FRANKLIN-SIMPSON NURSING AND REHABILITATION CENTER
For profit - Limited Liability company
98 Beds
BENJAMIN LANDA
Data: November 2025
Trust Grade
45/100
#162 of 266 in KY
Photo by Lisa Merritt
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Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Franklin-Simpson Nursing and Rehabilitation Center has a Trust Grade of D, which indicates below-average care with some significant concerns. Ranked #162 out of 266 facilities in Kentucky, this places them in the bottom half of the state's nursing homes, although they are the only option in Simpson County. The facility is showing an improving trend, reducing issues from three in 2021 to one in 2025, but there are still serious concerns regarding staffing, as they received a poor 1-star rating in this area and have a staff turnover rate of 55%, which is around the state average. While they have no fines on record, indicating a lack of financial penalties, there are troubling incidents, including a serious case of a resident being abused by staff when they asked for assistance and another case where the facility failed to protect a resident during an ongoing investigation into that abuse. Additionally, food safety practices were inadequate, with unsealed food items stored improperly, raising health concerns.
- Trust Score
- D
- In Kentucky
- #162/266
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 55% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Kentucky facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 21 minutes of Registered Nurse (RN) attention daily — below average for Kentucky. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 15 deficiencies on record. Higher than average. Multiple issues found across inspections.
45/100
Bottom 40%
Needs review
3 → 1 violations
★★☆☆☆
2.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2021: 3 issues
2025: 1 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below Kentucky average (2.8)
Below average - review inspection findings carefully
Staff Turnover: 55%
Near Kentucky avg (46%)
Higher turnover may affect care consistency
Chain: BENJAMIN LANDA
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 15 deficiencies on record
2 actual harm
Jul 2025
1 deficiency
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility failed to treat each resident with respe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for four (4) of 20 sampled Residents (R) (R11, R28, R32, R67) who were unable to freely go outside and one Resident (R32) who had a wander guard in place with no attempts to elope from facility. The findings include:Review of the facility's policy titled, Resident Rights Standard of Practice, dated April of 2024, revealed residents had the right to interact with members of the community and participate in activities both inside and outside of the facility. 1.Review of R11's admission Record revealed the facility admitted the resident on 12/11/2023 with diagnoses which included anxiety disorder and coronary artery disease. Review of R11's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. During an interview on 06/30/25 at 1:52 PM, R11 he stated the staff only let him hang out either in his room or a common room up near the front of the building. He stated he couldn't be in the hallway or by the nurse's station without them running him back into his room. R11 further stated he had never been told that he could go outside if he signed himself out. He further stated that a couple of years ago, residents used to be able to go outside without supervision, but that he hadn't been outside by himself in about 2 years. R11 stated the place was worse than a prison because if he sat with even his toes outside of his room, staff would come by and tell him to get back in his room. 2.Review of R28's admission Record revealed the facility admitted the resident on 03/11/2025 with diagnoses which included anxiety disorder, cerebral infarction, and major depressive disorder. Review of the R28's MDS assessment dated [DATE], revealed a BIMS score of 12 out of 15, indicating the resident was interviewable. During an interview on 07/03/25 at 1:56 PM, R28 stated she was unaware that she was allowed to sign herself out to sit outside. She stated she had never been outside on the porch without supervision. 3.Review of R32's admission Record revealed the facility admitted the resident on 01/21/2025 with diagnoses which included anxiety disorder, cerebral infarction, and diffuse traumatic brain injury. Review of the MDS assessment dated [DATE], revealed a BIMS score of 15 out of 15 indicating the resident was cognitively intact. During an interview on 07/02/25 at 4:34 PM R32 she stated she had a wander guard on because a long time ago she stepped off the porch to smell the flowers and wasn't supposed to step off the porch, so they put it on her. She stated staff told her that she could not go outside without supervision. R32 stated she really enjoyed going outside and not being able to bothered her. She stated that staff hadn't offered to reevaluate her for elopement. R32 further stated that staff rarely let her out because they stated they were to too busy to go outside with her. 4. Review of R67's admission Record revealed the facility admitted the resident on 11/02/2023 with diagnoses which included cerebral infarction, depression, and generalized muscle weakness. Review of the MDS assessment dated [DATE], revealed a BIMS score of 12 out of 15 indicating the resident was interviewable. In an interview on 07/03/25 at 1:00 PM, R67 she stated didn't know residents were allowed to go outside by themselves. She stated every once in a while, the right Certified Nursing Assistant (CAN) would ask her if she wanted to go outside and sit with her. Other than that, staff have told her they are too busy or short staffed to take her outside. In an interview on 07/03/25 at 11:00 AM, the Director of Nursing (DON) stated that residents could sign themselves out to go outside if they have a high enough BIMS score. He stated R32 had a history of pushing doors which sounded the alarm without letting anyone know. The DON stated he wasn't sure when the last date R32 had been reassessed for elopement, but nursing staff or administration did it at least once a year. In an interview on 07/03/25 at 12:43 PM, Certified Nursing Assistant 8 (CNA8) stated if a resident with a high enough BIMS wanted to go outside, staff would take them out if they could. She further stated it didn't happen that often and residents may not know they need to ask if they want to go outside. In an interview on 07/03/25 at 12:55 PM, Licensed Practical Nurse 5 (LPN 5) stated staff kept a list of when residents who ask to go outside in a binder. If someone with a high enough BIMS, the resident could ask staff and put their name on the list so they can go outside. LPN5 stated if a resident with a high BIMS who was immobile wanted to go outside, they would have to hit their call light to let staff know they wanted to go out. She stated that didn't happen often. Review of the Sign In/Out Binder revealed no documented evidence R11, R28, R32, and R67 had been signing out to go outside and sit on the porch. In an interview with the Administrator on 07/03/2025 at 1:46 PM, she stated residents would ask to go out and can go outside when they want. She stated she had not attended resident counsel, but staff communicated with residents through the meetings and the activities coordinator. She stated staff would take residents with low BIMS outside. She stated R32 walked a lot and has a history of approaching doors, so a wander guard was in place for safety. The Administrator further stated most residents with a wander guard have them in place for safety and are assessed to be elopement risks. She stated those elopement assessments were completed quarterly.
May 2021
3 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy, it was determined the facility failed to ensure the care ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy, it was determined the facility failed to ensure the care plan was followed related to the dietary needs of two (2) of eighteen (18) sampled residents. (Resident #66 and Resident #40)
Observation during lunch meal pass on 05/18/2021, Resident #40 and #66 did not have fortified mashed potatoes. Review of care plan interventions for both Resident #40 and #60 interventions directed staff to provide diet as ordered. Additionally, Resident #66 meal ticket required (2) two cartons of milk that were observed to not be on the tray of Resident #66 during meal service.
The Findings include:
Interview on 05/20/2021 at 4:05 PM, with Administrator, revealed the facility did not have policies or guidelines concerning physician orders, dietary needs or following of care plans for residents. However, the Administrator stated the facility followed the standard of practice for care from Center for Medicare and Medicaid (CMS).
Review of provided Clinical Standards of Practice, Comprehensive Care Plans Standard of Practice with revision date of 11/2017 revealed; It is the practice of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The resident will receive the appropriated treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
1. Record review revealed the facility admitted Resident #40 on 06/30/2020 with diagnoses to include Dementia with Behavioral Disturbance, Need for Assistance with Personal Care, Other Symptoms and Signs involving Cognitive Functions and Awareness, Age-Related Nuclear Cataract, and Retinal Vascular Appearance bilaterally.
Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #40 to have a brief interview mental status (BIMS) of (3) three which indicated the resident had severe cognitive impairment. Additionally, residents activities of daily living (ADLs) for eating required limited assistance, with no loss of weight in the last (6) six months of 10%.
Observation on 05/18/2021 at 11:55 AM, of the Lunch Meal, revealed Resident #40 did not have fortified potatoes on tray per the meal ticket requirement.
Review of Physician Orders for Resident #40 with start date of 01/05/2021 and ending date of 05/31/2021, revealed a regular consistency diet with thin liquids, fortified foods with meals was ordered.
Review of Resident #40's Care Plan, dated 04/05/2021, revealed, the resident was at risk for Alteration in Nutrition as evidenced by diagnosis of dementia which required cueing/assistance with all aspects of activities of daily living. The care plan interventions directed staff to provide diet as ordered, and fortified foods with meals.
Review of 05/18/2021 lunch Meal Ticket for Resident #40, revealed Resident to have half cup of fortified mashed potatoes. However, the potatoes was not on the meal tray per ticket requirement.
Interview with CNA #5, on 05/18/2021 at 12:03 PM, revealed she did not notice the fortified potatoes were not on the tray.
Interview with Assistant Director of Nursing (ADON), on 05/18/2021 at 12:00 PM, revealed, Resident #40's tray should contain the fortified potatoes. The ADON stated the kitchen staff were responsible for preparing the tray according to diet orders and staff that delivered trays should ensure it matched to Meal Ticket at time of service.
2. Record review revealed the facility admitted Resident #66 on 12/01/2020 with diagnoses to include Unspecified Dementia with Behavioral Disturbance, Iron Deficiency Anemia, Type II Diabetes Mellitus, Generalized Anxiety Disorder, Chronic Ishemic Heart Disease, Chronic Kidney Disease, and Need for Assistance with Personal Care.
