Bourbon Heights Nursing Home

Penalty

Inspection fine: $41,04031 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) Program, which led to a deficiency in infection prevention and control. The deficiency was evidenced by the facility's inability to establish and maintain an infection prevention and control program (IPCP) to prevent and control the development and transmission of communicable diseases. Specifically, the facility was cited for infection control related to legionellosis and their water management system. Despite submitting a plan of correction to address the deficiency, the facility did not follow through with the necessary actions, such as completing a Water Infection Control Risk Assessment (WICRA) and developing a Water Management Plan (WMP). The facility's failure to implement the plan of correction resulted in the identification of Legionella pneumophila SG1 and SG2-15 at uncontrolled growth levels in the Unit 3 shower, leading to the cessation of showers for all residents. The Division of Epidemiology and Health Planning (DEHP) provided recommendations to mitigate the spread of legionellosis, but the facility did not implement these recommendations. The QAPI Committee meetings lacked documentation supporting the development or implementation of a plan of correction when the facility's water quality did not meet appropriate parameters according to third-party testing results. Interviews with facility staff revealed a lack of communication and action regarding the DEHP's recommendations and the development of a WMP. The Infection Preventionist (IP) and other QAPI Committee members were aware of the recommendations but were waiting for guidance from a Certified Legionella Water Safety Expert (CLWSE) and the local health department. The former Director of Nursing (DON) and Administrator indicated that the QAPI Committee was waiting for the CLWSE to write the WMP and follow up on the DEHP recommendations, leading to delays in addressing the water contamination issue.

Removal Plan

• Review of the IJ Removal Plan
• Approval and submission of the WICRA to the LHD
• Adoption of the WMP
• Compliance monitoring
• Completion of the CDC Prevent LD online course by required staff
• Updates to the WICRA
• Discussion of the WMP
• Infection surveillance for LD

Penalty

Inspection fine: $41,04031 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to establish and maintain an effective infection prevention and control program, leading to the development and transmission of Legionella bacteria within the water system. The facility's water management plan was insufficient, as evidenced by the presence of Legionella pneumophila at uncontrolled growth levels in various units and rooms. Despite receiving recommendations from the Division of Epidemiology and Health Planning (DEHP) and the Local Health Department (LHD), the facility did not implement the necessary measures to control the outbreak, such as proper documentation of water management procedures and ensuring all staff completed the required training. The facility's staff were observed providing care without adhering to proper infection control protocols, such as hand sanitizing and following Enhanced Barrier Precautions. Additionally, there were failures in labeling and storing feeding tubes and handling clean laundry. The facility did not provide adequate bottled water for residents' daily hygiene needs, and staff continued to use potentially contaminated water from faucets for handwashing and oral care. Communication with residents and their families regarding the water contamination was also lacking, leading to confusion and concern among family members. Interviews with staff and family members revealed a lack of transparency and understanding of the situation. Staff were not adequately trained on the infection prevention and control program, and there was no consistent documentation of water flushing procedures. The facility's Director of Maintenance admitted to not having formal training on proper water line flushing, and there was no evidence of a comprehensive water management plan being developed or implemented. The facility's inaction and inadequate response to the Legionella outbreak resulted in ongoing positive test results and a failure to ensure a safe environment for residents and staff.

Removal Plan

• The facility provided an acceptable Immediate Jeopardy Removal Plan, alleging removal of the IJ.
• The State Survey Agency determined the IJ had been removed, with remaining non-compliance at a S/S of an F while the facility develops and implements a Plan of Correction and the facility's Quality Assurance monitors to ensure compliance with systemic changes.

