How many inspection deficiencies does Edgemont Healthcare have?

Edgemont Healthcare has 13 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at Edgemont Healthcare?

Edgemont Healthcare has a one-star staffing rating from CMS with 0.44 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is Edgemont Healthcare located?

Edgemont Healthcare is located in Cynthiana, KY. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does Edgemont Healthcare have?

Edgemont Healthcare has 68 certified beds.

Who owns Edgemont Healthcare?

Edgemont Healthcare is a for profit - corporation facility and operates independently (not part of a chain).

What questions should families ask when visiting Edgemont Healthcare?

Families visiting Edgemont Healthcare should ask about staff retention and training programs. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does Edgemont Healthcare compare to other nursing homes?

Edgemont Healthcare has a 1-star overall rating, which is below average compared to other nursing homes in KY. Families should carefully review inspection findings and consider alternatives.

Edgemont Healthcare

Name: Edgemont Healthcare
Address: 323 Webster Avenue, Cynthiana, KY, 41031, US
Telephone: (859) 234-4595
Rating: 1.0

323 Webster Avenue, Cynthiana, KY 41031 · (859) 234-4595

For profit - Corporation 68 Beds Independent Data: November 2025

Trust Grade

30/100

#221 of 266 in KY

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Edgemont Healthcare nursing home in Cynthiana, KY - Photo 1 of 4

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Last Inspection: March 2021

Over 2 years since last inspection. Current conditions may differ from available data.

Overview

Edgemont Healthcare in Cynthiana, Kentucky, has received a Trust Grade of F, indicating significant concerns about its quality of care. It ranks #221 out of 266 nursing homes in Kentucky, placing it in the bottom half of facilities in the state, and #2 out of 3 in Harrison County, meaning only one local option is better. The facility's trend is stable, with 13 identified issues remaining consistent over time. Staffing is a major concern, as it received a poor rating of 1 out of 5, with an alarming turnover rate of 80%, which is significantly higher than the state average. While there have been no fines, recent inspection findings included serious concerns about the environment, such as failing to accommodate resident preferences, leading to emotional distress, and inadequate temperature control, which could affect all residents' comfort and safety.

Trust Score: F
In Kentucky: #221/266
Safety Record: Moderate
Inspections: Holding Steady
Staff Stability: 80% turnover. Very high, 32 points above average. Constant new faces learning your loved one's needs.
Penalties: No fines on record. Clean compliance history, better than most Kentucky facilities.
Skilled Nurses: Each resident gets only 26 minutes of Registered Nurse (RN) attention daily — below average for Kentucky. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 13 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★☆☆☆☆

1.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2021: 3 issues

2025: 3 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below Kentucky average (2.8)

Significant quality concerns identified by CMS

Staff Turnover: 80%

34pts above Kentucky avg (46%)

Frequent staff changes - ask about care continuity

Staff turnover is very high (80%)

32 points above Kentucky average of 48%

The Ugly 13 deficiencies on record

1 actual harm

Sept 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

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Based on interview, record review, and review of the facility's policy, the facility failed to develop and implement policies and procedures that established a protocol for the determination of capacity to consent to sexual contact for 2 of 4 sampled residents, Resident (R) 4 and R13. Observations by staff on 07/27/2025 and 07/28/2025 revealed R4 and R13 were engaged in sexual behavior with one another. However, the facility's policy did not address the requirement to assess residents' capacity to consent to a sexual relationship and there was no evidence the facility assessed the residents for their capacity to consent to a sexual relationship.Additionally, the facility's policy failed to contain the eighth required component, in which the facility must coordinate situations of abuse with the Quality Assurance Performance Improvement (QAPI) program. The findings include:Review of the facility's policy titled, Abuse Investigation Policy Statement, dated 11/14/2016, revealed one of the seven components of the policy included prevention. Prevention was defined by identification, correction, and intervention of a situation in which abuse was more likely to occur. Further review revealed the policy did not address the identification of when, how, and by whom determinations of capacity to consent to a sexual contact would be made and where this documentation would be recorded. Continued review of the policy revealed the policy did not contain the eighth required component, in which the facility must coordinate situations of abuse with the Quality Assurance Performance Improvement (QAPI) program. 1. Review of R4's admission Record revealed the facility admitted the resident on 07/28/2021 with diagnoses which included vascular dementia, delusion disorder, bipolar disorder, Alzheimer's disease, and Lewy Body dementia.Review of R4's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 06/23/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 11 of 15, indicating moderately impaired cognition. Review of R4's Care Plan, undated, revealed the resident was care planned for male visitor(s), and staff should allow for privacy. She was also cared planned for a history of delusions, dementia, psychotropic medication, and antibiotics related to an acute urinary tract infection (UTI) and cellulitis of her right lower extremity. Review of R4's medical record revealed no documented evidence the facility had assessed the resident for the ability to consent to a sexual relationship prior to the State Survey Agency (SSA) September 2025 survey.Further review of R4's medical record revealed a Judicial Order, dated 07/21/2021, appointing the state as guardian and conservator of the resident.Review of R4's Psychiatric Progress Notes, dated 09/03/2025, revealed the Psychiatric Nurse Practitioner (PNP), performed an evaluation for capacity to sexually consent.During an interview on 09/03/2025 at 8:25 AM with R4's current State Guardian (SG), he stated he first met R4 during the first week of August 2025. He stated the previous SG told him they were waiting for the court to decide R4's capacity to consent.During an interview on 09/03/2025 at 8:33 AM with R4's previous SG, she stated, to her knowledge, they were not waiting on court proceedings but for the Psychiatric Nurse Practitioner (PNP), who had already been working with the resident, or the physician, to do a capacity to consent evaluation. She stated, unless there was a capacity to consent, the residents were not to have sexual relations of any kind. She stated she was under the impression sexual relations only happened one time. However, she stated when she went to the facility, it appeared it was continuing. She stated she did not know if the capacity to consent assessment was ever done because she was no longer R4's SG.2. Review of R13's admission Record revealed the facility admitted the resident on 09/05/2023, with diagnoses which included anxiety, major depression, and multiple physical co-morbidities.Review of R13's MDS, with an ARD of 06/06/2025, revealed the facility assessed the resident to have a BIMS score of 12 of 15, indicating moderately impaired cognition.Review of R13's medical record revealed no documented evidence the facility had assessed the resident for the ability to consent to a sexual relationship prior to the State Survey Agency (SSA) September 2025 survey.Review of R13's Nurses' Notes dated 07/27/2025 at 7:50 PM and written by Registered Nurse (RN) 3, revealed a State Registered Nurse Aide (SRNA) reported to RN3 that R4 was in R13's room, lying on the bed with no clothes on, and R13 was lying on top of her. The note stated R4 and R13 told RN3 the residents wanted to have sex, and they understood the potential consequences. Per the note, privacy was provided, and the Director of Nursing (DON) and the Administrator were advised of that by phone.Review of R13's Nurses' Notes, dated 07/28/2025 at 2:55 PM and written by RN1, revealed R4 was in R13's room, and R13 was sitting on his bed with his pants down, exposing himself. Per the note, R13's door was closed for privacy, and the Assistant Director of Nursing (ADON), DON, Social Services Director (SSD), and the Administrator were notified. During a telephone interview with State Registered Nurse Aide (SRNA)5 on 09/04/2025 at 3:04 PM, she stated she was passing ice. She stated she knocked on R13's door on the evening of 07/27/2025 and announced she was bringing ice. She stated she saw R13, with his pants down. She stated she saw R4 on the bed, but SRNA5 did not notice what R4 was wearing. She stated she told the nurse, RN3, what she saw.During an interview on 09/03/2025 at 8:39 AM with RN1, she stated R4 and R13 had been alone together on more than one occasion. She stated she was personally aware of three occasions, and the aides had reported it to her twice. She stated she was not sure what was done behind closed doors, and staff attempted to provide privacy. During an interview on 09/03/2025 at 8:47 AM with the Social Services Director (SSD), she stated R4 reported to her that she had been crazy about R13 for a long time. She stated she was made aware of the incident that occurred on 07/27/2025 the following day, on 07/28/2025. She stated she made R4's previous SG aware. She stated the previous SG told her R4 and R13 had the right to engage in sexual activities, so long as they were able to make that decision. She stated, at the time, both R4 and R13 had a BIMS score of 11 (moderate cognitive impairment). The SSD stated the previous SG requested a capacity to consent evaluation from the PNP who had been seeing R4 at the facility. She stated when she asked the PNP to do that, the PNP told her she would look into it. However, she stated R4 was in and out of the hospital around that time for a UTI. She stated, as far as she knew, R4 and R13 were allowed to engage in sexual activity. She stated the PNP came weekly, and it had not come up as an issue. During an interview with the PNP on 09/04/2025 at 12:30 PM, she stated her process to evaluate if a resident had the capacity to consent for sexual activity was to look at the context of the situation. She stated she had not done any assessment or evaluation of R4 or R13 prior to the residents being in a sexual relationship. She stated the facility informed her that R4 was having a relationship with a man, so she evaluated R4 on 09/03/2025.During an interview on 09/04/2025 at 10:13 AM with the Director of Nursing (DON), she stated R4 was highly flirtatious before the UTI, so for her to engage with this resident didn't surprise me. She stated she had not been aware of any sexual activity before these incidents. She stated she knew R4 would flirt with different men, and if the men did not respond, she would move on to someone else. During an interview on 09/04/2025 at 3:55 PM with the Medical Director, who was also R4's and R13's primary care physician, he stated he was aware of an intimate relationship on the first occasion. However, he stated he was not aware of much more than that. He stated he was not aware of a capacity to consent used at the facility, and it would be his preference to have that on file. He stated that, while the physical relationship was not his preference, he did feel that R4 was able to make those types of decisions, and to make her not be able to spend time with R13 seemed to not be in the best interest of either resident.During an interview on 09/04/2025 at 4:53 PM with the Administrator, she stated she was unaware the facility's abuse policy needed to include procedures to assess residents for the capacity to consent to sexual relationships and she was unaware the policy required the eighth component, in which the facility must coordinate situations of abuse with the QAPI program. She stated she felt R4 and R13's relationship was acceptable as she viewed them both to be consenting adults.

