Park Grove Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to store food in accordance with professional standards for food service safety. Food was not dated at the time of storage. Opened food was not covered and/or sealed to prevent contamination. This failure had the potential to affect 52 of the facility's 52 residents who consumed food from the kitchen.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to implement a comprehensive person-centered care plan to meet mental and psychosocial needs for one (Resident (R) 2) of three residents reviewed for activity care plans. The resident's care plan for the television (TV) to be on at all times was not consistently followed.

Inspectors wroteBased on observation, interview, record review, document review, and facility policy review, it was determined the facility failed to ensure residents' comprehensive care plans were developed and implemented for three (3) of eight (8) sampled residents assessed for elopement risk (Residents #13, #40, #52, #53). 1. The facility assessed Resident #13 to be at risk for elopement and was care planned as at risk for elopement and exhibited exit-seeking behavior. However, the resident exited the facility undetected by staff on 03/14/2024 at approximately 4:10 PM and was outside unsupervised for approximately five (5) minutes. 2. Resident #40 stated in interview she had carpal tunnel syndrome in both hands. However, review of Resident #40's care plan revealed the facility failed to develop a care plan related to pain or the potential for pain, with necessary interventions for the resident. 3. [...]

Inspectors wroteBased on observation, interview, review of facility policy, and review of the Kentucky Food Guide 2013 Food Code guidance, the facility failed to provide food at a palatable temperature for two (2) residents (Resident #1 and Resident #52). In addition, the facility failed to ensure point of service temperatures (temps) were within acceptable levels. Observation of the 400 Hall lunch meal on 04/02/2024 revealed the hot foods were below the acceptable levels for the point of service temps. The cold food/beverages were above the acceptable levels for the point of service temps.

Inspectors wroteBased on interview, and facility's policy review, Resident Matrix, and staff personnel files review, the facility failed to provide at least twelve (12) hours of required in-service training for nurse aides including dementia management training and resident abuse prevention training for 5 of 5 State Registered Nurse Aides (SRNA). (SRNA's #4, #9, #10, #12 and #13 ). This had the potential to affect the facility's fifty-eight (58) residents.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure an ongoing program of activities was developed to meet the resident's individual needs for four (4) of six (6) sampled residents (Residents #15, #38, #52, and #53). The facility failed to provide individualized activities based on residents' comprehensive assessments, care plans, and personal preferences.

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, for one (1) of six (6) sampled residents (Resident #1). Observation of Resident #1 on 04/03/2024, revealed the resident's catheter bag had no dignity cover in place.

Inspectors wroteBased on interview, record review and review of facility policy, the facility failed to ensure each resident had an active Advance Directive order in place for five (5 ) of 25 sampled residents (Residents #8, #9, #22, #28, and #61).

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to implement procedures that addressed and monitored the safe storage and handling of medications. Review of one (1) of two (2) medication storage refrigerator's, Refrigerator and Freezer Temperature Logs documentation revealed the facility failed to record temperatures for that refrigerator for three (3) days.

Inspectors wroteBased on observation, interview, record review, facility document and policy review, it was determined the facility failed to provide effective monitoring and supervision to prevent elopement for one (1) of eight (8) sampled residents assessed for elopement risk (Resident #13), out of the total resident sample of twenty-five (25). The facility assessed Resident #13 as at risk for elopement and care planned him/her for the elopement risk, Interventions included utilizing and monitoring a security bracelet for Resident #13 as per protocol. However, on 03/14/2024, facility staff failed to follow the resident's interventions, and allowed Resident #13, whose mobility was per wheelchair, to exit the facility without staffs' knowledge at approximately 4:10 PM. Resident #13 was located unsupervised outside the facility approximately five (5) minutes later. [...]

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to store food in accordance with professional standards for food service safety. Observations revealed that opened food items in the facility's pull-out refrigerator were not labeled or dated. Continued observations revealed other food items were not covered.

Inspectors wroteBased on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 User Manual, it was determined the facility failed to ensure its Minimum Data Set (MDS) Assessments accurately reflected the status for two (2) of forty-four (44) sampled residents (Resident #270 and Resident #68). 1. Review of Resident #270 MDS Assessments did not accurately reflect the residents' previous falls. (Refer to F-689) 2. Review of Resident #68's MDS Assessment did not accurately reflect the resident's discharge location.

Inspectors wroteBased on observations, interviews, and record review, it was determined the facility failed to ensure one (1) of forty-four (44) sample residents (Resident #26) care plan was developed to include the resident's need for Hemodialysis.

Inspectors wroteBased on interviews, record reviews, and review of facility policies, it was determined the facility failed to ensure one (1) of forty-four (44) sampled residents, (Resident #49) was not administered a psychotropic medication without an appropriate diagnosis. Resident #49 was administered an antipsychotic for a diagnosis of Agitation, which was not a medication that was appropriate for the given diagnosis.

Inspectors wroteBased on observation and interview, it was determined the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for the lunch meals served on 02/14/2023 and 02/15/2023 for four (4) of fourty-four (44) sampled residents (Resident #21, Resident #55, Resident #30, and Resident #29). On 02/14/2023, the State Survey Agency (SSA) Surveyor requested a point of service test tray. The tray was delivered at 1:05 PM and was served an aluminum foil covered pureed tray with tea, because the facility had no regular meals remaining. The SSA Surveyor found the foods on the test tray were below the acceptable temperature and tasted bland.

Inspectors wroteThe facility failed to follow the physician's orders for one (1) of forty-four (44) sampled residents (Resident #169). Resident #169 had a therapeutic diet order for Pureed Diet with Nectar Thick Liquids. Observation of the resident's meal tray and bedside table revealed the resident had two and one half (2 1/2) glasses of apple juice and two (2) foam cups of water that were not thickened to nectar consistency, as per the physician's orders.