Elkton Nursing and Rehabilitation Center

Based on observation, interview, and review of facility policy, the facility failed to ensure residents had the right to receive services in the facility with reasonable accommodations of resident needs and preferences for 7 out of 15 sampled residents, Resident (R)8, R9, R30, R32, R33, R36, and R49. R32 and R36 complained call lights were not answered timely. Additionally, observations on 07/22/2024, and 07/24/2025, revealed R8, R9, R30, R33, and R49's call light was out of reach, and inaccessible to the residents.Review of the facility policy titled, Resident Rights, undated, revealed the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Review of the facility policy titled, Placement of Call Light and Answering Call Light, undated, revealed the call light should be plugged in at all times, and when a resident is in bed or confined to a chair the call light shall be within reach of the resident. Further review of the policy revealed all defective call lights should 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility policy, staff failed to ensure a clean, comfortable, and home-like environment. Observations on 07/23/2025, 07/24/2025, and 07/24/2025, revealed the handrails along the hall corridor were filled with food wrappers, and crumbs. Also, there was a Styrofoam cup containing a liquid substance on the handrail by room [ROOM NUMBER].The findings include: Review of facility policy titled, Resident Rights, undated, revealed the resident has a right to a safe, clean, comfortable and homelike environment including but not limited to receiving treatment and supports for daily living safely. Observation on 07/23/2025 at 1:40 PM, 07/24/2025 at 3:21 PM, and 07/24/2025 at 5:32 PM, revealed the handrails along the hall corridor were filled with food wrappers, and crumbs. Continued observation revealed there was a Styrofoam cup containing a liquid substance on the handrail by room [ROOM NUMBER]. In an interview with Housekeeper (HK)1 on 07/25/2025 at 1:49 PM, she stated her…

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 policy, the facility failed to store drugs in a manner to preserve integrity.Observation of the medication room refrigerator, revealed 2 COVID-19 vaccine syringes, both expired and 1 of the syringes was shattered.Review of the facility's policy titled Medication Storage, reviewed 03/2025, revealed expired, contaminated, deteriorated medications, and medications in containers that are cracked, soiled, or without secure closures are to be immediately removed from stock and disposed of according to procedures for medication destruction and reordered from the pharmacy if a current order exists. Observation of the medication storage room refrigerator, on 07/23/2025 at 2:55 PM, revealed a plastic bag containing two expired COVID-19 vaccine syringes with an expiration date of 04/24/2025, and one of the syringes was shattered. During an interview with Kentucky Medication Aide (KMA)1, on 07/23/2025 at 3:00 PM, she stated nurses were responsible for checking the medication carts and medication refrigerators for expired medications. She…

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 facility policy, 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. Staff failed to maintain infection control practices during urostomy care for Resident (R)2; during wound care for R26; and during medication administration for R4. Additionally, the facility failed to ensure staff was fit tested for a N95 respirator mask required for respiratory protection when working with Coronavirus Disease 2019 (COVID-19) positive residents. These failures had the potential to affect all residents that resided in the facility. The findings include: Review of the facility policy titled, Infection Prevention and Control Program, dated 01/01/2024, revealed, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to ensure medications were obtained from the pharmacy in a timely manner for two (2) of three (3) sampled residents reviewed for pharmacy services, Resident (R)8 and R32. (Refer to F658) The findings include: Review of the facility policy titled, Administering Medications, revised on 11/15/2011, revealed, Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's Medical Director. 1. Review of R32's admission Record revealed the facility admitted the resident on 02/17/2020. According to the admission Record, the resident's medical history included a diagnosis of atrial fibrillation. Review of R32's Comprehensive Care Plan, revealed a focus area revised 02/25/2020, stating the resident had a self-care deficit. Interventions directed staff to administer medications as ordered. Review of R32's Quarterly Minimum Data Set (MDS), with an 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.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the medication error rate was less than 5 percent (%). Observation of medication administration revealed there were two (2) errors out of 27 opportunities, which resulted in a medication error rate of 7.41%. This affected two (2) of three (3) residents observed during medication administration, Resident (R)8 and and R32. Refer to F658 The findings include: A facility policy titled, Administering Medications, revised on 11/15/2011, revealed, Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's Medical Director. The policy further revealed the Director of Nursing Services is responsible for the supervision and direction of all personnel with medication administration duties and functions. Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal orders. Should a drug be withheld, refused, or given other than at the scheduled time, the individual…

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, facility document review, and review of facility policy, the facility failed to report an allegation of abuse within the two (2) hour time frame for one (1) of three (3) residents reviewed for abuse prohibition, (Resident (R) 40. The findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation, revised 04/10/2023, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. According to the policy, Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. The policy also revealed, under Reporting/Response, the facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies including law enforcement when applicable, immediately, but not later than two…

