Northpoint/lexington Healthcare Center

F-F689)

Resident R36's CCP was not developed with interventions to address the resident's and family's non-compliance with Resident R36's current diet order.

The findings include:

Review of the facility's Comprehensive Care Plan policy, revised on 06/30/2022, revealed a comprehensive person-centered care plan was developed and implemented for each resident, consistent with a resident's rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs.

1. Review of Resident 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 Resident 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 Resident 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 Resident 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 Resident R124's Medication Administration Record (MAR) revealed Resident 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 Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 16 185197 Department of Health & Human Services Printed: 09/12/2025 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 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

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 32635

Level of Harm - Actual harm 2. Review of Resident R36's Admission Facesheet revealed the facility admitted the resident on 04/27/2024 with diagnoses including dysphagia, oropharyngeal phase, and major depression. Residents Affected - Few

Review of Resident R36's annual MDS, with an ARD of 07/22/2024, revealed the facility assessed the resident to have

a BIMS score of 15 of 15, which indicated the resident was cognitively intact.

Review of Resident R36's Physician's Orders, dated 04/27/2024, revealed a controlled carbohydrate diet, pureed texture, regular fluid, and thin consistency was ordered.

Review of Resident R36's CCP, with the admitted [DATE REDACTED], revealed the area of focus, resident had dental problems related to missing teeth, dated 11/28/2023. The goal was for the resident to be free of infection, pain, or bleeding in the oral cavity through the next review date of 10/22/2024. The interventions were for a dietary consult as needed, encourage the resident to complete oral care, monitor for changes in nutritional status related to dental, and refer to dental services; the date initiated was 11/23/2023. Further review revealed no focus on the resident's/family's non-compliance with diet and education of the resident or family on the prescribed diet.

Observation on 08/14/2024 at 2:23 PM revealed Resident R36 had one small empty potato chip bag, one small full potato chip bag, and an opened package of saltine crackers on her bedside table.

In an interview with Resident R36 on 08/14/2024 at 2:24 PM, she stated she had no coughing or choking on regular food and could not eat hard-cooked hamburgers or chicken. She stated she did not pass the swallowing test at the hospital. She stated her family brought her food.

In an interview with Resident R36's daughter on 08/14/2024 at 3:59 PM, she stated the facility told them it was okay to bring in food; they monitored her. She stated Resident R36 did not have dentures and hard-to-chew meats was difficult. She stated Resident R93, the resident's spouse, brought food to the resident. She stated Resident R36 tolerated fish, baked beans, and cauliflower and ate a regular texture diet before her recent hospital admission on 04/22/2024.

In an interview with Certified Nurse Assistant (CNA) 11, Central Supply on 08/14/2024 at 3:52 PM, she stated she was not familiar with the resident's diet. However, she stated the family had a picnic with the resident and would bring food to the resident.

In an interview with Speech 1 on 08/14/2024 at 2:24 PM, she stated the family brought food to the resident.

She stated she educated the family on the resident's texture diet. She said she reassessed the resident in 07/2024, and the resident stated she wanted to remain on the puree diet because some foods were hard to swallow.

In an interview with the B Unit Manager on 08/16/2024 at 2:39 PM, she stated speech evaluated the resident's diet texture. She stated Resident R36's family members brought food to the resident, such as on the resident's birthday. She stated the food consisted of fried chicken, green beans, and mashed potatoes. She stated staff educated the family on the diet to prevent choking. She stated Resident R36's spouse lived at the facility and brought Resident R36 food. She stated Resident R36's care plan should address the diet texture, the resident's non-compliance, and the family's non-compliance with bringing regular-texture food to Resident R36.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 16 185197 Department of Health & Human Services Printed: 09/12/2025 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 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

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 the MDS Coordinator on 08/16/2024 at 2:59 PM, she stated she followed the Resident Assessment Instrument manual when she developed a care plan. She stated nurses could make changes to Level of Harm - Actual harm 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 Residents Affected - Few 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 16 185197 Department of Health & Human Services Printed: 09/12/2025 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 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

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 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51155

Residents Affected - Few Based on interview, record review, review of the Licensed Practical Nurse (LPN) job description, review of

the facility's Employee Handbook, review of the Kentucky Board of Nursing (KBN) website, and review of a certified letter from the KBN, the facility failed to ensure that nursing staff providing resident care was licensed. Review of LPN8's employee file revealed she performed duties as a licensed nurse in the facility, from [DATE REDACTED] to [DATE REDACTED], on a suspended license.