Review of quarterly 05/04/2021 MDS revealed Resident #66 was cognitively intact with a BIMS of (13) thirteen. In addition, the resident required limited assistance with eating.
Interview on 05/18/21 at 12:06 PM, with Resident #66 revealed resident was sitting in front of lunch tray stated where is my milk and tray with no milk on it or fortified potatoes.
Observation on 05/18/2021 at 12:06 PM with Resident #66 revealed lunch meal tray with no fortified mashed potatoes or milk visible on tray as required per lunch meal ticket.
Review of 05/18/21 lunch meal ticket revealed resident required to have 1/2 cup of fortified mashed potatoes and (8) eight ounces of milk (2 whole milks).
Record review of the dietary orders for Resident #66 dated 02/23/21 with ending date of 05/31/21 revealed; dietary order for regular vegetarian diet, consistency thin regular liquids, and vegetarian and fortified foods with all meals.
Record review of Resident # 66's care plan with target date of 06/30/2021 revealed, Alteration in nutrition as evidenced by diagnosis of Dementia: adjust for food allergies/intolerance, ethnic preferences with diet order, provide diet as ordered and maintain independent eating. Resident #66 is to maintain idea/usual body weight X 90 days.
Interview on 05/18/21 at 12:07 PM and on 05/20/21 at 9:38 AM with CNA #4 revealed milk and potatoes were not on the meal tray for Resident #66. Additionally, CNA #4 stated that milk is brought to the floor and served on the trays to the resident by staff.
Interview on 05/18/2021 at 12:10 PM, and on 05/20/21 at 09:39 AM with ADON revealed the tray did not have the milk or the potatoes, but should be on the tray when served. Additionally, ADON stated there was two (2) instances back-to-back related to the fortified mashed potatoes not being on the meal trays for residents, and milk is served by the nursing staff on the floor, and whomever passes the tray should ensure that the meal ticket requirements are the tray and kitchen should make sure as well.
Interview on 05/18/2021 at 12:10 PM and on 05/20/2021 at 3:54 PM with Licensed Practical Nurse (LPN) #4/Unit Manager (UM) #1 revealed he had served Resident #66 tray and stated he just looked and thought he saw the milk and potatoes but guessed he did not. LPN #4/UM #1 stated that dietary checks the ticket and puts on the tray what is supposed to be on the ticket, and the residents have fortified food because the diet is needed probably for weight gain; Additionally, LPN #4/UM #1 revealed all staff is to follow the care plan in the best interest of the resident.
Interview on 05/20/2021 at 10:32 AM with Dietician revealed the reason for dietary fortified foods and 8 ounces of milk for Resident #66 is that he/she is on lacto-ovo diet (milk eggs can have things like that to ensure calories),and he/she is a picky eater so did that to ensure additional calories and protein. Dietician stated if on meal ticket should be supplied when asked about fortified food for Unsampled Resident #40 and Resident #66 and milk required per meal ticket for Resident #66.
Interview on 05/20/21 at 3:56 PM with ADON revealed that everyone is to follow the care plan due to the care plan being the guide to take care of the residents and their nutrition.
Interview on 05/20/2021 at 3:59 PM with Staff Development Coordinator revealed that staff is to follow what is on the care plan for fortified foods and would expect the staff to get what is required on the meal ticket for the residents.
Interview on 05/20/2021 at 4:07 PM with Director of Nursing (DON) revealed that she expects staff to follow the care plan in providing care for residents and that the chain of command is to be followed to ensure that care is provided to the resident; everyone follows the residents plan of care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and Code of Federal Regulations (CFR) 483.45(g) review, it was determined the facility failed t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and Code of Federal Regulations (CFR) 483.45(g) review, it was determined the facility failed to ensure drugs used in the facility were labeled in accordance with currently accepted professional principles for one (1) of the facility's two (2) medication rooms.
On [DATE], observation of the medication room on the 200 Hall revealed a Levemir (insulin) pen and Bromfed (antihistamine, cough suppressant, decongestant) liquid were opened. However, the drugs were not dated when opened.
Interview with the Administrator revealed the facility did not have a policy for storage and labeling of drugs and biologicals.
The findings include:
Review of the CFR titled, 483.45(g) Labeling of Drugs and Biologicals and §483.45(h) Storage of Drugs and Biologicals revealed the facility staff should date the label of any multi-use vial when the vial was first accessed and access the vial in a dedicated medication preparation area. If a multi-dose vial had been opened or accessed, the vial should be dated and discarded within twenty-eight (28) days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.
On [DATE] at observation of the Medication Room on the 200 Hall, revealed a Levemir (insulin) pen and Bromfed (antihistamine, cough suppressant, decongestant) liquid were opened. However, the drugs were not dated when opened.
Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 4:05 PM, revealed the date should be written on any drug and/or biological when opened to ensure drugs and biologicals weren not stored past the use by date. Continued interview revealed the facility's policy was to date all drugs and biologicals when opened. LPN #2 stated it was important to write the date opened on the drug so others would know date of expiration.
Interview with the Director of Nursing (DON), on [DATE] at 4:47 PM, revealed the Levemir insulin pen and Bromfed liquid should have been dated when opened. Continued interview revealed staff who opened drugs and/or biologicals were responsible to date and initial the container. The DON stated dating drugs after opening was done to ensure residents were not given expired or outdated drugs.
Interview with the Administrator, on [DATE] at 4:49 PM, revealed the facility did not have a policy for labeling and storage of drugs and biologicals. Continued interview revealed the facility followed Federal and State guidelines for labeling and storage of drugs and biologicals.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to provide a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to provide a well-balanced diet to meet the dietary needs of for two (2) of eighteen (18) sampled residents, Resident # 66 and #40
During lunch meal pass on 05/18/2021, Resident #40 and #66 did not have fortified mashed potatoes per the Meal Ticket, physician order, or care plan. Additionally, Resident #66's Meal Ticket required (2) two cartons of milk to be provided, however, they were not on Resident #66's tray.
The Findings include:
Interview on 05/20/2021 at 4:05 PM, with the Administrator, revealed the facility did not have for policies or guidelines concerning physician orders, dietary needs or following of care plans for residents. However, the facility does follow the standard of practice for care from Center for Medicare and Medicaid (CMS).
Review of the Comprehensive Care Plans Standard of Practice, with revision date of 11/2017, revealed it was the practice of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The resident would receive the appropriated treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
1. Record review revealed the facility admitted Resident#40 on 06/30/2020, with diagnoses to include Dementia with Behavioral Disturbance, Need for Assistance with Personal Care, Other Symptoms and Signs involving Cognitive Functions and Awareness, Age-Related Nuclear Cataract, Blepharoconjunctivitis (inflammation of the transparent covering of the eye due to bacterial or viral infection)/Blepharitis Bilaterally (eye-lid drooping), and Retinal Vascular Appearance bilaterally. Review of Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a brief interview mental status (BIMS) of (3) three indicating severe cognitive impairment, and required limited assistance for eating related to activities of daily living (ADLs). Additionally, per K0300 of MDS the resident had not lost weight in month or 10% of weight loss in the last (6) six months.
Observation on 05/18/2021 at 11:55 AM, revealed Resident #40's tray did not have fortified potatoes on tray per the Meal Ticket requirement.
Review of Resident #40's Physician Orders, revealed and order with a start date of 01/05/2021 and ending date of 05/31/2021 which ordered staff to provide a regular consistency diet with thin liquids, fortified foods with meals.
Review of Resident #40's Plan of Care, dated 04/05/2021, revealed the resident was at risk for Alteration in Nutrition, as evidenced by diagnosis of Dementia which required cueing/assistance with all aspects of activities of daily living; with treatment/intervention to provide diet as ordered, and resident ate independently staff would provide assistance as needed, and would provide fortified foods with meals.
Review of 05/18/2021 lunch Meal Ticket for Resident #40, revealed Resident to have half cup of fortified mashed potatoes.
Interview on 05/18/2021 at 12:03 PM, with Certified Nursing Assistant (CNA) #5, revealed she served the tray for Resident #40 but did not notice the fortified potatoes were not on the tray.
Interview on 05/20/2021 at 10:32 AM, with Dietician, revealed the reason for fortified foods was to maintain or increase resident weight. The Dietician stated the ordered meal requirements should be served on the tray
Interview on 05/18/2021 at 12:00 PM, with Assistant Director of Nursing (ADON), revealed Resident #40's tray did not have the fortified potatoes as indicated on the Meal Ticket. The ADON stated when trays were passed staff should ensure the items on the tray matched the Meal Ticket prior to serving to the resident. In addition, the kitchen staff should ensure the required food items were on the tray as well.
2. Record review revealed the facility admitted Resident #66 on 12/01/2020 with diagnoses of Unspecified- Dementia with Behavioral Disturbance, Iron Deficiency Anemia, Type II Diabetes Mellitus, Generalized Anxiety Disorder, Chronic Ischemic Heart Disease, Chronic Kidney Disease, and Unspecified Systolic Congestive Heart Failure. Review of the MDS dated [DATE], revealed Resident #66 had a BIMS of (13) thirteen indicating the resident to be cognitively intact. Additionally, Resident #66 required limited assistance with eating concerning his/her ADLs and had not had a weight loss of 10% in (6) six months.
Record review of the dietary orders for Resident #66, dated 02/23/2021 with ending date of 05/31/2021, revealed a dietary order for a regular vegetarian diet, with thin liquids, and fortified foods with all meals.