Jul 2025 2 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Deficiency F0558 (Tag F0558)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policies, the facility failed to provide 2 (Resident (R) 54 and R10) of 21 sampled residents the right to reside and receive services with reasonable accommodation of the resident's needs and preferences except when to do so would endanger the health or safety of the resident or others. The facility moved or removed personal items, furnishings, and/or equipment without consideration of resident preferences and accommodation of each resident's individual needs. This failure caused R54 emotional distress over a sustained period of time and the resident was tearful as she related that the facility moved and mounted her television on the wall in a place where she had difficulty seeing it due to her physical limitations, as well as removed shelving that housed her personal collectibles. The findings include: Review of the facility's Homelike Environment Policy, revised 07/08/2023, revealed that it was the policy of the facility to provide a homelike environment for the residents. Further review of the policy revealed that it was the procedure of the facility to encourage residents to decorate their space using their personal belongings to reflect their identity and preferences.Review of the facility's policy titled, Resident Rights, revised 04/12/2024, revealed that it was the policy of the facility to promote the rights of the residents residing in the facility. Review of this policy stated that it was the procedure of the facility to provide the resident with a dignified existence, self-determination, and communication with and access to persons and services both in and outside of the facility. Further review of the policy revealed that the facility would make every effort possible to assist the resident in exercising his/her rights and to assure that he/she was always treated with respect, kindness, and dignity. The facility would ensure that the resident could exercise his/her rights without interference, coercion, discrimination, or reprisal from the facility.Review of the facility's policy titled, Notice of Resident Rights and Responsibilities, revised 03/27/2024, revealed that it was the policy of the facility to promote and protect the rights of all residents residing in the facility. Further review of the policy revealed that residents have the right to keep and use their own personal belongings and property if it did not interfere with the rights, safety, or health of others.1. Review of Resident (R)54's Face Sheet revealed that she was admitted to the facility on [DATE], with diagnoses of [NAME] Disease (a rare, chronic, progressive cerebrovascular disorder), multiple sclerosis, muscle contractures (where joints become permanently fixed in a bent or shortened position, limiting movement), stiffness of unspecified joint, and cerebrovascular disease. Review of R54's current Physician Orders revealed an order dated 09/08/2021 that stated, May have convoluted foam mattress [also known as an egg crate mattress] on bed.Review of R54's quarterly Minimum Data Set (MDS), dated [DATE], revealed that she was assessed as participating in assessments and goal setting. Review of R54's Assessments tab revealed a Brief Interview for Mental Status Evaluation (BIMS) score of 15/15, dated 07/02/2025, indicating that the resident was cognitively intact. Review of R54's Comprehensive Care Plan, with the initiation date of 10/28/2024 and a target date of 10/08/2025, revealed that R54 was care planned for being at risk for little or no participation at times in activities per her wishes. The goal for this focus was that R54 would be encouraged to attend or participate in activities of her choice and would socialize with staff and others to improve the quality of her life. One intervention for this focus was that during leisure times in her room, she liked to watch television (TV). Observation on 07/22/2025 at 2:50 PM of R54's room revealed R54 was sitting to the left of the TV, partially in the doorway so that she could view the TV by rolling her eyes to the left to view the TV out of the corner of her eyes. Further observation revealed that the resident had two shelves hanging over her bed. Both of these shelves were greater than 18 inches from the height of any sprinkler heads in the room. The shelves contained stuffed animals and a few Coca-Cola items, messily and tightly stuffed on them. R54's TV was mounted on the wall beside the door. R54's bed was unmade at the time of the observation and there was no foam mattress/mattress topper upon the bed.In an interview with R54 on 07/22/2025 at 2:50 PM, she said that the TV once sat on her bedside table, which was observed to be approximately 2 - 3 feet below where the TV was currently mounted on the wall. R54 tearfully stated that the Administrator told her that her television had to be mounted on the wall and that it was to be placed where the Administrator chose. R54 stated that she was not allowed to have the television placed where she (R54) could see it easily, explaining that due to her neck contracture, she had to sit beside the television and look out of the corner of her eyes to watch the TV. R54 also noted that the facility also took down one of her shelves and was planning on removing her other shelves. R54 stated she had no other place to display her Coca-Cola memorabilia and was told that she would have to box up her things and place them in her closet or send them home with her daughter because the facility would be removing her remaining shelves. R54 stated she was never told why the TV had to be mounted in that specific location or why the facility was removing her shelves. R54 stated she told the Administrator that she did not want her TV moved, or her shelves removed from the wall; however, the Administrator responded that the room belonged to her (the Administrator and the facility) and not to the resident. R54 stated that the Administrator also took away her mattress topper pad, making her bed uncomfortable to sleep upon. R54 asked repeatedly for a new one, but did not receive one, and her requests for moving her television and replacing her shelves and mattress pad were also denied. R54 stated she felt like this treatment was an infringement of her rights and negatively impacted her dignity by making her feel that her needs or opinions did not matter. R54 was unable to give the exact date when her shelf was removed, and her television mounted in a place which did not accommodate the resident's physical needs or preferences, but said it happened at the end of 06/2025. In an interview with State Registered Nursing Aide (SRNA) 2 on 07/23/2025 at 8:33 AM, SRNA2 stated R54 was very upset and screamed and cried when they removed her shelf from her wall and moved her TV to where she could not see it. SRNA2 stated the incident with the shelf being removed and the television being mounted on the wall in R54's room occurred at the same time. SRNA2 was unable to pinpoint an exact date that the incident occurred but knew that it was less than a month ago. In an interview with Registered Nurse (RN) 3 on 07/23/2025 at 9:05 AM, RN3 stated that R54 cried the first day they moved her television and screamed and cried for two days after the TV was mounted on the wall and the shelf removed from her room. R54 told the Administrator that she could not see the TV where it was mounted on the wall and was told by the Administrator that it had to be there. Per RN3, the Administrator told R54 that having shelves on the walls in residents' rooms was a code violation. In an interview with Ombudsman1 on 07/23/2025 at 9:32 AM, Ombudsman1 stated R54 could not understand why her television had to be mounted on the wall and why the facility removed her shelf that had her belongings on it. Ombudsman1 stated she was told the shelves needed to come down because the residents had too much stuff on their shelves, and it was a hazard. Ombudsman1 stated R54 was very upset about this. She stated that they never asked R54 where or if they could move her TV. Ombudsman1 stated R54 did not cry when telling her about the incident, but was very frustrated about it, instead.In an interview with Contract Staff (CS) 2 on 07/23/2025 at 10:49 AM, CS2 stated that R54 was distraught about her TV being placed on the wall where she did not want it and her shelf being taken down. CS2 stated residents' televisions were being mounted on the wall because they looked better there, per the Administrator. CS2 stated she felt the way R54 was treated infringed on her resident rights and diminished her dignity. Although multiple interviews with staff revealed they were aware of the resident screaming, crying, upset, and being distraught, review of R54's clinical record revealed no notes or evidence documenting this distress.2. Review of R10's Face Sheet, revealed that she was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar type, and anxiety. Review of R10's quarterly MDS, dated [DATE], revealed that R10 was assessed as having a BIMS score of 15/15, indicating that the resident was cognitively intact.Review of R10's Physician Orders, revealed an order dated 09/11/2023 that stated, May have convoluted foam mattress on bed.Observation of R10's room on 07/23/2025 at 1:08 PM revealed that she had two shelves on her wall. The resident's TV was sitting unmounted on a bedside chest. No mattress topper was apparent on R10's bed, which felt hard.In an interview with R10 on 07/23/2025 at 1:08 PM, R10 stated she was told the facility was going to mount her TV to the wall and were going to remove all her shelves. The resident stated no reason was given why this was occurring. She stated that she would like to keep her shelves. R10 added that it was OK if they mounted her TV to the wall; however, she wanted to be the one to decide where it was put. Further interview with R10 revealed that in the past, she had a personal mattress topper like R54; however, the facility came and took it away, stating that she was no longer able to have a mattress topper.In an interview with the Director of Maintenance (DM) on 07/23/2025 at 3:16 PM, the DM stated that the Administrator decided where to mount residents' televisions and he just did what the Administrator told him. He stated that residents do not have a choice in the matter. The DM stated that the Administrator instructed him to mount the televisions on the wall where residents could see the television while lying in bed. He stated he was not sure if the Administrator had asked any resident where to put their televisions or not. He added that shelves were also being taken down because of the televisions being mounted on the walls. The DM stated he did not try and move the shelves to another location in the resident rooms because it was difficult to do so because of the limited space and the shelves had to be eighteen inches from the sprinklers. He noted that the Administrator did not want the shelves moved, only taken down. The DM stated he did not remember when he mounted R54's TV on the wall or took her shelf down. He stated that he did what the Administrator instructed him to and did not receive written work orders or keep logs of maintenance items he performed at the facility,In an interview with the Director of Nursing (DON) on 07/24/2025 at 7:58AM, she stated R54's TV was initially placed in a manner that R54 could not see it; however, it was moved a few days later and R54 was happy with where the TV was now mounted. (However, interview and observation on 07/22/2025 at 2:50 PM with the cognitively intact resident revealed that R54 displayed tearful distress/unhappiness and physical limitation in viewing her TV in the location where it was currently mounted.) Further interview revealed the DON was unaware of the removal of a shelf in R54's room and did not think the other shelves were going to be removed. The DON stated that the mattress toppers were removed prior to her becoming the DON on 04/12/2025, indicating a belief that this was done for infection control, as well as the physician-ordered mattress toppers being a fire hazard. In an interview with the Administrator on 07/24/2025 at 9:24 AM, she stated that she wanted the TVs mounted to the wall, so they were not knocked off and broken. The Administrator stated that R54 wanted her television mounted on the wall where the divider curtain was halfway over the TV. Instead, it was placed on the same location on the wall above where it previously sat on R54's bedside table. The Administrator went on to explain that because some residents in the facility had shelves that were too close to the sprinklers, all resident shelves were being removed, adding that if there were items on the shelves touching the sprinklers, this was against regulations. Further interview with the Administrator revealed the mattress toppers were uncovered egg crate/foam mattress toppers which she considered an infection control issue for incontinent residents. She stated that the mattress toppers also interfered with the mattresses on the beds in preventing pressure ulcers or shearing injuries, adding that nothing else can go on top of the mattress or it does not work correctly. In the interview, the Administrator contradicted herself by first stating that she had told residents they could not have mattress toppers, and then later in the interview, stated that if their family provided a mattress topper, she would allow a resident to have one. When interviewed about honoring the residents' personal preferences/accommodating individual needs (such as TV placement for R54, whose contractures, MS, and muscle stiffness affected her ability to move her head to watch television), the Administrator repeatedly stated, We know what's best for them, indicating that the facility was making decisions for its cognitively intact residents, regardless of their input. Although the Administrator stated that the TVs had to be on the wall to keep the resident safe from injury, and then indicated that mattress toppers could not be used due to risk of fire, the Administrator provided no evidence to indicate that either R54 or R10 had sustained these type of consequences and therefore, could not have input into accommodations to their physical environment, based on safety concerns.