Parkwood Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Louisville, Kentucky.
- Location
- 900 Gagel Avenue, Louisville, Kentucky 40216
- CMS Provider Number
- 185096
- Inspections on file
- 24
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Parkwood Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of psychiatric conditions was able to leave the facility unsupervised by exploiting a faulty lock and a gap in a poorly maintained fence. The resident, known to be at risk for elopement, was not immediately noticed missing, and facility checks of exits were incomplete and not performed on weekends. The resident was later found outside a nearby store and returned without injury.
A resident with a history of wandering eloped from the facility despite having a wander guard device. The alarm on the emergency door was triggered, but staff did not respond promptly, allowing the resident to leave unsupervised. The resident was later found by police and returned to the facility. Staff interviews revealed that those present did not hear the alarm, indicating a failure in supervision and response systems.
The facility failed to store food according to its policy, as several food items in the kitchen were found without labels or dates. Staff interviews confirmed that opened food should be labeled and dated, and discarded if not, to prevent spoilage and potential harm to residents. This deficiency could affect 85 of the 89 residents consuming food from the kitchen.
The facility failed to maintain a clean and homelike environment, with strong urine odors and unclean conditions in hallways and rooms. Observations revealed dirty floors and persistent odors, confirmed by staff and residents. Bathrooms had unaddressed cleanliness issues, with language barriers affecting communication with housekeeping. Rust stains on floors and door jambs indicated maintenance neglect, with incomplete remodeling efforts. These deficiencies highlight the facility's failure to provide a safe, sanitary, and homelike environment.
The facility failed to implement an effective infection prevention and control program, resulting in deficiencies for two residents. An IC/RN did not perform proper hand hygiene or use barriers during wound care for a resident with a pressure ulcer. Another resident on Enhanced Barrier Precautions due to a colostomy did not have PPE readily available, and staff were unaware of proper protocols. The DON acknowledged these issues, highlighting a lack of staff education and PPE accessibility.
A facility failed to develop a comprehensive care plan for a resident within the required timeframe, missing critical components such as communication, functional ability, fall risk, and medical needs related to a tracheostomy. The resident was unaware of her care plan or discharge plans. Staff interviews revealed a lack of adherence to required timeframes for care plan completion.
Two residents with communication impairments were not provided with necessary communication aids as per their care plans. Despite having severe and moderate cognitive deficits, the residents lacked access to tools like communication boards and writing pads. Staff interviews revealed a lack of coordination in maintaining these aids, with no specific policy in place to ensure their availability.
Resident Elopement Due to Inadequate Supervision and Faulty Security Measures
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of psychiatric diagnoses, including bipolar disorder, paranoid schizophrenia, depression, and anxiety, was able to elope from the facility. The resident was assessed as having a severely impaired mental status and was care planned for behaviors such as wandering and attempting to leave the facility without a responsible escort. Despite these known risks, the facility's supervision and environmental safeguards were insufficient to prevent the resident from leaving the premises. On the day of the incident, the resident entered a vending machine room and subsequently exited the facility grounds through a courtyard gate. The gate was supposed to be secured, but the resident was able to manipulate the lock or exploit a gap in the fence, which was in poor condition at the time. Staff did not immediately notice the resident's absence; it was only after a period of time that a CNA discovered the resident was missing, prompting a search. The resident was eventually found outside a nearby store and returned to the facility without injury. Documentation revealed that prior to the incident, facility checks of entrances and exits, including the courtyard gate, were incomplete and not performed on weekends. The lock on the courtyard gate was found to be faulty, intermittently failing to latch, and the fence was described as being in very poor condition. Staff interviews confirmed that the resident was able to leave due to these environmental hazards and lapses in supervision, despite being identified as an elopement risk and having interventions in place on the care plan.
Resident Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
The facility failed to ensure resident safety, resulting in an elopement incident involving a resident identified as R140. On the night of the incident, the resident, who had a history of wandering and was equipped with a wander guard device, managed to exit the facility through a Southwest emergency door. The alarm on the door was triggered, but staff did not respond promptly, allowing the resident to leave the premises unsupervised. The resident was later found by police at a nearby convenience store and returned to the facility. The resident, R140, had been admitted with diagnoses including metabolic encephalopathy and alcohol dependence and was assessed as having a low risk for elopement initially. However, subsequent assessments indicated a high risk for wandering, and interventions such as a wander guard device and 15-minute location checks were implemented. Despite these measures, the resident was able to elope, indicating a failure in the facility's supervision and response systems. Staff interviews revealed that those present on the night of the elopement were either in resident rooms or on break and did not hear the alarm. The facility's investigation did not determine how long the alarm had been sounding before staff responded. The incident highlighted a lapse in the facility's ability to provide adequate supervision and timely response to alarms, which are critical in preventing elopements.
Removal Plan
- Resident no longer resides in the facility.
- A head-to-toe assessment was completed by a licensed nurse.
- The nurse practitioner was notified by a licensed nurse.
- SBAR was completed by a licensed nurse.
- An elopement assessment was completed by a licensed nurse.
- Ad Hoc QAPI meeting was held with the Administrator, Medical Director, Director of Nursing, Admissions Coordinator, Social Services Director, Dietary Manager, Human Resources Director, Housekeeping Director, Activities Director, and Therapy Director.