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 policy, the facility failed to initiate a new Level I Preadmission Screening and Resident Review (PASARR) for a resident who received new psychiatric diagnoses following admission. This affected one (1) of one (1) residents reviewed for PASARR requirements, (Resident (R)14. The findings include: An undated facility policy titled, Preadmission Assessment and Annual Resident Review (PASARR), revealed, The purpose of the Preadmission Assessment and Annual Resident Review Program (PASARR) policy and procedure is to develop guidelines for admission related to those individuals with mental illness and intellectual disabilities to ensure they receive the care and services needed in the most appropriate setting. R14's Pre-admission Screening and Resident Review (PASARR) Nursing Facility Identification Screen (Level I), dated 07/15/2013, prior to R14's admission to the facility, revealed the resident did not have a major mental disorder, to include severe anxiety disorder, other psychotic disorders, or another mental disorder that may…

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 facility policy, the facility failed to ensure services provided by the facility met professional standards of quality for one (1) of three (3) residents observed during medication pass, (Resident (R)8. R8's Physician's Order sheet for 09/2024, revealed a current order for metformin hydrochloride (HCL) 1,000 milligrams (mg) with instructions to give one (1) tablet by mouth every morning at 9:00 AM. The Physician's Order sheet further revealed a current order for metformin HCL 500 mg with instructions to give one (1) tablet at 5:00 PM. During an observation of medication administration on 09/10/2024 at 9:08 AM, Kentucky Medication Aide (KMA)12 was unable to locate R8's metformin hydrochloride (HCL) 1,000 milligram (mg) tablets. Staff interviews revealed R8's metformin HCL 1,000 mg tablets had been reordered on 08/31/2024, but had not been delivered. Staff interviews further revealed they had been administering two (2) 500 milligram (mg) tablets of metformin HCL instead of the ordered 1,000 mg tablet for the 9:00 AM dose.…

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, the facility failed to ensure staff provided assistance with activities of daily living (ADLs) for one (1) of one (1) sampled residents reviewed for ADLs, Resident (R)41. Although R41 had a contracture of the left hand, the facility failed to ensure R41's nails were trimmed. The findings include: Review of the facility's undated policy, titled Nail Care, revealed routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as weekly on Wednesday 3-11 shift). Nail care will be provided between scheduled occasions as the need arises. The resident's plan of care will identify the frequency of nail care to be provided; the type of nail care to be provided; the person(s) responsible for providing nail care such as licensed nurse, nurse aide, podiatrist, or activity professional. Review of R41's admission Record…

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, facility document review, and review of facility policy, the facility failed to ensure pharmacy recommendations were acted upon timely for one (1) of five (5) sampled residents reviewed for unnecessary medications, Resident (R)10. The findings include: A facility policy titled, Medication Regimen Review, revised 06/02/2024, revealed, the consultant pharmacist will conduct MRRs (medication regimen reviews) if required under a Pharmacy Consultant Agreement and will make recommendations based on the information made available in the residents' health record. The facility should alert the medical director where MRRs are not addressed by the attending physician in a timely manner. The attending physician/prescriber should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, per facility policy and state or federal regulations. Review of R10's admission Record revealed the facility admitted the resident on 02/03/2023 and readmitted the resident on 11/06/2023. According 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy review, and interview, it was determined that the facility failed to implement care plan interventions to prevent falls for one (1) of sixteen (16) sampled residents (Resident #20). Resident #20 had a care plan with a focus for falls that was initiated on 10/17/19. An intervention was initiated on 10/22/19 to have non-skid strips in place in front of the toilet to prevent falls. Observation on 12/05/19 revealed no non-skid strips in place in front of the resident's toilet. The findings include: Review of the facility's policy entitled Care Plan - Comprehensive, not dated, revealed an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs is developed for each resident. Further review of the policy revealed each resident's comprehensive care plan has been designed to incorporate identified problem areas and risk factors associated with the identified…

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, policy review, record review, and interview, the facility failed to ensure the resident's environment remains as free of accident hazards as is possible for one (1) of sixteen (16) sampled residents (Resident #20). Resident #20 had a physician's order dated 10/21/19 to have non-skid strips in front of the toilet due to a fall. Observation on 12/05/19 revealed there were no non-skid strips in place in front of the resident's toilet. The findings include: Review of the facility's policy entitled Fall Prevention, dated 08/04/09, revealed residents are comprehensively assessed for fall risk in order to avoid injury related to falls and maintain maximum physical functioning as much as possible. Further review of the policy revealed the post fall assessment is completed after any fall to accurately document possible causative factors, and revision of interventions to prevent further occurrences. Observation on 12/03/19 at 9:54 AM during the initial tour of the facility revealed Resident #20…

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.