Penalty

Inspection fine: $41,04031 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to effectively manage its resources to prevent and control the growth of Legionella bacteria, leading to a health deficiency. On 05/28/2024, uncontrolled growth levels of Legionella pneumophila Serogroup 1 and Serogroup 2 were identified in the Unit 3 shower. Despite receiving recommendations from the Division of Epidemiology and Health Planning (DEHP) on 07/26/2024 to prevent future outbreaks, the facility's administration did not review or implement these recommendations. Test results continued to show uncontrolled growth of Legionella bacteria in other areas of the facility through 09/18/2024. The facility's administration, including the Administrator and Director of Nursing Services (DON), were informed of the DEHP's findings and recommendations via an email from the Local Health Department (LHD) on 08/05/2024. However, the Infection Preventionist (IP) delayed communicating these recommendations to facility providers until 08/20/2024. The DON and Administrator were unaware of the DEHP's preliminary findings until the State Survey Agency (SSA) Representative brought them to their attention. The facility had not completed or submitted the Water Infection Control Risk Assessment (WICRA) form to the LHD, and the Water Management Plan (WMP) was not developed due to a lack of contractual agreement with a Certified Legionella Water Safety Expert (CLWSE). Interviews with facility staff revealed a lack of communication and responsibility in addressing the Legionella issue. The Interim DON stated that the IP was responsible for implementing infection control guidelines, but the IP did not document enhanced surveillance of possible new Legionella cases. The Administrator assumed the CLWSE was working pro bono to help the facility, but no contractual agreement was established until 10/04/2024. The facility's failure to act on the DEHP's recommendations and effectively manage its water system led to the identification of Immediate Jeopardy on 10/11/2024, which was determined to have existed since 08/05/2024.

Penalty

Inspection fine: $41,04031 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility's Governing Body failed to ensure the implementation of policies regarding the management and operation of the facility, specifically in the area of infection control. Immediate Jeopardy was identified due to the facility's failure to control the growth of Legionella pneumophila in the water system, particularly in Unit 3's shower. Despite receiving recommendations from the Division of Epidemiology and Health Planning (DEHP) and the Local Health Department (LHD), the facility did not effectively implement these recommendations to prevent and control legionellosis. The facility's Infection Preventionist (IP), Director of Nursing (DON), and Administrator were informed of the DEHP's recommendations via an email from the LHD. However, the facility did not act on these recommendations, which included developing a comprehensive Water Management Plan (WMP) and conducting adequate water sampling. The facility's water system continued to show detectable levels of legionella, and the necessary elements of a proper WMP were not documented. The facility's Board of Directors (BOD) was not fully aware of the severity of the problem or the specific recommendations from the DEHP until later. Interviews with various stakeholders, including family members, the LHD Director, and the Certified Legionella Water Safety Expert (CLWSE), revealed ongoing issues with water contamination and inadequate response measures. The facility's Administrator and BOD were criticized for not implementing timely water management infection control measures. The Administrator admitted to not reviewing the email attachment containing the DEHP's recommendations, and the BOD was not fully informed of the situation until after receiving a citation from the State Survey Agency.

Penalty

Inspection fine: $41,04031 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify a resident's physician of a significant change in the resident's physical status. A resident, identified as R76, experienced an unwitnessed fall and sustained elevated blood pressure readings. Despite these changes, the registered nurse (RN2) did not inform the nurse practitioner (NP) of the continued elevated blood pressure. The resident's condition worsened the following day, with symptoms including lethargy, confusion, and incoherent speech, yet these changes were not documented or communicated to the physician or NP. The resident's family expressed concerns about the resident's condition, prompting RN2 to contact the physician, who then ordered the resident's transfer to the hospital. The resident was diagnosed with a transient ischemic attack (TIA) at the hospital. Interviews with the family, RN2, the Director of Nursing (DON), and the nurse practitioner revealed that the facility's protocol for notifying changes in a resident's condition was not followed. The facility's policy required notifying the physician of any accidents or deterioration in a resident's condition. However, RN2 did not adhere to this policy, failing to communicate the resident's elevated blood pressure and mental status changes. The DON and NP both indicated that the nurse should have sent the resident to the hospital for evaluation due to these changes, highlighting a lapse in following the facility's procedures for ensuring resident safety.

