Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hazard Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain documentation of controlled medication reconciliation for all 8 medication carts. Facility policy required two licensed staff to complete and sign the narcotic count at shift change, but review of the narcotic count records showed numerous missing signatures across the carts. RN and DON interviews confirmed the counts were being done at hand-off, but staff were not consistently signing the count sheets, and oversight of the documentation was lacking.
Staff failed to follow infection control practices for multiple residents. A CNA entered a resident’s EBP room without donning gown and gloves and left without hand hygiene, a nebulizer kit was found on the floor instead of stored in a bag when not in use, another CNA entered a room without hand hygiene when the sanitizer dispenser was not working, an RN changed gloves during wound care without washing hands first, and a room had a nonworking sanitizer dispenser with yellow liquid observed around the toilet lid.
Housekeeping and maintenance failures left resident rooms and common areas unclean and damaged. Observations found cracked tile, broken toilet paper holders with sharp edges, broken wall bumpers, a black stain around a toilet, uncovered bedpans with yellow liquid, and debris under shower mats in men's shower rooms. The DON described one shower room as filthy, and interviews with the Maintenance Director, DON, Housekeeping Manager, and Administrator confirmed that staff were expected to report needed repairs, while the Maintenance Director said no active work orders were pending.
A resident with intact cognition and multiple medical conditions posted a social media image of herself after a fall, which did not show other residents or identify the facility. Despite a stated right to privacy in electronic communications, the SSD, at the request of administration, discussed the facility’s concerns about the post and assisted in deleting it after multiple staff had approached the resident about removing it. The resident reported feeling pressured by staff to delete the post, while the DON acknowledged being present during the discussion and the Administrator stated she had asked the SSD to address the care concerns mentioned in the post but denied directing its removal.
The facility failed to maintain complete, person-centered care plans for three residents. Two residents with PTSD had care plans that did not identify the causes or triggers of their trauma, even though staff and clinical records showed the diagnoses were known. A third resident with severe cognitive impairment and repeated falls had a fall care plan that listed interventions such as non-skid footwear and a walker, but the plan did not show when those interventions were implemented or consistently reflect the resident’s ongoing fall-related needs.
Failure to revise the care plan after repeated falls. A resident with severe cognitive impairment, weakness, gait difficulty, and lack of coordination had multiple falls, including one with major injury. The care plan listed non-skid footwear for fall risk, but the intervention was not dated and the resident later fell while wearing sandals instead of the identified footwear. The RN/MDS Nurse stated the care plan should have been updated after the fall investigation, but it was not revised with a new intervention.
The facility failed to maintain sanitary conditions in the kitchen and unit kitchenettes, risking foodborne illness for 151 residents. Handwashing sinks had inadequate water temperatures, and sanitizer solutions were too strong. Microwaves were soiled, and refrigerators/freezers were improperly monitored, with some not functioning correctly. Unlabeled food items were found, and maintenance practices were insufficient.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a feeding tube, as staff did not wear gowns during care despite orders. Observations and interviews revealed a lack of understanding and inconsistent application of EBP among staff. Additionally, the facility's infection control policies were not updated annually, with key personnel unaware of this requirement, highlighting systemic issues in infection control practices.
The facility failed to provide firmly secured handrails on both sides of two corridors, potentially affecting all ambulatory residents. Observations revealed missing handrails in several sections, including near the outpatient therapy room, front door, and various walls leading to smoke and fire doors. The Administrator confirmed these deficiencies.
The facility failed to provide written hospital transfer notices for four residents transferred for medical reasons, such as chest pain and septic shock. The facility's policy lacked provisions for such notices, and there was no documentation that residents or their representatives were informed. Additionally, the Ombudsman was not notified of these transfers, as required.
A resident with severe cognitive impairment was slapped by another resident with dementia in a secure unit. Despite one-to-one supervision due to the aggressor's known behaviors, the incident occurred while a CNA was assisting the victim. The facility's policy prohibits physical abuse, but the incident highlights a failure to protect residents from such occurrences.
The facility failed to provide written information on bed-hold daily pricing to three residents transferred to the hospital. The facility's policy required a written notice specifying the duration of the bed hold, but it did not include daily pricing. Interviews with staff confirmed the omission, potentially causing confusion for residents planning to return.
