Somerwoods Rehabilitation and Healthcare Center

Based on observation, interview, and facility policy review, the facility failed to prepare, store, and serve food in a sanitary manner to help prevent potential contamination and foodborne illness, which had the potential to affect all residents consuming food from the dietary department. The findings include: Review of the facility's policy titled, Dietary Employee Personal Hygiene, date reviewed/revised 09/01/2024, revealed the facility was to utilize guidelines for employee personal hygiene to prevent contamination of food by foodservice employees. Continued review revealed hands were to be washed after engaging in activities that contaminated the hands, and employees were not to use their bare hands to contact with ready-to-eat foods. The policy additionally stated gloves were to be worn and changed appropriately to reduce the spread of infection. Review further revealed all dietary staff were required to wear hair restraints, including hairnets, hats, and/or beard restraints, to prevent hair from contacting food. 1). Review of the 2013 U.S. Public Health Service Food Code,…

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 review of facility documentation, the facility failed to immediately report all allegations and incidents of potential abuse, to the appropriate external authorities, including law enforcement and/or the State Survey Agency (SSA), in accordance with facility policy and federal regulations for 1 of 38 sampled residents, (Resident (R)95). The findings include: Review of the facility's policy titled, Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation, undated, revealed the facility's policy prohibited abuse of residents by any other person, including any member of the facility's staff. Continued review of the policy revealed the facility was to educate all staff so that every employee understood the policy. Additionally, review of the facility's policy was to report all instances of alleged or suspected abuse. Review of the facility's policy titled, Resident Rights in Kentucky Nursing Homes, undated, revealed residents had the right to be free of abuse. Review of R95's electronic Health Record (EHR) Face…

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 document and policy review, the facility failed to store food in accordance with accepted professional standards for food service safety. Leftover food items were not labeled with a product name and open or use-by date. Raw meat was stored above cooked food items in a reach-in refrigerator. These failures had the potential to affect all residents receiving meals from the dietary department. Findings included: 1. The facility's Dietary Policy Manual, revised 01/23/2018, revealed a policy titled, Food Storage that specified, All incoming foods will have a delivery date and an 'open date' or 'use by' date. When the foods are stored in a container other than the original container, the container will be labeled with the name of the product. A concurrent observation of the reach-in refrigerator and an interview with the Dietary Supervisor on 02/17/2025 at 9:40 AM revealed leftover green beans and leftover green chili were stored without labels that included a product name or dates. In addition, a bag of petit fours (bite-sized desserts) 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.

Based on interview, record review, and facility policy review, the facility failed to report a possible incident of resident-to-resident abuse to the state survey agency (SSA) within two hours for two (Resident (R) 78 and R13) of four residents reviewed for abuse. The findings included: Review of the facility Abuse, Neglect, or Misappropriation of Resident Property Policy, revised 03/10/2017, revealed 'Abuse' is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm or pain or mental anguish. Further review of the policy revealed that it failed to define/address the meaning of willful, a term defined in the Code of Federal Regulations at §483.5 in the definition of abuse which means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A facility policy titled, Abuse, Neglect, or Misappropriation of Resident Property Policy, revised 03/10/2017, revealed the section titled Reporting/Response specified, The Administrator will ensure that the Division 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, and facility policy review, the facility failed to store medications securely in one of five medication carts. Specifically, nursing staff left a medication cart unlocked in the hallway while administering medications in resident rooms. The findings include: Review of a facility policy titled, Medication Storage, dated 09/2020, revealed, The medication cart shall be locked at all times, when not under the direct physical supervision of a licensed nurse or medication aide. Observation on 02/18/2025 at 8:53 AM revealed a medication cart located on the 200 Hall was unlocked. Registered Nurse (RN) 11 was observed in room [ROOM NUMBER], administering medications. RN11 was approximately 16 feet from the medication cart and was not within eyesight of the medication cart. Observation and interview on 02/18/2025 at 9:03 AM revealed RN11 was in room [ROOM NUMBER] administering medications. The medication cart remained unlocked in the hallway, out of R11's line of sight. RN11 exited room…

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 ensure staff donned personal protective equipment (PPE) when providing care to two (Resident (R) 42 and R29) of two residents reviewed for contact precautions. The findings include: A facility policy titled, Standard and Transmission - Based Precautions, revised 06/13/2024, revealed the section titled Contact Precautions, indicated, Necessary when transmission of microorganism is by direct contact [sic] Precautions include gloves, gown, and containment of microorganism. Facility signage titled, Contact Precautions, revised 04/2023, indicated, All Healthcare Personnel must .Wear gloves when entering room and remove before leaving room .Wear a gown when entering room and remove before leaving. 1. An admission Record revealed the facility admitted R42 on 10/16/2024. According to the admission Record, the resident had a medical history that included a diagnosis of recurrent enterocolitis due to clostridium difficile. A quarterly Minimum Data Set (MDS), with an 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.

