Citations in Kentucky Q

Penalty

No penalty information released

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 proper pharmaceutical services and accurate documentation of controlled substances for a resident with chronic pain who had an order for fentanyl patches. The resident was admitted with a diagnosis of chronic pain and had a physician's order for fentanyl 25 mcg patches to be applied every three days. When the pharmacy delivered two fentanyl patches, an LPN signed for the delivery without verifying the contents of the pharmacy bag. The LPN only felt one blister pack of pills inside the bag, discarded the bag at the nurse's station, and handed the pills to another nurse. The fentanyl patches were not identified or logged into the narcotic addition and deletion log at the time of delivery. The missing fentanyl patches were discovered two days later when the medication was not available for administration. The LPN realized she had likely thrown away the patches with the pharmacy bag and notified the DON. Interviews with staff confirmed that the expected process was for nurses to verify and sign in narcotics upon delivery, but this was not followed. The facility's investigation did not substantiate diversion or misappropriation, but the controlled substance was not properly received, verified, or documented as required.

Penalty

No penalty information released

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 its abuse and neglect prevention policies for two out of eleven personnel records reviewed. Specifically, the facility's policies required that all new offers of employment be contingent upon the successful completion of background checks, including checks against the Kentucky Adult Caregiver Misconduct Registry, OIG Exclusion List, and other relevant registries. However, documentation revealed that one Patient Care Assistant (PCA) was hired and began employment seven days before the completion of the required misconduct registry check, and another PCA started work three days before both the misconduct registry and OIG Exclusion List checks were completed. Interviews with facility leadership, including the Executive Director of Human Resources, Unit Manager, acting Director of Nursing, and Administrator, confirmed that the established process was to complete all background checks prior to allowing new employees to begin work. Despite this, the records showed that these procedures were not followed in the two identified cases, resulting in the potential for residents to be exposed to individuals who had not been fully vetted according to facility policy.

Penalty

No penalty information released

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

Facility staff failed to store medications and biologicals in a secure manner as required by facility policy and professional standards. During an observation, a medication cart was found unattended and locked, but medications labeled with a resident's name, a capped syringe, and a glucometer with a test strip were left on top of the cart. No staff were present in the area at the time. The facility's policy, reviewed and acknowledged by staff, clearly states that all drugs and biologicals must be stored in locked compartments and not left unattended. Interviews with the LPN involved, the unit manager, a registered nurse, and the Director of Nursing confirmed that leaving medications and syringes unattended on top of the cart was against facility policy and unsafe. The LPN admitted to being aware of the policy but stated he was trying to administer medications on time. Other staff members reiterated that medications and syringes should not be left unattended and that the LPN should have sought assistance if needed.

Penalty

No penalty information released

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 comprehensive, individualized care plan that accurately reflected the nutritional and dietary needs of a resident with a history of swallowing disorders. The resident had previously experienced choking incidents and had been evaluated by a Speech-Language Pathologist (SLP), who recommended a pureed diet with nectar thick liquids and specifically advised against peanut butter sandwiches. Despite these recommendations and physician orders, the resident's care plan did not include specific interventions to ensure that all snacks provided, including those outside of scheduled meals, met the prescribed therapeutic diet. On the day of the incident, a Certified Nurse Aide (CNA) provided the resident with a peanut butter sandwich at the resident's request, despite being aware of the pureed diet order. The CNA had previously observed the resident eating peanut butter sandwiches without difficulty and did not verify the current diet order through available resources such as the KARDEX, electronic medical record, or by consulting a nurse. The resident choked on the sandwich, became unresponsive, and later died at the hospital. The official cause of death was determined to be choking on a food bolus. Interviews with staff revealed a lack of clarity and consistency in care planning and implementation. The care plan did not incorporate the SLP's or dietary manager's recommendations, and there was no policy or standard provided regarding acceptable food items for different therapeutic diets. Staff members were aware of the resident's dietary restrictions, but the absence of clear, individualized interventions in the care plan contributed to the provision of an unsafe snack, resulting in the resident's death.