Penalty

Inspection fine: $41,04031 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement an effective system to ensure that a resident's Comprehensive Care Plan (CCP) interventions were followed when a change in condition occurred. Resident 76, who had a history of hypertension, experienced an unwitnessed fall and subsequently showed signs of elevated blood pressure and a headache. Despite these symptoms, the Registered Nurse (RN) on duty did not adhere to the care plan's directives to monitor, document, and report these changes to the medical provider. On the day following the fall, the resident continued to exhibit elevated blood pressure and a change in mental status, including lethargy and incoherent speech. However, the RN again failed to document these changes or notify the medical provider as required by the care plan. It was only at the family's request that the physician was notified, leading to the resident's transfer to the hospital, where they were diagnosed with a transient ischemic attack. Interviews with facility staff, including the MDS Nurse and the former Director of Nursing (DON), revealed that the resident's care plan was not updated with new interventions following the fall. The facility's policies required that care plans be revised to ensure resident-centered care and safety, but this was not done. The failure to implement and update the care plan as needed resulted in a deficiency under 42 CFR S483.21, Comprehensive Resident Centered Care Plan, F-656, with a Scope and Severity of a J.

Penalty

Inspection fine: $41,04031 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to promptly identify and intervene for a change in a resident's condition, leading to a deficiency in providing appropriate treatment and care. A resident, who had a history of essential hypertension, metabolic encephalopathy, and general anxiety disorder, experienced an unwitnessed fall. Following the fall, the resident's blood pressure remained elevated, with systolic readings consistently between 180 and 190. Despite these elevated readings, the registered nurse (RN) on duty did not notify the nurse practitioner (NP) about the resident's condition, nor were any additional orders given beyond continued monitoring. The following day, the resident's blood pressure remained elevated, and the resident began exhibiting a change in mental status, including lethargy and incoherent speech. However, these findings were not documented, and the physician was not notified of the resident's change in condition. It was only after the resident's family expressed concern and requested hospital evaluation that the resident was sent to the hospital, where they were diagnosed with a transient ischemic attack (TIA). Interviews with staff revealed a lack of consistent training and understanding of the signs and symptoms of a stroke, as well as the appropriate actions to take in such situations. The facility's failure to ensure timely notification and intervention for the resident's elevated blood pressure and change in mental status resulted in a deficiency under 42 CFR S483.25 Quality of Care, F684, with a scope and severity of a J, indicating Immediate Jeopardy.

Penalty

Inspection fine: $41,04031 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a baseline care plan for a newly admitted resident, identified as R425, which is necessary to provide effective and person-centered care. R425 was admitted with diagnoses including Congestive Heart Failure and End Stage Renal Disease requiring hemodialysis. Despite these significant medical needs, the facility did not create a baseline care plan upon admission to address the resident's hemodialysis requirements and known risk for falls. This omission was identified during a review of the resident's electronic health record, which lacked documentation of an admission assessment and baseline care plan. R425 had a history of falls, including a recent fall prior to admission, and was assessed to be at high risk for falls with a Fall Risk Score of 18.0. Despite this, the baseline care plan addressing fall risk was only developed three days after admission. During this period, R425 experienced multiple falls, one of which resulted in a subdural hematoma and required hospitalization. The facility's failure to implement a timely baseline care plan contributed to these incidents, as the staff lacked guidance on managing the resident's fall risk and hemodialysis needs. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for completing baseline care plans. The MDS Nurse and other nursing staff acknowledged the importance of these plans but admitted to not completing one for R425 upon admission. The Interim DON and Administrator confirmed that baseline care plans were expected to be completed promptly to ensure resident safety, yet this expectation was not met in R425's case, leading to the identified deficiency.

Penalty

Inspection fine: $41,04031 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to review and revise the comprehensive care plan (CCP) for a resident, identified as R76, following a significant change in her condition. R76 experienced a fall and was subsequently diagnosed with a transient ischemic attack (TIA) at the hospital. Upon her return to the facility, her family requested that she remain in her room to rest. However, the staff did not update the CCP to include interventions to prevent future falls or to incorporate the family's request. This oversight led to R76 sustaining another fall, resulting in a hip fracture. The facility's policy required that care plans be reviewed and revised as necessary to reflect any changes in a resident's care needs. Despite this, R76's CCP was not updated after her initial fall and hospitalization. Interviews with staff revealed a lack of clarity regarding who was responsible for updating care plans, with some staff believing only the MDS Nurse had access to make changes. This miscommunication contributed to the failure to implement necessary interventions for R76's safety. The deficiency was further compounded by the facility's failure to adhere to its own policies regarding care plan updates. The MDS Nurse and other staff members acknowledged that the CCP should have been revised to include new interventions following R76's fall and hospitalization. The lack of timely updates to the care plan resulted in inadequate monitoring and care for R76, ultimately leading to her second fall and subsequent decline in health.