Observation on 05/18/2021 at 12:06 PM, revealed Resident #66's lunch meal did not have fortified potatoes or milk on tray, as required per lunch Meal Ticket. The resident was heard to say where is my milk?.
Interview on 05/18/2021 at 12:06 PM, with Resident #66, revealed he/she was missing milk on his/her tray.
Review of the 05/18/2021 lunch Meal Ticket, revealed Resident #66 was required to have a half cup of fortified mashed potatoes and (8) eight ounces of milk (2 whole milks).
Record review of Resident # 66's Care Plan, with target date of 06/30/2021 revealed, the resident was at risk for Alteration in Nutrition as evidenced by diagnosis of Dementia. The interventions directed staff to adjust for food allergies/intolerance, allow for likes /dislikes, ethnic preferences with diet order, provide diet as ordered and maintain independent eating. Resident #66 was to maintain idea/usual body weight times ninety days.
Interview on 05/18/2021 at 12:07 PM, and on 05/20/2021 at 9:38 AM, with CNA #4, revealed milk and potatoes were not on the meal tray for Resident #66, and she did not know who provided the resident the tray. Additionally, CNA #4 stated that milk was brought to the floor and served on the trays to the resident by staff.
Interview on 05/18/2021 at 12:10 PM, and on 05/20/2021 at 9:39 AM with ADON revealed the tray did not have the milk or the fortified potatoes, but should have been on the tray when served. Additionally, the ADON stated there were two (2) instances back-to-back related to the fortified mashed potatoes not being on the meal trays for residents which was an issue. She stated the milk was served by the nursing staff on the floor and poured into a cup if resident desires, and whomever passed the tray should ensure the meal ticket requirements were on the tray and kitchen staff should ensure as well.
Interview on 05/18/2021 at 12:10 PM, with Licensed Practical Nurse (LPN) #4/Unit Manager (UM) #1, revealed he had served Resident #66 tray and stated typically opened the lid of the plate and checked to ensure the resident was getting everything he/she was supposed to according to the Meal Ticket. Additionally, LPN #4/UM #1, stated he just looked and thought he saw the milk and potatoes but guessed he did not. LPN #4/UM #1 stated that dietary checked the Meal Ticket to ensure the ordered dietary requirments were on tray. He stated the residents had fortified food because that diet was needed and was probably for weight gain.
Interview on 05/18/2021 at 12:20 PM, with Dietary Aide (DA) #1, revealed the resident tray was checked by the kitchen staff prior to sending to the unit. The DA was not sure how the fortified foods had been missed. Additionally, the Dietary Aide #1 stated the milk was taken to the unit for the nursing staff to pass out with the meal trays.
Interview on 05/20/2021 at 10:32 AM, with Dietician, revealed the reason for dietary fortified foods and eight ounces of milk for Resident #66 was that he/she was on lacto-ovo diet (milk/eggs). The Dietician stated the resident was a picky eater so the diet was to ensure additional calories and protein. The Dietician stated the ordered meal requirements should be on served on the tray.
Interview on 05/20/2021 at 4:07 PM with Director of Nursing (DON) revealed that she expected staff to follow the care plan in providing care for residents related to ordered meal requirements to ensure nutrition needs were met.
Feb 2019
11 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure each resident was free from abuse, neglect and corporal punishment of any...
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Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure each resident was free from abuse, neglect and corporal punishment of any type by anyone for one (1) of twenty-five (25) sampled residents (Resident #67).
Interviews with Resident #67 on 02/12/19 revealed during the night shift on 02/11/19, he/she asked a staff member to put a pillow behind his/her head and the staff member threw the pillow at him/her, hitting him/her in the face. Resident #67 stated the staff threatened the resident that he/she would remain in the facility longer for asking for help. Resident #67 stated this treatment caused him/her to be fearful and sad. In addition, the resident was sent to the hospital due to increased anxiety after attempting to identify the alleged perpetrator by looking at pictures of staff and staff walking by his/her room.
The findings Include:
Review of the facility policy titled, Abuse Prohibition Standards of Practice, last revised September 2016, revealed each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The resident has the right to be free from mistreatment, neglect, and misappropriation of property. The following standards of practice will be operationalized in order that residents will not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.
Record review revealed the facility admitted Resident #67 on 01/24/19 with diagnoses which included Anxiety Disorder, Muscle Atrophy, Headache, Diabetes Mellitus, and other abnormalities of gait and mobility. Review of admission Minimum Data Set (MDS) assessment, dated 02/10/19, revealed the facility assessed Resident #67's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated this resident was cognitively intact and interviewable.
Interview with Resident #67 on 02/12/19 at approximately 9:35 AM revealed Resident #67 reported that on the previous evening during the night shift the staff member that came into his/her room and assisted him/her was very mean and rude to him/her. Resident #67 stated he/she asked the staff member to put a pillow behind his/hr head and the aide threw the pillow at him/her hitting him/her in the face with the pillow. Resident #67 further stated the staff member told him/her in a very mean tone you're gonna have to learn to do this yourself. Resident #67 revealed the staff member also told him/her that she was going to put a note in the resident's chart reporting that the resident asked for help and that would ensure the resident remained at the facility longer. Resident #67 stated the incident made him/her feel fearful and sad. Resident #67 stated he/she did not know the name of the staff member that threw the pillow at him/her but described the staff as being female with long brown hair who wears glasses. At the end of the conversation, Resident #67 asked the Surveyor for some help adjusting his/her pillow behind his/her head. Surveyor informed an aide that Resident #67 needed some assistance and Surveyor observed the aide adjust the pillow behind Resident #67's head and observed the resident's face which appeared sad and on the verge of tears. Surveyor heard Resident #67 ask the aide, Am I gonna get written up? The aide told Resident #67 no, why would you get written up? Resident #67 stated the aides tell me I'm gonna get written up every time I ask them to help me and that I will have to stay at the facility even longer.
Interview with family member #1 on 02/12/19 at approximately 9:55 AM who was Resident #67's roommate's son revealed he had observed many of the aides having attitudes and talking rough with a lot of the residents and that it takes staff a long time to respond to call lights. Family member #1 stated some of the aides don't like to help Resident #67 and he has assisted Resident #67 in the past but the facility informed him that he was not allowed to do that. Family member #1 stated he knows Resident #67 was supposed to do a lot on his/her own but Resident #67 only asked for help from staff when he/she really needed it.
On 02/12/19 at approximately 10:10 AM, Surveyor informed the Administrator and Director of Nursing (DON) of the allegation of abuse made by Resident #67 and the description of the staff member. The Administrator and DON both reported they had no prior knowledge of the allegation and were not aware of the alleged incident. The Administrator and DON stated there was no staff employed at the facility that fit that description.
Review of Nursing Progress Notes dated 02/07/19 at 9:06 PM and interview with the DON on 02/12/19 at approximately 10:10 AM revealed Resident #67 made false allegations in the past when he/she reported to one staff member that he/she did not receive night time medications until 8:30 PM and reported to another staff member that he/she did not receive his/her medications until 10:00 PM. Review of Resident #67's Comprehensive Care Plan revealed the resident was care planned for making these false allegations; however, the facility was unable to provide documentation the facility completed an Investigation regarding the claims made by Resident #67 to try to determine if the allegations were false.
Further interview with family member #1 on 02/12/19 at 10:15 AM outside Resident #67's room revealed Therapy wanted Resident #67 to do things by him/herself but sometimes Resident #67 needs help and staff won't provide it to him/her. Family member #1 stated his parent (Resident #67's roommate) told him that neither resident gets much help at night and staff do not like them on the call light at night. At the end of the conversation Surveyor observed Resident #67's door open and the Administrator, DON and Assistant Director of Nursing (ADON) exit.
Interview with Resident #67 on 02/12/19 at approximately 10:30 AM revealed the Administrator and the DON just came into his/her room and they brought a boy with them this time. Resident #67 stated the Administrator told him/her the incident that was reported did not happen to you. Resident #67 revealed the Administrator and DON told him/her the nurse or aide did not hit him/her in the face with anything and that he/she was making the story up. Resident #67 stated she was more afraid he/she would not be able to leave the facility anytime soon.
Interview with Administrator, DON and team leader on 02/12/19 at approximately 11:00 AM revealed the Administrator reported she, along with the DON and ADON interviewed Resident #67 in regards to the alleged allegations. The Administrator stated Resident #67 reported the nurse or aide did not hit him/her in the face with the pillow but the nurse or aide tossed the pillow towards him/her after he/she requested a pillow. The Administrator revealed they spoke with Resident #67's roommate's son and he reported he never saw staff in the room assisting Resident #67 before leaving, and he observed staff being very encouraging to Resident #67 to try and do things on her own in regards to therapy, and that Resident #67 was very needy. The DON also stated Resident #67 reported having a hole in his/her mattress and they checked the mattress and there was clearly no hole implying that Resident #67 was confused and made false claims.
