Kingsbrook Lifecare Center

F-F684

The findings include:

Review of the facility's policy titled, Comprehensive Plan of Care (CCP), revised 11/2002, revealed the purpose was to provide an individualized plan of care for each resident, by means of a written document which included input from all disciplines involved in the provision of care. Further review revealed the Director of Nursing (DON) or Minimum Data Set (MDS) Coordinator, served as the coordinator of the interdisciplinary team (IDT), and the care planning team consisted of the resident if he/she chose; the Medical Director as necessary; MDS Coordinators; Physical, Speech, Audiological and Occupational Therapists as involved in resident care; Dietary Supervisor; Activities Director; Social Services Director; and others at the option of the resident, including family. Further review revealed the CCP must describe the services to be provided for the resident to attain or maintain the highest practicable physical, mental, and psychosocial well being with measurable objectives and timetables to meet the resident's needs in the Comprehensive Assessment. Continued review revealed each problem, with goals and approaches related to the problem, was written on the care plan and updated quarterly, annually, and whenever significant changes occurred. Continued review of the policy revealed the CCP would have documented disciplines responsible to have implemented interventions, the date of the problems identified, and the goal date as well as the interventions planned and the date initiated.

Review of the Kentucky Medicaid Nurse Aide Testing Procedures Manual and Study Guide, dated 01/01/2024, revealed for peri care for a male, to retract the foreskin for an uncircumcised person and to return the foreskin to its natural position, if uncircumcised.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 11 185449 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185449 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kingsbrook Lifecare Center 2500 State Route 5 Ashland, KY 41102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Review of Resident R99's Admission Record revealed the facility admitted Resident R99 on 02/11/2024 after an acute care admission at a nearby hospital. His admitting diagnoses included myocardial infarction, congestive heart Level of Harm - Actual harm failure (CHF), and chronic kidney disease, stage 4.

Residents Affected - Few Review of Resident R99's admission Minimum Data Set (MDS), dated [DATE REDACTED], revealed his Brief Interview for Mental Status (BIMS) assessment yielded a score of 14 out of a possible 15, indicating his cognitive status was intact. Further review of the MDS revealed the skin assessment showed no wounds, lesions, or moisture associated skin disruption.

Review of Resident R99's Care Plan revealed a focus for pressure ulcer risk, initiated 03/27/2024, with the intervention of aides conducting a skin inspection during care and bathing and then report to the nurse any areas of redness or skin breakdown. Further review revealed no other interventions related to maintaining perineal skin. Continued review revealed a focus for change in urinary elimination related to incontinence, initiated on 04/04/2024, with interventions of observe for incontinence approximately every 2 hours and as needed, and provide incontinence care. Additional review revealed a focus of risk for complications related to diabetes disease process, initiated 03/22/2024, with an intervention initiated at the same time to observe skin during daily care for areas of altered skin integrity and notify the nurse. Review of the care plan revealed no other focus related to skin care or assessments and none related to the care of his uncircumcised penis.

Review of Resident R99's Kardex (care plan used by State Registered Nurse Aides (SRNA)), undated, revealed SRNAs must perform skin inspection during care/bathing and report to the nurse of any area of skin breakdown or redness.

Review of Resident R99's initial Skilled Nursing Assessment, dated 02/13/2024, revealed no skin issues. In addition,

review of Resident R99's nursing assessments after 02/13/2024 and until 04/12/2024 revealed varying observations that included redness, excoriation, and scattered discolorations to the skin but no penile wound.

Review of the Nurse Progress Note, dated 04/12/2024 at 6:45 PM, revealed the nursing supervisor responded to a request for assistance after the staff nurse retracted Resident R99's foreskin to evaluate drainage reported by the aide. Further review revealed the nurse found an open wound to the top of Resident R99's penis with

a moderate amount of malodorous tan drainage noted.

Review of the Nurse Progress Note, dated 04/13/2024 at 12:45 AM, revealed Resident R99's foreskin was found to be retracted, and the tip of the penis was very swollen, red, and hard. Further review revealed his penis required elevation to reduce swelling before the foreskin could be returned to a normal position.