- One-on-one supervision was initiated, and the care plan was updated by the Interdisciplinary Team.
- The resident Representative was notified in person of the incident by a licensed nurse.
- Every shift behavior monitoring for exit-seeking behavior was continued per MAR and TAR until discharge.
- The resident had a wanderguard placement prior to the incident and was added to the care plan by a licensed nurse.
- Resident was seen by NP and/or physician.
- One-on-one monitoring was placed on orders.
- Resident was monitored by Social Services.
- Resident was reviewed by IDT for changes in behavior.
- An elopement assessment was completed for 81 residents by licensed nurses.
- Clinical and agency clinical staff were educated regarding elopement policy and elopement drill.
- As an ongoing practice, an elopement assessment will be completed upon admission, quarterly and as needed related to changes in the resident's exit-seeking behaviors.
- Discussion at clinical meetings of changes in behaviors with review of orders, review of MARs/TARs, care plan review, nurse' notes review, and reports by staff.
- Care plans will be updated as needed based on these reviews by the clinical leadership and IDT.
- Individual resident's care plans will be reviewed at least quarterly for needed updates as part of the resident's quarterly care plan conference.
- Resident reviewed by IDT for changes in behavior on multiple dates.
- One on Two monitoring and changed to every 15-minute checks with care plan revisions by licensed nurse, which remained until discharge.
- Ad Hoc QAPI meeting was held with the Administrator, Medical Director, and Interdisciplinary Team.
- Elopement Drills conducted daily by the Administrator, Director of Nursing, Housekeeping Supervisor, and/or the Maintenance Director.
Failure to Properly Label and Date Food Items
Penalty
Summary
The facility failed to store food in accordance with its policy and accepted standards of food service and management. During an observation of the kitchen, it was noted that several food items were not labeled or dated when opened. Specifically, a steam table pan in the walk-in refrigerator was covered in foil without a date or label, and a clear container in dry storage contained a white particle substance with no open date or label. Additionally, open packages of oatmeal, farina, elbow noodles, buttermilk mix, and brown sugar were found without open dates, along with five containers of seasonings in dry storage. Interviews with staff, including a Servesafe certified individual, two dietary aides, the Dietary Manager, and the Director of Nursing, confirmed that the facility's policy required all opened food items to be labeled with the current date and discarded if not labeled or dated. The staff acknowledged that food without a label or date should be thrown away due to the risk of spoilage and potential harm to residents. This deficiency had the potential to affect 85 of the 89 residents who consumed food stored and used in the kitchen.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment, as evidenced by strong urine odors and unclean conditions in various areas. Observations revealed that hallways and rooms, particularly those containing Rooms 106-116 and 121-135, had a persistent smell of urine. Floors were found to be dirty, with black marks, sticky substances, and dried urine puddles. Interviews with staff and residents confirmed these observations, with some staff acknowledging the odor while others denied it. The Director of Nursing attributed the smell to a resident's refusal to properly launder undergarments. Further deficiencies were noted in the cleanliness of individual resident bathrooms. One resident's bathroom had a brown substance, identified as stool, on the floor and wall, which had been present for several days despite daily cleaning claims by housekeeping staff. The resident expressed dissatisfaction with housekeeping services, citing language barriers with the staff. Another resident reported inadequate cleaning practices, such as failing to sweep before mopping and neglecting to clean vanities and mirrors. Interviews with CNAs and housekeeping staff revealed inconsistencies in cleaning routines and a lack of proper management oversight. Additionally, rust stains were observed on the floors and door jambs of several bathrooms, indicating a lack of maintenance. The Maintenance Director was unaware of these issues and mentioned that remodeling efforts were incomplete due to an external company's partial work. The DON confirmed that remodeling was ongoing, but there were no immediate plans to address the flooring issues. These observations and interviews highlight the facility's failure to provide a safe, sanitary, and homelike environment for its residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. For Resident 11, the Infection Control Registered Nurse (IC/RN) did not perform hand hygiene before and after a wound dressing change, placed personal items and clean dressings on potentially contaminated surfaces, and disposed of soiled dressings improperly. The IC/RN also failed to use a barrier when opening a clean dressing on the resident's bed, leading to potential contamination of the wound and surrounding areas. Despite these lapses, the IC/RN did not recognize any need for improvement in her practices. For Resident 35, who was on Enhanced Barrier Precautions (EBP) due to a colostomy, the facility did not ensure that Personal Protective Equipment (PPE) was readily available or used correctly by staff. During colostomy care, an LPN did not wear a gown and failed to perform hand hygiene after the procedure. Interviews with various staff members revealed a lack of understanding and awareness regarding EBP protocols, with some staff unaware of the need for gowns and gloves or the location of PPE supplies. The Director of Nursing (DON) and other administrative staff acknowledged the deficiencies in infection control practices and the lack of PPE availability. The DON confirmed that PPE should be accessible and that staff should be knowledgeable about EBP requirements. However, observations indicated that PPE was not consistently available in resident rooms or hallways, and staff education on EBP was insufficient, contributing to the facility's failure to prevent the spread of infections effectively.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as R85, within the required timeframe. The care plan was supposed to be completed no later than 21 days from the resident's admission, but it was not finalized by the deadline. The comprehensive care plan was missing critical components, including measurable objectives and timeframes to address the resident's medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. Specifically, the care plan did not address areas triggered by the Care Area Assessments (CAA), such as communication, functional ability, fall risk, psychotropic drug use, urinary incontinence, and pressure ulcer/injury. Additionally, the care plan failed to address the resident's medical needs related to her tracheostomy/stoma and did not include goals or plans for discharge. The resident, R85, was admitted with diagnoses including adult failure to thrive, malfunction of tracheostomy stoma, and a history of blood clots. Despite having a baseline care plan completed within 48 hours of admission, the comprehensive care plan was not completed by the required date. Interviews with the resident revealed that she was unaware of her plan of care, the duration of her stay, or any discharge plans. Interviews with facility staff, including the Assistant MDS Coordinator and the MDS Coordinator, highlighted a lack of awareness and adherence to the required timeframes for completing comprehensive care plans. The MDS Coordinator acknowledged the oversight and took responsibility for the incomplete care plan.