Interview with Resident #67 on 02/12/19 at approximately 11:30 AM in regards to the conflicting statements the Administration reported in regards to their questioning of Resident #67 revealed when Surveyor asked Resident #67 to explain what happened with the nurse or aide and the pillow to ensure Surveyor understood the scenario correctly. Resident #67 stated the nurse or aide threw the pillow at him/her and hit him/her in the face. Surveyor asked Resident #67 if he/she reported to the Administrator and DON that the staff member hit him/her in the face and Resident #67 replied yes, I told them the nurse or aide threw the pillow and it hit me in the face. Surveyor asked Resident #67 if her roommate's son was in the room when the incident occurred and he/she replied no, he had already gone home before it happened. Surveyor asked Resident #67 if he/she reported to the Administrator and DON that his/her roommate's son was present during the incident and Resident #67 stated no, he/she did not. Surveyor asked Resident #67 if she reported having a hole in his/her bed and he/she stated he/she did not have a hole in his/her bed but an indention in the middle of the bed where the mattress was sunk in and it was uncomfortable to sleep on.
On 02/12/19 at approximately 1:15 PM Surveyors told the Administrator the Surveyors had some concern since Administrator's interviews with Resident #67 and Surveyors interviews with the resident seemed to be conflicting statements and the Surveyors would like to Interview Resident #67 in regards to the allegation with the Administrator present. The Administrator stated she spoke with Resident #67's doctor and due to Resident #67's increased anxiety in relation to the allegations and questioning they felt that Surveyors should wait until the next day to talk with Resident #67 anymore in regards to the allegations.
Interview with Resident #67's Physician on 02/12/19 at approximately 3:20 PM revealed he never actually spoke with the Administrator but he did receive a fax from the facility stating Resident #67 had increased anxiety and Resident #67 was unable to do anything for herself as a result of the anxiety. Resident #67's Physician stated the only recommendation he made was for the facility to schedule a Psychological evaluation for Resident #67. Resident #67's Physician further revealed he did not feel like there was any reason why Surveyors could not speak with and interview Resident #67 in regards to the allegations.
Interview with Resident #67 on 02/12/19 at 4:18 PM with the Administrator present revealed Resident #67 stated the nurse or aide told him/her there were forty-eight (48) other residents she had to assist and the resident had no business being on the call light. Resident #67 stated the nurse or aide told him/her I'm going to tell you right now you're going to have trouble getting out of here. Resident #67 stated he/she asked the nurse or aide to get him/her a pillow and the nurse or aide tossed it at him/her and the pillow hit him/her in the face. The resident stated all staff look the same but the nurse or aide was wearing the colors teal/blue. Resident #67 stated she told his/her roommate's son about the incident the next morning. Resident #67 stated there is a blonde staff member who tells him/her that he/she can do it him/herself and does not offer assistance. Resident #67 stated he/she only wants help when he/she needs help.
Record review revealed on 02/12/19 when Administrator had initially advised Surveyors against further interviews with Resident #67 due to concerns over the resident's increased anxiety that Resident #67 had to be taken to the Medical Center of Bowling [NAME] for emergency medical attention for concerns of Anxiety and stress reaction. The Administrator admitted Resident #67's hospital visit occurred after the Administrator showed photos of the alleged perpetrator and had potential perpetrators walk pass Resident #67's door for Resident #67 to identify.
Interview with Resident #67 on 02/14/19 at approximately 8:20 AM revealed that girl came into his/her room last night (02/13/19) with LPN #4. Resident #67 stated he/she recognized her and that her name was SRNA #3. Resident #67 stated SRNA #3 was the aide that threw the pillow at him/her and hit him/her in the face. Resident #67 stated he/she does not want SRNA #3 or LPN #4 back in his/her room anymore because it made him/her feel uncomfortable.
On 02/14/19 at 8:30 AM with another Surveyor present the Administrator was informed Resident #67 had identified the alleged perpetrator as SRNA #3. The Administrator stated Resident #67 also reported to her that he/she had identified the alleged perpetrator as SRNA #3 but Administrator stated SRNA #3 has blonde hair. The Administrator was also informed that Resident #67 requested that SRNA #3 and LPN #4 not be allowed to provide him/her care. The Administrator stated Resident #67 made the same request to her but she explained to Resident #67 that was not possible due to potential safety concerns.
Attempted interview on 02/15/19 at approximately 10:40 AM with SRNA #3 was unsuccessful as the number provided by Administrator was disconnected.
Interview with DON on 02/15/19 at approximately 1:55 PM revealed when they interviewed Resident #67 in regards to the alleged allegation she, along with Administrator acted out the alleged incident in front of the resident to ensure they understood exactly what happened. The DON stated the resident stated the nurse pitched the pillow at him/her but resident was unable to catch the pillow and that is why the pillow hit resident in the face. Surveyor asked the DON if the resident reported the pillow did hit him/her in the face and DON stated yes, but the nurse did not mean for the pillow to hit him/her in the face. Surveyor asked DON why Administrator and DON reported to Surveyor and Lead Surveyor that Resident #67 stated to them specifically that the pillow never actually hit Resident #67 in the face. The DON stated she did not recall that being stated.
Interview with Administrator on 02/13/19 at approximately 10:00 AM revealed she in accordance with the facility have a zero tolerance in regards to abuse and that she takes the allegations very seriously and that it was her expectation that all staff treat residents respectfully and residents they feel safe in the facility.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Investigate Abuse
(Tag F0610)
A resident was harmed · This affected 1 resident
Based on interview, record review and review of facility policy, it was determined the facility failed to prevent further potential abuse, or mistreatment while an investigation was is in progress by ...
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Based on interview, record review and review of facility policy, it was determined the facility failed to prevent further potential abuse, or mistreatment while an investigation was is in progress by failing to suspend the alleged perpetrator for one (1) of twenty-five (25) sampled residents (Resident #67).
On 02/12/19, Resident #67 alleged he/she was abused by staff on the night shift on 02/11/19, but Resident #67 was unable to identify the staff by their name. On 02/14/19, Resident #67 stated the staff came into his/her room on the evening of 02/13/19 and he/she identified the staff as State Registered Nurse Aide (SRNA) #3. On the morning of 02/14/19, Resident #67 and Surveyors reported this information to the Administrator; however, the Administrator failed to suspend or remove SRNA #3 from care while the allegation was investigated,
The findings include:
Review of facility policy titled, Abuse, Neglect, Or Misappropriation of Resident Property Policy, last revised 03/10/17, revealed under section VI. Protection, in order to provide protection to the resident during an investigation of abuse, neglect or exploitation the following will be done; the alleged abuser will be removed from the facility immediately, and not allowed in the facility, pending the outcome of the investigation.
Record review revealed the facility admitted Resident #67 on 01/24/19 with diagnoses which included Anxiety Disorder, Muscle Atrophy, Headache, Diabetes mellitus, and other abnormalities of Gait and mobility. Review of Minimum Data Set (MDS) assessment, dated 2/10/19, revealed the facility assessed this resident's Brief Interview for Mental Status (BIMS) score as a fifteen (15), which indicated this resident was cognitively intact and interview able.
Interview with Resident #67 on 02/12/19 at approximately 9:35 AM revealed Resident #67 reported that on the previous evening (02/11/19), during the night shift, the aide that came into his/her room and assisted him/her was very mean and rude to him/her. Resident #67 stated he/she asked the aide to put a pillow behind her/his head and the aide threw the pillow at him/her hitting him/her in the face with the pillow. Resident #67 further stated the side told him/her in a very mean tone your gonna have to learn to do this yourself. Resident #67 revealed the aide also old him/her that she was going to put a note in the resident's chart reporting that the resident asked for help and that will ensure the resident remained at the facility even longer. Resident #67 stated the incident made her/him feel very fearful and sad. Resident #67 stated he/she did not know the name of the staff member that threw the pillow at him/her but described the aide as being female with long brown hair who wears glasses.
On 02/12/19 at approximately 10:10 AM the Administrator and Director of Nursing (DON) were informed of the allegation of abuse made by Resident #67 and the description of the staff member. The Administrator and DON stated there was no staff employed at the facility that fit that description.
Further interview with Resident #67 on 02/14/19 at approximately 8:20 AM revealed the girl who threw the pillow at him/her that hit him/her in the face came into his/her room on the night of 02/13/19 and she recognized her and she was SRNA #3.
On 02/14/19 at 8:30 AM the Administrator was informed Resident #67 had identified the alleged perpetrator as SRNA #3. The Administrator stated that Resident #67 also reported to her that he/she had identified the alleged Perpetrator as SRNA #3 but the Administrator stated SRNA #3 has blonde hair.
Interview with Administrator on 02/15/19 at 1:55 PM revealed the Administrator did not suspend or remove SRNA #3 because Administrator stated she did not feel like SRNA #3 was credibly identified as a perpetrator. The Administrator stated she investigated SRNA #3 and ruled her out as a potential perpetrator. The Administrator revealed SRNA #3 was not suspended or removed from the schedule prior to her being ruled out as a potential perpetrator. The Administrator stated on the evening of 02/12/19 after Surveyors had left for the day she showed Resident #67 several photos of different staff members and she also had staff members walk past Resident #67's door for Resident #67 to look at and Resident #67 did not identify SRNA #3 or any other staff as the alleged perpetrator. The Administrator stated she would show the resident the photos again in front of us to show that SRNA #3 was not the staff the resident identified.
On 02/15/19 at approximately 3:15 PM, in the presence of Surveyors, the Administrator informed Resident #67 that he/she would be shown several photos to see if he/she recognized the staff member was the person who struck him/her in the face with a pillow. The Administrator showed the resident a photo of the DON and the resident stated that was not the alleged perpetrator. The Administrator then pulled up a photo of SRNA #3 and the resident identified the person in the photo as the person that Resident #67 reported threw the pillow and hit Resident #67's face.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to treat one (1) of twenty-five (25) sampled residents with respect and dignity and...