A resident, post-stroke, was not provided with restorative services to maintain ambulation after physical therapy discharge. Despite recommendations for continued ambulation with staff assistance, the resident was not added to the restorative program due to capacity limitations, resulting in her being observed in a wheelchair instead of walking.
A facility failed to provide a resident with an ongoing activity program, as the resident was repeatedly observed without activities or a working television. Despite a care plan indicating preferred activities, staff interviews revealed issues with the television and a lack of response to other activities. The Administrator was unaware of these issues.
A resident with a history of stroke and hemiplegia did not receive necessary ROM exercises and splint applications after therapy discontinuation, as recommended by PT and OT. The facility's restorative program was not effectively implemented, and the resident was not added to the program due to limitations on the number of residents it could accommodate. Interviews and observations confirmed the lack of care, highlighting systemic issues in the facility's restorative care process.
A resident with respiratory failure and moderate cognitive impairment had their nebulizer mouthpiece improperly stored, increasing infection risk. Observations showed the mouthpiece uncovered, contrary to expected practice. Staff interviews confirmed the need for storage in a plastic bag, but no formal policy existed.
The facility failed to ensure two residents with dementia diagnoses had medication regimens free of unnecessary psychotropic medications. There was inadequate indication for antipsychotic use, lack of risk-benefit explanation, and insufficient monitoring of behaviors and side effects. Observations showed residents were often inactive, and staff interviews revealed a lack of appropriate documentation and monitoring systems.
A medication cart was left unlocked and unattended in a hallway with visitors present, with a resident's insulin pen on top. The resident had type two diabetes and moderate cognitive impairment. The incident was confirmed by an LPN and acknowledged by the DON and Administrator, who stated that carts should be locked when unattended.
Missing Controlled Medication Count Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services to meet each resident’s needs and to employ or obtain the services of a licensed pharmacist when it did not maintain and ensure documentation of controlled medication reconciliation for 8 of 8 medication carts. Facility policy required that, at shift change, a physical inventory of all controlled medications be completed by two licensed nurses or a licensed nurse and a medication aide, and that the inventory be documented on the controlled medication accountability record. Review of the Routine Narcotic Count Record forms for January and February 2026 showed numerous missing staff signatures across all eight carts, indicating the required medication reconciliation was not consistently documented as completed during shift change. The missing signatures were identified on the 100 Back Hall, 100 Front Hall, 200 Front Hall, 200 Back Hall, 300 Back Hall, 300 Front Hall, 400 locked unit, and 400 Hallway medication carts, with multiple omissions on each cart across January and February 2026. During interview, RN 11 stated the counts were performed at hand-off but staff were failing to sign the narcotics count sheet. The DON stated two licensed nurses were to sign the narcotics sheet at shift change, that she had not provided education on the policy in at least six months or longer, and that Clinical Coordinators should have been checking the signatures before the forms were sent to medical records. RN 12 stated she was supposed to check the narcotic count sheets for the required two signatures. The Administrator stated her expectation was for two staff to count narcotics and both sign the sheet, and she acknowledged she should have been providing oversight to ensure the counts were performed and documented as required.
Infection Control Lapses With PPE, Hand Hygiene, and Equipment Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for five sampled residents, including residents on Enhanced Barrier Precautions (EBP) and residents receiving wound care or using nebulizer equipment. Review of the facility’s policies showed that EBP required targeted gown and glove use during high-contact resident care activities, and that nebulizer tubing was to be kept in a sealed bag when not in use. During observation, CNA 2 entered R77’s room, which had an EBP sign on the door and gown and gloves available inside the doorway, without donning PPE before providing care and then left the room without washing or sanitizing her hands. CNA 2 stated residents on EBP should not be touched unless staff were wearing gloves and a disposable gown and acknowledged she should have performed hand hygiene upon exiting the room. Additional observations showed a nebulizer machine with tubing touching the floor in R28’s room and the nebulizer kit lying on the ground rather than being stored in a bag when not in use. In R42’s room, the hand sanitizer machine outside the room was not working, and CNA 4 entered the room without washing or sanitizing her hands. During R4’s wound care, RN 4 changed gloves after touching the inside of R19’s wound but did not wash her hands before putting on new gloves. In R50’s room, the hand sanitizer machine outside the room was not working, and yellow liquid was observed around the toilet lid, with some of it dried and some still wet. The IP, RN 1, and the Administrator all stated staff were expected to follow the facility’s infection control policies, including PPE use, hand hygiene, and nebulizer storage.