Failure to Provide Communication Aids to Residents
Penalty
Summary
The facility failed to provide necessary communication tools to two residents, leading to a decline in their ability to communicate. Resident 49, who was admitted with severe cognitive deficits and speech impairments, was supposed to have communication aids like picture pages and boards as per his care plan. However, during observations, these aids were not found in his room, and both the resident and his sister confirmed they had not seen any communication tools provided. Despite the resident's ability to nod and answer yes or no, the absence of these aids contradicted the care plan's interventions. Similarly, Resident 58, who had moderate cognitive decline and speech impairments following a stroke, was also not provided with the necessary communication aids. His care plan included the use of a steno pad and other augmentative devices to assist with communication. Observations revealed no such aids in his room, and the resident had to use the surveyor's pen and pad to communicate. Interviews with staff indicated that communication tools were not consistently available in the resident's room, despite the resident's ability to write legibly. Interviews with the facility's staff, including the Speech Therapist, LPN, Director of Rehabilitation, and Director of Nursing, revealed a lack of coordination and accountability in ensuring communication aids were available to the residents. The Speech Therapist claimed to have placed communication boards in the rooms, but they were not present during the survey. The Director of Rehabilitation acknowledged difficulties in maintaining these aids in the rooms and expected nursing staff to manage them post-therapy discharge. The facility administrator admitted there was no specific policy regarding communication devices for residents with deficits, leading to inconsistencies in care delivery.
Latest citations in Kentucky
The facility failed to maintain an effective pest control and sanitation program, resulting in a widespread gnat infestation in common areas, resident halls, the laundry room, medication cart trash, dirty utility room, and the kitchen. Surveyors observed gnats emerging from drains, stagnant mop water with a rancid odor, and extensive moisture, standing water, and organic debris in kitchen drains, cracked floor tiles, and hard-to-reach areas behind equipment. Pest control service reports over several months repeatedly documented unresolved issues such as drain debris, standing water, and debris accumulation, while the pest control provider stated that facility compliance with recommended cleaning and maintenance was inconsistent and many action items remained undone. The Dietary Manager reported ongoing gnat problems and use of a hose-mounted floor sprayer and vinegar in drains, which the pest control representative stated would not remove organic buildup or larvae. Leadership, including the VPO, DON, and Administrator, described expectations for cleaning, pest reporting, and drain use that were not reflected in observed conditions, and two residents reported that gnats were frequently present around them and their food, especially during meals.
A resident with morbid obesity and bilateral foot drop, whose care plan called for two staff for bed mobility and incontinence care, slid off the edge of the bed during perineal care and sustained abrasions and skin discoloration. The resident stated an SRNA rolled them too far while the SRNA was on the opposite side of the bed, and staff interviews confirmed the SRNA performed the care alone instead of waiting for another staff member. The ADON and DON stated the resident should have had two staff assist with the care.
An LPN was observed administering insulin via a pen injector to a resident with diabetes without priming the needle before either dose. The resident had type 2 DM with hyperglycemia and active NovoLog FlexPen orders, but the facility’s competency assessment covered insulin by syringe and did not show training or assessment for insulin pen use. The LPN stated she was not aware priming was required, and the DON and Administrator confirmed the facility had not provided competency training on insulin pens.
A resident admitted for rehab with muscle weakness and unsteadiness had PT and OT care plans and orders for treatment five times per week, but therapy logs showed missed PT/OT sessions on two days with no documented reason. The Director of Rehabilitation confirmed the resident received therapy only three of five days over two consecutive weeks, contrary to the plan of care, and could not explain or document why sessions were missed. The resident and the resident’s representative reported that the resident did not receive therapy as expected, that therapy minutes were insufficient, and that services were not tailored to the resident’s needs, including use of group therapy despite the resident’s stated preference against it.