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of National Weather Service records, the facility failed to ensure each resident had a right to a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all residents. The facility failed to promptly respond to problems with its cooling system and ensure that the facility was maintained at a safe, comfortable temperature, with temperatures in resident areas noted as high as 90 degrees Fahrenheit (F). The failure to provide safe, comfortable temperatures had the potential to affect all residents of the facility and constituted Substandard Quality of Care (SQC). In addition, multiple resident rooms (Rooms 209, 302, 317, and 320), a common resident gathering area, and the main dining hall needed repair and/or or cleaning. The findings include: In an interview with Ombudsman1 on 07/23/2025 at 9:32 AM, she stated she was first made aware that the facility's air conditioning (AC) was broken on 06/19/2025, which was also when the first family complaint about the AC being broken was called in to her office. She stated that she went to the facility at 8:30 PM at night and it was “like a sauna” in the facility. Ombudsman1 stated she was told by the Administrator that the AC repair person would be coming the next day. Continued interview revealed she called Ombudsman2 who came to the facility that evening and offered four large industrial fans for use in the interim. However, the Administrator declined this offer. Per interview, the following morning Ombudsman1 went back to the facility, and using her personal thermometer, found that the temperature was 83 degrees F (Fahrenheit) at 9:00 AM. By 5:30 PM when she went again it was even higher: 86-87 degrees F in the common area where the residents were eating. She stated the cook came out of the kitchen which was even hotter and almost passed out. She stated Ombudsman2 came to the facility again and the residents began saying that it was very hot. When they visited on Saturday at 2:00 PM, the facility had a large industrial fan in the hallway and had residents sitting in the hallway because the rooms had no air flow. She stated the vents were closed in many of the rooms, and one resident's room was extremely hot, at 88-89 degrees F. As part of the investigation of this concern, the survey team requested all documentation related to any issues with the cooling system. Although the Ombudsman stated she began receiving phone calls on 06/19/2025 and went to the facility that day to personally verify the complaints, the first “Work Order” from the Heating, Ventilation, and Air Conditioning (HVAC) repair company was not until 06/26/2025, one week later. Review of the National Weather Service Records revealed that, during the time from when the AC problem was first identified on 06/19/2025 until 06/26/2025, temperatures ranged as high as 91 degrees F on 06/23/2025, with a heat index of 104 degrees F. Review of the HVAC Work Order revealed that upon arrival on 06/26/2025, the repair person found the air temperature was 90 degrees F on the hallway where the HVAC unit the company was there to repair was located. In addition, there were two other units that were not cooling that the company was to also assess. Further review revealed that the HVAC systems were running properly but that the return drops on both systems in the attic were disconnected. It was found that the plenum (a piece of ductwork attached to the air handler) had major air leaks and the ductwork needed repair. Review of a “Work Order” from the HVAC repair company, dated 06/27/2025, revealed the facility had five units that the repair person was not able to look at and the work order stated they needed to get them cooling as best they could until they could return to finish the repair. Further review revealed that the repair company cleaned the condenser coils and added refrigerant, but they could not test fully until the systems were thoroughly cleaned. Per the work order, they scheduled a return appointment for performance of all units, indicating the need for spring maintenance. Review of a “Work Order” from the HVAC repair company, dated 06/30/2025, revealed the HVAC unit for the kitchen was not cooling and it was 91 degrees F. Inspection found the condensing coils for the unit that supplied the air conditioning (AC) to the kitchen was 80% blocked. The repair company cleaned the coil and placed more refrigerant and stated they would be back to do maintenance on the other units. Review of a “Work Order” from the HVAC repair company, dated 07/07/2025, revealed the kitchen HVAC unit was still having issues with temperatures reaching 110 degrees F in the kitchen. Review of a “Work Order” from the HVAC repair company, dated 07/10/2025, revealed system maintenance and cleaning was performed, and the system was now functioning as required, 21 days after the HVAC issues were first identified . Review of Resident (R) 27’s “Face Sheet” revealed a quarterly “Minimum Data Set (MDS),” with an assessment reference date (ARD) of 05/30/2025, which documented the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. In an interview with R27 on 07/23/2025 at 1:12 PM, she said that it had been hot during the time that the AC system was not working properly. She stated staff did not bring extra water and ice for residents that she remembered during this time. She stated that in the previous year during “hot spells” fans were purchased for residents by the facility and now she did not know where the facility put her fan. In an interview with State Registered Nurse Aide (SRNA) 2 on 07/23/2025 at 8:33 AM, she stated the facility’s AC broke down back at the end of June when there was a heat wave. She stated that the facility did not have fans on until the last two days that the AC was broken. She thought the AC was out for two weeks and noted that there was hot air coming out of the vents. SRNA2 stated the resident were complaining about the heat, and when staff mentioned how hot it was in the facility, the Administrator told staff they were complaining. In an interview with Registered Nurse (RN) 3 on 07/23/2025 at 9:05 AM, she stated that the AC was out about a month ago and the heat was “bad.” RN3 stated that only one large fan was brought in the facility, and it was placed in the East hallway. Residents were educated to leave their room door open and to sit in their doorways or in the hallway if possible. She stated that temporary AC units were never brought in to help cool the facility. In an interview with Contract Services (CS) 1 on 07/23/2025 at 10:49 AM revealed that during the time the HVAC was not functioning correctly, it would work on and off. She said that during this time, there was only one facility fan, which was blowing on the Back Hallway. She indicated that because of the heat, she educated residents to keep their doors open and sit in the hallway. She added that during morning meeting, staff were instructed to provide extra fluids and popsicles; however, she was unsure of this was effective due to the large number of agency staff who did not know the residents. In an interview with the Director of Maintenance on 07/23/2025 at 3:16 PM, he stated that the AC system never went completely out; however, six units had lower output than they should have and were not cooling the facility as well as needed during the time daily temperatures were in the high 80’s and 90’s. The facility called the repair man because the AC was not working well and because they needed it serviced and cleaned since the routine cleaning/maintenance which should have been completed in the Spring of 2025 had not occurred. Although interviews with the Ombudsman and review of work orders revealed problems with the HVAC system lasted 21 days, the Director of Maintenance stated he thought they were only having problems with the AC for a week. Further interview with the Director of Maintenance revealed he had no written evidence of verify his claim that the system was only down for a week. The Director of Maintenance added that although no portable AC units were provided during this time, large fans were brought in to cool down the facility. However, the Maintenance Director also had no evidence of verify this claim or the number of fans actually provided. He stated that he checked the temperature of the facility daily, but did not keep written logs of the temperatures, and as a result, had no evidence of how hot it became during the time that the HVAC system was not fully functioning. In an interview with the Director of Nursing (DON) on 07/24/2025 at 7:58 AM, she stated that the AC never stopped working completely and that the repair people were there several times throughout the week working on the AC. She stated there were fans and that staff gave out extra water and popsicles, and residents were able to get extra fluids anytime they requested them. In an interview with the Administrator on 07/24/2025 at 9:24 AM, she stated that the AC repair people were at the facility multiple times over the week the AC was not working, starting on 06/20/2025. However, review of all HVAC work records provided by the facility no work orders until 06/26/2025, one week after the AC issues were first noted. She stated that due to electrical plug issues, there could only be one large industrial sized fan, and this was why she did not accept the fans offered by Ombudsman2. Further interview with the Administrator revealed that the Director of Maintenance was supposed to be taking temperatures and recording them. The Administrator stated that it was never over 76 degrees in the facility during the time period in question. However, the Administrator could provide no evidence that this was, in fact, accurate. The Administrator confirmed that the Director of Maintenance failed to document and maintain a log of any temperatures during the period in which the AC system was not fully functioning and temperatures as high as 90 degrees in a residential area and 110 degrees in the kitchen were documented by the facility’s own contractor. Additional interview with the Administrator revealed that the facility had no policies/procedures related to mechanical failure of the HVAC system or temperature monitoring in the event of such a failure. This interview revealed that the lack of policies related to these areas was present at the time of the HVAC problems starting 06/19/2025, and continued as of the time of the survey, with no policies developed in response to this recent incident to ensure that in the future, appropriate temperatures were maintained, temperatures were monitored and recorded, and all necessary actions were taken to ensure both the comfort and health of residents. 2. Observation on 07/24/2025 at 1:00PM of resident rooms and common areas revealed the following: a. room [ROOM NUMBER] had large water stains and peeling paint on the ceiling above the bed area. Additionally, the baseboards were heavily scuffed and covered in visible dust and debris. b. room [ROOM NUMBER] had numerous cracks in the ceiling with brownish-yellow decolorization. c. room [ROOM NUMBER] had a wall behind the headboard of the bed with a large area (½ wall panel) of brownish-yellow discoloration, indentions, and holes. d. The hallway near room [ROOM NUMBER] had a cracked ceiling with remnants of water damage and decaying infrastructure, with multiple cracks and dust collection. e. In the common area where residents gather, the wall behind the television set had no baseboard, and exposed drywall and screws. Additionally, there were pieces of drywall present along the wall base and floor. Observation on 07/25/2025 at 11:00 AM in the main dining hall revealed the areas along the baseboard and corner panels had dust build up, peeling/cracks in the ceiling, chipped paneling, and old discoloration stains consistent with previous water damage. During an interview with R1 on 07/24/2025 at 2:30 PM, she stated the walls had looked like that for a while and it did not feel clean. During an interview with R37 on 07/24/2025 at 3:00 PM, he stated the facility's disrepair made him feel like nobody cares. During an interview with the Director of Maintenance on 07/24/2025 at 1:30 PM, he acknowledged that some of the damaged areas had been present for several months. He stated they tried to get to the repairs when they could, but there was a backlog of repairs, and they were short-staffed. He further stated he had no autonomy to make the repairs, and a day-to-day work list was given by the Administrator. During a concurrent interview with RN1 and SRNA1 on 07/25/2025 at 1:30PM, they revealed the damages were known to the administration, as residents and family had made multiple complaints due to the conditions of the facility. However, they continued, nothing was ever done to repair them. During an interview with the DON on 07/25/2025 at 2:00PM, she confirmed repairs were needed for multiple resident rooms. She stated a plan was in place, but it was not progressing as fast as the facility had hoped. The DON stated continued deterioration could lead to safety and health hazards for all residents, staff, and visitors. During an interview with the Administrator on 07/25/2025 at 2:30PM, she stated that a lot of work was needed to be done on the older building. The Administrator confirmed that the facility was aware of the conditions in the building and indicated a plan was in place to refurbish areas. However, no specific timeline was provided to indicate when needed repairs/cleaning would occur. Further interview with the Administrator revealed that all residents had the right to a safe and clean environment that was homelike.