Penalty

Inspection fine: $41,04031 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a safe environment and adequate supervision for Resident 76, who experienced two falls resulting in significant injuries. Initially, the resident fell while ambulating from the bathroom to the bed, leading to a hospital admission for a transient ischemic attack. Upon returning to the facility, the resident was taken to an activity against the family's request for rest, left unsupervised, and subsequently fell from a wheelchair, sustaining a hip fracture. The facility did not update the resident's care plan with new interventions after the first fall, and incident reports for the falls were missing. Another resident, Resident 425, was admitted to the facility with a history of falls and was not care planned for fall prevention upon admission. The resident fell twice shortly after admission, sustaining a subdural hematoma and an abrasion. The facility's baseline care plan for the resident was not implemented in a timely manner, and the original care plan could not be located. Interviews with staff revealed a lack of adherence to the facility's fall prevention policies. The facility's policies required fall risk assessments and care plans to be implemented based on residents' fall risks. However, these protocols were not followed for both residents, leading to preventable accidents and injuries. The facility's failure to maintain a safe environment and provide adequate supervision and assistive devices contributed to the deficiencies identified in the report.

Penalty

Inspection fine: $41,04031 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that licensed nurses and other nursing personnel had the necessary knowledge, competencies, and skill sets to provide care and respond to each resident's individualized needs as identified in their assessments and care plans. Agency staff reported not receiving training or education prior to being assigned to residents' care. The facility's policy on resident rights emphasized the need for reasonable accommodation of resident needs and preferences, but the facility assessment tool did not account for agency staffing in terms of training, assessment, and competency. Interviews with various staff members, including the Schedule Coordinator and agency nurses, revealed significant gaps in training and competency assessments for agency staff. The Schedule Coordinator mentioned that agency staff were not allowed to provide care if their online training was not current, but there was no tracking of agency staff competencies by the facility. Agency staff were reportedly trained by their agencies through computerized programs, but upon arrival at the facility, they did not receive additional training or competency assessments. Several agency nurses and aides expressed concerns about not receiving any training or skills check-offs from the facility, and some felt overwhelmed due to the lack of familiarity with residents' needs and preferences. Residents also expressed dissatisfaction with the care provided by agency staff, noting that they had to instruct the staff on what to do. The Interim DON and Interim Administrator acknowledged the challenges posed by the high percentage of agency staff, which accounted for 68% of the facility's staffing. They noted that this reliance on agency staff hindered continuity of care and presented issues with ensuring that residents consistently knew who would be taking care of them. The facility's board of directors was informed of these concerns, highlighting the significant staffing issues and the impact on resident care.

Penalty

Inspection fine: $41,04031 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to treat residents with respect and dignity by not providing showers for an extended period due to water contamination concerns. Legionella bacteria were detected in the Unit 2 shower, leading to the closure of all showers in the facility. Despite recommendations from an independent water systems company and a certified water safety expert to use portable showers, the facility declined to implement this temporary solution. The facility also did not reopen the showers on Units 1 and 3, which tested negative for legionella, until a month later, leaving residents without access to showers and only offering bed baths. Interviews with residents and their families revealed dissatisfaction and a lack of communication from the facility regarding the water contamination issue. Residents expressed that bed baths did not make them feel completely clean, and families were not informed about the situation until they inquired directly. The facility's policies stated that residents had the right to a dignified existence and to receive care in an environment that promoted their quality of life, which was not upheld in this situation. Staff interviews indicated confusion and a lack of clear communication regarding the use of showers. The facility's Infection Preventionist and Director of Nursing were unsure why showers on Units 1 and 3 were not used despite being safe. The facility awaited confirmation from the Local Health Department and other authorities, but the decision to keep showers closed was ultimately the facility's responsibility. The failure to provide adequate bathing facilities and communicate effectively with residents and families led to a deficiency in maintaining residents' rights and quality of life.