Review of the Physician's Order Note, dated 04/14/2024 at 12:16 PM, revealed the Nurse Practitioner (NP) found Resident R99 to have open lesion to the glans penis. Further review revealed the wound had purulent yellow and tan drainage, and the glans were noted to be erythematous with a lesion noted to the dorsal surface. Additional review revealed the decision was made to transfer Resident R99 to an area hospital emergency department (ED) for evaluation of possible options for treatment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 11 185449 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185449 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kingsbrook Lifecare Center 2500 State Route 5 Ashland, KY 41102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Review of the hospital's Operative Note, dated 04/17/2024 at 5:09 PM, revealed Resident R99 underwent penile ulcer debridement and partial excision of the glans penis after assessment of the wound. Further review revealed Level of Harm - Actual harm the wound was a 3 centimeter (cm) by 3 cm area with necrosis and granulation tissue that was excised.

Residents Affected - Few During interview with Resident R99 on 06/25/2024 at 10:07 AM, he stated he was sent to the hospital and had surgery due to an infection of his penis. He stated the staff should have assessed him upon admission to the facility. Resident R99 stated he was having a burning sensation for months, but they (staff) wanted no part of looking or examining him.

During interview with Resident R99's family on 06/26/2024 at 1:32 PM, he stated an aide found the wound, contacted

the nurse, who contacted the physician and sent Resident R99 to the hospital emergency department (ED). He stated

the ED physician told them the wound was a result of total neglect, and it should never have happened.

During interview with SRNA6 on 06/25/2024 at 10:48 AM, she stated Resident R99 stated he used to be able to do perineal (peri) care himself, but that he had reported the stinging and nobody had looked at it. She stated the head of the penis was so hard from swelling she could not retract the foreskin and went for the nurse. She stated they were able to loosen the skin with moisture and discovered the wound/ulcer and alerted the supervisor. SRNA6 stated she later went upstairs to Resident R99's previous unit and asked all the aides, who were not aware of the wound.

During interview with Licensed Practical Nurse (LPN) 6 on 06/26/2024 at 5:28 PM, she stated she was not aware of Resident R99's penis ulcer. She stated she did not do his daily assessments as they would have been completed on night shift. She stated nurse aides were expected to report any concerns to nurses, and some of the aides reported he wanted to do his own care. She stated at the time he was admitted and earlier on he walked to the bathroom with his walker. LPN 6 also stated daily assessments were head to toe, including backs and buttocks, and when nurse aides did care or bathing, they reported issues also.

During interview with LPN18 on 06/27/2024 at 2:49 PM, she stated the expectation was that aides looked at skin during care and/or showers and reported any changes.

During interview with LPN9 on 06/28/2024 at 11:35 AM, she stated if nurses were doing their skin assessments, they would know if a resident was uncircumcised. She stated she did not recall having seen that addressed on a care plan, but it would be reasonable to include it. She also stated there was not an option in the care plan to add it, but it might be added in the Additional Information box to free hand write it rather than use a check box.

During interview with LPN4 on 06/28/2024 at 12:15 PM, she stated the nurses conducted daily head to toe assessments on the skilled unit. She stated head to toe really meant full body, including the peri area and the foreskin. She stated information like circumcision status should be passed on in report. She stated the expectation was for nurses to retract the foreskin during skin assessments and that was especially important with residents who were more independent. She also stated she understood the MDS had begun capturing circumcision status and had populated that information onto the SRNA Kardex tasks. She further stated the SRNA task lists could be customized.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 11 185449 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185449 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kingsbrook Lifecare Center 2500 State Route 5 Ashland, KY 41102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During interview with RN1 on 06/28/2024 at 11:44 AM, she stated on initial assessment the fact that a new resident was uncircumcised would be apparent. She further stated there was a box for other in the Level of Harm - Actual harm assessment form that gave a dropdown box where that sort of detail could be documented, but she was not sure it would pop up in the care plan to use. She did state the admission Care Plan had a section that asked Residents Affected - Few about grooming, hygiene care, and toileting.

During additional interview with RN2 on 06/28/2024 at 11:51 AM, she stated whether something was captured on the care plan depended on an issue being flagged, but identifying peri care needs should be in a care plan.

During interview with the MDS Nurse on 06/28/2024 at 1:45 PM, she stated the nurse could add additional text through the comment box and that would be reviewed in the clinical meeting and by the MDS nurse as well. She stated sometimes an order would be added for something that needed to be care planned, and then it got picked up in the clinical meeting because staff ran an order report for the clinical meeting every morning. She additionally stated they could add a custom intervention for a particular issue only for the one resident. She stated it would be appropriate to add peri care for an uncircumcised male to a care plan, but

she did not recall adding that to a care plan.