Mar 2021 3 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to protect residents from abuse for one (1) of sixteen (16) sampled residents, Resident #16. Resident #16 was struck in the face by Resident #24. The findings include: Review of the facility's policy titled, Prevention and Reporting of Resident Abuse, revised 11/14/2016, revealed the facility was committed to protecting residents from abuse by anyone, including other residents, and revealed the facility did not condone abuse by anyone. Review of the facility's Initial Self-Reported Incident Form, dated 03/21/2021, revealed an allegation of resident-to-resident abuse, observed by Registered Nurse (RN) #1 and the Director of Nursing (DON), on 03/21/2021, who saw Resident #24 strike Resident #16 in the face. Review of the Facility Investigation File, dated 03/21/2021, revealed Resident #16 was physically abused by Resident #24, on 03/21/21 at 12:30 PM, when Resident #24 struck Resident #16 in the face, resulting in a small red area on the left temple that resolved after ten (10) minutes. Resident #16 had no lasting adverse reactions from the incident. Further review revealed Resident #16 was moved to another hallway and room as a result of the incident. Continued review revealed Resident #24 was placed on fifteen (15) minute checks, had exhibited no further behaviors, and had been referred to Psychiatric Services. Review of Resident #24's medical record revealed the resident was admitted to the facility, on 01/20/2020, with diagnoses including Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Bipolar Disorder, Type 2 Diabetes Mellitus, and Unspecified Dementia with Behavioral Disturbance. Review of Resident #24's Care Plan, revealed it was updated, on 03/21/2021, to include increased glucose monitoring to four (4) times a day and at hour of sleep for seven (7) days; then three (3) times a day as previously ordered. In addition, interventions for communication were to provide the resident with physical and verbal cues to alleviate anxiety; give positive feedback, and assist with verbalization of the source of the agitation. Further interventions included to remove others from harms way when the resident became agitated and to intervene before agitation escalated. Review of Resident #24's Annual Minimum Data Set (MDS) Assessment, dated 01/20/2021, revealed the facility assessed the resident, on the Brief Interview for Mental Status (BIMS), with a score of fifteen (15) out of fifteen (15), indicating intact cognitive status. In addition, Section E revealed the resident had exhibited no behaviors. Review of Resident #16's medical record revealed the resident was admitted to the facility, on 10/02/2020, with diagnoses including Dementia with Lewy Bodies; Heart Failure; Chronic Obstructive Pulmonary Disease; Diabetes Mellitus, Type 2; and Unspecified Visual Loss. Review of Resident #16's admission Minimum Data Set (MDS), dated [DATE] revealed the facility assessed the resident, on the Brief Interview for Mental Status (BIMS), with a score of fifteen (15) out of fifteen (15), indicating intact cognitive status. Interview with Resident #16, on 03/23/2021 at 1:30 PM, revealed he/she was hit by another resident. The resident stated he/she had used the restroom but did not make a mess. Further, he/she stated someone called him/her a MF, so the resident went to the next room to let that person know he/she did not make a mess. Observation at this time revealed Resident #16 was blind in the left eye. Resident #16 stated he/she then heard female voices tell him/her not to go into that room. Per interview, Resident #16 stated he/she knocked on the door and started to go in, but someone (unknown to the resident) hit the resident in the face. Resident #16 stated his/her face hurt for a while after the incident and he/she changed rooms. Interview with RN #1, on 03/23/2021 at 3:28 PM, revealed she had worked at the facility since June 2016 and had worked on 03/21/2021. RN #1 stated she saw Resident #16 go into Resident #24's room. In addition, she stated because of Resident #16's diagnosis of Lewy Body Dementia he/she sometimes got confused. Per interview, she directed Resident #16 to go to her/his room, to which he/she replied, Someone called me a MF. I'm going in to tell them I didn't make the mess in the bathroom. RN #1 stated suddenly and unexpectedly Resident #24 hit Resident #16 on the left side of the cheek, and she immediately stepped between the two (2) residents. Per interview, she stated she pushed Resident #16 out of the room and said to Resident #24, Wait a minute. RN #1 stated the DON pulled Resident #16 back, and then both of them assessed the residents. She stated Resident #16 had a red area on the left side of his/her face, which was about two (2) inches long, and it disappeared in ten (10) minutes. Per interview, neurological checks and vital signs were started on Resident #16; the doctor and both families were notified; the DON notified the Office of Inspector General (OIG) and began an investigation of the event; and Social Services and the Administrator were notified. RN #1 stated Resident #16 was moved to another room. Also, RN #1 stated Resident #24 was also assessed. Interview with Director of Nursing (DON), on 03/24/2021 at 10:15 AM, revealed she was present during the altercation between Resident #16 and Resident #24. She stated she was in the hall and saw Resident #16 going into the wrong room and told him/her so. Per interview, she stated he/she was not angry. Then, the DON stated Resident #24 went to Resident #16 and told him/her that he/she needed to flush the toilet; Resident #24 then struck Resident #16 on the face, causing a small red area to appear on Resident #16's left temple. Further, she stated the red area was gone within ten (10) minutes. In addition, after the incident, she stated Resident #16 was moved immediately to a room on another hallway. Per interview, the DON stated she notified the Executive Director, the Administrator, Social Services, the Physician, and families of both residents. Furthermore, she stated Resident #24's blood glucose was low, at sixty-seven (67) milligrams/deciliter (mg/dL) (normal was 80 to 120 mg/dL), with a recheck of one-hundred forty-five (145) mg/dL. The DON stated because Resident #24 had the low blood glucose level, his/her glucose checks were increased to four (4) times a day for seven (7) days. In addition, the DON stated this was the first time Resident #24 had ever hit another resident.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0813 (Tag F0813)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and review of the facility's policy, it was determined the facility failed to store food delivered from an outside source in accordance with professional standards of food service. The findings include: Review of the facility's policy titled, Food Brought in From Outside Sources, undated, revealed special circumstances could require that food be brought into the facility from the outside. Per policy, these outside foods or beverages would be labeled with the resident's name and dated by the receiving dietary staff with the current date the item(s) was brought to the facility for storage. The policy also stated that food or beverage items could be stored in facility pantries, refrigerators, or freezers. Observations completed during the initial kitchen tour, on 03/23/2021 at 9:12 AM, revealed two (2) commercial pizza boxes in the kitchen refrigerator, one (1) large box and one (1) smaller box. The large box contained pizza but was not marked with a resident name or date of receipt. The smaller box contained two (2) cinnamon rolls and had the resident's first initial and last name but no date or food name. Interview with the Dietary Manager, on 03/25/2021 at 3:23 PM, revealed she had been at the facility since 2013. She stated when a resident received food from outside the facility, it should be labeled with the resident's name and date received and should be stored in a separate refrigerator, located at the Nurse's Station. Per interview, if food brought in for a specific resident was given away, it would be misappropriation. Also, she stated there was a risk for cross-contamination of food with food brought in, so it was not kept in the kitchen refrigerator whose contents were used to prepare or store food for all residents. The Dietary Manager stated everyone was responsible to ensure food was stored correctly in the kitchen. Interview with the Director of Nursing (DON), on 03/25/2021 at 5:41 PM, revealed she expected outside food brought in for a resident to be labeled with the resident's name, dated, and stored in the refrigerator at the Nurse's Station by the staff member accepting the food. In addition, she stated dietary staff should note if a specific resident's food brought in from the outside was in the kitchen refrigerator and move it to the correct refrigerator. The DON stated it was important to maintain separate storage of facility foods from foods brought in to prevent possible cross-contamination.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, review of the U.S. Food and Drug Administration Food Code, 2017, and review of the facility's policies, it was determined the facility failed to store food in accordance with professional standards for food service safety. The findings include: Review of the U.S. Food and Drug Administration Food Code, 2017, Subpart 3-602, Food Labels, revealed packaged food must include the common name of the food, or absent a common name, an adequately descriptive identity statement. In addition, the code stated another form of information on the food label would be unconcealed or unaltered dating information. Review of the facility's policy titled, Food Storage, undated, revealed it was the policy of the facility to store, label, and date food properly and safely. In addition, the policy stated food would be correctly labeled with the name of the food item, the date of storage, and stored properly according to food safety guidelines. Review of the facility's policy titled, Food Brought in From Outside Sources, undated, revealed outside foods or beverages brought to the facility for a resident would be labeled with the resident's name and dated by the receiving dietary staff with the current date the item(s) was brought to the facility for storage. Observations, on 03/23/2021 at 9:12 AM, during the initial kitchen tour, revealed twelve (12) tan/brown patties in a gallon Ziploc bag in the freezer. They appeared to be hash browns but the label had worn off, leaving no date and no food name. Observation of the refrigerator contents revealed a gallon bag of shredded cheese with no food name on the label and four (4) bowls of a brown pudding-like substance with no food name on the label. Also observed in the refrigerator were two (2) commercial pizza boxes, one (1) large and one (1) smaller. The larger box contained pizza, but was not labeled with the resident's name, food name, or date brought to the facility. The smaller box contained two (2) cinnamon rolls, with the resident's name but no date or food name. Interview with the Dietary Manager, on 03/23/2021 at 9:20 AM, revealed she expected food that was out of its original box or container to have a label indicating the date it was removed and the food name. She stated the facility used markers for labeling, but the marks tended to wear off; and the facility did not have a sticker system. The Dietary Manager stated it was important for items to be correctly labeled to know the identity of the food for preferences and dates when the food should no longer be served. Additional interview with the Dietary Manager, on 03/25/2021 at 3:23 PM, revealed she had been with the facility since 2013. She stated when food was out of the original box or container, the procedure was to place those items in a zip lock bag with the label showing the food name and the date opened. Per interview, it was important to label food correctly with a date because if the food was kept in the refrigerator too long, it could spoil and cause illness, if ingested. In addition, she stated if one did not know specifically what the food item was, and the resident ate it, the food item ingested possibly could give the resident an allergic reaction. The Dietary Manager stated everyone was responsible to ensure foods were stored correctly in the kitchen. Interview with the Director of Nursing (DON), on 03/25/2021 at 5:41 PM, revealed she expected food labeling to be done per policy, and food should be labeled by the staff member that received or stored the food. She stated any food removed from its original container should be dated and labeled at the time of removal. The DON stated correct labeling and dating of food items was important for identifying it to ensure residents got the right foods of proper quality.

