Boyd Nursing and Rehabilitation

Based on interview, document review, and facility policy review, the facility failed to ensure health department recommendations were followed to test the facility water two times weekly for legionella. This deficient practice had the potential to affect all 57 residents who currently resided in the facility.The findings include:Review of the facility's policy titled, Water Management Policy, dated 05/01/2025, revealed, H. We will notify the local health department upon knowledge of any new presumptive or confirmed Legionella within 24 hours. We will make efforts to follow the guidance provided by health department officials and field experts.During an interview with the Maintenance Director on 11/21/2025 at 10:21 AM, he stated legionella water testing had been completed twice a week, and the results were being sent to the health department. The Maintenance Director stated there had been no failed test. He further stated the facility met with the health department, and they told him to test the dead-end areas and to run the water in the dead-end areas for three minutes. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure their medication error rate was not greater than 5 percent (%). There were seven errors out of 28 opportunities, which resulted in a mediation error rate of 25% for 2 of 3 residents observed for medication administration, Resident (R) 18 and R19.The findings include:Review of the facility's policy titled, Medication Administration, dated 01/02/2024, revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.1. Review of R19's admission Record revealed the facility admitted the resident on 10/11/2023 with diagnoses to include major depressive disorder, type 2 diabetes mellitus, B-group vitamin deficiency, and hypokalemia.Review of R19's Order Summary Report, for active orders as of 11/19/2025, revealed the following: an order dated 10/11/2023, for Januvia 100 milligrams (mg) by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and facility policy review, the facility failed to notify the physician when medications were not administered for 2 of 5 sampled residents reviewed for unnecessary medications, Resident (R) 4 and R20. The findings include: Review of the facility's policy titled, Medication Administration, dated 01/02/2024, revealed, 22. Physicians will be notified timely of medication omissions. 1. Review of R4's admission Record revealed the facility admitted R4 on 07/22/2024 with diagnoses to include hypertension, diabetes mellitus, major depressive disorder, psychotic disorder with hallucinations, and gastroesophageal reflux disease. Review of R4's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 09/08/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 3 out of 15, indicating the resident had severe cognitive impairment. Review of R4's medication administration record (MAR) for the timeframe 10/01/2025 through 10/31/2025, revealed the resident's medications ordered to be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and facility policy review, the facility failed to ensure the route of medication administration was accurate for 1 of 14 sampled residents, Resident (R) 7. The findings include:Review of the facility's policy titled, Documentation in the Medical Record, dated 01/02/2024, revealed, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.Review of R7's admission Record revealed the facility admitted the resident on 01/29/2024 with diagnoses to include dysphagia (difficulty swallowing) and gastrostomy status. Review of R7's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 09/25/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 3 out of 15, indicating the resident had severe cognitive impairment. Further review revealed R7 had a feeding tube. Review of R7's Care Plan Report…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, review of the facility staffing sheets, review of the facility assessment, review of the payroll-based journal staffing information, and review of resident grievances, the facility failed to have adequate nursing staff to maintain the highest practicable physical, mental, and psychosocial well-being of each resident, considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. The findings include: Review of the payroll-based journal (PBJ) data, dated April-June 2024, revealed the facility had an overall staffing rating of one star. Review of the facility assessment, dated 10/17/2024, revealed the facility determined it required three state registered nurse aides (SRNAs) each shift to meet the needs of the residents. Further review revealed the facility required one to two Licensed Practical Nurses (LPNs) per shift. Review of the facility report Daily Census, dated 10/12/2024 and 10/13/2024 revealed the facility's census was 58 and 57 residents, respectively. Review of the facility monthly staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and review of facility's policy, the facility failed to treat each resident with respect and dignity and care in a manner that promoted maintenance of his or her quality of life for 1 of 1 sampled residents (Resident (R) 62). R62's religious beliefs prohibited cutting of women's hair and R62 was given a haircut without consulting the resident's guardian. The findings include: Review of the facility's policy titled, Resident's Rights Policy, dated October 2019, revealed it was the responsibility of all staff members to recognize the rights of residents at all times to enable personal dignity, well-being, and proper delivery of care. Review of R62's Face Sheet found in the resident's electronic medical record (EMR) revealed the facility admitted R62 on 07/26/2021 with diagnoses to include vascular dementia unspecified, cognitive communication deficit, and generalized znxiety disorder. Review of R62's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/24/2022, revealed the facility assessed the resident to have a Brief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of facility's policy, the facility failed to follow an infection prevention and control policy to prevent the development and transmission of communicable diseases and infections for 1 of 8 sampled residents receiving blood glucose monitoring (Resident (R) 55). Observation on 10/23/2024 at 11:00 AM revealed Licensed Practical Nurse (LPN) 1 placed R55's glucometer on top of the treatment cart without a barrier prior to obtaining a blood glucose reading. Following the glucose reading, LPN1 cleaned the glucometer for two minutes and placed the glucometer on top of the treatment cart to dry without a barrier between the