The Pavilion At Kenton
Inspection history, citations, penalties and survey trends for this long-term care facility in Covington, Kentucky.
- Location
- 401 East 20th Street, Covington, Kentucky 41014
- CMS Provider Number
- 185038
- Inspections on file
- 17
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at The Pavilion At Kenton during CMS and state inspections, most recent first.
The facility failed to ensure food and beverages were served at safe and appetizing temperatures, as required by its Food Preparation and Service policy. Multiple test tray assessments documented hot items such as meats, vegetables, and starches being served within the temperature danger zone, and cold items such as desserts, milk, juice, and sandwiches above the required cold-holding temperature. A resident with DM2, major depressive disorder, and anxiety, who was cognitively intact, reported receiving cold food all the time, and residents in a Resident Council meeting also reported cold food at mealtimes. During a test tray observation, surveyors found hot entrée and vegetable items to be room temperature or cold and beverages warm. Despite these findings, dietary leadership and the RD stated that hot food was always hot and that temperatures taken during audits were accurate, while the DON and Administrator expressed expectations that hot food be hot and cold food be cold.
Surveyors found that nourishment refrigerators and freezers on several units were soiled with dried food debris, and multiple opened grape jelly containers were left undated and unrefrigerated despite labeling that required refrigeration after opening. Facility policies required refrigerators and freezers to be kept clean, free of debris, and that refrigerated or frozen foods be covered, labeled, and dated. Staff interviews showed that Dietary was responsible for cleaning nourishment refrigerators, that refrigerators were cleaned on a set schedule with spills expected to be wiped up by staff, and that opened jelly should have been dated and refrigerated. These practices had the potential to affect all current residents.
The facility failed to maintain a safe, clean, and homelike environment and to ensure adequate supplies for resident care. Over several months, grievances and Resident Council minutes documented repeated concerns about lack of needed supplies, use of wrong-size briefs, and the prolonged closure of a small dining room. Multiple STNAs reported frequent shortages of briefs, linens, washcloths, peri-care products, and other supplies, sometimes leading staff to cut towels into washcloths and to use ill-fitting brief sizes for residents. Environmental observations revealed inaccessible and damaged dining areas with buckled and broken floor tiles, missing and stained ceiling tiles, and a resident bathroom with uneven flooring, persistent staining, a cracked shower light cover containing a dead insect, and a soap dispenser installed above a non-functional outlet. Additional rooms and hallways had exposed wall cracks, sagging ceiling tiles, lifting and separating floor tiles, and buckled flooring attributed to leaks, while maintenance and housekeeping leaders acknowledged awareness of many of these issues but had not ensured timely correction.
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, and staff did not consistently follow existing care plan interventions. Several residents with PEG tubes, a dialysis catheter, and a colostomy either lacked appropriate EBP care plan focuses at admission or did not have EBP practices implemented as written, including missing door signage and failure to follow tube-feeding protocols. In addition, two residents with PTSD and other mental health diagnoses had active PTSD documented in assessments and psychiatric notes, but their care plans did not address PTSD-related triggers, symptoms, or trauma-informed interventions, despite staff acknowledging these omissions and the importance of accurate, complete care planning.
A deficiency was cited after surveyors found that multiple residents receiving enteral nutrition did not receive care consistent with facility policy, physician orders, or manufacturer guidance. Tube feeding bags were often hung without dates or times, tubing connectors were left uncapped between uses, and pumps and IV poles were visibly soiled with dried formula. A resident with a G-tube and severe cognitive impairment twice developed abdominal wall cellulitis identified by an adult day care center, with no prior documentation of infection signs by facility staff despite orders to monitor the site each shift. Other residents had medications administered via PEG or G-tubes without verification of tube placement, feedings started late or allowed to run past ordered stop times, and feeding systems spiked and primed hours before use with open, uncovered connectors. Staff interviews confirmed that protective caps were not supplied, that they were behind on tasks, and that they were aware these practices could introduce contamination, leading to the cited deficiency in enteral feeding management.
The facility failed to implement and maintain effective infection prevention and control practices, including missing Enhanced Barrier Precautions (EBP) signage for multiple residents with devices such as feeding tubes, colostomies, dialysis catheters, and indwelling urinary catheters, despite care plans and orders indicating EBP. Several residents receiving tube feedings had bottles and tubing hanging without dates or times and without protective end caps when not in use, contrary to staff statements that feedings should be dated, timed, and properly capped. Staff also did not consistently disinfect shared equipment and surfaces between residents, including a medication cart used for blood glucose checks, a blood pressure cuff used on more than one resident, and a mechanical lift that was returned to the hallway without cleaning after use, despite facility expectations and policies requiring cleaning between each resident.
The facility failed to maintain an effective pest control program, as gnats, roaches, mice, and other pests were repeatedly observed and reported in resident rooms, bathrooms, dining areas, and the kitchen. Surveyors noted gnats around urine-filled urinals on a bedside table, in the kitchen near an open freezer, and on dirty dishware in a unit dining room, as well as a cracked bathroom light fixture containing a dead moth. Exterior doors near the kitchen, courtyard, and parking lot were repeatedly propped open with objects, contrary to expectations stated by the DON, Dietary Manager, and Maintenance Director, allowing pests to enter. A resident reported seeing a mouse and cockroaches in his room, with a mouse glue trap observed there, while another resident reported a mouse in her window and mouse droppings in both the window and on a meal tray. STNAs described ongoing problems with gnats and large roaches and stated that routine pest control spraying and glue traps had not resolved the issues.
Surveyors identified expired oral and topical medications in five of six medication and treatment carts, with several types of medications found past their expiration dates or lacking clear expiration labeling. Interviews with nursing staff, the DON, and the pharmacist revealed inconsistent and unclear protocols for auditing and removing expired medications, leading to expired drugs remaining accessible. Facility policy required secure storage and timely removal of expired medications, but these procedures were not reliably followed.
The facility did not consistently implement infection prevention and control protocols, including proper use of PPE, hand hygiene, and signage for residents on transmission-based or enhanced barrier precautions. Staff were observed entering rooms and providing care without following required precautions, and meal trays were distributed without appropriate hand hygiene or glove changes. Additionally, improper management of urinary catheter bags was noted, and staff interviews revealed confusion about infection control procedures.