Mar 2019 4 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on observation, interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to develop and implement a comprehensive person centered care plan for each resident, that includes measurable objectives and timeframes to meet the resident's medical and nursing needs for one (1) of nineteen (19) sampled residents (Resident #22). Although Resident #22's Annual Minimum Data Set (MDS) Assessment, dated 07/17/18, and Quarterly MDS Assessment, dated 01/08/19, revealed the resident had Functional Limitations in Range of Motion for bilateral upper and lower extremities, there was no documented evidence the Comprehensive Care Plan was developed and implemented to address the resident's limited range of motion/contractures. (Refer to F-688) The findings include: Review of the facility Policy titled, Comprehensive Care Plans revised 04/26/17, revealed the Comprehensive Care Plan would reflect resident needs identified in the comprehensive assessment. The Comprehensive Care Plan describes the services to be furnished to attain or maintain the resident's highest practicable physical well-being. Review of the facility Restorative Nursing Care Policy, undated, revealed it was the policy of the facility to provide every resident with restorative nursing care. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of Resident #22's medical record revealed the facility admitted the resident on 07/05/17 with diagnoses including Congenital Hydrocephalus, Malignant Neoplasm of the Lung, Anxiety Disorder, Unspecified Intellectual Disability, and Reduced Mobility. Review of the Resident-Date Collection document, dated 07/05/19, completed on admission, revealed Resident #22 had bilateral hand and foot deformities, with no further description of the deformities noted. Review of the Nurse's Notes, dated 07/05/17 at 3:45 PM, revealed the resident had contractures of the arms and legs. Review of the Progress Note, dated 07/06/17, completed by the Advanced Practice Registered Nurse (APRN), revealed Resident #22 was noted to have decreased mobility with bilateral lower extremity contractures. Review of Resident #22's Annual Minimum Data Set (MDS) Assessment, dated 07/17/18, revealed the facility assessed the resident as having both short term and long term memory loss. Review of Section G0400, revealed the facility assessed the resident as having Functional Limitation in Range of Motion for bilateral upper and lower extremities. Review of Section G revealed the facility assessed Resident #22 as requiring total dependence of two (2) staff for bed mobility and transfers. Additional review of the MDS Assessment, Section O, revealed the facility assessed the resident as receiving no therapy services. Review of the Contract Physical Therapy Notes, dated 01/06/19, revealed therapy was not recommended for Resident #22 based on no change in condition. Review of Resident #22's Quarterly MDS Assessment, dated 01/08/19, revealed the facility assessed the resident as unable to complete a Brief Interview for Mental Status (BIMS) as the resident was rarely or never understood. Continued review of the MDS Assessment, Section G0400, revealed the facility assessed the resident as having Functional Limitation in Range of Motion for bilateral upper and lower extremities. Review of Section G of the MDS Assessment, revealed the facility assessed Resident #22 as requiring total dependence of two (2) staff for bed mobility and transfers. Further, Section O, revealed the facility assessed the resident as receiving no therapy services. Review of the Comprehensive Care Plan, undated, revealed there was no focus area to address Resident #22's limitations in range of motion of the bilateral upper and lower extremities/contractures. In addition, the Comprehensive Care Plan did not include goals or interventions to increase or prevent further decrease in range of motion (ROM), even though limitations in range of motion were identified on the Annual Minimum Data Set (MDS) Assessment, dated 07/17/18; and the Quarterly MDS Assessment, dated 01/08/19. Review of the Restorative Care Notebook kept at the Nursing Station, revealed there was no documented evidence Resident #22 was included in the restorative nursing program. Review of Resident #22's Nurse Aide Flow Sheet/Care Plan, dated March 2019, revealed a category titled Positioning with interventions to include: turn every two (2) hours, convoluted special mattress, lateral support positioning equipment, and ROM with care. However, there was no documentation to denote if ROM was provided, nor was the document signed by any State Registered Nurse Aide (SRNA) staff. Additional review of Resident #22's medical record, revealed no documented evidence the resident was included in the restorative care program, nor was there any documentation to support Range of Motion (ROM) was provided. Observation of Resident #22, on 03/06/19 at 9:39 AM, in the dining/sitting area, revealed contractures to the fingers of both hands. Observation of Resident #22, on 03/07/19 at 10:08 AM, revealed the resident flexed his/her knees above chest level while sitting in a reclined geri chair. Observation of Resident #22, on 03/07/19 at 2:33 PM, revealed the resident was in bed and the resident was noted to have hyperextended contractures of the fingertips, bilaterally. Interview with SRNA #3, on 03/07/19 at 10:15 AM, revealed any SRNA could perform restorative nursing care, and the SRNA assigned to restorative nursing care was to check the Restorative Care Notebook to ascertain which residents were included in the restorative program. Per interview, the facility policy stated all residents received restorative care; however, this was not the process. SRNA #3 revealed she was sometimes assigned to Resident #22 and this resident did not participate in the restorative program. Further interview revealed she performed passive range of motion (ROM) when assigned to Resident #22; however, she did not document she performed ROM. Interview with Licensed Practical Nurse (LPN) #1, on 03/07/19 at 12:53 PM, revealed SRNAs delivered restorative care to residents contingent on whether staffing was adequate for the shift. Further interview revealed she was unsure if Resident #22 received restorative care, even though facility policy stated all residents received restorative care. LPN #1 stated Resident #22's Comprehensive Care Plan should have included a focus area related to Resident #22's impairment to his/her lower and upper extremities. Interview with SRNA) #2, on 03/07/19 at 1:08 PM, revealed she was periodically assigned to Resident #22. SRNA #2 revealed she performed restorative nursing on occasion; however, Resident #22 was not in the restorative nursing program, nor did he/she get Range of Motion (ROM) exercise. Interview with SRNA #4, on 03/07/19 at 1:37 PM, revealed she was sometimes assigned to Resident #22. She revealed she received information related to the care to be provided to the residents verbally at the beginning of the shift from other SRNAs and also from the nurses. She further revealed Resident #22 did not receive restorative nursing care and was not in the restorative program. Per interview, she relied on the Restorative Care Notebook kept at the nursing station to check which residents received restorative care, when she was assigned to perform restorative nursing care. Continued interview revealed restorative care was recorded in the Restorative Care Notebook; however, if a resident only received ROM, this was not documented anywhere. Interview with Registered Nurse (RN) #2, on 03/07/19 at 1:45 PM, revealed if a resident was in the restorative nursing program, the contracted therapy agency would need to issue an order for restorative care. She further revealed the SRNAs performed restorative care and documented the care in the Restorative Care Notebook kept at the nursing station. Further interview revealed the SRNAs received information during report which included the need for restorative care. Additional interview revealed Resident #22 was not in the restorative program and only received ROM exercise; however, ROM was not documented anywhere in the medical record. Interview with RN #3, on 03/07/19 1:58 PM, revealed she was unsure as to the process for placing a resident in the facility restorative nursing program. She revealed the SRNAs were responsible for delivering restorative care and documenting the care provided in the Restorative Care Notebook at the nurse's station. RN #3 further revealed she was assigned to Resident #22 on occasion, but was unsure about whether the resident had contractures. Continued interview revealed the SRNAs provided ROM to residents, but she did not know whether the ROM was documented. Interview with the MDS Coordinator, on 03/07/19 at 12:36 PM, revealed she developed the Comprehensive Care Plans. She stated she attended the daily morning meetings where she received information requiring Care Plan updates. She further stated Comprehensive Care Plans were developed based on the comprehensive assessments. The MDS Coordinator revealed Resident #22's limited range of motion was identified on the Annual Minimum Data Set (MDS) Assessment, dated 07/17/18; and the Quarterly MDS Assessment, dated 01/08/19; and therefore the Comprehensive Care Plan should have addressed this concern. Interview with the Director of Nursing (DON), on 03/07/19 at 2:35 PM, revealed Resident #22 did not receive restorative care in accordance with facility policy because some residents were not part of the formal restorative nursing program. However, she stated Resident #22 received ROM exercise during daily care by the SRNAs, and ROM was an intervention on the Nurse Aide Flow Sheet/Care Plan. Per interview, the SRNAs did sign the Nurse Aide Flow Sheet/Care Plan to indicate the care was provided according to this document; however, she admitted there was no specific documentation to indicate ROM was actually provided to the residents. Additional interview with the DON, revealed the Comprehensive Care Plans were derived from the MDS Assessments, and Resident #22's MDS Assessments identified limitation in range of motion. She stated the resident's Care Plan should have been developed to address the resident's contractures in order for staff to implement interventions to prevent further decrease in range of motion. Interview with the Administrator, on 03/07/19 at 3:39 PM, revealed the SRNAs were to deliver ROM as part of the daily care for residents and she was unaware ROM was not being performed for Resident #22. She further revealed she expected the SRNAs to document the delivery of ROM because the documentation supported the care provided. Further interview revealed she was aware Resident #22 had contractures and it was her expectation the Comprehensive Care Plan be developed and implemented related to the resident's limited range of motion.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to provide services to increase or prevent further decrease in range of motion for one (1) of nineteen (19) sampled residents (Resident #22). Although Resident #22 had Functional Limitations in Range of Motion (ROM), record review and staff interview, revealed the resident was not receiving services to increase ROM and/or to prevent further decrease in ROM. (Refer to F-656) The findings include: Review of the facility Policy titled, Restorative Nursing Care undated, revealed the facility was to provide every resident with restorative nursing care. Review of Resident #22's medical record revealed the facility admitted the resident on 07/05/17 with diagnoses to include Congenital Hydrocephalus, Malignant Neoplasm of the Lung, Anxiety Disorder, Unspecified Intellectual Disability, and Reduced Mobility. Review of the Resident-Date Collection document, dated 07/05/19, completed on admission, revealed the resident had bilateral hand and foot deformities. There was no further description of the deformities. Review of the facility Nurse's Notes, dated 07/05/17 at 3:45 PM, revealed the resident had contractures of the arms and legs. No hand or finger contractures or deformities were noted. Review of the facility Progress Note, dated 07/06/17, completed by the Advanced Practice Registered Nurse, revealed the resident was noted to have decreased mobility with bilateral lower extremity contractures. No further contractures were addressed in the Note. Review of Resident #22's Annual Minimum Data Set (MDS) Assessment, dated 07/17/18, revealed the facility assessed the resident as having both short term and long term memory loss. Continued review of the MDS Assessment, Section G0400, revealed the facility assessed the resident as having Functional Limitation in Range of Motion for bilateral upper and lower extremities. Review of Section G of the MDS Assessment, revealed the facility assessed Resident #22 as requiring total dependence of two (2) staff for bed mobility and transfers. Further, Section O, revealed the facility assessed the resident as receiving no therapy services. Review of the Contract Physical Therapy Notes, dated 01/06/19, revealed no therapy was recommended for Resident #22 based on no change in condition. Review of the Quarterly MDS Assessment, dated 01/08/19, revealed the facility was unable to complete a Brief Interview for Mental Status (BIMS) because the resident was rarely or never understood. Further review of the MDS Assessment, Section G0400, revealed the facility assessed the resident as having Functional Limitation in Range of Motion for bilateral upper and lower extremities. Continued review of Section G, revealed the facility assessed Resident #22 as requiring total dependence of two (2) staff for bed mobility and transfers. In addition, review of Section O, revealed the facility assessed the resident as receiving no therapy services. Review of Resident #22's Comprehensive Care Plan, undated, revealed there was no focus area related to the resident's limitations in range of motion of the bilateral upper and lower extremities/contractures. Also, the Comprehensive Care Plan did not include goals or interventions to prevent further decreases in range of motion (ROM). Review of the Restorative Care Notebook at the Nursing Station, revealed there was no documented evidence Resident #22 was included in the restorative nursing program. Review of Resident #22's Nurse Aide Flow Sheet/Care Plan, dated March 2019, revealed a category titled Positioning with interventions including: turn every two (2) hours, convoluted special mattress, lateral support positioning