Dawson Springs Health and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Oct 7, 2021

  Based on interview, record review, review of the facility's policy, and review of the facility reported incident, it was determined the facility failed to have an effective system to ensure residents were free from abuse for two (2) of fifteen (15) residents; Resident #1 and Resident #2. Review of the medical records revealed Resident #1 and Resident #2 had been assessed by the facility to have low Brief Interview for Mental Status (BIMS) scores, indicating cognitive impairment. Resident #1 had a Power of Attorney and Resident #2 had a legal State Guardian for decisions making purposes. Both residents were assessed by the facility to have a history of sexual inappropriate behaviors and were able to self-mobilize. […]

• Immediate jeopardy, isolatedF607Oct 7, 2021

  Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure its abuse policy was implemented. On 05/17/2021, Resident #1 touched Resident #2's genital area. Additionally, on 05/18/2021, Resident #3, kissed Resident #1 on the lips. However, the facility did not implement their policy for protecting residents, thoroughly investigating allegations of sexual abuse and reporting. 1. Review of Resident #1 and Resident #2's Incident Reports, dated 05/17/2021 at 4:00 PM, revealed Resident #1 was observed in Resident #2's room with his/her hands resting on Resident #1's peritoneal area. Resident #1's clothing was pulled down. […]

• Immediate jeopardy, isolatedF610Oct 7, 2021

  Based on interview, record review and review of the facility's Policy, it was determined the facility failed to complete a thorough investigation in response to an alleged violation of abuse, allowing for further potential abuse for two (2) of fifteen (15) residents; Residents #1 and Resident #2. On 05/17/2021, Certified Nursing Assistant (CNA) #6 observed Resident #1 in Resident #2's room. Resident #2 had his/her pants and underwear pulled down exposing the genital area and Resident #1 was observed with his/her hands on Resident #2's genital area. The facility initiated an investigation on 05/17/2021; however, review of the investigation, dated 05/20/2021 revealed no documented evidence the facility implemented the facility's abuse policy related to completing a thorough investigation. […]

• Immediate jeopardy, isolatedF657Oct 7, 2021

  Based on observation, interview, record review, review of the facility's policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team (IDT) composed of individuals who had knowledge of the resident and his/her needs for three (3) of fifteen (15) residents; Resident #1, Resident #2, and Resident #3. The facility admitted Resident #1, on 09/08/2017, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident had severely impaired cognition and had a Power of Attorney (POA). […]

• Immediate jeopardy, isolatedF689Oct 7, 2021

  Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system in place to ensure each resident received adequate supervision to prevent abuse for two (2) of fifteen (15) residents; Resident #1 and Resident #2. The facility admitted Resident #1, on 09/08/2017, with diagnoses to include Alzheimer's Dementia, [CONDITION(S)], Anxiety, Depression, and High-Risk Heterosexual Behaviors. Record review revealed the resident had severely impaired cognition and had a Power of Attorney (POA). The facility admitted Resident #2, on 03/04/2020, with diagnosis to include Alzheimer's Dementia, Dementia with Behavioral Disturbances and Mood Affect Disorder. […]