Surveyors found that cold foods were left unrefrigerated for extended periods before meal service, and dietary staff failed to follow proper hand hygiene and glove use protocols, including touching surfaces and returning to food service without changing gloves or washing hands. The main dining room counter was also observed to be inadequately cleaned, with food crumbs and residue present.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to provide food and drink at safe and appetizing temperatures in accordance with its own Food Preparation and Service policy. The policy, dated 2001, defined the temperature danger zone as above 41°F and below 135°F, and required potentially hazardous foods to be maintained at or below 41°F or at or above 135°F. Multiple Providence Pavilion Test Tray Assessment documents for various meals showed hot foods such as baked ravioli, baked chicken, rice pilaf, carrots, rosemary chicken, mushroom rice, au gratin cauliflower, broccoli, mashed potatoes, beef stroganoff, and carrots being served at temperatures between 118°F and 132°F, which were within the policy’s stated danger zone. Cold items such as apple bar, milk, cold ham and cheese sandwich, pudding, juice, and lemonade were recorded at temperatures between 42°F and 61°F, also within the danger zone. During a test tray observation, surveyors tasted the beef stroganoff, broccoli, and lemonade and described them as room temperature, cold, and warm, respectively. Resident feedback corroborated these findings. One resident, admitted with diagnoses including type 2 diabetes mellitus, major depressive disorder, and anxiety, and assessed as cognitively intact with a BIMS score of 14/15, stated she received cold food all the time. Residents attending a Resident Council meeting also reported receiving cold food at mealtimes. Despite these reports and documented tray temperatures in the danger zone, the Dietary Manager stated she preferred hot food served at 130°F and reported that steam tables were turned on one-half hour before meal service. The RD reported that she conducted sanitation walkthroughs and test trays and stated that hot food was always hot and that recorded temperatures showed this, and further indicated that department heads passed trays and took temperatures during test tray audits. The DON and Administrator both stated their expectations that residents receive food at proper temperatures, with hot food hot and cold food cold, but the documented observations and resident interviews showed that this was not consistently occurring.
Improper Food Storage and Unsanitary Nourishment Refrigerators
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards and its own policies for food safety. Surveyors observed that nourishment refrigerators and freezers on multiple units, including the Honor, Pavilion, and Purpose Units, were soiled with dried food debris on shelves and throughout the compartments. On the Honor Unit, an opened grape jelly container was found sitting on top of the refrigerator, undated and not stored inside the refrigerator, despite the product label directing refrigeration after opening. In the kitchen, two additional opened and undated grape jelly containers were observed left out of the refrigerator. Review of facility policies from 2001 showed that refrigerators and freezers were to be kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis, and that all foods stored in the refrigerator or freezer were to be covered, labeled, and dated with a use-by date. Staff interviews further clarified practices and expectations related to the deficiency. A state tested nurse aide stated that Dietary was responsible for cleaning the unit nourishment refrigerators. The Dietary Manager reported that nourishment refrigerators were cleaned twice weekly and that any spills should be cleaned up by staff, and acknowledged that the jelly was kept out to make peanut butter and jelly sandwiches, but should have been dated when opened and kept refrigerated. The DON stated her expectation that nourishment refrigerators be clean, and the Administrator stated her expectation that staff wipe up any spills and maintain the cleanliness of nourishment and resident refrigerators. The deficient practices had the potential to affect all 80 current residents.
Failure to Maintain Safe, Clean, and Homelike Environment and Adequate Care Supplies
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with a safe, clean, comfortable, and homelike environment, including adequate supplies for daily care. The facility’s own policy on a homelike environment requires a safe, clean, comfortable setting that emphasizes residents’ independence and personal needs and preferences. Review of grievance logs and Resident Council minutes over several months showed repeated resident concerns about not having needed supplies and the prolonged inaccessibility of the small dining room. Grievances documented that residents lacked needed supplies and that the small dining room remained unusable, while Resident Council minutes reflected residents’ desire for the small dining room to be usable by Thanksgiving and ongoing concerns about not receiving needed supplies and aides using the wrong size briefs. Multiple staff interviews confirmed ongoing supply shortages affecting resident care. One STNA reported that the facility frequently did not have enough supplies, including hand sanitizers, soaps, clean linens, and briefs, and that this had been an issue for a few months. She stated that when briefs ran out, staff reported to nursing, who contacted central supply, and if unavailable, the Administrator was called to purchase supplies locally. Another STNA reported housekeeping budget cuts and stated the facility had run out of washcloths and disposable bed pads, leading staff to cut up towels to use as washcloths for peri-care. She also reported that a previous central supply staff member told STNAs the facility budgeted briefs to be changed once every six hours, which she felt was not sufficient for some residents, and that residents sometimes had to use larger or smaller brief sizes and complained about this. A third STNA stated the facility ran out of supplies on the unit, sometimes leaving no linens for night shift, and that peri-care supplies and specific brief sizes sometimes ran low, requiring use of different sizes. Environmental observations and staff interviews showed multiple areas of the building that were not maintained in a safe, clean, or homelike condition. The small dining/activity room off the main hall was observed with tables and chairs blocking entryways and a wavy, buckled wood-grain tile floor, and the room remained inaccessible to residents. In the Honor dining room, surveyors observed a large section of broken and mismatched wood-grain tiles with gaps between them and a missing ceiling tile. The bathroom in one resident room had an uneven floor, staining on the raised toilet seat, rust-colored stains running from a soap dispenser down past a non-functional wall outlet and onto the baseboard, and a cracked shower light cover containing a dead moth. The Housekeeping Manager acknowledged the staining had been present for two to three months, that attempts to remove it were unsuccessful, that the bathroom was not homelike, and that the floor needed to be replaced. Additional structural issues were observed in resident areas and common spaces. In another resident room, the wall with the window had an exposed crack with visible sheetrock, and ceiling tiles above the door included one missing tile and six stained and sagging tiles; an LPN stated there had been a leak and that maintenance was aware, but no repairs had been made. The Maintenance Director stated the leak was caused by the HVAC system and that repairs had not yet been completed. In the Providence hallway, blue border floor tiles were lifting and separating along the length of the hallway, with large scuff marks and dull, soiled center tiles; the Housekeeping Manager stated staff could not strip and wax the floor due to the tile’s condition, and the Regional Maintenance Director stated the facility was in the process of obtaining quotes to replace the floor. In another resident room, the floor appeared buckled and wavy, which the Maintenance Director attributed to a water leak in a wall coil assist located in the ceiling, and he stated there were plans to repair the flooring in multiple rooms. Interviews with maintenance and management staff showed awareness of many of these environmental issues but also revealed gaps in monitoring and timely correction. The Maintenance Assistant reported doing monthly room rounds for lights, extension cords, plugs, and handrails but was unaware of the bathroom issues in the identified room and had not noticed the damaged tiles in the Honor dining room or how long the small dining room had been closed. The Maintenance Director stated the small dining room floor damage was due to a water leak from an ice machine and believed it occurred months earlier, and he acknowledged that the non-live outlet in the bathroom would need to be removed and covered. The Housekeeping Manager stated she was aware of damaged and ill-fitting tiles in the Honor dining room and that floors in several areas, including the small dining room, needed replacement. The DON and Administrator both stated their expectations that the facility be kept clean, safe, and homelike, with all spaces utilized for residents and floors kept even, clean, dry, and free from clutter, but the observed conditions and staff reports demonstrated that these expectations were not being met.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for multiple residents, and failure of staff to follow existing care plan interventions. For two residents with PEG tubes and one resident with a dialysis catheter, the facility did not fully develop care plans at admission to reflect their diagnoses and required Enhanced Barrier Precautions (EBP). One resident was admitted with a PEG tube in August 2025, but EBP related to the PEG tube was not added to the care plan until March 2026, and there was no EBP signage on the door during observation. Another resident admitted with end stage renal disease and a dialysis catheter had no care plan focus for the dialysis catheter or EBP, despite having an order for EBP and being admitted with the catheter; there was also no EBP signage observed on the door. For a resident with diverticulitis and colostomy status, the care plan did include EBP, and there were orders for EBP and colostomy care every shift; however, there was no EBP signage on the door, and the MDS nurse stated she had been told that residents with colostomies did not require EBP, even though EBP remained on the care plan and staff were expected to follow care plan interventions. Another resident with cerebral palsy, epilepsy, and gastrostomy status had a care plan directing staff to check PEG tube placement and gastric contents/residual volume prior to medication administration per facility protocol, but observation showed an LPN administering medications via the PEG tube without checking for placement before pushing the medication. Two residents with PTSD diagnoses did not have their mental health needs fully addressed in their care plans. One resident admitted in 2023 with PTSD and other mental health diagnoses had a quarterly MDS showing a mood severity score of 18, with difficulty sleeping, little interest in activities, and feeling depressed or hopeless nearly every day, and psychiatry notes documented PTSD and schizoaffective disorder related to past trauma and ongoing nightmares; however, the care plan contained no focus for PTSD. Another resident admitted in 2016 with PTSD and borderline personality disorder had an active PTSD diagnosis on the MDS, but the comprehensive care plan did not address PTSD, including triggers, symptoms, or trauma-informed interventions. The Social Services Director, MDS nurse, DON, and Administrator all acknowledged that the PTSD diagnosis and related care plan focus had been overlooked and that care plans were expected to be fully developed and implemented so staff would know how to properly care for residents.