Penalty

Inspection fine: $41,04031 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for addressing ongoing legionella bacterial contamination in its water system. The Infection Control Risk Assessment section of the Facility Assessment Tool was incomplete, and the facility leadership did not address or include legionella when it was first discovered. The facility's Water Management Plan was deemed insufficient by the State's Division of Epidemiology and Health Planning, and the facility did not update its assessment to reflect the ongoing issues with legionella contamination. Additionally, the facility did not account for the high volume of agency staffing in its assessment, which was crucial for evaluating the resident population and identifying essential resources for care provision. Agency staffing comprised 68% of the facility's 24-hour staffing assignments, yet the assessment only addressed direct care providers such as RNs, LPNs, and SRNAs. Interviews revealed that agency staff often lacked proper training and orientation, leading to concerns about continuity of care and familiarity with residents' needs and preferences. Interviews with facility staff, including the Interim DON and Interim Administrator, highlighted the lack of systems in place to ensure proper administration and the challenges posed by the reliance on agency staff. Residents expressed dissatisfaction with the care provided by agency staff, noting that they often had to instruct them on their needs. The Interim DON and Administrator acknowledged the issues with agency staffing and presented their concerns to the facility's board of directors, emphasizing the need for continuity of care for residents.

Penalty

Inspection fine: $41,04031 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that an adequate number of staff were properly trained and certified in Cardiopulmonary Resuscitation (CPR) for Healthcare Providers, which is essential for providing basic life support until emergency medical services arrive. The review of the facility's policy revealed that all licensed nurses and Kentucky Medication Aides (KMAs) were required to obtain a Basic Life Support (BLS) CPR certification from an accredited licensing agency. However, it was found that eight nurses had expired CPR certifications, including two Licensed Practical Nurses (LPNs) who were working as charge nurses on a specific date. Interviews with various staff members, including a Registered Nurse (RN), the Infection Preventionist (IP) Nurse, and the Quality Assurance (QA) Nurse, highlighted a lack of clarity and responsibility regarding the tracking and renewal of CPR certifications. The IP Nurse, who provided CPR classes, stated it was not her duty to monitor certification expirations. The Scheduler/Staff Coordinator assumed the IP Nurse was responsible for full-time staff certifications, while she managed agency staff certifications. The Interim Director of Nursing (DON) later confirmed that the IP Nurse would now be responsible for tracking CPR certifications and expiration dates. The Interim Administrator expressed the expectation that all nurses maintain active CPR certifications for resident safety.

Penalty

Inspection fine: $41,04031 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents received food and drinks at a palatable, attractive, and safe temperature. This deficiency was identified for five of nine sampled residents. During a resident council meeting, multiple residents expressed concerns about their food being served cold. Observations during a lunch meal revealed that the beef and noodle entree and vegetable medley were not at an appetizing and acceptable temperature. The facility's policy indicated that hot foods should be served at temperatures over 140 degrees Fahrenheit, but conflicting documentation showed varying acceptable temperature ranges. The issue was further highlighted during a Resident Group meeting where several residents complained about consistently receiving cold food. Observations of the food service process showed significant temperature drops from the steam table to the point of service. For instance, the beef entree, initially at 192 degrees Fahrenheit, was served at 125 degrees Fahrenheit. The Dietary Manager acknowledged the temperature drop but was uncertain about the cause, suggesting that frequent opening and closing of the food cart might be a factor. Interviews with the Dietary Manager and Interim Director of Nursing revealed a lack of awareness and consistency in addressing the residents' complaints. The Dietary Manager mentioned that the concerns were reported to the dietician, who did not note any issues with food temperatures. The Interim Director of Nursing and Interim Administrator, both new to the facility, were unaware of the ongoing complaints. The report highlighted the need for consistent policy and practice to ensure food is served at acceptable temperatures to meet residents' satisfaction.

