Hartland Park Health & Rehabilitation
Hartland Park Health & Rehabilitation in Lexington, KY — inspection on August 16, 2024.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Observation revealed the carts labeled A, B, and C contained clothing washed and dried, with same day service and delivered to the resident. HK1 stated she was unaware of why residents were not escorted to the laundry room to claim items. HK1 stated the facility had purchased a labeler, to label the residents' items.
She stated she would do one room at a time, getting the inventory from Activites1 to verify each resident's items.
In an interview with the Social Worker (SW) on 08/15/2024 at 10:34 AM, she stated she was in charge of all grievances.
The SW stated there were grievance logs placed at each nurse's station on each unit.
The SW stated the quality assistance policy stated items must be replaced for the items that were not found in the facility.
The SW stated that usually staff found the residents' missing items, and the facility had a system in place to label clothing, toiletries, cell phones, and tablets for each resident.
The SW stated her expectation was for staff to work hard to find the missing items and provide a resolution with 72 hours from the time the grievance was filed.
In an interview with the Director of Nursing (DON) on 08/16/2024 at 2:37 PM, she stated her expectation was for staff to take a grievance request from the resident; to inform the unit nurse and social services; and to document it in the logbook provided for staff at the nurse's station in each unit.
The DON stated she reviewed the grievance logbooks daily and gave each department their grievance complaints for them to resolve.
The DON stated she believed it would be respectful to give residents a resolution for filed grievances, and the items should be replaced if not found.
In an interview with the Administrator on 08/16/2024 at 3:21 PM, she stated grievances should be taken from any resident that was missing any items in the facility.
She stated the grievances given verbally by residents or residents' representatives should be documented in the logbook provided on each unit and given to the appropriate departments for them to search and look to see if the item could be found.
She stated regardless, if the item was found or not, residents deserved to have a resolution.
She stated it was the residents' right to have the items replaced.
The Administrator stated moving forward they would reeducate staff on how to properly document grievances. .
185197 08/16/2024
Hartland Park Health & Rehabilitation 1500 Trent Boulevard Lexington, KY 40515
discussed resident care changes.
The MDS Nurse stated the MDS should reflect accurate resident
In an interview with the Director of Nursing (DON) on 08/16/2024 at 3:37 PM, she stated staff
completed the swallow and nutritional status section of the MDS.
In an interview with the Administrator on 08/16/2024 at 3:37 PM, she stated changes in resident care were discussed in the clinical morning meeting.
She stated the MDS Coordinator completed the MDS assessment to reflect the accurate care of the resident in the care plan.
185197 08/16/2024
Hartland Park Health & Rehabilitation 1500 Trent Boulevard Lexington, KY 40515
During interview with the MDS Coordinator on 08/16/2024 at 2:59 PM, she stated she followed the
make changes to the care plan.
She stated she attended the morning meetings and discussed readmissions and any updates or changes.
She stated care plans should be immediately changed and should reflect the resident's care accurately.
During interview with the Director of Nursing (DON) on 08/14/2024 at 3:11 PM, she stated the resident's care plan should be fully developed, implemented, and followed to meet the resident's care needs.
In an interview with the Administrator on 08/16/2024 at 3:30 PM, she stated changes in resident care were discussed in the clinical morning meeting, and the accuracy of the CCP depended on the MDS assessment.
She stated she expected staff to develop and implement care plans to meet the resident's needs.
185197 08/16/2024
Hartland Park Health & Rehabilitation 1500 Trent Boulevard Lexington, KY 40515
During an interview on [DATE] at 2:15 PM with the Assistant Administrator, she stated LPN8 had worked as a nurse with a suspended license.
She stated LPN8 was terminated once the facility discovered the suspension.
During an interview on [DATE] at 2:45 PM with the Director of Nursing (DON), she stated it was important to have staff with a valid license to ensure the staff was in compliance and to ensure staff members were up-to-date with education hours.
During continued interview on [DATE] at 3:45 PM with the Administrator, she stated it was important for staff to maintain an active license because they were responsible for taking care of residents and care being provided needed to be in accordance of regulation and to ensure residents safety.
185197 08/16/2024
Hartland Park Health & Rehabilitation 1500 Trent Boulevard Lexington, KY 40515
was to label all multi-use containers with the opened date and to follow the pharmacy's expiration
In an interview with the Administrator on 08/16/2024 at 3:26 PM, she stated it was the expectation
was away from the cart.
The Administrator stated it was important to maintain security of all medications to deter drug diversion and prevent accidental ingestion by residents.
She stated the facility's policy and her expectation was for all multi-use medications to be labeled when they were opened and not to be used past their expiration dates to ensure residents received effective medication.
185197 08/16/2024
Hartland Park Health & Rehabilitation 1500 Trent Boulevard Lexington, KY 40515
Observation on 08/14/2024 at 8:35 AM revealed R71 was on enhanced barrier precautions as indicated on the signage outside the room.
Registered Nurse (RN) 4 removed R71's medications from the medication cards and touched the medications without wearing gloves.
She then put R71's medications in a medication cup, went into the room, and administered the medication without gloves.
