Eastway Health & Rehabilitation

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to fully develop and implement the comprehensive person-centered care plan for one of 49 sampled residents, Resident (R)17. Resident 17 had a history of falls and was care planned for staff to place the Resident in a common area when she became restless. The care plan, however, was not fully developed with interventions to include supervision and monitoring while in the common area. While staff were in the nurses' station, the Resident was left unattended and fell in the common area, fracturing her hip. This caused actual harm to the Resident.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure each resident received adequate supervision to prevent injury for 1 out of 29 sampled residents, Resident (R)17. Resident 17 had a history of falls and was care planned to place the resident in a common area when she became restless. Staff implemented the resident's care plan by placing the resident in the common area; however, failed to ensure the resident was supervised while in the area. While staff were in the nurses' station, the Resident fell while in the common area unsupervised and sustained a fractured hip, which caused actual harm to the resident.

Inspectors wroteBased on observation, interview, record review, and review of facility policies, the facility failed to provide a safe, clean, comfortable and homelike environment. This had the potential to affect all residents residing in the facility.

Inspectors wroteAMENDEDBased on observation, interview, record review, and review of facility policies, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional needs, taking into consideration the preferences of each resident. Resident (R)44 had a known allergy to watermelon; however, staff continued to serve the Resident watermelon during her meal service. Additionally, R150's dietary order documented the resident should have no pork; however, this was not documented on the Resident's meal ticket and interview with R150 revealed staff continued to serve her pork which made her feel terrible. Further, the facility failed to ensure the Residents with allergies or specialized diets were care planned with appropriate interventions to address their needs. [...]

Inspectors wroteAMENDEDBased on observation, interview, and review of the facility's policy, the facility failed to ensure menus were prepared to meet the nutritional needs of residents in accordance with established national guidelines for 8 of 15 sampled residents of the total sample of 49 residents, (Resident (R)67, R88, R118, R115, R43, R70, R143, and R170). Interviews with the residents revealed they were often hungry and anxious as they were served small portions of food. Additionally, facility staff stated they did not have enough snacks to give to all the residents.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure each resident was provided a nourishing snack at bedtime. This had the potential to affect all residents receiving snacks from the facility's kitchen.

Inspectors wroteBased on observation, interview, and review of the facility's policies, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety which had the potential to affect all residents consuming meals from the kitchen.

Inspectors wroteBased on interview, policy review and record review, the facility failed to provide a bed hold notification for 2 out of 5 sampled residents (Resident (R)46 and R18) when an emergent transfer to the hospital was necessary.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure all drugs and medical supplies were stored in accordance with professional standards including expired medications and products. This affected 1 of 3 treatment carts.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies and procedures, the facility failed to implement appropriate transmission-based precautions for 3 of 49 sampled residents, Resident (R)183, R184, and R70. This failure had the potential to result in the transmission of a communicable disease to other residents, staff, and visitors.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined the facility to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observation revealed multiple food items in the pantry, refrigerator and freezer that were opened but not dated. Further observation revealed kitchen staff were not properly wearing hair restraints to prevent hair from contacting food.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Observations revealed staff entering resident rooms marked with precaution signage without donning (putting on) protective equipment. Additionally, observations of the facility laundry room revealed concerns including incorrect ventilation, lack of defined sorting areas, and no personal protective equipment available for staff use.