Housekeeping and Maintenance Failures Left Resident Areas Unclean and Damaged
Penalty
Summary
The facility failed to provide housekeeping services to ensure a clean and sanitary environment for 5 of 41 sampled residents, including R3, R36, R51, R100, and R181. Observation of R36's room revealed a cracked floor tile next to the baseboard and a broken toilet paper holder in the bathroom with a sharp edge. Observation of R51's room revealed a black stain around the toilet, and the resident stated the stain had been there ever since they had been in the facility and that they had tried to clean it up but were not allowed to do so. Observation of R100's and R181's rooms each revealed a broken toilet paper holder with a sharp edge. Additional observations showed a broken wall bumper with a sharp edge in the 200 hallway, broken wall bumpers in the 300 hallway and next to the dining room, and in R3's bathroom two bedpans stored on top of a black bag, with one uncovered bedpan containing yellow liquid. The 200 hall men's shower room contained hair, nail clippings, and a brown substance underneath the shower mat on the shower bed, and the 300 hall men's shower room contained hair, nail clippings, and a dry white non-odorous substance underneath the shower mat on the shower bed. The DON stated the shower room was filthy when shown the condition. Interviews with the Maintenance Director, DON, Housekeeping Manager, and Administrator confirmed expectations that staff report needed repairs and that residents deserve a clean, sanitary, and homelike environment, while the Maintenance Director stated there were no current active work orders and he had not been made aware of anything needing repair.
Failure to Protect Resident Privacy in Use of Electronic Social Media
Penalty
Summary
The facility failed to ensure a resident’s right to privacy in the use of electronic communications when staff became involved with a resident’s personal social media post. The resident, admitted with diagnoses including diabetes, cerebral infarction, major depressive disorder, hemiplegia and hemiparesis, and anxiety, had an intact cognition as evidenced by a BIMS score of 15/15. The resident posted a social media image of her own face after a fall, which did not show other residents or identify the facility by name. The facility’s Resident Rights packet, provided by the Kentucky State Long-Term Care Ombudsman Program, stated that residents have a right to privacy and confidentiality, including privacy in using electronic communications. According to a late-entry Social Service note, the Social Services Director (SSD), at the request of administration, encouraged the resident to consider removing the post and then assisted in deleting it while the resident had the post pulled up on her phone. In interview, the SSD stated she had been asked by the Administrator and Regional Nurse to speak to the resident about the post, which contained concerns about a fall, and acknowledged discussing the facility’s concerns about the post’s appearance because people knew where the resident lived. The resident reported that the SSD and other staff asked her to remove the post, that she did not know how to delete it, and that the SSD deleted it for her; she also stated she felt pressured by several staff members entering her room and asking her to remove it. The DON confirmed being present during the discussion but did not recall details and deferred to the Administrator, who stated she had asked the SSD to address the concerns about care in the post but denied instructing removal of the post and could not recall how she became aware of it or its exact content.