Failure to Maintain Safe, Timely, and Sanitary Enteral Feeding Practices
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services to prevent complications related to enteral nutrition for six residents with feeding tubes. Surveyors found that tube feeding systems were frequently hung without being dated or timed, and tubing connector tips were left uncapped between uses, despite facility policy and manufacturer guidance requiring protection of components that contact formula. Multiple residents had feeding containers spiked and primed but not infusing, with the open ends of tubing left exposed and no protective caps available. Staff interviews confirmed that caps were not provided by the facility, and nurses acknowledged that uncovered connectors could introduce germs and place residents at risk for infection. For one resident with a gastrostomy tube and severe cognitive impairment, the care plan and orders required monitoring the G-tube site for infection every shift and checking tube placement and gastric residuals. The resident was sent twice from an adult day care center to the Emergency Department and diagnosed with abdominal wall cellulitis on both occasions, after the day care staff identified abnormal G-tube findings, including leakage and inability to flush the tube. The facility’s clinical record contained no documentation that staff had identified or recorded signs or symptoms of infection before the resident left for day care on either occasion, and the Physician Assistant reported she had not been notified of excessive leakage that could contribute to recurrent cellulitis. During observation, this resident’s G-tube site was reddened with yellowish-green drainage, the feeding container had been spiked the previous day and was being reused, the connector was left uncovered, and the pump and IV pole had dried formula residue. Other residents with PEG or G-tubes also experienced deficiencies in enteral feeding management. Several residents had tube feedings hanging and infusing without dates or times on the bags, and tubing sets were observed primed and hanging with open, uncapped ends. One resident received medications via PEG tube without the nurse checking tube placement beforehand, despite a care plan intervention to check placement and gastric contents per protocol. Another resident’s feeding was labeled to start later in the day but was already spiked and primed hours in advance, with the connector left uncovered and the pump and IV pole soiled with dried feeding residue. For a resident ordered to receive tube feeding from late afternoon to early morning, the feeding was started approximately two hours late and then observed still infusing well past the ordered stop time; the resident was later found in bed with a large amount of emesis on the gown and linens, and the LPN stated she had been running behind and had not turned off the feeding. Throughout these observations, the DON, PA, RD, and product representative all confirmed that connectors should be covered, feedings should follow ordered schedules, and systems should not remain hanging beyond recommended timeframes, but the facility’s practices did not align with these expectations. Across multiple days of observation, the surveyors repeatedly noted that enteral feeding pumps and IV poles for several residents were coated with dried feeding residue on the exterior surfaces, along the poles, and at the bases, indicating that equipment used for tube feeding was not maintained in a clean and sanitary condition. Facility policies on enteral nutrition and G-tube site care required staff to monitor for signs of infection, maintain cleanliness of the tube site, assess for redness, swelling, pain, or drainage, and report signs of infection to a supervisor and physician. The policies also emphasized confirming tube placement prior to initiating feedings to reduce aspiration risk and recognizing complications such as aspiration, tube misplacement, skin breakdown, and gastrointestinal symptoms. Despite these written policies and the manufacturer’s guidance on closed versus open systems, hang times, labeling, and handling to prevent contamination, staff actions and inactions—including failure to document and report abnormal G-tube findings, failure to verify tube placement before medication administration, failure to adhere to ordered feeding schedules, and failure to keep connectors capped and equipment clean—led to the cited deficiency for all six residents receiving enteral nutrition.
Failure to Implement Effective Infection Prevention and Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program, as evidenced by multiple observations of noncompliance with policies, CDC guidance, and basic infection control practices. Surveyors observed that residents on Enhanced Barrier Precautions (EBP) did not have required signage posted on their room doors, despite care plans and orders indicating the need for EBP. Residents with devices such as a PEG tube, colostomy, dialysis catheter, and indwelling urinary catheter were under EBP, but their rooms lacked appropriate signage. Staff interviews confirmed that EBP should have been initiated and care planned upon admission for these residents and that signage should have been posted, but this was not done or was delayed. The deficiency also includes improper management of enteral nutrition systems for several residents receiving tube feedings. Surveyors observed tube feeding bottles and tubing hanging on poles without dates or times indicating when they were opened or hung, and with tubing primed but without protective end caps when not in use. Staff, including LPNs and the PA, acknowledged that tube feedings should be dated and timed, that they are only good for a limited period once hung, and that the absence of end caps could allow germs or bacteria to be introduced into the feeding system. The DON and Administrator stated their expectations that tube feedings be dated, timed, and capped, and that undated or uncapped systems should be replaced, but the observed practice did not align with these expectations. Additional deficiencies were identified in the cleaning and disinfection of shared equipment and surfaces between resident use. A nurse performing blood glucose checks placed used supplies and a glucometer on the medication cart surface, cleaned the glucometer, but did not disinfect the cart surface before preparing supplies for another resident on the same surface. Another nurse used a blood pressure cuff on two different residents without cleaning it between uses, stating she normally would use disinfectant wipes but forgot and did not have wipes in her cart. In a separate incident, staff used a mechanical lift to transfer a resident back to bed and then placed the lift in the hallway without cleaning it after use. Staff and leadership interviews confirmed that shared equipment and surfaces should be disinfected between residents to prevent cross-contamination, but this was not consistently done. Collectively, these observations show that the facility did not follow its own infection prevention and control policies related to EBP implementation and signage, safe handling of tube feedings, and cleaning and disinfection of shared equipment and surfaces. The facility’s policies required surveillance of staff adherence to infection control practices, proper use of standard precautions, and cleaning and reprocessing of reusable equipment between residents, but surveyors found repeated instances where these requirements were not met for multiple sampled residents.