Inspectors wrote[NAME] Based on observation, interview, record review and review of the facility's policies it was determined the facility failed to ensure residents were free from abuse for seven (7) of one hundred-thirteen (113) sampled residents (Residents #161, #47, #74, #344, #345, #90 and 136). Resident #161 and Resident #47 related to resident to resident sexual abuse; Resident #74 related to verbal abuse; and, Resident #344, Resident #345, Resident #90 and Resident 136 related to resident to resident physical abuse. 1. On 03/19/2021, after the dinner meal, around 7:30 PM, Certified Nurse Aide (CNA) #36 left the unit to go on break. The CNA left Resident #161 in the dining room/dayroom unsupervised. CNA #35 was at the nurse's station and watched the camera monitor. However, the CNA left the nurse's station to assist another resident, and was gone from the monitor for about five (5) minutes. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review it was determined the facility failed to develop or implement their policy related to facility abuse and neglect for two (2) of one hundred-thirteen (113) sampled residents (Residents #47 and #161) . The facility failed to develop a policy related to assessment for capacity to consent to sexual contact for Resident #47 and Resident #161. On 03/19/2021, Resident #47 and Resident #161 had sexual contact with each other. The facility assessed the resident Brief Interview for Mental Status (BIMS) scores after the incident, and used the BIMS' score results as a determination of capacity to consent to the contact. However, the facility did not have a policy to reference how to determine resident capacity, or when BIMS scores were used as the sole assessment for resident capacity. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the care plan was revised to incorporate behaviors, increased supervision and monitoring for one (1) of one-hundred and nineteen (119) sampled residents, Resident #87. Review of Resident #87's Comprehensive Care Plan last reviewed on 09/01/2021 revealed the behavior care plan was last revised on 07/10/2019. With the exception of one intervention updated on 04/02/2021, to check on resident frequently and to meet resident needs in a timely manner.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure two (2) of one hundred thirteen (113) residents received medically related social services related to assessment for a resident's capacity to consent to sexual contact with others. On 03/19/2021, Resident #47 and Resident #161 engaged in sexual contact with each other. At the time of the incident, the facility did not have a full time Social Worker to ensure Resident #47 and Resident #161 were assessed to determine his/her capacity to consent. The facility utilized a contracted social worker approximately one (1) day per week. Additionally, the facility failed to inform the contracted social worker of the sexual contact that occurred between Resident #47 and Resident #161. [...]

Inspectors wroteBased on interview, record review, review of the facility's policy, and review of repeated deficient practice citations, it was determined the facility failed to have effective administration responsible for establishing and implementing policies regarding the management and operation of the facility. This was evidenced by the facility being cited on 12/06/2019 for F584, F600, F656, F657, F689, F761, and F880; on 11/08/2020 for F656, and F689; and current citations including F584, F600, F656, F657, F689, F761, and F880. Record review and interview revealed the facility failed to ensure residents were free from abuse and ensure resident behaviors were addressed; failed to ensure residents' care plans were developed, revised and implemented; failed to ensure the facility was safe, comfortable, and supervised for residents, and medications were labeled and stored accordingly. [...]

Inspectors wrote2. Review of the facility's policy, Resident Rights, undated, revealed residents had the right to be free from verbal, sexual, physical or mental abuse. In addition, the facility implemented procedures to protect residents from abuse, neglect or mistreatment. In the event of an alleged violation, the facility is required to report to the appropriate officials and promptly and thoroughly investigated. Through interview, State Survey Agency (SSA) revealed Certified Nurse Assistant (CNA) #18 was sent home on [DATE] due to sleeping and related behaviors in front of residents. However, the facility had no report or documentation related to incident. Record review of time punches on 04/23/2021 revealed CNA #18 clocked in at 7:15 PM and clocked out 9:00 PM. [...]

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide adequate supervision for one (1) out of one-hundred and nineteen (119) residents sampled, Resident #87. Observation on 09/29/2021 at 4:00 PM, revealed Resident #87 wandering the Seventh (7th) Floor without supervision. Resident #87 was entered room [ROOM NUMBER], walked about ten (10) steps in, turned around and walked out. Resident #87 walked into room [ROOM NUMBER], went to the empty bed near the window, got in bed, under the covers and then got back up. Resident #87 went across the hall and entered the shower room and remained in there for three (3) minutes. Resident #87 came out of the shower room and went back to room [ROOM NUMBER] and got back in the same empty bed, under the covers and laid his/her head on the pillow as if to go to sleep. [...]

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to provide pain management for one (1) of one hundred thirteen (113) sampled residents (Resident #146). Interview with Resident #146 revealed he/she experienced pain and notified staff. Resident #146 stated the pain was so bad he/she cried himself/herself to sleep. However, staff did not administer the resident's ordered pain medication.

