Belmont Terrace Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of the facility's policies, it was determined the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment. Observations included a strong urine and feces odor throughout the facility; cracked and misshapen ceiling tiles; dirty air intake vents; dirty floors with stains; a loose and warped metal plate in the floor; and clean and dirty items stored together. The findings include: Review of the facility's policy titled, Resident Rights, not dated, revealed residents had the right to a safe, clean, comfortable, and homelike environment. Review of the facility's policy titled, Homelike Environment, dated 2001 and revised February 2021, revealed that facility staff and management maximized, to the extent possible, the characteristics of the facility that reflected a personalized, homelike setting. These characteristics included: a clean, sanitary, and orderly environment, with pleasant neutral scents. Observation on 02/26/2024 at 4:40 PM…

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 investigation reports, and review of the facility's policies, it was determined the facility failed to protect residents from abuse and neglect for eight (8) of one hundred and four (104) sampled residents (Residents #101, #112, #115, #152, #70, #88, #142, and #43). 1. Staff observed Residents #101 and #112 on two (2) separate occasions on 06/26/2023 engaged in sexual activity. Both residents were cognitively impaired and therefore unable to provide consent. 2. Resident #115 was verbally abused by a housekeeping staff who had not been trained on abuse on 03/27/2023. 3. Resident #152 was sent to hospital wearing two soiled briefs on 01/07/2024, indicating facility neglect. 4. On 12/31/2022, Resident #70 stated his/her roommate (Resident #88) had scratched him/her after both residents had a verbal argument over access to the bathroom. 5. On 04/03/2023, Resident #142 passed by Resident #43 in the 200 Hall and struck Resident #43 in the arm, with no apparent injuries. The findings include: Review of the facility'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, review of the facility's incident report forms and policy, it was determined the facility failed to ensure residents remained free from misappropriation of property for six (6) of one hundred and four (104) sampled residents (Residents #11, #42, #65, #122, #148, and #150). Resident #127 took items belonging to the five (5) of the six (6) residents. 1. The facility identified Resident #127 as responsible for multiple allegations of misappropriation of other residents' property which included taking $100 from Resident #148 on [DATE], and $15 from the same resident on [DATE]; and taking $10 from Resident #65 on [DATE]. 2. On [DATE] at 7:00 AM, at shift change it was identified a blister pack containing thirteen (13) pills of Hydrocodone 5/325 mg and three (3) Gabapentin tablets of 100 mg were missing during the shift change narcotic count. The missing medications belonged to Resident #11 and Resident #150. 3. LPN #1 stated in interview Resident #127 came to her with an iPad and…

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 the facility's investigation reports, review of the 135DE Secure Care System Installation Manual, review of google.com/maps, and review of the facility's policy, it was determined the facility failed to ensure the residents' environment remained free of accident and hazards as possible and failed to identify, evaluate, and implement interventions to reduce hazards and risks for eleven (11) out of one hundred and four (104) sampled residents. The facility failed to have accurate Elopement Binders which had correct or thorough information for ten (10) residents who were at high risk for elopement (Residents #32, #43, #67, #75, #82, #88, #112, #115, #127, and #156). 2. The facility failed to provide appropriate supervision for two (2) residents to prevent elopement (Residents #63 and #112). 3. The facility failed to have an effective alarm system in place to allow for appropriate monitoring and supervision of wandering and elopement risk residents. 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 the facility's policy, it was determined the facility failed to ensure nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Staff interviewed stated they had not received training in the areas of behavior management, catheter care, and providing for a resident's dignity. In addition, the facility failed to provide training for abuse, neglect and exploitation for one (1) out of thirty-five (35) State Registered Nursing Assistants (SRNA's). SRNA #34 stated in a phone interview that he/she was not given training for abuse neglect, and exploitation when he/she began working at the facility six (6) months ago. The findings include: Review of the facility job description titled, Nursing Assistant, undated, revealed the facility expected nursing assistants to wash their hands before and after resident care. Continued…

