Nicholasville Nursing and Rehabilitation

Inspectors wroteBased on observation, review of medication package inserts, and review of the facility's policy, the facility failed to ensure the provision of appropriate environmental controls to preserve the integrity of medications in 1 of 2 sampled medication refrigerators. Observation on the B Unit on 08/20/2025 revealed no medication refrigerator temperature log was initially observed, and when provided by the facility, temperatures had only been documented from 08/16/2025 to 08/20/2025. In addition, observation on the A Unit revealed an opened but unlabeled medication in one of the medication carts and an opened but unlabeled medication and an expired medication in the medication refrigerator.

Inspectors wroteBased on observation, interview, record review, review of the facility's signage, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases and to implement interventions to protect the residents for 4 of 27 sampled residents, Resident (R) 21, R34, R39, and R41. Observation on 08/19/2025 revealed staff donned (put on) N-95 masks over surgical masks prior to entering rooms designated as Covid positive rooms. Observation on 08/19/2025 revealed rooms designated as Covid positive rooms were without proper signage for droplet precautions. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to maintain correct recordkeeping of all controlled drugs, which ensured an accurate inventory of medications by accounting for controlled medicines the facility received, dispensed, and administered. A review of narcotic count sheets revealed staff failed to sign inventory sheets for controlled narcotics and sign narcotic count sheets at the change of shift, for four of four medication carts.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure all drugs used in the facility were labeled in accordance with professional standards for four of four medication carts. Undated opened medications were found in all medication carts.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 64 residents in the facility, Resident (R) 24, R55, R60, R63, and R267.

Inspectors wroteBased on observation, interview, record review, and review of facility's documents and assessment, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by the resident assessment for 3 of 64 residents in the facility, Resident (R) 5, R6, and R117.

Inspectors wroteBased on interview, record review, and review of the facility's policies, the facility failed to provide proof of vaccinations or declinations for four out of five sampled residents for immunization, Resident (R) 14, R16, R32, and R60.

Inspectors wroteBased on observation, interview, and review of the facility's documents and policies, the facility failed to provide 2 of 42 sampled and supplemental residents, Resident (R) 20 and R59, with a safe, clean, comfortable, and homelike environment. The room that R20 and R59 shared smelled of urine and other unpleasant odors.

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI), the facility failed in seven days to complete the resident assessment as return anticipated or not anticipated and electronically transmit the discharge assessment within 14 days for 1 of 25 sampled residents, Resident (R) 36. R36's discharge date was 05/28/2024, but R36's Minimum Data Set (MDS) was not submitted until 09/12/2024.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to develop a person centered care plan for each resident, consistent with the resident rights which included measurable objectives, and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 25 sampled residents, Resident (R) 267. Review of R267's Comprehensive Care Plan (CCP) revealed R267 was to be assessed for a bruit and a thrill. However, R267 did not have a fistula to assess, but instead had a dialysis central venous catheter. Further review of R267's CCP revealed the CCP had multiple instances where the resident's name was not documented, and R267 was referred to only by the generic term Resident Name.

Inspectors wroteBased on interview, record review, and review of facility's policies, the facility failed to revise the comprehensive care plan after a re-admission for 1 of 25 sampled residents, Resident (R) 167. R167's care plan for nutritional needs and dietary assessment after being re-admitted to facility on 08/04/2024 following an acute care hospital stay was not reviewed or revised.

Inspectors wroteBased on interview, record review, and review of the facility's Code Status Book, the facility failed to update each resident's Advance Directives in honoring resident wishes for code status to provide basic life support, including cardiopulmonary resuscitation (CPR), to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physicians orders and the resident's Advance Directives for 1 of 25 sampled residents, Resident (R) 9.

Inspectors wroteBased on interview, record review, review of the Registered Dietician's (RD) job description and contract, and review of the facility's policies, the facility failed to perform a comprehensive nutritional assessment by the RD to identify factors that placed the resident at risk for inadequate nutrition and dehydration for one of two sampled residents for nutrition, Resident (R) 167. R167 was readmitted to the facility on [DATE] following an acute care hospital stay for a fall sustained on 07/17/2024. R167, prior to being readmitted on [DATE], was identified as being at risk for inadequate nutrition and hydration.

Inspectors wroteBased on observation, interview, record review, and review of facility's policy, the facility failed to ensure a resident who needed respiratory care, was provided such care, for 1 of 25 sampled residents, Resident (R) 55. R55 had orders to receive oxygen (O2) at 3 Liters per minute (L/m) per nasal cannula (n/c); however, observations on 09/08/2024, 09/10/2024 and 09/11/2024 revealed the resident was receiving oxygen at 2 L/m or 2.5 L/m per n/c.

Inspectors wroteBased on interview, record review and review of the facility's Policy, it was determined the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. Review of the A Wing Refrigeration Log, dated August 2019, revealed an incomplete temperature log for the medication storage refrigerator.

Inspectors wroteBased on observation, interview and review of facility's Policy it was determined the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety and failed to ensure refrigerator temperatures were maintained per facility policy for the A Unit nourishment refrigerator, which was locked in the A Unit Nurse's Station. Observations of the A Wing nourishment refrigerator, on 08/28/19, 08/29/19, and 08/30/19, revealed an undated bag of fast food labeled with a resident's name. In addition, an incomplete temperature log was observed for the A Wing nourishment refrigerator. The Findings Include: [...]

Inspectors wroteBased on observation, interview, record review, and review of facility's Policy, it was determined the facility failed to establish mechanisms for documenting and communicating the resident's choices to the interdisciplinary team and to the staff responsible for the resident's care for two (2) of nineteen (19) sampled residents (Resident #1 and Resident #305). 1) The facility re-admitted Resident #1, on [DATE], with Physician Orders (P.O.) for Do Not Resuscitate (DNR). On [DATE], Physician's Orders were written to change the resident's Code Status to Full Code. However, review of Resident #1's physical chart, located at B-Wing nursing station, revealed resident's Code Status was DNR. Review of Resident #1's Comprehensive Care Plan, initiated on [DATE], revealed the resident was a Full Code. [...]

Inspectors wroteBased on interview, record review and review of the facility's Policy, it was determined the facility failed to ensure that residents were free from abuse, neglect, misappropriation of resident property, and exploitation for one (1) of nineteen (19) sampled residents, Resident #35. On 08/28/19, Resident #9 was witnessed with his/her hand on Resident #35's groin area.

Inspectors wroteBased on interview and record review, it was determined the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for one (1) of nineteen (19) sampled residents, Resident #305.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the Comprehensive Care Plan was reviewed and revised by the interdisciplinary team based on changing goals, preferences and needs of the resident and in response to current interventions for one (1) of nineteen (19) sampled residents (Resident #19). Resident #19 had a plan of care Do Not Resuscitate status (DNR) and a plan of care for Full Code status (staff will administer Cardio-Pulmonary Resuscitation) if resident has an arrest.

Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail, failed to assess the resident for risk of entrapment from bed rails prior to installation, failed to review the risks and benefits of bed rails with the resident or resident representative and failed to obtain informed consent prior to installation and use of bed rails for one (1) of nineteen (19) sampled residents (Resident #10). Resident #10 was observed on 08/27/19, 08/28/19, and 08/29/19 with one-half side rails installed on his/her bed. There was no documented evidence that the facility attempted appropriate alternatives, assessed the resident for risk of entrapment, reviewed the risks and benefits with the resident and/or representative, and obtained informed consent prior to installation. [...]