equipment, and ROM with care. However, there was no documentation to indicate if ROM was provided, nor was the document signed by any State Registered Nurse Aide (SRNA) staff. Further review of Resident #22's medical record, revealed no documented evidence the resident was included in the restorative care program, nor was there any documentation to support Range of Motion (ROM) was provided. Observation of Resident #22, on 03/06/19 at 9:39 AM, in the dining/sitting area, revealed the resident had contractures to the fingers of both hands. Observation of Resident #22, on 03/07/19 at 10:08 AM, revealed the resident flexed his/her knees above chest level when seated in a reclined geri chair. Observation of Resident #22, on 03/07/19 at 2:33 PM, revealed the resident was in bed and had hyperextended contractures of the fingertips, bilaterally. Interview with SRNA #3, on 03/07/19 at 10:15 AM, revealed any SRNA could provide restorative services to residents. Per interview, the SRNA assigned to restorative nursing care was to check the Restorative Care Notebook to ascertain which residents were included in the restorative program. Further interview revealed the facility policy stated all residents received restorative care; however, this was not the process. SRNA #3 stated she was sometimes assigned to Resident #22 and this resident did not participate in the restorative program. She further stated she performed passive range of motion (ROM) when assigned to Resident #22; however, she did not document she performed ROM on this resident or any resident. Interview with Licensed Practical Nurse (LPN) #1, on 03/07/19 at 12:53 PM, revealed nursing assistants (SRNAs) delivered restorative care to residents contingent on whether staffing was adequate for the shift. She further stated she was unsure if Resident #22 received restorative care, even though facility policy stated all residents received restorative care. Interview with State Registered Nursing Assistant (SRNA) #2, on 03/07/19 at 1:08 PM, revealed she was familiar with Resident #22 as she was periodically assigned to the resident. SRNA #2 stated she performed restorative nursing on occasion; however, Resident #22 was not in the restorative nursing program, nor did he/she get Range of Motion (ROM) exercise. Interview with SRNA #4, on 03/07/19 at 1:37 PM, revealed she was assigned to Resident #22 at intervals. She stated she received information related to the care to be provided to the residents verbally at the beginning of the shift from other SRNAs and also from the nurses. She further stated Resident #22 did not receive restorative nursing care and was not in the restorative program. SRNA #4 revealed she relied on the Restorative Care Notebook kept at the nursing station to check which residents received restorative care, when she was assigned to perform restorative nursing care. She further stated restorative care was recorded in the Restorative Care Notebook; however, if a resident only received ROM, this was not documented anywhere. Interview with Registered Nurse (RN) #2, on 03/07/19 at 1:45 PM, revealed if a resident was in the restorative nursing program, the contracted therapy agency initiated the order for restorative care. She further stated the SRNAs performed restorative care and documented the care in the Restorative Care Notebook kept at the nursing station. Continued interview revealed the SRNAs received information during report which included the need for restorative care. Further interview revealed Resident #22 was not in the restorative program and only received ROM exercise; however, ROM was not documented anywhere in the medical record. Interview with RN #3, on 03/07/19 1:58 PM, revealed she was unsure as to the process for placing a resident in the restorative nursing program. She stated the SRNAs were responsible for delivering restorative care and documenting the care provided in the Restorative Care Notebook at the nurse's station. RN #3 revealed she was assigned to Resident #22 on occasion, but was unsure about whether the resident had contractures. She further stated the SRNAs provided ROM to residents, but she did not know whether the ROM was documented. Interview with the Director of Nursing (DON), on 03/07/19 at 2:35 PM, revealed she was unsure if Resident #22 ever received therapy services; however, she stated therapy screened every new admission. The DON stated she was unaware Resident #22 had contractures. She further stated Resident #22 did not receive restorative care in accordance with facility policy because some residents were not part of the formal restorative nursing program. Further interview revealed Resident #22 received ROM exercise during daily care by the SRNAs, and ROM was an intervention on the Nurse Aide Flow Sheet/Care Plan. Per interview, the SRNAs did sign the Nurse Aide Flow Sheet/Care Plan to indicate the care was provided according to this document; however, there was no specific documentation to indicate ROM was actually provided to the residents. Continued interview with the DON, revealed she would expect a resident with contractures to receive the appropriate services to prevent further decrease in range of motion. Interview with the Administrator, on 03/07/19 at 3:39 PM, revealed the SRNAs were expected to deliver ROM as part of daily care for residents. She further stated she expected the SRNAs to document the delivery of ROM because the documentation supported the care provided. Further interview revealed the purpose of restorative nursing care and ROM was to help prevent decline and to achieve the best outcomes for residents. Continued interview revealed she was aware Resident #22 had contractures and it was her expectation the facility provide services to increase range of motion or to prevent further decrease in range of motion for this resident.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, interview, record review, review of facility Policies, and review of the Centers for Disease Control (CDC) Guideline for Hand Hygiene in Healthcare Settings, Volume 51, published 10/25/02, it was determined 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 two (2) of nineteen (19) sampled residents (Resident #25 and Resident #38). Observation on 03/05/19, revealed Registered Nurse (RN) #1 did not perform hand prior to or post administration of medication for Residents #25 and #38. In addition, RN #1 handled pills with her bare hands prior to administering the medication to these residents. The findings include: Review of the facility Policy titled, Brainwashing undated, revealed all personnel should perform handwashing procedures to prevent infection transmission before preparing or handling medications. Review of the facility Policy titled, Administration of Drugs, undated, revealed nursing personnel should follow current standards of infection control while administering medications. Review of the Centers for Disease Control (CDC) Guideline for Hand Hygiene in Healthcare Settings, Volume 51, published 10/25/02, revealed hand antisepsis reduced the incidence of healthcare associated infections. Recommendations included hand hygiene between patients (residents) to reduce infection transmission. Observation on 03/05/19 at 3:30 PM, revealed Registered Nurse (RN) #1 did not perform hand hygiene prior to beginning her medication pass for Resident #38. She retrieved Gabapentin medication from the locked controlled medication drawer, punched the medication from the blister package into her ungloved, unwashed hand, and placed the pill into a medication cup. RN #1 then administered the medication to the resident. After administration of the medication, RN #1 did not perform hand hygiene. Continued observation revealed RN #1 then began medication pass for Resident #25. She retrieved Gabapentin from the locked controlled medication drawer, punched the medication from the blister package into her ungloved hand, and placed the pill into a medication cup. RN #1 then administered the medication to Resident #25. She did not perform hand hygiene post medication pass. Interview with RN #1, on 03/05/19 at 3:35 PM, revealed she should have followed facility policy during the medication administration process. She stated she should have washed her hands prior to beginning the medication administration process. She further stated she should have placed the medication blister package over a medication cup and expelled the medication directly into the cup, rather than handle the medication with her unwashed, ungloved hand. Interview with Licensed Practical Nurse (LPN) #1, on 03/07/19 at 12:53 PM, revealed hand hygiene was taught to all staff by the Director of Nursing (DON). She stated nurses should perform hand hygiene prior to administering medications and should never directly touch a medication with a bare hand. LPN #1 stated nursing staff should discard medications prior to administration if proper infection control processes were not followed. Interview with RN #2, on 03/07/19 at 1:45 PM, revealed nurses should follow facility infection control policies when caring for residents to prevent the spread of infection. She stated pills should not be touched during the medication administration process in order to protect residents from disease transmission. RN #2 further stated medications should be placed directly into a medication cup or onto a spoon prior to administering to a resident. Interview with RN #3, on 03/07/19 at 1:58 PM, revealed she learned about hand hygiene from facility training staff. She stated when staff administered medications, proper infection control processes should be followed. RN #3 stated staff should not administer medications touched by unwashed, ungloved hands because of the risk of disease transmission. Interview with the DON, who also served as the Infection Control Preventionist (ICP), on 03/07/19 at 2:43 PM, revealed all staff learned about hand hygiene from education provided during orientation and periodically throughout the year. She stated she expected staff to follow infection control policies in order to reduce disease transmission amongst residents and staff. The DON stated staff should perform hand hygiene prior to administering medications to limit disease transmission risks. She further stated nurses should not touch oral pill medications with unwashed, ungloved hands. Interview with the Administrator, on 03/07/19 at 3:44 PM, revealed staff learned about infection control policies and processes during orientation and through annual inservices. She stated this was through hand in hand education. The Administrator stated staff should perform hand hygiene during the medication administration process to decrease disease transmission. The Administrator further stated the DON served as the infection control person for the facility and had the responsibility of ensuring infection control processes were followed. Further interview revealed she did not expect nursing personnel to touch medications with ungloved, unwashed hands.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and review of facility Policy, it was determined the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff and the public. Observation on 03/05/19, revealed sewage in the basement area where the dry goods were located. The findings include: Review of the facility's Food Storage Policy, undated, revealed food will be properly stored to preserve flavor, nutritive value, appearance and safety. Observation of the facility basement on 03/05/19 at 10:30 AM, revealed dry goods and a pantry area. Further observation revealed there was evidence of a sewage spill (toilet paper and fecal matter) discovered in the boiler room floor at the bottom of the stairs near the dry goods and pantry area. The space also contained an open sump pump well that was observed to contain dirty and possibly sewage contaminated water. This space was open to the corridor that was in regular use by kitchen staff when getting food items from the pantry area, located in the basement. Interview on 03/05/19 at 10:30 AM, with the Director of Maintenance (DOM) confirmed the observations. The DOM stated an overhead sewage pipe had been damaged several days prior to this discovery and had been repaired. He was unable to explain why the area had not been decontaminated upon completion of the repair. Upon exiting the basement kitchen storage and boiler room a small biohazard sign was observed to have been placed on the boiler room door by person(s) unknown. Further interview with the DOM, on 03/06/19 at 1:39 PM, revealed he was responsible for the Environment. He stated there was a sewage pipe that had backed up, and staff had alerted him of the situation and he had called the plumber. The DOM stated the sewage problem occurred recently; however, he was unable to recall when he was first notified of the concern. Further interview revealed he assumed the plumbers would have cleaned the floor after they had made the needed repairs. Additional interview revealed Dietary staff was responsible for keeping the area clean in the dry storage and pantry area of the basement and were required to wash the basement floor each week. He further stated someone should have cleaned the basement, as there was the possibility of cross contamination from the sewage remains in the floor of the basement to the kitchen food and supplies that were stored in the basement. Interview with the Dietary Manager, on 03/07/19 at 2:25 PM, revealed she was present when the sewage became backed up in the basement and she had to call the DOM in order to have the sump pump turned off and stop it from over flowing onto the floor. She stated it was dietary staff's responsibility to maintain cleanliness, such as mopping the dry storage and pantry floors in the basement. She further stated the sewage should have been cleaned up once the backup was fixed as this could lead to contamination of the dry goods and pantry supplies and foods stored in the basement. Interview with the Director of Nursing (DON), on 03/07/19 at 3:30 PM, revealed there should not have been any sewage in the basement near the dry storage or pantry. She stated this could cause possible contamination of the food items stored in the basement. Interview with the facility's Administrator, on 03/07/19 at 3:45 PM, revealed she was unaware of sewage on the floor of the basement until it was recently brought to her attention by staff. She stated the sewage mess should have been cleaned up when it occurred, as it was not safe or sanitary to have sewage present near the dry food storage and pantry.