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 facility's policy, it was determined the facility failed to have an effective antibiotic stewardship program to monitor antibiotic use as part of the overall infection prevention and control program (IPCP). Furthermore, the facility failed to incorporate monitoring and assessment of antibiotic use for five (5) of one hundred and four (104) sampled residents (Residents #20, #45 #71, #97, and #158). In addition, the facility failed to track antibiotic use in the facility and failed to report regularly on antibiotic use and resistance to the facility's leadership. The findings include: Review of the facility's policy, Antimicrobial Stewardship, dated December 2016, revealed antibiotics would be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of the policy was to ensure that the antibiotic stewardship program was used to monitor the use of antibiotics. 1. Review of Resident #20's admission record revealed the facility admitted the resident on 10/17/2019 with…

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, review of the Centers for Disease Control and Prevention (CDC) document, and review of the facility's policies, it was determined the facility failed to educate and offer COVID-19 immunization as required or appropriate for two (2) of five (5) sampled residents (Residents #126 and #128). In addition, the facility failed to maintain documentation of screening, education, offering, and current COVID-19 vaccination status. The findings include: Review of the Centers for Disease Control and Prevention's (CDC) document titled, Vaccines and Immunizations, reviewed 11/16/2023, revealed the CDC recommended all adults sixty-five (65) years of age or older should receive the COVID-19 vaccine unless medically contraindicated by a physician. Review of the facility's policy titled, Vaccination of Residents, revised 10/2019, revealed all residents were to be offered vaccines that aided in preventing infectious disease unless the vaccine was medically contraindicated or the resident had already been vaccinated. Per policy review, before receiving vaccinations,…

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, it was determined the facility failed to ensure a dignified existence for two (2) of one hundred and four (104) sampled residents (Residents #105 and #103). Resident #105 was not afforded privacy, as the State Registered Nursing Assistant (SRNA), did not close the curtain before performing catheter care. Additionally, Resident #105 was observed with no dignity bag for his/her catheter on 02/26/2024, 03/05/2024, 03/06/2024, and 03/07/2024. Resident #103 was not provided a privacy bag for his/her catheter in order to afford privacy, prevent embarrassment, and respect and dignity. The findings include: Review of the facility's policy, Resident Rights Under Federal Law, dated 11/28/2016, revealed the resident had the right to a dignified existence. 1a) Review of Resident #105's admission Record revealed the facility admitted the resident on 01/15/2024 with diagnoses that included metabolic encephalopathy (alteration in consciousness due to brain dysfunction), urinary tract infection, and hemiplegia (partial…

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 facility's policy, it was determined the facility failed to ensure the rights of the residents or his/her representative were observed for either the resident or the resident's representative to plan and participate in the care planning process for one (1) of one hundred and four (104) sampled residents (Resident #66). Resident #66 stated that he/she was not involved in his/her care planning. Record review revealed there were no notes in Resident #66's chart for the last care plan meeting on 01/11/2024. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed the resident and his/her representatives would be involved in the care planning process. Per policy review, the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, developed and implemented a comprehensive, person-centered care plan for the resident. Continued review 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 interview, record review, and review of the facility's policies, it was determined the facility failed to follow its policy regarding Advanced Directives for three (3) of one hundred and two (102) sampled residents (Residents #22, #57, and #103). Review of Residents #22's, #57's, and #103's medical records revealed the facility failed to ensure the resident's right to create an Advance Directive concerning their medical care, including the right to accept or refuse treatment. The findings include: Review of the facility's policy titled, Advance Directive Policy and Record, not dated, revealed the facility would recognize and implement the resident's right under state law to make decisions concerning his/her medical care including the right to accept or refuse medical treatment and the right to create Advance Directives. Review of the facility's policy titled, Advance Directives, revised 12/2016 revealed the facility displayed information regarding a resident's advance directive status prominently 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.

