Metcalfe Nursing and Rehabilitation Center

Based on interview and review of the facility's Mail Distribution policy, it was determined the facility failed to ensure residents had the right to send and receive mail. In addition, the facility failed to ensure residents were able to receive letters, packages and other materials delivered to the facility for residents on Saturdays and Sundays. The total census was sixty-two (62). The findings include: Review of the facility's policy titled, Mail Distribution, undated, revealed it was the intent of the policy that the facility developed a system of resident mail transport, which involved the Activities Department and the person who received the mail, i.e., the Receptionist. Continued review revealed it also included provisions whereby the Activities Department was informed of the arrival of, or was given, the mail. Further review of the policy revealed the Activities Director or Designated Volunteer was to deliver the mail to the residents within twenty-four (24) hours. Interview with Resident Council members, on 10/18/2022 at 3:14 PM, revealed the facility was not delivering…

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 policies, 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; to help prevent and control the development and transmission of communicable diseases; and, to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health (Health Department) state guidelines for COVID-19. Multiple observations, from 10/18/2022 to 10/20/2022, revealed staff members were not providing assistance with COVID screening; not wearing required personal protective equipment (PPE) or wearing it incorrectly, in a Contact Precautions room; not performing correct hand hygiene; not disinfecting reusable medical equipment or not disinfecting it with the correct contact time; and inappropriate handling of trash in a Contact…

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 and review of the facility's policy, it was determined the facility failed to provide residents with activities on Saturday and Sunday. The facility census was sixty-two (62). The findings include: Review of the facility's policy titled, Activity Procedures, undated, revealed the facility was to offer residents the opportunity for improving or maintaining physical functioning abilities in a recreational setting. Per the policy review, participation in exercise could also help maintain or increase cognitive abilities and feelings of self-worth and positive self-esteem. Interview with Resident Council members on 10/18/2022 at 3:14 PM, revealed the facility was not providing any scheduled activities for residents on Saturdays and Sundays. Interview with the Activities Director on 10/20/2022 at 2:00 PM, revealed the facility had provided supervised activities for the residents on weekends prior to the COVID pandemic. She stated, after COVID, the facility considered bringing activities back on weekends. Continued interview revealed she waited for the Administrator'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, medical record review, and review of the facility's policy, it was determined the facility failed to date and change weekly oxygen tubing as required for four (4) of thirty (30) sampled residents, Residents #28, #29, #37, and #54. The findings include: Review of the facility's policy titled, Respiratory Care Services Policy & Procedure, Oxygen Equipment: Supply Change, undated, revealed nasal cannulas and oxygen supply tubing were to be replaced every seven (7) days and as needed (PRN) per facility protocol. 1. Review of Resident #54's medical record revealed the facility admitted the resident, on 01/22/2019, with diagnoses to include Heart Failure, Coronary Artery Disease (CAD), Asthma, and Respiratory Failure. Review of Resident #54's Quarterly Minimum Data Set (MDS) Assessment, dated 09/03/2022, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of seven (7) of fifteen (15), which indicated the resident had severe cognitive impairment. Review of Resident #54's Care Plan, dated 08/22/2022, revealed…

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, review of medication package inserts, review of the Centers for Disease Control and Prevention's (CDC) Vaccine Storage and Handling, and review of the facility's policy, it was determined the facility failed to store all drugs and biologicals under proper temperature control. Observation of the two (2) medication refrigerators revealed one (1) had temperatures outside the recommended range for drug storage. The findings include: Review of the Centers for Disease Control and Prevention's (CDC) Vaccine Storage and Handling, updated 09/29/2021, revealed proper vaccine storage and handling played critical roles in efforts to prevent vaccine-preventable diseases. Vaccines exposed to storage temperatures outside the recommended ranges might have decreased efficacy, creating limited protection, and exposure to temperatures thirty-two (32) degrees Fahrenheit or colder could destroy potency. Per CDC recommendations, vaccine temperatures should be monitored and documented at…

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, review of the facility's policy, and review of Federal Regulations regarding Advance Directives, it was determined the facility failed to have a policy on Advance Directives which allowed two (2) of thirty (30) sampled residents, Residents #25 and #42 to have insufficient documentation concerning their directives for medical care. The findings include: Interview with the Social Service Director (SSD) on [DATE] at 10:30 AM, revealed the facility did not have a policy detailing how Advance Directives were to be obtained or what they should contain. Review of the facility's policy titled, Resident Rights, not dated, revealed the facility was to comply with the requirements specified in 42 CFR Part 489, Subpart 1, to provide information to all adult residents concerning the right to formulate an advance directive. Review of 42 CFR 489.100, Subpart 1, Advance Directives, revealed advance directives was defined as a written instruction, such as a living will or durable power of…

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, it was determined the facility failed to review and revise the comprehensive care plan (CCP) after each assessment following falls with interventions to prevent falls, for one (1) of thirty (30) sampled residents (Resident #42). Resident #42's CCP was not revised/updated for twelve (12) of the twenty-one (21) falls he/she experienced from 04/29/2022 through 10/14/2022. Refer to F-0689 The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated December 2016, revealed it was the facility's policy to review and update a resident's care plan when the desired outcome had not been met. Review of Resident #42's medical record revealed the facility admitted him/her on 04/23/2020, with diagnoses including Chronic Obstructive Pulmonary Disease, Polyneuropathy, Chronic Pain, Dizziness, History of Falls, Ataxic Gait, and Unspecified Dementia. Review of Resident #42's Annual Minimum Data…