Based on observation, interview, and review of the facility policy, it was determined the facility failed to ensure food was served under sanitary conditions. During observation of the lunch tray line on 07/21/19, a dietary staff member left the tray line and removed food from the oven and another warmer using pot holders. The dietary worker then returned to the tray line and continued to plate the food without changing gloves or performing hand hygiene. The findings include: Review of the facility policy, Resident Meal Service, dated August 2013, revealed gloves were to be worn when making sandwiches, salads, handling any ready-to-eat foods, food contact surfaces, and raw meats. The policy further stated if the gloves were damaged or soiled when an interruption occurred in the process, the gloves must be discarded and hand hygiene performed between glove changes. Observation of the tray line on 07/21/19 at 11:46 AM, revealed the dietary worker, who was plating the meal, left the tray line and used pot holders to remove a dish from a warmer and a dish from the oven. The worker then…

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 policy it was determined the facility failed to ensure an accurate significant change Minimum Data Set (MDS) assessment was conducted for one (1) of thirty (30) sampled residents (Resident #51). Resident #51 had a significant change MDS completed on 05/16/19 related to enrollment in the hospice program; however, the assessment did not reveal the resident was receiving hospice care. The findings include: Review of the facility policy, Resident Assessment Manual, dated October 2018, revealed residents in a hospice program would be coded on the Minimum Data Set assessment as receiving hospice services. Review of Resident #51's medical record revealed the resident was admitted to the facility on [DATE] and had diagnoses of Transient Cerebral Ischemic Attack, Hypertension, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Major Depressive Disorder, and Chronic Pain. Observation of Resident #51 on 07/23/19 at 10:42 AM, 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.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to ensure one (1) of five (5) sampled residents (Resident #24) with pressure ulcers received care consistent with professional standards of practice to promote wound healing and prevent infection of the ulcers. Observation of wound care on Resident #24 revealed proper hand hygiene was not performed between glove changes during wound care. The findings include: Review of the facility's Handwashing Policy, dated September 2014, revealed personnel were required to wash their hands before and after touching wounds and after removing gloves. Review of Resident #24's medical record revealed the facility admitted the resident on 09/30/16 with diagnoses including Hypertension, Neurogenic Bladder, Diabetes Mellitus, Vascular Dementia, and Depression. Review of Resident #24's Minimum Data Set assessment, dated 05/05/19, revealed the resident's Brief Interview for Mental Status (BIMS) score was three (3), which indicated the resident had severe cognitive impairment. The MDS…

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 policy, it was determined the facility failed to ensure appropriate care and services were provided to prevent urinary tract infections for one (1) of thirty (30) sampled residents (Resident #24). Observation of catheter care and incontinence care on 07/23/19, revealed State Registered Nurse Aide (SRNA) #1 failed to remove gloves and perform hand hygiene after performing bowel incontinence care for Resident #24 and prior to placing barrier ointment to the resident and applying a clean incontinence brief. The findings include: Review of the facility's Handwashing Policy, dated September 2014, revealed personnel were to their wash hands after contact with blood, body fluids, secretions, excretions, and contaminated equipment or articles. Review of Resident #24's medical record revealed the facility admitted the resident on 09/30/16 with diagnoses of Hypertension, Neurogenic Bladder, Diabetes Mellitus, Vascular Dementia, and Depression. Review of 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.

Based on observation, interview, and facility policy review, the facility failed to ensure medications were stored at the appropriate temperature in the medication refrigerator. Observation of the third floor medication refrigerator on 05/10/18, revealed medications stored in the refrigerator were required to be stored at 36-46 degrees F. Review of the facility's policy revealed medications should be stored at a temperature no less than 35 degrees F. However observation on 05/10/18 of the third floor medication refrigerator revealed the temperature of the refrigerator was 11 degrees Fahrenheit (F) with a buildup of ice in the freezer compartment. The findings include: Review of the facility policy titled, Temperature Chart for Refrigerators and Freezers, (undated) revealed the temperature of refrigerators that contain medications would be maintained between 35 and 41 degrees F. Further review of the policy revealed if a medication refrigerator temperature registered outside the acceptable range staff would immediately notify the Maintenance Department and the Unit Manager. Review 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.