Incomplete care plans for PTSD and fall prevention
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for three sampled residents. Review of facility policy showed the care plan was required to address each resident’s medical, nursing, mental, and psychosocial needs, and to be reviewed and revised by the interdisciplinary team after assessments and as needed. The facility also had a trauma assessment protocol requiring trauma screening on admission and on annual or significant change MDS assessments, with care planning based on the screening results. For one resident with diagnoses including PTSD, schizoaffective disorder, bipolar disorder, generalized anxiety disorder, and major depressive disorder, the care plan noted psychotropic medication use and mental health diagnoses, including PTSD, but did not identify what the PTSD related to or what interventions were needed to reduce the potential for psychosocial trauma. A psych NP note identified childhood sexual abuse as the cause of the PTSD, and the resident confirmed the PTSD diagnosis was related to childhood abuse. The SSD, UM, RN/MDS nurses, LPN/MDS nurse, primary NP, psych NP, DON, and Administrator all stated they were aware of the PTSD diagnosis but did not know the specific triggers or causes, and the resident’s care plan did not include that information. For another resident with diagnoses including encephalopathy, generalized anxiety, depression, essential tremor, sleep apnea, hypertension, and later PTSD, the admission trauma screening was negative, but the diagnosis of PTSD was added later. The resident’s guardian described multiple traumatic family deaths and stated she was unaware of specific PTSD triggers. Staff, including CNA, UM, RN/MDS nurses, LPN/MDS nurse, primary NP, psych NP, DON, and Administrator, stated they knew the resident had PTSD but did not know what it was related to or what triggers should be avoided. The care plan did not identify PTSD-related triggers or interventions to prevent unnecessary distress. For a third resident with severe cognitive impairment and a history of falls, the care plan identified high fall risk and included interventions such as non-skid footwear and a rolling walker, but the plan did not show when those interventions were implemented. The resident continued to fall multiple times, including falls associated with improper footwear and failure to use the walker. Facility records showed fall investigations identified interventions after each fall, but the comprehensive care plan did not consistently reflect those interventions with dates or measurable timeframes, and staff stated the interventions were not being followed appropriately.
Failure to Revise Fall Care Plan After Repeated Falls
Penalty
Summary
The facility failed to revise the comprehensive person-centered care plan for one resident after changes in condition and after falls were identified in the MDS assessments and fall investigations. The resident was admitted with diagnoses including polyneuropathy, osteoarthritis, and essential tremors, and later MDS assessments showed severe cognitive impairment with a BIMS score of 3 out of 15, as well as muscle weakness, difficulty walking, and lack of coordination. The quarterly MDS dated 09/19/2025 also documented that the resident had 2 or more falls with no injury and 1 fall with major injury since the prior assessment. The care plan initiated 01/27/2026 identified the resident as high risk for falls and included non-skid footwear as an intervention, but there was no date showing when that intervention was implemented. Facility fall investigations showed the resident fell on 08/18/2025 and the facility implemented non-skid footwear, yet the resident later fell again on 10/31/2025 while ambulating in sandals that slipped off her foot rather than the non-skid footwear. During interview, the RN/MDS Nurse stated she was responsible for updating care plans, that the Unit Coordinator investigated falls and identified interventions, and that the intervention from the fall investigation was supposed to be placed on the comprehensive care plan; she also stated the resident's comprehensive care plan was not revised with a new intervention after the later fall.
Sanitation and Temperature Control Deficiencies in Kitchen and Unit Kitchenettes
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, which posed a risk of foodborne illness to all 151 residents. During inspections, it was observed that the water temperature in three out of four handwashing sinks in the kitchen was not hot enough for adequate handwashing. The Dietary Manager confirmed that the water temperatures were below the required levels, with measurements ranging from 64 to 85 degrees Fahrenheit. Additionally, the sanitizer solutions used for cleaning were found to be too strong, with concentrations of 500 parts per million, which exceeded the recommended levels and could leave chemical residues on surfaces. Further observations revealed that the microwave ovens in the kitchen were soiled with accumulated food and beverage splatters, indicating a lack of regular cleaning. In the resident unit kitchenettes, the refrigerator and freezer temperatures were not properly monitored, and some were not functioning correctly. For instance, the refrigerator in the 400 Unit was not cold enough, with temperatures reading 43 and 44 degrees Fahrenheit, while the freezer in the 300 Unit was at 20 degrees Fahrenheit, which is above the required zero degrees or below. Unlabeled and potentially expired food items, such as Ready Care shakes, were also found in the refrigerators. Interviews with the Registered Dietitian and Maintenance Director highlighted further issues. The RD confirmed that the sanitizer solution was too strong and that individual health shakes should be labeled for proper tracking. The Maintenance Director initially stated that water temperatures were checked weekly but later admitted that handwashing sink temperatures had not been monitored. The lack of proper monitoring and maintenance of kitchen equipment and food storage practices contributed to the unsanitary conditions observed during the survey.
