Park Grove Nursing and Rehabilitation Center

Based on observation, interview, and review of the facility's policy, the facility failed to store food in accordance with professional standards for food service safety. Food was not dated at the time of storage. Opened food was not covered and/or sealed to prevent contamination. This failure had the potential to affect 52 of the facility's 52 residents who consumed food from the kitchen. The findings include: Review of the facility's policy titled, Food Storage, dated 2019, revealed food would be stored by methods designed to prevent contamination or cross-contamination. Further review revealed food would be stored in covered containers or wrapped carefully and securely and each item would be clearly labeled and dated before being refrigerated. Additionally, all frozen foods should be covered, labeled, and dated. a. Observation of the kitchen, on 06/03/2025 at 10:07 AM, revealed Refrigerator1's contents included four loaves of bread, one package of hot dog buns, and one package of rolls that were not dated when stored. b. Observation of Freezer1 revealed its contents included one…

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, the facility failed to implement a comprehensive person-centered care plan to meet mental and psychosocial needs for one (Resident (R) 2) of three residents reviewed for activity care plans. The resident's care plan for the television (TV) to be on at all times was not consistently followed. The findings include: Review of the facility policy, Care Plan Policy, dated 08/04/2024, revealed the policy statement stated, The facility will develop and implement a person-centered care plan for each resident, that includes measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. Per the policy, The Licensed Nurses and/or Interdisciplinary Team (IDT) develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain . The Comprehensive Care Plan will be…

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

Based on observation, interview, review of facility policy, and review of the Kentucky Food Guide 2013 Food Code guidance, the facility failed to provide food at a palatable temperature for two (2) residents (Resident #1 and Resident #52). In addition, the facility failed to ensure point of service temperatures (temps) were within acceptable levels. Observation of the 400 Hall lunch meal on 04/02/2024 revealed the hot foods were below the acceptable levels for the point of service temps. The cold food/beverages were above the acceptable levels for the point of service temps. The findings include: Review of the Kentucky Food Guide 2013 Food Code guidance revealed hot foods should be 135 degrees Fahrenheit (F) or greater and cold food/beverage products should be 41 F degrees or less. Review of the facility's policy titled, Food Preparation and Service, revised November 2022, revealed food and nutrition services employees were to prepare, distribute and serve food in a manner that complied with safe food handling practices. Continued review revealed,Danger Zone meant temperatures above…

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, and facility's policy review, Resident Matrix, and staff personnel files review, the facility failed to provide at least twelve (12) hours of required in-service training for nurse aides including dementia management training and resident abuse prevention training for 5 of 5 State Registered Nurse Aides (SRNA). (SRNA's #4, #9, #10, #12 and #13 ). This had the potential to affect the facility's fifty-eight (58) residents. The findings include: Review of the facility's policy titled, Staffing, Sufficient and Competent Nursing, dated 08/2022, revealed the facility was to provide a sufficient number of nursing staff. Continued review revealed the nursing staff were to have appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility's assessment. Per policy review, Competency was a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needed to perform work, roles, or occupational functions successfully.…

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, it was determined the facility failed to ensure an ongoing program of activities was developed to meet the resident's individual needs for four (4) of six (6) sampled residents (Residents #15, #38, #52, and #53). The facility failed to provide individualized activities based on residents' comprehensive assessments, care plans, and personal preferences. The findings include: Review of the facility's policy titled, Activity Programs, revised June 2018, revealed an activity program was to be designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. Continued review revealed the activities offered were to be based on the comprehensive resident-centered assessments and the preferences of each resident. 1. Review of Resident #15's admission Record revealed the facility admitted the resident on 03/27/2023, with diagnoses to include: traumatic brain injury, major depressive…

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, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, for one (1) of six (6) sampled residents (Resident #1). Observation of Resident #1 on 04/03/2024, revealed the resident's catheter bag had no dignity cover in place. The findings include: Review of the facility's policy titled, Dignity, revised February 2021, revealed each resident was to be cared for in a manner that promoted and enhanced his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Review of Resident #1s admission Record revealed the facility admitted the resident on 08/21/2023, with diagnoses to include: urinary retention, myelodysplastic syndrome, and major depressive disorder, severe with psychotic symptoms. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of facility policy, the facility failed to ensure each resident had an active Advance Directive order in place for five (5 ) of 25 sampled residents (Residents #8, #9, #22, #28, and #61). The findings include: Review of the facility's policy titled, Advance Directives, dated 09/2022 revealed residents had the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment. Further review revealed Advanced Directives were to be honored by state law and facility policy. Review of the facility's policy titled, Do Not Resuscitate Order, dated 03/2021 revealed Do Not Resuscitate (DNR) orders must be signed by the resident's attending physician on the physician's order sheet and maintained in the resident's medical record. Further review revealed the DNR order form must be completed and signed by the attending Physician and the resident or the resident's legal surrogate as permitted by state law. 1. Review of Resident #8'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, record review, and facility document and policy review, the facility failed to implement procedures that addressed and monitored the safe storage and handling of medications. Review of one (1) of two (2) medication storage refrigerator's, Refrigerator and Freezer Temperature Logs documentation revealed the facility failed to record temperatures for that refrigerator for three (3) days. The findings include: Review of the facility's policy titled, Storage and Expiration Dating of Medications and Biologicals, revised 08/07/2023, revealed the facility was to inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis. Continued review revealed the facility was to ensure medications and biologicals were stored at the appropriate temperatures according to the United States Pharmacopoeia guidelines for temperature ranges. Review further revealed the facility should monitor the temperature of medication storage areas at least once a day, and the temperature of vaccines twice a day. Observation on 04/04/2024 at 10:25 AM…