During interview with the Medical Director on 06/26/2024 at 2:07 PM, she stated the incident with Resident R99 was something that had led to a lot of education, particularly around differences with peri care for circumcised versus uncircumcised males. She stated staff was also educated on the expectation of regular skin assessments, including peri area skin. She stated it also brought discussions of when to allow more privacy and when to increase care.

During interview with the Director of Nursing (DON) on 06/28/2024 at 2:07 PM, she stated for SRNAs, she expected them to look at the whole body, observe all the skin, and to be sure to retract the foreskin for an uncircumcised male and report any redness or changes to the nurse. The DON stated it had not been their normal practice to care plan for uncircumcised male peri care, but it should have been done.

During interview with the Administrator on 06/28/2024 at 2:39 PM, she stated it would be reasonable to incorporate peri care into the care plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 11 185449 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185449 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kingsbrook Lifecare Center 2500 State Route 5 Ashland, KY 41102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44396

Residents Affected - Few Based on interview, record review, review of the Kentucky Medicaid Nurse Aide Testing Procedures Manual and Study Guide, and review of Mosby's Textbook for Nursing Assistants, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs for 1 of 3 residents assessed for skin care (Resident (R) 99). Staff failed to re-assess identified redness under Resident R99's penile foreskin, even though the resident was complaining of pain during urination, which resulted in worsening of an infection that required surgical intervention.

The findings include:

Review of the Kentucky Medicaid Nurse Aide Testing Procedures Manual and Study Guide, dated 01/01/2024, revealed for perineal care for an uncircumcised male, to retract the foreskin and to return the foreskin to its natural position.

Review of Giving Male Perineal Care from Mosby's Textbook for Nursing Assistants, page 370, revealed providing peri care to an uncircumcised male required retracting the foreskin, grasping the penis, cleaning

the tip in a circular motion, starting at the meatus and working outward, then rinsing the tip with another washcloth using the same circular motion, then returning the foreskin to its natural position after rinsing.

Review of the Male Perineal Care check off sheet, dated 02/14/2024, revealed the staff member should grasp the penis, retract the foreskin if the person is uncircumcised and return the foreskin to its natural position after cleaning.

Review of Resident R99's Admission Record revealed the facility admitted Resident R99 on 02/11/2024 after an acute care admission at a nearby hospital. His admitting diagnoses included myocardial infarction, congestive heart failure (CHF), and chronic kidney disease, stage 4.

Review of Resident R99's admission Minimum Data Set (MDS), dated [DATE REDACTED], revealed his Brief Interview for Mental Status (BIMS) assessment yielded a score of 14 out of a possible 15, indicating his cognitive status was intact. Further review of the MDS revealed the skin assessment showed no wounds, lesions, or moisture associated skin disruption.

Review of Resident R99's Kardex (care plan used by State Registered Nurse Aides (SRNA)), undated, revealed SRNAs must perform skin inspection during care/bathing and report to the nurse of any area of skin breakdown or redness.

Review of Resident R99's initial Skilled Nursing Assessment (SNA), dated 02/13/2024, revealed no skin issues, and continued review through 03/16/2024 revealed no skin issues. However, the SNA, dated 03/17/2024, revealed redness to coccyx and buttocks, with no notation of the foreskin of the penis. The SNA, dated 03/19/2024, revealed the addition of redness of the groin, and on 03/28/2024, addition of excoriation was added. Further review of Resident R99's SNA, dated 04/05/2024 and 04/06/2024, revealed redness and excoriation to his groin and buttocks. Additional review from 04/07/2024 to 04/10/2024 revealed no mention of skin problems to Resident R99's penile area.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 11 185449 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185449 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kingsbrook Lifecare Center 2500 State Route 5 Ashland, KY 41102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Review of Resident R99's Nurse Progress Note, dated 04/10/2024 at 3:30 PM, revealed Resident R99 transferred to a different unit at that time (from second floor to first floor). Level of Harm - Actual harm