The facility failed to maintain a safe, clean, and sanitary laundry environment and to properly manage a resident’s clothing. A resident with COPD, heart failure, type 2 DM, and ESRD had most of their clothing lost during a short stay, and the family member who searched for the items described the laundry room as extremely hot, messy, dirty, with clothes everywhere and overflowing trash. Staff interviews confirmed the laundry room had long‑standing issues with excessive heat and clutter. Surveyor observations found floors between and behind washers covered with dirt, a dry flaky substance, loose concrete, and residue on piping and chemical tubing, alongside buckets of corrosive chemicals. Interviews with housekeeping, EVS, a chemical vendor, and maintenance showed that a chemical spill behind the washers had occurred over a year earlier and was never properly cleaned up, with conflicting accounts over whether maintenance or EVS was responsible and no effective system to ensure cleaning behind the machines.
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident with mild cognitive impairment and multiple medical conditions was reported by the resident’s family member. The Administrator was notified of the allegation that someone had smacked the resident across the face, but the initial report to the state survey agency was not submitted until more than three and a half hours later, exceeding the required two-hour timeframe. Facility documentation did not show that law enforcement was notified, despite policy requiring reporting of suspected crimes, and interviews with the SSD, DON, and Administrator confirmed that the expected practice was to report such allegations promptly to the state survey agency and law enforcement when applicable.
Two residents reported serious allegations—one of missing money and identification and another of being slapped by a staff member—but the facility failed to conduct comprehensive investigations as required by its abuse policy. In the misappropriation case, a cognitively intact resident named a specific staff member by first name, and the schedule showed an SRNA with that name worked during the alleged timeframe, yet that SRNA was never interviewed or asked for a statement, and the DON acknowledged not knowing the investigative process. In the physical abuse case, a resident with mild cognitive impairment reported being slapped and told a family member that a manager over the office was responsible, but the facility obtained statements only from some floor staff, did not interview office staff, did not obtain statements from all staff who worked the relevant shifts, and limited resident interviews and skin assessments to one hall. These actions and omissions resulted in incomplete investigations of both abuse-related allegations.
A resident with dementia, osteoporosis, a right artificial hip, and severe cognitive impairment was care planned as dependent for bed mobility, toileting, and transfers, with an intervention requiring two staff for assistance. Despite this, an SRNA, who knew the resident was a two-person assist, began perineal care alone and rolled the resident onto the side, causing the resident to roll out of bed and fall. An LPN obtained stat x-rays that showed a displaced right femoral shaft fracture, and the resident was sent to the hospital, where surgery was performed and the resident later died on a hospice unit. Staff interviews confirmed that the two-person assist requirement had been in place for years and that the failure to follow the care plan led to the incident.
A resident with dementia, osteoporosis, and a right artificial hip joint, assessed as severely cognitively impaired and dependent for bed mobility, toileting, and transfers, had a care plan and Kardex requiring a two-person assist for these ADLs. An SRNA, despite knowing this requirement, began perineal care alone and rolled the resident onto her side, causing the resident to roll out of bed onto the floor. The incident report and IDT identified the root cause as failure to follow the Kardex, with contributing factors including the resident’s weakness and history of falls. An LPN and unit manager found the resident on the floor, obtained stat x-rays that revealed a displaced right femoral shaft fracture, and the resident was sent to the hospital, where imaging confirmed a comminuted, moderately displaced femoral fracture and an ORIF procedure was performed. Staff interviews confirmed that the resident had long required a two-person assist and that only one staff member was present at the time of the incident, and also revealed that nurses and managers had not routinely spot checked SRNAs for adherence to the care plan/Kardex prior to the event.
A resident with intact cognition and multiple comorbidities developed fever and abnormal urinalysis results consistent with a UTI, for which an NP ordered a single 3 g dose of Fosfomycin. The MAR showed the antibiotic order and later an entry placing it on hold due to unavailability from pharmacy, without a corresponding provider order or documentation explaining the delay or who was contacted. The medication was not administered until four days after the original order, during which time the resident reported going without treatment and later required ED transfer, where a complicated UTI was diagnosed and treated with IM Rocephin and Toradol.
