Pikeville Nursing and Rehab Center, LLC

Based on interview, record review, and facility document and policy review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 (Resident #100) of 2 residents reviewed for abuse. Specifically, on 07/01/2025, staff heard Resident #99 yell at Resident #100 and saw Resident #100 holding their right shoulder/arm. Resident #99 reported that they hit Resident #100 on the arm.Findings included: An undated facility policy titled, Abuse Protection, indicated, 1. Each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The policy also revealed, 3. Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. An admission Record 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.

Based on record review, interview, and facility document and policy review, the facility failed to ensure that an allegation of resident-to-resident physical abuse was reported to the state survey agency (SA) no later than two hours after the allegation was made for 1 (Resident #100) of 2 residents reviewed for abuse.Findings included: An undated facility policy titled, Abuse Protection, revealed 6. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: Reporting/response - The reporting and filing of accurate documents relative to incidents of abuse; reporting to State agencies as required, analyze and implement necessary changes to prevent future occurrences of abuse. The policy did not address timeframes for reporting abuse allegations to state agencies. An admission Record revealed the facility admitted Resident #100 on 04/23/2025. According to the admission Record, the resident had a medical history that…

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 facility's job descriptions, review of the facility's policies, and food establishment inspection reports, it was determined the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations from 10/27/2024 through 10/30/2024, revealed blunt, metal plumbing protruding from the wall above the toilet in two bathrooms shared by four resident rooms, flooring was uneven in hallways, and resident bathrooms; lighting issues in resident bathrooms and the kitchen, odors permeating from the floor in resident bathrooms, leaking pipes from equipment in the kitchen, chipped and peeling paint/drywall in resident rooms as well as the kitchen, peeling paint on the floor in the kitchen, rust on the door frames in resident rooms, large scuff marks on doors and walls in resident rooms and bathrooms, and a crack in the glass of the main entrance door. These identified issues provided potential impalement…

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 ensure all medications were securely stored to restrict access to only authorized personnel as evidenced by one (1) of two (2) treatment carts observed unlocked, and unattended by staff on the North Main Hallway. The findings include: Review of the facility's policy, Storage of Medications revised date December 15, 2018, and the facility's Medication Administration policy revised on April 2019, revealed compartments containing medications were required to be locked when not in use: and trays or carts used to transport such items are not left unattended if unlocked. Observation, on 10/28/2024 at 10:22AM, revealed a treatment cart on the North Main Hallway unlocked and unattended by Registered Nurse (RN)1. RN1 was standing at the medication cart, which was approximately 12-15 feet away from the treatment cart. RN1 stated on 10/28/2024 at 10:25AM, he had been using the treatment cart but had entered a resident's room to administer medications thus leaving the treatment cart…

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 facility policy, the facility failed to maintain an infection control program to help prevent the development and transmission of communicable diseases and infections related to enhanced barrier precautions for 2 of 3 residents investigated for tube feeding care, Resident (R2 and R7). Additionally, observations revealed four unlabeled bed pans and one unlabeled wash basin lying in the bathroom floors were uncovered. The findings include:. Review of the facility policy, MDRO [multi-drug resistant organism] PPE [personal protective equipment]- Enhanced Barrier Precautions, dated 01/2024, revealed facility staff were to wear gowns and gloves when performing high-contact care for a resident with an indwelling device, such as a feeding tube. Review of the facility's policy, titled Infection Control, revised 03/2020, revealed the facility was committed to providing a safe and healthy environment for residents and to minimize or prevent the spread of infections. 1a) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a safe, clean, comfortable home-like environment. Observation revealed damage to the floors/walls in the facility hallways and shower rooms, a toilet in the shower room that was loose from the floor, a missing/unrepaired shower curtain in the North Hall shower room, and Resident #41's overbed table padding was in disrepair. In addition, the facility failed to maintain a comfortable temperature in the bathroom in resident room [ROOM NUMBER]. The findings include: 1. Observation during the initial tour on 07/17/18, revealed a damaged area to the wallboard located at the corner of North A and North B Hallways across from the nurses' station. The damage included a section of the wallboard missing, approximately 3 inches in length by 2 inches in width, close to the baseboard, and two smaller sections of missing wallboard above the larger section. Observation of the North A Hallway revealed a damaged area to the corner of the wall at the end 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, and review of the facility's policy, it was determined the facility failed to ensure food was distributed and served in accordance with professional standards for food service safety. Observation of the three-compartment sink revealed the facility failed to ensure sanitizing solution was added to the water to ensure cooking utensils were sanitized. In addition, the facility failed to ensure two ice scoops stored in a container beside the ice machine were covered. The findings include: 1. Review of the Pots and Pans Sanitizing Solution policy (dated 07/12/16) revealed to ensure pots and pans were sanitized they must be immersed in water with a sanitizing agent for at least two (2) minutes or per manufacturer guidelines. Observation in the kitchen at 10:45 AM on 07/17/18, revealed the third (sanitizing) compartment of the pot/pan sink was filled with water and contained several pots, pans, and other cooking utensils. Facility staff tested the water in the third compartment of the sink for sanitizer solution accuracy. According to the sanitizing test…

