Citations in Kentucky
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Kentucky.
Statistics for Kentucky (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in Kentucky
Latest Citations in Kentucky
The facility did not consistently implement or develop comprehensive care plans for several residents requiring orthotic devices, resulting in splints and braces not being applied as ordered and necessary interventions, such as range of motion exercises, being omitted. Additionally, a resident with a history of falls did not have the required brightly colored tape applied to the call light as specified in the care plan. Staff interviews revealed confusion about responsibilities and a lack of policy guidance, contributing to the deficiencies.
A resident with hypertension, Alzheimer's disease, and chronic kidney disease was given Lisinopril multiple times by a CMT despite physician orders to hold the medication if systolic blood pressure was below 150 mm Hg. The CMT and other staff misunderstood the hold parameters, resulting in repeated administration of the medication outside the prescribed guidelines, as confirmed by MAR review and staff interviews.
Three residents with orders for hand splints and ROM did not consistently receive these interventions as prescribed, with splints often left unused and staff unclear about responsibilities for application and documentation. The facility lacked policies for splinting and restorative nursing, and staff interviews revealed confusion and inconsistent practices regarding the provision of care for residents with contractures.
The facility did not ensure that three residents with limited ROM received consistent application of prescribed hand splints or appropriate ROM services. For example, a resident with hemiplegia did not have her splint applied for months, another with contractures had her splint left unused on the bedside table, and a third with dementia was not wearing her splint as ordered. Staff interviews revealed confusion about responsibilities and a lack of a restorative nursing program or clear policy for splint use and ROM care.
The facility did not ensure that call light systems were accessible in all resident bathrooms and bathing areas, with observations showing that cords were only available near toilets and not within reach of showers, and some restrooms lacked functioning call systems entirely. A resident reported concerns about being unable to call for help if a fall occurred in the shower, and staff interviews confirmed that workarounds were used due to the lack of accessible call lights.
Staff failed to consistently implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter, as required by facility policy. Observations showed that two CNAs provided direct care without wearing the necessary PPE, and interviews revealed confusion among staff about identifying and following EBP versus contact precautions. Despite existing training and visual indicators, staff did not adhere to infection control protocols, resulting in a deficiency in the facility's infection prevention program.
Surveyors found multiple food items in the kitchen's reach-in cooler that were not labeled, dated, or were past their use-by dates, including containers of blackberries and blueberries with mold, hard-boiled eggs, and rice. The Dietary Manager confirmed that staff were responsible for labeling and checking items, but the task was not specifically assigned, leading to noncompliance with facility policy and FDA guidelines.
A nurse failed to follow infection prevention and control protocols while providing perineal care to a resident with severe cognitive impairment. The nurse used the same washcloth for multiple areas, discarded soiled linens on the floor, retrieved clean clothing without removing gloves, and did not follow proper PPE removal or hand hygiene procedures, all contrary to facility policy.
A resident admitted with schizophrenia, depression, and anxiety was not given a required PASARR Level I screening prior to admission, and was not referred for a Level II PASARR after two inpatient psychiatric treatments, despite facility policy. Staff interviews revealed confusion about PASARR responsibilities, and the resident was unaware of any assessment.
A resident with a history of schizophrenia, anxiety, and depression was readmitted from a behavioral health unit after exhibiting escalating behaviors, including paranoia, hallucinations, and threats. Despite facility policy requiring interdisciplinary review and revision of the comprehensive care plan after significant changes or hospitalizations, the care plan was not updated to reflect the resident's recent behavioral episode, new diagnoses, or recommendations from the behavioral health stay.