Failure to Maintain Effective Pest Control and Sanitary Conditions Resulting in Widespread Gnat Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free of insects and other pests, resulting in a widespread gnat infestation throughout the building. Surveyor observations over two days identified gnats in multiple common areas, including the conference room, resident halls, laundry room, medication cart trash can, and dirty utility room. In the laundry room, gnats were seen emerging from the washing machine discharge drain, and in the dirty utility room, gnats were concentrated around a mop bucket containing stagnant, foul-smelling water. On a resident hall, multiple gnats were observed flying around residents and on surfaces throughout the corridor. Extensive observations in the kitchen revealed multiple environmental and sanitation issues that contributed to the gnat activity. Behind and around the ice machine and juice cart, there was wet dust, dirt, and organic debris such as food crumbs, sugar packets, and trash items, all saturated with moisture. Cracked, loose, and broken floor tiles near the ice machine drain and in the dish room contained food debris lodged within and beneath the damaged tiles, with standing water collected beneath the tiles and pooled around the ice machine drain. Standing water was also observed in the spray room, dish room, along walls, and in corners, with water spread across the kitchen floor after staff used a hose-mounted sprayer to clean the floors. On a subsequent day, the kitchen floor again had visible standing water, and a floor drain contained accumulated debris, paper fragments, and organic material, with a broken drain grate that did not fully cover the drain and exposed additional trapped debris; gnats were present in and near this drain and throughout the kitchen. Review of facility work orders showed only one report of gnats in common areas and nursing units for one month and one report of bugs facility-wide in the following month, despite the widespread activity observed. Service reports from the contracted pest control company over several months documented ongoing, unresolved environmental concerns in the kitchen and adjacent areas, including repeated findings of drain debris, standing water in kitchen and dishwashing areas, debris accumulation, and moisture issues that remained uncorrected by the facility. The pest control representative and pest control account manager both stated that gnats were originating from drains, cracks, and crevices with organic debris and moisture, and that routine cleaning practices were ineffective when debris remained or was pushed into cracks and around drains. They reported that recommendations such as debris removal, proper drain maintenance, and cleaning of hard-to-reach areas were repeatedly communicated and documented, but the facility’s compliance with these recommendations was inconsistent, with many action items left undone and carried over on subsequent service reports. Interviews with staff and leadership further described the facility’s actions and inactions related to pest control and sanitation. The Dietary Manager reported ongoing gnat concerns for multiple weeks, stated that pest control services were provided twice monthly, and that kitchen staff performed routine cleaning weekly and as needed, using a hose-mounted spray system for floors and pouring vinegar down drains between pest control visits. The pest control representative stated that pouring vinegar down drains would not eliminate the infestation and might attract gnats, as it did not remove organic buildup or kill larvae. The pest control account manager identified contributing factors such as debris buildup in cracks and flooring, lack of routine cleaning behind equipment, standing water or improperly maintained mop buckets, inconsistent cleaning practices in non-visible areas, and lack of routine maintenance of drains and traps, and noted that environmental cleaning often improved only after issues became more apparent. The VPO acknowledged gnat activity throughout the building and that pest control reports had identified ongoing debris concerns in the kitchen, but could not clearly describe a process to ensure consistent cleaning of hard-to-reach areas or to verify cleaning effectiveness. The DON and Administrator described expectations for reporting pests, emptying mop buckets, removing trash from medication carts, removing debris before floor cleaning, and not sweeping debris into drains, but these expectations were not reflected in the observed conditions. Two cognitively impaired and intact residents reported that gnats were always present, especially around meal times and food, and that they found them bothersome and undesirable during meals.
Failure to Provide Two-Person Assistance During Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance to prevent a fall for one resident who had diagnoses of morbid obesity, left foot drop, and right foot drop. The resident’s care plan identified a need for two staff members for bed mobility and in-bed care related to bariatric status, and also directed staff to provide two-person assistance for bed mobility and total assistance for incontinence care as the resident allowed. The resident’s MDS indicated intact cognition and that the resident required supervision or touching assistance for rolling left and right in bed. During incontinence care, the resident slid off the edge of the bed to the floor and onto their knees. The acute change in condition assessment documented abrasions and skin discoloration after the incident. In interviews, the resident stated that a staff member rolled them out of bed during incontinence care and that they were able to assist with rolling by using the assist bars on either side of the bed. The resident stated that while rolling to the right side of the bed, they rolled too far and slid off the edge of the bed while the SRNA was standing on the opposite side of the bed. Staff interviews showed that the SRNA provided the incontinence care by herself even though the resident required two-person assistance. The SRNA stated she did not ask another staff member for help because she was used to performing the care alone, and later stated that having another SRNA in the room could have prevented the incident. Other staff, including the ADON and DON, stated the resident should have had two staff members assist with incontinence care. The DON also stated the resident could assist with turning using the bed rails, but the SRNA should have used another staff member and waited for assistance.
Insulin Pen Competency Not Demonstrated
Penalty
Summary
Licensed nursing staff were not shown to have the competencies and skill set necessary to administer insulin via an insulin injector pen for one LPN observed caring for a resident with diabetes. Review of the LPN’s competency assessment showed the DON assessed insulin administration by syringe, but it did not indicate assessment of insulin pen injector use, even though the competency document stated staff should have access to manufacturer instructions for all insulin delivery systems before use. The manufacturer’s instructions for NovoLog FlexPen required priming the pen before injection to avoid injecting air and ensure proper dosing. The resident involved was admitted with a diagnosis of type 2 diabetes mellitus with hyperglycemia and had active orders for NovoLog FlexPen, including a sliding scale order and a separate order for 16 units before meals. During observed medication administration, the LPN checked the resident’s blood glucose, which was 409, then administered 16 units of NovoLog FlexPen without priming the pen needle. After contacting the physician, the LPN later returned and administered 10 units from the sliding scale order, again without priming the insulin needle. The LPN stated she was not aware the pen needle needed to be primed and was unsure whether she had education on insulin pen injectors. The DON stated competency training covered insulin administration by syringe but not insulin pen injectors, and the Administrator stated the facility had not provided competency training related to insulin pens.