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 protect residents from involuntary seclusion for one (1) of one hundred and four (104) sampled residents (Resident #112). On 03/03/2024 at 7:45 PM, State Registered Nurse Aide (SRNA) #26 was observed escorting Resident #112 to his/her room and shutting the door tight, preventing the resident from opening the door and exiting the room. SRNA #26 stated he had not been told by the facility that he was not allowed to close the door on a resident who lacked the ability to open the door at will and/or without the resident asking for the door to be closed. The findings include: Review of the facility's policy titled, Identifying Type of Abuse, dated 04/2021, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. Review of Resident #112's Face Sheet, revealed the facility admitted 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 interview, record review, and review of the facility's policy, it was determined the facility failed to provide a complete and thorough investigation into the allegation of sexual abuse for two (2) of one hundred and four (104) sampled residents (Resident #101, and Resident #112). The facility failed to investigate the report, which involved Resident #101 and Resident #112, who were both severely cognitive impaired, were found in bed together with their hands down each other's pants and; failed to prevent further potential abuse while the investigation was in progress. The facility reported to state agencies on 06/26/2023, that Resident #101 and Resident #112 engaged in inappropriate sexual relations. The facility's report revealed Resident #101 had a Brief Interview of Mental Status (BIMS) score of 99 and Resident #112 had a BIMS of six (6). Both BIMS scores indicated the residents had severe cognitive impairment and therefore could not consent to sexual encounters of any kind. The facility noted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to ensure the MDS assessment accurately reflected the resident's status for two (2) of one hundred four (104) sampled residents (Residents #52 and #55). Resident #55's MDS assessment revealed the resident did not wear oxygen. However, the State Survey Agency (SSA) surveyor observed the resident wearing oxygen. Review of Physician's Orders revealed an order for oxygen. Additionally, the facility failed to assess dental care for Resident #52. The findings include: 1. Review of Resident #55's Face Sheet revealed the facility admitted the resident on 06/04/2021 with diagnoses of asthma, acute and chronic respiratory failure with hypoxia, obstructive sleep apnea, heart failure, and tracheostomy. Review of Resident #55's Physician Orders revealed the resident had an order for oxygen two (2) liters…

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, it was determined the facility failed to ensure residents who were unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming, personal, and oral hygiene for one (1) of one hundred four (104) sampled residents (Resident #117). The findings include: Review of the facility's policy, Activities of Daily Living (ADLs), Supporting, revised March 2018, revealed appropriate care and services would be provided for residents who were dependent on staff for assisting with activities of daily living (ADL), with the consent of the resident and in accordance with the plan of care. The policy stated appropriate support included assistance from staff for hygiene (bathing, dressing, grooming, and oral care); mobility (transfer and ambulation, including walking); elimination (toileting); dining (meals and snacks); and communication (speech, language, and any functional communication system). Review of Resident #117's Face Sheet revealed the facility admitted 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 review of the facility's policies, it was determined the facility failed to ensure an ongoing program of activities was developed to meet the individual needs of two (2) of one hundred and four (104) sampled residents (Residents #55 and #117). The facility failed to provide individualized activities based on the comprehensive assessment, the care plan, and the personal preferences of each resident. The findings include: The State Survey Agency (SSA) Surveyor requested a policy on activities for review on 02/29/2024 at 8:54 AM. However, the Activities Director stated the facility did not have one. Review of the facility's policy, Resident Rights, revealed residents had the right to make choices on matters that were significant to the resident, including activities, schedules (including sleeping and waking times), health care, and providers of heath care services consistent with his or her interests, assessments, and care plan. Further review revealed residents had the right to participate in community activities inside and outside…