Failure to Implement and Develop Comprehensive Care Plans for Orthotic Devices and Fall Prevention
Penalty
Summary
The facility failed to implement and develop comprehensive, person-centered care plans for several residents requiring orthotic devices and for a resident needing a specific fall prevention intervention. For four residents with orders for splints or braces, the care plans either lacked necessary interventions, such as range of motion (ROM) exercises, or the interventions listed were not carried out as specified. Observations revealed that splints and braces were not applied as ordered, and staff interviews confirmed inconsistent application and lack of awareness regarding care plan details. In some cases, splints were found unused in residents' rooms, and staff admitted to not performing required ROM prior to splint application. Additionally, the facility failed to ensure that interventions for fall prevention were implemented as documented in the care plan. One resident, who had experienced multiple falls, had a care plan intervention to apply brightly colored tape to the call light as a visual reminder to request assistance before ambulating. However, repeated observations showed that the call light did not have the required colored tape, and staff interviews confirmed that the intervention was not in place. There was also a lack of clarity among staff regarding responsibility for ensuring that such interventions were implemented and maintained. The facility's policies required that care plans be comprehensive, person-centered, and regularly updated by the interdisciplinary team, with staff notified of their responsibilities. However, interviews with staff, including CNAs, the MDS Coordinator, the DON, and the Administrator, revealed gaps in communication, training, and policy availability. Some staff were unaware of their roles in applying splints or following up on care plan interventions, and the facility lacked specific policies on restorative nursing services and splinting. These deficiencies resulted in residents not receiving care as planned and documented.
Failure to Adhere to Physician-Ordered Blood Pressure Parameters During Medication Administration
Penalty
Summary
A deficiency occurred when a certified medication technician (CMT) administered Lisinopril 20 mg to a resident diagnosed with essential hypertension, Alzheimer's disease, and chronic kidney disease, despite the physician's order to hold the medication if the resident's systolic blood pressure was less than 150 mm Hg. On the observed date, the resident's systolic blood pressure was 132 mm Hg, yet the medication was still given. The CMT later realized the error after reviewing the medication parameters and acknowledged that the medication should not have been administered. The facility's policy required medications to be administered as ordered and for vital signs to be checked and recorded, with medications held if outside prescribed parameters. Further review of the resident's Medication Administration Record (MAR) revealed that Lisinopril had been administered on multiple occasions when the resident's systolic blood pressure was below the ordered threshold of 150 mm Hg. Specifically, in the month of May, the medication was given 21 times despite the highest recorded systolic blood pressure being 136 mm Hg, and in June, it was administered on three occasions with all readings below 150 mm Hg. Interviews with staff indicated a misunderstanding of the hold parameters, with the CMT and nursing leadership referencing more common lower thresholds, rather than the specific order for this resident.
Failure to Provide Ordered Splinting and ROM Care for Multiple Residents
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for three residents who required range of motion (ROM) and orthotic devices. The facility did not have policies for splinting/orthotic devices or for Restorative Nursing Services, as confirmed by the Administrator. Staff interviews revealed a lack of clarity regarding responsibility for applying splints and performing ROM, with some staff unaware of which residents required these interventions or how to document them. One resident with hemiplegia and hemiparesis had a physician order for a resting hand splint to be applied daily, but reported that the splint had not been applied for about four months and that ROM was not performed prior to application, causing discomfort. Another resident with dementia and contractures had a splint order, but repeated observations showed the splint was left unused on the bedside table over several days. A third resident with dementia and contractures also had a physician order for a hand splint, but was repeatedly observed without the splint in place, and staff documentation showed inconsistent application. Interviews with CNAs, a CMT, and the Director of Rehabilitation indicated confusion about who was responsible for applying splints and performing ROM, with some staff stating that there was no restorative nursing program and that ROM was only provided during ADL care. The DON and Administrator acknowledged the lack of a restorative program and emphasized the expectation to follow physician orders, but confirmed that residents were not consistently receiving the ordered care.
