Mountain Manor of Paintsville

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide a dignified dining experience for 2 (Resident #81 and Resident #91) of 2 sampled residents.

Inspectors wroteBased on record review, interview, facility document review, and facility policy review, the facility failed to protect a resident's right to be free from misappropriation of property, which affected 1 (Resident #4) of 3 residents reviewed for personal property. Specifically, a staff member stole Resident #4's credit cards and made multiple unauthorized charges.

Inspectors wroteBased on record review, interview, facility document review, and facility policy review, the facility failed to report an allegation of misappropriation of resident's property to the state survey agency timely, which affected 1 (Resident #4) of 3 residents reviewed for personal property. Specifically, an allegation was made on 07/04/2025 that Resident #4's credit cards that were kept in the resident's room were stolen and unauthorized charges had been made, and the facility did not report the allegation to the state survey agency until 07/07/2025.

Inspectors wroteBased on record review, interview, and review of the Centers for Medicare & Medicaid Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to complete a discharge Minimum Data Set (MDS) upon discharge and transmit the data for 1 (Resident #101) of 1 resident reviewed for resident assessment.

Inspectors wroteBased on observation, interview, record review, facility document and policy review, the facility failed to provide nail care for 1 (Resident #126) of 3 sampled residents for activities of daily living (ADL).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to follow up on a urologist's orders and did not ensure that the physician's orders were transcribed and administered for 1 (Resident #11) of 2 residents sampled for catheter care.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to prevent a fall for 1 (Resident #95) of 3 sampled residents reviewed for accidents. Specifically, on 06/01/2025, State Registered Nursing Aide (SRNA) #6 was providing bathing assistance to Resident #95, who was dependent upon one staff member for bed mobility, when the SRNA rolled the resident onto their left side and then stepped to the resident's doorway to notify a nurse of a soiled bandage needing changed on the resident's coccyx, leaving the resident unattended. The resident fell from their bed and sustained a bruise to their right neck, a 2-centimeter (cm) skin-tear to their left inner wrist, and two skin tears (4 cm and 13 cm) to their right forearm.

Inspectors wroteBased on interview, record review, facility document and policy review, the facility failed to ensure medications were stored safely when a medication was found at the bedside for 1 (Resident #38) of 3 residents sampled for medication administration.

Inspectors wroteBased on observation, interview, facility policy review, and review of a Centers for Disease Control publication, the facility failed to maintain infection control practices during catheter care for 1 (Resident #11) of 2 residents sampled for urinary catheter. Specifically, a nursing assistant failed to don a gown as recommended for enhanced barrier precaution (EBP) while providing catheter care and placed a soiled washcloth into the same water basin as the clean washcloths, then continued to provide catheter care with the contaminated washcloths.

Inspectors wroteBased on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the status of one (1) of twenty-six (26) sampled residents (Resident #80). Resident #80 had experienced a greater than ten (10) percent weight loss in less than six (6) months (between 05/06/2021 and 10/12/2021); however the resident's weight loss was not reflected on the resident's annual MDS dated [DATE].

Inspectors wroteBased on interview, record review, and review of the Long Term Care Resident Assessment Instrument 3.0 User's Manual, it was determined the facility failed to ensure one (1) of four (4) closed records reviewed (Resident #1) had a discharge assessment completed and transmitted within 14 days after the resident expired in the facility on [DATE].

Inspectors wroteBased on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the status of one (1) of twenty-two (22) sampled residents (Resident #97). Resident #97 was admitted to hospice services on 10/22/18. However, a review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE] and a quarterly MDS dated [DATE] completed for the resident revealed the facility failed to ensure hospice services were coded on the assessments.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy it was determined the facility failed to ensure the implementation of the comprehensive care plan for two (2) of twenty-two (22) sampled residents. Resident #73 sustained a fall when only one (1) person assisted him/her with bed mobility while the care plan had determined the resident required two (2) persons for this activity. Resident #90 was observed to have only one (1) fall mat to the left side of the bed on dates of 05/06/19 through 05/08/19, yet the care plan had determined the resident required a fall mat to each side of the bed.

Inspectors wroteBased on observation, interview, record review, review of the facility's investigation, and review of the facility's policy, it was determined that the facility failed to ensure that one (1) of twenty-two (22) sampled residents received adequate supervision and assistance to prevent accidents (Resident #73). Resident #73 was assessed by the facility to require the assistance of two (2) staff members for bed mobility; however, on 01/20/19 at 10:00 AM one staff member provided care for the resident and the resident sustained a fall.

Inspectors wroteBased on observation, interview, and review of a facility agreement, it was determined the facility failed to provide pharmaceutical services, including the provision of emergency medications, for residents of the facility. Observation of one (1) of four (4) emergency drug boxes revealed an emergency box in the second floor medication room had one bottle of Gentamicin (antibiotic) 80 milligrams (mg) per 2 milliliters (ml), and four (4) bottles of Tobramycin (antibiotic) 80 mg per 2 ml that had expired, but was available for use.

Inspectors wroteBased on observation, interview, and review of the facility policy it was determined the facility failed to ensure medication was stored at the proper temperature in one (1) of three (3) medication rooms. Observation of the second floor medication refrigerator on 05/08/19 revealed Mi-Acid (an antacid that treats heartburn, indigestion, upset stomach, etc.) was in the refrigerator; however, a review of the medication label revealed the medication should be stored at room temperature.

Inspectors wroteBased on observation, interview, record review, and review of a facility policy, it was determined the facility failed to post the total number of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs or State Registered Nurse Aides) responsible for resident care each shift and the number of actual hours worked. Observation on 05/05/19 at 11:30 AM revealed the posted staffing form on the first floor was blank. Observation on 05/05/19-05/0819 and review of the past eighteen (18) months of daily staffing revealed the facility failed to maintain complete information regarding nurse staffing data.