During interview with RN4 at the time of the observation, she stated she was nervous.
She stated infectious organisms could have potentially been on her hands and transferred to the resident from not wearing gloves.
- Observation on 08/14/2024 at 3:08 PM revealed RN1 was at the bedside changing the dressing on
R12's left arm.
The signage on the door indicated the resident was on enhanced barrier precautions and required a gown and gloves for high contact resident care.
However, RN1 did not have on a gown or gloves.
During interview with RN1 on 08/14/2024 at 3:15 PM, she stated the gown was only worn when changing the dressing to R12's coccyx or when cleaning the resident.
During interview with the Director of Nursing on 08/14/2024 at 3:11 PM, she stated nursing staff discussed residents on enhanced barrier precautions daily in their morning meetings.
She stated they had not identified any issues with staff not following enhanced barrier precautions or hand hygiene requirements.
During interview with the Infection Preventionist on 08/15/2024 at 2:30 PM, she stated it was important for staff to follow enhanced barrier and contact precautions to prevent the spread of infectious organisms.
She stated she completed audits periodically to ensure staff was following the facility's policies.
During interview with the Administrator on 08/15/2024 at 3:30 PM, she stated it was her responsibility to ensure the infection control policies were implemented.
She stated infection control issues were discussed in the monthly Quality Assurance Performance Improvement (QAPI) meetings.
She stated she was not aware of any issues with infection control.
185197 08/16/2024
Hartland Park Health & Rehabilitation 1500 Trent Boulevard Lexington, KY 40515
Observation on 08/12/2024 at 4:06 PM revealed the [NAME] Hall was crowded with four wheelchairs folded up against the handrail on the right side of the hallway, across from a linen cart on the left side of the hallway.
In an interview on 08/16/2024 at 10:58 AM, Registered Nurse (RN) 5 stated the hallways in the facility were frequently crowded with linen carts, medication carts, meal tray carts, and extra resident equipment, such as wheelchairs.
She further stated the excess equipment created a safety issue for residents trying to maneuver the hallway, especially in an emergency. RN5 stated the residents' rooms were crowded and family members often asked for wheelchairs to be placed in the hallway due to a lack of space in the resident's room.
In interview on 08/16/2024 at 1:56 PM, the [NAME] Unit Manager stated the hallways needed to be kept clear for safety in case of an emergency.
She further stated that on 08/12/2024, the hallway was crowded because staff had washed the four wheelchairs, but they did not have residents' names on them, so the staff members did not know where to put them.
The Unit Manager stated she instructed staff to take the wheelchairs down to the therapy department so residents could use them there and keep the upstairs hallway clear.
Additionally, the Unit Manager stated her expectations were for staff to store wheelchairs folded up in the residents' rooms or folded up in the shower room if the shower room was not in use.
In an interview on 08/16/2024 at 2:58 PM, the Director of Nursing (DON) stated the hallways were to be kept clear of excess equipment for resident safety.
She further stated wheelchairs should have been stored in resident rooms.
The DON stated she expected management staff to be present on the units and assist with keeping the hallways clear.
Additionally, the DON stated the hallways tended to be more crowded during mealtimes when the tray carts were on the floor in addition to regular equipment.
In an interview on 08/16/2024 at 3:21 PM, the Administrator stated she expected the hallways to remain free from excess equipment for resident safety in case of an emergency.
Review of R124's Admission Facesheet revealed the facility readmitted the resident on 03/01/2024 at 12:30 PM from the hospital, with diagnoses of new fracture of the right and left femur (upper leg), not requiring surgery.
Review of R124's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 03/08/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating the resident was cognitively intact.
Review of R124's Physician's Orders revealed Oxycodone 5 mg every 12 hours as needed (PRN) for pain was ordered on 03/01/2024 at 2:00 PM.
Oxycodone 15 mg scheduled every six hours was ordered on 03/02/2024 at 4:52 AM.
Review of R124's CCP, initiated on 10/05/2023, revealed the resident was at risk for pain.
Interventions were to administer medications per orders.
Review of Resident 124's pain scores, on a scale of 0 to 10, with 10 being the highest, revealed on 03/01/2024 at 3:10 PM, the pain score was 5/10; on 03/02/2024 at 9:49 AM, the pain score was 8/10; on 03/02/2024 at 1:24 PM, the pain score was 8/10; and on 03/02/2024 at 5:40 PM, the pain score was 5/10.
Review of R124's Medication Administration Record (MAR) revealed R124 received 15 mg of Oxycodone on 03/02/2024 at 12:00 PM and 6:00 PM and 5 mg of Oxycodone on 03/02/2024 at 9:15 PM.
Further review revealed R124 did not receive Oxycodone 5 mg PRN for pain on 03/01/2024 at 3:10 PM; on 03/02/2024 at 9:49 AM; on 03/02/2024 at 1:24 PM; and on 03/02/2024 at 5:40 PM.
185197
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 185197 B.
Wing 08/16/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Hartland Park Health & Rehabilitation 1500 Trent Boulevard Lexington, KY 40515
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.