Failure to Implement Enhanced Barrier Precautions and Update Infection Control Policies
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) for a resident, identified as R108, who required specific infection control measures due to having a feeding tube. R108 was admitted with diagnoses including Alzheimer's Disease, dysphagia, and adult failure to thrive, and was noted to have severely impaired cognition. Despite physician orders for EBP every shift, observations revealed that Certified Nursing Assistants (CNAs) did not wear gowns while providing incontinence care to R108, only using gloves. Interviews with CNAs and a Registered Nurse (RN) indicated a lack of understanding and inconsistent application of EBP, with some staff unsure of the necessary Personal Protective Equipment (PPE) or unaware of the resident's EBP status. Further investigation into the facility's infection control policies revealed that they were not updated annually as required. The policy titled 'Infection Prevention & Control Program' lacked a date of last review, and the 'Antibiotic Stewardship Program' was last dated in 2017. Interviews with the Director of Nursing (DON) and the Infection Preventionist (IP) nurse indicated a lack of awareness regarding the requirement for annual policy reviews. The Administrator also struggled to provide documentation of recent updates, despite a facility assessment indicating that infection control training and audits were conducted. The deficiency highlights a systemic issue in the facility's infection control practices, particularly in the implementation and understanding of EBP among staff. The failure to update infection control policies annually and ensure staff compliance with EBP protocols poses a risk of infection spread among residents and staff. The facility's inability to provide adequate documentation of policy reviews further underscores the need for improved oversight and adherence to regulatory requirements.
Lack of Handrails in Facility Corridors
Penalty
Summary
The facility failed to ensure that two corridors were equipped with firmly secured handrails on each side of the hallway, which has the potential to affect all ambulatory residents. Observations made on 10/29/24 revealed multiple sections of the facility's corridors lacking handrails. Specifically, a 12-foot section on the north front corridor wall, a 6-foot section on the south front corridor wall near the outpatient therapy room, a 15-foot section near the front door, a 10-foot section on the east wall leading to the fire doors, a 5-foot section on the west wall from a second outpatient room door to the smoke doors leading to the 100 unit, a 17-foot section on the wall at the administrator office to the smoke doors leading to the 200 unit, and an 8-foot section on the wall at the ice cream room to the smoke doors were all noted to be without handrails. The Administrator confirmed the absence of handrails in these areas during an interview conducted on the same day.
Failure to Provide Written Hospital Transfer Notices
Penalty
Summary
The facility failed to provide written hospital transfer notices for four residents who were transferred to the hospital, as required by their policy. The residents involved were transferred for various medical reasons, including a possible pulmonary event, fever and nausea, chest pain, and septic shock with acute kidney injury. The facility's policy on transfer and discharge rights did not include provisions for written notices for hospital transfers, only for permanent discharges. This oversight led to a lack of documentation indicating that the residents or their representatives were informed in writing about the hospital transfers. Additionally, the facility did not inform the Ombudsman of these hospital transfers, as required. Interviews with facility staff, including the Accounts Receivable personnel and the Director of Nursing, revealed that while a transfer form with medical information was given to transport personnel, it did not include the reason for the transfer, nor was it provided to the residents or their representatives. The Accounts Receivable personnel claimed to notify the Ombudsman by phone, but there was no documented proof of these communications. The Administrator was made aware of these findings during the survey.
Resident Abuse Incident Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident, identified as R119, from abuse when another resident, R148, slapped her on the cheek. R119, who has severe cognitive impairment due to chronic lymphocytic leukemia, was residing in a secure unit at the facility. The incident occurred while R119 was being assisted back to her chair by a Certified Nurse Assistant (CNA10), who was also responsible for one-to-one monitoring of R148. Despite the presence of a monitor, R148, who also has severe cognitive impairment and a history of aggressive behaviors, managed to slap R119. The facility's policy clearly states that physical abuse, including slapping, is not tolerated under any circumstances. R148 had been admitted with a primary diagnosis of dementia and had a care plan that included one-to-one supervision due to her aggressive and impulsive behaviors. The facility's investigation confirmed that R148 slapped R119, although no injuries were noted. Interviews with staff revealed that R148 was known for her agitation and combativeness, requiring continuous monitoring. Despite these measures, the incident occurred, highlighting a lapse in the facility's ability to protect residents from abuse, as mandated by their policy.