Failure to Provide Ordered PT/OT and Document Missed Therapy Sessions
Penalty
Summary
The facility failed to provide specialized rehabilitative services as ordered for one resident admitted for rehabilitation with diagnoses of muscle weakness and unsteadiness on feet. The resident’s care plan, initiated shortly after admission, identified a rehabilitation focus with skilled PT and OT interventions, and physician orders specified PT and OT to evaluate and treat. The OT plan of care called for treatment five times per week for 60 days, and the PT plan of care called for treatment five times per week for 30 days. Review of the Service Log Matrix showed that the resident did not receive individual PT or OT on two specified dates, despite the plan of care requiring therapy five days per week. The Director of Rehabilitation confirmed that the resident missed PT/OT on those two dates, that the plan of care was for five days a week, and that the resident only received PT/OT three out of five days for two consecutive weeks. The resident and the resident’s representative reported concerns that the resident was not receiving the allotted amount of therapy time and that therapy was not tailored to the resident’s specific needs. The representative stated the resident was weaker upon discharge than at admission and that the family sought transfer to another facility for PT after expressing concerns without improvement. The resident reported not receiving any PT during the first week, receiving PT only after questioning staff, and that when PT was provided it lasted 30–40 minutes and included group therapy that was counted as PT despite the resident’s preference against group therapy. The Director of Rehabilitation stated she did not know why therapy was missed on the two identified dates and that no reasons were documented, although such reasons were typically recorded. The DON stated her understanding that if therapy was missed, staff should attempt to reschedule so that residents did not miss needed therapy, and the current Administrator stated her expectation that residents receive the therapy they are supposed to receive to reach their maximum potential.
Failure to Maintain Clean, Safe Laundry Environment and Proper Handling of Resident Clothing
Penalty
Summary
The facility failed to ensure a safe, clean, sanitary, and comfortable environment in the laundry area as required by its Safe and Homelike Environment and Resident Rights policies. The policies stated that the physical layout should not pose a safety risk and that a sanitary environment must be maintained, including proper cleaning and storage of resident care equipment and items used for activities of daily living. Despite these policies, observations on 04/17/2026 showed the floor between and behind the washing machines covered and caked with dirt, a dry flaky substance, loose concrete, and residue on piping and chemical tubing, while multiple buckets of corrosive laundry chemicals and detergents were present in the same area. A resident’s family member reported that during the resident’s four‑day stay, most of the resident’s clothing was lost, and when she was allowed into the laundry room to search for the items, she found the room extremely hot, messy, with clothes everywhere, dirty conditions, and overflowing trash. The resident involved had significant medical diagnoses including COPD, acute on chronic systolic heart failure, type 2 diabetes mellitus, and end‑stage renal disease. A SRNA corroborated that the laundry room had always been hot, especially in summer, and that the room had long been somewhat messy with clothes, worsening over the past couple of years. Interviews with housekeeping, environmental services, the chemical supplier, and maintenance staff revealed that a chemical spill behind the washing machines had occurred well over a year earlier when ports at the back of the machines became clogged, causing chemicals to leak onto the floor. The chemical representative stated he cleaned the ports and moved tubing, and an EVS staff member told him maintenance would clean up the spill, but it was never done. Housekeeping reported that maintenance told them to clean up the spill themselves, while the Maintenance Director stated that EVS was responsible for cleaning the washing machines and that he had not observed leaks during his tenure. The dried, flaky substance and damaged concrete remained in place until it was later cleaned and repaired, and there was no documented system in place to ensure regular cleaning behind the washers, despite the presence of paper checklists for other tasks such as lint trap cleaning.
Failure to Timely Report Alleged Physical Abuse to State Agency and Law Enforcement
Penalty
Summary
The facility failed to report an allegation of physical abuse to the state survey agency and law enforcement within the required two-hour timeframe. Facility policy titled “Abuse Prohibition Standard of Practice,” last reviewed 03/2026, required that alleged violations be reported immediately to the Administrator or designee and to the state survey agency, adult protective services, and other required agencies, including law enforcement when applicable, within specific time frames. The policy also required the Administrator or designee to report suspicion of a crime to local law enforcement authorities. Resident 94, admitted on 06/19/2025, had a medical history including anemia, difficulty in walking, dislocation of an internal right hip prosthesis, muscle weakness, and other symbolic dysfunctions. An admission MDS with an ARD of 06/24/2025 showed a BIMS score of 10, indicating mild cognitive impairment, and the care plan documented impaired cognition and psychosocial adjustment difficulties related to anemia. On 07/01/2025, the facility generated an Initial Report indicating that a family member reported the resident had stated someone smacked them across the face the previous day after lunch or dinner. The Administrator was notified of this allegation at 9:45 AM. An email from the Administrator to the state survey agency showed the initial report was sent at 1:41 PM, more than three and a half hours after the Administrator was notified, exceeding the two-hour reporting requirement. The Initial Report did not indicate that local law enforcement was notified. During interviews, the SSD, DON, and Administrator all acknowledged that allegations of abuse should be reported to the state survey agency within two hours, and the Administrator stated that their process was to notify law enforcement when a resident requested or when there was a chance a law had been broken, but she did not follow the appropriate process in this case.