Failure to Provide Consistent Range of Motion Care and Splint Application
Penalty
Summary
The facility failed to ensure that residents with limited range of motion (ROM) received appropriate treatment and services to prevent further decline in ROM for three residents. For one resident with hemiplegia and hemiparesis, staff did not consistently apply the prescribed resting hand splint as ordered by the physician. The resident reported that the splint had not been applied for approximately four months, and when it was applied, no ROM exercises were performed beforehand. The resident also experienced discomfort when the splint was first put on, and staff had to search for the splint in the closet, indicating a lack of routine and consistent care. Another resident with Alzheimer's disease and contractures had physician orders for both therapy evaluation and the application of a hand grip splint. Observations revealed that the splint was not being applied as ordered, as it was seen lying unused on the bedside table during multiple checks. Occupational therapy had recommended consistent use of the splint to maintain function, but there was no evidence of a restorative nursing program or consistent staff follow-through to ensure the splint was used as directed. A third resident with dementia and contractures also had orders for a resting hand splint and passive ROM exercises. Observations showed the splint was not being worn and was found in a chair in the resident's room. Interviews with staff revealed confusion about responsibilities for applying splints and a lack of restorative nursing services in the facility. Staff were unclear about which residents required splints, and there was no established policy or program to ensure the consistent application of splints or provision of ROM exercises, despite physician orders and therapy recommendations.
Inaccessible Call Light Systems in Resident Bathrooms and Bathing Areas
Penalty
Summary
The facility failed to provide an accessible and functioning call system in each resident's bathroom and bathing area, as required by its own policy. Observations revealed that in multiple private bathrooms, the call light cord was installed only near the toilet and did not extend to the shower area, leaving a significant distance between the shower and the call light. In one resident and staff accessible restroom, the call light system was present but lacked a pull cord, rendering it inoperable. Additionally, the therapy gym restroom had no call light system installed at all. These deficiencies were confirmed through direct observation and interviews with staff and residents. A resident expressed concern that the call light cord did not reach the shower, noting that if someone fell while showering, they would be unable to call for help. Staff interviews indicated that CNAs would remain in the room during showers due to the call light limitations, and the ADON stated she would stand outside the bathroom door if a resident showered independently without access to a call light. The DON and Administrator acknowledged the issue, with the Administrator stating she would further investigate. The facility's failure to ensure accessible call systems in all toileting and bathing areas directly contravened its policy and left residents without a reliable means to summon assistance in these areas.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter. Facility policy required the use of gowns and gloves during high-contact care activities for residents with wounds or indwelling devices, regardless of known infection status. However, observations revealed that staff did not consistently follow these precautions, as evidenced by two CNAs providing direct care to a resident on EBP without donning the required personal protective equipment (PPE). Interviews with various staff members, including CNAs, a hydration aide, and an LPN, indicated confusion and lack of clarity regarding the identification and differentiation between EBP and contact precautions. Staff relied on visual cues such as yellow dots or supply bags outside resident rooms but were unsure of the specific requirements or which residents were on which precautions. Some staff admitted to forgetting to use PPE or not paying attention to precaution indicators, despite having received training on infection control and PPE use. The resident involved had multiple diagnoses, including chronic obstructive pulmonary disease, emphysema, acute respiratory failure with hypoxia, and a urinary tract infection, and was assessed to have moderate cognitive impairment. The facility's infection preventionist and DON confirmed that audits and training were in place, but staff interviews and direct observation demonstrated lapses in adherence to EBP protocols, resulting in a failure to prevent potential transmission of communicable diseases and infections.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
Surveyors observed multiple food storage violations during a kitchen tour, including several items in the reach-in cooler that were not labeled or dated, and some with use-by dates that had already passed. Specifically, three opened containers of blackberries were found dried out, not labeled or dated, and covered with a white substance. Two containers of opened blueberries were also dried out, not labeled or dated, and contained mold. Additionally, a container with three hard-boiled eggs was not labeled or dated, and a bowl of white rice was found with a use-by date that was nine days prior to the observation. Interviews with the Dietary Manager revealed that all items were supposed to be labeled and dated before storage, and that kitchen staff were responsible for checking the coolers daily, though this task was not specifically assigned to anyone. The Dietary Manager and the Administrator both acknowledged that failure to follow these procedures could result in residents being served expired or improperly stored food. Facility policy required all food items to be stored in covered containers, labeled, dated, and arranged to prevent cross-contamination, in accordance with FDA Food Code guidelines.
