Barbourville Health and Rehabilitation Center

Based on observation, interview, and facility policy review, the facility failed to ensure food items were discarded when required, milk received from a vendor had a legible expiration date, food items in the walk-in freezer and dry storage room were stored appropriately, and the room temperature of the dry storage room did not exceed 70 degrees Fahrenheit (F). These deficient practices had the potential to affect all 114 residents who received food from the kitchen. Findings included: An undated facility policy titled, Food Storage, indicated, 2. Dry storage rooms must be well ventilated and illuminated, with adequate temperature and humidity controls to prevent condensation of moisture and growth of mold. The storeroom temperature should be 50 [degrees] to 70 [degrees] F. The policy specified, b. Food should be dated as it is placed on the shelves if required by state regulation. c. Date marking should be visible on all high-risk food to indicate the date ready-to-eat or TCS [time/temperature control food] food should be consumed, sold or discarded. Per the policy, All foods…

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 facility policy review, the facility failed to honor a resident's right to have a personal fan in their room for 1 (Resident 3) of 2 sampled residents reviewed for personal property.Findings included: A facility policy titled, Resident Rights, revised 12/2022, recorded, Purpose: To protect and promote the rights of each resident. The policy specified the resident had the right to u. To be able to retain and use personal possessions as space permits. An admission Record revealed the facility admitted Resident #3 on 06/17/2025. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease and anxiety disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/24/2025, indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. During a concurrent observation and interview on 08/25/2025 at 11:11 AM, Resident #3 stated Registered Nurse (RN) #7 took their personal black fan…

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 provide nail care for 1 (Resident #122) of 4 sampled residents reviewed for activities of daily living (ADL) care.Findings included: An undated facility policy titled Protocol for Nail Care, indicated, Nail care for all residents that do not have a diagnosis of Diabetes will have nail care provided weekly per Nurse Aide staff as needed and will document on the NA [nurse aide] flow sheets. An admission Record indicated the facility admitted Resident #122 on 08/22/2025. According to the admission Record, the resident had a medical history that diagnoses of B-cell lymphoma, restless leg syndrome, hyperlipidemia, and osteoarthritis. Resident #122's Brief Interview for Mental Status [BIMS] revealed the resident had a BIMS score of 5, which indicated the resident had severe cognitive impairment. Resident #122's 48 Hour Baseline Care Plan indicated the resident required assistance of two staff for hygiene, bathing, dressing, and grooming. During an observation on 08/25/2025 at 10:35 AM,…

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 a resident's bi-level positive airway pressure (BiPAP) mask was stored when not in use for 1 (Resident #15) of 2 sampled residents reviewed for respiratory care.Findings included: An undated facility policy titled Protocol for CPAP [continuous positive airway pressure/BiPAP Machines, did not specify how respiratory equipment should be stored when not in use. An admission Record revealed the facility admitted Resident #15 on 06/10/2025. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia. Resident #15's Care Plan Report included a focus area initiated 07/05/2025, that indicated the resident was at risk for alteration in respiratory status due to COPD with chronic supplemental oxygen use and had a BiPAP machine that was ordered for nighttime use. Resident #15's physician orders included an order dated 08/08/2025, for the resident to wear the BiPAP…

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 the medication rate was 5 percent (%) or less. The facility had 2 medication errors out of 29 opportunities, which yielded a medication error rate of 6.90 % for 2 (Resident #10 and Resident #45) of 7 residents observed for medication administration. Findings included: A facility policy titled, Administering Medications Policy, dated 03/2024, revealed, Medications are to be administered by licensed medical or nursing personnel as prescribed. Medications shall be administered accurately and timely. 1. An admission Record revealed the facility admitted Resident #10 on 02/04/2016. According to the admission Record, the resident had a medical history that included a diagnosis of atherosclerotic heart disease. Resident #10's Order Summary Report, that contained active orders as of 08/25/2025, revealed an order dated 06/30/2023, for potassium chloride extended release (ER) oral tablet 10 milliequivalents, give one tablet by mouth twice a day for supplement. The Full Prescribing…

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 review of the facility's policy, the facility failed to protect and promote the rights of 1 of 63 sampled residents (Resident (R) 95). R95 refused an injection on 08/25/2024; however, nurses administered the injection after the resident's refusal. The findings include: Review of the facility's policy titled, Policy and Procedure: Resident Rights, revised 12/2022, revealed its purpose was to protect and promote the rights of each resident. Continued review of the policy revealed each resident had a right to refuse treatment and to be given the opportunity to participate in care and treatment. Review of R95's admission Record revealed the facility admitted the resident on 12/30/2022, with diagnoses that included neuromuscular dysfunction of the bladder, type 2 diabetes mellitius without complications, urinary tract infections (UTIs), and Gullain-Barre syndrome. Review of R95's Quarterly Minimum Data Set (MDS) Assessment, dated 07/23/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS)…