Jan 2018 3 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of facility Policy, it was determined the facility failed to provide a written summary of the Baseline Care Plan to the resident and/or the resident representative for two (2) of twenty-one (21) sampled residents (Residents #155 and #255). Record review revealed no documented evidence the facility submitted a written summary of the Baseline Care Plan to Resident #155 and Resident #255 or to their representatives. In addition, interviews with Resident #155 and Resident #255's representatives and interviews with staff, revealed a written summary of the Baseline Care Plan was not provided to the residents or their representatives. The findings include: Review of facility policy titled Baseline Care Plan, dated 04/26/17, revealed it is the policy of the facility to develop and implement a baseline plan of care for each resident admitted that includes instructions to provide effective and person-centered care of the resident that meet professional standards of quality of care. The facility must develop a baseline care plan within forty-eight (48) hours of admission and provide the resident and their representative with a summary of the baseline care plan. 1. Review of Resident #255's medical record revealed the facility admitted the resident on 01/06/18 with diagnosis of Anxiety, Gastro-Esophageal Reflux Disease, Suicidal Ideation's, and Pacemaker. The facility assessed Resident #255 in an admission Minimum Data Set (MDS) dated [DATE], as severely cognitively impaired. Record review of the facility form titled admission Care Plan dated 01/08/18, revealed no documented evidence the baseline care plan was reviewed or signed by Resident #255's family representative. Interview on 01/10/18 at 3:31 PM, with Resident #255's family representative/responsible party, revealed she was not informed about the Baseline Care Plan and did not receive a copy of the care plan. Interview on 01/11/18 at 10:00 AM, with Registered Nurse (RN) #2, revealed the admitting nurse creates the Baseline Care Plan and then gives them to MDS staff for review. She further revealed she discussed Resident #255's Baseline Care Plan with the family representative; however, did not provide a copy of the care plan to the family representative. 2. Review of Resident #155's medical record revealed the facility admitted the resident on 01/05/18 with diagnoses including Acute Respiratory Failure, Anxiety, Congestive Heart failure, and Diabetes Mellitus. Record review of the facility form titled admission Care Plan dated 01/05/18, revealed no documented evidence the baseline care plan was reviewed or signed by Resident #155 or his/her family representative. Interview with Resident #155, on 01/09/18 at 11:00 AM, revealed the resident was not familiar with his/her Baseline Care Plan and had not been given this document. Resident #155 stated the facility may have reviewed the document with his/her daughter. Interview on 01/10/18 at 10:27 AM, with MDS Coordinator #1, revealed Social Services set up the first care plan meeting with the resident and family representative. Per interview, the MDS Coordinators did review the Baseline Care Plan received from the nurse, but the MDS staff did not review the care plan with the residents or families. Interview on 01/10/18 at 3:45 PM, with the Social Worker, revealed she sent a letter to the families seven (7) days prior to the first care plan meeting to inform them of the meeting. Further interview revealed the nurse creates the Baseline Care Plan and then gives the care plan to MDS for review. Interview with Resident #155's daughter, on 1/10/18 4:28 PM, revealed she was asked if she wanted vison/dental/podiatry services for the resident; however, a written summary of a Baseline Care Plan was not received by the resident or family. Further interview revealed she was not given any verbal information regarding a Plan of Care by the facility either. Interview with RN #2, on 01/11/18 at 9:30 AM, revealed she had heard of Baseline Care Plans, but had not yet completed any for the facility. Further interview revealed she had completed Baseline Care Plans at another facility where she also worked. RN #2 stated the Baseline Care Plans must address all care areas and be in a language the resident and/or family could understand. Interview with the Director of Nursing (DON), on 01/11/18 at 4:00 PM, revealed it was her expectation that Baseline Care plans be provided to the resident and/or family representative by nursing staff and that the nursing staff reviewed them with the family and submitted a copy to ensure they understand them. Continued interview revealed it was the facility goal to provide the Baseline Care Plan within forty-eight (48) hours to the resident and resident representative, but this had somehow fallen through the cracks. She further stated the facility was given a sample form to use at a training, but they did not start using it as they preferred to use their own and it somehow got overlooked in the process. Continued interview revealed the facility needed to have the process in place on how to communicate the Baseline Care Plan to the family. Interview with the Administrator, on 01/11/18 at 4:20 PM, revealed it was her expectation staff follow the policy and protocol related to Baseline Care Plans. Per interview, the family and/or representative should have the care plan in a written summary in a language they could understand within forty-eight hours (48) of admission. Further interview revealed all care areas should be addressed and this should be communicated to the resident/and or family ideally by the nursing staff that completed the Baseline Care Plan.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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Based on observation, interview and review of facility Policy, it was determined the facility failed to treat each resident with respect and dignity; and care for each resident in an environment that promotes maintenance or enhancement of his or her quality of life. Observation on 01/08/18 and 01/09/18, revealed staff assisting residents with meal service left domed plate covers turned upside down beside the trays to store paper and plastic waste from the tray. Also, paper and plastic waste was observed to be left on the dining trays during meal service. This affected Residents #2, #4, #5, #19, #26, #37 and #50. The findings include: Review of the facility Notice of Resident Rights and Responsibilities, Policy, revised 11/23/16, revealed the facility must provide a clean, comfortable, homelike environment. Observation on 01/08/18 at 12:53 PM, in the Unit One (1) Dining Room, revealed Resident #37 and Resident #5 were being assisted with dining by staff. Staff left plastic wrappers on both resident's trays and also left domed plate covers turned upside down beside the trays which was utilized to store plastic and paper waste. Observation on 01/08/18 at 01:05 PM, in the Unit One (1) Day Area, revealed Resident #26 and Resident #19 were being assisted by staff with dining. Staff were observed to turn the domed plate covers upside down and use the covers to store wrappers and trash during the meal service. Observation on 01/09/18 at 12:50 PM, in the Unit One (1) Dining Room, revealed Resident #50 and Resident #2 had upside down domed plate covers beside the trays which contained plastic wrap, and there was paper waste on the resident's trays. Also, it was noted on 01/09/18 at 12:51 PM, Resident #4 and Resident #5 were being assisted with dining. Both Resident Resident #4 and Resident #5's trays had plastic wrap and paper waste left on the trays while being assisted with dining. Observation on 01/09/18 at 1:00 PM, in the Unit One (1) Day Area, revealed during meal service while Resident #26 and Resident #19 were being assisted with dining, their domed plate covers were left on the tables upside down and contained wrappers and paper waste. Interview with State Registered Nursing Assistant, (SRNA) #1, on 01/11/18 at 2:00 PM, revealed she was responsible for assisting the residents on Unit One. Continued interview revealed the domed plate covers should be removed from the tray and any trash or wrappers should be discarded and not left on the tray or table. Further interview revealed it could be a dignity issue to leave the domed plate covers and paper and plastic waste on the tables during meal service. She further stated it was common sense to treat the residents the way you would want to be treated, regardless of the resident's cognition. Further interview revealed the facility did not provide ongoing training to the aides on assisting residents with dining, but the education was provided during orientation. Interview with Registered Nurse (RN), #2, on 01/11/17 at 1:45 PM, revealed she had been employed with the facility for five months and she was responsible for assisting residents with dining. Continued interview revealed while assisting with dining the domed plate covers and trash should be removed from the table to provide the residents with a more homelike environment. Further interview revealed this was important for safety to ensure the residents did not eat the paper. Per interview, it was a dignity issue to leave the domed plate covers and trash on the table during meal service. Interview with the Director of Nursing (DON), on 01/11/18 at 4:00 PM, revealed it was her expectation for staff to maintain a homelike environment for the residents by removing the domed plate covers and trash off the tables and trays. Continued interview revealed the facility provided the staff with a cart in which to place the domed plate covers during meal service. She further stated it could be a dignity issue for staff to leave the plate covers and trash on the table during the meal. Continued interview revealed the facility trained staff on how to assist with feeding and monitored daily with quality rounds which were completed by the business office. However, she stated the staff who were monitoring meal service must not have recognized during rounds that the domed plate covers and trash were being left on the tables during meal service on 01/08/18 and 01/09/18. Interview with the Administrator, on 01/11/18 at 4:20 PM, revealed it was her expectation for staff to remove the domed plate covers and trash from the tables and trays prior to assisting residents with dining because it was the residents' right to have a positive dining experience.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, interview and review of facility Policy, it was determined the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observation on 01/09/18 at 2:50 PM, during Follow Up Tour of the kitchen with the Dietary Manager (DM), revealed the Three (3) Compartment Sink Log revealed documentation the QAC (Quaternary) test strip read 200 ppm (parts per million) concentration on 01/09/18; however, observation of testing the sanitation bucket revealed the QAC space test strip read at zero (0) concentration and there was no sanitizing solution in the sanitizing bucket. Also, observation of the tubing in the sanitizing water bucket revealed it led to a sanitizer container under the sink which was empty. Also, observation of the kitchen on 01/09/17 at 3:00 PM, revealed the Dry Storage Flour had a scoop in the container and the Thickener had a plastic drinking cup in the container which was being used as a scoop. Additionally, observation on 01/09/18 at 3:09 PM, in the kitchen, revealed employees were not wearing hair nets properly while preparing and serving food. Furthermore, observation of the kitchen on 01/09/17 at 3:22 PM, revealed the ceiling around the heating unit had accumulated dust and the paint was peeling loose; the window blinds were bent and some of the strips on the blinds were broken; the dishwasher machine was leaking and had a plastic container under it to prevent water from getting on the floor; the juice machine filter visibly needed to be cleaned or changed; the ceiling light fixtures had brown spots and an accumulation of dust; and the floor edges had a buildup of grime. The findings include: Review of the facility's Sanitation Policy, undated, revealed the facility must procure food from approved sources and store, prepare, distribute, and serve food under sanitary conditions. Section C titled Personal Hygiene, revealed staff members should use hair covering appropriately and were to cover all hair under the hairnet. Section D titled Physical Environment, revealed between use, store wiping cloths in containers with the appropriate amount of sanitizing solution and notify maintenance when equipment problems arise and keep records. Review of the Three (3) Compartment Sink Log, revealed the sanitizing solution in the sanitizing bucket was at a level as required per manufacturer's instructions. The QAC (Quaternary) test strip should read between 150 - 200 ppm (parts per million) concentration and staff recorded, on each shift daily throughout the month of January 2018, a consistent reading of two hundred (200). Observation on 01/09/18 at 2:50 PM, during Follow Up Tour of the kitchen with the Dietary Manager (DM), revealed even though the log revealed a reading of 200 for 01/09/18, there was no sanitizing solution in the sanitizing bucket. The QAC space test strip read at zero (0) concentration. Observation of the tubing in the sanitizing water bucket revealed it led to a sanitizer container under the sink which was empty and needed to be refilled or replaced. Further observation during the Follow Up Tour of the kitchen on 01/09/17 at 3:00 PM, revealed Dry Storage Flour had a scoop in the container and Thickener had a plastic drinking cup in the container which was being used as a scoop. Further observation on 01/09/18 at 3:09 PM, in the kitchen, revealed two (2) employees were not wearing hair nets properly while preparing and serving food in order to reduce, eliminate, or prevent the possibility of a food safety hazard. [NAME] #1 had bangs and hair around her face and had hair around the neck which was not tucked inside her hair net. [NAME] #2 had hair pulled into a bun with the hair net loosely covering the bun only. Continued observation on 01/09/17 at 3:22 PM, revealed the overall appearance of the kitchen was soiled. The ceiling around the heating unit had accumulated dust and the paint was peeling loose. The window blinds were bent and some of the strips on the blinds were broken. The dishwasher machine was leaking and had a plastic container under it to prevent water from getting on the floor. The juice machine filter visibly needed to be cleaned or changed. In addition, the ceiling light fixtures had brown spots and an accumulation of dust and the floor edges had a buildup of grime. Interview with [NAME] #1, on 01/10/18 at 10:10 AM, revealed the sanitizer bucket should always have the sanitizing solution in it. [NAME] #1 revealed dietary staff were to get most of their hair into the hair net. [NAME] 1 further revealed hair could possibly get into the food if it was not completely covered by the hairnet. Interview with [NAME] 2, on 01/10/18 at 11:02 AM, revealed it was important to have sanitizer in the bucket to sanitize the rags and provide a sanitary environment. [NAME] 2 revealed hair nets were important and required by policy. [NAME] 2 further revealed the bun hair style seemed appropriate because [NAME] 2 stated I have thick hair so I can't get it all inside the hairnet. However, upon demonstration [NAME] 2 revealed the hair net would actually hold all of her hair and stated I guess it fits if I work at it. Interview on 01/10/18 at 4:10 PM, with the Dietary Manager (DM), revealed it was important to have sanitizer in the bucket and it was a shock to find the sanitizer container under the sink empty. Further interview revealed the hair nets should cover all of the staff member's hair. The DM revealed having a sanitary kitchen was a priority and there was no excuse for exceptions to the policy. The DM stated it was important to be diligent in keeping the kitchen sanitary and all equipment including the juice dispenser and the dish machine clean and in good working order. Per interview, the employees should know not to store a scoop in the dry storage ingredients and re-education and policy review needed to completed with the staff. The DM reported needed to be more diligent in reinforcing the policy. During the interview, the DM revealed the soiled areas of the kitchen should be cleaned by the Maintenance Department and it was her responsibility to fill out a work order and ensure the work was completed. The DM revealed the Maintenance Director completed tasks timely when notified and due to her busy schedule, filling out work orders had gone by the wayside. Interview on 01/10/18 at 4:30 PM, with the Dietitian, revealed the facility should store, prepare, distribute and serve food in accordance with professional standards for food service safety which included ensuring the sanitizing solution in the sanitizing bucket was at a level required per manufacturer's instructions. Per interview, all dietary staff's hair was to be covered by a hair net when in the kitchen. Further interview revealed the general appearance of the kitchen should be spotless. Interview on 01/11/18 at 4:11 PM, with the Director of Nursing (DON)/Infection Control Nurse, revealed the bucket with sanitizer should have the correct amount of sanitizer solution at all times; all kitchen staff should wear a hairnet and no scoops should ever be left in the dry storage ingredients. The DON revealed her expectation was for the kitchen to be sanitary and all kitchen policies followed. Interview on 01/11/18 at 4:23 PM, with the Administrator, revealed the kitchen staff should monitor and do rounds to ensure the container of sanitizer is never empty. The Administrator further revealed the dry storage ingredients should not ever have scoops or plastic drinking cups inside the bins and the dietary staff should cover all of their hair with the hair net. The Administrator stated Maintenance should receive a work order when there was an issue with the kitchen which needed to be handled by maintenance. Per interview, it was the responsibility of the DM to ensure dietary sanitation in the kitchen and to ensure the kitchen was running properly. .

