce a policy related to staff responsible for TF management despite multiple requests. Job descriptions for RNs and LPNs required integration of current standards of practice and applicable regulations into resident care, and state regulations specified that delegation of nursing tasks must fall within sound nursing judgment. The resident involved had a gastrostomy, dysphagia, abnormal weight loss, and a history of traumatic brain compression with bilateral craniotomy and revision, and was assessed as unable to complete a BIMS interview. A CNA reported that this resident was mostly in bed, that she turned the resident every two hours, and that she paused the TF pump when getting the resident up and down. One LPN stated she knew CNAs paused the TF pump but was unsure if this was within their scope of practice, while another LPN stated pausing TF was not within CNA scope. The unit manager reported that licensed nurses were responsible for managing the TF pump and that no caregivers other than nurses were authorized to touch the pump; CNAs were expected to get a nurse if the pump needed to be paused for repositioning. The DON stated that licensed nurses were responsible for controlling the TF pump, that pausing and restarting the pump was outside CNA scope, and that CNAs should notify a nurse if repositioning was needed. The Administrator stated her expectation that CNAs act within their scope of practice.
Failure to Integrate Pharmacy and Controlled Substance Issues into QAPI
Penalty
Summary
The facility failed to develop, implement, and maintain an effective, comprehensive QAPI system that addressed adverse events and pharmacy-related issues, including controlled substances and wasted medications. The facility’s QAPI policy stated that the QAPI committee was responsible for implementing and maintaining an ongoing systemwide process of quality improvement. However, the Director of Health Information Management (HIM) reported that although the QAPI committee met monthly and had recently held an emergency meeting related to a resident fall, she did not recall controlled substances being discussed in QAPI and was not aware of pharmacy issues identified in October and November 2025 and January 2026. She stated the current performance improvement plan focused on Medicare certification and inventory sheets, not on the pharmacy concerns cited by surveyors. The DON stated that medication concerns were never brought to QAPI meetings and that an internal audit involving extra narcotic sheets had been a concern, but those checks were not documented. She indicated that topics typically brought to QAPI included mealtime delivery, falls, and pressure ulcers, and that medication issues would only be sent to QAPI if not addressed by nursing. The Administrator acknowledged that wasted medication was a concern but stated the facility did not track wasted medications and that wasted medication issues, which she believed should have been brought to QAPI and to the Medical Director, were not addressed there. She described medication errors as wrong medications given or controlled substances pulled and not documented in the eMAR. The Medical Director reported he had not been informed of pharmacy audit concerns from October and November 2025 and stated he would want to know about discrepancies affecting his residents and believed such issues should be brought to QAPI to determine root causes and corrective actions.
Failure to Maintain Resident Dignity During Personal Care
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity and provided care in a manner and environment that promoted maintenance or enhancement of quality of life. The resident was admitted with diagnoses including atherosclerotic heart disease, lymphedema, anxiety disorder, and a history of venous thrombosis and embolism, and had a BIMS score of 15 out of 15, indicating she was cognitively intact. She reported that about two weeks before the interview, a CNA left her lying on her bed in her room and did not return to assist her with getting dressed, leaving her wearing only a brief. She stated she was very cold and did not like being left that way, and later that evening another CNA assisted her into night clothes and provided a blanket. The resident’s roommate stated she had awakened and seen a male walking out of the room and observed the resident lying on her bed without clothing, believing she had been naked. A CNA who worked the resident’s hall stated she had seen the resident lying on her bed wearing only a brief with her blanket on the floor and reported it to an LPN. Other staff stated the resident preferred to sleep in a brief and gown or t-shirt, but the DON stated staff were expected to meet all of a resident’s needs before leaving the room after assisting with ADLs, and the Administrator stated staff were expected to provide adequate privacy and maintain dignity in all circumstances.
Failure to Review Advance Directives During Care Planning
Penalty
Summary
The facility failed to inform and provide written information to all residents about the right to formulate an advance directive for one sampled resident, R113. The facility policy stated the interdisciplinary care planning team was to review advance directives with residents during quarterly care planning sessions to determine whether any changes were desired, but the 02/09/2026 quarterly care conference for R113 had no documentation that advance directives were discussed. R113 was admitted with diagnoses of hemiplegia and hemiparesis after a cerebral infarction on the left non-dominant side, and the 01/20/2026 quarterly MDS assessment showed a BIMS score of 15/15, indicating intact cognition. During interviews, the SSD stated advance directives were addressed on admission but was unsure about follow-up timing or documentation for R113 during quarterly care planning. The Admission Coordinator stated admission paperwork asked about advance directives, but she was unsure of follow-up procedures; if residents or families had questions, they were given state legal aid contact information, and advance directive documents were attached to the medical chart if provided. R113 stated he did not remember the facility addressing advance directives on admission or afterward, and he said his brother knew his preferences and he wanted to appoint him as his POA. The DON stated Social Services staff had not initially understood advance directives and she was unfamiliar with when directives were to be revisited, and the Administrator stated advance directives were reviewed at admission but had not been discussed in care planning meetings she attended.
