Fordsville Nursing and Rehabilitation Center

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) of fifty-five sampled residents (Residents #46, and #16). Resident #46 has a persistent rash with a diagnosis of scabies. Observation on 08/05/2023, revealed Certified Nursing Assistant #22 and Registered Nurse (RN) #2 failed to don Personal Protective Equipment (PPE) when providing direct care to Resident #16 who was on Enhanced Barrier Precautions (EBP). The findings include: Review of the facility's policy, Infection Control, revised October 2018, revealed the facility would maintain a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The facility would prevent, detect, investigate, and control infections within the facility and establish guidelines for implementing…

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 ensure a resident who was assessed to be mentally incapacitated had his/her Advance Directive information given to and signed by his/her Resident Representative for one (1) of three (3) residents sampled for closed records (Resident #214). Closed record review revealed on 05/25/2023, Resident #211 signed his/her own Kentucky Emergency Medical Services Do Not Resuscitate (DNR) Order and Cardiopulmonary Resuscitation Consent. Further review of Resident 214's Quarterly Minimum Data Set Assessment (MDS) Assessment, dated 05/15/2023, revealed the resident had severe cognitive impairment. The findings include: Review of the facility's policy, Advance Directive Standard of Practice, dated 10/2020, revealed resident's had the right to formulate an Advance Directive and to accept or refuse medical or surgical treatment. The facility would periodically assess the resident for decision making abilities and approach the health care proxy or legal representative if the resident was…

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 ensure each resident had a safe, clean, comfortable, and homelike environment for five (5) of five (5) residents' sampled rooms. Observations on 07/31/2023 through 08/04/2023, revealed multiple resident rooms had peeling wallpaper, chipped paint, and damaged walls (Rooms 3-A, 21-A, 28-B, 31-A and 37-A). The findings include: Review of the facility's policy, Homelike Environment Standard of Practice, dated 10/2020 revealed the facility would provide residents with a safe, clean, comfortable and homelike environment. The facility should maximize, to the extent possible, characteristics of the facility to reflect a personalized, homelike setting that should include cleanliness and order. 1. Observation of room [ROOM NUMBER]-A on 07/31/23 at 10:40 AM, revealed the wallpaper was peeling from the seams. 2. Observation of room [ROOM NUMBER]-B on 08/01/23 at 8:44 AM, revealed chipped and peeling paint on 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, and review of the facility's policy, it was determined the facility failed to expired medications were removed from the medication refrigerators, per the facility's policy for one (1) of two (2) medication refrigerators. Observation a medication refrigerator on 08/03/2023, revealed expired medications for Resident's #35 and #32 were stored in the refrigerator. The findings include: Review of the facility's policy, Label/Store Drugs & Biologicals Standard of Practice, dated 10/2020, revealed drugs and biologicals must be labeled in accordance with currently accepted professional principles, and include the expiration date when applicable. Further review revealed expired and/or discontinued medication shall be removed from the medication storage area for timely return to pharmacy and/or documented destruction. Review of the facility's policy, Medication Administration Standard of Practice, dated 10/2020, revealed expired/beyond use date medication should not be administered.…

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 protect residents from physical abuse for four (4) of fifty-five (55) sampled residents (Residents #36, #49, #50, and #213). On 01/15/2023, staff responded to an incident of Resident #213 striking Resident #50 on the face, in the common area. On 10/02/2022, staff had reported witnessing Resident #49 touching Resident #36's chest area above his/her clothing. The findings include: Review of the facility's policy, Abuse Prohibition Standard of Practice, dated 07/2022, revealed the facility would prohibit and prevent abuse, neglect, exploitation, misappropriation or resident property and ensure reporting and investigating of alleged violations, mistreatment and involuntary seclusion in accordance with Federal and State laws. 1 (a). Review of closed record revealed the facility admitted Resident #213 on 12/09/2022 with diagnoses which included include Vascular Dementia, Altered Mental Status Unspecified, and Major Depressive Disorder. Review of Resident #213's Quarterly Minimum…

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 facility policy, and review of the Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to review and revise a comprehensive person-centered care plan for one (1) of fifty-five (55) sampled residents (Resident #49). Record review revealed Resident #49's care plan was not revised after he/she exhibited inappropriate sexual behaviors on 10/02/2022, 10/25/2022, and 10/26/2022. The findings include: Review of the RAI Manual, Section 4.7 The RAI and Care Planning, dated 10/2019, revealed the care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident required. Review of the facility's policy, Comprehensive Care Plans Standard of Practice, dated 10/2020, revealed an individualized comprehensive care plan should include objectives and timetables to meet the residents medical, nursing, mental, and psychosocial needs, were to be developed for each resident. Assessments of residents were ongoing and care plans were revised as information about the resident and 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, review of the facility's polices and the Resident Assessment Instrument (RAI) it was determined the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives to meet the resident's medical, nursing, mental and psychosocial needs for three (3) of thirty-three (33) sampled residents (Residents #5, #21 and #41). Resident #5 sustained twenty-six (26) falls from 05/01/2021 to 05/01/2022. The facility failed to follow the resident's Care Plan to ensure the resident was assisted as he/she ambulated throughout the facility. On 06/19/2021, Resident #5 sustained a fall and was transferred to the Emergency Department (ED). This fall resulted in a laceration on the back on his/her head which measured 2.4 centimeters (cm) by 1.3 cm. Additionally, the facility failed to ensure the resident was monitored every fifteen minutes and had on appropriate shoes at all times. Review of the incident reports revealed Resident #21…