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No fines on record. Clean compliance history, better than most Kentucky facilities.

Concerns

• 13 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
• Grade F (30/100). Below average facility with significant concerns.
• 80% turnover. Very high, 32 points above average. Constant new faces learning your loved one's needs.

Bottom line: Trust Score of 30/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Edgemont Healthcare's CMS Rating?

CMS assigns Edgemont Healthcare an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Kentucky, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Edgemont Healthcare Staffed?

CMS rates Edgemont Healthcare's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 80%, which is 34 percentage points above the Kentucky average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Edgemont Healthcare?

State health inspectors documented 13 deficiencies at Edgemont Healthcare during 2018 to 2025. These included: 1 that caused actual resident harm and 12 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Edgemont Healthcare?

Edgemont Healthcare is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 68 certified beds and approximately 64 residents (about 94% occupancy), it is a smaller facility located in Cynthiana, Kentucky.

How Does Edgemont Healthcare Compare to Other Kentucky Nursing Homes?

Compared to the 100 nursing homes in Kentucky, Edgemont Healthcare's overall rating (1 stars) is below the state average of 2.8, staff turnover (80%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Edgemont Healthcare?

Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.

Is Edgemont Healthcare Safe?

Based on CMS inspection data, Edgemont Healthcare has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Kentucky. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Edgemont Healthcare Stick Around?

Staff turnover at Edgemont Healthcare is high. At 80%, the facility is 34 percentage points above the Kentucky average of 46%. Registered Nurse turnover is particularly concerning at 67%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Edgemont Healthcare Ever Fined?

Edgemont Healthcare has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Edgemont Healthcare on Any Federal Watch List?

Edgemont Healthcare is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 68
Avg. Residents: 64
Occupancy: 95.3%
Ownership: For profit - Corporation
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -10
1 Actual Harm citation: -5
13 Deficiencies: -5
Final Score: 30/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 185389