Hardinsburg Nursing and Rehabilitation Center

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 the environment was free of accident hazards for 1 of 2 sampled residents reviewed for accidents, Resident (R)39. Based on observation, interview, record review, and review of facility policy, the facility failed to ensure the environment was free of accident hazards for 1 of 2 sampled residents reviewed for accidents, Resident (R)39.FindingsCollapse[NAME]'s FindingsWriting Complete | Last Updated by [NAME] 07/25/2025 12:01 PM | The findings include: Review of the facility policy titled, Medication Administration Standard of Practice, dated 10/2020, revealed, Medications will be administered in a safe and timely manner, and as prescribed. Review of R39's admission Face Sheet indicated the facility admitted the resident on 11/26/2024. According to the admission Face Sheet, the resident had a medical history that included a diagnosis of low back pain. Review of R39's quarterly Minimum Data Set (MDS), 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 observation, interview, and record review, the facility failed to follow physician's orders for the administration of supplemental oxygen for 1 of 3 sampled residents reviewed for respiratory care, Resident (R)9. The findings include: Review of R9's admission Face Sheet revealed the facility admitted the resident on 05/02/2025. According to the admission Face Sheet, the resident had a medical history that included diagnoses of heart failure and pulmonary hypertension. Review of R9's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/2025, revealed the facility assessed R9 as having a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. Review of R9's Care Plan indicated a problem area initiated 05/26/2025, revealing the resident had a self-care deficit as evidenced by the need for moderate assistance with activities of daily living due to chronic obstructive pulmonary disease, diabetes, and generalized weakness. Interventions directed staff to give supplemental oxygen as ordered (initiated 05/26/2025).…

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 document and policy, the facility failed to report an allegation of sexual abuse to the State Survey Agency (SSA) within 2 hours for 1 of 1 sampled resident reviewed for abuse, Resident(R)36. The findings include:Review of the facility policy titled, Abuse Prohibition Standard of Practice, revised 07/2022, indicated Alleged violations shall be reported to the state survey agency, adult protective services, and all other required agencies within specified time frames.Review of R36's admission Face Sheet revealed the facility admitted the resident on 11/05/2024. According to the admission Face Sheet, R36 had a medical history that included a diagnosis of severe vascular dementia with anxiety and mood disturbance.Review of R36's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/11/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive impairment.Review of the facility Initial Report, indicated 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.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to store, prepare, and serve food in a sanitary manner and in accordance with professional standards for food service safety. The sanitation handwashing area, sanitation prep sink area, and flooring were dirty/soiled and in need of cleaning. Dry spices, as well as food stored in the refrigerator and freezer were open and unsealed, unlabeled, undated, and/or past their expiration date. Scoops used for serving food were dirty with old food particles dried to them. Staff were not trained and/or were unaware of food storage requirements. This failure had the potential to affect all residents of the facility who consumed food prepared in the kitchen. The findings include: Review of the facility's Casper Report, last updated 06/09/2024, revealed 59 of 59 residents received their food from the kitchen. 1. Review of the facility's Environment policy, dated 05/2014, revealed the purpose of the policy was to ensure that all food service areas would be maintained in 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 observation, interview, review of facility policy, and review of manufacturer's information, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards, including open/use by/expiration dates and/or resident name for at least seven (Resident (R) 39, R26, R43, R5, R34, R25, and R48) of 43 residents whose medications were observed during an audit of three of the facility's four medication carts. The findings include: Review of the facility policy, Medication Administration Standard of Practice, with a review date of 10/2020, revealed, When opening a multi-dose container, the date opened shall be recorded on the container. Expired/beyond use date medication should not be administered. Review of the facility policy, Label / Store Drugs & Biologicals Standard of Practice, last reviewed 10/2020, revealed, Drugs and Biologicals must be labeled in accordance with currently accepted professional principles and include the expiration…

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 ensure food was prepared in a safe and sanitary manner. Observation of the kitchen revealed surfaces and small appliances appeared dirty, and there were unlabeled and outdated foods in the refrigerator. In addition, staff failed to utilize proper hand hygiene during meal plating and staff failed to calibrate the food thermometer prior to testing the temperature of the food. The findings include: Review of the facility's policy, Food Storage and Retention, FDA Food Code 2017, undated, revealed ready to eat cereal could be stored for two (2) to three (3) months (opened), and ready to eat/prepared foods (leftovers, deli salads) up to seven (7) days. Review of the facility's policy, Handwashing, revised September 2017, revealed handwashing was to be completed with employees associated with handling food. Hands were to be washed at the kitchen hand sink station and use a seperate dry paper towel to turn off the faucet to avoid contact with the faucet germs. 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.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to store controlled medication in a permanently affixed, locked compartment in one (1) of two (2) medication rooms, on the [NAME] Wing. Observation revealed controlled medication stored in the refrigerator; however, it was not in a permanently affixed compartment. In addition, observations revealed two (2) of two (2) unlocked medication carts not under supervision of staff. The findings include: 1. Review of the facility's policy, Storage of Medications, revised April 2007, revealed medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station, or other secured location. Medications must be stored separately from food and must be labeled accordingly. The policy did not address controlled medications stored within a locked, permanently affixed box within the refrigerator. Observation of the [NAME] Wing Medication Room, on 03/28/19 at 10:24 AM, revealed the refrigerator contained a small white plastic basket with bags 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 facility policy review, it was determined the facility failed to ensure residents were free from unnecessary restraints for one (1) of four (4) sampled residents, Residents #5. The findings include: Review of the facility's policy, Restraints, dated 07/01/12, revealed it was the facility's belief residents had the right to be free from physical restraints. However if a resident developed medical symptoms which placed the resident at risk of harm to self or others and restraint alternatives had been unsuccessful, the resident's physician and staff would assess whether a restraint would be helpful and the physician would order the least restrictive restraint. The policy further stated the restraint would be discontinued as soon as the resident's condition no longer required the intervention. Review of Resident #5's clinical record revealed the facility admitted the resident on 08/16/18, with diagnoses of Unspecified Dementia, Ataxia, and Muscle Weakness. Review…

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, facility policy review, and review of the Plan of Correction (POC) for the 03/29/19 Recertification Survey, it was determined the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) program to ensure compliance was maintained regarding medication cart security. Observations revealed two (2) of four (4) medication carts were unlocked and unattended by staff. (Refer to F761) The findings include: Review of the facility's policy, Quality Review and QAPI Plan Standard Practice, revised November 17, revealed the goal of the facility was not to have repeated citations of a D level or higher in a fifteen (15) month time period. The committee was to monitor the compliance with the POC. Under the direction of the Administrator, the facility was to verify the action plan and Performance Improvement Plan (PIP) were in place. The QA committee was to monitor the facility's compliance with the POC. Review of the POC for the survey conducted 03/29/19, revealed the Director of Nursing (DON) completed a facility audit for unlocked…

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.