Owensboro Health Muhlenberg Community Hospital Lon

Based on observation, interview, and review of the facility's policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which had the potential to affect 37 of the facility's 37 residents who consumed food from the kitchen. Observation of the kitchen revealed food items were not sealed and/or covered to prevent contamination. Food items were labeled with a use-by date but had not been discarded after expiration. Review of the facility policy titled, Food and Supply Storage, revised 04/2025, revealed all food supplies used in food preparation should be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. All foods past the use by date should be discarded. Additionally, all unused portions and opened packages were to be covered, labeled and dated, and freezer food items were to be wrapped tightly to prevent cross-contamination. Observation during initial tour of the kitchen on 03/17/2026, revealed the following:a. Observation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to maintain a comprehensive care plan that is reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 4 out of 4 sampled residents.The findings include: Record review revealed Resident (R)8 was admitted on [DATE] with diagnoses including congestive heart failure, Type 2 Diabetes Mellitus, coronary artery disease, and chronic obstructive pulmonary disease. Additional diagnoses include class 3 severe obesity, sleep apnea, ischemic congestive cardiomyopathy, and atrial flutter. Further review revealed an order for Eliquis 5 mg, oral, 2 times daily, started on 10/17/2025. Review of the most recent MDS for R8, accepted on 03/14/2025, revealed that the resident was reported as being on an anticoagulant. Review of the Comprehensive Care Plan for R8 revealed no care planning regarding the for risk of bleeding related to taking an anticoagulant. 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 record review, policy review, and interviews, the facility failed to have follow-up procedures that must be in place to provide the information to the individual directly at the appropriate time for advance directives for one of the three residents sampled. A record review of Resident (R) 28's electronic chart on 03/18/2026 at 9:00 AM revealed the resident had an order for Do Not Resuscitate (DNR) as of 02/26/2026 and had advanced directive in parentheses behind the DNR located just beneath the resident's picture. A policy review of the documents titled Advance Directives & Medical Orders for Scope of Treatment (MOST), 600-024, revised date of 12/2025, on 03/18/2026 at 10:00 AM, revealed that the policy did not have direction on follow-up assessments for an advance directive. An interview with Resident #28's Daughter, Family #2 and power of attorney (POA) on 03/18/2026 at 9:37 AM, she revealed that she is her mother's POA but had not brought a copy to the facility. She denied that the facility had asked for the advance directive. During a review of Resident #28's durable…

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 Assessment, it was determined the facility failed to ensure the services of a Registered Nurse (RN) were utilized for at least eight consecutive hours a day, seven days a week. The facility failed to provide eight consecutive hours of RN coverage for 13 days between 07/01/2024 and 09/30/2024. This failure affected all persons residing in the facility on those 13 days, as the residents did not receive the required minimum nursing services. The findings include: Review of the Facility Assessment Staffing Plan, dated 07/2024 and revised 11/2024, revealed the facility received a one-star rating on staffing due to a high number of days without an RN on site daily. The facility had an RN house supervisor available 24 hours a day in the attached acute hospital. Due to her supervising in the attached acute hospital and not being assigned eight consecutive hours to the long-term care facility, the RN house supervisor's hours were not reflected on the Payroll Based Journal (PBJ) report. Review of the facility's PBJ Staffing 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, and review of facility policy, the facility failed to store food in accordance with professional standards for food service safety. Refrigerated foods were not dated, labeled, and/or discarded in a timely manner. These failures had the potential to affect 34 of 34 residents in the facility who consumed food from the kitchen. The findings include: Review of the facility policy titled, Food Safety Management System, revised 12/06/2024, revealed leftover foods must be properly labeled and date marked. The policy also stated that leftover foods must be discarded if required by local, state, or provincial health department regulation, but failed to identify specific discard dates. Observation during the initial kitchen tour on 01/07/2025 at 12:03 PM, with the Dietary Supervisor, revealed the cold prep cooler contained a small container of a red jelly-like substance that was not labeled or dated which the Dietary Supervisor identified as cranberry sauce, and a large container of pineapple chunks that was not labeled or dated. Additional observation…