Improper Food Storage and Handling
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety. Review of facility policy showed opened food items were to be securely closed, dented or damaged cans were to be removed from use and handled separately, non-TCS foods were to be stored in clean, dry locations away from contamination, and leftover foods were to be covered, labeled, dated, and stored properly. During the initial kitchen tour, the dry pantry contained five dented 120-ounce cans of apple pie filling and two dented 120-ounce cans of mushroom stems and pieces still in active rotation for resident use. The same area also had graham cracker crumbs stored in an open box with flaps and inner plastic packaging unsealed, and an opened, undated 97-ounce cannister of hot chocolate. Additional kitchen observations found a large unsealed container of leftover tomato soup exposed to air in the 3-door refrigerator. The refrigerator door seals had a dark-colored substance in multiple areas, and the Food Service Director stated she knew about the discoloration but had not reported it for replacement. Two large storage bins labeled flour and sugar were located between the refrigerator and a staff-accessible sink, beneath exposed pipes, and the flour bin had dried liquid droplets on the lid near the opening. The Food Service Director stated she was not aware the storage location was a concern until the soiled top was observed, and the Administrator stated dented cans were not to be served, food items were to be stored in appropriate sealed containers, and anything possibly contaminated was to be discarded.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure that all residents had the right to send and receive mail on Saturdays, as required by their policy. The policy, revised on 09/01/2014, stated that mail should be distributed to residents within 24 hours of delivery by the postal service. However, during a Resident Council meeting, a resident reported that mail was not delivered on Saturdays, and this was confirmed by other residents. The Activities Director acknowledged that mail was not distributed on Saturdays due to a lack of weekend staff in the activities department. The Administrator was aware of the issue and confirmed that the activities department was responsible for mail delivery from Monday to Friday, but there was a lapse in service on Saturdays.
Non-compliance with Food Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Food items in the three-door refrigerator were found open to air, not labeled, and undated, contrary to the facility's policy which requires food to be stored in original or approved containers, wrapped tightly, and clearly labeled with contents and use-by dates. Specific instances included an open box of hot dogs, a container of sliced raw carrots with an expired use-by date, and a container of sliced pineapple that exceeded the seven-day storage period. Additionally, a mislabeled container of vegetable soup and undated containers of oatmeal and gravy were found. The Food Service Manager acknowledged these discrepancies during the survey. Further observations revealed that dietary staff did not properly secure their hair and beards, as required by the facility's hygienic and safety practices policy. A cook was seen with a hair restraint that did not fully cover her hair, and an assistant cook was observed without a beard guard while handling food. Interviews with the Food Service Manager, Dietary Aide, Director of Nursing, and Administrator confirmed the expectation for staff to adhere to these policies to prevent food contamination. However, the observed practices did not align with these expectations, indicating a lapse in compliance with food safety standards.
Latest citations in Kentucky
The facility failed to maintain an effective pest control and sanitation program, resulting in a widespread gnat infestation in common areas, resident halls, the laundry room, medication cart trash, dirty utility room, and the kitchen. Surveyors observed gnats emerging from drains, stagnant mop water with a rancid odor, and extensive moisture, standing water, and organic debris in kitchen drains, cracked floor tiles, and hard-to-reach areas behind equipment. Pest control service reports over several months repeatedly documented unresolved issues such as drain debris, standing water, and debris accumulation, while the pest control provider stated that facility compliance with recommended cleaning and maintenance was inconsistent and many action items remained undone. The Dietary Manager reported ongoing gnat problems and use of a hose-mounted floor sprayer and vinegar in drains, which the pest control representative stated would not remove organic buildup or larvae. Leadership, including the VPO, DON, and Administrator, described expectations for cleaning, pest reporting, and drain use that were not reflected in observed conditions, and two residents reported that gnats were frequently present around them and their food, especially during meals.
A resident with morbid obesity and bilateral foot drop, whose care plan called for two staff for bed mobility and incontinence care, slid off the edge of the bed during perineal care and sustained abrasions and skin discoloration. The resident stated an SRNA rolled them too far while the SRNA was on the opposite side of the bed, and staff interviews confirmed the SRNA performed the care alone instead of waiting for another staff member. The ADON and DON stated the resident should have had two staff assist with the care.