Removal Plan

• The Dietary Manager labeled all snacks/snack-room foods with correct consistency per residents' diet orders.
• The DON, ADON, and SDC educated all licensed nurses, CMTs, and CNAs regarding: Reviewing the care plan, KARDEX, and diet orders before providing snacks; IDDSI standards for puree and mechanical soft diets; Specific instruction that peanut butter was not allowed for puree diets unless blended with another food to meet puree consistency.
• Staff completed return demonstrations and will not work unsupervised until competency verified.
• Care plans for all residents on modified diets were reviewed and updated by licensed staff to include: Speech therapist and dietary recommendations; Specific snack and supplemental food interventions; Cross-reference to diet order consistency requirements.
• Administrator initiated ongoing daily audits of snacks and care plans to ensure compliance.
• New staff will be educated during orientation and before working independently.

Penalty

No penalty information released

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

A facility failed to ensure that a resident received a therapeutic diet as ordered by the physician, resulting in a fatal choking incident. The resident, who had a history of cerebrovascular disease, anoxic brain damage, dementia, dysphagia, and other significant medical conditions, was prescribed a pureed diet with nectar-thickened liquids due to severe swallowing difficulties. Despite these orders, a Certified Nurse Assistant (CNA) provided the resident with a peanut butter sandwich, which was not permitted on the prescribed diet. The CNA was aware of the resident's dietary restrictions but gave the sandwich at the resident's request, having previously observed the resident eat similar food without apparent difficulty. The incident occurred when the resident began eating the peanut butter sandwich and subsequently choked, leading to a loss of pulse. Staff attempted the Heimlich maneuver and initiated CPR, but the resident was ultimately transferred to a hospital and expired. The official cause of death was listed as choking on a food bolus. Interviews with staff confirmed that the CNA did not verify the resident's current diet order through available resources such as the KARDEX, care plan, or by consulting a nurse, despite being aware of the resident's dietary restrictions and the facility's protocols for verifying diet orders before providing snacks. Further review revealed that the facility's policies required snacks to be compatible with therapeutic diets and that staff were trained to check diet orders before providing food to residents. However, there was no specific policy or standard provided regarding acceptable food items for different therapeutic diets. The resident had a documented history of swallowing disorders and previous choking incidents, including a prior event involving a peanut butter sandwich that led to a change in diet orders and additional speech therapy interventions. Despite these measures, the failure to follow the prescribed diet directly resulted in the resident's death.

Removal Plan

• All mechanical soft and pureed snacks in the snack room and refrigerator were labeled by the Dietary Manager with the appropriate consistency.
• The Administrator reviewed all snacks and supplemental foods available outside of meal service to ensure compliance with current diet orders.
• Education was initiated by the Director of Nursing, Assistant Director of Nursing, and Staff Development Coordinator for all licensed nurses, certified medication technicians, and certified nurse aides.
• Staff were instructed on the new process for labeled snacks, the requirement to verify diet orders through the Kardex, care plan, or physicians' order, and the inappropriateness of peanut butter on a pureed diet unless blended to proper consistency under IDDSI standards.
• All staff completed return demonstrations prior to working their next scheduled shifts, and competency validation was confirmed.
• A 100% audit of all resident diet orders and Kardex entries was completed by the DON, MDS nurse, and Regional Nurse.
• The ADON completed a 100% audit of all physician diet orders in Point-Click-Care against tray tickets to ensure accuracy.
• Ongoing monitoring was implemented, including nursing audits of 10 trays per week for four weeks, followed by 10 trays monthly for three months.
• The Administrator audited snacks three times per week for four weeks, then decreased frequency over the following two months.
• All new hires will receive training on therapeutic diets, Kardex review, and snack verification during orientation prior to assuming care responsibilities.
• The QAPI Committee held an ad hoc meeting to review corrective actions, with a monthly follow-up scheduled for three months.
• The Medical Director was notified of all corrective measures and ongoing monitoring efforts and agreed with the plan.

Penalty

No penalty information released

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 complete all required pre-employment checks for two of eight sampled new employees, specifically a Dietary Aide and an Activities Assistant. According to the facility's abuse prevention policy, all potential employees are to be screened for a history of abuse, neglect, or mistreatment, including checks of multi-state registries and license verifications. However, review of the personnel files revealed that the Kentucky Nurse Aide Abuse Registry check was not completed for either the Dietary Aide or the Activities Assistant prior to their employment. During an interview, the Administrator confirmed that while license verifications were performed for clinical staff such as CNAs and nurses, the registry check was not conducted for non-clinical staff, as they did not possess licenses to verify. The absence of a dedicated Human Resources staff member at the time contributed to this oversight.