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

Based on observation, interview, and facility policy review, it was determined the facility failed to store food in accordance with professional standards for food service safety. The facility census was forty (40) and thirty-nine (39) residents received meals from the kitchen and had the potential to be affected. Observation, during initial tour of the kitchen, revealed opened food items that were not labeled or dated. The findings include: Review of the facility's policy, Food Receiving and Storage, dated 02/2022, revealed, foods would be received and stored in a manner that complies with safe food handling practices. All food stored in the refrigerator or freezer would be covered labeled and dated with a use by date. Observation of the facility's kitchen on 11/14/2023 at 6:40 PM, revealed there was a container of four (4) biscuits and a container of bacon not dated or labeled in the walk-in cooler. During an interview with the Certified Dietary Supervisor on 11/14/2023 at 6:45 PM, she stated she expected all opened food items located in the refrigerator or freezer to be labeled…

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 that an alleged allegations of physical abuse was reported to the State Agency and local law authorities immediately, but no later than two (2) hours after the allegations were made for one (1) of twelve (12) sampled residents ( Resident #15). During a Resident Council Meeting on 11/15/2023 at 2:06 PM, Resident #15 stated he/she reported an allegation of abuse last week to the Nursing Supervisor/ However, the allegation was not reported to the Abuse Coordinator until 11/15/2023. Additionally, the facility failed to notify the State Survey Agency (SSA) of the allegation. The findings include: Review of the facility's policy, Abuse and Abuse Prevention, revised 05/2023, revealed all residents would be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms. All alleged violations involving…

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 develop and implement a Comprehensive Care Plan (CCP) for one (1) of twelve (12) sampled residents (Resident #24). Observations and record review revealed Resident #24 was being treated for a wound however, there was no documented evidence a care plan had been implemented to include wound care. The findings include: Review of the facility's policy. Careplan's Comprehensive, revised 02/2023, revealed an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs would be developed for each resident. Review of Resident #24's Demographics revealed the facility admitted the resident on 08/03/2022 with diagnoses which included Alzheimer's Disease with Behavioral Disturbances, Diabetes Mellitus Type II, and Thrombocytopenia. Review of Resident #24's Quarterly Minimum Data Set (MDS) assessment dated…

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 review and revise each resident's Comprehensive Person Centered Care Plan for one (1) of twelve (12) sampled residents (Resident #33). Resident #33 had a significant weight loss of nineteen percent (19%) from 07/02/2023 to 11/10/2023, with no revisions made to his/her plan of care. The findings include: Review of facility the policy's policy, Care Plans - Comprehensive, dated 02/2022, revealed, an individualized comprehensive care plan that included measurable objectives and timetables to meet the residents medical nursing mental and psychological needs would be developed for each resident. Assessments of residents were ongoing and care plans were revised as information about the resident and the residents condition change. The care plan Interdisciplinary Team (IDT), and or clinical staff were responsible for the review and updating of care plans when there had been a significant change in 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, including usual body weight for one (1) of four (4) sampled residents for weight loss of a total sample size of twelve (12) (Resident 33). Resident #33 had a significant weight loss of nineteen percent (19%) from 07/02/2023 to 11/10/2023. The findings include: Review of the facility's policy, Weight Protocol, Nutritional Risk, dated 02/2022, revealed the long-term care unit strived to maintain each resident at the appropriate weight for that resident and that all residents were screened for nutritional risk. An accurate weight of all residents should be obtained on admission and be weighed according to the physicians' orders but at a minimum monthly. The physician and the multidisciplinary care team would address unintended weight loss or gain in order that all residents were assessed for nutritional risk. Further review revealed the residents current weight would be compared to the previous weight…

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.