cart top and the glucometer. The findings include: Review of the facility's policy titled, Infection Prevention, dated March 2022, revealed it was the responsibility of nurses to practice aspectic technique when obtaining glucose readings and to follow the manufacturer's guidelines when performing cleaning of the glucometer. Review of the Validation Checklist for Glucometer Disinfection, undated, revealed the nurse is to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview, it was determined the facility failed to ensure the resident has a safe, clean, comfortable and homelike environment for two (2) of sixteen (16) sampled residents (Resident #7 and Resident #54). Observation of Resident #7's air conditioning unit on 10/02/19, revealed the unit was set to seventy-nine (79) degrees Fahrenheit (F), and when the resident attempted to lower the temperature on the air conditioning unit, the air conditioner remained in the seventy-nine (79) degree position. Interview with Resident #7, during the observation, revealed he/she had complained of the air conditioning not working properly six (6) months ago, and he/she was uncomfortable and hot during the summer months. In addition, observation on 10/02/19, of Resident #54's bathroom, revealed the commode as well as the hand rails positioned on each side of the commode were not secure, and shifted with movement. Interview with Resident #54 during this observation, revealed he/she had to use the toilet in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for two (2) of sixteen (16) sampled residents (Resident #32 and Resident #57). Resident #57's Comprehensive Care Plan, dated 02/15/19, was not implemented related to administering oxygen as ordered. Interview with the Hospice Nurse and review of the Hospice Interdisciplinary Nursing Notes, dated 08/12/19, revealed the Hospice Nurse entered the resident's room, and noted the resident to be in respiratory distress during a facility power outage, as the resident's oxygen concentrator was not plugged into the red emergency outlet supplied by the generator. (Refer to F-695) In addition, Resident #32's Comprehensive Care Plan, dated 09/14/19, was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, review of the facility's Policy, and review of the Kentucky Board of Nursing (KBN), Advisory Opinion Statements (AOS) #14, revised October 2015, Roles of Nurses in the implementation of Patient Care Orders, it was determined the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one (1) of sixteen (16) sampled residents, (Resident #16). The findings include: Review of the facility's Policy #7.2 titled Medication Administration General Guidelines, undated, revealed, The resident is always observed after medication administration to ensure that the dose was completely ingested. Additional review of the Policy, revealed residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Review of the KBN, AOS #14, revised October 2015, Roles of Nurses in the implementation of Patient Care Orders, revealed in accordance with Kentucky Revised Statutes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the Emergency Preparedness Manual utilized by the facility, it was determined the facility failed to ensure that a resident who needs respiratory care is provided such care for one (1) of sixteen (16) sampled residents (Resident #57). The facility failed to ensure appropriate measures were in place for Resident #57, in order to provide adequate respiratory services when the electricity/power went out on 08/12/19. (Refer to F-656 and F-849) The findings include: Review of the Emergency Preparedness Manual, undated, Appendix C.1, Electrical Outages/Loss of Power, utilized by the facility, revealed in the event of an electrical power outage the Director of Nursing is responsible for monitoring oxygen usage and other medical equipment, and ensure residents are switched to oxygen tanks when necessary due to the outage. Nursing team members are responsible for ensuring residents using oxygen are moved to areas with red emergency outlets or changed over from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility Policy, it was determined the facility failed to ensure proper storage of drugs and biologicals. Observation of the medication refrigerator, on [DATE], revealed an expired vial of Tubersol dated [DATE], accessible for use. The findings include: Review of the facility's Storage of Medications Policy, undated, revealed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Further review of the Policy, revealed when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse will check the expiration date of each medication before administering it. Observation of the medication refrigerator, on [DATE] at 10:43 AM, revealed a vial of Tubersol (Tuberculin Purified Protein Derivative for intradermal tuberculin testing), dated [DATE], that was half full of solution. Interview with Licensed Practical Nurse (LPN) #3, on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's Hospice Agreement, dated 08/30/19, it was determined the facility failed to designate a member of the facility's interdisciplinary team who is responsible for working with Hospice representatives to coordinate care to the resident provided by the Long Term Care (LTC) facility staff and Hospice staff. In addition, the facility failed to have an effective communication process between the LTC facility and the Hospice representative to ensure the needs of the resident are addressed and met twenty-four (24) hours per day. This affected two (2) of two (2) sampled residents reviewed for Hospice services out of a total of sixteen (16) sampled residents (Resident #32 and #57). Resident #57's oxygen concentrator was not plugged into the red outlet during a power outage on 08/12/19, and the Hospice Nurse entered the resident's room and noted the resident was in respiratory distress. The Hospice Nurse notified the assigned nurse; however, there…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Observation of the medication refrigerator, on [DATE], revealed the only vial of Tubersol was dated as opened [DATE], revealing it was expired. Interviews revealed this vial may have been used to administer Purified Protein Derivative (PPD) Skin Tests to State Registered Nurse Aides #3 and #4. In addition, observation of wound care on [DATE], performed by Licensed Practical Nurse (LPN) #2, revealed the nurse failed to perform hand hygiene between glove changes during wound care. The findings include: Review of the facility's Storage of Medications Policy, undated, revealed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.