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Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to treat one (1) of twenty-five (25) sampled residents with respect and dignity and care for the resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing the resident's individuality (Resident #36).
Resident #36 was resistive to care when staff identified the resident had food on his/her shirt and face after eating his/her meal; however, staff failed to provide a second attempt to clean the resident's face and change shirt for over and hour later and failed to follow facility protocol of having another staff attempt to clean the resident.
The findings include:
Review of the facility policy titled Resident Rights, not dated, revealed the resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility. The resident has the right to be treated with respect and dignity.
Record review revealed the facility admitted Resident #36 on 12/17/18 with diagnoses which included Muscle Weakness, Muscle Wasting and Atrophy, Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, and Generalized Anxiety Disorder. Review of Admissions Minimum Data Set (MDS) assessment, dated 01/03/19, revealed the facility assessed Resident #36's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3), which indicated this resident was interviewable.
Observation on 2/12/19 at approximately 1:45 PM revealed Resident #36 was lying on back in bed. Resident #36's shirt was completely covered in food and crumbs. Interview was attempted with Resident #36 as to why his/her shirt had so much food on it but Resident #36 was unable to verbalize anything. Further observation revealed there was no food tray present in Resident #36's room or anything to indicate Resident #36 was eating or had just finished eating.
Observation on 02/12/19 at approximately 1:50 PM revealed Resident #36 was still lying on is/her back in bed with his/her shirt completely covered in food and crumbs. Interview was attempted with Resident #36 as to why he/she had so much food on his/her shirt but Resident #36 was unable to verbalize anything.
Interview on 02/12/19 at approximately 2:04 PM with State Registered Nurse Aide (SRNA) #6 revealed she picked up Resident #36's tray today (02/12/19) after lunch and she asked Resident #36 if he/she was finished with his/her food. She stated when she attempted to clean Resident #36's face and change his/her shirt the resident would not allow her to clean his/her face or change the shirt. SRNA #6 revealed it was the normal process to ask a resident if staff can clean them or change their clothes. SRNA #6 stated she reported the incident to the DON and waited about forty-five (45) minutes to an hour before trying to go back into Resident #36's room again and trying to clean him/her again. SRNA stated she did not remember the time that she attempted to get Resident #36's tray and clean him/her, but tray pick up was usually between 12:30 and 1:00 PM daily. SRNA #6 revealed when she reported it to the DON, the DON instructed her to wait a while and then go back and check on Resident #36. SRNA #6 stated the DON did not attempt to intervene with the resident and did not have another staff attempt to assist SRNA #6 in changing Resident #36's clothes or clean his/her face.
Interview on 02/13/19 at approximately 9:20 AM with SRNA #7 revealed during tray pick up they knock on the resident's door and ask the resident if they have finished eating. SRNA #7 stated if the resident was not finished they leave and come back and check again. SRNA #7 revealed if she observed the resident's clothes were soiled she would change the resident's clothes but if the resident was resistive, staff protocol was to immediately notify the charge nurse on duty. SRNA #7 stated if a resident was covered in food and staff was having an issue with the resident allowing them to change their clothes, staff would wait a little before another attempt but leaving a resident in food for thirty (30) minutes before a 2nd attempt was too excessive. SRNA #7 stated she has provided care to Resident #36 and is familiar with his/her demeanor. SRNA #7 stated Resident #36 is usually reserved but Resident #36 is more aware of what is going on around him/her than he/she communicates. SRNA #7 revealed for the most part Resident #36 allows staff to change his/her clothes if needed. SRNA #7 stated there are some days Resident #36 yells out but Resident #36 does well with staff. SRNA #7 stated if Resident #36 appeared to be resistive she would redirect Resident #36 and the resident does well with most requests. SRNA #7 stated she has received training by the facility on how to care and interact with a resistive or combative resident.
Interview on 02/13/19 at approximately 9:40 AM with SRNA #8 revealed during tray pick up she goes to each resident's room and asks them if they are finished eating. SRNA #8 stated if the resident states yes, then she offers assistance to the resident to clean them up and change their shirt if the resident has food on them. SRNA #8 revealed she always kneels down and will make sure she is face to face when speaking to a resident to make them feel more comfortable. SRNA #8 stated nine (9) of ten (10) residents usually allow staff to assist. SRNA #8 stated if a resident is resistive, the protocol was to immediately get the charge nurse on duty to come into the resident's room to offer assistance. SRNA #8 revealed she would continue to check on the resident every ten to fifteen (10-15) minutes maximum and would never allow a resident to just remain in their bed covered in food. SRNA #8 stated she has provided care to Resident #36 and Resident #36 was confused at times but he/she was a sweet heart. SRNA #8 further revealed if Resident #36 becomes confused and resistive, she would calmly explain to Resident #36 what she was trying to do and there usually was no issue. SRNA #8 stated she was not aware of a situation when a SRNA was unable to provide care to Resident #36 when it was needed. SRNA #8 stated she has received training by the facility on how to care and interact with a resistant or combative resident.
Interview on 02/13/19 at approximately 9:55 AM with SRNA #9 revealed she knocks on the residents' doors before entering and asks the resident if they are done with their food and then takes the tray if they are finished. SRNA #9 stated if she observes the resident has food on them or soiled clothes she will change their clothes and wash their face. SRNA #9 revealed if the resident was resistant that protocol was to immediately notify the charge nurse on duty and then follow the charge nurses lead on the next steps to take. SRNA #9 stated she has never ran into a situation where a resident would be left for even a period of thirty (30) minutes to an hour covered in food. SRNA #9 further stated she has provided care to Resident #36 and Resident #36 was usually calm and she has never observed a situation in which Resident #36 was resistant and would not allow staff to provide assistance when needed. SRNA #9 stated she has received training by the facility on how to care and interact with a resistant or combative resident.
Observation and Interview with Charge Nurse #3 on 02/12/19 at approximately 2:00 PM revealed Resident #36 was still lying in bed on his/her back with his/her shirt covered in food and crumbs. Charge Nurse #3 stated SRNA's were responsible for picking up the trays after lunch and cleaning up the resident's face and/or changing the resident's clothes if the clothing was soiled or if the resident has food or any mess on their face. Charge Nurse #3 revealed the condition in which Resident #36 was left in his/her bed was unacceptable and no resident should ever be left in their bed covered in food.
Interview (Post Survey) with the DON on 03/01/19 at approximately 2:00 PM revealed SRNA #6 reported Resident #36 was being combative and would not allow SRNA #6 to change Resident#36's clothes. The DON stated she told SRNA #6 to reapproach Resident #36 at a later time and SRNA #6 went back after about a hour and was able to change Resident #36. The DON revealed residents have the right to refuse to be cleaned and have their clothes changed and that she expected staff to respect residents' right to refuse care. The DON stated protocol for SRNA's dealing with a combative or resistant resident was to notify any nurse on the floor and reapproach resident later.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0563
(Tag F0563)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review and facility Resident Rights review, it was determined the facility failed to ensure one (1) of twenty-five (25) sampled residents, the right to have rea...
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Based on observation, interview, record review and facility Resident Rights review, it was determined the facility failed to ensure one (1) of twenty-five (25) sampled residents, the right to have reasonable access to visit his/her son at the facility (Resident #48).
The findings include:
Review of the facility copy of Resident Rights, not dated, revealed the resident has a right to receive visitors of his or her choosing at the time of his or her choosing.
Review of the facility document titled, Resident Right - Inform of Visitation Rights/Equal Visitation Privileges, revealed it is the policy of the facility to inform residents and resident representatives of visitation rights and privileges in such a manner to acknowledge and respect resident rights. Further review of the document revealed the procedures that the facility will meet were as follows: 1. Inform each resident (or resident representative, where appropriate) of his or her visitation rights and related facility policy and procedures, including any clinical or safety restriction or limitation on such rights, consistent with the requirements of this subpart, the reasons for the restriction or limitation, and to whom the restrictions apply, when he or she is informed of his or her other rights under this section. 2. Inform each resident of the right, subject to his or her consent, to receive the visitors whom he or she designates, including, but not limited to, a spouse (including a same-sex spouse) a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time. 3. Not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation , or disability and 4. Ensure that all visitors enjoy full and equal visitation privileges consistent with resident preferences.
Record review revealed the facility readmitted Resident #48 on 04/27/18 with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Vascular Dementia with behavioral disturbance, Dyspnea, Anxiety, Psychotic Disorder with Delusions, Hypertension and Atrial Fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/17/19, revealed the #48's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3) whish indicated the resident was not interviewable.
Interview with the Complainant on 02/11/19 at 12:11 PM, revealed Resident #48's son was not allowed to visit with the resident since he got into an argument with a nurse and the son was told for a period of time. The Complainant stated when the son called the Administrator to see if he could come see the resident, he was told by the Administrator that he could not return to see the resident. The Complainant stated the son could get loud, but would never cause harm to anyone.
Observation on General Tour, on 02/12/19 at 10:32 AM, revealed Resident #48 was sitting in wheelchair near the nurses station. When asked by the surveyor, if he/she had visitors, the resident started to tear up and said that one of his/her sons was not allowed to visit. The resident went on to say Administrator and Police, but it was difficult to get further details from the resident.