Failure to Conduct Comprehensive Abuse and Misappropriation Investigations
Penalty
Summary
The deficiency involves the facility’s failure to conduct prompt, comprehensive investigations into allegations of abuse and misappropriation of resident property, contrary to its Abuse Prohibition Standard of Practice policy. That policy required the administrator or designee to oversee internal investigations of all alleged violations of abuse, neglect, exploitation, misappropriation of resident property, and injuries of unknown origin, including interviews of all involved persons and others who might have knowledge of the allegations. For one resident, the facility did not interview the staff member specifically named by the resident as the alleged perpetrator of misappropriation, despite documentation showing that a staff member with that first name was scheduled and worked during the timeframe of the alleged incident. For another resident, the facility did not obtain statements from all staff who worked during the relevant shifts and did not interview or obtain statements from office staff, even though the allegation involved a manager in an office area. One resident, admitted with diagnoses including aftercare following removal of a knee joint prosthesis, generalized anxiety disorder, and major depressive disorder, had a BIMS score of 13 indicating intact cognition, but was also care planned for progressive decline in intellectual functioning, memory deficits, and anxiety with agitation. This resident reported that $350, a driver’s license, and an insurance card were missing from their wallet or purse and identified by first name the person they believed took the items. The facility’s initial and final reports to the state survey agency documented the allegation and noted that no cash was recorded on the admission inventory and that no staff by the alleged name worked on the day the allegation was reported. However, the facility’s monthly schedule showed that an SRNA with the same first name as the alleged perpetrator was scheduled and worked the evening and night shift spanning the date of the alleged incident. The investigation packet contained 20 staff statements, but no statement from this SRNA or from any staff member with the alleged first name. The SSD stated she obtained statements from everyone who worked that day and did not interview the SRNA because she believed the SRNA did not work that day, while the SRNA later confirmed she had worked that shift, knew the resident, and was never asked for a statement. The DON acknowledged she did not interview the SRNA, was unaware of the investigative process, and did not know if there was a process for investigating such allegations, and the Administrator, who was the Abuse Coordinator, confirmed that the SRNA was not interviewed despite the resident naming a staff member with that first name. Another resident, admitted with diagnoses including anemia, difficulty in walking, dislocation of an internal right hip prosthesis, muscle weakness, and other symbolic dysfunctions, had a BIMS score of 10 indicating mild cognitive impairment and was care planned for impaired cognition and psychosocial adjustment difficulties. This resident’s family member reported that the resident said someone smacked them across the face after a meal, and a typed SSD statement documented that the family member reported the resident said the manager over the office smacked them. The facility’s final report stated that the resident reported being slapped in a hall after a meal, could not identify the meal or describe the individual, and said they reported the incident to an employee in the back office. The investigation packet included 17 staff statements from floor staff (SRNAs, LPNs, and RNs) but no statements from any office staff, despite the allegation involving a manager over the office and a report to an employee in the back office. Daily staffing guides showed that 34 different floor staff worked during the two 12-hour shifts on the day of the alleged incident and the following day shift, yet statements were not obtained from multiple identified RNs, LPNs, SRNAs, and KMAs who worked those shifts. The facility conducted skin assessments and interviews only for residents on the hall where the resident resided and did not complete resident interviews or skin assessments for residents on other halls. In interviews, multiple staff who had worked during the relevant timeframe stated they were never asked about any resident being slapped or asked to provide statements. The DON stated that her role in abuse investigations was to perform skin assessments and obtain staff statements, believed that therapy and office staff had been interviewed, and did not review surveillance cameras, while the Administrator stated they narrowed the investigation and did not review cameras because they only showed hallways and not the back hallway where offices and therapy areas were located. Overall, for both residents, the facility did not follow its own policy requirement that investigations be prompt, comprehensive, and include interviews of all involved persons and others who might have knowledge of the allegations. In the misappropriation case, the named SRNA who worked during the alleged timeframe was not interviewed or asked for a statement, and the DON acknowledged lack of familiarity with the investigative process. In the physical abuse case, the facility did not obtain statements from all staff who worked during the relevant shifts, did not interview office staff despite the allegation involving an office manager and a report to a back office employee, and limited resident assessments and interviews to one hall, without extending them to other halls where potential witnesses or victims might have been located. These omissions in investigative steps led to incomplete investigations of the reported allegations of abuse and misappropriation of property for the two residents.
Failure to Follow Two-Person Assist Care Plan Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan for a resident who required extensive assistance with activities of daily living (ADLs). The facility’s policy required development and implementation of care plans with measurable objectives and time frames to meet residents’ medical, nursing, mental, and psychosocial needs. The resident was admitted with osteoporosis, a right artificial hip joint, and dementia, and was assessed on a quarterly MDS as severely cognitively impaired, rarely or never understood, and dependent for bed mobility, toileting, and transfers. The resident’s care plan/kardex identified an ADL problem and included an intervention requiring two staff to assist with bed mobility, toileting, and transfers. On the day of the incident, a state registered nurse aide (SRNA) began providing perineal care to the resident and rolled the resident onto her left side without waiting for a second staff member, despite knowing the resident was care planned as a two-person assist. When the SRNA rolled the resident, the resident rolled out of bed and fell to the floor on her right side. The incident report documented that the root cause of the fall was the resident being rolled too far over, causing her to roll out of bed. Staff interviews confirmed that the resident had been a two-person assist for years and that there had been no changes to the care plan on the day of the incident. Following the fall, an LPN assessed the resident, notified the nurse practitioner, and obtained stat x-rays, which revealed a right femoral diaphyseal fracture with complete displacement and foreshortening, and an orthopedic consult was recommended. Hospital imaging later confirmed a comminuted and moderately displaced mid to distal right femoral shaft fracture, and the surgical team repaired the resident’s hip. Hospital documentation showed that the resident subsequently died while on the hospital’s hospice unit. Interviews with the SRNA, LPN, unit manager, infection preventionist/acting DON, and the administrator consistently indicated that staff were trained to follow the care plan/kardex and that the resident’s two-person assist requirement was known, but in this incident the care plan intervention was not followed.