Failure to Maintain Effective Pest Control and Environmental Practices
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and rodents, despite having a pest control contract and invoices showing routine service. Surveyors observed gnats in multiple areas of the facility on several days, including around urinals in a resident room, in the kitchen near an open double reach-in freezer, and on dishware in a unit dining room sink and tray. A cracked overhead bathroom light fixture in another room contained a large dead moth. Staff and residents reported seeing gnats, roaches, and mice in the facility, and invoices confirmed that pest control services were being provided for various pests including mice, rats, spiders, water bugs, silverfish, and roaches. Multiple observations showed that exterior doors were repeatedly propped open, allowing pests to enter the building. The kitchen delivery and emergency door was held open with a milk crate, creating a gap between the doors, and the kitchen back door was again observed held open with a milk crate on another day. Two side doors leading to the courtyard and toward the kitchen were observed open with wind blowing into the building, and a side door facing the parking lot was held open with two chairs, despite posted signs instructing that the door not be used. The Director of Maintenance, Dietary Manager, and DON each stated that these doors were expected to remain closed except during specific uses, and acknowledged that open doors allowed pests to enter and potentially contaminate food. Residents and staff provided additional accounts of pest activity. One resident reported seeing a mouse come from under a chair in his room, as well as cockroaches on the walls disappearing into ceiling tiles and gnats; a mouse glue trap was observed behind a chair in that room, and the resident stated he had reported the issue and pest control had sprayed. Another resident reported finding a mouse between the screen and window in her room, later seeing mouse droppings in the window, and receiving a meal tray with mouse droppings. STNAs reported seeing large roaches in hallways, ongoing problems with flies and gnats in dining rooms, and complaints from residents and families about gnats, while also stating that pest control spraying did not seem effective. The DON acknowledged that one resident did not like staff touching his belongings, which contributed to urinals with urine being left on a bedside table with gnats flying around them, and stated the facility should be kept clean and as nice as possible for residents.
Expired Medications Found in Multiple Medication Carts Due to Inconsistent Auditing
Penalty
Summary
Surveyors found that the facility failed to ensure proper storage and timely removal of expired oral and topical medications in 5 out of 6 medication and treatment carts. Observations revealed multiple expired medications, including ibuprofen, acetaminophen, midodrine, loperamide, ondansetron, multivitamins, magnesium citrate, naloxone, olanzapine, pantoprazole, Almacone, polyethylene glycol, Refresh eye drops, vitamin D3, Milk of Magnesia, Tylenol, Senna, nitroglycerin, Prostat, ketoconazole cream, and Minerin Cream. Some medications were found without clear expiration dates, and in some cases, pharmacy stickers and commercial bottle dates did not match. Interviews with nursing staff indicated inconsistent practices regarding the auditing and removal of expired medications. Some nurses stated that expired medications should be discarded and that audits were expected to be performed, typically by night shift staff, but there was no clear assignment or protocol for regular audits. Staff also reported that medications not used within 30 to 60 days should prompt a call to the physician, but there was no evidence of a systematic process to ensure this occurred. The facility's policy required medications to be stored securely and for staff to maintain storage areas in a clean and safe manner, with expired or discontinued medications to be returned or destroyed per pharmacy instructions. The pharmacist reported conducting monthly spot checks and removing medications within 30 days of expiration, but these checks were not comprehensive. The DON and Administrator both expected regular audits by nursing staff and managers, but interviews revealed that these expectations were not consistently met, resulting in expired medications remaining accessible in medication carts.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observations and interviews involving five residents. Staff did not consistently follow established protocols for transmission-based precautions (TBP), enhanced barrier precautions (EBP), and standard hand hygiene practices. For example, signage indicating required precautions was missing or inconsistently posted for residents with active orders for TBP or EBP, and staff were observed entering rooms or providing care without donning appropriate personal protective equipment (PPE) such as gowns and gloves. In one case, a resident with MRSA and pressure ulcers did not have TBP signage posted as ordered, and staff could not explain the omission. Another resident with orders for EBP due to multiple risk factors was cared for by a nurse who wore gloves but not a gown, contrary to policy and posted instructions. Staff also failed to adhere to hand hygiene and PPE protocols during routine activities such as meal tray distribution. Several nurse aides were observed passing lunch trays to residents, including those on EBP or TBP, without performing hand hygiene between residents or changing gloves, and in some cases, wearing the same gloves throughout the process. One aide stated she wore gloves for personal preference and did not change them due to time constraints, while another began assisting a resident in contact isolation without performing hand hygiene or donning PPE, despite signage and available supplies. These lapses occurred even though facility policy and posted signage required hand hygiene and PPE use in these situations. Additional deficiencies included improper management of urinary catheter bags, with one resident's catheter bag observed resting on the floor, contrary to infection control policy. Staff interviews confirmed awareness that catheter bags should not touch the floor to prevent infection, but the issue was attributed to the bed being in a low position. The facility's infection preventionist and nursing leadership acknowledged responsibility for ensuring proper signage, PPE use, and adherence to infection control protocols, but were unable to account for the observed lapses. Staff interviews revealed inconsistent understanding of when and how to implement precautions, with some staff unaware that contact precautions constituted isolation or unsure of the correct procedures.
Failure to Store and Handle Food Safely; Inadequate Hand Hygiene in Dietary Services
Penalty
Summary
Surveyors observed that the facility failed to store and handle food in accordance with professional standards and its own policies. During multiple observations in the kitchen, pre-plated cold foods such as juice, tossed salads, and cheese plates were left unrefrigerated on tray carts for extended periods before meal service. The Certified Dietary Manager (CDM) confirmed that these items were set up well in advance and only placed in refrigeration shortly before mealtime, contrary to the facility's policy and food safety guidelines requiring cold foods to be held at 41°F or less. Additionally, the main dining room counter was repeatedly found with food crumbs and a dried brown substance in the hand sink, indicating inadequate cleaning practices. Dietary staff were also observed failing to follow proper hand hygiene and glove use protocols. Staff members wore gloves while serving food but touched various surfaces, such as cabinet handles and the nurse's desk, without changing gloves or washing hands between tasks. The CDM, DON/Infection Control, and Administrator all acknowledged that these actions did not meet facility expectations or infection control standards, as outlined in the facility's hand hygiene policy. No specific residents were identified as being directly affected in the report.
