Tug Valley ARH Skilled Nursing Facility

Based on interview, record review, and review of the facility's policy, the facility failed to have a system in place to account for residents' funds or provide residents with a monthly statement of their funds for one of five sampled residents (R1). Based on interview, record review, and review of the facility's policy, the facility failed to have a system in place to account for residents' funds or provide residents with a monthly statement of their funds for one of five sampled residents (Resident 1 (R1).The findings include: Interview on 06/04/2025 at 10:36 AM, with the Interim Administrator, revealed the facility did not have a policy related to staff acting as a resident's payee. Review of the facility's policy titled, Patients' Rights and Responsibilities, undated, revealed upon written authorization of a resident, the facility must hold, safeguard, manage and account for the personal funds of the residents.Review of Resident (R) 1's medical record revealed a diagnosis of quadriplegia, unspecified. (Quadriplegia is a condition where all limbs are paralyzed.) Review 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 interview, record review, and review of the facility's policy, the facility failed to ensure residents were free from misappropriation of resident's property for one of five sampled residents (Resident (R)1), who were investigated for misappropriation. As the representative payee for the resident, the facility failed to properly manage the resident's account. It was determined through a Kentucky State Police (KPS) and Adult Protective Services (APS) investigations that the former Administrator had stolen more than $8,300.00 from Resident (R) 1's personal funds. The findings include:Review of the facility's policy titled, Patients' Rights and Responsibilities, undated, revealed upon written authorization of a resident, the facility must hold, safeguard, manage and account for the personal funds of the resident. Review of the facility's policy titled, Abuse, Neglect, Exploitation, of Patients and Reporting, adopted 05/2017, revealed exploitation included the misappropriation of an individual's property. Per policy review, misappropriation included deliberate misplacement,…

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, review of the facility's Position Descriptions, and review of the facility's policies and procedures, the facility failed to be administered in a manner that enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This practice affected one of five sampled residents (Resident 1 (R1)). Refer to F602. The findings include:Review of the facility's document, titled Nursing Home Administrator Job Description, last edited 07/12/2023, revealed the primary purpose of the Administrator was to manage the facility in accordance with current applicable federal, state, and local standards guidelines, and regulations that govern long-term care facilities to ensure the highest degree of quality care was always provided to residents.Review of the facility's document, titled Director of Nursing Services Job Description, last modified 11/06/2024, revealed the Director of Nursing (DON) was required to oversee all departmental health administration needs and requirements as…

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/document review, the facility's Governing Body failed to provide effective oversight to ensure the facility implemented policies to prevent the misappropriation of resident funds. This had the potential to affect all the facility's residents. The findings include:Review of the facility's policy titled, Patients' Rights and Responsibilities, undated, revealed upon written authorization of a resident, the facility must hold, safeguard, manage and account for the personal funds of the resident.Review of the facility's document, titled Nursing Home Administrator Job Description, last edited 07/12/2023, revealed the primary purpose of the Administrator is to manage the facility in accordance with current applicable federal, state, and local standards guidelines, and regulations that govern long-term care facilities. To ensure the highest degree of quality care is always provided to residents.Review of two Direct Deposit sign-up forms, both dated 03/15/2013, revealed the previous Administrator was listed as a payee on R1's bank…

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 develop and implement a comprehensive, person-centered care plan for one (1) of eighteen (18) sampled residents (R)13. A review of R13's care plan for Potential for Injury Related to Non-Compliance with No Smoking Policy, dated 06/11/2025, indicated that R13 should smoke in an area visible to staff. However, as outlined in the care plan and facility policies, the facility failed to provide supervision. The findings include: A review of the facility's policy, Care Plan Process, undated, revealed that the MDS coordinator would revise each resident's comprehensive care plan as identified and quarterly. A review of the facility's policy, Patient Supervision and Monitoring in the Medical Units, dated 03/19/2024, revealed that within eyesight supervision required staff to have a direct line of sight of the resident. A review of R13's admission Face Sheet revealed the facility admitted the resident on 11/03/2022 with diagnoses that included biliary cirrhosis, osteoarthritis, and anxiety. A review of R13's Quarterly…

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, and document review, it was determined the facility failed to ensure a Registered Nurse (RN) was designated to serve as the Director of Nursing (DON) on a full-time basis, which had the potential to affect all eighteen (18) residents currently residing in the facility. Per interview, the Administrator was also the facility's Director of Nursing (DON) and the facility had no Assistant Director of Nursing (ADON) in order to devote full time supervision of nursing services. The findings include: Review of the Facility Assessment Tool updated 10/23/2022, revealed the Administrator and the DON were noted as the same person. Interview, during the entrance conference on 02/27/2023 at 9:37 AM, revealed the Administrator/DON stated she oversaw the scheduling and mandatory training of nursing staff as part of her DON duties. The Administrator/DON stated she had a person who assisted with hiring staff and providing staff education and training. She further stated this had been the facility's process…