An LPN was observed administering insulin via a pen injector to a resident with diabetes without priming the needle before either dose. The resident had type 2 DM with hyperglycemia and active NovoLog FlexPen orders, but the facility’s competency assessment covered insulin by syringe and did not show training or assessment for insulin pen use. The LPN stated she was not aware priming was required, and the DON and Administrator confirmed the facility had not provided competency training on insulin pens.
A resident admitted for rehab with muscle weakness and unsteadiness had PT and OT care plans and orders for treatment five times per week, but therapy logs showed missed PT/OT sessions on two days with no documented reason. The Director of Rehabilitation confirmed the resident received therapy only three of five days over two consecutive weeks, contrary to the plan of care, and could not explain or document why sessions were missed. The resident and the resident’s representative reported that the resident did not receive therapy as expected, that therapy minutes were insufficient, and that services were not tailored to the resident’s needs, including use of group therapy despite the resident’s stated preference against it.
The facility failed to maintain a safe, clean, and sanitary laundry environment and to properly manage a resident’s clothing. A resident with COPD, heart failure, type 2 DM, and ESRD had most of their clothing lost during a short stay, and the family member who searched for the items described the laundry room as extremely hot, messy, dirty, with clothes everywhere and overflowing trash. Staff interviews confirmed the laundry room had long‑standing issues with excessive heat and clutter. Surveyor observations found floors between and behind washers covered with dirt, a dry flaky substance, loose concrete, and residue on piping and chemical tubing, alongside buckets of corrosive chemicals. Interviews with housekeeping, EVS, a chemical vendor, and maintenance showed that a chemical spill behind the washers had occurred over a year earlier and was never properly cleaned up, with conflicting accounts over whether maintenance or EVS was responsible and no effective system to ensure cleaning behind the machines.
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident with mild cognitive impairment and multiple medical conditions was reported by the resident’s family member. The Administrator was notified of the allegation that someone had smacked the resident across the face, but the initial report to the state survey agency was not submitted until more than three and a half hours later, exceeding the required two-hour timeframe. Facility documentation did not show that law enforcement was notified, despite policy requiring reporting of suspected crimes, and interviews with the SSD, DON, and Administrator confirmed that the expected practice was to report such allegations promptly to the state survey agency and law enforcement when applicable.
Two residents reported serious allegations—one of missing money and identification and another of being slapped by a staff member—but the facility failed to conduct comprehensive investigations as required by its abuse policy. In the misappropriation case, a cognitively intact resident named a specific staff member by first name, and the schedule showed an SRNA with that name worked during the alleged timeframe, yet that SRNA was never interviewed or asked for a statement, and the DON acknowledged not knowing the investigative process. In the physical abuse case, a resident with mild cognitive impairment reported being slapped and told a family member that a manager over the office was responsible, but the facility obtained statements only from some floor staff, did not interview office staff, did not obtain statements from all staff who worked the relevant shifts, and limited resident interviews and skin assessments to one hall. These actions and omissions resulted in incomplete investigations of both abuse-related allegations.
A resident with dementia, osteoporosis, a right artificial hip, and severe cognitive impairment was care planned as dependent for bed mobility, toileting, and transfers, with an intervention requiring two staff for assistance. Despite this, an SRNA, who knew the resident was a two-person assist, began perineal care alone and rolled the resident onto the side, causing the resident to roll out of bed and fall. An LPN obtained stat x-rays that showed a displaced right femoral shaft fracture, and the resident was sent to the hospital, where surgery was performed and the resident later died on a hospice unit. Staff interviews confirmed that the two-person assist requirement had been in place for years and that the failure to follow the care plan led to the incident.
A resident with dementia, osteoporosis, and a right artificial hip joint, assessed as severely cognitively impaired and dependent for bed mobility, toileting, and transfers, had a care plan and Kardex requiring a two-person assist for these ADLs. An SRNA, despite knowing this requirement, began perineal care alone and rolled the resident onto her side, causing the resident to roll out of bed onto the floor. The incident report and IDT identified the root cause as failure to follow the Kardex, with contributing factors including the resident’s weakness and history of falls. An LPN and unit manager found the resident on the floor, obtained stat x-rays that revealed a displaced right femoral shaft fracture, and the resident was sent to the hospital, where imaging confirmed a comminuted, moderately displaced femoral fracture and an ORIF procedure was performed. Staff interviews confirmed that the resident had long required a two-person assist and that only one staff member was present at the time of the incident, and also revealed that nurses and managers had not routinely spot checked SRNAs for adherence to the care plan/Kardex prior to the event.