Review of Resident R99's Nurse Progress Note, dated 04/12/2024 at 6:30 PM, revealed SRNA6 called Licensed Residents Affected - Few Practical Nurse (LPN) 7 to Resident R99's room to assess the resident's penis due to noted drainage and the penis appeared abnormal. Further review revealed she notified the evening nurse supervisor to further assess. The note stated the nurse supervisor responded at 6:45 PM, and another nurse, LPN9, retracted Resident R99's foreskin. Per the note, Resident R99 had an open wound to the top of his penis with a moderate amount of malodorous tan drainage. Continued review revealed the area was cleansed and covered with a dry sterile dressing, and the on-call physician was contacted for orders. Further review of the note revealed at 10:23 PM, Resident R99's penile wound and drainage was swabbed and sent to the lab for culture, an indwelling urinary catheter was placed without incident, and Bactroban (generic name mupirocin, an ointment used to treat skin infections) was applied to the wound.

Review of Resident R99's Nurse Progress Note, dated 04/13/2024 at 8:22 AM, revealed an order was obtained for mupirocin external ointment 2%, to be applied to penile wound topically three times per day for 5 days. Further review of the note revealed an order to cleanse the penile wound with normal saline, gently pat dry, then apply mupirocin ointment liberally to the wound and surrounding skin.

Review of Resident R99's Nurse Progress Note, dated 04/13/2024 at 12:45 AM, revealed Resident R99's penile assessment at that time found his foreskin was retracted, and the tip of the penis very swollen, red, and hard. Further review revealed his penis required elevation to reduce swelling before the foreskin could be returned to a normal position.

Review of Resident R99's Physician's Order Note, dated 04/14/2024 at 12:16 PM, revealed the Nurse Practitioner (NP) found Resident R99 to have an open lesion to the glans with a culture done and results pending. The note stated

the current treatment was Bactroban applied to the wound three times per day and an indwelling urinary catheter. Further review revealed the wound had purulent yellow and tan drainage, and the glans were noted to be erythematous with a lesion noted to the dorsal surface. Continued review revealed the wound bed was covered with thick yellow/tan slough with purulent drainage, and the foreskin was difficult to return to the normal position due to edema and pain. Additional review revealed the decision was made to transfer Resident R99 to

an area hospital emergency department (ED) for evaluation of possible options for treatment.

Review of Other Note, dated 04/14/2024 at 5:07 PM, revealed Resident R99 was admitted to the hospital for treatment of the penile wound.

Review of Resident R99's hospital ED Provider Note, dated 04/14/2024, revealed the resident was admitted to the hospital on 04/14/2024 due to balanoposthitis (inflammation of the foreskin and glans penis in uncircumcised males) and wound infection of the penis. Further review revealed his assessment revealed erythema to the foreskin, balanitis, and posthitis.

Review of the hospital's Nursing Note, dated 04/14/2024 at 2:05 PM, revealed the provider was at the bedside of Resident R99 and assessed the wound to the right side of his penis to have drainage and odor present upon inspection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 11 185449 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185449 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kingsbrook Lifecare Center 2500 State Route 5 Ashland, KY 41102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Review of Resident R99's culture report of the penile wound drainage done at the facility, with the results dated 04/15/2024 at 11:32 AM, revealed it was positive for Klebsiella oxytoca (a bacterium found in hospital Level of Harm - Actual harm acquired infections and having multiple drug resistance to commonly used antibiotics and Streptococcus intermedius bacterium). Residents Affected - Few

Review of the hospital's Operative Note, dated 04/17/2024 at 5:09 PM, revealed Resident R99 underwent penile ulcer debridement and partial excision of glans penis after assessment of the wound. Further review revealed the wound was a 3 centimeter (cm) by 3 cm area with necrosis and granulation tissue that was excised.

Review of Resident R99's hospital Discharge Summary, dated 04/18/2024, revealed Resident R99 would be discharged on oral antibiotics to complete the course and was discharged back to the facility on [DATE REDACTED].

Review of Resident R99's quarterly MDS skin assessment, dated 05/15/2024, only revealed moisture associated skin damage and the applications of ointments/medications other than to feet.

During interview with Resident R99 on 06/25/2024 at 10:07 AM, he stated when he was on the second floor, he had complained hourly of burning in his private area and asked for something to treat it, and they did nothing. He stated when he moved down to the first floor, they immediately found the infection, and he was sent to the hospital and had surgery the following day. Resident R99 further stated it was better now and the wound nurse checked it daily. He stated the nurse who found the problem was doing the initial assessment because he was new to the unit. He also stated in his opinion, this should have been assessed at admission to the facility. Resident R99 stated he was having the burning for months before moving downstairs, but they wanted no part of looking or examining it. He also stated he literally felt, when he was moved to the first floor, they were just moving him because there was nothing they could do.