Inspectors wroteBased on observation, interview, record review and review of the facility's policy it was determined the facility failed to ensure dietary staff were knowledgeable of procedures related to functions of the food nutrition service. Interviews revealed dietary staff were unaware of the procedures to clean carts; and how to clean and sanitize dishware and meal carts.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure food was stored and prepared in a sanitary manner. Observations during the survey revealed meat thawing over eggs, soiled preparation surfaces and walls and food items in the refrigerator not labeled or dated. Additionally, canned goods were stored directly on the floor, expired food items were present, and improper dishwasher temperatures. Further observations revealed the facility failed to ensure kitchen equipment was clean; staff transported drinks not covered; food carts remained open during tray delivery; and, improper or no hand hygiene during tray delivery. Additionally, the facility failed to ensure the nourishment refrigerator temperatures were monitored and clean for two (2) nourishment refrigerators.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective governing body that was responsible for establishing and implementing policies regarding the management and operation of the facility. This was evidenced by the facility's failure to maintain substantial compliance, since the 12/06/2019 recertification survey, in the areas of 42 CFR 482.10 Resident Rights (F584); 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F600); 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656 and F657); 42 CFR 483.25 Quality of Care (F689); 42 CFR 483.45 Pharmacy Services (F761); and, 42 CFR 483.80 Infection Control (F880). [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective system to address systerm failures through regular scheduled Quality Assurance Performance Improvement (QAPI) meetings. The facility failed to identify quality of care deficiencies, and failed to take actions aimed at performance improvement to ensure improvements were realized and sustained. This is evidenced by repeated deficient practice cited at 42 CFR 482.10 Resident Rights (F584); 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F600); 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656 and F657); 42 CFR 483.25 Quality of Care (F689); 42 CFR 483.45 Pharmacy Services (F761); and 42 CFR 483.80 Infection Control (F880). These deficiences were cited during the 12/06/2019 recertification survey. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure resident rights were promoted and protected for two (2) of one-hundred and thirteen (113) sampled residents (Residents #26 and #147). Residents #26 and #147 provided the facility with their food preferences. However, the facility did not promote the recognition of individuality of residents with preferred foods, food items requested, or menu preferences.

Inspectors wroteBased on interview, review of grievance forms and logs, review of Resident Council minutes, and review of the facility's policy it was determined the facility failed to ensure the resident council concerns were addressed and followed-up. The resident council concerns were not addressed and followed up for eight (8) of eight (8) sampled residents attending the Resident Council, out of a total resident sample of one hundred thirteen (113) residents (Residents #11, #15, #23, #73, #90, #96, #143, and #152). Residents voiced concerns related to missing laundry, housekeeping, nursing, food quality and temperature. However, the facility did not follow up with the Resident Council regarding the outcome of their concerns.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure confidentiality of resident records for one (1) of six (6) floors for Residents #57, #89, #92, and #96. The sixth (6th) floor chapel contained a clear trash bag of residents' face sheets, and empty blister packs with residents' names and medications visible.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy it was determined the facility failed to ensure a safe, clean, comfortable, and homelike environment for seven (7) of twelve (12) shower rooms; four (4) of six (6) ice machines; broken outlet, soiled privacy curtains, and peeling/missing wallpaper. In addition, Resident #102's wall and bathroom door were heavily soiled with a black, brown, and red substance; and, there was debris scattered on the floor.

Inspectors wroteBased on observation, interviews, and facility policy review, it was determined the facility failed to ensure discontinued controlled substances were disposed of in a timely manner. Observation, on 05/14/2021 at 9:51 AM, revealed one thousand four hundred and forty-nine and one-half (1449.5) controlled medication pills stored in the Director of Nursing's office. In addition, there were controlled liquid medications stored in the same location.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to ensure medications and biologicals were labeled and stored for four (4) of six (6) medication carts and three (3) of three (3) medication rooms. Observation revealed medication carts and treatment carts were unlocked, unattended and out of staff 's view. Observation revealed food items in the medication carts. Staff left medication unsecured at the fourth (4th) floor nurse's station. Additionally, three (3) of three (3) sampled emergency crash carts were not documented as checked for all needed supplies or had expired supplies. The medication refrigerator temperatures were not documented as checked, and glucometer controls were not documented as completed.