Three (3) unsuccessful attempts to reach Resident #4's son were made on 02/15/19 at 9:30 AM, 10:53 AM and 12:50 PM.
Interview with Licensed Practical Nurse (LPN) #2, on 02/15/19 at 9:36 AM, revealed when Resident #48's son came to the nurses station, he was yelling and cursing, and sounded very loud and threatening. LPN #2 stated she did not remember what he was upset about but he would always have an attitude towards staff. LPN #2 stated this was the worse she had ever seen him and she notified the DON and the Administrator who told her she should call the police. She revealed the son was leaving as the police officer was arriving. She stated the resident had never told her the son could not visit and she was not aware of any residents with a visitor restriction.
Interview with the facility Administrator, on 02/15/19 at 9:13 AM, revealed the Police Officer told them it was a two (2) year ban for the son to be allowed to come back for visiting. She stated the son is very aggressive and she must protect her residents and staff. She also stated the facility can get the resident a cab to take him/her to their home to ensure visitation, but the sons have declined.
Interview with the Complainant, on 02/15/19 at 9:17 AM, revealed the facility has never offered to send the resident to the family home but did say he could come get the resident and take her home for a visit but the son stated they do not have the means to care for the resident, so they have declined.
Interview with the Director of Nursing (DON), on 02/15/19 at 2:15 PM, revealed a resident can have visitors as long as every resident and staff are safe. She stated the facility did not set up an onsite, supervised visit for Resident #48's son but did offer to send the resident to the home but could not send staff to assist in the care of the resident. The DON stated, It would be just like going to a doctors office for an appointment. She revealed the family did not request other options for visitation but stated the facility would assist in any way they could.
Interview with the Administrator, on 02/15/19 at 2:36 PM, revealed she expected the resident be allowed visits from family as long as the visitors can abide by the policy and be respectful to staff and other residents. She stated that it was a recommendation from the police to not allow the particular son to visit, but that she had the final say.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of facility policy, and housekeeping inservice training, it was determine...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of facility policy, and housekeeping inservice training, it was determined that the facility failed to ensure the resident environment was sanitary for one (1) of twenty-five (25) sampled residents (Resident #17).
Observation of Resident #17's bathroom on 02/12/19 and on 02/13/19, revealed the commode had dried, crusted fecal matter smeared all over the commode seat and commode bowl in the same areas for the two (2) consecutive days.
The findings include:
Review of facility policy titled Complete Room Clean Checklist, not dated, revealed the residents' bathrooms were to be cleaned, including the commode, bath tubs, walls and floors.
Review of the facility's Housekeeping In-service training for housekeeping employees titled 7-Step Daily Washroom Cleaning, dated 1/1/2000, revealed step five (5) was to clean and sanitized the commode which includes the commode tank, the seat, the bowl and the base.
Record review, revealed the facility admitted Resident #17 to the facility on [DATE] with diagnoses which included: Anxiety Disorder and Major Depressive Disorder. Review of Resident #17's Quarterly Minimum Data Set (MDS) Assessment, dated 12/17/18, revealed the facility assessed Resident #17's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable.
Observation of Resident #17's bathroom on 02/12/17 at 2:02 PM, revealed there was dried, crusted fecal matter smeared all over the commode seat and commode bowl.
Observation of Resident #17's bathroom on 02/13/19 at 10:35 AM, revealed there was dried, crusted fecal matter smeared all over the commode seat and commode bowl.
Interview with Resident #17 on 02/12/19 at 2:00 PM, revealed he/she had been upset because his/her commode was very dirty with bowel movement all over it and nobody will clean it.
Interview with Resident #17 on 02/13/19 at 10:34 AM, revealed his/her commode was still filthy and he/she was upset because he/she felt like the commode was to dirty to even use and nobody will clean it.
Interview with Medical Records Clerk on 02/15/19 at 10:07 AM, revealed she was the department head at the facility that had Resident #17's room as part of her section of residents' rooms to check each morning for cleanliness. She stated she had noticed Resident #17's commode was soiled on 02/12/19 and on 02/13/19 and had told someone in housekeeping about the commode being dirty and needing cleaning. She revealed she would have expected housekeeping to have cleaned the commode due to it being very soiled.
Interview with Housekeeping District Manager on 02/15/19 at 10:25 AM, revealed he was currently filling in as the role of housekeeping supervisor at the facility due to the position was currently not filled. He stated he would expect a seven (7) step washroom cleaning to have been completed daily for Resident #17's bathroom. He stated he did not recall anyone reporting that Resident #17's commode was soiled and needed attention. He revealed he was not sure how Resident #17's commode had been missed for two (2) consecutive days but would investigate the matter.
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
**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 ensure each resident h...
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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 ensure each resident had a person-centered comprehensive care plan that was developed and/or implemented to meet the residents' preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for one (1) of twenty-five (25) sampled residents (Resident #20).
Resident #20 was prescribed Plavix 75 milligrams (mg) (anti-platelet) and Aspirin 325 mg daily. However, there was no documented evidence a care plan was initiated to monitor resident for complications of the medications. In addition, the resident had an uncontrolled nosebleed and was sent to the emergency room on [DATE]; however, the care plan was not revised due to an uncontrolled nose bleed, not reflected on the comprehensive care plan.
The findings include:
Review of the facility policy titled, Comprehensive Care Plans Standard of Practice, last revised November 2017, revealed it is the practice of the facility to develop and implement a comprehensive person centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.
1. Record review revealed the facility admitted Resident #20 on 07/13/16 with diagnoses which included Type II Diabetes Mellitus; Peripheral Vascular Disease; Flaccid Hemiplegia affecting dominant side, Anxiety Disorder; and Bipolar Disorder. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 12/12/18, revealed the facility assessed Resident #20's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fourteen (14) which indicated the resident was interviewable.
Review of the Physician's Order Sheet for February, 2019, revealed to administer Plavix 75 mg one tablet orally every day; and, Aspirin 325 mg coated tablet one (1) tablet orally every day.
Review of Nursing Progress Note, dated 01/25/19 at 11:22 AM revealed Resident #20 had a nose bleed and after multiple unsuccessful attempts to stop the bleeding, the physician was notified and the resident was sent to the emergency room for evaluation.
Review of the Comprehensive Care Plan, dated 07/25/16, revealed Resident #20 has multiple medical diagnoses that effect her health status including hypertension, hyperlipidemia; hypothyroidism, history of cerebral vascular accident, and history of seizure. Further review revealed the listed approaches included Antiplatelet/Aspirin medication as ordered. There is no documented evidence there was a care plan initated for provision of resident care related to antiplatelet / aspirin therapy.
Further review of the Comprehensive Care Plans revealed no documented evidence the nose bleed was recorded on the care plans.
Interview with Registered Nurse (RN) #1 on 02/15/19 at 12:36 PM revealed she was responsible for updating the care plans, and the resident should have had a care plan for taking a blood thinner but did not. RN #1 stated it was an over sight as was the nose bleed.
Interview with the Director of Nursing (DON) on 02/15/19 at 02:10 PM, revealed the facility is monitoring for bleeding via the Medication Administration Record/Treatment Administration Record (MAR/TAR). However, there is no care plan related to the resident taking Plavix and ASA. The DON stated she does not feel like there needs to be a care plan for Plavix and ASA because they are monitoring signs and symptoms of bleeding on the MAR/TAR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
Based on interview, record review, and review of facility 24 hour Report, it was determined the facility failed to ensure that residents receive proper treatment and assistive devices to maintain visi...
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Based on interview, record review, and review of facility 24 hour Report, it was determined the facility failed to ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the residents In making appointments, and by arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices for one (1) of twenty-five sampled residents (Resident #20).
Resident #20 was seen by an ophthalmologist on 01/22/18 and recommendations were made for the resident to be evaluated by a cataract surgeon. An appointment was scheduled for 02/19/18, however, the resident was a no show, as the resident refused to go to the appointment. He/she was again scheduled to see the ophthalmologist on 08/27/18, but he/she was out of the facility for another doctor's appointment and was not seen by the ophthalmologist. There was no documented evidence the facility attempted to schedule another appointment with the surgeon or followed up with the resident related to future appointments with the cataract surgeon or his/her wishes for future appointments. In addition, it has been over one (1) year since the resident has had an eye exam.
The findings include:
Interview with the Director of Nursing (DON) on 02/15/19 at 2:10 PM revealed the facility does not have a policy related to vision exams. She stated the facility follows the federal guidelines to assure the residents are seen as needed. Additionally, the DON stated the residents are seen by specialists more frequently than every year if they choose to do so.
Record review revealed the facility admitted Resident #20 on 07/13/16 with diagnoses which included Type II Diabetes Mellitus; Peripheral Vascular Disease; Flaccid Hemiplegia affecting dominant side. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 12/12/18, revealed the facility assessed Resident #20's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fourteen (14) which indicated the resident was interviewable.
Review of the Physician's Note, dated 01/22/18, revealed Resident #20 was seen by the Ophthalmologist on 01/22/18 with chief complaint eyes not so good/worse. The plan was to monitor at regular intervals as the cataracts were visually significant with recommendation for evaluation by a cataract surgeon and follow up in six (6) months 07/2018).
Review of the Departmental Note dated 01/22/18 revealed Resident #20 had an appointment with a cataract surgeon on 02/19/18 at 1:00 PM; however, there was no documented evidence the resident was seen by the surgeon.