A resident with intact cognition and multiple comorbidities developed fever and abnormal urinalysis results consistent with a UTI, for which an NP ordered a single 3 g dose of Fosfomycin. The MAR showed the antibiotic order and later an entry placing it on hold due to unavailability from pharmacy, without a corresponding provider order or documentation explaining the delay or who was contacted. The medication was not administered until four days after the original order, during which time the resident reported going without treatment and later required ED transfer, where a complicated UTI was diagnosed and treated with IM Rocephin and Toradol.
Failure to Maintain Effective Pest Control and Sanitary Conditions Resulting in Widespread Gnat Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free of insects and other pests, resulting in a widespread gnat infestation throughout the building. Surveyor observations over two days identified gnats in multiple common areas, including the conference room, resident halls, laundry room, medication cart trash can, and dirty utility room. In the laundry room, gnats were seen emerging from the washing machine discharge drain, and in the dirty utility room, gnats were concentrated around a mop bucket containing stagnant, foul-smelling water. On a resident hall, multiple gnats were observed flying around residents and on surfaces throughout the corridor. Extensive observations in the kitchen revealed multiple environmental and sanitation issues that contributed to the gnat activity. Behind and around the ice machine and juice cart, there was wet dust, dirt, and organic debris such as food crumbs, sugar packets, and trash items, all saturated with moisture. Cracked, loose, and broken floor tiles near the ice machine drain and in the dish room contained food debris lodged within and beneath the damaged tiles, with standing water collected beneath the tiles and pooled around the ice machine drain. Standing water was also observed in the spray room, dish room, along walls, and in corners, with water spread across the kitchen floor after staff used a hose-mounted sprayer to clean the floors. On a subsequent day, the kitchen floor again had visible standing water, and a floor drain contained accumulated debris, paper fragments, and organic material, with a broken drain grate that did not fully cover the drain and exposed additional trapped debris; gnats were present in and near this drain and throughout the kitchen. Review of facility work orders showed only one report of gnats in common areas and nursing units for one month and one report of bugs facility-wide in the following month, despite the widespread activity observed. Service reports from the contracted pest control company over several months documented ongoing, unresolved environmental concerns in the kitchen and adjacent areas, including repeated findings of drain debris, standing water in kitchen and dishwashing areas, debris accumulation, and moisture issues that remained uncorrected by the facility. The pest control representative and pest control account manager both stated that gnats were originating from drains, cracks, and crevices with organic debris and moisture, and that routine cleaning practices were ineffective when debris remained or was pushed into cracks and around drains. They reported that recommendations such as debris removal, proper drain maintenance, and cleaning of hard-to-reach areas were repeatedly communicated and documented, but the facility’s compliance with these recommendations was inconsistent, with many action items left undone and carried over on subsequent service reports. Interviews with staff and leadership further described the facility’s actions and inactions related to pest control and sanitation. The Dietary Manager reported ongoing gnat concerns for multiple weeks, stated that pest control services were provided twice monthly, and that kitchen staff performed routine cleaning weekly and as needed, using a hose-mounted spray system for floors and pouring vinegar down drains between pest control visits. The pest control representative stated that pouring vinegar down drains would not eliminate the infestation and might attract gnats, as it did not remove organic buildup or kill larvae. The pest control account manager identified contributing factors such as debris buildup in cracks and flooring, lack of routine cleaning behind equipment, standing water or improperly maintained mop buckets, inconsistent cleaning practices in non-visible areas, and lack of routine maintenance of drains and traps, and noted that environmental cleaning often improved only after issues became more apparent. The VPO acknowledged gnat activity throughout the building and that pest control reports had identified ongoing debris concerns in the kitchen, but could not clearly describe a process to ensure consistent cleaning of hard-to-reach areas or to verify cleaning effectiveness. The DON and Administrator described expectations for reporting pests, emptying mop buckets, removing trash from medication carts, removing debris before floor cleaning, and not sweeping debris into drains, but these expectations were not reflected in the observed conditions. Two cognitively impaired and intact residents reported that gnats were always present, especially around meal times and food, and that they found them bothersome and undesirable during meals.