During interview with Resident R99's family member on 06/26/2024 at 1:32 PM, he stated an aide found the wound and contacted the nurse, who contacted the physician and sent Resident R99 to the hospital ED. He stated the ED physician told them the wound was a result of total neglect, and it never should have happened. He stated

he understood the ED nurse scolded the facility's staff over the phone as well. In continued interview, he stated when Resident R99 did have surgery after transfer to the hospital, the surgeon had him observe the wound, and it looked like a roasted marshmallow that was burned, black, and crusty.

During interview with SRNA6 on 06/25/2024 at 10:48 AM, she stated Resident R99 told her he used to be able to do perineal (peri) care himself, but he had reported the stinging and nobody had looked at it. She stated the head of the penis was so hard from swelling she could not retract the foreskin and went for the nurse. She stated they were able to loosen the skin with moisture and discovered the wound/ulcer and alerted the supervisor. SRNA 6 stated she later went upstairs to Resident R99's previous unit and talked with all the aides, who were not aware of the wound.

During interview with SRNA19 on 06/26/2024 at 5:41 PM, she stated for a while Resident R99 did his own care and staff was helping him; then later staff started doing more. SRNA19 stated after the nurse got a powder order for a groin rash, staff was really trying to keep his groin area as dry as possible. She stated he started using

the urinal because he was having a harder time walking, and she remembered him complaining of pain, which staff thought was from a rash. She stated she thought there was a plan for Resident R99 to see the doctor, and

she had communicated concerns about his pain to the nurse and NP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 185449 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185449 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kingsbrook Lifecare Center 2500 State Route 5 Ashland, KY 41102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 During interview with SRNA3 on 06/28/2024 at 11:59 AM, she stated she did not receive training for peri care specific for an uncircumcised male in her nurse aide school and also not during orientation at the facility. She Level of Harm - Actual harm stated the only reason she knew how to do peri care on an uncircumcised male was from caring for a family member. Residents Affected - Few

During interview with SRNA14 on 06/28/2024 at 12:07 PM, she stated she had not received peri care training

in school nor in facility orientation. She stated SRNA3 taught her what to do when caring for a male resident who was uncircumcised.

During interview with LPN6 on 06/26/2024 at 5:28 PM, she stated Resident R99 complained of burning when urinating, so a cream and powder were ordered, and she thought there was a urinalysis (UA) ordered. She stated she was not aware of the penis ulcer. She stated she did not do his daily assessments as they would have been completed on night shift. In further interview, she stated nurse aides were expected to report any concerns to nurses, and some of the aides reported he wanted to do his own care. She stated at the time he was admitted and earlier on he walked to the bathroom with his walker. LPN6 also stated daily assessments were head to toe, including backs and buttocks, and when nurse aides did care or bathing, they reported issues also. She stated aides completed shower sheets as well, and someone always assisted residents with showers.

During telephone interview with LPN16 on 06/26/2024 at 5:52 PM, she stated Resident R99 had complained of burning in that area. She stated he would normally use his call light, get assistance to the bathroom, and staff would stand by outside the bathroom. She stated he did his own care, and he was set up for baths when not showering. She stated she had not completed his skin assessments because night shift would have done his, so she had never seen his wound. She also stated their head to toe assessments were expected to be complete as all of it had to be charted. LPN 16 also stated a skin assessment should have captured a wound. She stated he had complained of discomfort in the groin area some time back, and he had not wanted her to look. However, she stated Resident R99 did allow it. She stated she retracted his foreskin, and

the skin was reddened on the shaft under the foreskin, with no wound at that time. She stated she had placed in the NP/Medical Director book for Resident R99 to be seen. She stated she did not recall the date, but it was fairly soon after admission.

During interview with LPN9 on 06/27/2024 at 2:35 PM, she stated she was working as midnight supervisor when the wound was discovered and was asked to look at it with the evening supervisor. She stated the wound was like open skin on the right side, and it did not look swollen or black. She stated she did pull back

the foreskin and there was a little hole. She stated nurses were expected to complete head to toe skin assessments every day, including the peri area. She stated head to toe skin assessment was expected to include retracting the foreskin, as this was just a standard of nursing practice. LPN9 stated she was not aware of the wound or any skin irritation prior to the observation or treatment for that. She stated staff had received re-education on peri care since this incident, including to be sure to retract the foreskin for assessment and to pull it back down after assessment.