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The facility failed to maintain an effective pest control and sanitation program, resulting in a widespread gnat infestation in common areas, resident halls, the laundry room, medication cart trash, dirty utility room, and the kitchen. Surveyors observed gnats emerging from drains, stagnant mop water with a rancid odor, and extensive moisture, standing water, and organic debris in kitchen drains, cracked floor tiles, and hard-to-reach areas behind equipment. Pest control service reports over several months repeatedly documented unresolved issues such as drain debris, standing water, and debris accumulation, while the pest control provider stated that facility compliance with recommended cleaning and maintenance was inconsistent and many action items remained undone. The Dietary Manager reported ongoing gnat problems and use of a hose-mounted floor sprayer and vinegar in drains, which the pest control representative stated would not remove organic buildup or larvae. Leadership, including the VPO, DON, and Administrator, described expectations for cleaning, pest reporting, and drain use that were not reflected in observed conditions, and two residents reported that gnats were frequently present around them and their food, especially during meals.
A resident with morbid obesity and bilateral foot drop, whose care plan called for two staff for bed mobility and incontinence care, slid off the edge of the bed during perineal care and sustained abrasions and skin discoloration. The resident stated an SRNA rolled them too far while the SRNA was on the opposite side of the bed, and staff interviews confirmed the SRNA performed the care alone instead of waiting for another staff member. The ADON and DON stated the resident should have had two staff assist with the care.
An LPN was observed administering insulin via a pen injector to a resident with diabetes without priming the needle before either dose. The resident had type 2 DM with hyperglycemia and active NovoLog FlexPen orders, but the facility’s competency assessment covered insulin by syringe and did not show training or assessment for insulin pen use. The LPN stated she was not aware priming was required, and the DON and Administrator confirmed the facility had not provided competency training on insulin pens.
A resident admitted for rehab with muscle weakness and unsteadiness had PT and OT care plans and orders for treatment five times per week, but therapy logs showed missed PT/OT sessions on two days with no documented reason. The Director of Rehabilitation confirmed the resident received therapy only three of five days over two consecutive weeks, contrary to the plan of care, and could not explain or document why sessions were missed. The resident and the resident’s representative reported that the resident did not receive therapy as expected, that therapy minutes were insufficient, and that services were not tailored to the resident’s needs, including use of group therapy despite the resident’s stated preference against it.
The facility failed to maintain a safe, clean, and sanitary laundry environment and to properly manage a resident’s clothing. A resident with COPD, heart failure, type 2 DM, and ESRD had most of their clothing lost during a short stay, and the family member who searched for the items described the laundry room as extremely hot, messy, dirty, with clothes everywhere and overflowing trash. Staff interviews confirmed the laundry room had long‑standing issues with excessive heat and clutter. Surveyor observations found floors between and behind washers covered with dirt, a dry flaky substance, loose concrete, and residue on piping and chemical tubing, alongside buckets of corrosive chemicals. Interviews with housekeeping, EVS, a chemical vendor, and maintenance showed that a chemical spill behind the washers had occurred over a year earlier and was never properly cleaned up, with conflicting accounts over whether maintenance or EVS was responsible and no effective system to ensure cleaning behind the machines.
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident with mild cognitive impairment and multiple medical conditions was reported by the resident’s family member. The Administrator was notified of the allegation that someone had smacked the resident across the face, but the initial report to the state survey agency was not submitted until more than three and a half hours later, exceeding the required two-hour timeframe. Facility documentation did not show that law enforcement was notified, despite policy requiring reporting of suspected crimes, and interviews with the SSD, DON, and Administrator confirmed that the expected practice was to report such allegations promptly to the state survey agency and law enforcement when applicable.
Two residents reported serious allegations—one of missing money and identification and another of being slapped by a staff member—but the facility failed to conduct comprehensive investigations as required by its abuse policy. In the misappropriation case, a cognitively intact resident named a specific staff member by first name, and the schedule showed an SRNA with that name worked during the alleged timeframe, yet that SRNA was never interviewed or asked for a statement, and the DON acknowledged not knowing the investigative process. In the physical abuse case, a resident with mild cognitive impairment reported being slapped and told a family member that a manager over the office was responsible, but the facility obtained statements only from some floor staff, did not interview office staff, did not obtain statements from all staff who worked the relevant shifts, and limited resident interviews and skin assessments to one hall. These actions and omissions resulted in incomplete investigations of both abuse-related allegations.
A resident with dementia, osteoporosis, a right artificial hip, and severe cognitive impairment was care planned as dependent for bed mobility, toileting, and transfers, with an intervention requiring two staff for assistance. Despite this, an SRNA, who knew the resident was a two-person assist, began perineal care alone and rolled the resident onto the side, causing the resident to roll out of bed and fall. An LPN obtained stat x-rays that showed a displaced right femoral shaft fracture, and the resident was sent to the hospital, where surgery was performed and the resident later died on a hospice unit. Staff interviews confirmed that the two-person assist requirement had been in place for years and that the failure to follow the care plan led to the incident.
A resident with dementia, osteoporosis, and a right artificial hip joint, assessed as severely cognitively impaired and dependent for bed mobility, toileting, and transfers, had a care plan and Kardex requiring a two-person assist for these ADLs. An SRNA, despite knowing this requirement, began perineal care alone and rolled the resident onto her side, causing the resident to roll out of bed onto the floor. The incident report and IDT identified the root cause as failure to follow the Kardex, with contributing factors including the resident’s weakness and history of falls. An LPN and unit manager found the resident on the floor, obtained stat x-rays that revealed a displaced right femoral shaft fracture, and the resident was sent to the hospital, where imaging confirmed a comminuted, moderately displaced femoral fracture and an ORIF procedure was performed. Staff interviews confirmed that the resident had long required a two-person assist and that only one staff member was present at the time of the incident, and also revealed that nurses and managers had not routinely spot checked SRNAs for adherence to the care plan/Kardex prior to the event.
A resident with intact cognition and multiple comorbidities developed fever and abnormal urinalysis results consistent with a UTI, for which an NP ordered a single 3 g dose of Fosfomycin. The MAR showed the antibiotic order and later an entry placing it on hold due to unavailability from pharmacy, without a corresponding provider order or documentation explaining the delay or who was contacted. The medication was not administered until four days after the original order, during which time the resident reported going without treatment and later required ED transfer, where a complicated UTI was diagnosed and treated with IM Rocephin and Toradol.