Failure to Provide Two-Person Assistance During Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance to prevent a fall for one resident who had diagnoses of morbid obesity, left foot drop, and right foot drop. The resident’s care plan identified a need for two staff members for bed mobility and in-bed care related to bariatric status, and also directed staff to provide two-person assistance for bed mobility and total assistance for incontinence care as the resident allowed. The resident’s MDS indicated intact cognition and that the resident required supervision or touching assistance for rolling left and right in bed. During incontinence care, the resident slid off the edge of the bed to the floor and onto their knees. The acute change in condition assessment documented abrasions and skin discoloration after the incident. In interviews, the resident stated that a staff member rolled them out of bed during incontinence care and that they were able to assist with rolling by using the assist bars on either side of the bed. The resident stated that while rolling to the right side of the bed, they rolled too far and slid off the edge of the bed while the SRNA was standing on the opposite side of the bed. Staff interviews showed that the SRNA provided the incontinence care by herself even though the resident required two-person assistance. The SRNA stated she did not ask another staff member for help because she was used to performing the care alone, and later stated that having another SRNA in the room could have prevented the incident. Other staff, including the ADON and DON, stated the resident should have had two staff members assist with incontinence care. The DON also stated the resident could assist with turning using the bed rails, but the SRNA should have used another staff member and waited for assistance.
Insulin Pen Competency Not Demonstrated
Penalty
Summary
Licensed nursing staff were not shown to have the competencies and skill set necessary to administer insulin via an insulin injector pen for one LPN observed caring for a resident with diabetes. Review of the LPN’s competency assessment showed the DON assessed insulin administration by syringe, but it did not indicate assessment of insulin pen injector use, even though the competency document stated staff should have access to manufacturer instructions for all insulin delivery systems before use. The manufacturer’s instructions for NovoLog FlexPen required priming the pen before injection to avoid injecting air and ensure proper dosing. The resident involved was admitted with a diagnosis of type 2 diabetes mellitus with hyperglycemia and had active orders for NovoLog FlexPen, including a sliding scale order and a separate order for 16 units before meals. During observed medication administration, the LPN checked the resident’s blood glucose, which was 409, then administered 16 units of NovoLog FlexPen without priming the pen needle. After contacting the physician, the LPN later returned and administered 10 units from the sliding scale order, again without priming the insulin needle. The LPN stated she was not aware the pen needle needed to be primed and was unsure whether she had education on insulin pen injectors. The DON stated competency training covered insulin administration by syringe but not insulin pen injectors, and the Administrator stated the facility had not provided competency training related to insulin pens.
Failure to Provide Ordered PT/OT and Document Missed Therapy Sessions
Penalty
Summary
The facility failed to provide specialized rehabilitative services as ordered for one resident admitted for rehabilitation with diagnoses of muscle weakness and unsteadiness on feet. The resident’s care plan, initiated shortly after admission, identified a rehabilitation focus with skilled PT and OT interventions, and physician orders specified PT and OT to evaluate and treat. The OT plan of care called for treatment five times per week for 60 days, and the PT plan of care called for treatment five times per week for 30 days. Review of the Service Log Matrix showed that the resident did not receive individual PT or OT on two specified dates, despite the plan of care requiring therapy five days per week. The Director of Rehabilitation confirmed that the resident missed PT/OT on those two dates, that the plan of care was for five days a week, and that the resident only received PT/OT three out of five days for two consecutive weeks. The resident and the resident’s representative reported concerns that the resident was not receiving the allotted amount of therapy time and that therapy was not tailored to the resident’s specific needs. The representative stated the resident was weaker upon discharge than at admission and that the family sought transfer to another facility for PT after expressing concerns without improvement. The resident reported not receiving any PT during the first week, receiving PT only after questioning staff, and that when PT was provided it lasted 30–40 minutes and included group therapy that was counted as PT despite the resident’s preference against group therapy. The Director of Rehabilitation stated she did not know why therapy was missed on the two identified dates and that no reasons were documented, although such reasons were typically recorded. The DON stated her understanding that if therapy was missed, staff should attempt to reschedule so that residents did not miss needed therapy, and the current Administrator stated her expectation that residents receive the therapy they are supposed to receive to reach their maximum potential.