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 facility policy review, it was determined the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three (3) of one hundred four (104) sampled residents (Residents #91, #86, and #126). 1. On 03/02/2024, the facility failed to ensure Resident #91's sacral wound dressing was changed as ordered by the physician to be completed on every day shift. 2(a). Observation of Resident #86's jejunostomy tube (J-tube; a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine) site revealed the area surrounding the J-tube insertion site was crusted with an approximate dime-sized amount of purulent drainage. Continued observation revealed no visual evidence of the ordered gauze dressing to cover that area. 2(b). Observation of Resident #126's gastrostomy tube (g-tube) site revealed the area surrounding it was excoriated (reddened) and, the upper half portion 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, record review, and review of the facility's policy, it was determined, the facility failed to maintain acceptable parameters of nutritional status, to include weight, for one (1) of one hundred four (104) residents (Residents #126). The facility failed to ensure physician's orders for Resident #126's enteral tube feedings were followed. The findings include: Review of the facility's policy titled, Enteral Nutrition, and revised 2018, revealed the facility would provide adequate nutritional support through enteral nutrition to residents as ordered. Per policy review, residents who were receiving enteral nutrition would have appropriate recommendations for interventions to enhance nutrition. Further review of the policy revealed staff caring for residents with feeding tubes were to be trained on how to recognize and report complications associated with the insertion of the feeding tube such as skin breakdown around the insertion site. Review of Resident #126's medical record revealed the facility readmitted the resident on 12/21/2023, with diagnoses…

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, it was determined the facility failed to ensure the medication error rate was less then five percent (5%). Observation during medication administration on 02/28/2024 revealed the nurse made eight (8) medication errors out of thirty (30) opportunities for a medication administration error rate of 26.67%. Observation also revealed Resident #63 and Resident #37 resided in the same room, and Licensed Practical Nurse (LPN) #6 administered eight (8) medications to Resident #63 that were prescribed for Resident #37. The findings include: Review of the facility's policy, Administering Medications, revised April 2019, revealed medications were administered in a safe and timely manner and as prescribed. Further review revealed the Director of Nursing supervised and directed all personnel who administered medications and/or had related functions. Continued reviewed revealed medications were administered in accordance with prescriber orders, including any required time frame. Review of the policy also 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, review of the [NAME] website nursing references on medication administration, Nursing Rights of Medication Administration, and review of the facility's policy, it was determined the facility failed to ensure it was free of significant medication errors for one (1) of one hundred four (104) sampled residents (Resident #63). Observation during medication administration on 02/28/2024 revealed the nurse failed accurately identify residents in their room resulting in Resident #63 receiving medications prescribed for Resident #37. The findings include: Review of the facility's policy, Administering Medications, revised April 2019, revealed medications were administered in a safe and timely manner and as prescribed. Further review revealed the Director of Nursing supervised and directed all personnel who administered medications and/or had related functions. Continued reviewed revealed medications were administered in accordance with prescriber orders, including any required time frame.…

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, it was determined the facility failed to have an effective system to ensure the residents' medications were properly labeled for two (2) of one hundred and four (104) sampled residents (Residents #128 and #285). On 02/28/2024, State Registered Nurse Aide/Kentucky Medication Aide (SRNA #12/KMA #1) failed to properly label and store drugs in accordance with currently accepted professional principles. She put Resident #285's and #128's medications in medication cups and put them in the top drawer of the medication cart. There was no label on the medication cups indicating the names of the residents. The findings include: Review of the facility's policy, Medication Labeling and Storage, revised 02/2023, revealed medications and biologicals were stored in the packaging, containers, or other dispensing systems in which they were received. Only the issuing pharmacy was authorized to transfer medications between containers. Per the policy, each resident's medications were assigned to an individual cubical,…

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 policies, it was determined the facility failed to provide residents with a nourishing, palatable, well-balanced diet that met the daily nutritional and special dietary needs, taking into consideration the preferences of each resident for two (2) of one hundred and four (104) residents (Resident #58 and #70). Observation of the tray line service on 02/26/2024, revealed Resident #58 was ordered a controlled carbohydrate (CCHO) diet with large portions of vegetables but only received one (1) small scoop of potato salad and one (1) small scoop of mashed potatoes. In addition, there were no alternative/substitutions for the CCHO diet. Observation of the dinner meal on 03/01/2024, revealed Resident #70 did not receive fish, as identified on the residents list of personal preference for fish at lunch and supper meal. The findings include: Review of the facility's policy titled, Therapeutic Diets, revised October 2017, revealed therapeutic diets were prescribed by the attending physician to support the resident's treatment and…