Failure to Follow Two-Person Assist Care Plan Resulting in Fall and Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance during care, resulting in a fall with fracture for one resident. The resident was admitted with osteoporosis, a right artificial hip joint, and dementia, and was assessed on the Quarterly MDS as severely cognitively impaired and rarely/never understood. The MDS further documented the resident as dependent for bed mobility, toileting, and transfers. The resident’s care plan, as reflected on the Kardex, identified an Activities of Daily Living (ADL) problem and included an intervention requiring two staff to assist with bed mobility, toileting, and transfers. On the day of the incident, an SRNA began providing perineal care to the resident alone, despite knowing the resident required a two-person assist. The SRNA rolled the resident onto her left side, which caused the resident to roll out of bed on her right side onto the floor next to the other bed in the room. The incident report documented that the root cause was the resident being rolled too far over during care, and the IDT determined that the SRNA failed to follow the resident’s Kardex. At the time of the incident, the resident had predisposing physiological factors of weakness and situational factors including a history of falls. Following the fall, an LPN and the unit manager responded to the room and found the resident lying on her right side on the floor, with no apparent distress or obvious injury initially observed. The LPN documented notification of the NP and family and obtained orders for x-rays of the right shoulder, hip, and knee. Mobile x-ray results showed a right femoral diaphyseal fracture with complete displacement and foreshortening, and an orthopedic consult was recommended. The resident was subsequently sent to the hospital, where imaging confirmed a comminuted, moderately displaced mid to distal right femoral shaft fracture, and an ORIF procedure with plate and screw fixation was performed. The resident later expired in the hospital’s hospice unit. Interviews with the SRNA, LPN, another SRNA, the unit manager, the acting DON/IP nurse, and the administrator consistently confirmed that the resident had long been a two-person assist and that only one staff member was present providing care at the time of the incident, contrary to the care plan and Kardex. Staff interviews further revealed that, prior to the incident, nurses and unit managers did not routinely spot check SRNAs to ensure they were following the care plan/Kardex when providing care. The SRNA involved acknowledged she had been trained during orientation to follow the care plan/Kardex and admitted she did not follow it in this case, stating she started care alone while expecting her partner to join later. The LPN, another SRNA, the unit manager, the acting DON/IP nurse, and the administrator all stated that the resident’s care plan and Kardex required two staff for bed mobility and related ADLs and that there had been no change to this requirement on the day of the incident. The administrator and acting DON/IP nurse both stated it was their expectation that staff follow the care plans and Kardex when providing care, and the administrator confirmed that only one staff member was present when the incident occurred.
Delayed Administration of Ordered Antibiotic for UTI
Penalty
Summary
The deficiency involves the facility’s failure to provide timely pharmaceutical services and administer an ordered antibiotic for a resident with a suspected urinary tract infection (UTI). The resident, who had intact cognition and diagnoses including arthropathic psoriasis and morbid obesity, was care planned for elimination deficits with interventions such as PRN straight catheterization for urinalysis and monitoring for UTI signs and symptoms. On one occasion, the resident developed a fever of 102°F, and a urinalysis showed significant abnormalities, including 3+ leukocytes, 3+ bacteria, and red blood cells too numerous to count. Based on these findings, the nurse practitioner ordered a single 3 g dose of Fosfomycin to treat the UTI while awaiting culture results. The medication order for Fosfomycin was entered with a start date of the day after the follow-up note, but the drug was not administered as ordered. The MAR showed that the Fosfomycin was to be given one time by mouth for UTI, and a subsequent entry documented that the medication was on hold because it was not available from the pharmacy. There was no documented physician order to hold the medication, and no progress note was found explaining the delay, who was contacted, or what actions were taken when the medication was reportedly unavailable. The Fosfomycin was ultimately documented as administered four days after the original order date, indicating a significant delay in treatment. Interviews and record reviews further clarified the circumstances leading to the deficiency. The infection preventionist stated that the facility followed McGeer criteria for antibiotic use and that the urinalysis did not meet those criteria, but he was not aware of this specific incident. The DON stated she did not know why the Fosfomycin was not given as ordered, noted that this medication was commonly used and readily available from the pharmacy, and confirmed it was not stocked in the emergency medication supply. The DON also stated her expectation that medications be received timely from the pharmacy and administered to residents, and that any delay in antibiotics could possibly lead to sepsis and pain. The resident reported having gone without treatment for approximately three weeks after developing a UTI, stated she never received the originally ordered one-time antibiotic dose, and later required transfer to the emergency department where she was diagnosed with a complicated UTI and treated with IM Rocephin and Toradol for pain.
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