Failure to Maintain Clean, Safe Laundry Environment and Proper Handling of Resident Clothing
Penalty
Summary
The facility failed to ensure a safe, clean, sanitary, and comfortable environment in the laundry area as required by its Safe and Homelike Environment and Resident Rights policies. The policies stated that the physical layout should not pose a safety risk and that a sanitary environment must be maintained, including proper cleaning and storage of resident care equipment and items used for activities of daily living. Despite these policies, observations on 04/17/2026 showed the floor between and behind the washing machines covered and caked with dirt, a dry flaky substance, loose concrete, and residue on piping and chemical tubing, while multiple buckets of corrosive laundry chemicals and detergents were present in the same area. A resident’s family member reported that during the resident’s four‑day stay, most of the resident’s clothing was lost, and when she was allowed into the laundry room to search for the items, she found the room extremely hot, messy, with clothes everywhere, dirty conditions, and overflowing trash. The resident involved had significant medical diagnoses including COPD, acute on chronic systolic heart failure, type 2 diabetes mellitus, and end‑stage renal disease. A SRNA corroborated that the laundry room had always been hot, especially in summer, and that the room had long been somewhat messy with clothes, worsening over the past couple of years. Interviews with housekeeping, environmental services, the chemical supplier, and maintenance staff revealed that a chemical spill behind the washing machines had occurred well over a year earlier when ports at the back of the machines became clogged, causing chemicals to leak onto the floor. The chemical representative stated he cleaned the ports and moved tubing, and an EVS staff member told him maintenance would clean up the spill, but it was never done. Housekeeping reported that maintenance told them to clean up the spill themselves, while the Maintenance Director stated that EVS was responsible for cleaning the washing machines and that he had not observed leaks during his tenure. The dried, flaky substance and damaged concrete remained in place until it was later cleaned and repaired, and there was no documented system in place to ensure regular cleaning behind the washers, despite the presence of paper checklists for other tasks such as lint trap cleaning.
Failure to Timely Report Alleged Physical Abuse to State Agency and Law Enforcement
Penalty
Summary
The facility failed to report an allegation of physical abuse to the state survey agency and law enforcement within the required two-hour timeframe. Facility policy titled “Abuse Prohibition Standard of Practice,” last reviewed 03/2026, required that alleged violations be reported immediately to the Administrator or designee and to the state survey agency, adult protective services, and other required agencies, including law enforcement when applicable, within specific time frames. The policy also required the Administrator or designee to report suspicion of a crime to local law enforcement authorities. Resident 94, admitted on 06/19/2025, had a medical history including anemia, difficulty in walking, dislocation of an internal right hip prosthesis, muscle weakness, and other symbolic dysfunctions. An admission MDS with an ARD of 06/24/2025 showed a BIMS score of 10, indicating mild cognitive impairment, and the care plan documented impaired cognition and psychosocial adjustment difficulties related to anemia. On 07/01/2025, the facility generated an Initial Report indicating that a family member reported the resident had stated someone smacked them across the face the previous day after lunch or dinner. The Administrator was notified of this allegation at 9:45 AM. An email from the Administrator to the state survey agency showed the initial report was sent at 1:41 PM, more than three and a half hours after the Administrator was notified, exceeding the two-hour reporting requirement. The Initial Report did not indicate that local law enforcement was notified. During interviews, the SSD, DON, and Administrator all acknowledged that allegations of abuse should be reported to the state survey agency within two hours, and the Administrator stated that their process was to notify law enforcement when a resident requested or when there was a chance a law had been broken, but she did not follow the appropriate process in this case.
Failure to Conduct Comprehensive Abuse and Misappropriation Investigations
Penalty
Summary
The deficiency involves the facility’s failure to conduct prompt, comprehensive investigations into allegations of abuse and misappropriation of resident property, contrary to its Abuse Prohibition Standard of Practice policy. That policy required the administrator or designee to oversee internal investigations of all alleged violations of abuse, neglect, exploitation, misappropriation of resident property, and injuries of unknown origin, including interviews of all involved persons and others who might have knowledge of the allegations. For one resident, the facility did not interview the staff member specifically named by the resident as the alleged perpetrator of misappropriation, despite documentation showing that a staff member with that first name was scheduled and worked during the timeframe of the alleged incident. For another resident, the facility did not obtain statements from all staff who worked during the relevant shifts and did not interview or obtain statements from office staff, even though the allegation involved a manager in an office area. One resident, admitted with diagnoses including aftercare following removal of a knee joint prosthesis, generalized anxiety disorder, and major depressive disorder, had a BIMS score of 13 indicating intact cognition, but was also care planned for progressive decline in intellectual functioning, memory deficits, and anxiety with agitation. This resident reported that $350, a driver’s license, and an insurance card were missing from their wallet or purse and identified by first name the person they believed took the items. The facility’s initial and final reports to the state survey agency documented the allegation and noted that no cash was recorded on the admission inventory and that no staff by the