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 facility policy review, it was determined the facility failed to follow the menu and provide the required nutritional needs for one (1) of one hundred and four (104) sampled residents (Resident #50). The findings include: Review of the facility's Nutritional Assessment Policy, dated 10/2017, revealed the resident's nutritional assessment identified special food formulations and calorie, protein, fluid needs. Review of the facility's Resident Rights Under Federal Law Policy, dated 11/28/2016, revealed it was required by the facility that each resident be treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of his/her quality of life, and recognized each resident's individuality. Review of Resident #50's face sheet revealed the facility admitted Resident #50 on 04/10/2015 with diagnoses including traumatic amputation of left lesser toe, end stage renal disease, and Type 2 diabetes. Review 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.

Based on observation, interview, and review of the facility's policies, it was determined the facility failed to provide food that was palatable, attractive, and at an appetizing temperature for three (3) of one hundred and four (104) sampled residents (Residents #35, #66, and #113). The findings include: Review of the facility's policy, Policy and Procedure Manual: General Food Preparation and Handling, dated 2019, revealed food items would be prepared to conserve maximum nutritive value, develop and enhance flavor, and keep free of harmful organisms and substances. Review of the facility's policy, Policy and Procedure Manual: HACCP and Food Safety, dated 2019, revealed the Director of Food and Nutrition Services and the Registered Dietician should determine the appropriate temperature ranges for the food service operation. Continued review revealed it was noted the United States Department of Health and Human Services Food Code used the minimum safe temperature requirement of 41 degrees Fahrenheit (F) for cold foods and 135 degrees F for hot foods. 1. Observation of Resident #35'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 interview, record review, review of the Centers for Disease Control and Prevention (CDC) document, and review of the facility's policies, it was determined the facility failed to provide immunization as required or appropriate; to ensure the resident or the resident's representative had the opportunity to refuse immunizations; and failed to ensure the medical record included documentation of the resident's or resident representative's education regarding the benefits and potential side effects of immunizations for one (1) of one hundred four (104) sampled residents, Resident #128. The findings include: Review of the facility's policy, Vaccination of Residents, revised 10/2019, revealed all residents would be offered vaccines that aided in preventing infectious disease unless the vaccine was medically contraindicated or the resident had already been vaccinated. Per the policy, before receiving vaccinations, the resident or legal representative would be provided information and education regarding the benefits and potential side effects of the vaccinations, and all education…

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 the facility's policy, it was determined the facility failed to provide a comfortable homelike environment for four (4) of thirty (30) sampled residents (Residents #84, #88, #108, and #114) and three (3) unsampled residents (Residents #41, #59, and #96). Observations conducted, on 04/12/2021 through 04/15/2021; 04/22/2021 through 04/28/2021; and 05/11/2021 through 05/14/2021, revealed strong urine and fecal odors were present upon entering the facility and throughout the areas of the facility where residents resided. Interviews with staff and residents revealed concerns had been voiced to Administration related to odors in the facility. The findings include: Review of the facility's policy titled, Resident Rights, dated 03/01/2018, revealed residents had the fundamental right to considerate care that safeguarded their personal dignity along with respecting cultural, social, and spiritual values. Further review of the policy revealed the facility complied with and…

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 observations, interview, record review and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals were stored in an orderly manner and labeled in accordance with currently accepted professional principles and include the expiration date for six (6) of thirty (30) sampled residents (Residents #7, #80, #81, #130, #335 and #336). On 05/05/2021 the facility discharged Resident #81 home with medications; however, on 05/07/2021 resident #81 noticed he/she had medication belonging to Resident #80. Observation on 05/13/2021 at 9:30 AM revealed Resident #7's fluticasone 50 microgram nasal spray was in the medication cart drawer with Resident #2's medications. Three (3) other residents' medications, Resident #335, Resident #130, and Resident #336, were also observed in the medication cart drawers that were labeled for other residents' rooms. The findings include: Review of Medication Storage policy Storage and Expiration Dating of Medications, Biological's, Syringes…

