Frankfort Community Care Home

Inspectors wroteThe facility identified a census of 27 residents, with one resident reviewed for elopement (when a resident leaves the premises or a specific safe area without authorization and/or necessary supervision). Based on record review, observation, and interview, the facility failed to provide adequate supervision to prevent an elopement for cognitively impaired Resident (R) 7, whom the facility identified the resident as at high risk for wandering. On 08/26/25 at approximately 07:41 PM, R7 exited the South delayed-egress door in her wheelchair, which alarmed, and no staff responded to the sounding alarm. R7 exited the facility unsupervised, mobilized to the driveway, and continued to independently propel herself in a wheelchair across the concrete driveway into the city street, traversing approximately 200 feet. [...]

Inspectors wroteThe facility had a census of 27 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 27 residents who reside in the facility and received meals from the facility kitchen.

Inspectors wroteThe facility had a census of 27 residents. Based on observation, record review, and interview, the facility kitchen staff failed to take the food temperatures before serving the noon meal.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food safety, and failed to consistently document sink and bucket PPM (parts per million) sanitation on the facility's PPM log (a record keeping document used in food service to monitor the concentration of sanitizing solutions in sinks and other equipment to ensure food safety).

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure their Medical Director attended the Quality Assessment and Assurance (QAA) Committee quarterly meetings.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to provide enhanced barrier precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R) 2.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents, with three residents reviewed for the Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on the record review and interview, the facility failed to provide the CMS Form 10123, Advanced Beneficiary Notice (ABN), to the resident or their representative for Residents (R) 4.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents, with three reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO- a public official who works to resolve resident issues in nursing facilities) for two residents. Resident (R) 4 and R5 and failed to provide R5 with written information regarding the facility's bed hold policy when they were transferred to the hospital.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for two residents, Resident (R) 14 for lymphedema (swelling caused by accumulation of lymph) and R6 for his diagnosis of posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress).

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents, with one reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to provide necessary respiratory care and services for Resident (R) 14, when staff stored the uncovered nebulizer (turns liquid medication into a mist so that you can inhale it into your lungs) mask on top of the nebulizer machine, and failed to ensure R14's nasal cannula (NC - a thin hollow tube that assists in providing supplemental O2) was appropriately stored when not used.

Inspectors wroteThe facility identified a census of 27 residents. The sample included 12 residents, with three residents reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R) 6 posttraumatic stress disorder (PTSD - a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization, and major depressive disorder (MDD- major mood disorder that causes persistent feelings of sadness).

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold blood pressure medication per the physician-ordered parameters for Resident (R) 4.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 27's insulin (a hormone that lowers the level of glucose in the blood) flex pens when initially opened for use and when expired.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents, with one reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure coordinated care and services provided by the facility with the care and services provided by hospice for Resident (R) 1.

Inspectors wroteThe facility identified a census of 37 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to protect Resident (R) 1 from intimidation and abuse. This placed R1 at risk for impaired psychosocial well-being and ongoing abuse.

Inspectors wroteThe facility identified a census of 33 residents with three residents reviewed for elopement. Based on record review, observation, and interview, the facility failed to provide adequate supervision to prevent cognitively impaired Resident (R) 1, identified at high risk for elopement, from eloping through a facility window. On 03/30/24 at 03:00 PM, R1 sat at the end of the North hall and looked out the window. R1's home was visible from the North hall window. At 03:05 PM, R1's neighbor in the community noticed R1 walking towards the resident's home. A little while later, the neighbor noticed R1 sitting on his porch at his home and at 03:40 PM, the neighbor called the facility and alerted Administrative Nurse D to R1's location. [...]