Failure to Provide Bed-Hold Daily Pricing Information
Penalty
Summary
The facility failed to provide written information regarding the bed-hold daily pricing to three residents who were transferred to the hospital. The facility's policy required that at the time of transfer for hospitalization or therapeutic leave, a written notice specifying the duration of the bed hold or if no bed hold days were available should be provided to the resident or their representative. However, the policy did not include the requirement to provide daily pricing information. This omission was identified for three residents who were transferred to the hospital for various medical reasons, including a possible pulmonary event, a temperature with weakness and nausea, and chest pain with bilateral arm pain. Interviews with facility staff, including Accounts Receivable and the Director of Nursing, confirmed that the form used by the facility did not include daily pricing for the bed-hold. The Accounts Receivable staff mentioned that the form explained timeframes and insurance obligations but lacked the cost per day for the bed-hold. The Director of Nursing also confirmed the absence of daily pricing information on the bed-hold form. This failure had the potential to cause confusion for residents planning on returning to the facility.
Failure to Provide Restorative Services Post-Physical Therapy
Penalty
Summary
The facility failed to ensure that a resident, who had been discharged from physical therapy, received necessary services to maintain her ability to ambulate. The resident, who had suffered a stroke and was admitted with conditions including hemiplegia and difficulty walking, had a goal to ambulate 50 feet with a Hemi-Walker and moderate assistance. Despite meeting this goal during physical therapy, the resident did not receive restorative nursing services to continue her progress after therapy was discontinued. The physical therapist had recommended that the resident continue ambulating with staff assistance using a Hemi-Walker, and this recommendation was communicated to the nursing staff. However, the resident reported that she had not walked since her discharge from therapy and had not been informed about any restorative program. Observations during the survey confirmed that the resident was consistently seen in a wheelchair, indicating a lack of follow-up on the therapist's recommendations. Interviews with facility staff revealed that there were limitations in the restorative nursing program, which had recently been re-implemented. The program could only accommodate a limited number of residents at a time, and the resident in question had not yet been added to the program. Staff acknowledged the resident's desire to return home and the importance of maintaining her ambulation abilities, but due to program constraints, she had not received the necessary restorative services.
Failure to Provide Resident with Activity Program
Penalty
Summary
The facility failed to provide an ongoing program to support a resident's choice of activities, both facility-sponsored and group activities. The resident, who was diagnosed with multiple conditions including Pick's Disease, Parkinson's Disease, and Alzheimer's Disease, was observed multiple times over several days either in bed or in a wheelchair in her bedroom with no activities or television on. The resident's care plan indicated a goal for involvement in activities such as television, music, and sensory stimulation, but these were not being implemented effectively. Interviews with staff revealed that the resident's television remote was missing, and the television had not been working for an unspecified period. The Activity Director admitted to placing the resident in her room to watch television, despite the lack of response to other activities like sensory stimulation and music. The Administrator was unaware of the television issue, indicating a lack of communication and oversight in ensuring the resident's activity needs were met.
Failure to Implement Restorative Care for Resident Post-Therapy
Penalty
Summary
The facility failed to ensure that a resident, identified as R147, received necessary services to prevent further declines in range of motion (ROM) after the discontinuation of therapy. R147, who was admitted with diagnoses including cerebral infarction, hemiplegia, and difficulty in walking, was recommended by physical and occupational therapy to wear right foot and hand splints and to receive ROM exercises. However, these interventions were not implemented, creating the potential for R147 to decline in ROM, which could impact her goal of discharge to the community. The facility's policy for the Restorative Nursing Program was not effectively implemented for R147. Despite recommendations from therapy staff, the nursing staff did not document the provision of ROM exercises in R147's care plan, nor did they address any issues with R147 refusing the application of her splints. Interviews with R147 revealed that she was not receiving the necessary ROM exercises and that her splints were not being applied consistently, as observed during the survey. Interviews with facility staff, including the PT, OT, CNAs, MDS Coordinator, and the Director of Nursing, highlighted systemic issues in the implementation of the restorative program. The facility had limitations on the number of residents who could be included in the restorative program, and R147 had not yet been added to the program despite being identified as a good candidate. The facility's restorative program was relatively new, and there were constraints on the number of residents that could be managed by the restorative nurse aides, which contributed to the deficiency in care for R147.