Inspectors wroteBased on interview, record review, and review of the facility's policies, it was determined the facility failed to prepare meals with preferred foods, requested food items and menu preferences to meet residents' choices for three (3) of one-hundred and thirteen (113) sampled residents (Residents #18, #26, and #147). Residents #18, #26 and #147 provided the facility with food preferences; however, the facility did not provide the food requested, menu preferences, or the preferred foods.

Inspectors wroteBased on observation, interview, and review of the facility's policy it was determined the facility failed to implement an effective infection control program related to transmission-based precautions (TBP). Staff stored food in two (2) of four (4) medications carts on the 2nd and 4th floors; entered a TBP room on the 3rd floor without appropriate personal protective equipment (PPE); and, failed to remove PPE prior to exiting a TBP room on the 2nd floor. In addition, staff failed to redirect a resident with prescribed Transmission Based Precautions (TBP) from leaving the room or the Yellow Zone nursing unit located on the 2nd floor (Resident #341).

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy it was determined the facility failed to ensure dignity during dining for residents on two (2) of six (6) floors (2nd and 5th floors). The facility provided disposable cutlery and dishware for residents dining on the second and fifth floors.

Inspectors wroteBased on interview, record review and facility policy review, it was determined the facility failed to notify the resident's responsible parties of a change in condition for one (1) of twenty-eight (28) sampled residents (Resident #87). On 07/31/2021 at 6:16 PM, Licensed Practical Nurse (LPN) #2, heard a resident call out that Resident #87 was lying on the floor. The LPN found Resident #87 lying on the floor; with no injury noted. Resident #87 had a Resident Representative (RR) listed (his/her sister); however, LPN #2 documented attempts to notify the resident's son, and failed to notify his/her RR of the resident's fall. On 09/25/2021, Resident #87 sustained a laceration to his/her forehead, which staff determined was an injury of unknown origin. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review it was determined the facility failed to ensure allegations of abuse/neglect were thoroughly investigated for one (1) of one hundred thirteen (113) sampled residents (Residen #146).

Inspectors wroteBased on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure accuracy of resident assessments for one (1) of one hundred-thirteen (113) sampled residents (Resident #109). The facility assessed Resident #109 as moderately vision impaired with corrective lenses.

Inspectors wroteBased on observation, interview, record review, and facility policy review it was determined the facility failed to ensure resident care plans were implemented for seven (7) of one hundred thirteen (113) sampled residents (Residents #75, #123, #130, #146, #179, #344 and #345). 1. The facility failed to implement the transfer care plan for Resident #123 during a maxi-lift transfer. The facility assessed the resident for extensive assist with two plus (2+) persons with physical assistance, however one (1) staff member completed the Maxi-lift transfer. The resident was later found with a leg fracture. 2. The facility failed to implement the care plan to manage pain for Resident #146. The resident reported pain, however facility staff did not address the resident's pain as noted in the care plan. 3. The facility failed to implement care plan interventions related to falls for Resident #130. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy it was determined the facility failed to identify resident needs and provide related services for one (1) of 113 sampled residents (Resident #15). The facility failed to identify Resident #15's pacemaker and ensure it was monitored for function.

Inspectors wroteBased on observation, interview, record review, and review of the Kentucky Board of Nursing (KBN kbn.ky.gov) website it was determined the facility failed to ensure competent staff for one (1) of one (1) Registered Nurse Applicant (RNA). The facility assigned an RNA to train with a Licensed Practical Nurse (LPN). However, the KBN required an RNA be supervised by a Registered Nurse (RN) or Advanced Registered Nurse Practitioner (ARNP).

Inspectors wroteBased on observation, interview, record review, and facility policy review it was determined the facility failed to ensure a medication error rate less than 5%. Observations of medication administration on 05/09/2021 revealed the Certified Medication Technician (CMT) made two (2) medication errors out of thirty-six (36) opportunities for a medication administration error rate of 5.56%. The facility failed to administer one (1) dose of Senna laxative for Resident #102. In addition, Resident #4's Depakote was administered greater than sixty (60) minutes after the scheduled time.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy it was determined the facility failed to ensure routine dental services were provided for one (1) of one hundred thirteen (113) sampled residents (Resident #15). Resident #15 did not receive dental services when requested.