Barbourville Health and Rehabilitation Center

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure food items were discarded when required, milk received from a vendor had a legible expiration date, food items in the walk-in freezer and dry storage room were stored appropriately, and the room temperature of the dry storage room did not exceed 70 degrees Fahrenheit (F). These deficient practices had the potential to affect all 114 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to honor a resident's right to have a personal fan in their room for 1 (Resident 3) of 2 sampled residents reviewed for personal property.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide nail care for 1 (Resident #122) of 4 sampled residents reviewed for activities of daily living (ADL) care.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's bi-level positive airway pressure (BiPAP) mask was stored when not in use for 1 (Resident #15) of 2 sampled residents reviewed for respiratory care.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the medication rate was 5 percent (%) or less. The facility had 2 medication errors out of 29 opportunities, which yielded a medication error rate of 6.90 % for 2 (Resident #10 and Resident #45) of 7 residents observed for medication administration.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to have an effective system to ensure care plans were revised to provide necessary interventions for supervision and monitoring for residents to prevent falls/accidents for 8 of 10 sampled residents, (Resident (R)10, R15, R27, R51, R75, R93, R111, and R274). The facility failed to thoroughly investigate and evaluate residents' falls by performing root cause analysis (RCA) to determine the root cause of the numerous residents' falls in order to review/revise the residents' care plans to prevent additional falls and injuries for residents. In addition, the facility failed to ensure residents' comprehensive care plans (CCP) were reviewed/revised for each of the residents' falls, and failed to ensure the date was noted when care plan interventions were initiated.

Inspectors wroteBased on observation, interview, record review and review of the facility's policies, the facility failed to have an effective system to ensure adequate supervision and monitoring to prevent falls/accidents for eight (8) of ten (10) sampled residents reviewed for falls/accidents, Resident (R)10, R15, R27, R51, R75, R93, R111, and R274. The facility had a total of 346 falls during the six (6) month time period from 02/28/2024 to 08/28/2024, and an additional 26 falls from 08/29/2024 to 09/25/2024. However, the facility failed to thoroughly investigate and evaluate the falls to determine the root cause of each fall; and, failed to develop individualized care plan interventions to prevent further falls/injuries for each resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for the management of falls for five of ten sampled residents, (Residents (R)10, R15, R93, R111, and R274). Review of the facility's document titled, Incidents by Incident Type, dated 02/28/2024 through 08/28/2024 revealed the facility noted 44 witnessed falls and 302 unwitnessed falls for a total of 346 fall during that six month time period. Further review revealed 42 of the 346 falls had an injury noted. [...]

Inspectors wroteBased on observation, interview, record review, review of the facility's fall report documentation and Quality Assurance Performance Improvement (QAPI) Policy, the facility failed to maintain an effective, comprehensive, data driven QAPI program which focused on criteria for outcomes and quality of life related to falls for 8 of 10 sampled residents, (Residents (R)10, R15, R27, R57, R75, R93, R111, and R274. Review of the facility's Incidents by Incident Type, documentation dated 02/28/2024 through 08/28/2024, revealed the facility had a total of 346 resident falls during that six-month timeframe. Review of the facility's QAPI documentation however, revealed no documented evidence the facility brought the issue of multiple residents' falls to the QAPI Committee prior to August 2024. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to protect and promote the rights of 1 of 63 sampled residents (Resident (R) 95). R95 refused an injection on 08/25/2024; however, nurses administered the injection after the resident's refusal.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to immediately consult with the resident's Physician and notify the resident's representative(s) when there was an accident or need to alter treatment for 3 of 63 sampled residents, (Resident (R)15, R95 and R274). 1. R15 sustained a fall on 04/29/2024; however, the facility failed to notify the resident's State Guardian and Physician until 04/30/2024. On 04/30/2024, the facility transferred R15 to the Emergency Department (ED) for evaluation. R15 was diagnosed with a spiral humeral fracture (a type of bone break occurring from a twisting motion in the upper arm) which was comminuted (when a bone breaks into multiple pieces) and displaced. 2. R274 sustained an injury on 07/06/2022; however, the facility failed to notify the resident's Responsible Party and Physician until 07/08/2022. [...]

Inspectors wroteSurveyor [NAME] Based on interview, record review, and review of the facility's policy, it was determined the facility failed to report an injury of unknown origin immediately, but not later than two hours after the allegation was made to the facility's Administrator and other officials, including the State Survey Agency and Adult Protective Services (APS) for 1 of 63 sampled residents, (Resident (R) 274).

Inspectors wroteSurveyor: [NAME] Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a thorough investigation was completed for an injury of unknown origin for 1 of 63 sampled residents (Resident (R) 274). The facility admitted R274 with contractures of both upper and lower extremities. On 07/06/2022, two Certified Nursing Assistants were bathing R274, when one CNA lifted the resident's left arm and heard two pops. On 07/08/2022, an injury of unknown source was identified; however, the facility's investigation was not initiated until the day after the injury was discovered. In addition, the facility failed to interview all the staff present when the incident occurred. The facility transferred R274 to the hospital emergency department (ED). [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure the Comprehensive Care Plan was implemented for four (4) of thirty-one (31) sampled residents (Residents #59, #70, #85, and Resident #105). The facility assessed and care planned Resident #105 and Resident #70 to require the assistance of two or more staff members with bed mobility. However, on 05/26/19, at approximately 1:30 PM, SRNA #3 attempted to reposition Resident #105 in bed without another staff member present. As a result, the resident sustained a fall from the bed and fractures to the left ankle. The facility had also assessed Resident #70 to require two staff members for turning and repositioning; however, on 06/27/19, Registered Nurse (RN) #1 was observed to turn and reposition the resident without another staff member present. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure one (1) of thirty-one (31) sampled residents received quality care based on the comprehensive assessment of the resident and the resident's comprehensive person-centered care plan. On 05/28/19, staff assessed Resident #105's left foot to be red, swollen, and hot to touch. Although staff notified the resident's physician on 05/28/19 and an order for a Doppler ultrasound of the left foot and the initiation of an antibiotic was obtained, staff failed to follow up on the ordered ultrasound results and failed to monitor the resident's left foot/ankle. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to provide supervision to prevent accidents for two (2) of thirty-one (31) sampled residents (Resident #70 and Resident #105). On 05/26/19, State Registered Nurse Aide (SRNA) #3 was repositioning Resident #105 in bed without assistance from another staff member, which the facility had assessed the resident to require. Subsequently, on 05/31/19, five days later, Resident #105 was diagnosed with a fractured left ankle. In addition, observation on 06/27/19 revealed Registered Nurse (RN) #1 turned and repositioned Resident #70 in bed without assistance from another staff member, which the resident was assessed to require.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to ensure one (1) of thirty-one (31) sampled residents received care and services to maintain appropriate grooming. The facility assessed Resident #59 to require extensive assistance of staff for personal care and grooming. However, observations on 06/25/19 through 06/27/19, revealed the resident's fingernails were long and in need of trimming with a brown substance caked under each of the nails on both hands.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure tracheostomy care was provided for one (1) of thirty-one (31) residents in accordance with the facility policy and professional standards. Observation on 06/26/19 revealed endotracheal supplies required for suctioning Resident #105 were not available at the resident's bedside.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to ensure drugs and biologicals used in the facility were stored in a locked compartment and available only to authorized personnel. Observation on 06/27/19, revealed a bottle of eye drops was left unsecured in a resident's room.