Daviess County Nursing and Rehabilitation

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate supervision to prevent elopement for one resident, Resident #44, failed to provide adequate supervision to prevent falls for Resident #10, and failed to provide safe transfers for Resident #10 and Resident #31. This affected three of 14 sampled residents. The facility census was 55. Review of the facility's Wandering and Elopement Policy dated 03/2019 showed:-Facility will identify residents who are at risk of unsafe wandering and strive to prevent harm;-Residents identified as high risk for elopement, the resident's care plan will have strategies and interventions to maintain resident safety;-Any time a resident elopes, the attending physician and legal representative are notified. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of quality when staff failed to obtain a physician's order, obtain authorization from the resident's representative, complete and assessment for use of chair alarm for three residents (Resident #32, #17, and #24). The facility census was 58. Review of facility policy, physical restraints, dated April 2006, showed: -Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. -Assess resident's need for restraint use. -Obtain physician's order for restraint. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an on-going program of activities that was designed to meet the interests and physical, mental, and psychosocial well-being of each resident. This affected five residents (#48, #4, #17, #11 and #23) out of 15 sampled residents and could potentially affect all residents. The facility census was 58. Review of the facility policy, Preparation for Activities, dated 6/2018, showed the Activity Director was responsible for the scheduling of all activity functions; The facility did not provide activity participation records for requested residents. 1. Review of Resident #48's admission MDS, dated [DATE], showed: -Severely impaired cognition; -It was very important to have books, magazines, and newspapers to read; -It was somewhat important to listen to music he/she likes; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to employ a qualified activity professional to oversee the activity program of the facility. The facility employs a part time activity director, but he/she had not completed an approved activity professional training program. The facility census was 58. The facility did not provide a policy regarding activities professional training and requirements. Review of facility's job description for the Activities Director showed: Responsibilities Included: -Plans, organizes, and implements programs to meet the social, intellectual, emotional, educational, and physical needs of residents in a long-term care facility; -Creates and facilitates activities that promote socialization, intellectual stimulation, and physical activity; -Maintains accurate records of resident participation and program evaluations; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff cleaned and changed two continuous positive airway pressure (CPAP) equipment per professional standards for two residents (Resident #14 and #11) of 15 sampled residents. The facility census was 58. Review of the facility provided, undated, policy: Cleaning and Disinfection of Resident Care Items and Equipment showed: -Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Center for Disease Control) recommendations for disinfection and OSHA (Occupational Safety and Health Administration)Bloodborne pathogen standards. -Reusable resident care equipment will be decontaminated and/or sterilized according to manufacturers guidelines. Review of the Resmed manufacturer CPAP cleaning guide dated 2022 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to cover and date refrigerated/frozen food and drink items, failed to ensure the freezer was in good repair, failed to ensure kitchen walls and ceiling were in good repair and failed to wear hair nets appropriately. The facility census was 58. 1. The facility did not provide a policy regarding the labeling and dating of refrigerated/frozen food. Observation on 4/22/25 at 9:54 A.M., showed: -Four dessert bowls of applesauce in the refrigerator were uncovered and undated; -No opened date on two 46 oz. Hormel Thick and Easy liquid; -No opened date on a 3-gallon container of [NAME] moose tracks ice cream; -No opened date on a 3-gallon container of Blue Bunny cotton candy ice cream; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain resident wheelchairs in a safe operating condition, when resident wheelchairs had ripped and peeling arm rests. This affected four of fifteen sampled residents (Resident #49, #11, #39, and #32). The facility census was 58. The facility did not provide a policy of maintenance of wheelchair equipment. 1. Review of Resident #49's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 4/22/25, showed: -Cognition severely impaired; -He/She was dependent on a wheelchair for mobility; -He/She was dependent on nursing staff for all cares and mobility; -Diagnoses included: Alzheimer's disease, depression, and malnutrition. Observation on 4/24/25 at 7:01 A.M. showed resident's wheelchair had foam sticking out of arm rest on both ends of right and left arms of the chair. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an acceptable accommodation of needs when staff did not provide a physician ordered leg extender on one resident's wheelchair (Resident #23) to keep his/her leg elevated. The facility census was 58. Review of facility's Resident Accommodation policy, revised January 2020, showed: -The facility's environment and staff behavior are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. -The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an on going basis. [...]