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. Observations revealed that opened food items in the facility's pull-out refrigerator were not labeled or dated. Continued observations revealed other food items were not covered. The findings include: Review of the facility's policy titled, Food Storage; Cold Foods, revised 04/2018, revealed all Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, would be appropriately stored in accordance with the guidelines of the Food and Drug Administration (FDA) food code. Further review revealed all foods would be stored wrapped or in covered containers, labeled, dated, and arranged in a manner to prevent cross-contamination. Observation of the facility's kitchen area with the Dietary Cook, on 02/13/2023 at 11:12 AM, revealed the reach-in refrigerator had one plate of salad with meat, wrapped with plastic but was not labeled or dated, two (2) bowls of labeled applesauce were not dated and a tray…

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 Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 User Manual, it was determined the facility failed to ensure its Minimum Data Set (MDS) Assessments accurately reflected the status for two (2) of forty-four (44) sampled residents (Resident #270 and Resident #68). 1. Review of Resident #270 MDS Assessments did not accurately reflect the residents' previous falls. (Refer to F-689) 2. Review of Resident #68's MDS Assessment did not accurately reflect the resident's discharge location. The findings include: Interview with the Administrator, on 02/21/2022 at 4:17 PM, revealed the facility utilized the RAI Manual to complete the MDS Assessments. Review of the CMS RAI Manual, dated 10/01/2019, revealed it was important that information obtained would cover the same observation period as specified by the MDS items on the Assessment. Per review, the information would be validated for accuracy by the Interdisciplinary…

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 observations, interviews, and record review, it was determined the facility failed to ensure one (1) of forty-four (44) sample residents (Resident #26) care plan was developed to include the resident's need for Hemodialysis. The findings include: Review of the facility's policy titled, Person-Centered Care Plan, revised on 10/24/2022, revealed the facility would develop and implement a person-centered care that met professional standards of quality care. Further review revealed the care plan would be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to changing needs and goals. Review of Resident #26's medical record revealed the facility admitted Resident #26 on 12/23/2022, with diagnoses that included: End-stage renal disease (ESRD), Acquired Absence of Left Leg Below Knee and Dependence on Renal Dialysis. Review of the five (5) Day Minimum Data Set (MDS) Assessment, dated 12/27/2022, revealed the resident was assessed to have a Brief Interview…

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 interviews, record reviews, and review of facility policies, it was determined the facility failed to ensure one (1) of forty-four (44) sampled residents, (Resident #49) was not administered a psychotropic medication without an appropriate diagnosis. Resident #49 was administered an antipsychotic for a diagnosis of Agitation, which was not a medication that was appropriate for the given diagnosis. The findings include: Review of the policy titled, Psychotropic Medication Use, revised on 10/24/2022, revealed Psychotropic drugs included but were not limited to antipsychotics, anti-anxiety, antidepressants, or sedative-hypnotics that affect brain activities associated with mental processes and behavior. Further review of the policy revealed the facility would comply with the psychopharmacologic Dosage Guidelines created by the Centers for Medicare and Medicaid Services (CMS), the State Operations Manual, and all other Applicable Law relating to the use of psychopharmacologic medications including gradual dose reductions. A continued review of the policy revealed psychotropic…

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 and interview, it was determined the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for the lunch meals served on 02/14/2023 and 02/15/2023 for four (4) of fourty-four (44) sampled residents (Resident #21, Resident #55, Resident #30, and Resident #29). On 02/14/2023, the State Survey Agency (SSA) Surveyor requested a point of service test tray. The tray was delivered at 1:05 PM and was served an aluminum foil covered pureed tray with tea, because the facility had no regular meals remaining. The SSA Surveyor found the foods on the test tray were below the acceptable temperature and tasted bland. The findings include: Review of the facility policy titled, Food; Quality and Palatability, revision dated 09/2017, revealed foods would be prepared by methods that preserved nutritive value, flavor, and appearance. Further review revealed food would be palatable, attractive, and served at a safe and appetizing temperature. Review of the facility policy titled, Food Preparation, revision 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to follow the physician's orders for one (1) of forty-four (44) sampled residents (Resident #169). Resident #169 had a therapeutic diet order for Pureed Diet with Nectar Thick Liquids. Observation of the resident's meal tray and bedside table revealed the resident had two and one half (2 1/2) glasses of apple juice and two (2) foam cups of water that were not thickened to nectar consistency, as per the physician's orders. The findings include: Review of the facility's policy, Therapeutic Diets, not dated, revealed all residents have a diet order including regular, therapeutic, and texture modification that was prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines. Mechanically altered diet means one in which the texture of the diet was altered. Further review revealed that when the texture was modified, the type of texture must be specific and part of the physician's or delegated registered or licensed…

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.