Fordsville Nursing and Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF880Aug 5, 2023

  Based on observation, interview, record review and review of facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) of fifty-five sampled residents (Residents #46, and #16). Resident #46 has a persistent rash with a diagnosis of scabies. Observation on 08/05/2023, revealed Certified Nursing Assistant #22 and Registered Nurse (RN) #2 failed to don Personal Protective Equipment (PPE) when providing direct care to Resident #16 who was on Enhanced Barrier Precautions (EBP). […]

• No harm, potential for more than minimal, isolatedF578Aug 5, 2023

  Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a resident who was assessed to be mentally incapacitated had his/her Advance Directive information given to and signed by his/her Resident Representative for one (1) of three (3) residents sampled for closed records (Resident #214). Closed record review revealed on 05/25/2023, Resident #211 signed his/her own Kentucky Emergency Medical Services Do Not Resuscitate (DNR) Order and Cardiopulmonary Resuscitation Consent. Further review of Resident 214's Quarterly Minimum Data Set Assessment (MDS) Assessment, dated 05/15/2023, revealed the resident had severe cognitive impairment. […]

• No harm, potential for more than minimal, isolatedF584Aug 5, 2023

  Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure each resident had a safe, clean, comfortable, and homelike environment for five (5) of five (5) residents' sampled rooms. Observations on 07/31/2023 through 08/04/2023, revealed multiple resident rooms had peeling wallpaper, chipped paint, and damaged walls (Rooms 3-A, 21-A, 28-B, 31-A and 37-A). The findings include: Review of the facility's policy, Homelike Environment Standard of Practice, dated 10/2020 revealed the facility would provide residents with a safe, clean, comfortable and homelike environment. […]

• No harm, potential for more than minimal, isolatedF600Aug 5, 2023

  Based on interview, record review and review of the facility's policy, it was determined the facility failed to protect residents from physical abuse for four (4) of fifty-five (55) sampled residents (Residents #36, #49, #50, and #213). On 01/15/2023, staff responded to an incident of Resident #213 striking Resident #50 on the face, in the common area. On 10/02/2022, staff had reported witnessing Resident #49 touching Resident #36's chest area above his/her clothing. The findings include: Review of the facility's policy, Abuse Prohibition Standard of Practice, dated 07/2022, revealed the facility would prohibit and prevent abuse, neglect, exploitation, misappropriation or resident property and ensure reporting and investigating of alleged violations, mistreatment and involuntary… […]

• No harm, potential for more than minimal, isolatedF657Aug 5, 2023

  Based on interview, record review, review of facility policy, and review of the Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to review and revise a comprehensive person-centered care plan for one (1) of fifty-five (55) sampled residents (Resident #49). Record review revealed Resident #49's care plan was not revised after he/she exhibited inappropriate sexual behaviors on 10/02/2022, 10/25/2022, and 10/26/2022. The findings include: Review of the RAI Manual, Section 4.7 The RAI and Care Planning, dated 10/2019, revealed the care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident required. […]