Inspectors wroteBased on observation, record review and interviews the facility failed to ensure the use of appropriate interventions for potential skin breakdown resulting in pain for one resident (Resident #4). This had the potential to effect all residents. The census was 58. Review of the facility provided policy Pressure Ulcer, Care and Prevention dated April 2006 showed: -To prevent and treat further breakdown of pressure sores; -The nurse is responsible for carring out the treatment as ordered and for implementing measures to prevent pressure ulcers. -Equipment: lotion, elbow/heel protector, pressure reducing mattress, prssure reducing chair pad, foot cradle, pillows; -Use pressure reducing devices to relieve pressure. 1. Review of Resident #4 Quarterly MDS dated [DATE] showed: -Brief Interview of Mental Status (BIMS) of 3; -Substantial assitance of staff for toileting, showering and dressing; [...]

Inspectors wroteBased on interviews and facility document review, the facility failed to employ a dietary manager (DM) with the appropriate qualifications to carry out the functions of the food and nutrition services in 1 of 1 kitchen, providing nutrition services to all residents in the facility. Review of a facility document titled Job Description, dated November 2007, for the position of Director of Food Service/Dietary Manager, in the section titled Qualifications/ Education and Training revealed, Candidate must possess a high school diploma or equivalent. Must have completed the Dietary Manager Course. Sanitation certification through the State or County Health Department required. Certification for Food Protection through the Dietary Manager Course preferred. Professional certification through the Dietary Managers Association is preferred. [...]

Inspectors wroteBased on observations, interviews, and facility document review, the facility failed to prepare food in accordance with professional standards for food service safety. Specifically, the stove vent hood was covered with buildup in 1 of 1 kitchen providing nutrition services to all residents in the facility. Observation made during the initial tour of the kitchen on 01/23/2024 at 9:04 AM revealed the vent hood over the stove was covered with a gray fuzzy substance. During an interview on 01/23/2024 at 9:20 AM, the Dietary Manager (DM) said that there was dust buildup on the vents over the stove. She said someone was supposed to come in and clean them, but she was not sure who and did not know the last time they were cleaned. During a follow-up interview on 01/26/2024 at 11:21 AM, the DM said she did not know who was responsible for cleaning the vent hood, but it needed cleaning. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to have assessments and consents for the use of bed rails for 2 (Resident #1 and Resident #5) of 2 sampled residents reviewed for the use of bed rails. A copy of the facility's policy for the use of bed rails was requested from the facility on 01/25/2024 at 1:24 PM and on 01/26/2024 at 11:36 AM, the Administrator confirmed that the facility did not have a policy for the use of bed rails. 1. A review of Resident #1's Resident Face Sheet indicated the facility admitted the resident on 07/22/2022 with diagnoses that included hemiplegia and hemiparesis (paralysis and weakness of one side of the body) following cerebrovascular disease (a group of medical conditions that affect the blood vessels and blood supply to the brain) affecting the left non-dominant side. [...]

Inspectors wroteBased on observations and interviews, the facility failed to conduct regular inspections of bed frames, mattresses, and bed rails to identify areas of possible entrapment for 2 (Resident #1 and Resident #5) of 2 sampled residents reviewed for the use of bed rails. A copy of the facility's bed rail policy was requested on 01/25/2024 at 1:24 PM. During an interview on 01/26/2024 at 11:36 AM, the Administrator confirmed they did not have a policy for bed rails. 1. A review of Resident #1's Resident Face Sheet indicated the facility admitted the resident on 07/22/2022 with diagnoses that included hemiplegia and hemiparesis (paralysis and weakness of one side of the body) following cerebrovascular disease (a group of medical conditions that affect the blood vessels and blood supply to the brain) affecting the left non-dominant side. [...]