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 Comprehensive Care Plan interventions related to side rail use were consistently implemented to maintain safety for eight (8) out of nine (9) sampled residents reviewed for use of side rails, Residents #1, #2, #3, #4, #5, #7, #8, and #15. Observations conducted throughout the survey revealed the side rails for the residents in question were raised while the residents were in bed. Use of the side rails was not reflected in the respective residents' care plans to direct staff regarding the type of side rails to be utilized or their expected and safe deployment. The findings include: Review of the facility policy titled, Side Rail Assessment, dated as reviewed 03/2018, revealed, Upon admission, all residents will be assessed using the Skilled Nursing Side Rail Assessment form. Continued review revealed the Skilled Nursing Side Rail Assessment was to be mapped on the side rail decision tree…

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 and documents, it was determined the facility failed to ensure: (a) resident-appropriate alternatives were attempted prior to installing side rails on residents' beds: side rail assessments were consistently conducted and documented; (b) resident-specific risks and benefits of side rail use were evaluated and discussed with the residents and/or their responsible parties; (c) and informed consents were obtained for nine (9) of nine (9) sampled residents (Residents #1, #2, #3, #4, #5, #7, #8, #14, and #15) reviewed for the use of side rails. The findings include: Review of a facility policy titled, Side Rail Assessment, dated as reviewed 03/2018, revealed when admitted all residents were to be assessed using the Skilled Nursing Side Rail Assessment form. Continued review revealed the Skilled Nursing Side Rail Assessment was to be mapped on the side rail decision tree for determining the use of side rails. Further review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy it was determined the facility failed to revise the Comprehensive Care Plan for one (1) of eight (8) sampled resident, Resident #16. The facility failed to review Resident #16's care plan to address the resident's safety and smoking needs. The findings include: Review a of the facility's resident demographic document for Resident #16 revealed the facility admitted the resident with diagnoses that included Anxiety Disorder, Traumatic Subdural Hemorrhage (brain bleed), and left Clavicle Fracture. Review of the facility's Quarterly Minimum Data Set (MDS) assessment dated [DATE], for Resident #16 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact. Review of Resident #16's Interdisciplinary Plan of Care dated 11/03/2022 and revised 02/03/2023, revealed the facility care planned the resident as at risk for respiratory…

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 received adequate supervision and remained as free of accident hazards as possible for one (1) of ten (10), Resident #16. Resident #16 was observed sitting in a wheelchair with a blanket covering his/her legs outside the facility smoking without staff's supervision. Interview revealed the facility failed to develop and implement policies to ensure the assessment and safety of residents who smoked. The findings include: Review of the facility's policy titled, Smoking dated 07/26/1991, and review of the facility's undated resident admission agreement, revealed the facility's Smoking Policy was to prohibit smoking and to discourage other use of tobacco, among its employees, residents and visitors. Further review of the resident admission agreement revealed there would be no exceptions to the NO SMOKING POLICY for residents, employees, or family members. Review of 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.

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 conduct regular inspections of all resident bed frames, mattresses, and bed rails, to identify any risk of entrapment for three (3) of nine (9) sampled residents reviewed for accidents (Residents #2, #3, and #8). The findings include: Review of an undated, unlabeled typed document on facility letterhead revealed, Checks beds for electronic and mechanical functionality according to the specific manufacturer's bed recommendation. Further review revealed the checks were to be performed every six (6) months and as needed with any issues with the bed. 1. Review of the facility's resident demographic document for Resident #2 revealed the facility admitted Resident #2 with diagnoses that included Dementia, Urinary Tract Infections (UTIs), and Peripheral Vascular Disease. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief…

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 record review, it was determined the facility failed to establish smoking policies as required to ensure the safety of one (1) out of ten (10) residents sampled for smoking, Resident #16. Interview on 02/28/2023 at 3:02 PM, with the Administrator (also the facility's Director of Nursing) revealed the facility had no policy regarding resident smoking, smoking areas, or smoking safety. The findings include: Review of the resident demographic document for Resident #16 revealed the facility admitted the resident with diagnoses that included Anxiety Disorder, Left Clavicle Fracture, and Traumatic Subdural Hemorrhage (brain bleed). Review of the facility's admission Data/Social History, dated 11/03/2022, for Resident #16 revealed the resident smoked cigarettes every day. Review of the facility's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14), indicating…

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.