alleged name worked on the day the allegation was reported. However, the facility’s monthly schedule showed that an SRNA with the same first name as the alleged perpetrator was scheduled and worked the evening and night shift spanning the date of the alleged incident. The investigation packet contained 20 staff statements, but no statement from this SRNA or from any staff member with the alleged first name. The SSD stated she obtained statements from everyone who worked that day and did not interview the SRNA because she believed the SRNA did not work that day, while the SRNA later confirmed she had worked that shift, knew the resident, and was never asked for a statement. The DON acknowledged she did not interview the SRNA, was unaware of the investigative process, and did not know if there was a process for investigating such allegations, and the Administrator, who was the Abuse Coordinator, confirmed that the SRNA was not interviewed despite the resident naming a staff member with that first name. Another resident, admitted with diagnoses including anemia, difficulty in walking, dislocation of an internal right hip prosthesis, muscle weakness, and other symbolic dysfunctions, had a BIMS score of 10 indicating mild cognitive impairment and was care planned for impaired cognition and psychosocial adjustment difficulties. This resident’s family member reported that the resident said someone smacked them across the face after a meal, and a typed SSD statement documented that the family member reported the resident said the manager over the office smacked them. The facility’s final report stated that the resident reported being slapped in a hall after a meal, could not identify the meal or describe the individual, and said they reported the incident to an employee in the back office. The investigation packet included 17 staff statements from floor staff (SRNAs, LPNs, and RNs) but no statements from any office staff, despite the allegation involving a manager over the office and a report to an employee in the back office. Daily staffing guides showed that 34 different floor staff worked during the two 12-hour shifts on the day of the alleged incident and the following day shift, yet statements were not obtained from multiple identified RNs, LPNs, SRNAs, and KMAs who worked those shifts. The facility conducted skin assessments and interviews only for residents on the hall where the resident resided and did not complete resident interviews or skin assessments for residents on other halls. In interviews, multiple staff who had worked during the relevant timeframe stated they were never asked about any resident being slapped or asked to provide statements. The DON stated that her role in abuse investigations was to perform skin assessments and obtain staff statements, believed that therapy and office staff had been interviewed, and did not review surveillance cameras, while the Administrator stated they narrowed the investigation and did not review cameras because they only showed hallways and not the back hallway where offices and therapy areas were located. Overall, for both residents, the facility did not follow its own policy requirement that investigations be prompt, comprehensive, and include interviews of all involved persons and others who might have knowledge of the allegations. In the misappropriation case, the named SRNA who worked during the alleged timeframe was not interviewed or asked for a statement, and the DON acknowledged lack of familiarity with the investigative process. In the physical abuse case, the facility did not obtain statements from all staff who worked during the relevant shifts, did not interview office staff despite the allegation involving an office manager and a report to a back office employee, and limited resident assessments and interviews to one hall, without extending them to other halls where potential witnesses or victims might have been located. These omissions in investigative steps led to incomplete investigations of the reported allegations of abuse and misappropriation of property for the two residents.
Failure to Follow Two-Person Assist Care Plan Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan for a resident who required extensive assistance with activities of daily living (ADLs). The facility’s policy required development and implementation of care plans with measurable objectives and time frames to meet residents’ medical, nursing, mental, and psychosocial needs. The resident was admitted with osteoporosis, a right artificial hip joint, and dementia, and was assessed on a quarterly MDS as severely cognitively impaired, rarely or never understood, and dependent for bed mobility, toileting, and transfers. The resident’s care plan/kardex identified an ADL problem and included an intervention requiring two staff to assist with bed mobility, toileting, and transfers. On the day of the incident, a state registered nurse aide (SRNA) began providing perineal care to the resident and rolled the resident onto her left side without waiting for a second staff member, despite knowing the resident was care planned as a two-person assist. When the SRNA rolled the resident, the resident rolled out of bed and fell to the floor on her right side. The incident report documented that the root cause of the fall was the resident being rolled too far over, causing her to roll out of bed. Staff interviews confirmed that the resident had been a two-person assist for years and that there had been no changes to the care plan on the day of the incident. Following the fall, an LPN assessed the resident, notified the nurse practitioner, and obtained stat x-rays, which revealed a right femoral diaphyseal fracture with complete displacement and foreshortening, and an orthopedic consult was recommended. Hospital imaging later confirmed a comminuted and moderately displaced mid to distal right femoral shaft fracture, and the surgical team repaired the resident’s hip. Hospital documentation showed that the resident subsequently died while on the hospital’s hospice unit. Interviews with the SRNA, LPN, unit manager, infection preventionist/acting DON, and the administrator consistently indicated that staff were trained to follow the care plan/kardex and that the resident’s two-person assist requirement was known, but in this incident the care plan intervention was not followed.