Penalty

No penalty information released

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

A resident with Alzheimer's disease and severe cognitive impairment was subjected to verbal abuse by a staff member during a transfer to bed. The incident occurred when the resident became combative, causing a walker to be pushed over and nearly resulting in a staff member falling. During the transfer, the resident's knee was caught under the bedrail, and after being alerted by another staff member, the staff member in question moved the rail and made a disparaging remark to the resident, stating, "That's what your bratty [curse word] gets." The same staff member also made a sarcastic comment, "See, you lived," after the resident complained of leg pain. These comments were made in a sarcastic and giggling manner, as observed by another staff member present during the incident. The facility's policy strictly prohibits all forms of abuse, including verbal abuse, and defines it as the use of language that includes disparaging or derogatory terms directed at residents. Interviews and witness statements confirmed that the staff member's remarks were inappropriate and met the facility's definition of verbal abuse. The resident, due to severe cognitive impairment, was unable to recall the specifics of the incident but did remember that something mean was said. The incident was reported by a witness to the charge nurse, and the facility's investigation substantiated the occurrence of verbal abuse based on their policy.

Penalty

No penalty information released

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 a sanitary and safe physical environment to prevent the presence of pests within resident care areas. Observations during environmental rounds revealed insect carcasses, identified as cockroaches, in a resident room, the dining area, and the common area. Additional evidence of pest residue was found in multiple resident rooms. Interviews with staff confirmed ongoing pest activity, with one CNA reporting daily sightings of roaches in specific rooms over the previous month and noting that residents were aware of the infestation. Another staff member acknowledged pest presence in common areas, though not directly in resident rooms. Record review showed that the facility had a pest control policy in place, with a local contractor providing monthly and as-needed treatments. However, the most recent documented treatment was on 09/19/2025, and pest activity persisted despite these interventions. The Maintenance Director confirmed the existence of a pest control contract but was unaware of pest issues in resident or common areas. The DON acknowledged awareness of pest infestations but stated she was not directly involved in pest control. The Administrator also confirmed the pest control contract and recognized the potential for pests to transmit diseases to residents.

Penalty

No penalty information released

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

A resident with a tracheostomy, impaired cognition, and multiple medical diagnoses was observed receiving tracheostomy care that did not adhere to professional standards, the resident's care plan, or facility policy. During the procedure, an LPN failed to maintain sterile technique by using her designated 'dirty' hand to adjust the resident's oxygen and then used the same hand to open a bottle of normal saline, contaminating the sterile field. The LPN then poured the saline into the tracheostomy care kit without recognizing the breach in sterility. Additionally, the LPN did not oxygenate or hyper-oxygenate the resident between suction passes, as required by evidence-based procedures, and performed three consecutive suction passes without providing rest periods or assessing the resident's respiratory tolerance. The LPN acknowledged during an interview that she broke sterile field and did not follow proper oxygenation procedures, attributing her actions to nervousness and lack of experience, having only started three weeks prior. The facility's policy and infection control procedures were not followed during the tracheostomy care, and the LPN did not set up a clean working area or barrier for the sterile procedure. Interviews with other nursing staff confirmed knowledge of the correct procedures and the importance of restarting the process if sterility is compromised.

Penalty

No penalty information released

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

A deficiency occurred when a resident with severe cognitive impairment and a history of psychiatric diagnoses, including bipolar disorder, paranoid schizophrenia, depression, and anxiety, was able to elope from the facility. The resident was assessed as having a severely impaired mental status and was care planned for behaviors such as wandering and attempting to leave the facility without a responsible escort. Despite these known risks, the facility's supervision and environmental safeguards were insufficient to prevent the resident from leaving the premises. On the day of the incident, the resident entered a vending machine room and subsequently exited the facility grounds through a courtyard gate. The gate was supposed to be secured, but the resident was able to manipulate the lock or exploit a gap in the fence, which was in poor condition at the time. Staff did not immediately notice the resident's absence; it was only after a period of time that a CNA discovered the resident was missing, prompting a search. The resident was eventually found outside a nearby store and returned to the facility without injury. Documentation revealed that prior to the incident, facility checks of entrances and exits, including the courtyard gate, were incomplete and not performed on weekends. The lock on the courtyard gate was found to be faulty, intermittently failing to latch, and the fence was described as being in very poor condition. Staff interviews confirmed that the resident was able to leave due to these environmental hazards and lapses in supervision, despite being identified as an elopement risk and having interventions in place on the care plan.