The findings include:

During an interview on [DATE REDACTED] at 3:45 PM with the Administrator, she stated the facility did not have a policy regarding staff licensure.

Review of the KBN's website, www.kbn.ky.gov, under Privilege to Practice Important Facts, revealed it's the responsibility of the nurse to notify the employer of any action taken by the BON [board of nursing] against their license.

Review of the facility's job description Licensed Practical/Vocational Nurse revealed the applicant must have

a valid LPN or licensed vocational nurse license in the state employed.

Review of the facility's Employee Handbook, dated [DATE REDACTED], revealed, Licensed and Certified employees are to furnish copies of all required degrees, certifications, licenses, transcripts, etc., which will be placed in your personnel record. Proof of current registration and/or licensure in the state you are applying for work, if the state requires registration for your profession will be required prior to beginning work and must be updated annually. Validation of license/certification must be made available to The Facility as it is renewed. This evidence of renewal becomes part of your permanent personnel record. Licensed and Certified employees who fail to renew their license and submit a copy of the renewal to The Facility will not be allowed to work until the expired license or certification is current and a copy is given to The Facility. The employee could be subject to disciplinary actions up to and including termination.

Review of the facility's document Acknowledgement and Receipt of Handbook revealed LPN8 signed acknowledgment and receipt of the Employee Handbook on [DATE REDACTED].

Review of a certified letter from the KBN, dated [DATE REDACTED], revealed LPN8 received a letter from the KBN on [DATE REDACTED], notifying LPN8 of the intent to suspend her LPN license. The letter advised LPN8 of her right to submit a written request for an administrative hearing to the KBN regarding this matter within 20 days from [DATE REDACTED]. The letter stated LPN8 did not submit a written request for an administrative hearing, so LPN8 was given official notice by the KBN that, for the reasons stated in the attached letter dated [DATE REDACTED], her LPN license was suspended for a period of at least two years, effective [DATE REDACTED]. The letter stated LPN8 was prohibited from engaging in the practice of nursing within the Commonwealth of Kentucky, and any continued practice of nursing on her part would be in violation of Kentucky Revised Statute (KRS) 314.031(1), which was punishable by criminal sanctions. The letter stated the suspension would be public information and could be disseminated according to the regulations of the KBN, the Kentucky Open Records Act, and any other state or federal law as required.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 16 185197 Department of Health & Human Services Printed: 09/12/2025 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 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

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 0726 Review of LPN8's employee file revealed the facility's nursing schedule, from [DATE REDACTED] through [DATE REDACTED]. The nursing schedule showed LPN8 worked 82 shifts between [DATE REDACTED] (the suspension of license date) to Level of Harm - Minimal harm or [DATE REDACTED], the date of termination of employment with the facility. potential for actual harm

The State Survey Agency (SSA) Surveyor attempted to call LPN8 for interview on [DATE REDACTED] at 10:27 AM, but Residents Affected - Few she did not respond.

During an interview on [DATE REDACTED] 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 REDACTED] 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 REDACTED] 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 16 185197 Department of Health & Human Services Printed: 09/12/2025 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 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

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50000 Residents Affected - Few Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents as evidenced by one of six medication carts. Medication cart 1 on the [NAME] unit, was unlocked and unattended on 08/12/2024.

In addition, the facility failed to ensure all drugs used in the facility were labeled in accordance with professional standards, including expiration dates, for 1 of 32 sampled residents, Resident (R) 132.

The findings include:

1. Review of the facility's policy titled, Medication Storage, revised 01/30/2024, revealed all drugs and biologicals would be stored in locked compartments (i.e., medication carts, drawers, refrigerators, medication rooms), and only authorized personnel would have access to the keys to locked compartments.

Observation made on 08/12/2024 at 3:18 PM revealed medication cart 1 on the [NAME] Memory Care Unit was unlocked and unattended.

Observation made on 08/12/2024 at 3:21 PM revealed Unit Manager 1 walked past medication cart 1 and pushed the locking device, so the cart was locked.

In an interview with Registered Nurse (RN) 1 on 08/12/2024 at 4:00 PM, she stated she was unaware that

she had walked away from the medication cart without locking it. She stated it was important to always keep

the medication cart locked so residents, visitors, and other staff did not have access to medications that could cause harm if taken.