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 revise a comprehensive person-centered care plan for residents with measurable objectives to meet a resident's medical, nursing, and mental and psychosocial needs for two (2) of thirty-three (33) sampled residents (Resident's #5 and #6). The facility failed to update Resident #5's care plan after the resident fell on [DATE], 06/01/2021, 08/10/2021, 10/08/2021, 11/09/2021, and 03/11/2022, to reflect the interventions staff implemented on the resident's fall report. The facility failed to update Resident #6's care plan with a tab alarm after the resident had a fall on 12/31/2021. Resident #5 sustained a fall on 05/10/2021, 06/01/2021, 08/10/2021, 10/08/2021, 10/15/2021, 11/09/2021, 12/02/2021, 12/09/2021, 02/18/2022, 03/11/2022, and 04/25/2022. The facility failed to revise the resident's Comprehensive Care Plan (CCP) to establish interventions for each of the noted falls. The findings…

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 provide the needed care and services to ensure the residents met the highest practical physical, mental and psychosocial needs for one (1) of thirty-three (33) sampled residents (Resident #41). The findings include: Record review revealed the facility admitted Resident #41, on 01/17/2020 with diagnoses which included: Other Secondary Parkinsonism, Contracture, Unspecified joint, and Cerebral Palsy, Unspecified. Review of Resident #41 Quarterly Minimum Data Set (MDS) assessment, dated 10/01/2020, revealed the facility assessed Resident #41's cognition as impaired with a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was not interviewable. Review of Section G: Functional Status, revealed the facility assessed the resident as totally dependent for care. Review of Resident #41's care plan revealed the resident was to wear Thera Carrots (a device placed in the palm Review of Resident #41's care plan, revealed the resident…

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 provide supervision to ensure an environment free from accidents and hazards for one (1) of thirty-three (33) sampled residents (Resident #5). Review of Resident #5's Electronic Medical Record revealed since 05/01/2021 to 05/01/2022, the resident had twenty-six (26) falls and eighteen (18) of those falls were unwitnessed. Additionally, most of the falls occurred when the resident attempted to go to the bathroom. Resident #5 sustained an injury to his/her head on 06/19/2021 from an unwitnessed fall which resulted in a laceration of two-point four (2.4) centimeters (cm) by one-point three (1.3) cm on the back of his/her head. The facility sent Resident #5 to the Emergency Department (ED). Resident #5 sustained another fall with injury on 04/17/2022 which resulted in a fractured finger. The resident's finger was splinted. The findings include: Review of the facility's policy titled, Falls…

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

Based on observation, interview, record review, review of the facility's policy and the ProView Assure Glucometer User's Guide, it was determined the facility failed to ensure a glucometer meter was calibrated per the manufacturer's guidelines for one (1) of two (2) hallways, the Harmony Hall. Record review revealed the Harmony Hall Glucose Quality Control (QC) Log, dated April 2022, was missing the glucose control testing results from April 11, 2022, through April 20, 2022. Furthermore, the facility did not provide the Harmony Hall QC Log for March 2022 after it was requested. The manufacture's guidelines revealed the QC testing was to be completed weekly. The findings include: Interview with the Director of Nursing (DON), on 05/05/2022 at 1:00 PM, revealed the facility did not have a policy for glucometer monitoring or calibration. The DON stated the facility used the manufacturer's guideline for testing. Review of the ProView Assure Glucometer User's Guide, undated, revealed the facility should perform QC solution tests weekly, with a new bottle of strips; and, a new meter, if…

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, facility policy review, and the Center for Disease Control and Prevention (CDC) guidance, it was determined the facility failed to ensure an open vial of Tuberculin Purified Protein Derivative (PPD) serum used for the tuberculin skin test (TST) for Tuberculosis (TB) screening for residents and staff was labeled with an open date. Observations revealed one (1) of three (3) vials of PPD serum was opened and undated in the Foxes Drive Hall's medication refrigerator. The findings include: Review of the facility's policy, Tuberculosis, Employee Screening, revised [DATE], revealed all employees were screened for latent TB infection and active TB disease using the tuberculin skin test (TST) and symptom screening. Review of the facility's policy, Tuberculosis, Screening Residents, revised [DATE], revealed the facility screened all residents for TB infection and TB disease. The resident, who may have been exposed to TB or was at increased risk for TB infections would be screened using 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.