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 29 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for impaired nutrition.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to meet the nutritional needs of residents in accordance with established national guidelines, placing the residents at risk for unmet nutritional needs.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to check sanitization for the dishwasher, and the three-compartment sink in the facility's only kitchen. This placed the residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to provide Resident (R) 16 with dignity and respect during care, placing the resident at risk for an undignified experience.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents. Based on record review and interview the facility failed to ensure staff identified concerning behaviors as potential allegations of abuse and/or mistreatment and failed to report to the facility administrator as required. This placed the resident at risk for unidentified and ongoing abuse and/or mistreatment.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to develop a comprehensive care plan to include Resident (R)9's diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). This deficient practice placed the resident at risk for inappropriate care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to update Resident (R)23's Care Plan with interventions for staff to follow regarding care of her fractured wrist. The facility failed to update R26's Care Plan with interventions for staff to follow regarding her post-traumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). These failures placed the residents at risk for inadequate care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents, of which two were reviewed for behaviors. Based on observation, record review, and interview, the facility failed to complete a trauma-informed care assessment for Resident (R)26, to identify any history of trauma This placed the resident at risk for unmet behavioral and mental health needs.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents, of which two were reviewed for behaviors. Based on observation, record review, and interview, the facility failed to provide adequate medical social services to meet Resident (R) 26's mental and behavioral health needs. This placed the resident at risk for decreased quality of care and life.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure an appropriate indication for use, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R)12 and R20. This placed the resident at risk for unnecessary psychotropic (alters mood or thought) medications.

Inspectors wroteThe facility had a census of 29 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance when dietary staff failed to follow a recipe while preparing two residents' pureed diets. This placed the residents at risk for impaired nutrition.

Inspectors wrote- R13's Electronic Medical Record (EMR) documented R13 had diagnoses of UTI., urinary incontinence and urine retention (when the bladder does not empty all the way or at all). R13's Significant Change Minimum Data Set (MDS), dated [DATE], documented R13 required total staff assistance with activities of daily living (ADLs) except supervision with eating. The MDS documented R13 had an indwelling urinary catheter. R13's Incontinence and Indwelling Catheter Care Area Assessment CAA, dated 05/27/22, documented R13 had urinary retention and urinary catheter. R13's ADLs Care Plan, revised 6/01/21, documented R13 required staff assistance for toileting and she had a urinary catheter. The care plan instructed staff to position the catheter bag and tubing below the level of R13's bladder and away from the entrance room door. [...]

Inspectors wroteThe facility had a census of 26 residents. The sample included 12 residents with one reviewed for completion of a Quarterly Minimum Data Set (MDS-an assessment which contains resident specific information for payment and quality measure purposes). The facility failed to complete the Quarterly MDS for Resident (R) 2. This placed the resident at risk for unidentified needs.

Inspectors wroteThe facility had a census of 26 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to assess one of 12 sampled residents' cognition, Resident (R)16 on the Minimum Data Set (MDS). This placed the resident at risk for an inaccurate care plan and unmet care needs.

Inspectors wroteThe facility had a census of 26 residents. The sample included 12 residents with one reviewed for urinary catheter. Based on observation, record review, and interview the facility failed to provide appropriate treatment and services to prevent urinary tract infections, when staff failed to change gloves while providing Resident (R) 13, who had history of urinary tract infections (UTIs-infection of any part of the urinary system) and a urinary catheter (tube inserted into the bladder to drain urine into a collection bag), perineal and catheter care. Staff continued to provide care with soiled gloves. The facility staff failed to ensure R13's urinary catheter bag remained off contaminated surfaces. This placed R13 at increased risk for recurring UTI and related complications.

Inspectors wroteThe facility had a census of 26 residents. The sample included 12 residents of which five were reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R) 20's blood glucose readings greater than 250 milligram (mg)/deciliter(dl), and the lack of administration of physician ordered insulin (medication used to lower blood sugars) for these blood sugars. This placed the resident at risk for hyperglycemic (increased blood sugar levels) side effects.

Inspectors wroteThe facility had a census of 26 residents. The sample included 12 residents of which five were reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure staff administered physician ordered Humalog (fast acting insulin medication) insulin (medication used to lower blood glucose) for Resident (R) 20's blood glucose readings greater than 250 milligram (mg)/deciliter(dl). This placed the resident at risk for hyperglycemic (increased blood sugar levels) side effects.