In an interview with RN9 on 08/15/2024 at 3:40 PM, she stated she was assigned to medication cart 1 on the [NAME] Memory Care Unit for the current shift. She stated it was important to keep the medication cart locked at all times so residents who were confused did not open drawers and take medications that could cause harm. RN9 stated ensuring the medication cart was locked should be done every single time before you walked away.

In an interview with Unit Manager 1 on 08/12/2024 at 4:10 PM, she stated she saw medication cart 1 was unlocked while walking past it and walked over and locked it. Unit Manager 1 stated it was the policy of the facility and the expectation that all medication carts should be locked at all times to ensure the safety of residents and to prevent diversion of medications. Unit Manager 1 stated the nurse assigned to the medication cart would receive verbal counseling and be re-educated on the facility's policy for medication storage and the importance of keeping carts locked at all times.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 16 185197 Department of Health & Human Services Printed: 09/12/2025 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 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

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 0761 2. Review of the facility's policy titled, Medications and Biologicals-Labeling Of, revised 06/20/2024, revealed labels for individual drug containers must include the expiration date when applicable. Further review Level of Harm - Minimal harm or revealed labels for multi-use vials must include the date the vial was initially opened or accessed, and all potential for actual harm opened or accessed vials should be discharged within 28 days unless the manufacturer specified a different date for that opened vial. Residents Affected - Few

Review of Resident R132's Admission Facesheet revealed the facility admitted the resident on 04/05/2024 with diagnoses of deep vein thrombosis, diabetes, and pre-glaucoma.

Review of Resident R132's Physician's Orders, start date 04/05/2024, revealed he was prescribed latanoprost ophthalmic solution 0.005%, instill one drop in both eyes at bedtime related to pre-glaucoma.

Review of Resident R132's medication administration record (MAR) for 08/2024 revealed he received the prescribed latanoprost eye drops in both eyes at bedtime, nightly from 08/01/2024 through 08/09/2024, at which time he was out of the facility.

Observation made on 08/12/2024 at 3:40 PM revealed latanoprost 0.005% eye drops, multi-use vial labeled for Resident R132, was dated as opened on 06/20/2024 on the outside of the medication box. Further observation revealed the label provided from the pharmacy on the container itself read good for 42 days after opening, with an area to write in the opened date, which was left blank, which meant the eye drops would have expired on 08/01/2024, if opened on 06/20/2024.

In continued interview with RN1 on 08/12/2024 at 4:00 PM, she stated she was assigned to medication cart 1 and understood it was important to follow the manufacturer and pharmacy instructions for medications in regard to following expiration dates. RN1 stated giving expired medications to a resident could cause adverse reactions or not have the desired effects due to no longer being effective. RN1 stated it was important to have the opened date on the container because the box and the container could be separated, and staff would not know the opened date.

During interview with RN9 on 08/15/2024 at 3:40 PM, she stated it was important to check multi-use medications to ensure they had been dated when opened, and the box and the container should both have a date that matched. She stated it was important not to use the medication past its expiration date, which could lead to a resident receiving medications that were not providing any therapeutic benefits.

In continued interview with Unit Manager 1 on 08/12/2024 at 4:10 PM, she stated it was the policy of the facility to always write the opened date on multi-use vials and containers and also on the box they came in so, if separated, the nurse knew the opened date to ensure the medication was still okay to administer. She stated the expectation was for the nurse to check the expiration date before every administration to make sure they were not giving an out-of-date medication.

In an interview with the Pharmacist on 08/16/2024 at 9:57 AM, he stated that latanoprost 0.005% eye drops were good for 42 days after being opened. He stated that the potency of the medication decreased the further out from the expiration date, but it did not cause any adverse effects if used, it just was not as beneficial.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 16 185197 Department of Health & Human Services Printed: 09/12/2025 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 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

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 0761 In an interview with the Director of Nursing (DON) on 08/16/2024 at 2:38 PM, she stated it was the policy and

the expectation of the facility that every medication cart on every unit would be locked and secured every Level of Harm - Minimal harm or time the nurse was not actively removing or preparing medications at the cart. The DON stated it was potential for actual harm important to ensure the carts were locked when unattended for resident safety that, if unlocked and accessible to residents, could result in overdosing and adverse reactions. She also stated it was important to Residents Affected - Few prevent any potential drug diversion by visitors, residents, and staff. The DON stated if a medication cart was observed to be unlocked, it should be immediately secured, and the person who identified it should then report it to the nurse or unit manager to ensure nothing was missing. In addition, she stated the nurse assigned to the cart would be educated and given a verbal warning with escalation, if indicated. The DON stated the expectation and the facility's policy was to label all multi-use containers with the opened date and to follow the pharmacy's expiration date to ensure residents received effective medications.