Penalty

Inspection fine: $41,04031 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify a resident of changes to services covered by Medicare and/or Medicaid in a timely manner. Specifically, one resident, identified as R38, did not receive the required documentation, including the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) and the Notice of Medicare Non-Coverage (NOMNC). This oversight occurred despite the resident receiving therapeutic services under Medicare Part A, with the last covered day being 10/25/2024. The facility's documentation did not show evidence that these forms were issued to the resident or their representative, which is necessary for informing them of the end date of services and their right to appeal. Interviews with facility staff revealed a breakdown in communication and process. The Admissions Coordinator (AC) was not informed or included in the notification process, as she did not receive the necessary email alerts. The Interim Director of Nursing (DON) and Interim Administrator both acknowledged the importance of these forms for ensuring residents or their families are aware of service terminations and can appeal if needed. However, the Interim Administrator, who was new to the facility, was not familiar with the existing process for beneficiary notification, indicating a lack of established procedures or training for staff involved in this process.

Penalty

Inspection fine: $41,04031 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate dialysis care and services for a resident, identified as R425, who required such services. The deficiency was identified through interviews, record reviews, and policy reviews, revealing that the facility did not conduct ongoing assessments of R425's condition and failed to monitor for complications before and after dialysis treatments. Additionally, there was a lack of documented evidence of communication and collaboration with the dialysis facility regarding R425's care and services. R425 was admitted to the facility with diagnoses including Congestive Heart Failure and End Stage Renal Disease requiring Hemodialysis. The facility's policy required pre and post dialysis assessments, including monitoring the thrill and bruit of the dialysis shunt/fistula. However, the facility's documentation showed only four dialysis communication forms, with no evidence of post dialysis assessments. The resident's care plan included interventions for checking the arteriovenous fistula, but there was no consistent documentation of these assessments. Interviews with facility staff, including LPNs, RNs, and the MDS Nurse, revealed inconsistencies in completing dialysis communication forms and reassessments. Staff reported a lack of training provided by the facility, and the QA Nurse admitted to not providing education or training to staff. The Interim Director of Nursing and Interim Administrator acknowledged the lack of communication between the dialysis clinics and the facility and stated that a new process was being developed to address these issues.

Penalty

Inspection fine: $41,04031 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all drugs used were labeled in accordance with professional standards. During an observation, it was found that one of the four medication carts contained opened and undated medications, including Flonase inhalers, Ipratropium Bromide nasal spray, Milk of Magnesia, Geri-Tussin, Keppra, and Guaifenosorb. The facility's policy required that once a medication package is opened, the date should be recorded on the primary medication container to adhere to manufacturer guidelines regarding expiration dates. Interviews with staff revealed a lack of awareness and adherence to the facility's medication labeling policy. A Kentucky Medication Aide was unaware that medication containers needed to be dated. An LPN acknowledged that medications should be dated when opened to prevent usage past expiration, and any undated opened medication should be discarded and reordered. The Interim DON and Administrator both stated that it was their expectation for staff to date opened medications to ensure resident safety, indicating a gap between policy and practice among staff members.

Penalty

Inspection fine: $16,80116 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, leading to the development and transmission of communicable diseases and infections. Specifically, the facility did not implement the state's Division of Epidemiology and Health Planning's recommendation to use faucet filters or bottled water to prevent the spread of a water-borne infection with legionella. Staff interviews revealed that they were unaware of water contamination concerns and continued to use the sink faucets in residents' rooms for brushing teeth, hygiene, drinking water, and hand hygiene for staff. The facility's Infection Preventionist (IP) was informed by the Local Health Department (LHD) about a PRN employee diagnosed with Legionnaires' Disease. Despite this, the facility only provided bed baths instead of showers and did not take further recommended actions such as installing faucet filters or providing bottled water. The IP communicated the recommendations to the Administrator, but no immediate action was taken. Staff continued to use potentially contaminated water for various hygiene purposes, and residents were not provided with bottled water. Interviews with staff, including State Registered Nurse Aides (SRNAs) and the Director of Maintenance (DOM), revealed concerns about water quality and a lack of communication from the administration regarding the water contamination. The facility's Director of Nursing (DON) and Administrator were aware of the legionella presence but did not inform staff, residents, or families about the water issue. The facility's failure to follow the health department's recommendations and properly manage the water contamination led to a serious risk of infection for residents and staff.