During interview with LPN18 on 06/27/2024 at 2:49 PM, she stated for skin protection, aides should look for redness during activities of daily living (ADL) care. She stated the nurses looked at residents during medication administration as well, such as for reddened heels. She stated she expected aides to look at the residents' skin during care and/or showers and report any changes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 185449 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185449 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kingsbrook Lifecare Center 2500 State Route 5 Ashland, KY 41102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 During telephone interview with LPN17 on 06/27/2024 at 8:33 PM, she stated the expectation was that nurses would follow the standard of care and retract the foreskin during skin assessments for uncircumcised Level of Harm - Actual harm males. She stated a lot of nurses did not do this, but they should. With Resident R99, she stated he would try to cover himself and wanted to limit what he allowed the staff to see. LPN 17 stated Resident R99 had initially been fairly Residents Affected - Few self-sufficient, such as walking to the bathroom with just a standby assist, but even with that level of independence, nurse aides would have had to attend showers and would have observed his skin.

During interview with LPN4 on 06/28/2024 at 12:15 PM, she stated the nurses conducted daily head to toe assessments on the skilled unit. She stated head to toe really meant full body, including the peri area and foreskin. She stated Resident R99 had complained of burning when he urinated a couple of times, so staff suspected

a urinary tract infection (UTI), and staff collected a urine sample. When the UA was negative, she stated staff thought it was irritation because he did have redness in the groin. She stated information like circumcision status should be passed on in report. She stated the expectation was for nurses to retract the foreskin during skin assessments, and it was especially important with residents who were more independent.

During telephone interview with Registered Nurse (RN) 1 on 06/26/2024 at 6:03 PM, she stated she did not care for Resident R99 directly, but nurses were to lay eyes on each resident daily with a head to toe assessment, including all skin. She further stated when nurse aides reported something new, the nurses must assess it.

She stated they must follow the schedule per protocol for conducting assessments so that every resident got

a look every day. She stated night shift nurses did skin assessments on residents in odd numbered rooms while day shift staff did assessments for residents in even numbered rooms. RN1 stated for any finding that might require treatment, the nurses were expected to call the NP or the physician. RN1 stated the expectation was that nurse aides must report to nurses any skin changes observed during ADL care and showers.

During interview with RN10 on 06/27/2024 at 3:36 PM, she stated upon admission, the wound care nurses did skin assessments. She stated Resident R99 did not have a wound at admission that she remembered. She stated

she recalled he was prescribed creams or something based on itching. She stated he went to the hospital and had the debridement, and the wound care nurses were aware of it already upon his return due to collaboration with the wound care physician. When he returned, staff formed Resident R99's plan of care to continue here. RN10 stated Resident R99 had necrotic tissue, so he had mechanical debridement via Santyl ointment, which pulled that tissue off for removal. She stated the wound improved over the first couple of weeks, and then the order was switched to exufiber, a calcium alginate wound treatment. RN10 stated a head to toe assessment included assessing all skin, including the back, buttocks, and peri areas. She stated that also included retracting the foreskin of uncircumcised males.

During interview with RN1 on 06/28/2024 at 11:44 AM, she stated on initial assessment, the fact a new resident was uncircumcised would be apparent. She further stated there was a box for other in the assessment form that gave a dropdown box where that sort of detail could be documented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 185449 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185449 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kingsbrook Lifecare Center 2500 State Route 5 Ashland, KY 41102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 During interview with Staff Development Assistant/Infection Prevention Nurse (SDC/IP) on 06/28/2024 at 9:27 AM, she stated in the annual Skills Fair nursing staff were instructed on head to toe assessment and Level of Harm - Actual harm how to chart it. She stated the facility did a competency with nursing department staff upon hire and did ongoing peri care audits. She stated nursing leaders, including herself, did ongoing face-to-face, one-on-one Residents Affected - Few education and could add education based on observed patterns, such as an increase in urinary tract infections (UTI) could lead to reeducation on peri care. She stated head to toe assessments meant everywhere, and skin assessments had to include backs, buttocks, and peri area, including retracting the foreskin of the penis. She stated the outcome of good peri care and hygiene was less infection because the best place for bacteria to grow was a place that was warm, dark, and moist.