Failure to Maintain Effective Pest Control and Sanitary Conditions Resulting in Widespread Gnat Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free of insects and other pests, resulting in a widespread gnat infestation throughout the building. Surveyor observations over two days identified gnats in multiple common areas, including the conference room, resident halls, laundry room, medication cart trash can, and dirty utility room. In the laundry room, gnats were seen emerging from the washing machine discharge drain, and in the dirty utility room, gnats were concentrated around a mop bucket containing stagnant, foul-smelling water. On a resident hall, multiple gnats were observed flying around residents and on surfaces throughout the corridor. Extensive observations in the kitchen revealed multiple environmental and sanitation issues that contributed to the gnat activity. Behind and around the ice machine and juice cart, there was wet dust, dirt, and organic debris such as food crumbs, sugar packets, and trash items, all saturated with moisture. Cracked, loose, and broken floor tiles near the ice machine drain and in the dish room contained food debris lodged within and beneath the damaged tiles, with standing water collected beneath the tiles and pooled around the ice machine drain. Standing water was also observed in the spray room, dish room, along walls, and in corners, with water spread across the kitchen floor after staff used a hose-mounted sprayer to clean the floors. On a subsequent day, the kitchen floor again had visible standing water, and a floor drain contained accumulated debris, paper fragments, and organic material, with a broken drain grate that did not fully cover the drain and exposed additional trapped debris; gnats were present in and near this drain and throughout the kitchen. Review of facility work orders showed only one report of gnats in common areas and nursing units for one month and one report of bugs facility-wide in the following month, despite the widespread activity observed. Service reports from the contracted pest control company over several months documented ongoing, unresolved environmental concerns in the kitchen and adjacent areas, including repeated findings of drain debris, standing water in kitchen and dishwashing areas, debris accumulation, and moisture issues that remained uncorrected by the facility. The pest control representative and pest control account manager both stated that gnats were originating from drains, cracks, and crevices with organic debris and moisture, and that routine cleaning practices were ineffective when debris remained or was pushed into cracks and around drains. They reported that recommendations such as debris removal, proper drain maintenance, and cleaning of hard-to-reach areas were repeatedly communicated and documented, but the facility’s compliance with these recommendations was inconsistent, with many action items left undone and carried over on subsequent service reports. Interviews with staff and leadership further described the facility’s actions and inactions related to pest control and sanitation. The Dietary Manager reported ongoing gnat concerns for multiple weeks, stated that pest control services were provided twice monthly, and that kitchen staff performed routine cleaning weekly and as needed, using a hose-mounted spray system for floors and pouring vinegar down drains between pest control visits. The pest control representative stated that pouring vinegar down drains would not eliminate the infestation and might attract gnats, as it did not remove organic buildup or kill larvae. The pest control account manager identified contributing factors such as debris buildup in cracks and flooring, lack of routine cleaning behind equipment, standing water or improperly maintained mop buckets, inconsistent cleaning practices in non-visible areas, and lack of routine maintenance of drains and traps, and noted that environmental cleaning often improved only after issues became more apparent. The VPO acknowledged gnat activity throughout the building and that pest control reports had identified ongoing debris concerns in the kitchen, but could not clearly describe a process to ensure consistent cleaning of hard-to-reach areas or to verify cleaning effectiveness. The DON and Administrator described expectations for reporting pests, emptying mop buckets, removing trash from medication carts, removing debris before floor cleaning, and not sweeping debris into drains, but these expectations were not reflected in the observed conditions. Two cognitively impaired and intact residents reported that gnats were always present, especially around meal times and food, and that they found them bothersome and undesirable during meals.
Failure to Provide Two-Person Assistance During Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance to prevent a fall for one resident who had diagnoses of morbid obesity, left foot drop, and right foot drop. The resident’s care plan identified a need for two staff members for bed mobility and in-bed care related to bariatric status, and also directed staff to provide two-person assistance for bed mobility and total assistance for incontinence care as the resident allowed. The resident’s MDS indicated intact cognition and that the resident required supervision or touching assistance for rolling left and right in bed. During incontinence care, the resident slid off the edge of the bed to the floor and onto their knees. The acute change in condition assessment documented abrasions and skin discoloration after the incident. In interviews, the resident stated that a staff member rolled them out of bed during incontinence care and that they were able to assist with rolling by using the assist bars on either side of the bed. The resident stated that while rolling to the right side of the bed, they rolled too far and slid off the edge of the bed while the SRNA was standing on the opposite side of the bed. Staff interviews showed that the SRNA provided the incontinence care by herself even though the resident required two-person assistance. The SRNA stated she did not ask another staff member for help because she was used to performing the care alone, and later stated that having another SRNA in the room could have prevented the incident. Other staff, including the ADON and DON, stated the resident should have had two staff members assist with incontinence care. The DON also stated the resident could assist with turning using the bed rails, but the SRNA should have used another staff member and waited for assistance.
Insulin Pen Competency Not Demonstrated
Penalty
Summary
Licensed nursing staff were not shown to have the competencies and skill set necessary to administer insulin via an insulin injector pen for one LPN observed caring for a resident with diabetes. Review of the LPN’s competency assessment showed the DON assessed insulin administration by syringe, but it did not indicate assessment of insulin pen injector use, even though the competency document stated staff should have access to manufacturer instructions for all insulin delivery systems before use. The manufacturer’s instructions for NovoLog FlexPen required priming the pen before injection to avoid injecting air and ensure proper dosing. The resident involved was admitted with a diagnosis of type 2 diabetes mellitus with hyperglycemia and had active orders for NovoLog FlexPen, including a sliding scale order and a separate order for 16 units before meals. During observed medication administration, the LPN checked the resident’s blood glucose, which was 409, then administered 16 units of NovoLog FlexPen without priming the pen needle. After contacting the physician, the LPN later returned and administered 10 units from the sliding scale order, again without priming the insulin needle. The LPN stated she was not aware the pen needle needed to be primed and was unsure whether she had education on insulin pen injectors. The DON stated competency training covered insulin administration by syringe but not insulin pen injectors, and the Administrator stated the facility had not provided competency training related to insulin pens.
Failure to Provide Ordered PT/OT and Document Missed Therapy Sessions
Penalty
Summary
The facility failed to provide specialized rehabilitative services as ordered for one resident admitted for rehabilitation with diagnoses of muscle weakness and unsteadiness on feet. The resident’s care plan, initiated shortly after admission, identified a rehabilitation focus with skilled PT and OT interventions, and physician orders specified PT and OT to evaluate and treat. The OT plan of care called for treatment five times per week for 60 days, and the PT plan of care called for treatment five times per week for 30 days. Review of the Service Log Matrix showed that the resident did not receive individual PT or OT on two specified dates, despite the plan of care requiring therapy five days per week. The Director of Rehabilitation confirmed that the resident missed PT/OT on those two dates, that the plan of care was for five days a week, and that the resident only received PT/OT three out of five days for two consecutive weeks. The resident and the resident’s representative reported concerns that the resident was not receiving the allotted amount of therapy time and that therapy was not tailored to the resident’s specific needs. The representative stated the resident was weaker upon discharge than at admission and that the family sought transfer to another facility for PT after expressing concerns without improvement. The resident reported not receiving any PT during the first week, receiving PT only after questioning staff, and that when PT was provided it lasted 30–40 minutes and included group therapy that was counted as PT despite the resident’s preference against group therapy. The Director of Rehabilitation stated she did not know why therapy was missed on the two identified dates and that no reasons were documented, although such reasons were typically recorded. The DON stated her understanding that if therapy was missed, staff should attempt to reschedule so that residents did not miss needed therapy, and the current Administrator stated her expectation that residents receive the therapy they are supposed to receive to reach their maximum potential.