Inspectors wroteBased on record review and interview, the facility failed to keep one resident (Resident #1) free from verbal abuse when Certified Nurse Aide (CNA) A was giving the resident a shower on 9/11/23, CNA A and was yelling and cussing at the resident. This affected one of five sampled residents. The facility census was 50. Review of the facility Abuse policy dated 7/18/23, showed: -Facility will not condone resident abuse by anyone, including staff members; -Facility will not permit its residents to be subjected to abuse by any person, including staff members; -Facility will thoroughly investigate all allegations of resident abuse, including neglect or misappropriation of resident property. Facility will also report all findings to the state abuse registry per regulatory guidelines. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure staff provided a written notice of transfer or discharge to residents and their representative, including the reason for the transfer, in writing and in a language they understood. This affected two of 12 sampled residents, (Resident #14 and #29). The facility census was 41. The facility did not provide a policy for transfers and discharges. 1. Review of Resident #14's quarterly minimum data set (MDS, a federally mandated assessment completed by facility staff), dated 2/5/22, showed: - Severely cognitively impaired; - He/she required limited assistance from staff with activities of daily living. - He/she required total assistance from staff with toileting and bathing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they developed and implemented a comprehensive person-centered plan of care which included measurable objectives and timeframe's to meet each resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for five of 12 sampled residents (Residents #9, #14, #23, #32, and # 38). The facility census was 41. Review of the facility policy Resident Participation -Assessment/Care Plans revised November 2019 shows in part: - Policy Statement: The resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. - The care planning process will: a. Facilitated the inclusion of the resident and /or representative; b. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff administered medications with a medication rate of less than five percent. Facility staff made 12 medication errors out of 29 opportunities for error resulting in a medication error rate of 41% which affected seven out of 12 sampled residents (Resident #1, #7, #9, #16, #26, #28, and #30). The facility census was 41. Review of the facility's undated administering medications policy, showed, in part: - Medications are administered in a safe and timely manner, and as prescribed; - Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication; b. Preventing potential medication or food interactions; and c. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to prepare and serve food in accordance with professional standards for food service safety, and failed to ensure they stored food properly. The facility census was 41. Review of the facility's policy, dated April 2011, Receiving and Storage of Food said: - The dining services manager is responsible for receiving and storing food and nonfood items. - All food and nonfood items received must be checked; invoice should be matched to Order Inventory Control Sheet to assure receipt of all items ordered. - All perishable items are stored in either refrigerators (at temperature of 40 degrees Fahrenheit or below) or freezers (at a temperature of 0 degrees Fahrenheit or below). - Follow the rule of First In, First Out (FIFO). - Food is stored in designated areas, away from chemicals/cleaning items. [...]

Inspectors wroteBased on interview and record review, the facility failed to clarify the status of two of 12 sampled residents (Residents #32 and #38) advanced directive and code status . The facility census was 41. The facility did not provide a policy on advanced directives. 1. Review of the Resident #32's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 1/6/22, showed staff conducted the brief interview for mental status (BIMS) with the resident and he/she received a score of 12, which indicated no cognitive impairment. Review of the resident's care plan for DNR code status, dated 10/4/21, showed staff included the following: - The resident has a DNR code status; - Goal: My advanced directive will be followed through my next review date. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assure staff provided proper respiratory care when staff failed to date oxygen tubing and nebulizer tubing for one of 12 sampled residents (Resident #9). The facility census was 41. Review of the facility's undated oxygen administration policy, showed: - The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Review of the resident's care plan, revised 11/8/21, showed: - The resident had chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing) and used oxygen; - The oxygen tubing is changed according to facility policy; - The care plan did not address the resident's use of nebulizer therapy. Review of the resident's physician order sheet (POS), dated February 2022, showed: - Change oxygen tubing weekly on Sunday. [...]