Improper Storage of Nebulizer Mouthpiece
Penalty
Summary
The facility failed to maintain the cleanliness of a nebulizer mouthpiece for a resident, identified as R133, who required nebulizer therapy. R133 was admitted with a diagnosis of acute and chronic respiratory failure with hypoxia and had a moderate cognitive impairment, as indicated by a BIMS score of eight out of 15. Physician orders for R133 included the administration of Ipratropium-Albuterol Inhalation Solution twice daily. During observations on two separate occasions, the nebulizer mouthpiece was found propped up on the nebulizer machine and not covered in a plastic bag, contrary to the facility's expected practice. Interviews with staff, including a Registered Nurse, a Licensed Practical Nurse, the Director of Nursing, and the Infection Preventionist nurse, confirmed that the nebulizer mouthpiece should be stored in a plastic bag when not in use. However, it was revealed that the facility did not have a formal policy regarding the storage of nebulizer mouthpieces. The lack of adherence to proper storage procedures for the nebulizer mouthpiece increased the risk of infection for R133, as the mouthpiece was left exposed when not in use.
Failure to Monitor and Justify Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents with dementia diagnoses had medication regimens free of unnecessary psychotropic medications. For one resident, there was a lack of adequate indication and identification of behaviors warranting the use of antipsychotic medications, duplicate therapy, and a lack of explaining risks versus benefits prior to the initiation of the medications. Additionally, there was a lack of qualitative and quantitative monitoring of behaviors and side effects, creating the potential for overmedication. The resident was observed to be frequently in bed, and interviews with staff indicated that the resident was anxious but did not exhibit any behaviors that would justify the use of antipsychotic medication. For the second resident, the facility also failed to ensure a medication regimen free of unnecessary psychotropic medications. The resident was admitted with a diagnosis of dementia and was prescribed multiple psychotropic medications, including an antipsychotic, without adequate documentation of behaviors warranting their use. The facility did not document the risks versus benefits of these medications, nor did they adequately monitor for side effects. Observations revealed the resident was often sleeping or staring off, and interviews with family and staff indicated a decline in the resident's activity level and ability to perform daily tasks. The facility's policies on medication monitoring and management were not adequately followed, as evidenced by the lack of documentation and monitoring for adverse reactions and the absence of a formal system for monitoring potential side effects of psychotropic medications. The facility's Director of Nursing acknowledged the high use of psychotropic medications and the lack of a system for monitoring side effects, while the pharmacist noted the presence of duplicative therapy and the need for gradual dose reductions, which were not implemented effectively.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to secure medications in a locked medication cart when left unattended on the 300 Hallway unit. A registered nurse (RN) left the medication cart unlocked and unattended, with a resident's insulin pen placed on top of the cart. This occurred in a hallway where visitors, including two adults and two children, were present, creating the potential for unauthorized access to the medication. The resident involved, identified as R80, was admitted with a diagnosis of type two diabetes mellitus and had a moderate cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. The resident's physician orders included the administration of Basaglar KwikPen insulin. The incident was confirmed by a licensed practical nurse (LPN) and acknowledged by the Director of Nursing (DON) and the facility Administrator, who both confirmed that medication carts should be locked when unattended. The facility's policy on medication storage mandates that only authorized personnel have access to medications, and that medication carts must be locked or attended at all times.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hazard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Paul E Patton Eastern Ky Veterans Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Hyden Health And Rehabilitation Center | 12.9 mi | ★★★★★ | 0 | 0 |
| Knott County Health & Rehabilitation Center | 13.4 mi | ★★★★★ | 0 | 0 |
| Breathitt Health & Rehabilitation | 21.2 mi | ★★★★★ | 5 | 0 |
| Tri Cities Rehabilitation And Healthcare Center | 24 mi | ★★★★★ | 5 | 0 |
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