Failure to Maintain Clean, Safe Laundry Environment and Proper Handling of Resident Clothing
Penalty
Summary
The facility failed to ensure a safe, clean, sanitary, and comfortable environment in the laundry area as required by its Safe and Homelike Environment and Resident Rights policies. The policies stated that the physical layout should not pose a safety risk and that a sanitary environment must be maintained, including proper cleaning and storage of resident care equipment and items used for activities of daily living. Despite these policies, observations on 04/17/2026 showed the floor between and behind the washing machines covered and caked with dirt, a dry flaky substance, loose concrete, and residue on piping and chemical tubing, while multiple buckets of corrosive laundry chemicals and detergents were present in the same area. A resident’s family member reported that during the resident’s four‑day stay, most of the resident’s clothing was lost, and when she was allowed into the laundry room to search for the items, she found the room extremely hot, messy, with clothes everywhere, dirty conditions, and overflowing trash. The resident involved had significant medical diagnoses including COPD, acute on chronic systolic heart failure, type 2 diabetes mellitus, and end‑stage renal disease. A SRNA corroborated that the laundry room had always been hot, especially in summer, and that the room had long been somewhat messy with clothes, worsening over the past couple of years. Interviews with housekeeping, environmental services, the chemical supplier, and maintenance staff revealed that a chemical spill behind the washing machines had occurred well over a year earlier when ports at the back of the machines became clogged, causing chemicals to leak onto the floor. The chemical representative stated he cleaned the ports and moved tubing, and an EVS staff member told him maintenance would clean up the spill, but it was never done. Housekeeping reported that maintenance told them to clean up the spill themselves, while the Maintenance Director stated that EVS was responsible for cleaning the washing machines and that he had not observed leaks during his tenure. The dried, flaky substance and damaged concrete remained in place until it was later cleaned and repaired, and there was no documented system in place to ensure regular cleaning behind the washers, despite the presence of paper checklists for other tasks such as lint trap cleaning.
Failure to Timely Report Alleged Physical Abuse to State Agency and Law Enforcement
Penalty
Summary
The facility failed to report an allegation of physical abuse to the state survey agency and law enforcement within the required two-hour timeframe. Facility policy titled “Abuse Prohibition Standard of Practice,” last reviewed 03/2026, required that alleged violations be reported immediately to the Administrator or designee and to the state survey agency, adult protective services, and other required agencies, including law enforcement when applicable, within specific time frames. The policy also required the Administrator or designee to report suspicion of a crime to local law enforcement authorities. Resident 94, admitted on 06/19/2025, had a medical history including anemia, difficulty in walking, dislocation of an internal right hip prosthesis, muscle weakness, and other symbolic dysfunctions. An admission MDS with an ARD of 06/24/2025 showed a BIMS score of 10, indicating mild cognitive impairment, and the care plan documented impaired cognition and psychosocial adjustment difficulties related to anemia. On 07/01/2025, the facility generated an Initial Report indicating that a family member reported the resident had stated someone smacked them across the face the previous day after lunch or dinner. The Administrator was notified of this allegation at 9:45 AM. An email from the Administrator to the state survey agency showed the initial report was sent at 1:41 PM, more than three and a half hours after the Administrator was notified, exceeding the two-hour reporting requirement. The Initial Report did not indicate that local law enforcement was notified. During interviews, the SSD, DON, and Administrator all acknowledged that allegations of abuse should be reported to the state survey agency within two hours, and the Administrator stated that their process was to notify law enforcement when a resident requested or when there was a chance a law had been broken, but she did not follow the appropriate process in this case.
Failure to Conduct Comprehensive Abuse and Misappropriation Investigations
Penalty
Summary
The deficiency involves the facility’s failure to conduct prompt, comprehensive investigations into allegations of abuse and misappropriation of resident property, contrary to its Abuse Prohibition Standard of Practice policy. That policy required the administrator or designee to oversee internal investigations of all alleged violations of abuse, neglect, exploitation, misappropriation of resident property, and injuries of unknown origin, including interviews of all involved persons and others who might have knowledge of the allegations. For one resident, the facility did not interview the staff member specifically named by the resident as the alleged perpetrator of misappropriation, despite documentation showing that a staff member with that first name was scheduled and worked during the timeframe of the alleged incident. For another resident, the facility did not obtain statements from all staff who worked during the relevant shifts and did not interview or obtain statements from office staff, even though the allegation involved a manager in an office area. One resident, admitted with diagnoses including aftercare following removal of a knee joint prosthesis, generalized anxiety disorder, and major depressive disorder, had a BIMS score of 13 indicating intact cognition, but was also care planned for progressive decline in intellectual functioning, memory deficits, and anxiety with agitation. This resident reported that $350, a driver’s license, and an insurance card were missing from their wallet or purse and identified by first name the person they believed took the items. The facility’s initial and final reports to the state survey agency documented the allegation and noted that no cash was recorded on the admission inventory and that no staff by the alleged name worked on the day the allegation was reported. However, the facility’s monthly schedule showed that an SRNA with the same first name as the alleged perpetrator was scheduled and worked the evening and night shift spanning the date of the alleged incident. The investigation packet contained 20 staff statements, but no statement from this SRNA or from any staff member with the alleged first name. The SSD stated she obtained statements from everyone who worked that day and did not interview the SRNA because she believed the SRNA did not work that day, while the SRNA later confirmed she had worked that shift, knew the resident, and was never asked for a statement. The DON acknowledged she did not interview the SRNA, was unaware of the investigative process, and did not know if there was a process for investigating such allegations, and the Administrator, who was the Abuse Coordinator, confirmed that the SRNA was not interviewed despite the resident naming a staff member with that first name. Another resident, admitted with diagnoses including anemia, difficulty in walking, dislocation of an internal right hip prosthesis, muscle weakness, and other symbolic dysfunctions, had a BIMS score of 10 indicating mild cognitive impairment and was care planned for impaired cognition and psychosocial adjustment difficulties. This resident’s family member reported that the resident said someone smacked them across the face after a meal, and a typed SSD statement documented that the family member reported the resident said the manager over the office smacked them. The facility’s final report stated that the resident reported being slapped in a hall after a meal, could not identify the meal or describe the individual, and said they reported the incident to an employee in the back office. The investigation packet included 17 staff statements from floor staff (SRNAs, LPNs, and RNs) but no statements from any office staff, despite the allegation involving a manager over the office and a report to an employee in the back office. Daily staffing guides showed that 34 different floor staff worked during the two 12-hour shifts on the day of the alleged incident and the following day shift, yet statements were not obtained from multiple identified RNs, LPNs, SRNAs, and KMAs who worked those shifts. The facility conducted skin assessments and interviews only for residents on the hall where the resident resided and did not complete resident interviews or skin assessments for residents on other halls. In interviews, multiple staff who had worked during the relevant timeframe stated they were never asked about any resident being slapped or asked to provide statements. The DON stated that her role in abuse investigations was to perform skin assessments and obtain staff statements, believed that therapy and office staff had been interviewed, and did not review surveillance cameras, while the Administrator stated they narrowed the investigation and did not review cameras because they only showed hallways and not the back hallway where offices and therapy areas were located. Overall, for both residents, the facility did not follow its own policy requirement that investigations be prompt, comprehensive, and include interviews of all involved persons and others who might have knowledge of the allegations. In the misappropriation case, the named SRNA who worked during the alleged timeframe was not interviewed or asked for a statement, and the DON acknowledged lack of familiarity with the investigative process. In the physical abuse case, the facility did not obtain statements from all staff who worked during the relevant shifts, did not interview office staff despite the allegation involving an office manager and a report to a back office employee, and limited resident assessments and interviews to one hall, without extending them to other halls where potential witnesses or victims might have been located. These omissions in investigative steps led to incomplete investigations of the reported allegations of abuse and misappropriation of property for the two residents.