Interview with the receptionist at the cataract surgeon's office on 02/15/19 at 11:20 AM revealed the referral was received from the facility and an appointment was scheduled for 02/19/18; however, the resident did not show up for the appointment. She stated the appointment was not canceled, the resident was a no show and another appointment has not been scheduled.
Review of the facility's 24-Hour Report dated 02/19/18, revealed the resident refused to go to the appointment with the surgeon stating I'm not having surgery.
Review of the note from the contract ophthalmologist dated 08/27/18, revealed Resident #20 had an appointment on this day, however, the appointment was canceled as the resident was out of the facility. However, further record review revealed no documented evidence that an appointment was rescheduled with the cataract surgeon, that the facility had interviewed the resident to determine his/her wishes regarding future appointments with a cataract surgeon, or had attempted to reschedule an appointment with the contracted eye doctor despite resident's complaints of on-going vision problems.
Interview with Resident #20 on 02/12/19 at 1:13 PM revealed he/she is going blind. Resident #20 stated he/she is seeing black floaters and he/she has told the nurses about the vision problems but he/she had not been scheduled for an eye appointment.
Interview with the DON on 02/14/19 at 3:14 PM and on 02/15/19 at 2:10 PM revealed Resident #20 saw the ophthalmologist on 01/22/18 and requested another appointment that was scheduled on 08/27/18. The DON stated the resident missed the 08/27/18 appointment because he/she was at an appointment with the cardiologist; and, she does no know why another appointment was not scheduled,. The DON further stated there is no documentation evidence that there was another attempt to get the resident another appointment for the surgeon after 02/19/18.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a resident, with or without an indwelling catheter, receives the appropriate...
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Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a resident, with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible for one (1) of twenty-five sampled residents (Resident #32).
Three (3) observations revealed improper positioning of Resident #32's urinary catheter tubing and drainage bag placement.
The findings include:
A signed statement from the Administrator and the Director of Nursing, dated 02/14/19, revealed the facility does not have a policy for urinary catheter care. However, review of the facility policy titled, Catheter Care, not dated, revealed to secure catheter properly. Coil and secure tubing to the bed.
Review of the facility policy titled, Infection Control Tracking and Trending, last revised September, 2013, revealed the purpose of the policy was to prevent the spread of infection and provide appropriate education for staff and residents concerning infection control.
Record review revealed the facility admitted Resident #32 on 01/26/18 with diagnoses which included Neuromuscular Dysfunction of Bladder, Urinary Tract Infection, and Acute Kidney Failure. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 12/26/18, revealed the facility did not complete the Brief Inventory of Mental Status (BIMS) exam, the resident had long-term and short-term memory impairment with severely impaired cognition, which indicated the resident was not interviewable. Further review of the MDS revealed the resident required total care with activities of daily living (ADL) and has an indwelling urinary catheter.
Observation on 02/13/19 at 10:44 AM revealed Resident #32's urinary catheter tubing was hanging from the bedside and looped to the drainage bag, not coiled and secured to the bed per facility policy.
Observations on 02/13/19 at 3:36 PM and on 02/14/19 at 5:36 PM revealed the urinary catheter drainage bag covered with a dignity bag was laying flat on the floor at bedside, not hanging from the bed frame.
Interview with Certified Nurse Assistant on 02/15/19 at 12:51 PM revealed when she was in the resident's room on 02/14/19, she did not notice the position of the catheter drainage bag, but it should not have been laying flat on the floor.
Interview with Licensed Practical Nurse (LPN) #1 on 02/15/19 at 10:05 AM revealed the urinary catheter drainage bag should not be flat on the floor, it should be hanging from the bed frame to promote proper urine flow.
Interview with Registered Nurse (RN) #1, Unit Manager, on 02/15/19 at 10:18 AM revealed the catheter drainage bag should be on the side of the bed away from the door in a privacy bag, and should be hanging from the bed frame. RN #1 stated if it is not hanging from the bed frame it could create too much tension. The RN further stated I did see the catheter bag on the floor yesterday, but there was no other choice because the bed was in a low position. RN #1 revealed she expected the catheter drainage bag not to rest flat on the floor, as it should be hung from the bed frame after it has been emptied, and I should have noticed it.
Interview with the Director of Nursing (DON) on 02/15/19 at 02:10 PM revealed she expected staff to ensure the bedside drainage bag be in a privacy bag and hanging on bed frame. She stated she expected the staff to monitor the position of the bedside drainage bag with every round and on care partner rounds. The DON revealed if the privacy bag and the catheter drainage bag is observed flat on the floor, then it should be hung up on the bed frame to help the flow and prevent infection.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and facility policy review, it was determined the facility failed to apply oxygen (O2) therapy according to the Physician's Order for one (1) of twenty-...
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Based on observation, interview, record review, and facility policy review, it was determined the facility failed to apply oxygen (O2) therapy according to the Physician's Order for one (1) of twenty-five (25) sampled residents (Resident #7).
Observation on 02/12/19 revealed staff failed to ensure Resident #7 received O2 at three (3) liters per minute (LPM) per the Physician's Order.
The findings include:
Review of the facility's policy titled, Oxygen Administration and Maintenance, not dated, revealed Oxygen will be administered in accordance with physician's orders. The nurse will be responsible for ensuring oxygen is applied per physician's orders.
Record review revealed the facility admitted Resident #7 on 03/03/18 with diagnoses which included Chronic Obstructive Pulmonary Disease, Chronic Bronchitis, and Dyspnea. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/16/18 , revealed the facility assessed Resident #7's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was not interviewable.
Review of the February 2019 Physician's Order revealed to administer O2 at 3 LPM continuously every shift, to check oxygen saturations every shift and as needed, and to check a room air saturation every Wednesday.
Review of Resident #7's Comprehensive Care Plan, dated 09/19/16, revealed an intervention for O2 per Physician's Orders via nasal cannula related to ineffective gas exchange. Further review of the care plan revealed additional interventions to assess portable O2 tank every two (2) hours and as needed (PRN) while in use for need to fill.
Observation on 02/12/19 at 11:15 AM, revealed Resident #7's portable O2 tank was empty, while he/she was up in the wheelchair in the dining room.
Interview with Licensed Practical Nurse (LPN) #3, on 02/12/19 at 1:54 PM, revealed the portable tank was three-fourths (3/4) full on random check with an oxygen saturation level of 97%. She revealed that it was the nurses responsibility to check the portable oxygen every two (2) hours and that she had checked it earlier in the morning, but wasn't sure what time that was.
Interview with the Director of Nursing (DON), on 02/15/19 at 2:15 PM, revealed the nurses were responsible for checking oxygen on every two (2) hour rounds and she expected the tanks to be refilled at those times.
Interview with the Administrator, on 02/15/19 at 2:36 PM, revealed a resident should have continuous delivery of oxygen and staff should ensure the resident has access to oxygen.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure each resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure each resident care plan was reviewed and revised by the interdisciplinary team ongoing with any changes pertinent to the residents' care needs, for five (5) residents (Residents #20, #21, #32, #36, and #71), in the selected sampled of twenty-five (25).
Resident #32 had a history of Urinary Tract Infections (UTIs) and had an indwelling urinary catheter. He/she was hospitalized on [DATE] with diagnoses of UTI and Sepsis. However, the comprehensive care plan did not reflect a history of UTIs or Sepsis.
Resident #20 had an appointment for cataract surgery on 02/19/18. However, the resident refused to go to the appointment stating I'm not having surgery. The comprehensive care plan was not updated to reflect the resident's preferences related to cataract surgery.
Residents #21, #36, and #71 have all had multiple falls in the facility over the course of the last six (6) months. However, the comprehensive care plan does not reflect any new updates or new interventions being implemented by the interdisciplinary team after any of the falls to potentially prevent any future falls from occurring.
The findings include:
Review of the facility policy titled, Comprehensive Care Plans, Standard of Practice, last revised November, 2017, revealed it is the practice of the facility to develop and implement a comprehensive person centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will describe, at a minimum, any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her rights to refuse treatment.
Interview with the Administrator, on 03/01/19 at 2:14 PM, revealed the facility does not have a policy that specifically addressed Care Plan Timing and Revision. The Administrator stated the facility followed the RAI guidelines and as needed.
1. Record review revealed the facility admitted Resident #32 on 01/26/18 with diagnoses which included Neuromuscular Dysfunction of Bladder, UTI, and Acute Kidney Failure. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 12/26/18, revealed the facility did not complete the Brief Interview for Mental Status (BIMS) score. The resident had long-term and short-term memory impairment with severely impaired cognition, which indicated the resident was not interviewable. Further review of the MDS revealed the resident required total care with activities of daily living (ADLs) and had an indwelling urinary catheter.
Review of the Nurse's Progress notes, dated 09/08/18, revealed Resident #32 was hospitalized with diagnoses of UTI and Sepsis. He/she returned to the facility on [DATE].
Review of the Comprehensive Care Plan, not dated, revealed Resident #32 had alteration in elimination as evidenced by incontinence of bowel and foley catheter, history of Cerebral Vascular Accident, diagnosis of Hypertension, Osteoarthritis, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Dementia, and required extensive assistance with ADLs. However, the problems listed did not include a history of UTI or Sepsis. Approaches included report changes to characteristics of urine such as color, odor, and sediment. There was no documented evidence the facility assessed for signs and symptoms of infection or discomfort related to the catheter.
