Jeffersontown Rehabilitation

Inspectors wroteBased on observation, interview and review of facility policy, the facility failed to ensure resident foods in nourishment refrigerators were stored in accordance with policy and accepted standards. Foods were not labeled with resident's name, name of food item, and date/time or use by date in three of three nourishment refrigerators located on the resident units.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to implement the comprehensive care plan for one (1) of twenty-two (22) sampled residents, (Residents #18). Resident #18 was care planned to be up in wheelchair (w/c) with supervision; however, the facility failed ensure the resident was supervised when in wheelchair and the resident sustained a fall which resulted in a fracture to the resident's right femur and elbow which required surgical intervention. In addition, the resident was care planned for staff to establish a voiding pattern for the resident; however, further review of the record revealed there was no documented evidence staff attempted to determine the resident's voiding pattern.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to update and revise the care plan for three (3) of twenty-two (22) sampled residents, related to falls, wound care, and incontinent care (Residents #18, #58, and #31). Resident #18 had a fall on 01/03/19 due to getting up without assistance and not calling for assistance as care planned; however, the facility failed to revise the care plan to address the resident getting up without assistance and not using call light. On 01/30/19, Resident #18 sustained another fall due to not using call light and getting up without assistance again which resulted in the resident sustaining a fracture of the left hip which required surgery. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent avoidable accidents for two (2) of five (5) sampled residents who were reviewed for falls (Residents #18 and #58). Resident #18 was assessed and care planned at risk for falls on admission. Resident #18 sustained three (3) falls with major injuries on 01/03/19, 01/30/19 and 04/16/19 while in his/her bedroom; however, the facility failed to identify the resident was getting up without supervision and not using the call light to call for assistance and no interventions were put in place to address the resident getting up/ambulating without assistance per facility policy. In addition, the facility failed to conduct a post fall assessment after each fall per the facility policy. [...]

Inspectors wroteBased on observation, interview and review of facility policy, it was determined the facility failed to store and serve food in accordance with professional standards for food service safety. Observations in the kitchen on 05/07/19 revealed staff failed to ensure heads of cabbage were covered while stored in the refrigerator. In addition, observation on 05/07/19 during a supper meal revealed staff failed to wash or sanitize their hands. Review of the facility Census and Condition, dated 05/07/19, revealed sixty-eight (68) of sixty-eight (68) residents received their meals from the kitchen.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to ensure gloving procedures were followed related to a medication pass. Observation on 05/08/19 revealed licensed staff handled a resident's medication with her bare hands.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, it was determined the facility failed to treat one (1) of twenty-two (22) sampled residents with dignity and respect (Resident #18). Staff failed to close the privacy curtains and window blinds prior to giving Resident #18 a bed bath to ensure privacy while providing perineal care.

Inspectors wroteBased on interview, record review and review of facility policy, it was determined the facility failed to ensure each resident who experiences a significant change in status is comprehensively assessed using the CMS-specified Resident Assessment Instrument (RAI) process for one (1) of twenty-two (22) sampled residents (Resident #58). Resident #58 had a decline in three (3) care areas, however, the facility failed to complete a significant change assessment.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined the facility failed to provide quality of care and treatment in accordance with professional standards of practice for one (1) of twenty-two (22) sampled residents (Resident #24). Observation on 05/10/19 revealed staff failed to change Resident #24's transparent occlusive dressing every seven (7) days per facility policy. Resident #24's dressing was dated 04/24/19, which indicated the dressing had not been changed in sixteen (16) days.

Inspectors wroteBased on observation, interview, record review, and review of facility's policy, it was determined the failed to ensure a resident with pressure ulcer received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (1) of three (3) sampled residents, (Resident #31). Staff identified Resident #31 had a Stage II pressure ulcer to his/her right buttock on 05/07/19; however, licensed staff failed to notify the physician/practitioner of the ulcer and resident's condition to obtain orders for treatment; and, document the type of wound, the degree of tissue damage, location of the area, measurements, and ulcer characteristics per facility policy.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure each resident receives necessary respiratory care and services that is in accordance with professional standards of practice, the resident's care plan, and the resident's choice for two (2) of two sampled residents reviewed for respiratory care (Residents #12 and #62). Observations on 05/07/19, 05/08/19, and 05/09/19 revealed Resident #12's oxygen (O2) tubing was not being stored in a plastic bag when not in use according to facility policy. In addition, Resident #62 was care planned and had Physician Orders for O2 at two (2) liters per minute (LPM) per nasal cannula; however, observations on 05/07/19, 05/08/19 and 05/10/19 revealed the resident was not receiving O2 at two (2) LPM.

Inspectors wroteBased on interview, record review, and review of facility policy, it was determined the facility failed to ensure the pharmacy review reports included any irregularities related to appropriate diagnosis for the use of psychotropic medications for one (1) of five (5) sampled residents on psychotropic medication (Resident #15). Resident #15 was administered Risperidone (Risperdal-an antipsychotic) and Quetiapine (Seroquel-an antipsychotic) with a diagnosis of Dementia in Other Diseases Classified Elsewhere With Behavioral Disturbance which was not an appropriate diagnosis; however, the pharmacy failed to identify this during his monthly medication reviews.

Inspectors wroteBased on interview, record review, and review of facility policy, it was determined the facility failed ensure one (1) of five (5) residents on psychotropic medications was administered a psychotropic medication without an appropriate diagnosis (Resident #15). Resident #15 was administered Risperidone (Risperdal-an antipsychotic) and Quetiapine (Seroquel-an antipsychotic) with a diagnosis of Dementia in Other Diseases Classified Elsewhere With Behavioral Disturbance which was not an appropriate diagnosis for the use of Risperidone and Quetiapine.

Inspectors wroteBased on observation, interview, and review of the facility's policy and procedure, it was determined the facility failed to ensure drugs used in the facility were labeled in accordance with currently accepted professional principles. On 05/08/19, observation of medication room refrigerator revealed a medication vial dated 03/29/19 and still available for use.