Failure to Follow Two-Person Assist Care Plan Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan for a resident who required extensive assistance with activities of daily living (ADLs). The facility’s policy required development and implementation of care plans with measurable objectives and time frames to meet residents’ medical, nursing, mental, and psychosocial needs. The resident was admitted with osteoporosis, a right artificial hip joint, and dementia, and was assessed on a quarterly MDS as severely cognitively impaired, rarely or never understood, and dependent for bed mobility, toileting, and transfers. The resident’s care plan/kardex identified an ADL problem and included an intervention requiring two staff to assist with bed mobility, toileting, and transfers. On the day of the incident, a state registered nurse aide (SRNA) began providing perineal care to the resident and rolled the resident onto her left side without waiting for a second staff member, despite knowing the resident was care planned as a two-person assist. When the SRNA rolled the resident, the resident rolled out of bed and fell to the floor on her right side. The incident report documented that the root cause of the fall was the resident being rolled too far over, causing her to roll out of bed. Staff interviews confirmed that the resident had been a two-person assist for years and that there had been no changes to the care plan on the day of the incident. Following the fall, an LPN assessed the resident, notified the nurse practitioner, and obtained stat x-rays, which revealed a right femoral diaphyseal fracture with complete displacement and foreshortening, and an orthopedic consult was recommended. Hospital imaging later confirmed a comminuted and moderately displaced mid to distal right femoral shaft fracture, and the surgical team repaired the resident’s hip. Hospital documentation showed that the resident subsequently died while on the hospital’s hospice unit. Interviews with the SRNA, LPN, unit manager, infection preventionist/acting DON, and the administrator consistently indicated that staff were trained to follow the care plan/kardex and that the resident’s two-person assist requirement was known, but in this incident the care plan intervention was not followed.
Failure to Follow Two-Person Assist Care Plan Resulting in Fall and Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance during care, resulting in a fall with fracture for one resident. The resident was admitted with osteoporosis, a right artificial hip joint, and dementia, and was assessed on the Quarterly MDS as severely cognitively impaired and rarely/never understood. The MDS further documented the resident as dependent for bed mobility, toileting, and transfers. The resident’s care plan, as reflected on the Kardex, identified an Activities of Daily Living (ADL) problem and included an intervention requiring two staff to assist with bed mobility, toileting, and transfers. On the day of the incident, an SRNA began providing perineal care to the resident alone, despite knowing the resident required a two-person assist. The SRNA rolled the resident onto her left side, which caused the resident to roll out of bed on her right side onto the floor next to the other bed in the room. The incident report documented that the root cause was the resident being rolled too far over during care, and the IDT determined that the SRNA failed to follow the resident’s Kardex. At the time of the incident, the resident had predisposing physiological factors of weakness and situational factors including a history of falls. Following the fall, an LPN and the unit manager responded to the room and found the resident lying on her right side on the floor, with no apparent distress or obvious injury initially observed. The LPN documented notification of the NP and family and obtained orders for x-rays of the right shoulder, hip, and knee. Mobile x-ray results showed a right femoral diaphyseal fracture with complete displacement and foreshortening, and an orthopedic consult was recommended. The resident was subsequently sent to the hospital, where imaging confirmed a comminuted, moderately displaced mid to distal right femoral shaft fracture, and an ORIF procedure with plate and screw fixation was performed. The resident later expired in the hospital’s hospice unit. Interviews with the SRNA, LPN, another SRNA, the unit manager, the acting DON/IP nurse, and the administrator consistently confirmed that the resident had long been a two-person assist and that only one staff member was present providing care at the time of the incident, contrary to the care plan and Kardex. Staff interviews further revealed that, prior to the incident, nurses and unit managers did not routinely spot check SRNAs to ensure they were following the care plan/Kardex when providing care. The SRNA involved acknowledged she had been trained during orientation to follow the care plan/Kardex and admitted she did not follow it in this case, stating she started care alone while expecting her partner to join later. The LPN, another SRNA, the unit manager, the acting DON/IP nurse, and the administrator all stated that the resident’s care plan and Kardex required two staff for bed mobility and related ADLs and that there had been no change to this requirement on the day of the incident. The administrator and acting DON/IP nurse both stated it was their expectation that staff follow the care plans and Kardex when providing care, and the administrator confirmed that only one staff member was present when the incident occurred.
Delayed Administration of Ordered Antibiotic for UTI
Penalty
Summary
The deficiency involves the facility’s failure to provide timely pharmaceutical services and administer an ordered antibiotic for a resident with a suspected urinary tract infection (UTI). The resident, who had intact cognition and diagnoses including arthropathic psoriasis and morbid obesity, was care planned for elimination deficits with interventions such as PRN straight catheterization for urinalysis and monitoring for UTI signs and symptoms. On one occasion, the resident developed a fever of 102°F, and a urinalysis showed significant abnormalities, including 3+ leukocytes, 3+ bacteria, and red blood cells too numerous to count. Based on these findings, the nurse practitioner ordered a single 3 g dose of Fosfomycin to treat the UTI while awaiting culture results. The medication order for Fosfomycin was entered with a start date of the day after the follow-up note, but the drug was not administered as ordered. The MAR showed that the Fosfomycin was to be given one time by mouth for UTI, and a subsequent entry documented that the medication was on hold because it was not available from the pharmacy. There was no documented physician order to hold the medication, and no progress note was found explaining the delay, who was contacted, or what actions were taken when the medication was reportedly unavailable. The Fosfomycin was ultimately documented as administered four days after the original order date, indicating a significant delay in treatment. Interviews and record reviews further clarified the circumstances leading to the deficiency. The infection preventionist stated that the facility followed McGeer criteria for antibiotic use and that the urinalysis did not meet those criteria, but he was not aware of this specific incident. The DON stated she did not know why the Fosfomycin was not given as ordered, noted that this medication was commonly used and readily available from the pharmacy, and confirmed it was not stocked in the emergency medication supply. The DON also stated her expectation that medications be received timely from the pharmacy and administered to residents, and that any delay in antibiotics could possibly lead to sepsis and pain. The resident reported having gone without treatment for approximately three weeks after developing a UTI, stated she never received the originally ordered one-time antibiotic dose, and later required transfer to the emergency department where she was diagnosed with a complicated UTI and treated with IM Rocephin and Toradol for pain.
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