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 maintain an effective pest control program. Review of a pest control report dated 06/21/18, revealed action was required to prevent entry of pests; however, the facility failed to make the repairs and flies were observed in the facility. The findings include: Review of the facility's Pest Policy, dated January 2005, revealed the facility maintained an ongoing pest control program to ensure the building was free of insects and rodents. Further review revealed the facility had contracted a company to provide pest control. Observation on 07/17/18 at 12:24 PM, revealed Resident #72 sitting up in bed with a fly swatter lying on the bed. Further observation revealed two flies on the resident's bed. Resident #72 was observed to be hard of hearing and unable to be interviewed. However, Resident #72 stated, I don't like these flies. Observation of Resident #72 on 07/18/18 at 11:38 AM, revealed the resident was lying in bed with his/her eyes closed with a fly swatter 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.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to notify the responsible party for one (1) of twenty-one (21) sampled residents (Residents #48 and #83) when there was a need to transfer the resident. The facility failed to notify Resident #48's responsible party of a physician appointment for treatment of Parkinson's Disease and memory loss. The facility transferred the resident to the appointment unaccompanied by family or staff. The findings include: Review of the medical record for Resident #48 revealed the facility admitted the resident on 09/03/13 with diagnoses of Atrial Fibrillation, Heart Failure, Hypertension, Diabetes Mellitus, Dementia, Anxiety Disorder, Depression and Manic Depression, and Psychotic Disorder. Review of an Order of Appointment of Guardian, dated 11/05/15, revealed two family members, one of which was Family Member #2, were appointed guardianship of Resident #48. Review of the Minimum Data Set (MDS) quarterly assessment for Resident #48 dated 06/18/18, revealed the facility…

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 Minimum Data Set (MDS) assessments were accurately completed for two (2) of twenty-one (21) sampled residents. The facility documented that Resident #48 had received insulin on a quarterly assessment; however, the resident was not prescribed and did not receive insulin. In addition, the facility documented Resident #73 developed a pressure ulcer on 06/19/18; however, the resident had the pressure ulcer upon admission to the facility and the date the pressure ulcer developed was not known. The findings include: Review of the facility policy, Resident Assessment Instrument, Version 3.0, revealed assessments were required to accurately reflect the resident's status. 1. Observation of Resident #48 on 07/17/18 at 12:00 PM, revealed the resident was observed in the dining room, feeding himself/herself. Review of the medical record for Resident #48 revealed the resident was admitted to…

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 implement the plan of care for one (1) of twenty-one (21) sampled residents (Resident #6). Resident #6's comprehensive care plan required staff to administer pain medication as needed for pain. However, interview with Resident #6 revealed on 07/17/18, the resident had right ear pain and the facility failed to administer pain medication. The findings include: Review of the facility's Care Plans-Comprehensive policy with a revision date of 10/31/17, revealed a person-centered comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs was developed for each resident. The policy stated the care plan would assist the resident to meet their needs, goals, and preferences; and care plan interventions would be implemented after consideration of the resident's problem areas and their causes. According to the policy, 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 facility policy review, it was determined the facility failed to ensure the care plan for one (1) of twenty-one (21) sampled residents (Resident #11) was developed by an interdisciplinary team that included the resident's family. Interviews revealed the facility failed to include Resident #11's family in care plan meetings. The findings include: Review of the facility's policy entitled Care Plans - Comprehensive, revealed that the comprehensive care plan was prepared by an interdisciplinary team including at least: the attending physician/nurse practitioner/physician assistant; Registered Nurse; Nurse Aide; member of the food/nutrition services team; the resident; and the resident representative to the extent practicable. Interview with Resident #11's Responsible Party (RP #3) on 07/18/18 at 10:12 AM, revealed he/she had not received notification that a care plan meeting was being held for Resident #11 in approximately one year. The Responsible Party stated…

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 pain management was provided consistent with the resident's care plan and the resident's goals and preferences for one (1) of twenty-one (21) sampled residents (Resident #6). On 07/17/18, Resident #6 informed staff that he/she was having right ear pain. However, the facility failed to treat the resident's pain with physician ordered Norco (narcotic pain medication). The findings include: Review of the facility's Pain Management policy with a revision date of 02/15/18, revealed each resident would have a monitoring system and a comprehensive person-centered plan of care to address pain management. The policy stated the facility was committed to helping each resident attain or maintain their highest reasonable level of well-being and to prevent or manage pain to the extent possible. According to the policy, if a resident complained of pain, staff were required to assess the pain for 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 one (1) of twenty-one (21) sampled residents was free of significant medication errors. On 07/19/18, Resident #83's Midodrine medication (a medication to treat orthostatic hypotension, which is when an individual experiences low blood pressure when sitting or standing) was observed on the floor in the hallway. Interview with the resident revealed he/she did not receive the medication as ordered at 9:00 AM on 07/19/18. At 1:00 PM on 07/19/18, the resident's blood pressure was low (91/50) and staff failed to administer the medication again because the staff believed the medication was used to treat high blood pressure. The findings include: Review of the facility's Medication Administration policy dated May 2016 revealed personnel authorized to administer medications should do so only after they had familiarized themselves with the medication. Observation on 07/19/18 at 10:08 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.