Removal Plan

• The facility's Administrator, Director of Nursing (DON), Infection Preventionist (IP), and Plant Maintenance Director (PMD) participated in a conference call with representatives from the state's Department of Public Health (DPH), Division of Epidemiology and Health Planning's (DEHP), Local Health Department (LHD), and the independent water systems company to determine an appropriate plan to move forward.
• An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the Medical Director, the Administrator, and the DON to discuss the findings and plan for removal of the Immediate Jeopardy. The Quality Assurance Performance Improvement (QAPI) Committee would meet monthly to review compliance and adjust as deemed necessary by the QAPI Committee to maintain compliance for recommendations and further follow-up regarding the plan of correction.
• The DON, IP, and the Minimum Data Set (MDS) Nurse would educate staff on Legionnaires' Disease. Staff must complete all education and post-testing before being allowed to work. The DON, IP, and MDS Nurse would educate agency staff before they worked assigned shifts. A post-test was given, requiring a minimum score of 100 percent. Those who did not receive a score of 100 percent were re-educated and tested again until they achieved a score of 100 percent. Any staff members not receiving education would be provided with the education before working their next shift. The DON was responsible for tracking all education to ensure all facility and agency staff were educated before working.

Penalty

Inspection fine: $16,80116 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure residents were free from abuse, as evidenced by multiple incidents involving resident-to-resident physical altercations. On 06/04/2023, a staff member witnessed Resident 3 strike Resident 4 on the right side while shouting, 'I told you to move.' Both residents were seated in their wheelchairs in the hallway outside their shared room. Despite the facility's policy prohibiting physical abuse, the incident report and subsequent psychiatric consult revealed that Resident 3 had severe cognitive impairment and had been treated for a urinary tract infection, which may have contributed to the behavior. The facility's interventions included separating the residents and placing them on 15-minute checks, but the incident highlighted a failure to prevent the altercation initially. On 09/05/2023, Resident 4 struck Resident 5 on the cheek while they were conversing in the lobby. The receptionist witnessed the incident and reported that the residents were laughing and getting along before the altercation. Both residents were placed on 15-minute checks, and a psychiatric consult was conducted for Resident 5, who had moderate cognitive impairment. The facility's care plan for Resident 4 included monitoring for behavior changes and psychiatric services, but the incident indicated a lapse in preventing resident-to-resident abuse. On 10/24/2023, Resident 6 struck Resident 3 on the neck while trying to enter their shared room. A staff member witnessed the incident and reported that Resident 6 wanted to go into the room, but Resident 3 was in the way. Both residents were separated, and neither sustained injuries. Resident 6, who had severe cognitive impairment, was placed on behavior monitoring and received a psychiatric consult. Despite these measures, the facility's failure to prevent the altercation demonstrated a deficiency in ensuring residents were free from abuse.

Penalty

Inspection fine: $16,80116 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to immediately report an alleged incident of sexual abuse involving a resident with severe cognitive impairment. The resident, who had diagnoses including dementia and cerebral atherosclerosis, reported the abuse to staff on two separate occasions. The first report was made on 03/19/2024 at 2:48 AM to an SRNA, who then informed an LPN. The LPN did not report the incident to the administration, believing the resident was confused. The second report was made on 03/20/2024 at 1:15 PM to another SRNA, who then informed another LPN. This time, the incident was reported to the Director of Nursing (DON) and other relevant personnel at 2:00 PM, and subsequently to the State Survey Agency (SSA) at 4:29 PM, well beyond the required two-hour reporting window. Interviews with staff revealed that the initial report of abuse was not taken seriously due to the resident's cognitive impairment and confusion. The LPN who received the first report did not follow the facility's policy of immediate reporting, which mandates that any alleged abuse be reported to the administration within two hours. The second report was handled more appropriately, but still did not meet the immediate reporting requirement. The facility's policy, dated 11/2016, clearly states that all alleged violations involving abuse must be reported immediately to the Administrator or designee, who would then notify the appropriate state agencies. The delay in reporting was confirmed through interviews with various staff members, including the DON, SSD, and the Administrator. The DON emphasized the importance of immediate reporting for evidence preservation, while the Administrator acknowledged that delays in reporting hinder the activation of investigations and notification of required agencies. The facility's failure to adhere to its own policy and regulatory requirements resulted in a significant delay in addressing the resident's allegations of abuse, potentially compromising the investigation and any subsequent actions.