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 policy, the facility failed to immediately consult with the resident's Physician and notify the resident's representative(s) when there was an accident or need to alter treatment for 3 of 63 sampled residents, (Resident (R)15, R95 and R274). 1. R15 sustained a fall on 04/29/2024; however, the facility failed to notify the resident's State Guardian and Physician until 04/30/2024. On 04/30/2024, the facility transferred R15 to the Emergency Department (ED) for evaluation. R15 was diagnosed with a spiral humeral fracture (a type of bone break occurring from a twisting motion in the upper arm) which was comminuted (when a bone breaks into multiple pieces) and displaced. 2. R274 sustained an injury on 07/06/2022; however, the facility failed to notify the resident's Responsible Party and Physician until 07/08/2022. On 07/09/2022, the facility transferred R15 to the Emergency Department (ED) for evaluation. R274 was diagnosed with an…

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 Surveyor [NAME] Based on interview, record review, and review of the facility's policy, it was determined the facility failed to report an injury of unknown origin immediately, but not later than two hours after the allegation was made to the facility's Administrator and other officials, including the State Survey Agency and Adult Protective Services (APS) for 1 of 63 sampled residents, (Resident (R) 274). The findings include: Review of the facility's policy titled, Abuse, Neglect, Misappropriation and Exploitation Policy revealed all allegations involving suspected abuse, neglect, misappropriation or exploitation including injuries of unknown source or misappropriation of a resident's property were to be reported immediately, but no later than two hours after the allegation was made to the Director of Nursing (DON) and/or Administrator. Continued review revealed the DON, Administrator or Designee were to report such allegations to the appropriate state and federal agencies, including law enforcement, as…

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 Surveyor: [NAME] Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a thorough investigation was completed for an injury of unknown origin for 1 of 63 sampled residents (Resident (R) 274). The facility admitted R274 with contractures of both upper and lower extremities. On 07/06/2022, two Certified Nursing Assistants were bathing R274, when one CNA lifted the resident's left arm and heard two pops. On 07/08/2022, an injury of unknown source was identified; however, the facility's investigation was not initiated until the day after the injury was discovered. In addition, the facility failed to interview all the staff present when the incident occurred. The facility transferred R274 to the hospital emergency department (ED). Hospital staff diagnosed R274 with an angulated spiral (corkscrew like fracture) fracture of the midshaft of the left humerus with mild impaction. The findings include: Review of the facility's policy titled, Abuse, Neglect,…

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, the facility failed to provide care and services to ensure one (1) of thirty-one (31) sampled residents received care and services to maintain appropriate grooming. The facility assessed Resident #59 to require extensive assistance of staff for personal care and grooming. However, observations on 06/25/19 through 06/27/19, revealed the resident's fingernails were long and in need of trimming with a brown substance caked under each of the nails on both hands. The findings include: A request for policies and procedures related to activities of daily living and grooming was made to the Administrator during the survey; however, the facility failed to provide the requested policies and procedures. Review of Resident #59's medical record revealed the facility admitted the resident on 02/27/17 with diagnoses including Muscle Weakness, Lack of Coordination, Dementia, and Chronic Obstructive Pulmonary Disease. A review of Resident #59's Minimum Data Set (MDS) assessment…

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 facility policy, it was determined the facility failed to ensure tracheostomy care was provided for one (1) of thirty-one (31) residents in accordance with the facility policy and professional standards. Observation on 06/26/19 revealed endotracheal supplies required for suctioning Resident #105 were not available at the resident's bedside. The findings include: Review of the facility's Tracheostomy Care policy, not dated, revealed supplies and equipment necessary to care for a resident's tracheostomy would be available at the resident's bedside at all times. Supplies and equipment listed included a suction machine, suction catheters, exam and sterile gloves, and a flush solution. Review of Resident #105's medical record revealed the facility admitted the resident on 12/12/12. The resident's diagnoses included Diabetes Mellitus, Persistent Vegetative State, Tracheostomy, and Contractures of the Upper and Lower extremities. Review of Resident #105's…

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 facility policy review, it was determined the facility failed to ensure drugs and biologicals used in the facility were stored in a locked compartment and available only to authorized personnel. Observation on 06/27/19, revealed a bottle of eye drops was left unsecured in a resident's room. The findings include: Review of the facility's policy titled Proper Storage of Biologicals/Hazardous Materials/Items, not dated, revealed drugs/biologicals were to be securely stored in a locked area that was not accessible to residents. During observation of a medication pass on 06/27/19 at 9:23 AM, a bottle of artificial tears labeled for Resident #79 was observed sitting on top of the refrigerator in the resident's room. Interview with Registered Nurse (RN) #2 on 06/27/19 at 09:24 AM, revealed eye drops should be stored in the medication cart and not left in the resident's room. RN #2 stated she did not leave the eye drops in the resident's room, and could not say why the eye drops were there. Interview with the Unit Manager for Resident #79's unit 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.