During interview with the Quality Manager on 06/27/2024 at 9:25 AM, she stated staff nurses were expected to complete daily charting for residents who were in for a rehabilitation stay and weekly for long term residents. She stated that night shift nurses completed the charting for residents in odd numbered rooms, while day shift completed the charting for residents in even numbered rooms. She stated the charting included a complete head to toe assessment, including skin. She stated skin assessments meant complete head to toe, looking at every nook and cranny.

During telephone interview with the NP on 06/27/2024 at 7:18 PM, she stated she was alerted by staff of the wound that was located on Resident R99's penis. She stated that when she assessed the resident she found he was uncircumcised, but he looked normal until she retracted the foreskin and found a wound with yellow slough and eschar. She stated it was so painful for him to have the skin retracted, she felt he needed a urology consult and possibly IV antibiotics. She stated it was a weekend when she saw him, and she felt Resident R99's wound would be addressed more quickly if he went to the ED. She stated before she assessed the resident and found the wound, Resident R99 had complained of burning with urination, so a UA and other labs were ordered, and those had negative results. She stated Resident R99 was getting calmoseptine (a moisture barrier ointment) and then miconozole (an anti-fungal powder) thinking it was caused by excoriation over the general skin in the groin. She stated she was unsure of the facility's policy for skin assessments. She also stated on one hand, with an alert and oriented resident, it was difficult to assess how invasive the staff should be with him, but if a resident did not have an issue with it, staff should examine the skin. In retrospect, she stated she felt retraction of Resident R99's foreskin and inspecting it should have been part of his skin assessment.

During interview with the Medical Director on 06/26/2024 at 2:07 PM, she stated the incident with Resident R99 was something that led to a lot of education, particularly around differences with peri care for circumcised versus uncircumcised males. She stated staff was also educated on the expectation of regular skin assessments, including peri area skin. She stated it also brought discussions of when to allow more privacy and when to increase care. She further stated she had seen Resident R99 the day or two before the wound was discovered, but he had not mentioned concerns for pain or other indicators of the wound. She stated the NP was in the building

on the day the wound was found and responded to the nurse's request for Resident R99's assessment. She stated

they started treatment, but the wound was so painful, they transferred Resident R99 to the hospital the following day or two. She stated Resident R99 had mentioned to staff that it burned when he urinated, and in response, a UA was done, which was negative for infection. Further, she stated they thought the burning was from excoriation, so

an anti-fungal powder was ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 185449 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185449 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kingsbrook Lifecare Center 2500 State Route 5 Ashland, KY 41102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 In further interview with the Medical Director, on 06/26/2024 at 2:07 PM, she stated Resident R99 said he had reported this issue, but he really did not talk as much until after he returned from the hospital. The Medical Level of Harm - Actual harm Director stated early in Resident R99's admission, he was able to do his own peri care. She stated Resident R99 was discharged on oral levofloxacin (an antibiotic). However, she stated the resident insisted on the IV route, and Residents Affected - Few she consulted with the surgeon. She stated Resident R99's surgeon confirmed his plan had been prophylactic oral antibiotics because Resident R99 probably did not need them. The Medical Director stated Resident R99 was so insistent, she ordered IV levofloxacin, and it was for three doses every other day due to consideration of his renal function.

During interview with the Director of Nursing (DON) on 06/28/2024 at 2:07 PM, she stated she expected SRNAs to look at the whole body, observe all the skin, be sure to retract the foreskin for an uncircumcised male, and report any redness or changes to the nurse. She stated she expected nurses to do a complete skin assessment and that was head to toe, front and back, and a thorough look at the peri area, heels, and everywhere. She stated it was important to take good care of skin because if not done, the residents' skin could break down and create a portal of entry for bacteria, which could cause discomfort, pain, and infection.

She stated nursing staff mostly used Mosby's as a standard of care, they had the resource in the building, and staff could have accessed it via the intranet. She stated nurses and aides got checked off on peri care

during their education on it.

During interview with the Administrator on 06/28/2024 at 2:39 PM, she stated her expectation was that SRNAs would observe the resident's skin during any care episode and report redness or changes to the nurse. She also stated her expectation of nurses would be to protect dignity and respect of personal choice but also ensure the integrity of the skin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 185449