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, it was determined the facility failed to keep food in a safe and sanitary environment as determined by observations during initial and continued tour of the kitchen. Observations on 04/20/2021 and 04/21/2021 revealed a fan in the dish room was covered with a dust-like substance and the floors underneath and behind equipment with food debris. Observation of the resident nourishment refrigerators on three (3) of three (3) resident care units, revealed food products not labeled or dated for expiration. The findings include: Review of the facility policy titled Food: Safe handling for Foods from Visitors, dated 07/2019, revealed the responsible facility staff member, would ensure the food brought to the facility was easily distinguishable from the facility food. Continued review revealed the responsible staff member would ensure the food was in a sealed container to prevent cross contamination and would label the food with the resident's name and the current date. Review of the facility policy titled Snacks, dated 09/2017,…

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, review of the Director of Nursing's Job Description, review of the Administrator's Job Description, and review of the facility's policies, it was determined the facility's administration failed to ensure it was administered in manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental foe its residents. Observations of the 100, 200, and 300 Units and specific residents' rooms revealed urine and fecal odors on each unit and in residents' rooms throughout the facility. Interviews with residents and staff revealed there were unpleasant, foul odors in the facility and in their rooms which were concerning to them. Interviews with the Administrative staff revealed they were aware of the unpleasant, foul odors, and it was their responsibility to manage them, but they had failed to eliminate the odors. The findings include: Review of the facility's policy titled, Resident Rights, dated 03/01/2018, revealed residents had the fundamental right to considerate care that safeguarded their…

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 facility's policies, it was determined the facility failed to protect residents from resident-to-resident abuse for four (4) of thirty (30) sampled residents (Residents #24, #68, #71, and #235). On 02/28/2021, Resident #24 slapped Resident #71 for inviting someone into their shared room, and Resident #71 slapped Resident #24 back. On 02/20/2021, Resident #65 struck Resident #235 in their shared room, as Resident #235 was in the room going through Resident #65's possessions. On 03/29/2021, Resident #334 observed Resident #68 taking food from a tray at the nurse's station. Resident #334 thought Resident #68 was stealing his/her food and stabbed Resident #68 with a fork. The findings include: Review of the facility's policy titled, Abuse Prohibition, dated 04/09/2021, revealed physical abuse was prohibited and included hitting, slapping, pinching, kicking, as well as controlling behavior through corporal punishment. 1. Review of Resident #71's medical 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's Policy, it was determined the facility failed to ensure the consultant pharmacist's recommendation from the monthly medication regimen reviews (MRR) were received, reviewed, and acted upon by the Attending Physician or Advanced Registered Nurse Practitioner (ARNP) for five (5) of thirty (30) sampled residents (Residents #49 #64, #101, #114 and #125). The Pharmacist made monthly MRR reports on each resident and sent the medication irregularities to the facility via email. However, there was no documented evidence the facility regularly provided the reports to the care providers in a timely manner or reviewed the reports in the Quality Assurance and Performance Improvement (QAPI) meetings, as per policy. The findings include: Review of the facility's Policy, Medication Regimen Review, effective [DATE] and revised [DATE], revealed that when the MRR Consultant Report was received from the Consultant Pharmacist, the Center Nurse Executive (CNE) would…

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 facility's policy, it was determined the facility failed to ensure each resident's drug regimen was free from unnecessary drugs and psychotropic drug regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. The facility failed to ensure that medication gradual dose reduction (GDR) recommendations from the consultant pharmacist were received and responded promptly by the care providers, to ensure residents did not receive unnecessary drugs or failed to indicate that the continued use of the drug to be a valid therapeutic intervention for five (5) of thirty (30) sampled residents (Resident #49, #64, #101, #114 and #125). The findings include: Review of the facility's policy, Medication Regimen Review, (MRR) effective date [DATE], and revised [DATE], revealed that when the MRR Consultant Report was received from the Consultant Pharmacist, the Center Nurse Executive (CNE) would…

