Barbourville Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Barbourville Health and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, patternF657Sep 30, 2024

  Based on observation, interview, record review, and review of the facility's policies, the facility failed to have an effective system to ensure care plans were revised to provide necessary interventions for supervision and monitoring for residents to prevent falls/accidents for 8 of 10 sampled residents, (Resident (R)10, R15, R27, R51, R75, R93, R111, and R274). The facility failed to thoroughly investigate and evaluate residents' falls by performing root cause analysis (RCA) to determine the root cause of the numerous residents' falls in order to review/revise the residents' care plans to prevent additional falls and injuries for residents. […]

• Actual harm, patternF689Sep 30, 2024

  Based on observation, interview, record review and review of the facility's policies, the facility failed to have an effective system to ensure adequate supervision and monitoring to prevent falls/accidents for eight (8) of ten (10) sampled residents reviewed for falls/accidents, Resident (R)10, R15, R27, R51, R75, R93, R111, and R274. The facility had a total of 346 falls during the six (6) month time period from 02/28/2024 to 08/28/2024, and an additional 26 falls from 08/29/2024 to 09/25/2024. […]

• Actual harm, patternF835Sep 30, 2024

  Based on observation, interview, and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for the management of falls for five of ten sampled residents, (Residents (R)10, R15, R93, R111, and R274). Review of the facility's document titled, Incidents by Incident Type, dated 02/28/2024 through 08/28/2024 revealed the facility noted 44 witnessed falls and 302 unwitnessed falls for a total of 346 fall during that six month time period. […]

• Actual harm, patternF865Sep 30, 2024

  Based on observation, interview, record review, review of the facility's fall report documentation and Quality Assurance Performance Improvement (QAPI) Policy, the facility failed to maintain an effective, comprehensive, data driven QAPI program which focused on criteria for outcomes and quality of life related to falls for 8 of 10 sampled residents, (Residents (R)10, R15, R27, R57, R75, R93, R111, and R274. Review of the facility's Incidents by Incident Type, documentation dated 02/28/2024 through 08/28/2024, revealed the facility had a total of 346 resident falls during that six-month timeframe. Review of the facility's QAPI documentation however, revealed no documented evidence the facility brought the issue of multiple residents' falls to the QAPI Committee prior to August 2024. […]

• No harm, potential for more than minimal, widespreadF812Aug 28, 2025

  Based on observation, interview, and facility policy review, the facility failed to ensure food items were discarded when required, milk received from a vendor had a legible expiration date, food items in the walk-in freezer and dry storage room were stored appropriately, and the room temperature of the dry storage room did not exceed 70 degrees Fahrenheit (F). These deficient practices had the potential to affect all 114 residents who received food from the kitchen. Findings included: An undated facility policy titled, Food Storage, indicated, 2. Dry storage rooms must be well ventilated and illuminated, with adequate temperature and humidity controls to prevent condensation of moisture and growth of mold. The storeroom temperature should be 50 [degrees] to 70 [degrees] F. […]