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, it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (1) of thirty (30) sampled residents, Resident #42. Resident #42 experienced twenty-five (25) falls from 04/14/2022 through 10/21/2022. The findings include: The State Survey Agency (SSA) Surveyor requested the facility's policy on Falls; however, the facility did not provide the policy as requested. Review of the facility's policy titled, Resident Rights, undated, revealed residents had the right to a safe environment. Review of Resident #42's medical record revealed the facility admitted the resident on 04/23/2020, with diagnoses that included History of Falling, Polyneuropathy, Chronic Pain, Chronic Obstructive Pulmonary Disease (COPD), Dizziness, Ataxic Gait, and Unspecified Dementia. Review of Resident #42's Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the facility…

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 the facility's policy, it was determined the facility failed to keep staff food and drink items in the designated staff area and not in the residents' food nourishment room. The findings include: Review of the facility's policy titled, Food Brought in From Outside/Home, not dated, revealed the residents had the right to have foods brought in by family or visitors, and the facility had the responsibility to ensure the residents' safety. The State Survey Agency (SSA) Surveyor requested, from the Director of Nursing (DON), the facility's policies titled, Break Room Policy and Drink and Food but did not receive them. Observation of the nourishment room located on the 200 Hall, on 10/19/2022 at 6:19 PM, revealed six (6) used Styrofoam cups, with lids and straws, and two (2) bottles of soda that belonged to the staff. The cups were placed around the sink and next to the ice maker. Observation of the nourishment room located on the 100 Hall, on 10/20/2022 at 10:00 AM, revealed three (3) used Styrofoam cups, with lids and straws, that belonged…

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 interviews, record review, document review, review of the Certified Nursing Assistant (CNA) Job Description, and review of the facility's policy, it was determined the facility failed to accurately maintain medical records on food and fluid consumption for one (1) of thirty (30) sampled residents (Resident #7). The findings include: Review of the facility's policy titled, Documenting of Food Consumption, not dated, revealed nursing personnel shall record each resident's intake of meals immediately following mealtime. The policy further stated intake of meals shall be recorded by food categories, and documentation of consumption by food categories provided in-depth information on a resident's food intake patterns. Per the policy, the Food Service Manager and/or Consultant Dietitian, along with nursing personnel, would monitor intake routinely or according to the resident's individual care plan. Review of the facility's document titled, Certified Nursing Assistant Job Description, not dated, revealed CNA's were to report and document nutritional and fluid intake. Further…

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 policy it was determined the facility failed to ensure food was stored in accordance with professional standards for food service safety. On 10/29/19, during the initial tour, the ice cream freezer was observed to have a thick layer of frost on all sides of the freezer as well as a black sediment along the tracks where the top slid to provide access to the freezer. The frost on the sides was also observed to have some of the black sediment present. The findings include: Review of the cleaning schedule, undated, revealed the ice cream freezer was not on the schedule to be cleaned. Observation of the kitchen on 10/29/19 at 11:04 AM, during the initial tour with the Dietary Manager, revealed the ice cream freezer had a thick layer of frost on all sides and a black residue was present on the tracks where the top lid slid to open. Further observation revealed the black residue was also on the layer of frost next to the track. No food containers were observed to have any black residue on them. Observation 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.

Based on observation, interview, and a palatability test of a lunch meal, it was determined the facility failed to ensure that food served to residents was palatable. Interview with residents and a palatability test of a lunch test tray on 10/24/18 at 11:20 AM CDT, revealed the facility failed to season food to ensure food served to residents was palatable. The findings include: Interview with the Dietary Manager (DM) at 3:25 PM CDT on 10/24/18 revealed the facility did not have a policy related to food palatability. A group interview conducted at 3:00 PM on 10/23/18 with six (6) facility residents revealed the food served at the facility was not seasoned. The residents further stated that they only received one (1) packet of salt on their meal trays, which was not enough salt to season their food. A test tray was requested to conduct a palatability test for the lunch meal on 10/24/18. At 11:20 AM CDT on 10/24/18, the palatability test was conducted with the facility Dietary Manager (DM). The green beans served had not been salted/seasoned and tasted bland. Interview with the DM…

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 and review of the facility policy, it was determined the facility failed to protect residents' rights to manage their personal funds. Interview with Resident Council members revealed the facility managed the residents' money they won from Bingo and residents did not have access to their money on weekends. The findings include: Review of the facility's policy, Resident Trust Fund, (undated) revealed residents shall have access to their personal funds within a reasonable period of time when requested, and the same day if possible. The policy stated the facility's banking hours were from 8:30 AM to 4:00 PM Monday through Friday, and typically closed on holidays. Further review of the policy revealed if funds were needed at a time after business office hours, arrangements would be made by the office or the Administrator upon request. A group interview was conducted at 3:00 PM Central Daylight Time (CDT) on 10/23/18 with six (6) facility residents. The residents stated during the interview that for the past few months, the facility had not allowed residents to keep…

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 ensure an accurate medical record was maintained for one (1) of thirty-one (31) sampled residents (Resident #54). On 07/09/18, Resident #54's physician prescribed Norvasc (medication to treat high blood pressure and/or chest pain) daily. Observation revealed the facility administered the medication to the resident as ordered; however, the facility failed to ensure the resident's October physician's order summary and Medication Administration Record (MAR) accurately reflected the physician's order. The findings include: Review of the facility's Medication Administration-General Guidelines, dated 12/18/12, revealed medications were administered in accordance with written orders of the physician. The Director of Nursing stated in interview on 10/24/18 at 3:45 PM, that the facility did not have a policy regarding accurate medical records. Review of the medical record revealed the facility admitted Resident #54 to 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.