Bluegrass Care & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Bluegrass Care & Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761Aug 30, 2024

  Based on observation, interview, record review, and facility policy review, the facility failed to store medications and biologicals in accordance with professional standards for 2 of 6 residents observed for medication administration, Resident (R) 121 and R122 and 2 of 2 medication refrigerators. The findings include: Review of the facility's policy titled, Medication Administration, revised 06/24/2024, revealed the facility's nursing staff was to administer medications at the time they were prepared. 1, Review of R121's Face Sheet revealed the facility admitted the resident on 08/24/2024 with diagnoses including acute COVID, muscle weakness, and unspecified dementia. […]

• No harm, potential for more than minimal, patternF600Apr 7, 2021

  Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure residents were protected from abuse by another resident, Resident #2, for two (2) of six (6) sampled patients, Resident #3 and Resident #4. On 03/31/2021, Resident #2 pushed Resident #3 and Resident #3 fell against the wall causing a cut on the back of the head. Resident #3 was sent to the emergency room and found to have no serious injury. On 04/04/2021, Resident #2, using his/her fist, punched Resident #4 in the back. […]

• No harm, potential for more than minimal, patternF880Jan 6, 2021

  Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, to properly prevent and/or contain COVID-19, and to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Center for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19. Observation of the lunch meal pass revealed resident hand hygiene was not performed prior to meals in four (4) of eleven (11) sampled residents' rooms. […]

• No harm, potential for more than minimal, isolatedF658Jul 16, 2026

  Based on interview, record review, review of Mosby's Clinical Nursing Skills and Techniques, 11th edition, review of Kentucky Board of Nursing (KBN) standards, and review of the facility's documents and policies, the facility failed to ensure services provided met professional standards of practice for 1 of 26 sampled residents, Resident (R) 133.The facility discharged R133 on 12/30/2025, and R133 was given a medication that belonged to a different resident, R71.The findings include:Review of the facility's policy titled, Discharge Medication, last revised 04/14/2024, revealed a physician's order was required to discharge a resident with medications before they would be dispensed. […]

• No harm, potential for more than minimal, isolatedF641Jul 25, 2025

  Based on interview and record review, the facility failed to accurately reflect with the Minimum Data Set (MDS) assessment, the resident's status for 1 of 29 sampled residents. (Resident (R)15). The Significant Change MDS dated [DATE] and the Quarterly MDS dated [DATE], did not document R15 as receiving Hospice Care. The findings include:Review of R15's Face Sheet revealed the facility admitted R15 on 03/16/2025 with diagnoses to include Acute Respiratory Failure, Dementia, and Anxiety. Review of R15's medical record revealed the resident started on Hospice care on 3/10/2025.Review of the Significant Change MDS dated [DATE] and the Quarterly MDS dated [DATE] revealed no documented evidence the facility coded R15 as receiving Hospice care in section O. […]