Interview with Registered Nurse (RN) #2/MDS Coordinator, on 02/15/19 at 12:33 PM, revealed she was responsible for updating the care plan to reflect the diagnoses upon Resident #32's return from the hospital. RN #2 stated the care plan should have been updated, but it was overlooked.
Interview with the Director of Nursing (DON), on 02/15/19 at 2:10 PM, revealed she did not think the care plan needed to reflect the diagnoses of UTI and Sepsis since it was the first UTI the resident had since he/she had been at the facility. However, the resident had a diagnosis of UTI upon admission to the facility.
2. Record review revealed the facility admitted Resident #20 on 07/13/16 with diagnoses which included Type II Diabetes Mellitus, Peripheral Vascular Disease, and Flaccid Hemiplegia affecting the dominant side. Review of the Quarterly MDS assessment, dated 12/12/18, revealed the facility assessed Resident #20's cognition as intact with a BIMS score of fourteen (14), which indicated the resident was interviewable.
Review of the Departmental Note, dated 01/22/19 at 4:07 PM, revealed Resident #20 had an appointment with the Ophthalmologist on 02/19/18 at 1:00 PM. However, review of the Twenty-four (24) Hour Report, dated 02/19/18, under the 10:00 PM to 6:00 AM shift remarks, revealed the resident refused to go to the MD appointment. There was no documented evidence of an attempt to reschedule another appointment.
Review of the Comprehensive Care Plan, dated 07/25/16, revealed Resident #20 was at risk for visual deficit as evidenced by resident wearing glasses, and will wear other residents' glasses as well. There was no documented evidence the resident refused cataract surgery on 02/19/18.
Three (3) attempts to contact RN #2 (MDS Coordinator) for a post-survey interview, on 02/22/19, who was responsible for updating care plans, was unsuccessful.
Interview with the DON, on 02/15/19 at 2:10 PM, revealed Resident #20 had an appointment with the surgeon, but refused to go. The DON stated it is the resident's right to refuse to go to appointments. The DON was unable to provide any further information regarding attempts to reschedule the appointment.
3. Record review revealed the facility admitted Resident #36 on 12/17/18 with diagnoses which included Muscle Weakness, Muscle Wasting, and Atrophy, Type 2 Diabetes, Chronic Obstructive Pulmonary Disease (COPD), and Generalized Anxiety Disorder. Review of the admission MDS assessment, dated 01/03/19, revealed the facility assessed the resident's BIMS score as a three (3), which indicated the resident was not cognitively intact and was non-interviewable.
Review of the Comprehensive Care Plan, dated 01/16/18, revealed the resident was at risk for injury related to a history of falls, and the resident had an injury resulting in a left hip fracture related to a diagnosis of impaired cognition, weakness, and Diabetes Mellitus. Additional review of the care plan revealed there had been no updates or revisions to the care plan after falls which occurred in the facility. Review of the Falls Investigation Report, dated 01/04/19, 01/07/19 and 02/11/19, revealed the resident had falls in the facility. Further review of the Comprehensive Care Plan revealed there was no evidence revisions were made in regard to any of the resident's falls.
4. Record review revealed the facility admitted Resident #21 on 06/15/18 with diagnoses which included COPD, Muscle Weakness, Unspecified Lack of Coordination, and Unspecified Abnormalities of gait and mobility. Review of the Annual MDS assessment, dated 09/05/18, revealed he/she had a BIMS score of Zero Zero (00), which indicated the resident was not cognitively intact and was non-interviewable.
Review of the Comprehensive Care Plan, dated 01/02/19, revealed the resident was care planned for injury related to a history of falls, related to cognition, impaired gait and mobility, resident continues with unsafe transfers and ambulation, and decreased safety awareness. Review of the Falls Investigation report, dated 08/22/18 and 11/23/18, revealed the resident had falls in the facility. Further review of the Comprehensive Care Plan revealed no evidence revisions were made in regard to any of the resident's falls.
5. Record review revealed the facility admitted Resident #71 on 03/28/11 with diagnoses which included Muscle Weakness, Other Lack of Coordination, and Other abnormalities of gait. Review of the Quarterly MDS assessment, dated 12/14/18, revealed he/she had a BIMS score of thirteen (13), which indicated the resident was interviewable.
Review of the Comprehensive Care Plan, dated 05/02/14, and revised 12/19/18, revealed the resident was at risk for injury related to falls, extensive assistance when fatigued, muscle weakness, confused at times, and a history of falls at home. Review of the Falls Risk Assessment revealed a fall occurred on 08/20/18. Further review of the care plan revealed no evidence the care plan was revised after the fall occurred.
Interview with the MDS Coordinator, on 02/15/19 at approximately 12:18 PM, revealed her expectation was that new interventions be updated and followed per the care plan. She stated it was the Nursing Department's job to update the Care Plans with immediate interventions, and that updated interventions be reflected on the current Care Plans. She stated she was instructed by staff not to put revision dates on the care plans.
Interview with the DON, on 02/15/19 at approximately 2:15 PM, revealed the facility's software did not allow staff to show revision dates on the care plans.
Further interview with the Administrator, on 02/15/19 at approximately 2:15 PM, revealed her expectations were that care plans be updated within 24 to 48 hours, depending on the weekday, after new interventions were identified.
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
Based on observation, interview and review of facility policy, it was determined the facility failed to ensure food was Stored, prepared, distributed and served in accordance with professional standar...
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Based on observation, interview and review of facility policy, it was determined the facility failed to ensure food was Stored, prepared, distributed and served in accordance with professional standards for food service safety.
Kitchen observations on 02/12/19, revealed open, unsealed foods being stored in the freezer, dirty kitchen equipment and staff sanitation concerns.
Review of Census and Condition dated 02/12/19 revealed eighty-two (82) of eighty-six (86) resident receive there meals from the kitchen.
The findings include:
1. Review of facility policy titled Food Storage: Cold Foods, revised 4/2018, revealed all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.
Observation of the kitchen on 02/12/19 at 09:29 AM, revealed in the three (3) door freezer multiple break apart beef steak slices were laying in the freezer open to air uncovered with no wrapping or container in place and a plastic bag of bread rolls were present with no labeling or dating noted on the bag.
2. Review of facility policy titled Cleaning and Sanitizing, not dated, revealed surfaces that come in contact with food, must be cleaned and sanitized after each use.
Observation of the kitchen on 02/12/19 at 09:35 AM, revealed the kitchen's manual can opener had a build up of black moist material on cutting edge and surrounding area.
Interview with the Dietary Manager on 02/12/19 at 9:40 AM, revealed all foods being stored in the refrigerators and freezers should be covered, sealed completely with a label and date present. She stated she expected staff to clean the manual can opener after each use to prevent any build up of material.
3. Review of facility policy titled Handwashing Procedure for Dining Services, not dated, revealed after an employee blows their nose, coughs, sneezes, touches their hair, face or clothes the are required to perform hand hygiene.
Observation of the kitchen on 02/12/19 at 11:12 AM, revealed during lunch meal trayline observation of staff, Dietary Aide #1 was observed grabbing bowls of dessert for residents' lunch trays while placing her thumb on the inside area of the bowls after she had been licking her thumb to separate meal ticket slips to review.
Interview with Dietary Manager on 02/12/19 at 11:16 AM, revealed staff should not be licking their thumbs then handling dishes. She stated this was a sanitation and infection control issue.
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
- "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
- • 15 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • Grade D (45/100). Below average facility with significant concerns.
Bottom line: Trust Score of 45/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Franklin-Simpson's CMS Rating?
CMS assigns FRANKLIN-SIMPSON NURSING AND REHABILITATION CENTER an overall rating of 2 out of 5 stars, which is considered 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 Franklin-Simpson Staffed?
CMS rates FRANKLIN-SIMPSON NURSING AND REHABILITATION CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 55%, compared to the Kentucky average of 46%. RN turnover specifically is 77%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Franklin-Simpson?
State health inspectors documented 15 deficiencies at FRANKLIN-SIMPSON NURSING AND REHABILITATION CENTER during 2019 to 2025. These included: 2 that caused actual resident harm and 13 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Franklin-Simpson?
FRANKLIN-SIMPSON NURSING AND REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by BENJAMIN LANDA, a chain that manages multiple nursing homes. With 98 certified beds and approximately 81 residents (about 83% occupancy), it is a smaller facility located in FRANKLIN, Kentucky.
How Does Franklin-Simpson Compare to Other Kentucky Nursing Homes?
Compared to the 100 nursing homes in Kentucky, FRANKLIN-SIMPSON NURSING AND REHABILITATION CENTER's overall rating (2 stars) is below the state average of 2.8, staff turnover (55%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Franklin-Simpson?
Based on this facility's data, families visiting should ask: "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?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Franklin-Simpson Safe?
Based on CMS inspection data, FRANKLIN-SIMPSON NURSING AND REHABILITATION CENTER 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 2-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 Franklin-Simpson Stick Around?
FRANKLIN-SIMPSON NURSING AND REHABILITATION CENTER has a staff turnover rate of 55%, which is 9 percentage points above the Kentucky average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Franklin-Simpson Ever Fined?
FRANKLIN-SIMPSON NURSING AND REHABILITATION CENTER 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 Franklin-Simpson on Any Federal Watch List?
FRANKLIN-SIMPSON NURSING AND REHABILITATION CENTER 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.