Failure to Follow Two-Person Assist Care Plan Resulting in Fall and Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance during care, resulting in a fall with fracture for one resident. The resident was admitted with osteoporosis, a right artificial hip joint, and dementia, and was assessed on the Quarterly MDS as severely cognitively impaired and rarely/never understood. The MDS further documented the resident as dependent for bed mobility, toileting, and transfers. The resident’s care plan, as reflected on the Kardex, identified an Activities of Daily Living (ADL) problem and included an intervention requiring two staff to assist with bed mobility, toileting, and transfers. On the day of the incident, an SRNA began providing perineal care to the resident alone, despite knowing the resident required a two-person assist. The SRNA rolled the resident onto her left side, which caused the resident to roll out of bed on her right side onto the floor next to the other bed in the room. The incident report documented that the root cause was the resident being rolled too far over during care, and the IDT determined that the SRNA failed to follow the resident’s Kardex. At the time of the incident, the resident had predisposing physiological factors of weakness and situational factors including a history of falls. Following the fall, an LPN and the unit manager responded to the room and found the resident lying on her right side on the floor, with no apparent distress or obvious injury initially observed. The LPN documented notification of the NP and family and obtained orders for x-rays of the right shoulder, hip, and knee. Mobile x-ray results showed a right femoral diaphyseal fracture with complete displacement and foreshortening, and an orthopedic consult was recommended. The resident was subsequently sent to the hospital, where imaging confirmed a comminuted, moderately displaced mid to distal right femoral shaft fracture, and an ORIF procedure with plate and screw fixation was performed. The resident later expired in the hospital’s hospice unit. Interviews with the SRNA, LPN, another SRNA, the unit manager, the acting DON/IP nurse, and the administrator consistently confirmed that the resident had long been a two-person assist and that only one staff member was present providing care at the time of the incident, contrary to the care plan and Kardex. Staff interviews further revealed that, prior to the incident, nurses and unit managers did not routinely spot check SRNAs to ensure they were following the care plan/Kardex when providing care. The SRNA involved acknowledged she had been trained during orientation to follow the care plan/Kardex and admitted she did not follow it in this case, stating she started care alone while expecting her partner to join later. The LPN, another SRNA, the unit manager, the acting DON/IP nurse, and the administrator all stated that the resident’s care plan and Kardex required two staff for bed mobility and related ADLs and that there had been no change to this requirement on the day of the incident. The administrator and acting DON/IP nurse both stated it was their expectation that staff follow the care plans and Kardex when providing care, and the administrator confirmed that only one staff member was present when the incident occurred.
Delayed Administration of Ordered Antibiotic for UTI
Penalty
Summary
The deficiency involves the facility’s failure to provide timely pharmaceutical services and administer an ordered antibiotic for a resident with a suspected urinary tract infection (UTI). The resident, who had intact cognition and diagnoses including arthropathic psoriasis and morbid obesity, was care planned for elimination deficits with interventions such as PRN straight catheterization for urinalysis and monitoring for UTI signs and symptoms. On one occasion, the resident developed a fever of 102°F, and a urinalysis showed significant abnormalities, including 3+ leukocytes, 3+ bacteria, and red blood cells too numerous to count. Based on these findings, the nurse practitioner ordered a single 3 g dose of Fosfomycin to treat the UTI while awaiting culture results. The medication order for Fosfomycin was entered with a start date of the day after the follow-up note, but the drug was not administered as ordered. The MAR showed that the Fosfomycin was to be given one time by mouth for UTI, and a subsequent entry documented that the medication was on hold because it was not available from the pharmacy. There was no documented physician order to hold the medication, and no progress note was found explaining the delay, who was contacted, or what actions were taken when the medication was reportedly unavailable. The Fosfomycin was ultimately documented as administered four days after the original order date, indicating a significant delay in treatment. Interviews and record reviews further clarified the circumstances leading to the deficiency. The infection preventionist stated that the facility followed McGeer criteria for antibiotic use and that the urinalysis did not meet those criteria, but he was not aware of this specific incident. The DON stated she did not know why the Fosfomycin was not given as ordered, noted that this medication was commonly used and readily available from the pharmacy, and confirmed it was not stocked in the emergency medication supply. The DON also stated her expectation that medications be received timely from the pharmacy and administered to residents, and that any delay in antibiotics could possibly lead to sepsis and pain. The resident reported having gone without treatment for approximately three weeks after developing a UTI, stated she never received the originally ordered one-time antibiotic dose, and later required transfer to the emergency department where she was diagnosed with a complicated UTI and treated with IM Rocephin and Toradol for pain.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