Failure to Follow Infection Control Protocols During Perineal Care
Penalty
Summary
A deficiency was identified when a nurse failed to follow established infection prevention and control protocols during the provision of perineal care to a resident with severe cognitive impairment. The resident, who had diagnoses including unspecified dementia, hypertension, and depression, was observed standing in her room with wet socks and pants on the floor. The nurse entered the room wearing PPE, although the resident was not on any type of precautions, and did not assist the resident to the bed or provide privacy. During care, the nurse used a single washcloth to wipe both the resident's buttocks and between her legs, contrary to facility policy requiring separate washcloths for each area. The soiled washcloth and towel were thrown onto the floor instead of being placed in a designated receptacle. The nurse then retrieved clean clothing from the closet without removing her gloves, dressed the resident, and only after handling soiled linens and removing PPE did she doff her gloves, not following the correct order for PPE removal or hand hygiene procedures. Interviews with the nurse, DON, and Administrator confirmed that the actions taken did not align with facility policies for infection control, perineal care, handling of soiled linens, and PPE use. The nurse admitted to not following proper procedures, including the handling of soiled items and PPE removal, and facility leadership stated expectations that staff adhere to established infection control guidelines.
Failure to Complete Required PASARR Screenings and Referrals for Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a required pre-admission screening and resident review (PASARR) for a resident with mental disorders prior to admission. The facility's policy required all applicants to be screened for serious mental disorders or intellectual disabilities before admission, and to coordinate assessments with the PASARR program. The resident in question was admitted with diagnoses including schizophrenia, depression, and generalized anxiety disorder, but there was no evidence that a PASARR Level I screening was completed prior to admission. Additionally, the facility did not refer the resident for a Level II PASARR following two separate inpatient psychiatric treatments after admission, as required by policy for residents exhibiting behavioral or psychiatric symptoms or following intensive psychiatric treatment. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for PASARR assessments. The interim DON believed admissions staff and the social worker were responsible, while the Administrator stated she completed Level I assessments but did not believe hospitalization on a behavioral health unit necessitated a Level II assessment. The resident confirmed being sent out for behavioral issues twice since admission and was unaware of any PASARR assessment. The facility's failure to complete the required screenings and referrals resulted in noncompliance with both facility policy and regulatory requirements.
Failure to Revise Care Plan After Behavioral Health Readmission
Penalty
Summary
The facility failed to review and revise the comprehensive care plan (CCP) for a resident following her readmission from a behavioral health unit (BHU). The facility's policy required that the CCP be reviewed and updated by the interdisciplinary team (IDT) after each comprehensive and quarterly Minimum Data Set (MDS) assessment, as well as after significant changes in the resident's condition. Despite this, the care plan for the resident, who had diagnoses including generalized anxiety disorder, schizophrenia, and depression, was not updated to reflect her recent behavioral health episode and subsequent readmission. The resident had a history of behavioral symptoms, including resisting care, urinating on the floor, and sitting on the floor, which were documented in her initial care plan. However, in the period leading up to her transfer to the BHU, she exhibited escalating behaviors such as paranoia, hallucinations, threats to staff and her roommate, and requests for police intervention. Nursing progress notes documented these behaviors, as well as the facility's actions to reassure her and eventually arrange for her transfer to the BHU for medical stabilization due to hallucinations, delusions, and threatening behavior. Upon her return from the BHU, the facility did not revise the resident's care plan to include her recent behaviors, updated diagnoses, or recommendations from the behavioral health stay. Interviews with the DON and Administrator confirmed that the expectation was for care plans to be reviewed and revised after hospital stays and to reflect all current and historical behaviors, but this was not done in this case.
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