Owenton Healthcare and Rehabilitation

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview, record review, document review, and facility policy review, the facility failed to protect the resident's right to be free from physical abuse by another resident for two (Resident (R) 60 and R70) of three sampled residents reviewed for abuse. Resident-to-resident abuse occurred in two different incidents. On 10/02/2025, R60 swatted R70 and made contact with the resident's chest. On 10/27/2025, R65 hit R60 on the shoulder.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure one (R) 4) of two sampled residents reviewed for nutrition received their diet as ordered. R4, who was at nutritional risk, failed to receive his physician-ordered therapeutic diet for additional protein and fortified foods.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 sampled residents, (Resident (R)3). R3 began vaginal treatment with Monistat 7 (antifungal vaginal cream) for a yeast infection on 11/29/2024. R3 had complaints of pain and discomfort. The facility transferred R3 to a hospital on [DATE]. At the hospital, R3 had a computed tomography (CT) scan performed which revealed the resident had a foreign object present in her vaginal canal, which was later determined to be a Monistat vaginal cream applicator. R3 stated the whole situation was unnecessary, caused her unnecessary pain and was humiliating.

Inspectors wroteBased on observation, interview, record review and review of facility policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that included measurable objectives and timeframes for 7 of 28 sampled residents (R). R1, R5, R22, R36, R61, R64 and R76 were observed in the dining room consuming meals without the assistive devices or nutritional supplements they had been care planned to receive.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to accommodate food preferences for 5 of 7 sampled residents (R) 61, R36, R22, R76 and R64. Observation during the noon meal service on 08/06/2024 at 12:17 PM, revealed the facility failed to provide residents with their nutritional supplements and double portions as ordered by the physician.

Inspectors wroteBased on observation interview and review of facility policy, it was determined the facility failed to provide special adaptive equipment and utensils for residents who needed them when consuming meals and snacks for 5 of 15, out of 28 sampled residents, (R)1, R5, R22, R76, and R64.

Inspectors wroteBased on observation, interview, and review of the facility's policies, the facility failed to ensure its staff performed hand sanitation measures and maintained appropriate infection control measures during medication administration for 3 out of 39 sampled residents (R47, R52, R16, R57), which placed residents at increased risk for healthcare-associated infections (HAI).

Inspectors wroteThe facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made for 3 of 23 sampled residents (R)2, R48, R86.

Inspectors wroteBased on interview, record review and review of facility policy, the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 1 of 23 sampled residents (R), R86.

Inspectors wroteBased on observation, interview and review of facility Policy, it was determined the facility failed to prepare and store food under sanitary conditions. Observation on 10/29/19, during initial kitchen tour, revealed two (2) beverage pitchers were not labeled or dated, the ingredient bins had dry dusty food particles on the outside and the kitchen had a general dusty appearance. In addition, observation revealed the Manager in Training was not using correct procedure to to measure the sanitizer in the pot and pan sink. Continued observation of the kitchen on 10/29/19, revealed two (2) holes in the back wall over the back prep table. In addition, the floors to the base boards appeared soiled; window sills were dusty; walls throughout the kitchen needed paint, and paint was peeling off the wall near the hand sink. Further, the exhaust hood fire extinguisher pipes were dusty; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to develop and implement a Comprehensive Care Plan (CCP) for each resident, that includes measurable objectives and timeframes to meet a resident's needs for four (4) of twenty-two (22) sampled residents (Residents #9, #33, #42, #56). Resident #9's Monthly October 2019 Physician's Orders, revealed current orders for left hand splint as needed dated 11/28/16; and gentle stretch and wear left resting hand splint at night, dated 02/10/17. However, there was no documented evidence the facility developed the CCP to include interventions related to the left resting hand splint. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable for four (04) of five (05) residents reviewed related to Limited Range of Motion (ROM) out of twenty-two (22) sampled residents (Resident # 9, Resident #33, Resident #42, and Resident #56). Resident #9's Monthly October 2019 Physician's Orders, revealed current orders for left hand splint as needed and Therapy evaluation and treatment as recommended, dated 11/28/16; and gentle stretch and wear left resting hand splint at night, dated 02/10/17. [...]

Inspectors wroteBased on observation, interview, and review of facility Policy, it was determined the facility failed to ensure each resident receives food and drink that is palatable, attractive, and at a safe and appetizing temperature. Observation of the test tray conducted on the 200 unit at the lunch meal service on 10/31/19, revealed the hot foods were not hot, the cold foods were at room temperature, and some food items were not palatable. In addition, interviews with Resident #29 and #49, revealed foods were not served at appropriate temperatures and was not palatable.

Inspectors wroteBased on observation and interview, it was determined the facility failed to provide maintenance services necessary to maintain a safe clean and comfortable environment for the 100 unit residents. Observation of the 100 unit hall ceiling vents from rooms 101 through 115, on 10/29/19, 10/30/19, and 10/31/19, revealed dust accumulation.

Inspectors wroteBased on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure each resident was free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, for one (01) of one (1) sampled resident reviewed for restraints out of twenty-two (22) sampled residents (Resident # 33). The facility initiated a self-releasing alarming seatbelt to Resident #33's wheelchair as a fall intervention, on 02/11/19. However, there was no documented evidence they Physician's Order identified the medical symptom being treated when using the restraint. In addition, observation on 10/29/19, revealed Resident #33 was sitting in the joy room (dining room) in his/her wheelchair at a table, with no staff in the room. [...]

Inspectors wroteBased on interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for two (02) of twenty-two (22) sampled residents (Resident #33 and Resident #56). Resident #33 sustained a fall on 10/18/19 and the Fall Investigation revealed a fall floor mat was placed on the favored side of the bed; however, there was no documented evidence which side of the bed was the favored side (left/right) or that the Care Plan was revised to include this intervention. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure adequate supervision and assistive devices to prevent accidents for two (02) of four (4) sampled residents reviewed for falls out of twenty-two (22) sampled Residents (Resident #33 and Resident #56). Resident #33 sustained a fall on 10/18/19 from his/her bed, and received a skin tear injury. The Fall Investigation revealed a fall floor mat was placed on the favored side of the bed; however, there was no documented evidence which side of the bed was the favored side (left/right) or that the Care Plan was revised to include the intervention to place a fall mat on the favored side of the bed. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure residents are free of any significant medication errors for one (1) of twenty-two (22) sampled residents. Resident #55 did not receive injections of Lantus insulin 10 units daily as ordered by the Physician from 10/01/19 through 10/30/19.