In an interview with the Administrator on 08/16/2024 at 3:26 PM, she stated it was the expectation and policy of the facility to ensure all medication carts were kept locked at all times when the nurse 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 16 185197 Department of Health & Human Services Printed: 09/12/2025 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 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

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 44000 potential for actual harm Based on observation, interview, record review, review of the Centers for Disease Control and Prevention Residents Affected - Few (CDC) documents, and review of the facility's policies, the facility failed to follow infection control precautions for 3 of 51 residents on infection control precautions, Resident (R) 12, Resident R71, and Resident R124.

The findings include:

Review of the facility's policy titled, Infection Prevention and Control Program, revised date 12/27/2023, revealed the facility had established and maintained 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 as per accepted national standards and guidelines. The policy stated hand hygiene shall be performed in accordance with the facility's established hand hygiene procedures. Per the policy, reusable items and equipment shall be cleaned in accordance with the facility's current procedures governing the cleaning of contaminated equipment.

Review of the facility's policy titled, PSTG (Prestige) Hand Hygiene (Soap and Water and Sanitizer), undated, revealed hand hygiene shall be performed between resident contacts and after handling contaminated objects/potentially contaminated objects; before handling medications (licensed nurse); before and after handling clean or soiled dressings, linens, etc.; before performing resident care procedures; before and after providing care to residents in isolation; after handling items potentially contaminated with blood, body fluid, secretions, or excretions; and during resident care and moving from a contaminated body site to a clean body site (nurses).

Review of the CDC's document Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 04/02/2024, revealed examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions included wound care for any skin opening requiring a dressing. Further review revealed contact precautions were intended to prevent transmission of infectious agents, like MDROs, that were spread by direct or indirect contact with the resident or the resident's environment.

1. a. Observation on 08/15/2024 at 9:50 AM of Resident R124's room revealed the resident was in enhanced barrier precautions and contact precautions with signage of this outside the room. Observation of the Social Service Assistant (SSA) in Resident R124's room revealed she picked up a clip board from a surface behind the curtain. She was wearing gloves, she put the clipboard on the sink, removed her gloves, picked up the clipboard, and left

the room.

During interview with the SSA after she left the room, she stated it was a mistake she did not wash her hands and clean the clipboard before leaving the room. She stated she should have washed her hands and not have placed the clip board on the resident's furniture.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 185197 Department of Health & Human Services Printed: 09/12/2025 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 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

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 0880 b. Observation on 08/15/2024 at 9:59 AM revealed Licensed Practical Nurse (LPN) 4/Wound Care Nurse went into Resident R124's room and changed Resident R124's dressing. LPN4 wore a gown, gloves, eye shield, and a Level of Harm - Minimal harm or facemask. After providing wound care, she removed the gown, gloves, and mask and threw them in the trash potential for actual harm container under the sink. She placed the eye shield on the sink and washed her hands. She picked up the eye shield from the sink, left the room, and laid it on the top of the treatment cart. She reached in the bottom Residents Affected - Few drawer and removed a container of disinfectant. She cleaned the eye shield and placed it and the container of disinfectant in the bottom drawer of the treatment cart. She did not clean the top of the treatment cart.

During interview with LPN 4/Wound Care Nurse at the time of the observation, she stated she should have disinfected the top of the treatment cart because there could have been infectious organism on the cart from

the eye shield.

2. Observation on 08/14/2024 at 8:35 AM revealed Resident R71 was on enhanced barrier precautions as indicated

on the signage outside the room. Registered Nurse (RN) 4 removed Resident R71's medications from the medication cards and touched the medications without wearing gloves. She then put Resident 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.

3. Observation on 08/14/2024 at 3:08 PM revealed RN1 was at the bedside changing the dressing on Resident 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 Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 185197 Department of Health & Human Services Printed: 09/12/2025 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 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

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 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46710

Residents Affected - Few Based on observation and interview, the facility failed to provide a safe environment for residents, staff, and

the public for one of three resident care units.

The findings include:

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 185197