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, the Centers for Medicare and Medicaid Services (CMS), the Center for Disease Control and Prevention and the Kentucky Department for Public Health (Health Department) state guidelines for COVID - 19 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 and control the development and transmission of communicable diseases. Observation, on 04/13/2021, revealed staff failed to properly doff and dispose of personal protective equipment (PPE) and perform hand hygiene after providing resident care. Observation revealed staff failed to empty contaminated linen and trash causing storage barrels to overflow and prevent secure closure. Contaminated trash and linen barrels were stored in a shower room actively used for residents. Continued observation revealed multiple staff failed to redirect a…

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 facility's policies, it was determined the facility failed to protect residents from abuse related to Misappropriation of resident property for one (1) of thirty (30) sampled residents (Resident #93). On 01/17/2021, Resident #93 reported that he/she did not receive a bag with two (2) candy bars and two hundred forty dollars ($240) which was left for him/her at the front door when staff was not available to receive the items. The findings include: Review of the facility's policy titled, Abuse Prohibition, dated 04/09/2021, revealed misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Review of Resident #93's medical record revealed the facility admitted the resident, on 12/18/2021, with diagnoses of Atrial Fibrillation, Hypertension, and Diabetes Mellitus Type 2. Review of Resident #93's Quarterly 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.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents who were unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming, personal and oral hygiene for three (3) of thirty (30) sampled residents (Resident #114, Resident #36, and Resident #102). Resident #114 was observed to be unshaven with full facial hair, unclean and messy clothing, and an unpleasant body odor. Observation of Resident #36, on 04/21/2021, revealed the resident had greasy uncombed hair. The resident had food stuck between his/her teeth, and they appeared dirty. Further observation noted a strong smell of urine, and the resident stated he/she was wet, with the brief under his/her slacks appearing saturated. Observation of Resident #102, on 04/20/2021, revealed his/her hair was greasy, and the resident smelled of urine. Interview with Resident #102, revealed he/she had issues with the ability of staff to help residents take showers and clean up. The findings include: 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 policy, it was determined the facility failed to have an effective system to ensure pain management was provided to residents who required such services. The facility failed to ensure pain medication was available to the resident per the Physician's Orders, the Comprehensive Care Plan, and the goals and preferences for one (1) of thirty (30) sampled residents (Resident #110). The facility admitted Resident #110, on [DATE], with diagnoses that included Chronic Pain and Thoracic, Thoracolumbar, and Lumbosacral Intervertebral Disc Disorder. Resident #110 was hospitalized , on [DATE], with Altered Mental Status, Condition Decline, and Respiratory Failure. Prior to the [DATE] acute care hospitalization, the resident was receiving Oxycodone with Acetaminophen (a narcotic opioid pain reliever given for moderate to severe pain) on a every six (6) hour schedule. When Resident #110 returned from the hospital to the facility, on [DATE], 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 the facility's Policy, it was determined the facility failed to review medication orders that were written on an as needed basis (PRN) for psychotropic drugs limited to 14 days and for the attending physician or prescribing practitioner to evaluate the resident for the appropriateness of the medication for one (1) of thirty (30) sampled residents (Resident #84). Resident #84 had a Physician's order, dated 03/16/2021, for Ativan (psychotropic medication) one-half (0.5) milligram (mg) to be administered through the G-tube (gastric/feeding tube) every eight (8) hours as needed for anxiety. The order failed to contain a fourteen (14) day stop date or documentation of rationale in the resident's medical record indicating the appropriateness for the PRN order to be extended beyond the fourteen (14) days and the duration for the PRN order. The findings include: Review of the facility's Policy titled Psychotropic Medication Use, dated 11/28/2016, revealed PRN…

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.